Title: Prevalence of Menstrual Symptoms Change and Influencing Factors among International
Female Students Studying in China during Acculturation Period
Version: 5 Date: 16 May 2022
Reviewer's report:
Thank you for your revisions. While the manuscript has improved, I believe there are still some
significant areas that need to be addressed, which I’ve included below. Some of these were
present in my previous feedback, while others are new due to new information/understanding:
1. Background. The background section, in it’s current form, does not clearly justify or lead your
reader to your research question. The rationale for the research should be made clearer - why is
it important to understand how college students’ menstrual symptoms might change during the
acculturation period in China? For example, is there any data that suggests that foreign visiting
students perform worse academically, have lower absenteeism, experience poor mental health
symptoms, sleep worse, etc. compared to local students in China? One statistic I did observe in
your Background is that based on the previous data you reported, it seems like the prevalence of
menstrual symptoms among college students in China was lower than other countries reported
(Egypt, Australia, Ghana, etc.). It’s possible that this information could be used to help justify
looking at menstrual symptoms among college students who are studying in China but are from
other countries.
The other “big point” to clarify in your background is the definition of menstrual symptoms. I
appreciate that you streamlined your terminology, but how you’re defining menstrual symptoms
is still unclear. It seems that the menstrual symptoms scale was based off dysmenorrhea
symptoms. Why not focus on dysmenorrhea symptoms then in your background?
2. Methods. The timing aspect of the menstrual symptoms data collection in your survey is
clearer (e.g., that it was a cross-sectional survey with recall for the first 6 months in China versus
before coming to China). At the same time, it’s not clear to me what the recall period is for
sociocultural adaptation, higher education satisfaction, perceived stress, and sleep quality. If
students are reporting on those measures at the time of the survey, I don’t think it makes sense
to include them as predictors of menstrual symptoms / changes in menstrual symptoms based
on potentially years prior. This confuses the direction of the relationship. Based on some of the
points you made in your background section, it seems that a more relevant question might be to
include the change in menstrual symptoms as a predictor of these measures in separate models
with adaptation, education satisfaction, etc as outcomes. This seems to align with the argument
that it’s important to understand menstrual symptoms during acculturation periods bc changes
in symptoms may be related to other health outcomes.
Please also clarify whether your variable is menstrual symptoms or changes in menstrual
symptoms, and make sure that is clear in all of your text and table labels.
3. Limitations. I think you need to elaborate more on recall bias as limitation, including how the
presence of recall bias may impact your findings (for example, if people with worse symptoms
remember them more). There are also some steps you can take to assess the potential for recall
bias by, for example, seeing if students who have been in China longer have significantly
different symptoms/changes in symptoms than those who haven’t. Looking through your Table
2, it seems that for all items the average score increased (meaning that the closer recall period
of first 6 months in China is consistently higher than the further recall period of before coming
to China). The consistency of this directional change alone warrants mention of potential recall
bias.
I recommend spending time revising the paper based on some of these “bigger picture” questions
regarding the motivation for the research question and the potential role of bias in your findings.
Best of luck!