42 Original article

Attitudes toward menopause among middle-aged women in Semnan, Iran Raheb Ghorbania, Mohammad Nassajib, Akram Shahbazic, Samira B. Tabard and Fatemeh Rahaeie a Unit of Biostatistics, bUnit of Infectious Diseases, Department of Community Medicine, Research Center for Social Determinants of Health, Faculty of Medicine, Semnan University of Medical Sciences, cDepartments of Social Medicine, dInternal Medicine and eResearch committee, Semnan University of Medical Sciences, Semnan, Iran

Correspondence to Mohammad Nassaji, MD, Kovsar Hospital, Basij Blvd, 3519899951 Semnan, Iran Tel: + 98 231 443 7844; fax: + 98 231 443 7837; e-mails: [email protected], [email protected]

Received 26 November 2013 Accepted 25 January 2014 Journal of the Egyptian Public Health Association 2014, 89:42–45

Background and objective The menopause marks a major biological transition in the lives of all women. Understanding the attitude of women about menopause facilitates the implementation of public health policies that focus on improving women’s health. This study was designed to determine the attitude of a group of Iranian women toward menopause with respect to sociodemographic variables and menopausal status. Materials and methods A cross-sectional study was conducted at Primary Health Centers of Semnan during 2012. A total of 747 women aged 45–60 years were interviewed. Sociodemographic characteristics and attitude toward menopause were collected through a structured pretested questionnaire. The attitude scale consisted of 17 questions, each rated on a five-point Likert scale with a total score of 85 points. Results The mean ( ± SD) age of women was 51.3 ( ± 4.5) years. Women were classified as premenopausal (38.4%), perimenopausal (16.9%), and postmenopausal (44.8%). The majority of respondents (63.5%) were illiterate or have had low level of education (o9 years), and 86.3% were unemployed. The mean ( ± SD) attitude score was 53.3 ( ± 6.8). Most of the women (71%) had neutral attitude, 22.8% had positive, and only 6.3% had negative attitude toward menopause. Menopausal status, educational level, marital status, place of residency, and employment were not associated with women’s attitude. Conclusion In general, women’s attitude toward menopause ranged from neutral to positive. The attitude did not differ significantly on the basis of menopausal status, educational level, marital status, place of residency, and employment. Keywords: attitudes, menopause, middle-aged, women J Egypt Public Health Assoc 89:42–45 & 2014 Egyptian Public Health Association 0013-2446

Introduction The menopause is defined as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. It is an important event in the natural processes of women’s life [1]. Although menopause is a normal event for women, individual experiences vary, and some women seek medical advice for the management of symptoms [2]. Natural menopause is defined as no menses for 12 consecutive months, with no obvious intervening cause. Most women experience menopause between 45 and 54 years, with an average onset of 51 years [3]. It is estimated that, in the year 2030, 1.2 billion will be perimenopausal or postmenopausal, and will increase by 4.7 million a year [4]. The menopause marks a major biological transition in the lives of all women, with potentially deep psychological and socioeconomic changes in their life. Most women 0013-2446 & 2014 Egyptian Public Health Association

think that this time is coupled with unbearable difficulties. This negative perspective of the menopause can lead to enormous anxiety among women [5]. Many women during menopause manage their problem by themselves, with only about 10% seeking help from healthcare providers [6]. Attitudes, perceptions, and expectations are part of the psychosocial phenomena surrounding menopause. Health professionals believe that attitudes play an important role in the experience of menopause [7]. The attitudes toward it vary across cultures and countries. These differences have been related to female age, parity, and hormonal status as well as to social, economical, cultural, educational, and geographical factors [8]. Some ethnic and cultural differences in attitude have been documented, particularly between developing and western countries [9,10]. Attitudes toward menopause have been studied for several decades with different results. These studies differ in terms of tools used to assess attitudes, sample population, and study design [11–15]. DOI: 10.1097/01.EPX.0000443986.36638.73

Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.

Attitudes toward menopause among middle-aged women Ghorbani et al.

The aim of this study was (a) to determine the current attitude toward menopause in a group of Iranian women before and during menopause and probable difference with other communities and (b) to identify a number of sociodemographic and contextual factors related to these attitudes. Such information is clearly needed to facilitate the development and implementation of public health policies that focus on improving women’s knowledge regarding menopause and its impact on the quality of life.

Materials and methods This cross-sectional descriptive study was conducted between February and May 2012 on women aged 45–60 years in Semnan city, central Iran. This city consists of seven districts. To ensure that the sample was representative of the overall population, women were selected from the different districts. Each district is covered by a Primary Health Care (PHC) center. After coordination with these centers, the list of households covered by the seven centers was extracted. Women were selected by the multistage sampling method. At the first step, all seven PHC centers were included. At the second step, 784 clusters (households) were selected randomly using systematic sampling technique. Finally, from each household, a woman aged 45–60 years was selected randomly. If there was no woman with the defined age, the next household was selected until the calculated sample was attained. The menopausal status was defined on the basis of the WHO criteria: (a) premenopause – women who had regular menstrual periods in the last 3 months; (b) perimenopause – absence of menses in at least three cycles but no more than 11 during the past 12 months; and (c) postmenopause – women who had no periods in the last 12 months or longer [3]. Women who had undergone hysterectomies were treated as postmenopausal. After calling and attending women in PHC centers, the aim of the study was described to them. Eligible participants were interviewed face-to-face by trained female interviewers using semistructured questionnaires. This questionnaire was designed by the researchers, guided by different questionnaires included in other previous studies. The reliability of questionnaire was ascertained by means of pilot testing using a selected group of women which were excluded from study. Its validity was confirmed by two experts’ panel. The questionnaire was divided into two parts. The first part contains sociodemographic data consisting of age, educational level, place of residency, marital status, employment, and menopausal status. The second part was an attitude scale consisting of 17 questions. For each item, women were asked to indicate the degree to which they agree with each item on a five-point (strongly disagree, disagree, neither agree nor disagree, agree, strongly agree) scale. This five-point Likert scale ranged from 1 (strongly disagree) to 5 (strongly agree). The total attitude score was divided as positive (Z60), neutral (40–59), and negative (o40).

43

Ethical considerations

The study was approved by Research Committee of Semnan University of Medical Science. Ethical approval was also obtained from University Ethical Committee. Participants were informed that the questionnaire was confidential and anonymous, and informed consent was obtained. Statistical analyses

Statistical analyses were performed using SPSS version 16 (SPSS Inc., Chicago, Illinois, USA). Data were analyzed using the Mann–Whitney U-test and the Kruskal–Wallis test. The P-value of less than 0.05 was considered statistically significant.

Results Of the 784 participants who fulfilled the criteria, 37 were omitted from the study because of incomplete data. Hence, 747 women were enrolled and interviewed. From these participants, 286 (38.4%) were premenopausal, 126 (16.9%) were perimenopausal, and 335 (44.8%) were postmenopausal. The mean ( ± SD) age of women was 51.3 ( ± 4.5) years. The majority of women (63.5%) were illiterates or have had low level of education (o9 years). The majority of women (86.3%) were unemployed and 92% were married. The main sociodemographic characteristics of the study population are presented in Table 1. The mean ( ± SD) attitude score was 53.3 ( ± 6.8). The majority of women (71%) had neutral attitude, 22.8% had positive, and only 6.3% had negative attitude toward menopause. Most women (82%) believed that ‘Menopause is a usual and natural change in women life’. When comparing this item based on menopausal status, there was significant difference between premenopausal, perimenopausal, and postmenopausal women (P = 0.009). More than half of women (52.6%) agreed with the statement that ‘Menopause is a pleasant experience because it improves their status in society and family’. Similarly, more than half of the women (54.1%) believed that ‘After the menopause, a woman gets more interested Table 1. Characteristics of study participants Variables Educational level Illiterate Primary Intermediate Secondary University Employment Yes No Marital status Married Single Residency Urban Rural Menopausal status Premenopause Perimenopause Postmenopause

n (%) 95 247 132 232 41

(12.7) (33.1) (17.7) (31.1) (5.5)

102 (13.7) 645 (86.3) 687 (92.0) 60 (8.0) 689 (92.2) 58 (7.8) 286 (38.3) 126 (16.9) 335 (44.8)

Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.

44

Journal of the Egyptian Public Health Association

in community and creational affairs than before’. Only about one-third of women believed that ‘there is no prevention or treatment for symptoms of menopause’. Seventy-seven percent of women agreed that ‘Menopause as natural phenomena should not be intervened by drugs and other treatments’. When being asked about their relationship with their husbands and their sexual life, 55.9% of women agreed that ‘After the menopause, there is no change in sexual relationship’. Associations between variables and attitudes toward menopause are shown in Table 2. Menopausal status, educational level, marital status, place of residency, and employment were not associated with women’s attitude.

Discussion Women’s attitudes toward menopause are multidimensional and are influenced by hormonal status, psychological factors, lifestyle, interpersonal relationships, and social and cultural factors. Understanding the similarities and differences among women’s perceptions, attitudes, and expectations improves the delivery of appropriate care and promotes lifestyles and increase the quality of life. Findings from some previously published study indicated that most women have positive attitude [16–19]. In the present study, we found that a high percentage of women had neutral or positive attitude. Similarly, in the study by Sommer et al. [20], the majority of respondents had neutral or positive attitude toward menopause. This finding can be interpreted in light of the general life context of women and that menopause may simply be one transition in natural life’s course. In contrast, some studies reported that most women have negative attitude toward menopause [21,22]. Holmes-Rovner et al. [23] reported that African-American women had neither a positive nor a negative view of menopause. The differences between these studies might be because

of different types of sampling, population, and cultural differences. Earlier reports have indicated that attitudes toward menopause significantly differed among categories of education. Some studies have showed that well-educated women have a more positive attitude [24,25]. However, other studies indicated that education had a significantly negative impact on menopausal attitudes [26,27]. Our study did not show significant association between educational level and attitude. In agreement with this finding, a study on Caribbean women reported little correlation between the level of education and knowledge and attitude [28]. Our study population differs from most others as it has low educational levels (63.5% illiterate or not completing high school). Similarly, in their study on the influence of demographic characteristics on women’s attitudes toward menopause, Wilbur et al. [29] did not find a significant relationship between women’s attitude and their educational level. The menopausal status may affect women’s attitudes. The results of this study showed that menopausal status was not significantly related to attitude. Similarly, one study on Swedish women showed that menopausal status was not associated with attitude toward menopause [17]. In addition, Bell [30] in his study (USA) did not find association between menopausal status and attitude. These findings are not consistent with most other studies reporting that positive attitude was more common in postmenopausal women, suggesting that experiencing menopause tends to result in more positive attitude [20,24–26,31]. Marital status did not show association with attitude. This is comparable with the data of the study by Eman and colleagues [22,29]; they did not report a significant relationship between marital status and women’s attitude toward menopause.

Table 2. Women’s attitude toward menopause according to sociodemographic characteristics and menopausal status Attitude [n (%)] Characteristics Educational level Illiterate Primary Intermediate Secondary University Employment Yes No Marital status Married Single Residency Urban Rural Menopausal status Premenopause Perimenopause Postmenopause

Positive 23 61 38 44 4

(24.2) (24.7) (28.8) (19.0) (9.8)

Neutral 65 164 83 183 35

(68.4) (66.4) (62.9) (78.9) (85.4)

Negative

Mean

SD

P-value

7 22 11 5 2

(7.4) (8.9) (8.3) (2.2) (4.9)

53.5 52.8 53.5 53.7 52.7

7.4 7.3 7.5 5.8 5.3

0.786a

19 (18.6) 151 (23.4)

78 (76.5) 452 (70.1)

5 (4.9) 42 (6.5)

53.5 53.2

6.1 6.9

0.759b

160 (23.3) 10 (16.7)

482 (70.2) 48 (80.0)

45 (6.6) 2 (3.3)

53.3 53.6

6.9 5.8

0.939b

161 (23.4) 9 (15.5)

481 (69.8) 49 (84.5)

47 (6.8) –

53.3 53.6

7.0 5.0

0.838b

69 (24.1) 27 (21.4) 74 (22.1)

198 (69.2) 94 (74.6) 238 (71.0)

19 (6.6) 5 (4.0) 23 (6.9)

53.2 54.0 53.1

6.9 6.0 7.0

0.616a

a

Using Kruskal–Wallis test. Using Mann–Whitney U-test.

b

Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.

Attitudes toward menopause among middle-aged women Ghorbani et al.

This diversity in the effect of some variables on the attitudes toward menopause reflects the role played by culture in shaping attitudes in different parts of the world. In addition, the type of sampling and study method can affect the result of studies. This study has a number of limitations that warrant mention. First, this study was cross-sectional. Second, women included in this study cannot be thought of as a random sample of all Iranian women in Semnan, and results cannot be totally extrapolated to the general female population.

45

9 Richard-Davis G, Wellons M. Racial and ethnic differences in the physiology and clinical symptoms of menopause. Semin Reprod Med 2013; 31: 380–386. 10 Kowalcek I, Rotte D, Banz C, Diedrich K. Women’s attitude and perceptions towards menopause in different cultures. Cross-cultural and intra-cultural comparison of pre-menopausal and post-menopausal women in Germany and in Papua New Guinea. Maturitas 2005; 51:227–235. 11 Sievert LL, Espinosa-Hernandez G. Attitudes toward menopause in relation to symptom experience in Puebla, Mexico. Women Health 2003; 38:93–106. 12 Huffman SB, Myers JE, Tingle LR, Bond LA. Menopause symptoms and attitudes of African women: closing the knowledge gap and expanding opportunities for counseling. J Couns Dev 2005; 83:48–56. 13 Ayers B, Forshaw M, Hunter MS. The impact of attitudes towards the menopause on women’s symptom. Maturitas 2010; 65:28–36. 14 Dasgupta D, Ray S. Attitude toward menopause and aging: a study on postmenopausal women of West Bengal. J Women Aging 2013; 25: 66–79. 15 Shojaeizadeh D, Gashtaee M. Assessing the relationship between knowledge, attitude and healthy behavior among menopaused women in Tehran in 2000. Iran J Publ Health 2002; 31:19–20.

Conclusion Women in our study displayed different attitudes toward menopause, with their general attitudes ranging from neutral to positive. Sociodemographic and reproductive factors were not significantly related to attitudes toward menopause.

16 Donati S, Cotichini R, Mosconi P, Satolli R, Colombo C, Liberati A, et al. Menopause: knowledge, attitude and practice among Italian women. Maturitas 2009; 63:246–252. 17 Olofsson AS, Collins A. Psychosocial factors, attitude to menopause and symptoms in Swedish perimenopausal women. Climacteric 2000; 3:33–42. 18 Malik HS. Knowledge and attitude towards menopause and hormone replacement therapy (HRT) among postmenopausal women. J Pak Med Assoc 2008; 58:164–167. 19 Shea JL. Chinese women’s symptoms: relation to menopause, age and related attitudes. Climacteric 2006; 9:30–39.

Acknowledgements The research was supported by Research Committee of Semnan University of Medical Science. The authors thank managers and personnel of Semnan Primary Health Care center.

Conflicts of interest There are no conflicts of interest.

20 Sommer B, Avis N, Meyer P, Ory M, Madden T, Kagawa-Singer M, et al. Attitudes toward menopause and aging across ethnic/racial groups. Psychosom Med 1999; 61:868–875. 21 Kısa S, Zeynelog˘lu S, Ozdemir N. Examination of midlife women’s attitudes toward menopause in Turkey. Nurs Health Sci 2012; 14:148–155. 22 Eman S, Abdulmajeed A, Ibtisam O. Assessment of women knowledge and attitude toward menopause and hormone replacement therapy (HRT) in Abu Dhabi, UAE. Suez Canal Univ Med J 1999; 2:217–222. 23 Holmes-Rovner M, Padonu G, Kroll J, Breer L, Ronver DR, Talarczyk G, et al. African-American women’s attitudes and expectations of menopause. Am J Prev Med 1996; 12:420–423. 24 Papini DR, Intrieri RC, Goodwin PE. Attitude toward menopause among married middle aged adults. Women Health 2002; 36:55–68.

References 1 Santoro N, Randolph JF Jr. Reproductive hormones and the menopause transition. Obstet Gynecol Clin North Am 2011; 38:455–466. 2 Nelson HD. Menopause. Lancet 2008; 371:760–770. 3 Research on the menopause in the 1990s. Report of a WHO Scientific Group. World Health Organ Tech Rep Ser. 1996; 866:1–107. 4 Jin YL, Chang SS. The attitude of postmenopausal women towards hormone replacement therapy (HRT) and effects of HRT on Lipid profiles. Proceedings of the first consensus meeting on menopause in East Asian region. 26-30 May 1997; Geneva, Switzerland. Available at: http://www.gfmer.ch/ books/bookmp/7.3.htm. 5 Bloch A. Self-awareness during the menopause. Maturitas 2002; 41:61–68. 6 Roberts H. Managing the menopause. BMJ 2007; 334:736–741. 7 Avis NE, Colvin A, Bromberger JT, Hess R, Matthews KA, Ory M, et al. Change in health-related quality of life over the menopausal transition in a multiethnic cohort of middle-aged women: Study of Women’s Health Across the Nation. Menopause 2009; 16:860. 8 Obermeyer CM. Menopause across cultures: a review of the evidence. Menopause 2000; 7:184–192.

25 Morrison LA, Sievert LL, Brown DE, Rahberg N, Reza A. Relationships between menstrual and menopausal attitudes and associated demographic and health characteristics: the Hilo Women’s Health Study. Women Health 2010; 50:397–413. 26 Cheng MH, Wang SJ, Wang PH, Fuh JL. Attitudes toward menopause among middle aged women: a community survey in an island of Taiwan. Maturitas 2005; 52:348–355. 27 Leon P, Chedraui P, Hidalgo L, Ortiz F. Perceptions and attitudes toward the menopause among middle aged women from Guayaquil, Ecuador. Maturitas 2007; 57:233–238. 28 Thomas SE. Menopause knowledge and attitudes of English-speaking Caribbean women: implications for health education. Californian J Health Promot 2005; 3:167–176. 29 Wilbur J, Miller A, Montgomery A. The influence of demographic characteristics, menopausal status, and symptoms on women’s attitudes toward menopause. Women Health 1995; 23:19–39. 30 Bell ML. Attitudes toward menopause among Mexican American women. Health Care Women Int 1995; 16:425–435. 31 Jassim GA, Al-Shboul Q. Attitudes of Bahraini women towards the menopause: implications for health care policy. Maturitas 2008; 59:358–372.

Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.

Attitudes toward menopause among middle-aged women in Semnan, Iran.

The menopause marks a major biological transition in the lives of all women. Understanding the attitude of women about menopause facilitates the imple...
218KB Sizes 1 Downloads 3 Views