Attitudes towards menopause and its relationship with sociodemographic factors among postmenopausal women living in a rural area of Jammu: a cross-sectional study

INTRODUCTION

In her lifetime a women passes through many transitions like physical, social and physiological. Out of all, physiological transition menopause is most important but usually ignored. In the current century, a woman is expected to live more than one-third of her lifetime after menopause, taking into consideration ongoing trends in life expectancy.¹ Although, menopause is a natural phase of life but is listed as disease in International Classification of Diseases- 9 and 10, Disease Database, e-Medicine, and medical subject headings. It alters the function of human body resulting in menopausal symptoms termed as ‘menopausal syndrome’.²

Worldwide about 25 million women reached menopause in the year 1990 and it is projected to be doubled by the year 2020.³ In India, according to National Family Health Survey (NFHS- 4) survey done in 2015-2016 about 17.5% of women have attained menopause. This percentage is similar to findings of NFHS 3 (2005-2006) 18% and NFHS 2 (1998-1999) 17.7%.⁴ About 12.6 million women in India are above 45 years of age, contributing to about 10.4% of the total population.⁵ While the women in reproductive age group (15-45 years) are covered under various health programmes and schemes like Reproductive and Child Health program II, Janani Suraksha Yojana, Integrated Child Development Service, Rashtriya Kishor Swasthya Karyakram etc., at present, there is no specific health programme catering the health need and demands of women above the age of 45 years.^5,6 It is important to focus on this group of women which has grown in number and is expected to increase at tremendous rate in coming years that cannot be ignored.

Perception, attitude and knowledge regarding the menopause may differ from one population to another. For some women menopause with its symptoms becomes a life time crisis whereas for others it passes like any other normal physiological phase of life. Knowledge and beliefs about menopause is influenced by number of factors like education, marital status, physical activity and social background. Attitude plays an important role in experiencing menopause. It has been observed that adequate knowledge about menopause among women builds right perception which inculcates positive attitude towards menopause (ATM) in them, thereby improving their menopausal experience. Moreover, negative attitudes towards menopause are associated with negative experiences of menopause.^6-13 There is plenty of literature available on menopausal attitude from western society. However, this aspect of menopause remains unexplored in the Indian subcontinent especially Northern India. The purpose of this research was to have better understanding of ATM to improve the quality of life to this group of population.

METHODS

Research site

This community-based cross sectional study was conducted in villages falling under Keri zone of health Block Kot Bhalwal, Jammu.

Research approach

Exploratory research approach.

Source of data

Post-menopausal women from selected research site.

Study period

The study was conducted from November 2015 to August 2016.

Sampling method

Out of four health zones under Block Kot Bhalwal, Keri health zone was selected randomly. One village from this zone was randomly selected. On completion of survey in first selected village, next village was randomly chosen from the adjoining villages.

Method of data collection

After seeking ethical approval from institutional ethical committee, Government Medical College, Jammu, the study commenced with the sensitization of the members of Panchayat, women groups, social workers, accredited social health activist workers and other health workers of the randomly selected villages for assuring the proper cooperation at the time of data collection. Thereafter, all those postmenopausal women who agreed to participate in this study by giving informed written consent were covered in the study. Data collection was conducted by face-to-face interview on house-to-house visit. In order to maintain clarity of the study instrument, at the time of interview, the structured interview questionnaire was translated in the local language of the participants by researcher herself.

Tool for research

Data collection was done using two part questionnaire. The first part consist of information regarding Sociodemographic and lifestyle variables i.e., age, religion, marital status, education, monthly income, type of family, self-employment status, occupation of husband, no. of living children, smoking status and physical activity and was collected using semi-structured performa. The second part of questionnaire included information regarding attitude of study participants towards menopause and was collected using modified ATM scale.^14-16 The modified ATM scale comprised of 19 items, agreement with which is expressed on 5-point Likert’s scale ranging (1: strongly disagree to 5: strongly agree). Total score was calculated for each subject through summing up the points of the responses to each question and the mean attitude score for each person was calculated as well. The higher summary scores reflect an overall more positive attitude. The Cronbach’s alpha reliability of this scale for the current study was 0.82.

Statistical analysis

Data from the surveys was first entered into a master chart on a Microsoft Excel spreadsheet. For descriptive statistics, data was grouped, tabulated and presented as means with standard deviation and percentages for quantitative and qualitative variables respectively. For finding statistical significance, unpaired t-test and analysis of variance by using Open Epi version 3.1, were used wherever needed. P value ≤0.05 was considered to be significant.

RESULTS

A total of 245 postmenopausal women were interviewed during this study. The mean (±SD) age of the study participants were 56.49±9.9 years ranging from 36 to 106 years. Majority of the study women were in the age group 50-59 years (40.8 %) followed by age group 60-69 years (30.6%), and majority of the study participants were Muslims (52.3%). The detailed results of descriptive data have been published elsewhere.¹⁷

Table 1 displays the total percentage scores of agreement with each of the 19 statements about menopause on the ATM rank ordered by frequency of response. The highest percentage of agreement with the positive item was for “a woman gets more confidence in herself after menopause” (77%) and the lowest percentage of agreement with the positive item was for “going through menopause really does not change a woman in any important way” (42.5%). In the negative items, the highest percentage of agreement was for “a woman should see a doctor at menopause” (58.7%).

*: Positive item; ǂ: Mean±standard deviation and median of the total score of attitude was 62.30±11.25 and 64. (Range: 29-88); ǂǂ: Mean average attitude score was 3.02 (SD±0.34); ǂǂǂ: Both mode and median response was 4.

It was followed by another negative item, “menopause is one of the biggest changes that happen in a woman’s life” which had 54.1% agreement. More than 80% of study participants disagreed over the two negative items, i.e., “frankly speaking, just about every woman is depressed about menopause” and “menopause is a disturbing thing that women generally dread.” The item, “a woman is concerned about how her husband will feel about her after menopause” had equal number of agreement and disagreement responses of the participant.

As presented in the Table 2 there was a statistically significant mean difference between mean attitude score and religion (F value=3.14, p value=0.002). The results have also revealed a statistically significant association between number of living children a women is having with ATM mean score (p<0.0002). Other demographic parameters like age groups and marital status exhibited non-significant association with the ATM check list.

A high significant mean difference (f=3.680, p value=0.027) between various categories of education and attitude while rest of the socioeconomic parameters did not show any statistically significant mean difference for attitude. With respect to education, highest mean ATM score (78.50) was recorded in college/ university which was followed by higher secondary group (69.38) while lowest was recorded in primary/middle (61.79) and Illiterate group (61.38) (Table 3).

There was no statistical significant association for parameters like physical activity and smoking status with ATM scores (Table 4).

DISCUSSION

In our study responding to questions of the ATM Checklist; most of the study participants exhibited a positive ATM. Our results concur with the results of Leon et al as well as Adewuyi et al, thereby depicting that the positive frame of mind about menopause was consistent over different cultures.^18-20

70% of our respondents were in agreement to the statement “a woman gets more confidence in herself after menopause” in contrast to Ghadheri, Jasim and Huffman’s studies it was 46.3%, 43.1 and 51.8%.^9,21,22 The freedom from various cultural and religious restrictions after menopause can be cited reason for this finding.

Knowing more about menopause may enable women to better cope up with menopausal changes and this can be put forward as a justification for our finding in the present study that educated women had more positive ATM than their illiterate counterparts. This result was found in concordance with Avis et al.⁸ However, Tsehey et al, Cheng et al and Leon et al found a significant negative impact of education on menopausal perception.^12,18,23 On the other hand, Wilbur et al did not find any statistically significant relationship between women’s ATM and educational level.²⁴

The results revealed a statistically significant association of positive attitude with number of living children. The reason behind this association could be the moral support from the family members for women during this crucial stage of menopause. In this study, no significant difference in menopausal attitudes across marital status and age was found. Other authors from Ecuador and Ethiopia also reported similar results.^17,19

CONCLUSION

The general perception to menopause (as revealed by ATM checklist) was positive. A statistically significant association of attitude with religion, educational status and type of family was found. Health, education and planning ahead for challenges can make this period as one of the most rewarding and enriching time.

Recommendations

With growing emphasis on universal health coverage, it is the need of hour to improve women’s menopausal attitude hereby, experiences during this stage of life.It is imperative upon the authorities to identity the preventive strategies and incorporate counselling for this neglected segment of the society for improving quality of their life.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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