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Little is known about how culture influences menopausal symptom experience, and few comparative qualitative studies have been conducted among multiethnic groups of midlife women in the United States.
To explore commonalities and differences in menopausal symptom experience among four major ethnic groups in the US (Whites, Hispanics, African Americans, and Asians).
This was a secondary analysis of qualitative data from a larger national Internet-based study. The qualitative data from 90 middle-aged women in the US who attended four ethnic-specific online forums of the larger study were examined using thematic analysis.
The themes reflecting commonalities across the ethnic groups were: just a part of life, trying to be optimistic, getting support, and more information needed. The themes reflecting the differences among the ethnic groups were: open and closed, universal and unique, and controlling and minimizing. Overall, the findings indicated positive changes in women’s menopausal symptom experience, and supported the existence of cultural influences on women’s menopausal symptom experience across the ethnic groups.
Systematic efforts need to be made to empower midlife women in their management of menopausal symptoms.
Recently, researchers have reported ethnic differences in menopausal symptoms, and there has been a growing challenge to universality of menopausal symptoms (Avis et al., 2001). Despite these findings, most knowledge about the existence and management of menopausal symptoms still comes from studies of White women (Andrist & MacPherson, 2001). Furthermore, researchers rarely have explored qualitative commonalities and differences in menopausal symptom experience among diverse ethnic populations in the United States (Im, 2009; Sampselle, Harris, Harlow, & Sowers, 2002).
Although there is a lack of knowledge on ethnic commonalities and differences in the menopausal symptom experience, it has been reported frequently that some cultural values, meanings, and attitudes are associated with menopausal symptom experience of specific ethnic groups (Beyene, Gilliss, & Lee, 2007; Sievert et al., 2008), including those related to aging; middle age; the end of reproductive life; menstruation; women’s bodily experiences; women’s social status; physical, psychological, and psychosomatic symptoms; sexuality; women’s work; industrialization; Western and traditional medicine; hormone replacement therapy; the medical and pharmacological industries; and immigration transition (Beyene et al., 2007; Sievert et al., 2008). However, little is known about how culture--including cultural values, meanings, and attitudes--influences menopausal symptom experience.
The purpose of the study was to explore commonalities and differences in menopausal symptom experience among four major ethnic groups of midlife women in the United States (Whites, Hispanics, African Americans, and Asians) through analyzing the qualitative data from a national Internet study. Here, middle age means the period of life from age 40 to 60 years when women go through physiological changes associated with the cessation of menstruation. Symptom experience means subjective experiences reflecting changes in a person’s biopsychosocial function, sensation, and cognition (Blacklow, 1983). This in-depth qualitative comparison of menopausal symptom experience among the four ethnic groups could provide significant information on how culture circumscribes women’s menopausal experience and contextual understanding of how women in different cultures perceive and manage menopausal symptoms. Furthermore, qualitative comparison could provide direction for culturally competent menopausal symptom management in the multiethnic U.S. society.
A feminist approach by Im (2007) was taken for this analysis. Based on this approach, it was assumed that inadequate management of menopausal symptoms comes not only from pure biology, but also from women’s continuous interactions with their environments and from biases reflecting the ways they and their health care providers view the world. In addition, women’s views and experiences were prioritized as the approach prescribed. Also, based on the feminist approach, ethnicity was considered to be a significant characteristic that influences menopausal symptom experience. Finally, as the feminist approach suggested, the focus of this study was what women perceived about their menopausal symptom experience, and on ethnic-specific contexts within which women described experiencing menopausal symptoms.
The institutional review board of the researchers’ institution approved the study. This study was a secondary analysis of a larger study, including both quantitative and qualitative sections, comparing the menopausal symptom experience of four major ethnic groups in the United States through an Internet survey and four ethnic-specific online forums (Im, Lee, Chee, Dormire, & Brown, in press, 2009a, 2009b). Only qualitative data from the four online forums were used for this secondary analysis. More detailed information on the Internet survey and the ethnic-specific online forums can be found elsewhere (Im et al., in press, 2009a, 2009b). The online forums allowed both asynchronous and synchronous communication, through which potential research participants could be approached in various geographical areas promptly and directly heard about their opinions and experiences (Kollock & Smith, 1999). It also provided an inexpensive, efficient access to the women across the country.
The settings of the larger study included Internet communities or groups (ICs) for middle-aged women and ICs for ethnic minorities, including ICs for ethnic-specific churches, organizations, forums, health care centers, and professional groups. More detailed information on the settings can be found elsewhere (Im et al., 2009a). Through these two types of ICs, 512 women (160 Whites, 120 Hispanics, 121 African Americans, and 111 Asians) were recruited for the Internet survey that was a part of the larger study. Among the 512 women, 90 were recruited for four ethnic-specific online forums. This sample size was considered adequate for the online forums because 6–12 participants are thought to be ideal for a focus group discussion (Stevens, 1996). All participants in the online forums were middle-aged women who could read and write English; who were online; whose self-reported ethnic identity was Hispanic, White, African American, or Asian; and who were early perimenopausal, late perimenopausal, or postmenopausal. Being online means that the women were familiar with the Internet as a medium of communication and had access to e-mail and the web. For the online forums, only English was used because using multiple languages was considered to be practically unfeasible. Subsequently, only those who could read and write English were recruited for this study. The four ethnic groups were chosen because they were the most common ethnic groups in the US (US Census Bureau, 2000). Quota sampling by menopausal status and socioeconomic status was used to recruit an adequate number of women from each menopausal, ethnic, and socioeconomic category. Sociodemographic characteristics of the participants (only those retained by the end of the 6-month period of the online forums) are summarized in Table 1. The data on sociodemographic characteristics were obtained through the Internet survey, using questions on sociodemographic characteristics, ethnicity-related factors, and self-reported health and menopausal status.
For the online forums, seven topics related to menopausal symptom experience and ethnic-specific contexts surrounding women’s menopausal experience were used. The topics and sample prompts are in Table 2. Each topic included 5–8 prompts. The topics and related prompts were reviewed by five experts in menopause and two experts in qualitative research methods in previous studies, and then modified to reflect feedback from the experts (Im & Chee, 2005).
For the larger study, a project website was developed, which conformed to the Health Insurance Portability and Accountability Act (HIPAA) and the joint SysAdmin, Audit, Network, Security Institute (SANS)/Federal Bureau of Investigation recommendations. The project website included an informed consent sheet, Internet survey questions, and ethnic-specific online forum sites. Through the study announcements, potential participants were asked to visit the project website using their usual access to the Internet (either their own computer of wherever they usually got online). When potential participants came to the project website for the first time, the opening page showed the general purpose of the study, and the visitors were asked to click to enter the “informed consent sheet.” Then, the participants were asked to read the informed consent and to click the “I agree to participate” button to give consent to participate. After getting their consents, the potential participants were screened against the inclusion criteria and quota requirements by computer-side automatic programs. Then, they were linked in to the Internet survey site that included questions on sociodemographic characteristics, ethnicity-related factors, health and menopausal status, and the Midlife Women’s Symptom Index (Im & Chee, 2005).
When they completed the Internet survey, women were asked if they would be interested in participating in an additional online forum. Only those who checked yes were contacted. In the contact e-mail messages for the initiation of the online forums, the usernames and passwords that they could use to log in to the online forum sites were provided. The women were asked to introduce themselves when they logged in to the online forum site for the first time, and encouraged to engage in the discussion on the topics. Two to three new topics were posted in the online forum site each month, and the women were asked to post messages at their convenience. The women were informed of the duration of the online forums and what would be expected from them during the forums. In each ethnic-specific online forum, the women were asked to add topics that they wanted to discuss with other participants at the end of the 5th month; only 1–2 topics related to menopause were added for each ethnic-specific online forum. Each topic included 5–8 related prompts that were used to steer the discussion. In the final month, participants discussed the added topics as needed. The researchers moderated the online forums and monitored and controlled the access of the participants to the forum sites while preventing possible hacking attempts. Retention rates in the online forums ranged from 44% (Hispanics) to 97% (Whites). More detailed information on data collection procedures can be found elsewhere (Im et al., in press, 2009a, 2009b).
For this secondary analysis, the qualitative data from the four ethnic-specific online forums were examined using thematic analysis (Boyatzis, 1998). Serial identification numbers assigned by the researchers were attached to the online forum data. The data analysis process began as soon as the data were collected. The data were printed out as transcripts from each ethnic-specific online forum, then the printed transcripts were read thoroughly for line-by-line coding. The codes were summarized in a coding book used to develop categories. To extract the themes representing menopausal symptom experience and ethnic-specific contexts of each group, relationships between categories were formulated by mapping associative links among the categories. For each ethnic group, 3–4 themes were extracted based on the relationships between categories. Qualitative comparisons were made among the four ethnic groups to explore ethnic-specific contexts. In addition, the interactive process that involved reading text to produce more abstract and refined ideas about domains of interest was used to identify themes common to and different across the ethnic groups. During the analysis process, possible effects of variable contextual factors including health status, socioeconomic circumstances, family responses and roles, stability of the women’s daily lives, and social support networks were examined by carefully reading the transcripts. Any changes in the women’s views during the 6-month period of the online forums were examined.
The standards of rigor in feminist qualitative research by Hall and Stevens (1991; dependability, reflexivity, credibility, relevance, and adequacy) were used. To ensure dependability of each ethnic-specific online forum, the methodological and analytic decision trails created by the investigators during the course of the study itself were examined. A chronological research diary, memos, and field notes were written to support reflexivity. To achieve credibility and relevance of the study, the developing analytic categories were posted on the website, and the women were asked to provide their feedback on the analysis. To assure adequacy of the study, research methods, goals, research questions, design, scope, analysis, conclusions, and impact of the study within the social and political environment were questioned continuously. In addition, monthly group meetings with the research team were held to ensure the quality of data collection and analysis.
Four themes reflecting commonalities in menopausal symptom experience among the four ethnic groups of midlife women and three themes reflecting differences among the groups were extracted.
Across the ethnic groups, women viewed menopausal symptoms as an unavoidable and unstoppable part of their lives. The women perceived and accepted the changes brought by the menopausal transition and felt that they became more mature than ever before. The following are what two women wrote:
I usually call periods ‘that time of the month’ or ‘women troubles.’ As for menopause I usually just refer to it as ‘the changes’ since I guess that is what it really is. Funny how when reading some of the other posts it occurs to me yet again that something that is natural and part of our development as women is usually referred to in ‘abnormal’ or troublesome type of terms. [White woman]
The change of life which I have always heard it been called in Hispanic culture is like entering a new phase in your life. Your body is going through changes, irregularity or end of periods, and your way of thinking changes. [Hispanic woman]
Across the ethnic groups, the women tried to be optimistic about their menopausal symptom experience. They tried to be humorous and laughed a lot during stressful changes, while trying to embrace menopause and subsequent symptoms. They tried to be positive about their lives, menopause, and menopausal symptoms. Some of them mentioned relief and benefits from menopause. To many of them, menopausal symptoms were a sign of “maturity” and “increasing wisdom.” Two women mentioned:
I feel that we…should be embracing this new part of our life and see where it leads us instead of focusing on the negative aspects of this. If we look back at our life…we…had changes and we dealt with them and continued on to become mature women. [White woman]
Menopausal symptoms aren't exactly enjoyable but everything in life is about growth and learning. If we keep that in mind than focus on discomfort, the journey is much more fulfilling.” [Asian woman]
Women across the ethnic groups were getting support from their family members and friends. Although there were slight ethnic differences in the sources of social support, the women were satisfied with the support that they were getting. Support was sometimes inaudible and invisible--family members and friends helped them without the women sometimes knowing about it at the time. Interestingly, ethnic minority women preferred support from those who were of the same ethnicity, gender, and age. Two women wrote:
Fortunately I’m in a phase of life with the age of the last kid in the house and with my husband having grown more attuned to my needs, where I finally feel entitled enough to ask for help when I need it. They made dinner without making me feel guilty, and my husband rubbed my back…It made me feel appreciated and loved. [African American woman]
I think that most of us Hispanics come from a male dominated world, so we definitely don’t talk to the men in our life, but the women of my community we do share a lot. We absolutely need each other to survive and thrive. [Hispanic woman]
Women across the ethnic groups mentioned a lack of information on menopause and menopausal symptoms. All the women wished for better treatment by their physicians regarding their menopausal symptoms. Many of them searched the Internet for more information, feeling that they did not have much information about or knowledge of menopause and menopausal symptoms. Most sources of information were informal, such as friends, women’s magazines, sisters, or mothers. Some women mentioned wishing for educational programs on menopausal symptoms. Two women wrote:
I’d like to say that WebMD is a great source of information for any medical conditions. I also don’t hesitate to ask the doctor lots of questions when I’m there. And when all else fails, I ask my family and friends what helps them get through… [Hispanic woman]
Because of the information age we live in, and the openness of society today, one way that I deal with my problems and discomfort and frustrating symptoms, is to search for solutions and read experiences of folks. [Asian woman]
One prominent difference between the White women and the other ethnic groups was that White women tended to be open about their menopausal symptoms and freely discussed them, while ethnic minorities mentioned staying silent about menopausal symptoms. The ethnic minority women thought that it was inappropriate to discuss menopausal symptoms in their cultures. Some of them even mentioned that this online forum was their first time talking about their menopausal symptoms. The following comments contrast the differences between White women and the other ethnic groups:
I think we deal with it very openly, I was just going through a local magazine today listing activities and amusements in our area and one of them was a theater production called “Menopause the musical.” It really struck me as funny. Menopause is now discussed in TV ads, many magazines are dealing with help tips on how to deal with menopause, as was said before it’s much more open now. [White woman]
In my specific culture we are taught as Black women to survive, no matter how you feel, so menopausal symptoms were not really discussed until my sisters and I reached that point in our lives when we started having the symptoms ourselves. [African American woman]
Another interesting ethnic difference in menopausal symptom experience was that most of the White women perceived menopause and menopausal symptoms as a universal experience that all women went through in the same way, while most of the ethnic minority women thought that there were unique situations (e.g., genetic differences, immigration transition, financial difficulties) that made their menopausal symptom experiences unique in their culture. The following show how White and ethnic minority women perceived menopausal symptom experiences differently:
I think that the symptoms are pretty much the same for everyone no matter what ethnic group or race you are. What’s inside a woman’s body is pretty much the same as every other woman. [White woman]
In my culture we are used to just getting along and not complaining a lot about natural things like pregnancy, menopause, etc. Like in the western world there are terms like post-partum depression etc., these terms are unheard of in my culture. We just have to get along and take things in our stride instead of making a big deal out of it. [Asian woman]
White women tended to control menopausal symptoms by making clinical visits and using diverse strategies for symptom management, while ethnic minorities tried to minimize their symptoms by mainly enduring the symptoms. At most, ethnic minority women took some over-the-counter medicines in case of intolerably severe symptoms. The following show how women talked about their menopausal symptom management.
I went running to my General Practitioner when my symptoms first started…She calmed me down a little and referred me to an OBGYN. He diagnosed my “disorder” as menopause and discussed it with me at length. He said we may consider HRT at some future date…I prefer relaxation therapy and acetaminophen… [White woman]
As African American women, we are always expected to be strong women who aren’t supposed to whine about anything. You just take life as it comes and do what you have to do. If you are having troubles or problems, you should just pray about it and keep going. I don’t think that my culture believes that menopausal symptoms are something that you would have to run to the doctor. [African American woman]
In this study, both commonalities and differences in menopausal symptom experience among four major ethnic groups of midlife women in the US were found. Some of these findings have already been seen in the literature, but others add new information. First, the themes of just a part of life and trying to be optimistic have been reported frequently in the literature on menopausal symptom experience of ethnic minority women, including Asian, African American, and Hispanic women (Im & Meleis, 2000; Lock, Kaufert, & Gilbert, 1988; Sampselle et al., 2002; Villarruel, Harlow, Lopez, & Sowers, 2002). However, these themes have been reported rarely in the literature on menopausal symptom experience of White women. Rather, White women have been reported in the literature as considering menopause as a harbinger of physical aging and the ensuing disadvantage of diverging from society’s youthful ideal (Sampselle et al., 2002; Sommer et al., 1999). The positive views of menopausal symptoms that were found in this study have been reported to be associated negatively with menopausal symptoms, which is interpreted subsequently as a positive indicator of women’s successful menopausal transition (Lock et al., 1988; Sampselle et al., 2002). Thus, the fact that these themes were found even among White women may mean a positive change in the women’s attitudes.
The themes of getting support and more information needed can be interpreted also as positive changes in women’s menopausal symptom experiences. Usually, White women have been reported to get adequate support from family members and friends during the menopausal transition (Sampselle et al., 2002), but ethnic minority women have been reported to be marginalized during their menopausal transition and to go through their transition without adequate support (Grisso, Freeman, Maurin, Garcia-Espana, & Berlin, 1999; Im & Meleis, 2000; Lock et al., 1988). Thus, the fact that getting support was found among all ethnic minority groups can be interpreted as a positive change for women’s health and well-being during the menopausal transition. Also, the theme of more information needed has been reported rarely in the literature on menopausal symptom experience of ethnic minority women. Rather, the hesitance to disclose menopausal symptoms has been reported frequently among ethnic minority women (Cooper & Barthalow Koch, 2007; Grisso et al., 1999; Strickland & Dunbar, 2000). Thus, this theme as a common finding across the ethnic groups can be viewed as a positive sign for the health and well-being of ethnic minority midlife women.
The three themes reflecting ethnic differences in menopausal symptom experience have been reported episodically in the literature. However, they have been reported rarely in the studies in which different ethnic groups were compared. Indeed, very few comparative studies have been conducted, and all of these studies were quantitative in nature, with very little information on ethnic commonalties and differences in menopausal symptom experience provided (Avis et al., 2001; Gold et al., 2006). Despite the lack of the comparative studies, the theme of open and closed is found frequently in the literature on menopausal symptoms. As discussed above, ethnic minorities tended not to discuss their menopausal symptom experience with others because of cultural values, beliefs, and attitudes related to menopause itself; symptoms of menopause; aging; women’s body issues; and women’s health in general (Cooper & Barthalow Koch, 2007; Grisso et al., 1999; Strickland & Dunbar, 2000). However, the finding reported in this paper is more positive than previous findings because the ethnic minority participants of this study mentioned their needs for information and their getting support from family members and friends as discussed above.
The theme of universal and unique reflects ethnic differences in women’s views on cultural influences on menopausal symptom experience. Because of recent reports on ethnic differences in menopausal symptoms (Avis et al., 2001; Gold et al., 2006; Randolf et al., 2003), researchers began to consider that menopausal symptom experiences might be ethnic-specific. However, little is known about how women themselves view and perceive ethnic differences in menopausal symptom experience. Thus, this theme would inform the literature of how women themselves view cultural influences on their menopausal symptom experience. However, the reasons that some specific ethnic groups viewed menopausal symptoms as a universal experience while others viewed them as culturally unique experiences were not clear in this study.
The final theme of controlling and minimizing has been reported in the literature; ethnic minorities tend to manage their symptoms by tolerating, ignoring, normalizing, and minimizing (Cooper & Barthalow Koch, 2007; Grisso et al., 1999; Strickland & Dunbar, 2000) while White women tend to adopt diverse management strategies for menopausal symptoms (Brett & Cooper 2003; Whiteman, Staropoli, Benedict, Borgeest, & Flaws, 2003). The controlling theme among the White women might come from the individualism embedded in White culture, wherein individualists are viewed as having control over and taking responsibility for their actions (Green et al., 2003). The minimizing theme among ethnic minority women might come from their unique cultural attitudes and values related to being women in their patriarchal culture and cultural stoicism. For example, African American culture that emphasizes that women should be strong (Bailey, Erwin, & Belin, 2000) might make African Americans minimize their menopausal symptoms so that they would not be viewed as whiners.
In this study, there are several limitations because the participants tended to be a selected group of midlife women. For example, subethnic compositions of each ethnic group did not represent all the diverse ethnic subgroups within each major ethnic group. Also, retained participants tended to be highly educated midlife women with high incomes, despite the quota sampling to ensure diversity of the samples. Furthermore, all the women had access to the Internet and were able to use computers to interact each other. Finally, the original intent was to include only early peri-, late peri-, and postmenopausal women in order to get vivid descriptions of their menopausal symptom experience. However, 8 premenopausal women were included in the final sample because of discrepancies in their data on menopausal status between the Internet survey and the online forum; this may limit interpretation of the findings.
The findings reported in this paper indicated some positive changes in women’s menopausal symptom experience across the ethnic groups, and supported the existence of cultural influences on women’s menopausal symptom experience across the ethnic groups. Based on these findings, the following implications are presented. First, researchers and health care providers should consider these recent positive changes in women’s attitudes toward menopause and menopausal symptoms in their health care practices and research projects. These positive changes could be interpreted to have occurred as a result of the collective efforts in the US by increasing numbers of women’s health groups, projects, health centers and clinics, and health professionals who have provided education and contributed to change health policy legislation to improve the quality of women’s health care (i.e., National Women's Health Network 2002). These systematic efforts should be made continuously to empower the women in self-management of menopausal symptoms. Also, researchers and health care providers should develop and test educational programs to provide information and knowledge on menopause and menopausal symptoms. The participants of this study clearly expressed their need for more information, and some of them even expressed their need for educational programs. Probably, Internet educational programs based on virtual (not face-to-face) interactions would be more acceptable to ethnic minority women because they would not need to disclose their identities to discuss their menopausal symptoms or to get information on menopausal symptoms.
This study was conducted as part of a larger study funded by the National Institutes of Health (NIH/NINR/NIA; R01NR008926). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Thank you to the research assistants, Chia-Chun Li, Enrique Guevara, Yi Liu, and Hyun-Ju Lim, who helped in recruitment, data collection, and data analysis.
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Eun-Ok Im, La Quinta Motor Inns Inc., Centennial Professor, School of Nursing, The University of Texas at Austin, Austin, Texas.
Bok Im Lee, School of Nursing, The University of Texas at Austin, Austin, Texas.
Wonshik Chee, College of Engineering, The University of Texas at Austin, Austin, Texas.
Sharon Dormire, School of Nursing, The University of Texas at Austin, Austin, Texas.
Adama Brown, School of Nursing, The University of Texas at Austin, Austin, Texas.