The experiences of menstrual symptom changes among international students studying in China during the acculturation period: Aphenomenology study

Asm Alkhatib ,Wizi Wu ,Hoda Alshikh Ahmad ,Rat Pakwan Suwal ,Zhao Ni ,Xianhong Li

a Xiangya School of Nursing,Central South University,Changsha,Hunan,China

b Faculty of Nursing,Hama University,Hama,Syria

c School of Nursing,University of Connecticut,Storrs,Connecticut,USA

d Xiangya School of Public Health,Central South University,Changsha,Hunan,China

e National Academy of Medical Science,Bir Hospital (NAMS),Mahaboudha,Kathmandu,Nepal

fSchool of Nursing,Yale University,New Haven,CT,USA

g Yale Institute for Global Health,Yale University,New Haven,CT,USA

Keywords: Acculturation Female International students Life change events Menstruation

ABSTRACT Objectives: Menstruation is a normal physiological phenomenon among female which could be influenced by the process of acculturation.Few studies have explored the experience of menstrual symptom changes among international female students studying in China.Therefore,this paper aims to summarize international female students’ experiences of menstrual symptom changes when they were studying in China and interpret these changes through considering the influence of acculturation on their social and academic lives.Methods:We used a descriptive phenomenology approach.Structured in-depth face-to-face interviews were conducted between May and November 2019 among ten international female students studying in one Province located in south central China.Participants were those who reported having experienced menstrual symptom changes during the acculturation period,which was defined as the first six months of living in China.All interviews were audio-recorded,transcribed verbatim,and analyzed using NVivo 11.0 with the guidance of Colaizzi's seven-step method.Results:The international female students’ experiences of menstrual symptom changes were summarized and grouped into five main categories and 13 subcategories.The main categories include: 1)demonstration of menstrual symptom changes,2) challenges of maintaining menstrual function in the new setting,3) coping styles to take care of menstrual health,4) consequences of the menstrual symptom changes,and 5) culture-based attitude toward menstruation.Conclusions:International female students reported experiences of menstrual symptom changes,including somatic and psychological symptoms during the acculturation period.Culture barriers,academic stress,and sleep patterns are common factors influencing their menstrual symptom changes.More culturally-tailored interventions should be explored to improve the menstrual health of international female students in China.

What is known?

·Menstruation is a normal physiological phenomenon that can be influenced by the environment,nutrition,weather,lifestyle,and psychological pressures.

·Negative experiences of menstruation negatively impact a woman’s daily life and work.

·Acculturation process can affect the social and psychological well-being of international students.

What is new?

·International female students reported experiences of menstrual symptom changes,including somatic and psychological symptoms during the acculturation period.

·Menstrual changes had negative consequences on their social and academic lives.

·Culture barriers,academic stress,and sleep patterns were influencing factors.

·Students’ culture-based attitudes toward menstruation led to different coping strategies against their menstrual symptom changes.

1.Introduction

Menstruation is a normal physiological phenomenon [1] that can be influenced by lifestyle[2],environment[3],weather[4]and nutrition [5].Studies have shown that perceived experiences of menstruation vary among women and are influenced by the culture of the place where a woman was born [6].Generally,mild menstrual symptoms do not impact women’s life and work [7],but perceived negative experiences of menstruation could negatively impact a woman’s daily life and work [8].Dysmenorrhea is the most common menstrual symptom that includes pain,cramp,changes in mood and appetite [9].Dysmenorrhea may begin several days before the menstruation and could last for a few hours to several days [10].Many research projects have studied dysmenorrhea and found that up to 90% of young females and adolescents experienced dysmenorrhea [11].The reported rate of dysmenorrhea varies among regions and countries.For example,the dysmenorrhea rate was reported to be 40%-85%[11-15]among women in China,Ethiopia,Ghana,Spain,and Turkey.

Females’attitudes toward menstruation and its care are greatly influenced by sociocultural traditions[6,16].For example,people in some societies believe that menstruation is a dirty period and menstruating females are impure;therefore,menstruating women are restricted from cooking and eating certain foods,and are not allowed to worship or shower [17,18].Consequently,this stigma and discrimination toward menstruation,also known as the ‘culture of shame and silence,’could prevent females from seeking care or help [19].In other cultures,menstruation is considered as a woman’s functional period,which she needs special care.For instance,college students in Ireland used non-pharmacological strategies,including hot shower and hot water bottle [20],to mitigate menstrual symptoms.In China,drinking warm water and taking traditional Chinese herbs are popular strategies for college students to reduce menstrual symptoms [21].

Globalization has made the world a more connected place,where every year 4.78 million international students study and live overseas [22].Studying in a foreign county involves a process of acculturation that can impact the social and psychological wellbeing of international students [23].As a special group,international female students’ experiences of menstruation are unique,given that they will experience a process of acculturation in hosting countries.Unfortunately,this topic is overlooked in the literature.To the best of our knowledge and according to our search results among the published studies through the international databases,we found only our previous cross-sectional survey,conducted among 345 international female students in Hunan province.We showed that 18.49%reported menstrual symptom changes[24].In contrast,rare studies focused on this phenomenon and have reported changes in menstruation due to acculturation without specifying precise data and in the general population,not limited to international students[25-28].In the recent decade,the number of international students studying and living in China has remarkably increased from 223,499 in 2008 to 492,185 in 2018 [29].International female students’ menstrual health has become an urgent concern that needs to be addressed by school educators and healthcare providers in China.However,little is known about international female students’ perceived experiences of menstrual symptom changes,and the challenges they face in maintaining menstruation health.Therefore,this paper aims to understand the perceived experience of menstrual symptom changes among international female students and the challenges they face during their acculturation period in China.

2.Methods

2.1.Study design

This study used the descriptive phenomenology approach to understand the experience of menstrual symptom changes among international female students studying in China.The descriptive phenomenology approach was used because it is the best method to understand people’s experiences and interpret the meaning of the experience[30].In this study,the menstrual symptom changes were the phenomenon that we were interested in.We defined menstrual symptom changes as the changes in regularity,including the changes in bleeding volume,severity,or frequency of the symptoms,such as cramps,irritation,pain,or fatigue.

2.2.Participants and settings

We used purposive sampling method to recruit international female students from three large universities located in the capital city of one Province located in south central China.This is because those three universities hosted nearly 80% of the international students studying in the capital city [31].Inclusion criteria of participants were:(a)female students who self-reported experiencing menstrual symptom changes during the acculturation period (the first six months of living in China),(b) received primary and high school education in a foreign country or region outside of China,(c)pursuing a bachelor’s,master’s,or doctoral degree in China,and(d)could speak Mandarin or English.Exclusion criteria included pregnancy,having physical illnesses (diagnosed gynecological disorders such as primary amenorrhea,polycystic ovary syndrome,and any pathological situations that could cause pathological disturbances of the menstruation),or taking medications that could impact their menstrual symptoms.Formal permissions were obtained from the targeted universities,and the invitation flyers for the study were posted on their boards and were also sent electronically via WeChat groups(an instant online chatting platform).Those who were interested in this study contacted the researcher who verified their eligibility for this study.Eligible students read the informed consent explaining the purpose,risk,and benefit of the study and signed it before starting the interview.Participants were continuously recruited until no new category and subcategory emerged,which was considered as data saturation.In total,ten participants were recruited and interviewed [32].

2.3.Data collection procedure

Data were collected through in-depth interviews from May to November 2019 using a semi-structured interview guide.The interviews were conducted in English and audio recorded using a digital recorder after obtaining the recording permission and approval from the interviewees.The interviews were conducted in a classroom or an office at a time that was agreed upon by participants,and each interview lasted for 50-65 min.The first two interviews were conducted by one of the corresponding authors of this study,who had extensive experience in conducting qualitative studies;the other two interviewers included a female graduate student and a male doctoral student.The male interviewer was majoring in women’s health and familiar with the physiology of menstrual function.Before the interview,the interviewer introduced his specialty and established rapport with the participants.They attended the course on qualitative research methodology at the graduate school and received training before starting the study;in addition,they were supervised by the corresponding author (X.L.) by regular meetings.The interviewer set up rapport at the beginning of the interview with non-judgmental and open attitude towards communication on menstruation topic,encouraged them to express their experiences freely,and gave them the opportunity not to answer any questions.Follow-up questions were probed,and notes were taken during the interviews to gain a full understanding of the participants’ experiences.Participants were given a monetary compensation of 100 RMB(equivalent to 15 USD)for their time and travel expenses.No personal identifiers were collected,and all the data were used exclusively for the purposes of the study.

2.4.Interview guide

The research team initially developed an interview guide with open-ended questions according to the study aims through two rounds of discussion.Then the interview guide was validated and revised based on the first two interviews,and finally,the following questions were included: 1) please tell me about your menstrual situations in the first six months of living in China;2) what challenges did you face to maintain your menstrual health? 3) what strategies did you take to maintain your menstrual health?4)how did your menstrual symptom impact your life?and 5)what is your perspective on menstruation based on your culture?

2.5.Data analysis

The recorded interviews were transcribed verbatim by two well-trained researchers.The two researchers created their codes independently followed by comparing their codes and discussing the difference.If the two researchers could not reach an agreement,a team meeting would be held for the purpose of consulting a senior researcher.Colaizzi’s seven-step method was used to generate the categories and subcategories [33].Specifically,the researchers coded the data through the following seven steps: 1) reading and understanding the data,2) highlighting and extracting significant statements,3) clarifying the statements’ meaning and creating initial codes,4) grouping similar codes together and organizing them into categories,5) developing a comprehensive description,6) defining and naming the categories,and 7) verifying the main structure.To ensure credibility,two researchers reviewed the coding process,discussed the main and subcategories preparation,and discussed their different perceptions with the principal researcher to reach an agreement on interpretations of the data.Literal quotes were used to support the findings.The NVivo 11.0 software was used to assist the coding process and data management.

2.6.Rigor and trustworthiness

The rigor and trustworthiness of the study was confirmed by using the criteria presented by Lincoln and Cuba [34];two researchers(A.A.and W.W.)worked intensively on data collection and primary analyzes and became familiar with the data at an indepth level and maintained a broad sense of the picture,the preliminary analysis was separately established by each of them and discussed with the corresponding author (X.L.),and then the subcategories were created,presented and reviewed by other two researchers(who are experts specialized in qualitative research as well as conducted and supervised many qualitative studies).During the analysis we used the tools of continuous theoretical comparison,theoretical sensitivity and triangulation to ensure categories saturation and to reduce the individual researcher bias.Reflective notes were taken during each interview,documented in a notebook,and reviewed during the analysis process to provide full understanding and as reference explanation points.During the interview preparation process,the cultural,environmental and societal aspects of the city was studied to identify all the possible risk factors related to the participants of the study and to obtain a comprehensive understanding of the participants’ experience.

2.7.Ethical consideration

This study received ethical approval from the Ethics Review Committee of Xiangya School of Nursing of Central South University(Approval No.2018036).Also,permission to conduct this study in participating universities was obtained from each site’s School of International Education Office.Written informed consent was obtained from all participants before the interviews.Participation in the study was voluntary,and participants had the right to withdraw at any time and without any consequences.Identification codes were assigned to each participant and were used to present findings.No personal information or identifiers were collected in this study.All raw data were kept in a password-protected offline computer,and only the research team members who received ethical training could access the license key to the database.

3.Results

Our participants were from Pakistan,Nepal,Indonesia,and Zambia.The mean age of the participants was 28.8(SD=9.6)years.Among all participants,six were single,and nine were from Asian countries,including Pakistan(5/10),Nepal(3/10),and Indonesia(1/10).Half of the participants received Chinese government’s scholarship and majored in medical sciences in their undergraduate (5/10),master’s (3/10) and doctoral (2/10) programs.The detailed information is shown in Table 1.

Table 1 Sociodemographic characteristics of participants.

Five main categories emerged from participants’ descriptions,including demonstration of menstrual symptom changes,challenges of maintaining menstrual function in the new setting,coping styles to take care of menstrual health,consequences of the menstrual symptom changes,and culture-based attitude toward menstruation.

3.1.Demonstration of menstrual symptom changes

Encountering menstrual symptom changes was unexpected for the international female students during their acculturation periods in China.They reported various changes regarding the bleeding volume,menstrual cycle,and associated body symptoms and psychological symptoms,which included three main types.

3.1.1.Changes of regularity and bleeding volume

More than half of the female students indicated the change of frequency and volume of their menstruation during the first six months of living in China,including symptoms such as regularity changes,changes in the amount of bleeding from light to heavy.

“It’s irregular,before coming to China it was 20 to 21 days…in China more irregular than before,it takes a longer time,one and half months and sometimes 2 months….Duration time(bleeding)is also longer.It takes 10,or 11,12 days sometime,it was 6 to 7 days before.” (N2)

“In China,it was huge bleeding,and period was 3 days and then finished,that’s was the first time in China and was very difficult,but now it becoming better.…I had more bleeding comparing to the situation in my country.” (N5)

“I don’t have that much bleeding….in China,the bleeding period is lesser,it’s stop in 3 days my bleeding(volume)is very low,and stop in the third day;it should be 4 to 5 days at least,it seems that I have no blood.” (N7)

3.1.2.Changes of somatic symptoms

Along with the menstrual symptom changes,participants reported encountering some physical symptoms,which included pain,cramp,fatigue,weight gain and acne.

“I had acute pain one day before the menstruation….It’s like in the belly,it’s like I don’t know exactly,you can say in the lower abdomen,it’s like its spreading through;it takes the whole body with it….Currently,the acute pain is severe much more,I can’t bear it,I must take 2 pain killers,twice a day.” (N5)

“There are some acne and feeling tired and angry every period….one or two days before menstruation….But in China it’s one week before I get these….” (N9)

“And here at the moment because my period is not well,the acne increases more and more…I gained weight.…my weight is increasing more and more.” (N10)

3.1.3.Changes of psychological symptom

Participants also reported new psychological symptoms.The most significant psychological symptoms reported were feeling sad,angry and depressed.

“(In China)At first it was like the same as that in my country,then my mood changed;I don’t know why (laughing),and before my period I get very angry,angry with every one (laughing),I don’t know these things,it’s new for me.” (N7)

“Once starting the period,I feel very sad,sometime very angry and like that in the period….in my country(I)only feel pain and(mood changing) was so rare.” (N4)

“On the day before menses I keep quiet even when people talking,I don’t like to talk (laughing),just prefer to be quiet and feel likemaybe depression or something like that you can say….In my country I had this feeling but can’t be compared to the situation here,here much more and every period feel that.” (N6)

3.2.Challenges of maintaining menstrual function in the new setting

Our participants indicated that they had learned relevant techniques to take care of their menstrual health in their youth.However,when they moved to a new cultural setting,they often found many difficulties in maintaining their menstrual health.Cultural barriers,academic stress,and feeling homesickness were the commonly challenges mentioned by the female international students to maintain their menstrual function in the host country.

3.2.1.Cultural barriers

Most international students studying in China are from the‘One belt and One Road’ countries,where people live in warm or hot areas.The first challenge they needed to face after coming to China was the weather.Participants told us that,in general,the temperature in China was lower than in their home countries.Many of them indicated that their menstrual symptoms were influenced by the cold weather in the winter.

“The weather is the main I think(smiling),because when I feel cold,my stomach directly gets pain,especially when menstruation period.” (N9)

“The cold affects a lot,here the weather is much more colder than that in my country,so when I feel cold I get more severe pain,and this happens more frequently,but I can’t do anything for it,just try to keep warm during period.” (N5)

Participants also demonstrated concerns about adapting to the spicy food in the local studying area,because the school canteen and local restaurant were used to provide spicy food,they had less choice but to adopt spicy food,while the consequence was that it affected the menstrual symptom.

“I try to focus on my intakes,the food and drinks,because I don’t eat spicy food too much (especially) when I was on cycle…the main problem here that we don’t get our food and the food here very spicy,and I guess that is the reason (for the irregularity of the menstruation)” (N8)

“My problem with the food is the taste change and the spicy,the Chinese food is different than my country food.At the beginning I couldn’t eat,but after sometime adapting to it,my menstrual cycle suffered.Because the body isn’t adjusted to the amount of food we take and the type of things…so if (we) have good diet then (we)will not have menstruation trouble,it’s hormonal regularities,it’s related to hormonal changes which may influenced by stressor changes,especially nutrition.” (N3)

However,some international female students faced challenges in adapting to the ‘so-called’ techniques to take care of menstrual health.For example,when they were discussing the technique of drinking hot water to reduce menstrual pain,a student from Pakistan said she could not take it.

“I use cold water,I don’t drink too much water but I drink cold,they told me the cold things will increase my menstrual changes,I can’t drink hot water,I do not like it.In my country,it just like we are not used to hot water,and we use cold water from the refrigerator;(it is) difficult to drink hot water,I tried but I couldn’t.” (N5)

Besides,when the international students explored menstruation care,for example,going to stores to buy menstrual stuff,language barrier became their biggest challenge during the early stage of arriving in China.

“At the beginning of the time(just entering China),I was looking for hot water bag because I needed it,but didn’t know where to find,I tried to go to medical shop but needed to talk with them,they couldn’t understand my English and I can’t speak Chinese,I used translator of my phone,it helped but unfortunately I didn’t find it there;then one senior helped me and bought it online by Taobao(an online shopping center).” (N1)

“Sometimes when I walked in the market and wanted to buy sanitary pads,I didn’t learn Chinese language,so when I asked Chinese people,they escaped from me because they can’t understand English and I can’t explain in Chinese,so I feel very hard(at the very beginning).” (N3)

Due to the time difference between China and the participants’home countries,many participants experienced unsatisfied sleep,which might lead to the disorder of hormone system and thus influence the menstrual function or symptom changes.

“I have difficulties to sleep,for example,I feel sleepy at about 2 am or after,and I used to wake up at 7,no alarm wakes me up,I just wake up….I don’t get to sleep enough,and sometime I can’t sleep at all,I will be awake,I want to sleep and the body is tired,but the mind does not agree (laughing).I think I couldn’t sleep quietly so that weakens my body,when my body is not well then menstruation will be in trouble,that’s why I think.” (N6)

“I feel difficult to sleep,usually I sleep in my country around 10 or 11,but in China I always sleep at 2 am or later….I don’t know,maybe because of weather or don’t know…I need more time to sleep,and I am always feeling tired.” (N9)

3.2.2.Academic stress

All the participants in this study were pursuing academic degrees.The differences of the education system,culture and language barrier exacerbated the academic stress,which in turn resulted in menstrual disorder.

“When we have class we have to sleep late at night and wake up early morning,we feel so tired,we feel so busy that we can’t get our self-time.Maybe it’s an impact (on menstruation).” (N5)

“I think stress affects my hormonal and that can affect my menstruation period,I think,I am not sure,but I believe that,actually not exactly stress,that time I had some work in my paper and stay till late night to finish it.I think every kind of stress can influence menstruation,including academic pressure,just because sleep in late time because of the work…” (N1)

3.2.3.Feeling homesickness

For many participants,studying in China was their first time leaving their home countries.Except the common negative mood of feeling homesick and lonely,the international students also felt grief because they could not fulfill their family responsibilities of taking care of significant others.

“I miss my family.My parents take care of my child.I have one child only,somehow,when I know they have anything(happened)but I can’t take care of them,I feel some…(grief) because I can’t take care of them.These feelings increase the pressure every time I talk or communicate with them.” (N9)

“Some kind of separation from my family could affect (menstruation)too.The stress I had was only in the beginning because I had never been away from my home,so I missed my parents and sister,and I had no friends in the beginning,then I started making friends,now I have a lot of friends (laughing),but I still miss my family sometimes.” (N7)

3.3.Coping styles to take care of menstrual health

Although some international female students might take passive attitudes of just accepting those changes and enduring the discomfort,most of them tried to find effective methods to alleviate the negative influences of these changes.The commonly used strategies were 1) keeping original cultural habits,2) seeking support from peers,and 3)taking medications to counter negative symptoms.

3.3.1.Keeping original cultural habits

Most of the female students contacted their families to discuss their menstrual symptom changes and were advised to use traditional cultural methods to encounter the symptom changes,such as drinking warm water with honey,eating almonds,taking traditional herbs,and avoiding taking baths during menstruation.

“I consulted with my mother…she advised me to start to drink warm water with honey,and warm stuff and eat almonds and sometimes some kind of milkshake like mango milkshake….she said it’s kind of home remedy.” (N7)

“Actually,my sister is a doctor and I discussed with her…I just used that like herb,you put it in the water then drink it before to get breakfast,it’s from my country.It looks like seed,when you put that in water it swelling.I don’t know if it has English name,when you wake up and just drink it.It’s can relieve the pain,it really works,thus I used that every time I had cycle.” (N5)

“…mostly we follow our culture tips for this thing like to avoid taking bath during the period,I don’t know the reasons behind that.” (N10)

3.3.2.Seeking support from peers

Although communicating menstrual care was not common among international female students due to the feeling of shy to initiate such a topic,a small proportion of them tried to seek suggestions from their classmates or friends about how to deal with menstrual changes.

“I consulted them(friends who were international students) what should I do when I am having irregular menstruation,then they suggested me to drink warm stuff.” (N7)

“One time I discussed with a Chinese friend about these changes I am facing in my menstruation,and she told me to conduct hormone test and told me how she dealt with similar things she faced.”(N10)

In addition,some female students also try to seek professional support from their teachers in medical school.

“When I have problems,I ask my teacher,and after that,if the teacher is not available then I Baidu(a popular searching engine in China) it.” (N4)

3.3.3.Taking medications to counter negative symptoms

Some of the international female students had to seek medical services in the host country to relieve the severe pain.While some just brought some medications from their own country as preparation due to the fear of lacking enough information about Chinese medications.

“In China,I went to doctor and(she)gave me some medicine.After I used the medicine,I feel relaxed,but when I doesn’t eat medicine I feel pain and cramps again….doctor suggested me to take proper diet and provided me some instructions and I followed it,after that it became better.” (N4)

“I didn’t use Chinese medicine,I brought some medicine from my country,and usually I use it whenever feel problems or pain and I preferred to use the Pakistani medicine because my friends do not have good and enough ideas for that.” (N10)

3.4.Consequences of the menstrual symptom changes

International female students reported various consequences due to the menstrual symptom changes,mainly including affecting daily activities,affecting academic work,affecting sleep quality,and getting stressed.

3.4.1.Affecting daily activities

The most common consequence of the menstrual symptom change was that it affected daily activities,such as doing housework,going outside,practicing exercise,and so on.

“…but the back pain is usually common I can’t mop the floor so usually in these days my roommate helps me to mop the floor,if accidentally I mop the floor I have to lay down cause I will have severe pain.” (N7)

“On period I can’t do anything,I don’t want to do anything,I don’t know.” (N4)

3.4.2.Affecting academic work

As described above,academic stress might lead to menstrual symptom change,and vice versa,these changes also affected their academic work.For example,students might miss class attendance for several days before or during the menstruation period due to severe pain and tiredness,which increased the students’ worries about their educational performance or loss of scholarship in case of academic failure.

“When I have severe pain,we don’t want to do anything,I can’t study or go to classes,because when I sit on chair,there is severe pain and it is very difficult for me.When I have exams in the period,it is so difficult for me,because I can’t sit when I have the pain.”(N4)

“You know when I am in my period I can’t do anything,sometimes I miss class because the pain.” (N6)

3.4.3.Affecting sleep quality

International female students reported not being able to fall asleep or taking longer time to fall asleep while experiencing menstrual changes,which affected the students’sleep patterns and quality.

“When I was in cycle I can’t sleep at night,it’s painful.The whole day it doesn’t pain,but at night I try to sleep then it pains a lot,so usually don’t go to bed but sit and put my hands on the belly.I can’t sleep.” (N5)

“When having a little more severe pain,I can’t sleep at night,or I take more time to fall asleep,I don’t know why,maybe because of the pain….only in china in my period I have the intensive pain.”(N8)

3.4.4.Getting stressed

Culture adaptation and academic stress might lead to menstrual symptom changes,which in turn created more stress on female students,mainly due to the comfortless during the menstrual period and its impact on daily activities and academic life.Because of the menstrual symptom changes,the female students worried about getting weak,gaining weight or influencing their body image.

“We just keep it to ourselves and we fall into depression or stress,I can’t normally do things like usually do in Pakistan,…in China,I have to go to class,but can’t walk,can’t sleep,can’t eat,during the cycle,I don’t feel hungry,so it affects a lot.” (N5)

“I am worried about it(menstruation)too much,it will make a lot of problem for me and my future,and my weight was increasing more and more,secondly when my period was not well,I got acne issue,and this acne made me more painful.” (N10)

“I think it made me became weak you could say,because if not bleeding much that means the body is weak,…I think internally I am weak.” (N7)

3.5.Culture-based attitude toward menstruation

The attitudes towards menstruation from our participants were very different.For example,in Zambia,females regarded menstruation as a natural thing,while in some religions,like in Nepal or Pakistan,menstruation was deemed as an impure thing.There were some restrictions for women during menstruation.

“The fact that menstruation is not considered as shame in my religion,it is a good thing,and it’s a positive thing for us,you don’t need to stay away from people because of you are in menses,it’s a natural thing for girls.” (N6)

“In my culture,they think menstruation is dirty,impure,so they keep (women in menstruation) separately….women are not allowed to be in the room(including kitchen),they have to sit in a separate room with a separate bed.” (N2);“It is not allowed to do god worship.”(N1);“During menstruation time we can’t take bath according to our culture.” (N3)

“In menstruation,we don’t pray,because in our religion it is not allowed,so we don’t pray and even we don’t touch our holy book.”(N4)

Due to some culture or religion backgrounds,for example in Pakistan,talking about menstruation made them feel shy,thus,when they encountered those changes,they preferred to‘keep it to themselves,’ or just ‘ignore’ it.

“I only wait to get menstruation(next period),if I get menstruation or don’t get it,it’s ok for me,no problem.” (N9)

“According to our culture,we can’t discuss this thing with guys….actually they consider it’s not respectable if a woman discusses it with any men,even with (male) doctor,and we can’t discuss this matter in family…I feel shy,that’s why I didn’t discuss,so just ignore it…” (N10)

Although the menstrual symptom changes were prevalent,most of them viewed it as ‘normal’ event.Some of the participants psychologically and passively accepted the changes,while some of them experienced stress in maintaining their menstrual health.

“It’s normal for everybody,and almost everybody (the female) in our university has the same feeling,(and we are) facing the same problem,and feeling the same pain.I have asked around whether I am abnormal,but they said,‘no,we are facing the same problem’;a lot of them had the same problem.” (N5)

“Only accept the things,accept the situation,and accept everything,so that you can get used to the things.” (N8)

“Sometimes I try to cook the food by myself and try to not eat very spicy in menstruation time,others nothing to do for weather,just accept it and trying to live with it.” (N10)

4.Discussion

This study investigated the experiences of menstruation symptom changes among international female students in China.In this study,the menstrual symptom changes among the international female students during their acculturation period in China varied in regularity,volume,severity,and psychological and somatic symptoms.These findings were consistent with three previous studies,in which one described menstrual disturbances among South Korean students studying in the United States [25],and the other two studies described menstrual changes among immigrant Vietnamese women in South Korea[26]and Japan[27].As stated in the literature,weather,temperature,food,and nutrition of the hosting country were common factors reported by the international female students that could influence their menstrual symptoms[35,36].In addition to these factors,one key influencing factor identified by the participants was stress,especially academic stress.Generally,international female students are worried about academic failure and its impact on their scholarships supporting their studies and living in China.A major source of international female students’ academic pressures is the language barrier.To reduce stress,it is important for international female students to improve their language skills before coming to China.

The relationship between stress and menstrual symptom changes has been shown to be highly correlated in many studies[37,38].The literature has identified that stress could cause hormonal changes through the hypothalamic-pituitary-ovarian axis[39],and affected the neurotransmitters epinephrine,norepinephrine,and serotonin,which could cause the changes to occur in ovarian hormones,and thus women became more susceptible to menstrual symptom changes [40].On the other hand,the severity of the menstrual symptoms could also negatively impact international students’academic performance[25,28,41],which results in a vicious cycle.

Our study revealed that international female students have adopted a variety of strategies to fight against menstrual symptom changes,and those coping methods were often related to the conditions of their social,cultural,and economic upbringing[14,42].Literature showed a significant relationship between culture and methods used to treat menstrual symptoms.In China,female students often prefer to drink warm water and take traditional Chinese herbs as an alternative therapy [21],while herbal tea,massage,and heat application are preferred methods among Turkish female students [43].In addition,seeking advice from female family members has been mentioned as a main coping strategy.According to Parra-Fern′andez’s study [44],females who have suffered from menstrual symptoms previously would be more likely to pass down what they believe to be effective coping methods to their family’s younger generations.Family’s and peers’advice was predominantly used by the international female students in our study,as well as those female college students in Japan[3] and Ghana [45],although these techniques might not be scientifically examined.Some studies reported that people did not want to use western medicine until they had very severe symptoms[14].This finding is consistent with our finding that international female students prefer using complementary or alternative therapies rather than taking western medicine or seeking medical assistance from western medicine hospitals.

International female students’ attitudes toward menstruation were largely influenced by the cultural and religious background of the places where the students were born and raised [46].In our study,some students considered menstruation as a physiological function;therefore,they were less anxious about their menstrual symptom changes.Whereas,many other female students considered menstruation as impure,and thus they often faced difficulties in dealing with their menstrual symptom changes,especially when they experienced unexpected timing of menstruation or their menstruation period got longer [18].For example,they avoided some activities,such as attending religious events,cooking food or sleeping at home.The same experiences were also mentioned by other studies conducted in Asia [17,47].Some students stated that they felt ashamed or embarrassed to talk about the menstrual symptom changes because they considered it a defective matter because of their cultural roots,and they kept their own experiences to themselves for fear of being discriminated against or stigmatized with the mark of‘disrespectful or naughty.’This fear often leads to female students' silence about these menstrual symptom changes or stops them from seeking medical assistance to maintain their menstrual health [48].

5.Study limitation

This study is the first one to investigate international female students’menstrual symptoms within the Chinese cultural context.It contributed important knowledge to the field of women's health,but it does not without limitations.First,participants were recruited from three universities in one province,and their experiences may not be generalized to other international female students in other provinces,considering the largeness of China.Second,most of the participants specialized in medical sciences and belonged to Asian cultures,thus,the experiences were not representative of all the international female students'experiences in China.Third,the sample size was small,because the topic was sensitive and those who were feeling shame to talk about such a topic did not participate in our study,which also might lead to information bias.However,holding a philosophical basis of Hermeneutics,phenomenology emphasizes the lived experiences of a certain group of people,which could help to understand their experience by bringing light and reflecting upon the lived meaning of their experience in a phenomenological approach.

6.Study implications

Despite the limitations,our findings provide education and health policy makers with evidence to improve the menstrual health of international female students in China.First of all,this study helps to provide new information about influencing factors of menstrual symptom changes,which in turn could help to prevent the menstrual symptom changes during the acculturation period.Second,it draws attention to the need of international female students who are subjected to acculturative stress for additional and special care.Thus,it provides evidence on the significance of relieving acculturative stress.Finally,this study highlights the need for more research about menstrual symptom changes,and to develop appropriate interventions to improve menstrual health considering the rapid increase in the number of international students in China in recent years.

7.Conclusion

In conclusion,this study’s findings provide a deep understanding of the experience of menstrual symptoms changes among international female students during the acculturation period in China.Cultural barriers,academic pressure and homesickness were the most common challenges faced by female students.The students either kept the original cultural habits,sought social support,or took medical assistance to deal with these changes,and these depended on their attitudes toward menstruation,which were largely influenced by their cultural values and background.Our results provide references for health care providers and policy makers in the host universities to design specific interventions to facilitate the cultural adaptation process and improve the menstrual health of international female students.

Funding

This study was funded by Hunan Province Social Science Fund(18YBA438) to one of the corresponding authors named Xianhong Li.The funding source had no role in study design,data collection and analysis,decision to publish,or preparation of the manuscript.

CRediT authorship contribution statement

Asem Alkhatib:Conceptualization,Methodology,Validation,Formal analysis,Investigation,Data curation,Writing -original draft.Weizi Wu:Formal analysis,Investigation,Data curation.Hoda Alshikh Ahmad:Validation,Investigation,Data curation.Ratee Pakwan Suwal:Validation,Investigation,Data curation.Zhao Ni:Supervision,Writing -review &editing,Visualization.Xianhong Li:Conceptualization,Methodology,Formal analysis,Investigation,Funding acquisition,Writing -review &editing,Project administration.

Data availability statement

The datasets generated during and/or analyzed during the current study are not publicly available due to concerns about protecting participants’ privacy but are available from the corresponding author upon reasonable request.

Declaration of competing interest

Authors have no conflicts of interest.

Acknowledgements

We thank all participants for their contribution to this study project.

Appendix A.Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2023.03.004.