Title: Illuminating health aspects for immigrant Thai women in Swedish transnational marriages
Version: 4 Date: 27 Sep 2022
Reviewer's report:
Review of Revised Manuscript: BMC Women’s Health - ID 63a8ea18-92c9-4154-
b4c6-33381d2c4b5d Illumination health aspects for immigrant Thai women living in Swedish
transnational marriages
Thank you to the authors for their serious consideration of reviewers’ feedback and for making
significant changes to their manuscript in response to our suggestions. I believe that the paper
is improved in important ways; however, I continue to have some concerns, particularly with
the methodology and findings that lead me to share more feedback and recommend additional
revisions. I also continue to believe that the research you conducted has merit for the scholarly
community who studies and the health practice community who supports immigrant women in
transnational families. I trust that my feedback will be accepted in that spirit.
Background: Thank you for adding more background about the Thai women who migrate to
Sweden to cohabitate/marry. I encourage you to do a bit more synthesis of that literature on
reasons for migration and the gendered patterns that exist. The individual statements, citing one
article at a time, are at times almost contradictory. For example, one study noted the economic
motivation masked as love and in the next sentence, a statement regarding “a loving marriage”
that is cherished by Thailand… There is also a judgmental statement about women ‘abandoning”
their previous families and children but the actual point is more about their migration making
them more susceptible to intimate partner violence. Did the article say that they were abandoning
their families or was that your interpretation? Women who experience IPV by their spouse often
leave those relationships only to form a new relationship with a man who also perpetrates IPV
(there is research on this) I’m not sure what the article you cite says about the reason for leaving
Thailand, but I would be careful about characterizing it as ‘abandoning’ if that’s not how it was
stated in the article. I would also think about how to characterize major health risks and the three
factors you highlight that are problematic about marriage migration.  Not all of these happen in
all cases of marriage migration and they are qualitatively different types of risks. Not knowing
the language is vastly different than spousal violence.
Theory: I appreciate that you included a very brief paragraph that stated that the Neuman System
Model was used in the data analysis process versus in the study design process. I have no
argument with that and appreciate that it is now transparent. However, a reader who is unfamiliar
with the NSM is still left to figure out how the five domains of wellness – physiological,
psychological, sociocultural, developmental, and spiritual – are conceptually defined. Without
those definitions, it isn’t clear if or how your dilemma groupings fit into those domains as
conceptually defined by the NSM. I also wonder if the NSM allows for intersections among
the domains. Certainly your examples illustrate that these are not discrete aspects of health;
there are many dilemmas that are complex and involve multiple domains. However, this is never
discussed with regard to the NSM or discussed in your results.
Method: I am a bit perplexed with what seems to be a contradiction when you state that you used
an inductive approach for your analysis (p. 8) but the NSM ‘inspired’ identification of the main
health dilemmas. That ‘inspiration’, which is not really methodologically sound as far as I know
(if it is, please add the citation for inspiration as method), appears to be closer to a deductive
process rather than an inductive one. I actually think it would be a strength if you own the NSM
as your guide for a deductive analysis of your interview data. Or you could discuss the inductive
part as phase one as open coding in which you identified critical incidents, then you moved
into a deductive phase two where you used the NSM model to categorize them by the domains
of that model. Right now there’s still something missing in terms of a logical process in your
explanation of the methodology.
Results: There are still some results about which I’m confused. The sociocultural health
dilemmas category includes several critical incident areas which you described at the beginning
of the section. However, I’m not sure which of them you are describing at what time or what
your quotes illuminate. And unfortunately your decision not to add more quotes to illustrate the
nature of these critical incidents in the voices of the women (which you say is a primary goal of
your study) leaves me unconvinced of what you found. For example, on the bottom of page 10,
the sentence immediately preceding a quote is about seeking extra work to earn money to send
home. Is that an example of “execute transnational duties”? However, the quote is more about
caring for the husband which suggests that she may be feeling more like a servant, a different
type of critical incident.
I’m also not clear where “critical incidents in domestic work” (p. 11) fit into the five types in
the sociocultural health dilemmas category. Are they executing transnational duties? Refraining
from family duties? Being a servant in the household? She describes taking care of her husband
and working outside the home…. So was it the ‘servant’ category that was coded for this
example, or something else?
I am also confused about the example about the Thai friends finding a partner for the woman. Did
that happen before she left Thailand or while she was living in Sweden? In the same paragraph,
you discuss providing economic support to people at home. Those are two very different ideas
but  are all included in one paragraph. And again – which critical incident idea do they align with?
The rest of your findings sections hold similar confusion for me. I urge you to use subthemes
within your larger critical incident dilemma areas and provide at least one quote that illustrates
each one so we have a sense of what they entail for these women. The voices/experiences of
these women then carry the manuscript and provide the validity for your findings.
Discussion: I encourage you to think carefully about how far you can generalize your findings.
This was a unique, convenient sample of Thai women married to Swedish men in Sweden.
Suggesting that this knowledge can be transferable to migrant women from other parts of
Thailand and other Asian countries is going beyond your data and is not responsible. Your
findings have merit and I believe with stronger methods and findings sections, would make
a good contribution to the literature. However, these findings help us understand what some
women, namely those in your unique sample, experienced in migration when partnered with
these particular men. You acknowledged that half of the women you interviewed had no
problems. Then, how could you suggest that these negative experiences could be generalized to
all Thai women, let alone all Asian women?
You also state that these experiences seem “to be a standard part of marriage migration that the
wife will be unprepared for …..” Again, your sample does not let you conclude that this is a
‘standard’ experience for migrating women. Please be careful not to overstate your findings.
Another concern was the statement about age difference which you said was “confirmed” by
the women in your study. I might suggest you be a little less definitive because of your sample
limitation. You could say that the pattern was similar to that which has been found in other
studies. You also discuss these women as being illiterate, or at least suggest that they were,
because you talk about some spiritual practices as the women in your study mentioned as being
“common in illiterate women” (p. 18). That is very demeaning, in my opinion, and a judgement
unwarranted.
The merit of the study is in highlighting post-migration experiences that happen to SOME Thai
women married to Swedish men. They are significant to warrant attention by health care and
social service providers, but one should not conclude that all women will experience these types
of dilemmas.
I’m curious about your recommendation that Thai health professionals should “consider what
Thai women need to know before migrating to Sweden”. How would this help? Under what
circumstances would they have an opportunity to interact with these women prior to their
migration? What would they do specifically that would help them with their transition? Are
you thinking that they would interact with Thai health professionals in Sweden? Or if these are
Thai health professionals in Thailand, how would they ever know what Thai women need to
know about Sweden and Swedish men and marriage? More information would help the reader
understand your thinking here. Likewise, why do you think that the Thai embassy should play
a role here? That seems a bit odd to me unless they employ trained professionals to handle
relationship and health issues.