Maturitus, 15 (1992) 183-194

183

Elsevier Scientific Publishers Ireland Ltd. MAT 00709

Attitudes towards and level of information on perimenopausal and postmenopausal hormone replacement therapy among Norwegian women S. Hunskaara and B. Backeb ‘Division for General Practice, Department of Public Health and Primary Health Care, University of Bergen, UIriksdol8c, N-J&l9 Bergen and bNorwegian Institute of Hospital Research, N-7034 Trondheim-NTH (Norway)

(Received September 6, 1991; revision received November 26, 1991; accepted December 9, 1991)

In order to investigate women’s attitudes towards and level of information on perimenopausal and postmenopausal hormone replacement therapy (HRT) 1019 women over 17 years of age constituting a representative sample of the Norwegian female population were interviewed in 1990 as part of a monthly national opinion poll (response rate 96.5%). Women’s magazines proved to be the most important source of information on hormone therapy. Only in the over-45 age group were doctors mentioned frequently as information sources. A high self-assessed information level was associated with a positive attitude towards hormone therapy. Those who had obtained information from a doctor were more positive than those who had not. More than half of those who expressed an opinion believed that hormone therapy increased the risk of heart infarction, stroke, breast cancer and cancer in general. There was a strong association between a negative attitude, towards using hormones and belief in an increased risk of serious disease. The women were more positive towards the use of HRT for the prevention of osteoporosis and for postmenopausal urogenital complaints than for the alleviation of climacteric symptoms.

Key words: menopause; oestrogens; attitude to health; hormone replacement therapy

IntrodUetioo Hormone replacement therapy (HRT) for the alleviation of climacteric symptoms has been used for several decades, but views have tended to change regarding the associated risks and benefits. Among doctors. HRT seems to be advocated because of its efficacy in relieving climacteric symptoms and in preventing osteoporosis and possibly also cardiovascular disease [l]. Many women however, are ambivalent about the desirability of starting this kind of treatment, especially when they have to make an informed decision based on available facts as to the advantages and disadvantages. Correspondence to: S. Hunskaar, Division for General Practice, Department of Public Health and Primary Health Care, University of Bergen, Ulriksdal 8c, N-5009 Bergen, Norway.

0378-5122/92/$05.00 0 1992 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland

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In Norway, hormones have been used on a relatively small scale during the climacteric and after the menopause compared with some other countries. In November 1990 the Norwegian Research Council for Science and the Humanities together with The Norwegian Institute of Hospital Research held a consensus conference on the use of oestrogens with a view to providing updated advice [2]. Women’s own views on this type of treatment have rarely been investigated [3-61. In a recent study Rothert et al. [7] used written case histories to study the factors that impact on perimenopausal women’s judgments about HRT. They identified three main groups by cluster analysis. Group 1 attached the most importance to relief of hot flushes. Group 2 weighed the information on the advantages against the risk of cancer. Group 3 was influenced by the severity of hot flushes and osteoporosis risk, was not particularly concerned about cancer and was negative regarding cyclic bleeding occuring on combination therapy. The authors concluded that women are mainly concerned about hot flushes and disruption of their daily life, and that, for many, this is a more important consideration than morbidity and mortality risk. The menopausal syndrome has been extensively studied in Norway, as well as coping styles, social background variables and cultural context [8,9]. It has been suggested that Norwegian women and general practitioners are very sceptical about HRT because of fears concerning cancer and cardiovascular disease and that such negative views may partly explain the low prescription rate [lo]. The present study was carried out in order to obtain data on the attitudes of Norwegian women towards HRT and how well they were informed on the subject. Besides asking questions designed to reveal such attitudes we also investigated sources of information on HRT and women’s willingness to use it for climacteric symptoms, urogenital symptoms in old age and for the prevention of osteoporosis. Subjects and Metbads A total of 1019 women constituting a representative sample of the Norwegian female population over 17 years of age were interviewed by telephone in August and September 1990 as part of a regular monthly national poll (Opinion A/S, Bergen). Eighty-six percent of the interviewers were female. The women were randomly selected from the telephone book. In Norway this population is very similar to the population in general, apart from women over 60 years, where discrepancies may be found. The data were not adjusted for this because the effect would be less than 1% and the findings are in any case within the 95% confidence interval (pers. commun., Opinion A/S). The accuracy of the study can be calculated and expressed in terms of 95% confidence intervals. A 10190 or 50/50% distribution of the answers would result in a 95% confidence interval of 3.8 and 6.2%, respectively. The accuracy was therefore sufficient for our purpose. The respondents answered several questions on their background before they were informed about the purpose of the main part of the interview. They were introduced to the topic of HRT by a short text read by the interviewer. All the women who were unwilling to answer the questions about HRT thus answered the other questions. The background and demographic variables included in the analyses were age and

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age group (< 30,30-44,45-59, L 60 years), duration of higher education, annual household income and location (urban/rural) (Table I). The women then answered questions about attitudes towards HRT, self-assessed level of information on HRT, sources of information about HRT, HRT-related risks and osteoporosis prevention. The questions are reproduced in Table II. Data are mainly presented as percentage distributions. For analytical purposes we sometimes dichotomized the answers concerning attitudes and self-assessed level of information (e.g. positive/negative and high level/low level). In order to analyze attitudes towards HRT, self-assessed level of information and risk estimation, an analytical statistical approach was used. The relative contributions of several background variables were analyzed by multiple regression and discriminant analysis. Other statistical analyses were performed using chi-square tests. The level of significance was set at 5% (P < 0.05).

TABLE I BACKGROUND VARIABLES: DATA ON THE 983 WOMEN WHO ANSWERED THE QUESTIONS ON HORMONE REPLACEMENT THERAPY, NUMBERS AND PERCENTAGES Variable

Mean (SD.) Range

Number

Percentage

44 (~16) 17-88

Age groups (years) 0.05, data not shown). Opinions on risks associated with HRT Table VII shows that almost two-thirds of the women did not express any opinion on whether HRT influences the risk of heart infarction, stroked breast cancer or cancer in general. Among those who did, more than half believed that HRT increased the risk for all 4 conditions.

TABLE IV SOURCES OF INFORMATION ON HORMONE REPLACEMENT THERAPY AMONG 983 NORWEGIAN WOMEN - A TOTAL OF 977 DIFFERENT ANSWERS WERE GIVEN BY 739 WOMEN (75%) Source

Percentage

Women’s magazines Newspapers Friend or relative Doctor Radio/TV Other/not sure No answer

34 23 19 19 12 18 25

188 TABLE V SELF-ASSESSED LEVEL OF INFORMATION: Independent variable

MULTIPLE REGRESSION

Unstandardized regression coefficient

Information from a doctor Information from other sources Information from a friend or relative Age Household income Duration of education Information from newspapers Information from women’s magazines Information from radiom Constant

12.297

Standardized regression coefficient

P-value*

1.216 0.885 0.420

0.420 0.278 0.145

0.0000 0.0000 0.0000

-0.008 -0.000 0.107 0.199 0.165

-0.110 0.108 0.088 0.073 0.068

0.0004 0.0006 0.0046 0.0204 0.0212

-0.012

-0.003

0.9095 0.0059

*Two-tailed test of the coefficients’ t-value. R’, 0.347; n = 984; F = 52.21; significance F = 0.0000.

Women who had obtained information from either a doctor or the newspapers voiced an opinion about potential risks more often than women who did not mention these sources of information (46% as against 35%). Women informed by a doctor largely believed that HRT decreased the risk of infarction (6% as against 2%) and stroke (3% as against 1%) and increased the risk of breast cancer (35% as against 20%).

TABLE VI ATTITUDES TOWARDS (PERCENTAGES)

HORMONE

REPLACEMENT

THERAPY

AMONG

983 WOMEN

Attitude

In general

Osteoporosis prevention

Urogenital symptoms

Very positive Positive Neither positive nor negative Negative Very negative No opinion

25 20 25

30 30 20

30 30 17

11 8 13

4 5 11

5 4 15

The first question concerned treatment of climacteric complaints in general. We then recorded opinions where women had relatives with osteoporosis regarding the presupposition that treatment could reduce their own risk of developing the condition. Lastly, the women gave their opinion on treatment for urogenital symptoms in old age.

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0.032 0.000 0.073 0.024 0.044 -0.021 0.118 0.001 0.002 0.034 -4.005

0.073 0.000 0.030 0.013 0.019 -0.077 0.107 0.002 0.005 0.018 -4.497 0.017 0.029 -0.079 0.140 0.070 -0.013 0.025

0.254 -0.021 0.037 0.039 0.076 -0.026 0.176 0.066 0.007 0.055

0.125 0.040 0.105

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Infarction

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Standardizied regression coefficient

Unstandardized regression coefficient

AND STROKE (MULTIPLE REGRESSION ANALYSIS)

*Two-tailed test of the coefficients’ f-value. Infarction: R’: 0.083; n = 351; F = 3.080; significance F = 0.0009. Stroke: R’: 0.057; n = 345; F = 2.006; significance F = 0.0321.

Self-assessed information level Household income Information from a friend or relative Information from a doctor Information from women’s magaz Information from radiom Information from other sources Age Duration of education Information from newspapers Constant

Independent variable

BELIEF IN RISK OF HEART INFARCTION

TABLE IX

0.7787 0.6229 0.1518 0.0180 0.2409 0.8223 0.6788 0.0824

0.4955 0.2121 0.6473 0.0039 0.2739 0.9096 0.3956 0.0936

0.0514 0.4955 0.0536

0.0000

0.7064 0.4873

Stroke

Infarction

P-value’

191 TABLE X DISCRIMINANT FUNCTION: WOMEN WHO EXPRESSED A RISK ESTIMATION (INCREASED, DECREASED OR NO CHANGE) COMPARED WITH THOSE WHO DID NOT (n = 894,2 GROUPS) Eigenvalue 0.2222 Canonical correlation coefficient 0.4264 Wilks’ lambda 0.8182 P-value O.oooO Standardiid canonical discriminant function coeflicients Information from newspapers 0.221 Information from radiom 0.112 Information from a friend or relative -0.110 Information from a doctor 0.310 Information from other sources 0.338 0.214 Age Household income 0.240 Self-assessed information level 0.628

significantly towards characterization of the women who expressed a specific opinion about the risks associated with HRT, whether positive or negative (Table X). The self-assessed information level was outstanding, however, as regards interpretation of the discriminant function, since a high self-assessed level strongly predicted that a woman would express a considered point of view on HRT risks. Discussion This survey of a representative sample of adult Norwegian women reveals that perimenopausal and postmenopausal women are moderately well informed about HRT and that the majority have a positive attitude towards this kind of treatment. Many women are concerned about the risks of such treatment, but their opinions on the actual risk profile do not correspond with present scientific knowledge. The self-assessed level of information differed with age. Women aged 45-59 rated their information level highly more frequently than did the elderly and the very young. Well-educated women reported a higher level of information than the others. It has previously been shown that those of lower educational level and older women are more likely to believe in a medical model of the menopause, regarding it as a disease that should be treated [ 111. The younger age groups may find the question of HRT currently irrelevant and hence not bother to seek information or form a considered opinion. Generally, it cannot be taken for granted that a self-assessed level of information represents the true level of information. It may also reflect the selfconfidence of the individual respondent. Thus, the present survey may have underestimated the level of information in women with low self-confidence and correspondingly overestimated that among those with high self-confidence. We cannot exclude the possibility that the women who had discussed HRT with their doctors

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felt more confident about questions concerning HRT and thus may also have reported a higher level of information than they really possessed. However, our data do not allow correction for this possible bias. Doctors did not emerge as a major source of information about HRT in our study. Much information was obtained from the media or from friends and relatives, these being findings that correspond with those of other studies [3,12,13]. We found doctors to be the principal providers of information to elderly women. This may be explained by the higher consultation rate in general in this age group. Hunt found that sources of information varied by social class and that high social class was associated with the mass media as the main source [3]. Anecdotally, women may feel fobbed off by their doctor when the question of HRT is raised [ 131. We think that most women have already collected some information and formed an opinion of their own before consult a physician. The role of the doctor will thus consist in sensing the situation and then discussing the subject and correcting and advising the woman. This process must be based on her knowledge and her general attitude towards HRT and should not aim at persuading every woman to use it. Yet many women follow their doctor’s recommendation, suggesting that simple communication could significantly alter the use of HRT [14]. Our multivariate model was able to explain more than a third of the variance. However, information from other sources (i.e. unknown) had a high regression coefficient, which can be interpreted in several ways. Obviously, women who could not remember the exact source of information may have described it as unknown. Nevertheless, there may have been a weakness in our model; we were not able to choose variables in advance that could later, in the analyses, explain the self-assessed information level. More than half of the women were positive or very positive towards the use of HRT for the different indications we investigated. There was scepticism about the use of HRT as symptomatic treatment during the climacteric. More positive attitudes were expressed towards HRT for the prevention of osteoporosis and for urogenital complaints. However, the model we used in the multivariate analyses was not very successful and we must conclude that demographic variables and information sources cannot explain women’s attitudes towards HRT. Comparable studies have shown a more equal distribution among the groups of women having positive, neutral or negative attitudes towards HRT [4,11]. A recent British study on perimenopausal women’s views on taking HRT to prevent osteoporosis revealed considerable interest [6]. However, the results may have been biased by a rather promotional introductory letter. It is essential to understand how patients feel about decisions affecting their health if the appropriate medical therapy involves hazards. Views on acceptable levels of risk vary between individuals and also depend on the different therapeutic situations or on how information is presented [15]. In our study the majority of the women expressed no clear view on whether HRT increases, decreases or does not change the risk of heart infarction, stroke, breast cancer or other cancers. This may reflect a lack of knowledge, but may also be due to reluctance to answer a direct question when faced with the possibility of giving a wrong answer, The distribution of the definite answers is therefore of more interest. Over half the women believed that the risks

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increase for all four health hazards mentioned and we found a strong association between the answers given by each individual woman, We therefore concluded that the risk profile of HRT as seen by the women did not correspond with up-to-date medical knowledge. Traditionally, cancer risk has been the main concern of both women and doctors [6,12], while the possible positive effects on cardiovascular morbidity have only recently been recognized [l]. The results also indicate that lay people have difficulty in differentiating between the various conditions and the magnitude of the related risks. The strong association between a negative attitude towards HRT and perceived increased risk also emphasizes the fact that the ultimate opinion formed is not simply a result of unprejudiced professional information. We found an increasing polarization in risk estimation with higher educational level. This is a challenge to health-care professionals who provide information on the subject, because well-educated women will often be trendsetters. As in the case of the results concerning attitudes to HRT, multiple regression analyses did not explain much of the variance in risk estimation. Our model was able to account for a statistically significant part of the variance where heart infarction and stroke were concerned, but the percentages were rather low. When breast cancer and other cancers were analyzed, the model had almost no explanatory power at all. This must be interpreted in terms of difficulties in explaining complex issues by simple demographic or other variables. We performed a discriminant analysis in order to investigate possible differences between the women who had arrived at a considered point of view on the risks of HRT and those who answered that they did not know. The analysis revealed that a high self-assessed level of information was strongly associated with having a view on risk. Information from a doctor and from other sources also contributed significantly to the discriminant function. It would accordingly seem that information in itself gives rise to a standpoint as to the risks of HRT, but not necessarily a correct one. The women who had been informed by a doctor gave risk estimations more in line with current medical knowledge. It is tempting to explain this in terms of the possible effect of a doctor’s influence. Women consulting for climacteric problems will receive personal advice and recommendations based on their symptoms and current medical indications for treatment. However, the results may be biased if women with a more positive view of HRT consult a doctor. What then should be the doctors’ role? General practitioners occupy a key position in the management of women who consult for climacteric problems. The doctor must explain the rationale behind the treatment, the treatment options and the possible hazards and then give the woman time to consider the situation [ 131. Perhaps health-care professionals are currently placing too little emphasis on decisionmaking factors when discussing options with a patient [7]. The process of decisionmaking is complex both for the woman and for her doctor. The ultimate decision will be influenced by whether therapy is to be long-term or short-term, palliative or preventive and also by the existence of relative contraindications. Irrespective of the decision taken, a sympathetic attitude to the individual woman’s experience is essential [3]. In the public health context it is clearly important for doctors to involve themselves in health education, preferably through the mass media.

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Acknowledgements The study was supported by grants from the Norwegian Research Council for Science and the Humanities. The authors wish to thank Ole-Johan Eikeland for help with data processing. References 1

2 3 4 5 6 I 8 9 IO 11 12 13 14 15

Swedish National Board of Health and Welfare Drug Information Committee. Pharmacological treatment of the climacteric syndrome. Workshop Series. Uppsala: Swedish National Board of Health and Welfare, 1990: 3. Backe B ed. The consensus conference on the use of estrogen during and after the menopause. Report. NIS-Rapport 5/90. Trondheim: Norsk Institutt for sykehusforskning, 1990. Hunt K. Perceived value of treatment among a group of long-term users of hormone replacement therapy. J R Co11Gen Pratt 1988; 38: 398-401. Pedersen SH, Jeune B. Prevalence of hormone replacement therapy in a sample of middle-aged women. Maturitas 1988; 9: 339-345. Kadri AZ. Attitudes to HRT. Practitioner 1990; 234: 880-884. Draper J, Roland M. Perimenopausal women’s views on taking hormone replacement therapy to prevent osteoporosis. Br Med J 1990; 300: 786-788. Rothert M, Rovner D, Holmes M et al. Women’s use of information regarding hormone replacement therapy. Res Nurs Health 1990; 13: 355-366. Holte A, Mikkelsen A. Menstrual coping style, social background and climacteric symptoms. Psychiatry Social Sci 1982; 2: 41-45. Holte A, Mikkelsen A. The menopausal syndrome: a factor analytic replication. Maturitas 1991; 13: 193-203. Iversen OE. Estrogen replacement therapy [in Norwegian]. Tidsskr Nor Laegeforen 1989; 109: 2531-2534. Leiblum SR, Swartzman LC. Women’s attitudes towards the menopause: an update. Maturitas 1986; 8: 47-56. Kadri AZ. Perimenopausal women’s views on hormone replacement therapy. Br Med J 1990; 300: 1017. Kilshaw J. Patients’ views of HRT. Practitioner 1990; 234: 488. Ferguson KJ, Hoegh C, Johnson S. Estrogen replacement therapy. A survey of women’s knowledge and attitudes. Arch Intern Med 1989; 149: 133-136. Eraker SA, Sox HC. Assessment of patients’ preferences for therapeutic outcomes. Med Decision Making 1981; 1: 29-39.

Attitudes towards and level of information on perimenopausal and postmenopausal hormone replacement therapy among Norwegian women.

In order to investigate women's attitudes towards and level of information on perimenopausal and postmenopausal hormone replacement therapy (HRT) 1019...
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