Menstrual Attitudes in the U.S. and China: Insights from Mobile Menstrual Tracking Applications for Teenagers

1. Introduction

Growing up in the digital age, more and more adolescents are familiar with devices like smartphones and computers. In the U.S., 95% of adolescents have access to a smartphone in 2022, compared to 73% in 2014 [1]. In China, over 90% of adolescents under the age of 18 accessed the Internet through smartphones in 2018 [2]. It is unsurprisingly that digital technologies are becoming more prevalent and have been assuming increasingly important roles in healthcare and health communication [3,4,5]. From a communication studies perspective, mobile software applications (apps) are personal informatics, as they are designed to help people gain self-knowledge (i.e., one's "behaviors, habits, and thoughts") and reflect on them [6]. Personal informatics is central to digital health and risk communication [7,8]. From a medical anthropology point of view, which underscores that health and illness are shaped by cultural, historical, and political contexts, health tracking apps contribute to the ongoing discussion on self-monitoring and self-responsibility. Under neoliberal practices, digital health technologies direct health management away from the healthcare system and toward the individual [9,10]. For example, fitness trackers permit users to closely watch over their own health using a wearable device rather than rely on frequent visits to healthcare providers. Advocates support the potential of this voluntary self-tracking to promote patient engagement, self-care, and preventive health behaviors [9]. There are benefits to direct access to health information, however, from a public health standpoint, some major concerns with mobile health (mHealth), or the use of digital technologies for public health and clinical practice, are the sources and accuracy of information within a predominantly unregulated environment [11].

This study, with a focus on the relatively understudied menstrual tracking apps for teenagers, is the first to compare apps in English and Chinese and critically analyze their reflection of the general public's attitudes toward menstruation in the U.S. and China.

1.1. Menstrual Tracking

Hundreds of menstrual tracking apps exist, with an estimated combined download of 500 million worldwide [12]. Most of them allow users to document cycle characteristics, such as length, flow, symptoms, and sexual behavior. While many apps self-claim to enhance education around menstruation, a study of 17 menstrual tracking apps revealed that most apps are unsatisfactory in achieving this goal [13]. In particular, menstrual literacy, which is defined as “a baseline of knowledge and skills with regard to understanding the anatomical and biological facts of menstruation, caring for the menstruating body, and carrying out tasks related to menstrual care,” was lacking [13]. For example, most apps allowed users to track symptoms, yet none provided information for teenagers to self-manage or treat symptoms. In another study that examined popular menstrual tracking apps from a human-computer interaction lens using a mixed-methods approach, it was found that women’s needs were not adequately met [8]. Participants perceived the apps to be unreliable in predicting periods and biased against sexual and gender minorities. Most apps also fail to take into consideration the life-stage development of users, with minimal differentiation for girls who recently experienced menarche, or the first period, women who have been menstruating, or women who are approaching menopause [8,13]. Only a few apps that are designed to prevent unintended pregnancies have been tested by clinical trials [14], with the rest ineffective in serving contraceptive purposes [13,15].

Aside from practical purposes, many menstrual tracking apps promote the message of empowerment and advertise their products as means of "understanding one's body better, avoiding stain stigma, or as natural birth control" [16]. However, closer examinations of those messages reveal that menstrual tracking apps might, in reality, be perpetuating menstrual stigma by suggesting the maintaining of dignity through secrecy and further medicalizing normal bodies as needing to be fixed. While menstrual tracking apps have the immense potential to alleviate health disparities and empower girls to understand their cycles, girls may be exposed to insufficient menstrual literacy and period negativity as the norm at an early age.

1.2. Menstrual Stigma

Menstruation has a long history of being taboo, resulting in negativity and confusion toward a normal bodily process. Enduring cultural and religious beliefs and practices consider menstrual blood as unclean or impure [17]. In an empirical study, known as the “tampon experiment,” researchers revealed that participants who saw a female confederate drop a tampon, versus a hair clip, out of her handbag led to more unfavorable judgments of her – and general objectification of women [18]. These findings demonstrate that menstruating women are, on average, deemed as less competent and likable than non-menstruating women. In part due to feelings of disgust toward menstrual blood, signs or reminders of periods, like the presence of menstrual products, are tied to negative perceptions of women who menstruate. Existing stereotypes of menstruating girls and women as “ill, disabled, out-of-control, unfeminine, or even crazy” further contribute to menstrual stigma [17].

Menstrual symptoms can also vary by culture. A cross-cultural study on premenstrual distress uncovered that Chinese women reported fewer emotional and mental well-being symptoms, such as pain, concentration, and affect, than American women [19]. It is possible that differences in cultural perception and societal attitudes toward menstruation influence people's understanding, bodily sensation, and exhibition of menstruation-related discomfort. These differences, in turn, could be displayed through the default options for symptoms provided by apps in the U.S. and China.

Here, we begin our cross-cultural research by comparing and contrasting the U.S. and China, which are both leaders in the global economy but culturally unique [20]. In the U.S., there have been ongoing efforts to address misconceptions about menstruation and increasing advocacy for period positivity. However, there are mixed messages about menstruation that it is a normal bodily process but should be hidden [21]. Compared to the U.S., China is more socially conservative, and menstruation is treated as a dirty, polluting bodily waste [21]. Such social norms may be expressed in the prevailing narrative around periods in popular American and Chinese digital menstrual trackers.

1.3. Study Objectives

This research focuses on English and Chinese menstrual tracking apps for adolescents and investigates the symptoms provided for users. The goal of this study is to uncover the availability of menstrual literacy, any cross-cultural differences in menstrual symptoms, and the framing, or presentation, of menstrual symptoms in apps for adolescents.

1.4. Study Hypotheses

Based on prior research, we predicted that there would be insufficient menstrual literacy on symptom management or treatment across apps. Menstrual literacy was operationalized as the number of resources for users to seek help and support for menstrual symptoms. We expected that Chinese apps would have less emotional symptoms compared to physical symptoms for users to track than English apps. We also expected that the symptoms in Chinese apps, relative to English apps, would be framed more negatively, which was operationalized as the sentiment, or emotional tone, of the content.

2. Materials and Methods

2.1. Study Design

A mixed methods content analysis [22] was conducted of the top 8 English and 7 Chinese free apps (N = 15) from the Apple App Store. The total sample size was based on a previous study that investigated menstrual tracking apps, which found that a purposive sample of at least 15 apps was adequate [13]. The App Store was searched using variations of relevant keywords involving adolescents or teenagers and period tracking. All apps were publicly available and chosen based on their age ratings (10-18 years old), average user ratings (scale of one to five stars), and total number of ratings (higher sum representing greater influence).

2.2. Data Collection

The authors downloaded the apps (N = 15) and inspected their features. All available symptoms were systematically logged on a shared spreadsheet. The options in Chinese apps were translated from Chinese to English by two independent coders fluent in both languages, which received near perfect agreement (Cohen’s kappa = .896).

2.3. Data Analysis

There were three parts to this mixed methods approach to content analysis. The first part involved observing whether the menstrual trackers provided the ability to document symptoms and availability of resources for managing or treating symptoms as a way of assessing menstrual literacy. The second part consisted of developing a comprehensive codebook with categories for the tracking options, then manually coding the collected qualitative data. Based on the U.S. Department of Health & Human Services definitions of menstrual symptoms [23] and premenstrual syndrome (PMS) [24], physical and emotional are the two types of symptoms. In the digital menstrual trackers, there were a range of other health and well-being factors to monitor. Other categories that users were able to track were fertility (i.e., signs of ovulation, types of contraception), lifestyle (i.e., factors such as diet, exercise, sleep), medical (i.e., abnormal health issues), menstrual (i.e., cycle characteristics like flow and blood color), and sexual (i.e., sexual desire and activity). Two independent human coders were trained to analyze the categories. The interrater reliability for the English apps (Cohen’s kappa = .941) and Chinese apps reached almost perfect agreement (Cohen’s kappa = .939). We also explored any cultural differences for English and Chinese audiences. The third part entailed a sentiment analysis of physical and emotional symptoms using a dictionary-based computational technique to automatically detect the tone communicated in text. A validated word-emotion association dictionary from the National Research Council Canada [25] with pre-annotated words of negative and positive sentiment was applied to the symptom dataset. Analyses were performed in Google Sheets and R version 4.2.3.

3. Results

3.1. Menstrual Literacy

All the apps (N = 15) served to log menstrual cycle information on a calendar and provided options for users to track symptoms. However, they did not all offer educational resources for users to manage or treat symptoms. In the English app sample (n = 8), 5 (63%) provided resources and 3 (37%) did not. For instance, there were articles and videos on how to relieve menstrual cramps, but emotional changes were not addressed. A few apps provided a chat or forum feature that facilitated peer-to-peer conversations among teenage users. Only one of the apps connected users directly to chat with a health educator. In the Chinese app sample (n = 7), 3 (43%) provided resources and 4 (57%) did not. For example, there were articles that gave diet recommendations and advice on menstrual pain. Similar to the English apps, Chinese apps did not discuss emotional symptoms. One of the apps allowed users to communicate with a healthcare provider and another app had a feature for users to make friends with peers.

3.2. Symptom Type

There are two types of menstrual symptoms: physical and emotional, which are broken down in Table 1. In the English app sample (n = 8), there were 150 (60%) emotional and 101 (40%) physical symptoms. The top three emotional symptoms were happy, sad, and anxious. The top three physical symptoms were cramps, acne, and tender breasts. In the Chinese app sample (n = 7), there were 52 (34%) emotional and 101 (66%) physical symptoms. The top three emotional symptoms were sad, unhappy, and very happy. The top three physical symptoms were dizziness, headache, and diarrhea.

Table 1. Counts of Symptom Types among English and Chinese Menstrual Tracking Apps.

Symptom Type	English Apps (n = 8)	Chinese Apps (n = 7)
Emotional	150	52
Physical	101	101
Total	251	153

Table 1. Counts of Symptom Types among English and Chinese Menstrual Tracking Apps.

Symptom Type	English Apps (n = 8)	Chinese Apps (n = 7)
Emotional	150	52
Physical	101	101
Total	251	153

Beyond symptoms, there were five other categories: fertility, lifestyle, medical, menstrual, and sexual. Other options that users can track by category are shown in Table 2. In the English app sample (n = 8), the top three other categories were fertility (45/143, 31%), lifestyle (32/143, 22%), and menstrual (30/143, 21%). In the Chinese app sample (n = 7), the top three other categories were menstrual (32/119, 27%), medical (32/119, 27%), and lifestyle (25/119, 21%). In the sexual category, there were 25 (17%) options to track in the English sample and 7 (6%) in the Chinese sample. Sexual items in the English apps consisted of protected/unprotected sex, masturbation, and feeling horny. Sexual items in the Chinese apps were specified as love making and there was no emotional tracking of sexual desire.

Table 2. Counts of Other Categories among English and Chinese Menstrual Tracking Apps.

Other Categories	English Apps (n = 8)	Chinese Apps (n = 7)
Fertility	45	23
Lifestyle	32	25
Menstrual	30	32
Sexual	25	7
Medical	11	32
Total	143	119

Table 2. Counts of Other Categories among English and Chinese Menstrual Tracking Apps.

Other Categories	English Apps (n = 8)	Chinese Apps (n = 7)
Fertility	45	23
Lifestyle	32	25
Menstrual	30	32
Sexual	25	7
Medical	11	32
Total	143	119

3.3. Symptom Framing

Physical and emotional symptoms were further investigated. In both samples, there was more negative than positive sentiment, exhibited in Table 3. In the English app sample (n = 8), 87 (66%) of symptoms were negative and 44 (34%) were positive in tone. The top three negative words were pain, anxious, and angry. The top three positive words were happy, tender (breast), and love. In the Chinese app sample (n = 7), 93 (76%) of words were negative and 30 (24%) were positive in tone. The top three negative words were pain, dizziness, and headache. The top three positive words were happy, tenderness (breast), moderate (pain).

Table 3. Counts of Negative and Positive Sentiment among Physical and Emotional Symptoms in English and Chinese Menstrual Tracking Apps.

Category	English apps (n = 8)	Chinese apps (n = 7)
Negative	87	93
Positive	44	30
Total	131	123

Table 3. Counts of Negative and Positive Sentiment among Physical and Emotional Symptoms in English and Chinese Menstrual Tracking Apps.

Category	English apps (n = 8)	Chinese apps (n = 7)
Negative	87	93
Positive	44	30
Total	131	123

4. Discussion

Our study explored menstrual tracking apps for American and Chinese teenagers, specifically concentrating on symptoms. These apps aim to support users in tracking their menstrual cycle and symptoms, however menstrual literacy on symptom management or treatment was generally inadequate. From a health communication perspective, information availability and sources are important for promoting healthy behaviors. In this mixed methods content analysis of 15 apps, symptom tracking was available to users, but educational resources to support symptoms and find help can be improved. Majority of the apps lack the ability to contact a healthcare provider, which is a protective factor that reduces negative health outcomes and essential feature that bolsters health and well-being. This finding is consistent with past research within health informatics [13]. Credible sources of information that cite scientific literature and involve healthcare professionals are also crucial for supporting adolescents who are considered to be a vulnerable population. Social support for adolescents is pivotal in addressing health concerns as well. A minority of the analyzed apps connected adolescent users with other teenagers, indicating that digital health tools can be beneficial for developing peer relationships and building a sense of community among girls who are newly menstruating. Peer connection and support can help with navigating this sensitive period of life.

When assessing the type of symptoms, more emotional symptoms were available for American users to track than Chinese users. On the other hand, Chinese apps offered more options for physical, or somatic discomfort, than English ones. This cross-cultural difference in features between English and Chinese apps could be interpreted in a few ways. Firstly, this could originate from the pathologizing of women's emotions in Western culture. Ussher and Perz argued that American women diligently track their periods with extra caution against any signs of negative emotions and subsequently engage in self-monitoring, self-policing, and self-silencing [26]. Engaging in self-care practices, like taking a break from household tasks, might be considered a remedy for PMS, whereas normal emotional reactions to stressful events, such as irritability and moodiness, might be dismissed and explained away as "symptoms" [27]. Secondly, this finding aligns with a widely held perception that Chinese people are not as emotionally inclined as American counterparts even though Chinese women still report emotional menstrual symptoms [28]. In Eastern culture, echoing the classical studies in medical anthropology that focused on the presentation of depression in the Chinese population, Chinese people tend to report more somatic complaints in place of psychological ones [29]. Fear of stigma against mental illnesses and a cultural discouragement of expressing negative emotions or relationship strain has contributed to the Chinese population's skewed presentation of physical discomforts. Therefore, it is possible that menstruation-related symptoms were also somaticized and illustrated through the availability for reporting more physical rather than emotional distress. Interestingly, there were more options for tracking sexual activities available in English apps than in Chinese apps. Chinese apps also used love making as a euphemism for sexual intercourse, reflecting a more conservative, and potentially more stigmatized, attitude toward sex among teenagers in China [30].

Symptoms were framed more negatively than positively, consistent with prior work on menstrual stigma [16], within English and Chinese apps, respectively. When comparing negative sentiment, Chinese apps had slightly more than English apps. Additional research is needed to understand the accuracy of information as well as the underlying reasons behind these differences in default symptom presentations in English and Chinese apps. Nevertheless, this study suggests that there may be possible priming effects in menstrual tracking apps. Past research has revealed that people's menstrual experiences are highly subject to priming. For example, previous knowledge of PMS could lead to an increase in reporting of negative, PMS-related symptoms [31]. In addition, participants who filled out the Menstrual Joy Questionnaire in the first week and the Menstrual Distress Questionnaire in the second week scored significantly higher on the "menstruation as a natural event" subscale (e.g., “menstruation is a reoccurring affirmation of womanhood,” “menstruation allows women to be more aware of their bodies”) of the Menstrual Attitudes Questionnaire than their counterparts who filled out the two questionnaires in the reverse order [32,33]. This showed that participants can be primed to report more positive experiences of menstruation. Therefore, while menstrual tracking apps provide convenience and strengthen self-knowledge, it is also important to keep in mind that more negative sentiment of menstruation can prime more negative attitudes and experiences as well as further pathologize menstruation at an early age during adolescence.

4.1. Implications

Despite the lack of menstrual literacy and mostly negative framing of menstrual symptoms in the popular free apps assessed in this study, digital trackers are advantageous in empowering girls with information about their own bodies. Consequently, self-tracking of menstrual cycles using accessible digital health tools could provide girls with greater personal awareness and control over decisions related to their own sexual and reproductive health. Given that adolescents are constantly connected online, there are still opportunities for menstrual tracking apps to uniquely meet teenagers where they are. Digital menstrual trackers can help adolescents remember their last period and predict their upcoming period. Information from apps could be used to inform discussions with healthcare providers and parents or caregivers. There should also be more menstrual tracking apps specifically tailored to teenage audiences, since the majority of the apps analyzed here appear to be geared toward adult populations. Areas of improvement in menstrual tracking apps for adolescents include increasing evidence-based information that is still easy to understand for young girls, enhancing involvement of healthcare professionals, cultivating peer relationships, presenting positive, or neutral, information in order to encourage corresponding attitudes toward menstruation, as well as aiding conversations between parents and teenagers. Last but not least, digital menstrual trackers need to ensure data privacy and confidentiality.

4.2. Limitations and Future Directions

This study is limited in its generalizability due to the purposive sampling method. Since this was not a comprehensive sampling or random sampling of menstrual tracking apps, these findings are not generalizable to the wider population. Further, our study was also limited in that this is a descriptive study with a restricted sample. Future studies should collect more data and test for statistically significant differences in a larger sample of English and Chinese apps. This suggests a follow-up to look at differential menstrual health outcomes for English and Chinese adolescents in other publicly available datasets. A deeper secondary data analysis is needed that takes into account varying aspects within the U.S. and China that includes important variables like urbanization, access to reliable technology, religion, and other relevant factors that could affect how adolescent girls interact with this technology. Additional studies should investigate the accuracy of information in menstrual tracking apps as well as decision-making from user experience researchers and designers who determine default symptom features in apps. Future research can also incorporate primary data collection and analysis of interviews or surveys with American and Chinese teenagers who use menstrual tracking apps to understand user needs and experiences firsthand.

5. Conclusions

In this mixed methods content analysis, we explored symptoms in menstrual tracking apps in English and Chinese. The findings highlighted inadequate menstrual literacy within popular free apps, cross-cultural differences in symptoms, and a negativity bias in symptoms presented to users. Overall, the benefits and risks of using digital technology for tracking menstrual cycles need to be carefully weighed by adolescent users and their parents or caregivers. Such digital health tools are valuable for voluntary self-monitoring yet there are gaps in information that need to be filled in order to properly support adolescents during menstruation. In a rapidly advancing digital environment, the vast majority of teenagers have access to a smartphone. Used wisely, technology can be leveraged to improve menstrual health during adolescence.