Title: Illuminating health aspects for immigrant Thai women in Swedish transnational marriages
Version: 3 Date: 03 May 2022
Reviewer's report:
Review: BMC Women’s Health - ID 63a8ea18-92c9-4154-b4c6-33381d2c4b5d Illuminating
health aspects for immigrant Thai women living in Swedish transnational marriages.
Thank you for submitting an interesting paper on the health challenges of Thai immigrant women
living in Sweden. Research on transnational marriages is sparse and the challenges that are often
integral to these couples are rarely exposed, particularly for women who are most often  migrants
from the global south to the global north, and who most likely hold much less power than their
male partner in the relationship. My feedback is offered in a spirit of support for continuing to
hone your paper for clarity and depth for publication.
Title: You use ‘marriage’ in your title, but 27 were cohabiting. Does that mean they were
married and living together? In the U.S., cohabiting doesn’t mean marriage. Perhaps using terms:
Married, living together; Married, living apart; Divorced; Widowed would be more clear.
Background: The literature on immigration needs synthesis to provide a more complex picture
of why people choose to migrate, their path to the new country, and their situation on arrival. In
the case of Thai women, especially those from Isaan, there are compelling economic reasons that
women have been choosing marriage migration for decades. One of your findings, a woman who
felt betrayed by her ‘friend’ who introduced her to her controlling/abusive partner, hints to the
organization behind this pipeline from the global south to the global north. The demographics
of your sample also provide hints about this migrant population – the majority had a high school
diploma or less, 19 (close to ½) had not graduated from high school. 34 of the 40 sent money
home; about 1/3 on a monthly basis. Without an education, they are tremendously naïve about
the prospects of earning money in their new homelands which leaves them fully dependent on
their partners for income or if ‘allowed to work’, relegates them to jobs in the service sector
which may or may not be something they want to do or have the skills to do.
Poverty is high in the Isaan region of Thailand; women are vulnerable to what they see as
opportunities to improve their lives and help their families. Moving to Bangkok to work in bars
where they have opportunities to meet tourists is not uncommon. This can lead to international
marriage even when neither partner speaks each other’s language. I didn’t see any mention of
where these women met their husbands but if you have those data, I think it would be a good
addition to understanding their backgrounds. I also think it’s important to know a little bit about
their husbands. For how many was this their 2nd or even 3rd marriage? Some of your results
suggest that there were children involved. My anecdotal data (from about 40 years of experience
with Thai people in Thailand and in my own U.S. community where we have many Thai wives/
U.S. husbands), is that many men seek a Thai wife later in life to ‘take care of them’. Often the
women are considerably younger than the men and get saddled with care responsibilities which
you found in your study.
You mention that ‘immigrant women are supposed to have equal rights (emphasis added) to
fulfill their needs in the new country (I believe this is from the Ekblad & Kastrup, 2016 citation).
Immigrants’ rights upon arrival vary by country and immigration statute. It is important to know
what kind of legal and work status these women have on arrival. Are they considered Swedish
citizens? Are they on some type of dependent visa and if yes, for how long? Can they work
immediately? I noted that most of them were cohabiting with their partners. How does this
affect their legal status and financial support? Again, these are important contextual factors in
understanding your findings.
In summary, I think your study needs a much more extensive background section before readers
can truly grasp your findings. Unless they know the bi-national, bi-cultural context of these
marriages, it’s difficult to make sense of what you found. It’s especially important to know the
context in the sending country in order to understand the migrants, their motivations, and their
subsequent experiences as immigrants.
Theory: I appreciated learning about the Neuman System Model, which seems to have withstood
the test of time, created initially in 1989 wand its most recent inclusion in a nursing text in
2002. This model seems to be ecological in scope, noting that it pays attention to multiple
dimensions of a person’s health as well as the internal, external, and created environments
surrounding the person. I note that you pay attention to some aspects of the NSM, namely the
psychological, sociocultural, development, and spiritual health dimensions, but seem to ignore
the environmental dimensions of the model. That is where I see room for developing a deeper,
more complex analysis of these women’s narratives that is truly guided by your theory.
Method: I would like more information on the critical incidents methodology. The question you
included seemed to be asked from a phenomenological approach and was very broad. What
were your follow-up questions? Did you need to ask any specific questions to elicit responses
about their relationships with their partners? About whether or not they had considered returning
home? You have some very specific findings related to the immigrant experience that your ‘How
do you deal with everyday life in Sweden? Question would not uncover.
You mention that interviews were conducted in Thai, Thai and English, or Isaan and that they
were transcribed verbatim. However, there was no mention of the language in which the data
were analyzed. I assume you needed to translate the transcripts to English or Swedish so that
your third author could be involved in the analysis process. Please describe if that happened and
how you did it. I also know that Thai Isaan is quite different than central Thai. How did you
handle those differences?
Please provide an example or two of your analysis steps. Describe some of the ‘contextual
and complementary information’ that was found by the ‘horizontal reading’. Likewise, what
is an example of a ‘common feature’ found from the ‘vertical reading’? Transparency is one
of the ways that qualitative researchers document the rigor of their methodology. Therefore,
researchers need to provide enough detail about their analysis process for the reader to follow
the step by step method and ‘see’ how it unfolds. One cannot fill in the blanks as you are asking
us to do.
Results: Qualitative research rigor is evaluated in multiple ways; transparency as mentioned
earlier is one way. I encourage you to read about establishing rigor in qualitative research
(See Morrow, 2005; or Anfara et al., 2002). Providing significant quotes from one’s data to
demonstrate the credibility of the theme is another way one demonstrates rigor. I found your
use of women’s quote quite minimal. The dilemmas were all very complex, for example,
the psychological dilemma included emotional abuse, overloaded with family responsibilities,
leaving unpaid debts behind excessive gambling, being thrown out of one’s home, and being
left by a spouse. Yet you provide only two quotes for this dilemma. You also draw some fairly
serious conclusions such as “experiences of emotional violence and exploitation both verbal
and non-verbal increased women’s loss of self-confidence”, but there is no evidence to back
that up. I expected that you would have at least 5 sub-themes within this dilemma reflecting the
subcategories you named. As written, it is not a robust finding; my sense if you have a first-
round draft that needs more analysis and synthesis.
Ditto for all the other dilemmas in your results section.
I believe your paper has tremendous potential to shed light on a serious issue for immigrant
women in international partnerships. I encourage you to amplify the voices of the women in
your paper; it will be more rigorous methodologically and more respectful to your participants
as you honor their willingness to share these difficult experiences.