Asem Alkhatib
Hoda Alshikh Ahmad2
Ci Zhang
Wenwen Peng- 1Xiangya School of Nursing, Central South University, Changsha, Hunan, China
- 2Xiangya School of Public Health, Central South University, Changsha, Hunan, China
Background: Menstrual symptoms were the common complaints of international female students during the acculturation period, and the symptoms negatively affected the daily life and school performance of those women. The present study aimed to evaluate the effectiveness of the traditional Chinese Baduanjin exercise on reducing menstrual symptoms for international female students studying in China during the acculturation period.
Methods: We conducted a randomized controlled trial among 62 international female students who suffered menstrual symptoms during the first 6 months after arriving in China. The study was carried out at three campuses of the two largest universities in the capital of a province in south-central China from March to October 2021. After screening, participants were randomly assigned to a control or intervention group. The intervention group engaged in 24 weeks of Baduanjin exercise for at least 30 min per day. The menstrual symptoms, sociocultural adaptation, perceived stress, and sleep quality were evaluated at baseline, the 12th week, and the 24th week. The chi-square test or Fisher's exact test, paired sample t-test, and multivariate analysis of variance (MANOVA)were adopted to analyze the data using SPSS 25.0.
Results: Totally, 62 participants were enrolled in this study from 30 countries. Their mean age was 27.87 ± 5.58 years. None of the participants reported an adverse event. The results of the MANOVA test showed that the traditional Chinese Baduanjin exercise reduced the total score of MSQ among international female students (intervention: 47.83 ± 8.71 vs. control: 65.12 ± 16.86; F = 19.49, P < 0.01). In addition, the results of the MANOVA indicated statistically significant decreases in scores for the two subscales of MSQ: premenstrual symptoms (intervention: 17.07 ± 3.33 vs. control: 28.42 ± 7.56; F = 44.70, P < 0.01)and menstrual pain (16.03 ± 4.53 vs. 19.58 ± 5.14; F = 6.50, P < 0.05). Moreover, the results showed that traditional Chinese Baduanjin exercise reduced the scores of the sociocultural adaptation level, the perceived stress level, and sleep quality and improved the blood progesterone hormone and blood estrogen hormone.
Conclusion: Regular Baduanjin exercise is a safe, acceptable, and effective form of exercise to promote international female students' menstrual health, reduce stress levels, and improve sleep quality.
Trial registration: www.chictr.org.cn, Chinese Clinical Trial Registry: ChiCTR2300072376.
1 Introduction
Globalization has changed all aspects of life in recent decades. Education in particular has become more international, with 4.78 million students studying abroad each year (1). In recent years, China has become one of the most popular destinations, and the number of international students studying and living in China has significantly increased from 223,499 in 2008 to 492,185 in 2018 (2). Studying in a foreign country involves a process of acculturation, which can affect the social and psychological wellbeing of international students (3). Although many studies have examined the consequences of acculturation for international students, such as culture shock, psychological distress, anxiety, and withdrawal behaviors in seeking help (4, 5), only a few have focused on the international students' menstrual health disturbances caused by the acculturation (6).
Menstruation is a normal physiological phenomenon that can be affected by the environment, weather, nutrition, lifestyle (such as sociocultural adaptation), blood hormone levels (such as progesterone, estrogen, and prolactin), and psychological pressures (7, 8). Previous studies found that menstrual irregularities occurred among the women after they relocated to a new country (9–11). Our team's previous study also reported that 18.49% of international female students experienced a change in their menstrual symptoms after arriving in China (6). Generally, mild menstrual symptoms do not affect women's life or work (12). Still, troublesome experiences of menstruation, such as severe menstrual pain associated with poor sleep quality (13), could negatively affect a woman's daily life and work (14). Our previous qualitative interviews indicated that international female students reported missing classes or examinations due to the severe menstrual symptoms caused by acculturation (15). Therefore, the menstrual health of international female students has become an important concern that needs to be addressed by school educators and healthcare providers.
Current evidence clearly shows that exercise or physical activity is effective in relieving menstrual symptoms and promoting menstrual health in women (16). A recent meta-analysis based on a systematic review of randomized controlled trials indicated that general aerobic exercises could reduce depression and anxiety symptoms, improve self-esteem, and increase menstruation-related hormone levels, such as progesterone, estrogen, and prolactin (17). Moreover, Mohebbi Dehnavi's study also indicated that general aerobic exercise could significantly decrease the physical symptoms of headache, nausea, constipation, diarrhea, and swelling during women's menstrual period (18). Moreover, Jang's study in China showed that Qigong therapy (a traditional Chinese aerobic exercise)could reduce premenstrual symptoms of pain, negative feelings, and water retention (19). Çitil's study using Pilates exercises found that it could relieve depressive symptoms, anxiety, irritability, fatigue, pain, changes in appetite, changes in sleep, and swelling during the menstrual period (20), and Günebakan's study confirmed Yoga exercises' effectiveness in reducing somatic discomfort and menstrual pain and improving women's coping strategies (21).
As a traditional aerobic exercise for body and mind in China, Baduanjin is one of the most common forms of traditional Chinese exercise and has been practiced for over 1,000 years. It has repetitive movements of low intensity and meditation (22), and it integrates using breathing techniques in a harmonious way (23). Many studies have reported that Baduanjin exercise has a positive effect on improving physical functions, for example, flexibility, physical fitness, muscle strength, and cardiorespiratory endurance (24), and it could also improve sleep quality (25), mood status (26), quality of life (27), and general wellbeing (28). However, only two studies in the literature examined the effectiveness of Baduanjin in reducing menstrual symptoms. One was done among Chinese female college students and showed effectiveness in relieving the symptoms of primary dysmenorrhea (29); another study was conducted among Chinese women in Macau, and it also indicated significant improvements in reducing the general symptoms of premenstrual syndrome, especially the physical symptoms (30). Currently, there is no study examining this traditional Chinese exercise's impact on improving menstrual health, especially for international female students studying in China who are undergoing the acculturation period and hold different cultural beliefs. Therefore, our study aimed to examine the acceptability and impact of Baduanjin exercise on the menstrual health of international female students who were studying in China and enduring changed menstrual symptoms.
2 Materials and methods
2.1 Study design
The study was a two-arm randomized controlled trial and consisted of an experimental group (EG)and a control group (CG). This study was conducted from March to October 2021 and reported following the Consolidated Standards of Reporting Trials (CONSORT 2010 Checklist).
2.2 Participants
The study recruited international female students from three campuses of the two largest universities in Changsha, the capital city of Hunan Province, Mainland China. International female students who met the following criteria were recruited into the study: (a)aged 18 years and above; (b)had primary and secondary education in a foreign country or region outside of China; (c)were pursuing a bachelor's, master's, or doctoral degree in China; and (d)self-reported experiencing menstrual symptoms change after arriving in China. We defined the menstrual symptoms change as “changes in severity or frequency of symptoms such as cramps, irritability, pain, or fatigue that were not experienced before living in China, and the changes lasted at least two consecutive menstrual cycles before joining the study”; (e)understood Mandarin or English; and (f)would live in Hunan province for the following 6 months. Those who were pregnant, having a physical illness (diagnosed with gynecological disorders such as primary amenorrhea, polycystic ovary syndrome, and any pathological situations that could cause menstrual disturbances), taking any medication that could affect their menstrual symptoms, or having an injury that prevents them from exercising properly would be excluded.
2.3 Procedures
2.3.1 Screening
Initially, official permission was obtained from the two universities, which allowed the study flier to be posted on their advertising boards. A flier was also sent electronically through WeChat (an online instant chat platform)groups established by each university for their international students. Those interested in participating in this study contacted the researcher's assistant, who examined their eligibility. The eligible participants made an appointment to meet with the research assistant to fully understand the study procedure, benefits, and potential risks and sign the informed consent; then they completed the baseline questionnaires and had blood tests in the designated hospital. After that, they were randomly assigned to either the experimental group (EG)or the control group (CG).
2.3.2 Intervention procedure
Participants in the CG received an information sheet to elaborate on the influencing factors for menstrual symptoms changes and the potential useful exercises (e.g., aerobics, yoga, and Pilates)to relieve the symptoms, not including Baduanjin practice. Relevant web links to these exercises were sent to them for their practice based on their willingness.
Participants in the EG group had two phases of Baduanjin practice. The first phase was practicing Baduanjin in a group (~10–12 people)with a guided mentor once a day for 12 consecutive weeks. There were three groups located on the three campuses. Every day, they needed to exercise Baduanjin in a group for ~30 min. One of the guided mentors had more than 2 years of experience in practicing Baduanjin, and the other two mentors were graduate students who received Baduanjin training for 1 week and practiced for 2 months. The researcher assigned one participant in each group as a leader who was responsible for the participants' maintenance in practice by sending reminders every day through the WeChat group. Debriefings were also conducted in each group every week, led by the first author of this study. They could share their practicing experiences, feelings, thoughts, and some perceived body or mood changes, or any other confusion regarding practicing Baduanjin. They were also encouraged to share and discuss their thoughts or feelings in the WeChat group.
The second intervention phase was the exercise by the participants themselves without supervision for another 12 weeks. The participants in each group were asked to continue practicing with the same frequency as the supervised phase at an agreed-upon time and place. The research assistant sent reminders three times a week in the WeChat group to remind them of their practice and facilitate their debriefing and discussion in the WeChat group.
The whole procedure of the Baduanjin exercise was conducted according to the “Health Qigong Baduanjin Standard” published by the General Administration of Sports of China in 2003 (31). The whole set of Baduanjin exercises consists of 10 postures (including the preparation and ending postures). The eight postures (excluding the preparation and ending postures)are “holding the hands high with palms up to regulate the internal organs,” “posing as an archer shooting both left- and right-handed,” “holding one arm aloft to regulate the functions of the spleen and stomach,” “looking backwards to prevent sickness and strain,” “swinging the head lowering the body to relieve stress,” “moving the hands down the back and legs and touching the feet to strengthen the kidneys,” “thrusting the fists and making the eyes glare to enhance strength,” and “raising and lowering the heels to cure diseases.” This exercise set aims not only to reinforce musculoskeletal fitness and blood circulation along with breathing training but also to adjust emotions to achieve the fitness of the body and mind. The general postures were clearly explained and shown through many formal videos, such as the Chinese Health Qigong Association “YouTube channel” at https://www.youtube.com/watch?v=poxClwHOLgs&ab_channel=ChineseHealthQigongAssociation.
2.4 Data collection
Data were collected online through a specialized Chinese questionnaire platform (http://www.sojump.com), which could ensure the data's confidentiality and the participants' privacy. Links to the surveys were sent to the participants via WeChat. The questionnaire was collected at three time points of the baseline (T0), which was set before the start of the intervention, and the second time point (T1), which was set at the end of the supervised intervention phase (the 12th week), and the third time point (T2), which was set at the end of the program (the 24th week), and blood hormones were collected for the participants at the baseline and at the end of the program (the 24th week)only. Participants were taken to a designated hospital for blood tests, and only the required samples for these hormone tests were provided based on laboratory staff recommendations, while the rest of the samples were destroyed directly after completion of the tests. The research assistant explained the whole process of blood tests and the fate of the remaining blood samples to each participant in detail, then recorded the testing results, and sent them to each of them individually.
2.5 Outcomes and measures
The demographic characteristics assessed included age, marital status, home country, study information such as major, education program, enrollment year, source of funding for education, whether they have been to China before, and whether they have medical insurance.
The primary outcome was the menstrual symptoms, and it was assessed using the menstrual symptoms questionnaire (MSQ)(32). The MSQ was a 24-item self-reported scale originally developed to assess dysmenorrhea symptoms, and it has been widely used around the world. A 5-point Likert scale ranging from 1 (never)to 5 (always)was used as responses, with a higher overall score, indicating more severe menstrual symptoms. The reliability of MSQ designated by Cronbach's alpha was 0.93 (33), and in another study, Cronbach's alpha was 0.91 (34). According to Wildman and White's research (35), the MSQ scale was divided into three dimensions: premenstrual symptoms, psychophysiological discomfort, and menstrual pain, which are presented in Supplementary Table S1.
The secondary outcomes of the study were the sociocultural adaptation, stress, sleep quality, and blood hormone level, including progesterone and estrogen, and the outcomes were measured as follows:
(1) Sociocultural adaptation was measured using the Sociocultural Adaptation Scale (SCAS), developed by Ward and Kennedy (36). The scale included 21 items, and each item was rated using a 5-point Likert scale ranging from 1 (no difficulty)to 5 (extreme difficulty). The average total score was used to evaluate the level of sociocultural adaptation, with a higher score indicating greater difficulty. Cronbach's alpha of the SCAS ranged from 0.75 to 0.91, as reported by a number of studies (36, 37).
(2) Stress level was assessed using the Perceived Stress Scale (PSS)(38), which consisted of 10 items. Each item was rated on a 5-point Likert scale (0 = never, 4 = very often), with a higher score reflecting a greater perceived stress level. The PSS had an internal consistency designated by Cronbach's alpha of 0.78 (39).
(3) Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI)(40). The self-reported scale contained 19 individual items, creating seven components. Each item was rated from 0 (no difficulty)to 3 (severe difficulty). The global PSQI score was calculated by adding scores from the seven components, with a higher value indicating poorer sleep quality. The coefficient of Cronbach's alpha of PSQI was 0.83 (40).
(4) Blood hormone tests (progesterone and estrogen)were performed using a chemiluminescent immunoassay method in the hospital.
2.6 Randomization and blinding
After screening, those eligible participants were invited to complete the baseline assessment, including the baseline questionnaire and blood hormones test, in the designated hospital. Then, a team member randomly divided the participants into two groups using a random number table generated using SPSS 25.0 (SPSS Inc., Chicago, IL, USA). The campuses were used to stratify the randomization. An identification code was assigned to each participant in the dataset, so the statistician was blinded to the groups.
2.7 Statistical analysis
Frequencies and percentages were used to describe the categorical variables, and means and standard deviations were used to describe the distributions of continuous variables. Categorical data were analyzed using the chi-square test (sample size no <40 and the expected number in each cell no <5)or Fisher's exact test (sample size <40 or the expected number in any one cell <5)(41). An independent sample t-test was conducted to compare the difference between the two study groups for the factors studied at baseline only among all the study variables. A paired sample t-test was performed to compare the difference between the two study groups for the factors examined at only two time points, such as blood hormones. A multivariate analysis of variance (MANOVA)was performed between the two study groups for all the primary and secondary outcomes among the three time points of this study, and the effects evaluated included the main effects of time and groups (EG and CG)as well as the interaction effect(s)of time by the groups. A P-value < 0.05 was considered statistically significant. All statistical analyses were performed using SPSS 25.0 (SPSS Inc., Chicago, IL, USA).
2.8 Sample size
Based on the previous study of the effect of Baduanjin exercises on menstrual symptoms (30), a sample size of 50 women would provide 80% power with an alpha of 0.05 to detect a medium to large statistically significant difference of 0.529. We calculated Cohen's d effect size, and threshold values were set as small (≥0.2 and <0.5), moderate (≥0.5 and <0.8), and large (≥0.8)(42). The mean difference between the menstrual symptoms was calculated using the data of Zhang's study as a reference (e.g., Cohen's d = mean of baseline—mean of last evaluation/baseline standard deviation), and based on the data of Zhang's study, the effect size was 0.529. Assuming a maximum loss to follow-up rate of 20%, the total sample size for this study is about 60 participants.
2.9 Ethical consideration
This study was approved by the Institutional Review Board of Behavioral and Nursing Research at the Xiangya School of Nursing of Central South University (Approval No. E2020193). Permission to conduct the study at the targeted universities was obtained from the School of International Education at each site. The study's purpose, duration, and procedures were fully explained to the participants, and written informed consent was obtained from all participants. Each participant participated in the study voluntarily and could withdraw without any consequences. The information obtained from the participants was confidential and was only being used for this study. After collecting the last-time-point data, we provided the video of the exercise to the control group participants. This study was carried out in accordance with relevant ethical guidelines and regulations of the Declaration of Helsinki.
2.10 Trial registration
This study was registered with the Chinese Clinical Trial Registry (www.chictr.org.cn, ID: ChiCTR2300072376).
3 Results
3.1 Demographic characteristics
In total, 66 international female students contacted the research assistant; among them, three were not eligible after screening and one refused to have a blood test for hormones. Finally, 62 were randomly assigned to either an intervention group or a control group, and all of them had finished the follow-ups (Figure 1). The participants were enrolled from 30 countries, with a mean age of 27.87 ± 5.58 years. The majority were single (79%), studying in a master's program (58.1%), and beneficiaries of the Chinese government scholarship. The other socio-demographic characteristics are shown in Table 1. There are no statistically significant differences between the two groups.
Figure 1. The study flowchart.
Table 1. General characteristics and socio-demographics of participants.
3.2 Comparison of the menstrual symptoms at the baseline
The scores of MSQ at the baseline between the intervention group (63.93 ± 13.27)and the control group (63.48 ± 16.93)were comparable. In addition, for the three subscales of MSQ, the scores were comparable, with premenstrual symptoms (intervention group: 26.81 ± 7.56 vs. control group: 27.42 ± 7.57), psychophysiological discomfort (17.52 ± 3.60 vs. 16.52 ± 5.22), and menstrual pain (19.61 ± 5.32 vs. 19.55 ± 5.16). There are no statistically significant differences among the total scores of the MSQ scale, the three subscales of MSQ, and the individual items of the MSQ scale between the intervention group and the control group, which are presented in Table 2 and Supplementary Table S1.
Table 2. Comparison of the changes in scores of menstrual symptoms between the two groups.
3.3 Menstrual symptom changes during the study period
The results of the MANOVA test showed traditional Chinese Baduanjin exercise reduced the total score of MSQ among international female students studying in China (intervention group: 47.83 ± 8.71 vs. control group: 65.12 ± 16.86; F = 19.49, P < 0.01), which are presented in Table 2 and Figure 2. The total score of MSQ for participants in the intervention group decreased with the increase in follow-up time (F = 4.13, P < 0.05), as presented in Figure 2 and Table 2. In addition, results of the MANOVA indicated statistically significant decreases in scores for the two subscales: premenstrual symptoms (intervention group: 17.07 ± 3.33 vs. control group: 28.42 ± 7.56; F = 44.70, P < 0.01)and menstrual pain (intervention group: 16.03 ± 4.53 vs. control group: 19.58 ± 5.14; F = 6.50, P < 0.05; Table 2). However, no statistically significant difference was found in the subscale of psychophysiological discomfort between the intervention (14.74 ± 3.29)and control groups (17.13 ± 5.22; F = 2.06, P > 0.05; Table 2). The differences in the 24 individual items of the MSQ between the intervention and control groups were compared, and the results are presented in Supplementary Table S1.
Figure 2. Comparison of the changes among the study variables between the intervention and control groups during the study period (A–D).
3.4 Comparison of the secondary outcomes
There were no statistically significant differences in the baseline scores among scores of sociocultural adaptation (SCAS), stress level (PSS), sleep quality (PSQI), blood progesterone hormone, and blood estrogen hormone between the two groups (P > 0.05). The results of the MANOVA test showed traditional Chinese Baduanjin exercise reduced the scores of the sociocultural adaptation level (intervention group: 2.47 ± 0.71 vs. control group: 3.11 ± 0.60; F = 21.67, P < 0.01), perceived stress level (intervention group: 13.23 ± 5.73 vs. control group: 18.67 ± 4.56; F = 15.95, P < 0.01), and sleep quality (intervention group: 4.13 ± 1.94 vs. control group: 6.806 ± 2.16; F = 12.90, P < 0.01)among international female students studying in China (Table 3). In addition, compared to participants in the control group, the intervention significantly improved the blood progesterone hormone (intervention group: 170.33 ± 87.57 vs. control group: 135.10 ± 85.32; F = −5.21, P < 0.01)and blood estrogen hormone (intervention group: 15.30 ± 10.86 vs. control group: 8.30 ± 10.35; F = −7.35, P < 0.01)for participants in the intervention group (Table 3).
Table 3. Comparison of the secondary outcomes during the study period.
3.5 Intervention adherence
As for the intervention maintenance, two-thirds of participants completed all planned practice sessions for the two phases of intervention, while the remaining one-third completed more than 85% of planned practice sessions. None of them reported an adverse event.
4 Discussion
This randomized controlled trial indicated that the traditional Chinese Baduanjin exercise is acceptable and could reduce not only the menstrual symptoms but also the acculturation-related stress and sleep problems for international female students. The gestures and movements of the Baduanjin exercise are simple and easy to learn; thus, the adherence to the Baduanjin exercise is optimal, with all of them having completed at least 85% of the practice sessions without any adverse events, which indicates the participants' satisfaction with the practice and the ease and safety of the exercise.
Our results showed that Baduanjin exercise has a positive effect on reducing menstrual symptoms over time, and the longer the practice, the fewer the menstrual symptoms. Many symptoms have been relieved after practicing Baduanjin for 3–6 months, such as fatigue, constipation, weight gain, abdominal discomfort and bloating, backaches, and irritability. Previous studies demonstrated that physical symptoms were often associated with fluctuations in the estrogen, progesterone, and serotonin levels among females with menstrual symptoms (17), and our study results also confirmed such an association and showed that the progesterone and estrogen levels also increased along with the decrease in menstrual symptom levels. The possible mechanism might be that Baduanjin exercises lower renin-angiotensin activity, increase progesterone and estrogen, and decrease serum aldosterone levels, resulting in symptomatic improvement (18).
Regarding the subscales, our study showed that Baduanjin could significantly reduce premenstrual symptoms and menstrual pain, which were consistent with previous studies (43, 44). Our study did not show a significant effect on the subscale of psychophysiological discomfort. However, we can see a decreasing trend in the total score of this subscale in the intervention group compared with the control group, and it might take longer intervention time to detect the statistical difference between the two groups. Similarly, Zhang's study also showed that Baduanjin exercise was more effective in reducing physical symptoms than psychological symptoms (30).
Several studies have found that university students reported higher levels of perceived stress due to regular examinations, specified deadlines, and the competition to perform well (45). Our results showed that university students' stress levels and psychological wellbeing could be improved through Baduanjin exercise. As Baduanjin exercise allows participants to practice body, breath, and mind control (46)through slow, continuous movements and steady postures, which highly demand mental focus and breathing control (47). Another rationale might lie in the distraction hypothesis (48)because the Baduanjin exercise is intended to induce practitioners to focus on the moment and forget about moments of stressful events. In addition, the positive impact on reducing stress by practicing Baduanjin can result in the individual's participation in a new interesting activity that develops the self and enhances social interactions, and this is consistent with the social interaction hypothesis that assumes the occurrence of mutual support between the individuals participating in the exercise (49). Moreover, the biological theory states that physical activity increases monoamines synaptic transmission, including serotonin, adrenaline, and dopamine, which are hypothesized to function as anti-depressives (50).
Sleep is a biological regulatory process essential to the nervous system and basic human needs, including metabolism, immunity, and hormonal balance (51, 52). Sleep disturbance impacts a considerable number of people (53), in particular, university students and international students who may experience sleep problems due to academic pressures, environmental changes, and housing conditions, which leads to a deterioration in health and academic performance (54, 55). The American Academy of Sleep Medicine recommends regular exercise to maintain healthy sleep (56). Systematic reviews have reported a positive effect of exercise on sleep duration and quality (57, 58), which our study has also confirmed. The beneficial effect of the Baduanjin exercise on sleep quality may be related to several properties of Baduanjin: modulating the mind and spirit, enhancing respiratory function via promoting a calm state and relaxation, and encouraging regular and deep breathing (59). In addition, practicing Baduanjin exercise could stimulate metabolism, reinforce Qi (energy)and blood circulation, mitigate stress, and enhance spiritual life (60). Baduanjin could enhance sleep quality by increasing melatonin, an influential hormone regulating sleep-wake rhythm and the autonomic nervous system (61).
4.1 Study limitations
Some potential limitations are inevitable in this experimental study. First, this study was conducted at only two universities in one province, so the results might not be representative of all international female students in China. Second, the symptom assessment was self-reported, and recall bias and social desirable bias might exist. Third, due to financial limitations, we did not have a wider laboratory evaluation of hormones, such as luteinizing hormone (LH)and follicle stimulating hormone (FSH)during all the study phases. Fourth, contamination might exist when participants in the EG group and the CG group knew each other. Participants in the CG group could learn Baduanjin from those in the EG group. Fifth, the actual intensity of the Baduanjin exercise was not evaluated in this study. Finally, confounding factors, such as smoking status, body mass index, alcohol consumption, the intensity level of other daily activities, and exposure to stressful events, were not controlled during the program period.
4.2 Study implications
Despite the limitations, our results have practical implications. The results of the current study improve our knowledge regarding the safety, acceptability, and beneficial effects of Baduanjin practice on menstrual physical and psychological symptoms for international female students who endure menstrual symptoms due to acculturation stress. This practice provides an additional option for non-pharmacological treatment and self-care to maintain menstrual health and psychological health for international students during the acculturation period.
5 Conclusion
Our findings indicate that regular Baduanjin exercise could be an effective, safe, and acceptable form of exercise for reducing menstrual symptoms and enhancing the wellbeing of female students studying in China. Qualitative studies are needed in the next step to better understand their feelings and perceptions, barriers, and facilitators about practicing such traditional Chinese exercises for international students.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding authors.
Ethics statement
The studies involving humans were approved by Institutional Review Board of behavioral and Nursing Research in Xiangya School of Nursing of Central South University (Approval No. E2020193). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.
Author contributions
AA: Conceptualization, Formal analysis, Investigation, Methodology, Validation, Writing—original draft, Writing—review & editing. HA: Investigation, Methodology, Validation, Writing—review & editing. CZ: Data curation, Formal analysis, Methodology, Writing—review & editing. WP: Investigation, Methodology, Validation, Writing—review & editing. XL: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing—review & editing.
Funding
The author(s)declare financial support was received for the research, authorship, and/or publication of this article. This study was funded by the Hunan Province Social Science Fund (18YBA438). The funding source had no role in study design, data collection and analysis, the decision to publish, or the preparation of the manuscript.
Acknowledgments
We thank all participants for their contribution to this study project.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2024.1259634/full#supplementary-material
References
1. UNESCO (United Nations Educational SaCO). Institute for Statistics. 2018. Data Center: Student Mobility Country of Origin. (2018). Available online at: http://statsuisunescoorg/unesco/TableViewer/documentaspx?ReportId=136 (accessed October 2, 2023).
2. Ministry-of-Education. National Statistics for International Students Studying in China in 2018. (2019). Available online at: http://enmoegovcn/documents/reports/201904/t20190418_378692html (accessed April 18, 2019).
3. Sheng L, Dai J, Lei J. The impacts of academic adaptation on psychological and sociocultural adaptation among international students in China: the moderating role of friendship. Int J Intercult Relat. (2022) 89:79–89. doi: 10.1016/j.ijintrel.2022.06.001
4. Iorga M, Soponaru C, Muraru I-D, Socolov S, Petrariu F-D. Factors associated with acculturative stress among international medical students. BioMed Res Int. (2020) 2020:2564725. doi: 10.1155/2020/2564725
5. Ma K, Pitner R, Sakamoto I, Park HY. Challenges in acculturation among international students from Asian collectivist cultures. High Educ Stud. (2020) 10:34–43. doi: 10.5539/hes.v10n3p34
6. Alkhatib A, Zhou Q, Bajinka O, Pakwan Suwal R, Wiley J, Li X. Prevalence of menstrual symptoms change and influencing factors among international female students studying in china during acculturation period. BMC Womens Health. (2022) 22:1–11. doi: 10.1186/s12905-022-01897-6
7. Critchley HO, Babayev E, Bulun SE, Clark S, Garcia-Grau I, Gregersen PK, et al. Menstruation: science and society. Am J Obstet Gynecol. (2020) 223:624–64. doi: 10.1016/j.ajog.2020.06.004
8. Kapadi R, Elander J. Pain coping, pain acceptance and analgesic use as predictors of health-related quality of life among women with primary dysmenorrhea. Eur J Obstet Gynecol Reprod Biol. (2020) 246:40–4. doi: 10.1016/j.ejogrb.2019.12.032
9. Jang IA, Kim MY, Lee SR, Jeong KA, Chung HW. Factors related to dysmenorrhea among Vietnamese and Vietnamese marriage immigrant women in South Korea. Obstet Gynecol Sci. (2013) 56:242–8. doi: 10.5468/ogs.2013.56.4.242
10. Lee Y, Im EO, A. path analysis of stress and premenstrual symptoms in Korean international and Korean domestic students. J Adv Nurs. (2016) 72:3045–59. doi: 10.1111/jan.13061
11. Shinohara A, Kawasaki R, Kuwano N, Ohnishi M. Interview survey of physical and mental changes and coping strategies among 13 Vietnamese female technical interns living in Japan. Health Care Women Int. (2024) 45:1–17. doi: 10.1080/07399332.2021.1963966
12. Thakur H, Aronsson A, Bansode S, Stalsby Lundborg C, Dalvie S, Faxelid E. Knowledge, practices, and restrictions related to menstruation among young women from low socioeconomic community in Mumbai, India. Front Public Health. (2014) 2:72. doi: 10.3389/fpubh.2014.00072
13. Hall NL. Women and girls in remote Indigenous Australian communities: cultural, financial and knowledge barriers to menstrual hygiene management. Aust Indig Health Bull. (2018) 18.
14. Maqbool R, Maqbool M, Zehravi M, Ara I. Menstrual distress in females of reproductive age: a literature review. Int J Adolesc Med Health. (2021) 34:11–7. doi: 10.1515/ijamh-2021-0081
15. Alkhatib A, Wu W, Ahmad HA, Suwal RP Ni Z, Li X. The experiences of menstrual symptom changes among international students studying in China during the acculturation period: a phenomenology study. Int J Nurs Sci. (2023) 10:221–9. doi: 10.1016/j.ijnss.2023.03.004
16. Armour M, Ee CC, Naidoo D, Ayati Z, Chalmers KJ, Steel KA, et al. Exercise for dysmenorrhoea. Cochrane Database Syst Rev. (2019) 9:CD004142. doi: 10.1002/14651858.CD004142.pub4
17. Ravichandran H, Janakiraman B. Effect of aerobic exercises in improving premenstrual symptoms among healthy women: a systematic review of randomized controlled trials. Int J Womens Health. (2022) 14:1105–14. doi: 10.2147/IJWH.S371193
18. Mohebbi Dehnavi Z, Jafarnejad F, Sadeghi Goghary S. The effect of 8 weeks aerobic exercise on severity of physical symptoms of premenstrual syndrome: a clinical trial study. BMC Womens Health. (2018) 18:1–7. doi: 10.1186/s12905-018-0565-5
19. Jang H-S, Lee MS. Effects of qi therapy (external Qigong)on premenstrual syndrome: a randomized placebo-controlled study. J Altern Complement Med. (2004) 10:456–62. doi: 10.1089/1075553041323902
20. Çitil ET, Kaya N. Effect of pilates exercises on premenstrual syndrome symptoms: a quasi-experimental study. Complement Ther Med. (2021) 57:102623. doi: 10.1016/j.ctim.2020.102623
21. Günebakan Ö, Acar M. The effect of tele-yoga training in healthy women on menstrual symptoms, quality of life, anxiety-depression level, body awareness, and self-esteem during COVID-19 pandemic. Irish J Med Sci. (2023) 192:467–79. doi: 10.1007/s11845-022-02985-0
22. Wei X-L, Yuan R-Z, Jin Y-M, Li S, Wang M-Y, Jiang J-T, et al. Effect of Baduanjin exercise intervention on cognitive function and quality of life in women with breast cancer receiving chemotherapy: study protocol of a randomized controlled trial. Trials. (2021) 22:405. doi: 10.1186/s13063-021-05355-w
23. Zhao F, Sun S, Xiong J, Zheng G. The effect of Baduanjin exercise on health-related physical fitness of college students: study protocol for a randomized controlled trial. Trials. (2019) 20:1–9. doi: 10.1186/s13063-019-3672-1
24. Li M, Fang Q, Li J, Zheng X, Tao J, Yan X, et al. The effect of Chinese traditional exercise-Baduanjin on physical and psychological well-being of college students: a randomized controlled trial. PLoS ONE. (2015) 10:e0130544. doi: 10.1371/journal.pone.0130544
25. Fan B, Song W, Zhang J, Er Y, Xie B, Zhang H, et al. The efficacy of mind-body (Baduanjin)exercise on self-reported sleep quality and quality of life in elderly subjects with sleep disturbances: a randomized controlled trial. Sleep Breath. (2020) 24:695–701. doi: 10.1007/s11325-019-01999-w
26. Zhang X-B, Zhang J-L, Li M-X, Yuan Y-P, Sun J. Baduanjin exercise can alleviate anxiety and depression of patients with COVID-19 in Square cabin hospital: a cross-sectional survey. Medicine. (2021) 13:e26898. doi: 10.1097/MD.0000000000026898
27. Ye X-X, Ren Z-Y, Vafaei S, Zhang J-M, Song Y, Wang Y-X, et al. Effectiveness of Baduanjin exercise on quality of life and psychological health in postoperative patients with breast cancer: a systematic review and meta-analysis. Integr Cancer Ther. (2022) 21:15347354221104092. doi: 10.1177/15347354221104092
28. Kong L, Ren J, Fang S, He T, Zhou X, Fang M. Effects of traditional Chinese mind-body exercise-Baduanjin for type 2 diabetes on psychological well-being: a systematic review and meta-analysis. Front Public Health. (2022) 10:923411. doi: 10.3389/fpubh.2022.923411
29. Wu Z, Liu N. Observation on curative effect of eight–sectioned exercise with manipulation in treating primary dysmenorrhea of female university students. Health Med Res Pract High Inst. (2013) 10:14–7.
30. Zhang H, Zhu M, Song Y, Kong M. Baduanjin exercise improved premenstrual syndrome symptoms in Macau women. J Tradit Chin Med. (2014) 34:460–4. doi: 10.1016/S0254-6272(15)30047-9
31. Health Qigong Management Center. Health Qigong Management Center of General Administration of Sport of China: Health Qigong—Baduanjin. Beijing: People's Sports Publishing House of China (2003).
32. Chesney MA, Tasto DL. The development of the menstrual symptom questionnaire. Behav Res Ther. (1975) 13:237–44. doi: 10.1016/0005-7967(75)90028-5
33. Öksüz E, Guvenc G. Relationship of premenstrual and menstrual symptoms to alexithymia among nursing students. Perspect Psychiatr Care. (2018) 54:391–7. doi: 10.1111/ppc.12271
34. Issa R, Kharaba ZJ, Azzi V, Obeid S, Sawma T, Said AS, et al. Menstrual symptoms variation among Lebanese women before and after the COVID-19 pandemic. Pharm Pract. (2022) 20:1–8. doi: 10.18549/PharmPract.2022.3.2699
35. Wildman BG, White PA. Assessment of dysmenorrhea using the Menstrual Symptom Questionnaire: factor structure and validity. Behav Res Ther. (1986) 24:547–51. doi: 10.1016/0005-7967(86)90035-5
36. Ward C, Kennedy A. The measurement of sociocultural adaptation. Int J Intercult Relat. (1999) 23:659–77. doi: 10.1016/S0147-1767(99)00014-0
37. Cemalcilar Z, Falbo T, Stapleton LM. Cyber communication: a new opportunity for international students' adaptation? Int J Intercult Relat. (2005) 29:91–110. doi: 10.1016/j.ijintrel.2005.04.002
38. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. (1983) 24:385–96. doi: 10.2307/2136404
39. Cohen S, Williamson G. Perceived stress in a probability sample of the United States. In:Spacapan S, Oskamp S, editors. The Social Psychology of Health: Claremont Symposium on Applied Social Psychology. Newbury Park, CA: Sage (1988), p. 31–67.
40. Buysse DJ, Reynolds III CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. (1989) 28:193–213. doi: 10.1016/0165-1781(89)90047-4
42. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Cambridge, MA: Academic Press. (2013). doi: 10.4324/9780203771587
43. Sanchez BN, Kraemer WJ, Maresh CM. Premenstrual Syndrome and exercise: a narrative review. Women. (2023) 3:348–64. doi: 10.3390/women3020026
44. Jaleel G, Shaphe MA, Khan AR, Malhotra D, Khan H, Parveen S, et al. Effect of exercises on central and endocrine system for pain modulation in primary dysmenorrhea. J Lifestyle Med. (2022) 12:15–25. doi: 10.15280/jlm.2022.12.1.15
45. Herbert C, Meixner F, Wiebking C, Gilg V. Regular physical activity, short-term exercise, mental health, and well-being among university students: the results of an online and a laboratory study. Front Psychol. (2020) 11:509. doi: 10.3389/fpsyg.2020.00509
46. Gu Q, Hu Q-C, Wei Y-L, Chen K, Dong J-J, Li S-Y, et al. Emotion regulation effect of Baduanjin on college students: a pilot event-related potential study on late positive potential. World J Tradit Chin Med. (2021) 7:408. doi: 10.4103/wjtcm.wjtcm_43_21
47. Zhu X, Chu T, Yu Q, Li J, Zhang X, Zhang Y, et al. Effectiveness of Mind-Body Exercise on Burnout and Stress in Female Undergraduate Students. Int J Ment Health Promot. (2021) 23:353–60. doi: 10.32604/IJMHP.2021.016339
48. Dolcos F, Katsumi Y, Moore M, Berggren N, de Gelder B, Derakshan N, et al. Neural correlates of emotion-attention interactions: from perception, learning, and memory to social cognition, individual differences, and training interventions. Neurosci Biobehav Rev. (2020) 108:559–601. doi: 10.1016/j.neubiorev.2019.08.017
49. Sharon-David H, Tenenbaum G. The effectiveness of exercise interventions on coping with stress: research synthesis. Stud Sport Human. (2017) 22:19–29. doi: 10.5604/01.3001.0012.6520
50. Basso JC, Suzuki WA. The effects of acute exercise on mood, cognition, neurophysiology, and neurochemical pathways: a review. Brain Plast. (2017) 2:127–52. doi: 10.3233/BPL-160040
51. Ezati M, Keshavarz M, Barandouzi ZA, Montazeri A. The effect of regular aerobic exercise on sleep quality and fatigue among female student dormitory residents. BMC Sports Sci Med Rehabil. (2020) 12:1–8. doi: 10.1186/s13102-020-00190-z
52. Medic G, Wille M, Hemels ME. Short-and long-term health consequences of sleep disruption. Nat Sci Sleep. (2017) 9:151–61. doi: 10.2147/NSS.S134864
53. Jaiswal SJ, Owens RL, Malhotra A. Raising awareness about sleep disorders. Lung India. (2017) 34:262. doi: 10.4103/0970-2113.205331
54. Yassin A, Al-Mistarehi A-H, Yonis OB, Aleshawi AJ, Momany SM, Khassawneh BY. Prevalence of sleep disorders among medical students and their association with poor academic performance: a cross-sectional study. Ann Med Surg. (2020) 58:124–9. doi: 10.1016/j.amsu.2020.08.046
55. Shonia T, Lobjanidze M, Antia K, Lobjanidze T. Stress and sleeping disorders among international students of the University of Georgia. Eur J Public Health. (2020) 30(Supplement_5):ckaa166.779. doi: 10.1093/eurpub/ckaa166.779
56. Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. (2017) 13:307–49. doi: 10.5664/jcsm.6470
57. Dolezal BA, Neufeld EV, Boland DM, Martin JL, Cooper CB. Interrelationship between sleep and exercise: a systematic review. Adv Prev Med. (2017) 2017:1–14. doi: 10.1155/2017/1364387
58. Chen Z, Ye X, Shen Z, Chen G, Chen W, He T, et al. Effect of pilates on sleep quality: a systematic review and meta-analysis of randomized controlled trials. Front Neurol. (2020) 11:158. doi: 10.3389/fneur.2020.00158
59. Chen M-C, Liu H-E, Huang H-Y, Chiou A-F. The effect of a simple traditional exercise programme (Baduanjin exercise)on sleep quality of older adults: a randomized controlled trial. Int J Nurs Stud. (2012) 49:265–73. doi: 10.1016/j.ijnurstu.2011.09.009
60. Hsu M-C, Wang T-S, Liu Y-P, Liu C-F. Effects of Baduanjin exercise on oxidative stress and antioxidant status and improving quality of life among middle-aged women. Am J Chin Med. (2008) 36:815–26. doi: 10.1142/S0192415X08006260
Keywords: acculturation, Baduanjin, international students, menstrual health, symptoms
Citation: Alkhatib A, Alshikh Ahmad H, Zhang C, Peng W and Li X (2024) Impact of traditional Chinese Baduanjin exercise on menstrual health among international female students studying in China: a randomized controlled trial. Front. Public Health 12:1259634. doi: 10.3389/fpubh.2024.1259634
Received: 16 July 2023; Accepted: 08 January 2024;
Published: 07 February 2024.
Edited by:
Teresa Vilaça, University of Minho, PortugalReviewed by:
Agustín Aibar-Almazán, University of Jaén, SpainYang Gao, Hong Kong Baptist University, Hong Kong SAR, China
Copyright © 2024 Alkhatib, Alshikh Ahmad, Zhang, Peng and Li. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Xianhong Li, eGlhbmhvbmdfbGkmI3gwMDA0MDtjc3UuZWR1LmNu; Ci Zhang, emhhbmdjaTIwMTcmI3gwMDA0MDtob3RtYWlsLmNvbQ==