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Using a feminist approach, we examined the menopausal symptom experience of Hispanic midlife women in the U.S. This was a qualitative online forum study among 27 Hispanic midlife women in the U.S. Seven topics related to menopausal symptom experience were used to administer the 6-month online forum. The data were analyzed using thematic analysis. Four themes were identified: (a) “Cambio de vida (change of life),” (b) “being silent about menopause,” (c) “trying to be optimistic,” and (d) “getting support.” More in-depth studies with diverse groups of Hispanic women are needed while considering family as a contextual factor.
Ethnic differences in menopausal symptom experience have recently been reported (Adler et al., 2000; Avis et al., 2001; Berg & Taylor, 1999; Freeman et al., 2001; Crawford, 2007; Fu et al., 2003; Gold et al., 2000; Im & Meleis, 1999; Kravitz et al., 2003; Lasley et al., 2002; Lovejoy et al., 2001; McCrohon et al., 2000; Obermeyer, 2000; Oddens, 1994; Probst-Hensch et al., 2000; Randolph et al., 2003; Wilbur et al., 1998; Woods & Mitchell, 1999). In these studies, it was reported that the menopausal symptom experience of Hispanic women was highly prevalent and similar to that described among Western women (Pedro et al., 2003). Hispanic women were reported to have positive attitudes toward menopause, but they perceived menopause as a potentially disturbing transition associated with irritability and depression (Bell, 1995; Villarruel, Harlow, Lopez, & Sowers, 2002). Despite these findings, very little is still known about the menopausal symptom experience of Hispanic midlife women across the countries.
Because midlife is a multifaceted transitional stage in women's development (Palacios et al., 2002; Short, 2003; Rosenberger, 1993; Stotland, 2002; Woods & Mitchell, 1999), understanding of cultural contextual factors that may influence the menopausal symptom experience is essential (Carolan, 2000; Deeks, 2003; Hewner, 2001). Menopause occurs at a time of life when women are facing many threats and challenges (e.g., children leaving home, the illness of their partner, or the death of elderly parents), and cultural perspectives of these challenges vary depending on ethnic-specific cultural contexts (Woods & Mitchell, 1999). However, very little is also known about the influences of ethnic-specific cultural contexts on the menopausal symptom experience of Hispanic midlife women.
Through this study, we aimed to explore the menopausal symptom experience of a specific group of Hispanic women, Hispanic midlife women in the U.S., within the framework of their cultural attitudes toward menopause and ethnic-specific cultural contexts. The contextual understanding is essential for health care providers to provide culturally competent care for any ethnic groups of midlife women nationally and internationally (Lock, 1998; 2001; Lock, Kaufert, & Gilbert, 1988). The findings of the study reported in this paper could be used to help complete the picture of menopause in culturally diverse and complex socio-cultural contexts throughout the world.
The feminist approach suggested by Im (2007) was used as a theoretical perspective of the study. This approach can be used with both quantitative and qualitative methods. A qualitative approach was used in this study because a more in-depth exploration of the lived experience of menopausal symptoms among Hispanic midlife women was needed. In the feminist approach, researchers respect and prioritize research participants’ own views in order to help disclose their experience throughout the research process. Thus, in this study, menopausal symptoms were defined from the women's own views, and description of their experience was sought repeatedly throughout the research process. In the feminist approach, researchers need to view gender and ethnicity as the significant characteristics that may influence women's menopausal symptom experience and to carefully examine how these contexts may have influenced women's experience. Thus, ethnicity and culture were viewed as significant characteristics that might have influenced Hispanic women's menopausal symptom experience.
This study was designed as a qualitative online forum among Hispanic midlife women in the U.S. This was a part of a larger study comparing the menopausal symptom experience of four major ethnic groups (Non-Hispanic Whites, Non-Hispanic African Americans, Non-Hispanic Asians, and Hispanics) of midlife women in the U.S. More detailed findings on non-Hispanic White women's menopausal symptom experience have been reported elsewhere (Im, Liu, Dormire, & Chee, 2008). The online forum method was selected because it is a mechanism commonly used among middle-aged women to provide electronic emotional and informational support (Hsiung 2000).
The settings of the study were Internet communities/groups among midlife women (ICMWs) and Internet communities/groups for Hispanic women in the U.S. (ICHWs). In recent studies, the popularity of Internet communities/groups was indicated; the importance of these Internet communities/groups as a resource for researchers who are investigating middle-aged women who reside in different geographical areas was found (Baehring et al. 1997, Bowker & Liu 2001, Barrera et al. 2002). In order to reach Hispanic women in various geographical areas in the U.S., the study was nationally announced through the ICMWs and ICHWs.
A total of 27 Hispanic women were recruited using quota sampling method so that an adequate number of early peri-menopausal, late peri-menopausal, and postmenopausal women from diverse socioeconomic groups were included. Six to 12 participants are usually considered as ideal for focus groups including qualitative online forums (Stevens 1996). Among 27 participants, only 12 remained by the end of the 6-month online forum. Sociodemographic characteristics of the 27 women are summarized in Table 1.
Seven topics were used for the online forum: (a) language (terminology) used to describe menopause, symptoms, and menopausal symptoms and their linguistic meanings; (b) women's daily life schedules, and hardships and sufferings in daily lives; (c) culturally universal and specific descriptions of menopausal symptoms; (d) women's ethnic-specific attitudes and responses to menopausal symptoms; (e) women's perceived ethnic-specific causes of menopausal symptoms and management strategies for menopausal symptoms; (f) things/life events influencing women's menopausal symptom experience in their daily lives; and (g) women's preferences for symptom management strategies. Throughout the 6-month period of the online forum, each topic was serially posted. The online forum topics were developed from an earlier study by Im and Meleis (2000). Then, they were subsequently reviewed by seven experts in the area of menopause and/or qualitative research methods, and revised prior to use in this study.
Institutional Review Board approval at the home institution of the researchers was obtained prior to initiation of data collection. The Internet survey for the larger study was conducted before participants were invited to participate in the online forum. After participants agreed to be on the online forum, their ethnicity, socioeconomic status, and menopausal status were identified so that forum quotas could be maintained. Only those participants who met the inclusion criteria for the forum were permitted to register for the online forum. When they registered, IDs and initial passwords were emailed to the participants with a registration confirmation message; IDs and passwords were required for participants to log in to the online forum site. Each participant visit to the forum site was recorded and monitored. Only those who registered were allowed to enter the online forum to ensure confidentiality and protect privacy.
When a total number of 27 Hispanic midlife women were recruited for the online forum, the forum was initiated by emailing all participants that the forum was now initiated. When the participants visited the online forum site for the first time, in the opening page, introductory questions designed to enable participants to introduce themselves to other forum members were shown. At that time, the participants were asked to choose pseudonyms for the forum discussions so that their real names could not be identified by other participants. Next, the seven online forum topics were serially posted on the forum site and remained there for the entire 6 months so that the participants could post messages about the topics at their convenience. The participants were allowed to post the messages in any forms they wished (e.g., stories, conversations, responses to others’ messages, etc.). The number and length of messages were not limited, yet at least two messages per topic were required for reimbursement of participation.
Various retention strategies were used for this forum: (a) monthly e-mail messages to communicate the research team's continuing interest, inquire about how participation was going, and encourage continuing participation, (b) personal e-mails sent to the participants who had not posted a message for more than 2 months in order to determine if there were research participation issues, (c) e-mail birthday and holiday cards, and (d) an electronic quarterly study newspaper that reported the ongoing status of the research and announced any presentations or publications coming from the study.
Data were analyzed using descriptive content and thematic analysis (Boyatzis 1998). Data saved in ASCII files were first printed out as transcripts, and the transcripts were thoroughly read and re-read for line-by-line coding. A coding book was then developed by summarizing data from the line-by-line coding process. Categories were developed through internal cognitive processes and reflexive thinking analyzing content and contexts of the code book. After developing the categories, relationships between categories were formulated by mapping associative links among the categories. Themes representing the women's menopausal symptom experience were extracted through an interactive process that involved reading and re-reading text to produce successively more abstract and refined ideas about domains of interest. This analytic process was used as an ongoing system of checks and balances providing opportunities to double-check if specific codes, categories, and themes actually represented the participants’ own experience.
The standards for rigor in feminist qualitative research by Hall and Stevens (1991) were used to ensure rigor of the study (Hall & Stevens 1999). Dependability was ensured by examination of the methodological and analytical decision trails used during data collection and analysis. Another standard, reflexivity, was ascertained by maintaining a chronological research diary plus memos and field notes. Also, credibility and relevance suggested by Hall and Stevens (1991) were assured through posting the developing analytic categories on the online forum site and asking for participants’ reactions. Finally, adequacy was ensured through questioning research methods, goals, research questions, design, scope, analysis, conclusions, and impact of the study within the social and political environment continuously throughout the data collection and analysis process. In addition, biweekly group meetings with the research team were held to ensure the quality of data collection and analysis.
Four themes were identified through the data analysis process: (a) “Cambio de vida (change of life),” (b) “being silent about menopause,” (c) “trying to be optimistic,” and (d) “getting support.” Each theme is described in detail as follows.
The women viewed menopause as “just a change of life (Cambio de vida)” from one stage of their life to another stage, which is accompanied with physical changes moving them from their ability to conceive to loss of that ability. Many of the women perceived these physical changes as positive liberating them from a monthly menstrual period. Two women stated:
It's like you're a new person, a new beginning. The first half of your life is done with, and you're 100% adult. It's also a great freedom from many things; you're starting to if you haven't already done so to live for yourself with little or no regards as to what others have to say.
It's a natural process that all women go through and as far as the symptoms go, they too will pass. For me, I see menopause as almost liberating. I no longer have the heavy periods I had for many years, I feel more calm, I'm not affected by monthly mood swings.
Although menopausal symptoms were bothersome to some of the women, they thought that menopause is a natural process of life change and it would end ultimately. Two of the women wrote:
Menopause is just a part of life. If you just accept it and go on with it, it will be fine. I think that the important thing is to be aware of what you are feeling and to deal with it as best as possible. It's not the end of the world.
My initial response is to try to find a “cure.” Isn't there a pill I can take to make it all better?, but the realist in me says it will come to pass, I just need to be patient and good to my body and it will all pass.
While giving their attention to other life events, most of the women placed menopause in the lowest priority because it is a normal stage of their life. One woman stated:
The process of ending a 35 year marriage is the hardest thing I've gone through, especially trying to do this without bitterness...It's forcing me to look deep within myself and figure out what really makes me happy, and feel good about myself. My (menopausal) symptoms haven't changed all that much. But I am enjoying life with a better outlook...Menopause is not a concern to me because it will naturally go away.
Menopause was not discussed in the women's families because it was considered as a bodily thing, a female issue, and a private issue that should not be discussed even with their mothers. Two women wrote:
In my family didn't talk about such things. I don't know if this had anything to do with culture or not. I still wouldn't think of talking to my mom about this because she never wanted to discuss bodily functions. Since I was raised not to talk about menstruation, menopause or anything about body functions, I thought everyone felt this way.
I feel that historically the women in our culture have been less open about menopause as a whole which makes it difficult to get information from my mother or her peers. She will never share those types of issues because in her eyes, they are private matters.
Partially due to these cultural attitudes, all of the women who participated in the online forum tried to deal with menopausal symptoms by themselves. Women believed that they just needed to be patient until the transition passed. They also thought that silence would be the best way to deal with the symptoms. To many of the participants, the online forum of this study was the first time for them to talk about their menopausal symptom experience. Two women wrote:
I feel that our culture makes us a little likely to ask questions or share our concerns with others. I was always told to not make a fuss if wasn't feeling well...suffer in silence... A lot of patience is needed during this time. And don't forget that silence is the golden rule in menopause.
I really don't get education on menopause. As symptoms appear, I just try to adjust and take over the counter medication. And I don't really read or search the Internet on menopause. This forum is the only time I learn about menopause. I never realized how widespread the symptoms could be, I was suffering for a long time before I got help.
While trying to be optimistic about menopause and its symptoms, women tried to accept any menopause related difficulties and to adjust their life styles to adapt to the symptoms. The women tried to keep healthy lifestyles (e.g., eating healthy foods, exercising regularly, etc), which they believed a key element in successfully going through menopause. Also the women tried to get more rest than before. Two women stated:
This part of my life requires some real changes in how I live my life and maintaining a healthy lifestyle is one of the key elements in keeping all my symptoms in perspective. I am trying but not as hard as I should. I take more naps now than I ever took before and that is the biggest change in my life since menopause arrived.
I am still exercising now with more focus on stretching every part of my body, they say this is an excellent tool to relax one's spirit and also one's body. Well, I prefer trying to take better care of myself like eating healthier and exercising.
Although most of the women rarely shared their menopausal symptom experience even with their family members, many of the women mentioned about how supportive their families had been during the transition. The women identified that, in their culture, people believe that women in the menopausal transition need to relax more than usual. Because of this cultural attitude, the women found their families supportive during the menopause transition, they could increase the amount of rest they had, and they could decrease their stress along with managing their physical changes due to menopause. Two women mentioned:
I feel that my culture definitely recognizes them and realizes that a woman needs to relax when she is in that state of her life. My friends and family are forever telling me to relax and get some extra sleep because of menopause. I think in my culture, people take menopause more seriously than other cultures.
My family stresses that I get some extra sleep when I come home from work....My culture views menopause as a serious time in a woman's life and they are willing to comfort the woman in her time of need.
Only one woman mentioned about getting support from their friends. Sharing menopause with friends alleviated her menopausal symptoms and assured her that she was just going through a normal life stage. The woman wrote:
The friends I have now from this generation say it is exactly how it is spelled, “take a pause from men” and go out with women. My sisters who are a couple of years younger will follow in my mothers footsteps. I moved away and was affected differently. I don't know who is right or if there is a right or a wrong. All I know is that it can be a rollercoaster ride. We can share more with each and not feeling that we're going crazy when we have these setbacks... The people I work with are very supportive and happy that I will be spending time with my family members.
In addition, some women searched the Internet to get more information on menopause and to see how others coped with menopausal symptoms. One woman wrote:
I spend time with myself, I also like to research what other people do who have the same things I am dealing with, I like to find this info on the internet using different forums such as this one, or discussion boards or even blogs.
Based on the findings of the study reported in this paper, we could support the importance of contextual understanding in providing culturally competent care for women in culturally diverse and complex socio-cultural contexts throughout the world. In this study, it was found that the Hispanic midlife women's menopausal symptom experience in the U.S. was circumscribed by the socio-cultural contexts of their daily lives. In the socio-cultural contexts, the Hispanic midlife women in the U.S. normalized their experience and tried to adjust the changes of menopause while being silent about menopause and its symptoms. They also tried to be optimistic and got support through their families and friends and the Internet. All the themes that we found in this study were reported in the current literature, but one theme, “getting supports,” tends to be new to the literature on the menopausal symptom experience of Hispanic women.
The first theme, “Cambio de vida (change of life), has frequently been reported in the literature across ethnic groups including Hispanics (Im & Meleis, 1999; Villarruel et al., 2002; Woods & Mitchell, 1999). Menopause has frequently been associated with a cluster of symptoms (Avis et al., 2001), which are frequently connected to declining levels of estrogen and have been assumed to be experienced by all women during the menopause transition, regardless of ethnicity (Gill et al., 2002; Riggs, 2002). Menopause has also been reported to occur at a time of life when women are facing many threats and challenges including changes in their social roles, stresses of parenting adolescent children, children leaving home, the illness of their partner, or the death of elderly parents (Palacios et al., 2002; Short, 2003; Rosenberger, 1993; Stotland, 2002; Woods & Mitchell, 1999). The literature is also clear about that menopause usually means a natural transition in women's life cycle that they have to go through (Adler et al., 2000; Villarruel et al., 2002). Thus, in this aspect, we could say that the menopausal symptom experience of Hispanic women in the U.S. was similar to that of other groups of midlife women.
The second theme, “being silent about menopause,” has also been reported in the existing literature on menopausal symptom experience among ethnic minority women in the U.S. Women in many non-Western or developing societies were reported not to disclose or discuss their menopausal symptoms with others including their own family members (Im & Meleis, 1999; Lock, 1998; Oddens, 1994). Furthermore, in some studies among international populations, it was reported that menopausal women did not place any meaning on menopause and menopausal symptoms because of their cultural backgrounds (Lock, 1998; Oddens, 1994). Similarly, it was reported that some groups of ethnic minority women in the U.S. were silent about their menopause, did not disclose menopausal symptoms, and tried to live normal lives (Im et al., 1999b). Consequently, the women frequently ignored symptoms of menopause because of prevailing cultural attitudes (Im et al., 1999b). This theme can mean a concern to health care providers because some menopausal symptoms that Hispanic women may ignore and be silent might mean serious diseases (e.g., diabetes, cervical cancer, etc).
The third theme, “trying to be optimistic,” can also be found in the existing literature on menopausal symptom experience across ethnic groups (Agee, 2000; Berg & Taylor, 1999; Im & Meleis, 1999). Researchers have recently found that midlife women in some ethnic groups showed more positive attitudes toward menopause compared with others (Sampselle et al., 2002a; Sommer et al., 1999). African American women viewed menopause as a normal, even welcome, part of life (Sampselle et al., 2002a). Although African American women were also attuned to the physical signs of aging, their affirmation of menopause as “just a part of life” seemed to be the stronger response (Sampselle et al., 2002a). Furthermore, Asian women living in cultures where social status increases with age have also been reported to have positive attitudes toward menopause and aging (Chompootweep et al., 1993; Im et al., 1999a; Lock et al., 1988; McCarthy, 1994; Ramoso-Jalbuena, 1994; Samil & Wishnuwardhani, 1994; Weng et al., 2001). Hispanic women have also been reported to have positive attitudes toward menopause (Bell, 1995; Stewart,2003; Villarruel et al., 2002). This positive and optimistic view on menopause has been reported to be negatively associated with menopausal symptoms, which can be interpreted as a good indicator of women's successful menopausal transition (Bell, 1995; Lock, 1998; Sampselle et al., 2002a; Sommer et al., 1999).
The final theme, “getting support,” can be interpreted in the contexts of “familism” in Hispanic culture, but includes new information on Hispanic women's menopausal symptom experience. “Familism” is a well-known cultural tradition of Hispanics that respects responsibility toward family even at the expense of their own needs (Lagana & Gonzales-Ramirez, 2003; Marshall et al., 1998; Salazar, 1996). However, very little has been known about how familism influences Hispanic midlife women's menopausal symptom experience. This final theme of “getting support” is grounded in how familism is beneficial for Hispanic midlife women in their menopausal transition. Although the women did not talk about their menopausal transition to their families, the women could get strong support from their family because their family considered and cared about the needs for help of midlife women. Actually, this finding is similar to those found among Mayan women in Mexico who did not report any symptoms, whose menopause was welcomed in their culture, and who mostly accepted menopausal symptoms with equanimity and rejoiced at the cessation of their periods (Beyene & Martin, 2001; Stewart, 2003).
The findings of this study must be carefully interpreted because the Hispanic women who participated in the study did not represent all the diverse ethnic subgroups of Hispanics. For example, the Hispanic population in the U.S. is a blend of cultural groups with approximately 59 % of Hispanics of Mexican origin, 10% Puerto Ricans, 4% Cubans and the remaining 27% of other Hispanic origins (US Census Bureau, 2001). Yet, in this study, about 33.3 percent were Mexican, 11% were Puerto Ricans, 3% were Venezuelans, 11% were mixed, and 47% did not report their specific sub-ethnicity.
Also, the participants tended to be a select group of Hispanic midlife women because they were recruited only through the Internet and the study was conducted only online. Despite the changing sociodemographic composition of Internet populations, women recruited through the Internet still tend to be well-educated, high-income women (Im et al., 2008). Furthermore, only English was used in the online forum limiting participants to those who read and write English. Thus, the participants might be a selected group of highly acculturated Hispanic women compared with those who cannot read and write in English.
The findings of the study reported in this paper add an important piece of information to the current literature on menopausal symptom experience of Hispanic women. In this study, it was found that Hispanic midlife women in the U.S. rarely disclosed their menopause and menopausal symptoms with others including their own families, but they were optimistic and positive about their menopause and menopausal symptoms. Also, in this study, it was found that Hispanic women got strong support from their families during their menopausal transition. Based on these findings, we want to propose the following implications for health care practice and research with Hispanic women, nationally and internationally.
First, cultural values, beliefs, and attitudes related to menopause and menopausal symptoms need to be further explored among diverse national and international groups of Hispanic midlife women. Because of the inherent limitations of Internet recruitment, the participants of this study tended to be a selected group of Hispanic midlife women in the U.S. Thus, further investigation of the menopausal symptom experience of Hispanic midlife women must include diverse national and international groups of Hispanic women to complete the picture of menopausal symptom experience of Hispanic women. Menopausal symptom experience of Hispanic women in rural areas of Mexico would be different from that of Hispanic women in New York City in the U.S. Second, more in-depth studies on communication issues between diverse national and international groups of Hispanic midlife women and health care providers are needed for better understanding of their menopausal experience and management of the symptoms of menopause. Women's cultural attitudes toward menopause and its symptoms may prohibited them from disclosing their experiences even with their family members; cultural prohibitions regarding discussion of personal health issues and concerns related to menopausal symptoms could have significant impact on relationships with health care providers who are total strangers to them. Subsequently, their being silent about menopausal symptoms could possibly result in ignorance of some symptoms of drastic diseases that could be treated and cured at an early stage. Finally, the study reported in this paper indicated that families were a strong source of support for the Hispanic women during the menopause transition, although the women did not disclose their experience to their family. Thus, we suggest that families be considered in future research and health care as an important support source in menopausal symptom management for Hispanic midlife women, nationally and internationally.