KNOWLEDGE, ATTITUDE AND EFFECTS OF MENOPAUSAL CHALLENGES AMONG OLDER WOMEN IN ISEYIN LOCAL GOVERNMENT.

CHAPTER ONE

INTRODUCTION

Background of the study

The experience of menopause varies among women as they age. Adolescent females between the age range of 45 to 55 years are naturally affected by this phenomenon (Faubion et al., 2015; Laven et al., 2016; World Health Organisation [WHO], 2022). Menopause is the process by which ovarian function declines and menstruation stops (WHO, 2022). The absence of a monthly menstrual cycle for a duration of 12 months, without any identifiable biological or physiological cause, is often acknowledged (World Health Organisation, 2022). Menopause, sometimes referred to as the transitional phase in a woman's life, denotes the conclusion of her reproductive phase and the start of the ageing phenomenon (Hatice et al., 2016). 

The onset of menopause may be attributed to the inefficiency of DNA repair mechanisms, which contribute to the ageing process of the soma. This ageing process ultimately leads to the inability to reproduce and the subsequent manifestation of natural menopause (Laven et al., 2016). Therefore, menopause is an inherent phase in a woman's life that warrants comprehension, assistance, and self-preservation.

Comprehension, assistance, and self-preservation during menopause are particularly crucial due to the potential physical and psychological changes and challenges that may arise during this period. During the menopausal phase, women may encounter a range of physiological manifestations, such as hot flashes, irregular menstrual cycles, and dyspareunia (World Health Organisation, 2022). In addition, it seems that the occurrence and severity of these symptoms are impacted by several factors, including education, self-esteem, anxiety, and low levels of blood oestrogen (Zhang et al., 2020). 

In addition to these factors, age has a substantial influence on psychological concerns during menopause. Multiple studies have shown that natural menopause does not have any detrimental impact on the mental well-being of middle-aged women who are in good health (Busch et al., 2016). Nevertheless, it has been shown that women who deviate from the expected age patterns in terms of the initiation of natural menopause, whether it occurs sooner or later, tend to have more pronounced symptoms of sadness and psychological distress (Faubion et al., 2015). In due course, women may navigate this transition with more ease and comfort if they possess knowledge about the many elements that influence menopausal symptoms. However, formal education for women often does not include coverage of menopause, and a significant number of general practitioners possess insufficient expertise in the management of menopause (Harper et al., 2022; WHO, 2022). Furthermore, it is worth noting that menopause has often been seen as a deficient ailment and a detrimental encounter throughout a woman's lifespan by both the media and the medical community (Harper et al., 2022). 

Similarly, Brewis, Beck, Davies, and Matheson (2017) emphasised that previous research has shown menopause as a medical ailment that elicits more negative emotions, rather than presenting it as an inherent aspect of the ageing process or a process of life transition (Arseneau et al., 2021; Hickey et al., 2022). Although menopause is significant, there is a lack of adequate formal knowledge on this topic. Consequently, women may possess incorrect perspectives about menopause, which might impact their perception and readiness for this phase of life. Hence, it is crucial to do research that perceives menopause as an inherent phase, with a specific emphasis on its beneficial outcomes. It is crucial to present menopause in a more optimistic light, since attitudes about menopause seem to impact the intensity of menopausal symptoms and the overall experience of menopause (Arseneau et al., 2021). 

According to Beck, Brewis, Davies, Fish, and Garlick (2016), an attitude refers to an individual's emotional response and evaluation of an item or event. Hence, menopausal attitudes may be defined as the evaluation and position on the occurrence of menopause. Numerous research conducted so far have shown that women's perspectives on menopause may be shaped by a range of characteristics, including their menopausal state, social background, educational attainment, and self-perceived mental and physical well-being. An instance of enhanced attitudes towards menopause may be seen via the acquisition of information and readiness for this physiological process (Liao & Hunter, 1998). The correlation between information and menopausal attitudes is substantiated by the observation that women tend to have more favourable perspectives about menopause subsequent to their own experience with the condition. 

According to a recent research conducted by Dashti et al. (2021), postmenopausal women exhibit more favourable views compared to women in pre- or perimenopausal stages. These findings are consistent with previous research indicating that the majority of women, particularly those who have reached menopause, have neutral or positive views regarding menopause and do not see it as as stressful as they first believed. Research substantiates this claim by demonstrating a slight decrease in menopausal anxiety as individuals get older. The drop in question may be attributed to the variability in the perception of experiences, which is contingent upon an individual's life stage (Brewis, Beck, Davies, & Matheson, 2017). Due to the multitude of physiological changes that often occur during menopause, younger women tend to have more unfavourable views about menopause compared to middle-aged women. Middle-aged women often see menopause as a normal occurrence with less apprehension around the loss of reproductive capacity. Hence, elderly women do not see menopause as a critical or extreme occurrence, but rather as an inherent phase of gradual metamorphosis. This finding illustrates that age has a substantial influence on individuals' thoughts regarding menopause. Hence, it is essential to provide education to younger women on the symptoms associated with menopause, as well as to equip and assist them in preparing for the start of their menopausal transition. 

The presence of unfavourable views regarding menopause has the potential to impact the overall well-being of young women. According to Kopenhager and Guidozzi (2015), the level of well-being is at its lowest among young women. It then has a mild increase from age 18 to midlife, which typically occurs around the age of 50, and then slightly decreases thereafter. According to Kopenhager and Guidozzi (2015), the improvement in women's self-reported mental health may be attributed to their changing expectations for their health as they approach adulthood, as well as their reorientation of values around midlife, which leads to psychological enhancements. Furthermore, research findings from the early 1990s suggest that women who had a generally high level of well-being had favourable views regarding menopause. This corroborates the hypothesis that younger women have diminished well-being due to unfavourable evaluations of menopause and the process of ageing. According to Brewis, Beck, Davies, and Matheson (2017), there exists a negative correlation between well-being and many factors such as psychosomatic and respiratory symptoms, prior premenstrual problems, and interpersonal stress.  Moreover, there exists a favourable correlation between it and the current state of general health and the overall appraisal of health (Brewis, Beck, Davies, & Matheson, 2017). The findings of this study indicate that middle-aged women exhibit elevated levels of well-being due to favourable assessments of life stage problems, such as menopause, notwithstanding the developmental obstacles associated with the ageing process.  Therefore, the researcher aims to assess the knowledge, attitude and effects of menopausal challenges among older women in Iseyin Local government.

Statement of the problem

Menopause is a crucial period of change in a woman's life, characterised by the end of menstrual periods and the loss of reproductive ability. Menopause, while a normal occurrence, often presents a range of medical, psychological, and social difficulties that may greatly affect a woman's overall well-being. Although menopause is an unavoidable process, there is still a lack of comprehension about how older women view and handle the difficulties linked to it (Brewis, Beck, Davies, and Matheson, 2017). Hence, the objective of this study is to examine the understanding, beliefs, and impacts of menopausal difficulties among elderly women. Nevertheless, there exist several obstacles that restrict women's comprehension of menopause, including but not limited to the dearth of complete information pertaining to older women's knowledge of menopause, its physiological alterations, and the accompanying health hazards. 

This lack of awareness may lead to misunderstandings and insufficient readiness for handling menopausal symptoms. Women's perceptions and coping mechanisms towards menopause are significantly influenced by their attitudes towards it. An investigation of the perspectives of elderly women on menopause may provide insights into the cultural, societal, and personal elements that impact their encounters and methods of dealing with it (Brewis, Beck, Davies, and Matheson, 2017). 

Moreover, the manifestation of menopausal symptoms, such as hot flashes, mood swings, sleeplessness, and vaginal dryness, may have a substantial influence on several dimensions of a woman's existence, encompassing her bodily well-being, emotional state, interpersonal connections, and occupational pursuits. Comprehending the magnitude and characteristics of these impacts is crucial in order to build effective treatments and support structures. 

According to Brewis, Beck, Davies, and Matheson (2017), women's experiences of menopause may be greatly influenced by sociocultural variables such as society norms, cultural beliefs, and healthcare practices. This analysis may provide valuable insights into the contextual elements that impact the process of acquiring information, attitudes, and coping strategies among elderly women. Hence, the need to assess the knowledge, attitude and effects of menopausal challenges among older women in Iseyin Local government.

1.3 Objective of the study

The broad objective of the study is to assess the knowledge, attitude and effects of menopausal challenges among older women in Iseyin Local government. The specific objectives is as follows

Examine  the level of knowledge among older women regarding menopause.

Find out  the attitudes of older women towards menopause, and how do these attitudes influence their perceptions and coping strategies.

Assess  the physical, psychological, and social effects of menopausal challenges on the lives of older women.

Analyze how sociocultural factors influence older women's experiences of menopause.

1.4 Research Questions

The following questions have been prepared to guide the study

What is the level of knowledge among older women regarding menopause?

What are the attitudes of older women towards menopause, and how do these attitudes influence their perceptions and coping strategies?

What are the physical, psychological, and social effects of menopausal challenges on the lives of older women?

How do sociocultural factors influence older women's experiences of menopause?

1.5 Research hypotheses

The hypotheses have been formulated for the study

H01: The level of knowledge among older women regarding menopause is low

H02: The attitudes of older women towards menopause does not influence their perceptions and coping strategies.

1.6 Significance of the study

The study will be significant to the following

Ministry of health: Understanding the knowledge and attitude towards menopause among older women is crucial for promoting awareness about this natural transition in a woman's life. Many women lack accurate information about menopause, leading to misconceptions and anxiety. This study can contribute to filling this knowledge gap and empowering women to make informed decisions about their health.

Healthcare Provision: Findings from the study can inform healthcare providers about the specific challenges and concerns faced by older women during menopause. This can lead to improved healthcare provision tailored to the needs of menopausal women, including better counseling, support, and treatment options.

Policymakers: Findings from the study may have implications for healthcare policies related to women's health, aging, and menopause. Policymakers can use this information to advocate for better healthcare services, research funding, and public health campaigns aimed at promoting menopausal health and well-being.

Academia: the study will be beneficial to the academic community as it will contribute to the existing literature.

1.7 Justifications of the study 

Menopause marks a significant transition in a woman's life, accompanied by various physiological and psychological changes. Despite its universal nature, there exists a noticeable gap in understanding and addressing the challenges faced by older women during this phase. Investigating their knowledge and attitudes towards menopause, as well as the effects of these challenges, is crucial for bridging this healthcare gap. Menopausal symptoms can significantly impact the quality of life of older women. By exploring their knowledge and attitude towards menopause, we can identify areas where education and support interventions are needed. Understanding the effects of menopausal challenges on various aspects of life such as physical health, mental well-being, social relationships, and professional life can inform strategies to improve the overall quality of life for this demographic. Effective allocation of healthcare resources requires an understanding of the prevalence and impact of menopausal challenges. By elucidating the knowledge, attitudes, and effects among older women, policymakers and healthcare providers can tailor resources to meet the specific needs of this population. This may involve implementing educational programs, providing access to support groups, or developing specialized healthcare services targeting menopausal health. In addition, Menopausal transition is associated with an increased risk of certain health conditions such as osteoporosis, cardiovascular diseases, and mood disorders. Examining the knowledge and attitudes of older women towards menopause can shed light on their awareness of these health risks and their willingness to adopt preventive measures. This information is invaluable for designing targeted preventive health interventions to mitigate the long-term health consequences of menopause.Menopausal challenges not only have physiological ramifications but also significant psychosocial implications. Older women may experience feelings of isolation, anxiety, or depression as they navigate through this life stage. Understanding the effects of menopausal challenges on their mental health and social well-being can guide the development of support networks and mental health interventions tailored to their specific needs.  Investigating the knowledge, attitudes, and effects of menopausal challenges among older women is essential for enhancing healthcare provision, improving quality of life, and addressing the psychosocial and preventive health needs of this demographic. By shedding light on these aspects, this study seeks to pave the way for targeted interventions and support mechanisms tailored to the unique experiences of older women during menopause.

1.8 Scope of the study

The study focuses on the knowledge, attitude and effects of menopausal challenges among older women in Iseyin Local government. Hence, the study will examine  the level of knowledge among older women regarding menopause, find out  the attitudes of older women towards menopause, and how do these attitudes influence their perceptions and coping strategies, assess  the physical, psychological, and social effects of menopausal challenges on the lives of older women and analyze how sociocultural factors influence older women's experiences of menopause. The study is delimited to Iseyin Local government.

1.9 Limitation of the study

Like in every human endeavour, the researchers encountered slight constraints while carrying out the study. The significant constraint are: 

Time: The researcher encountered time constraint as the researcher had to carry out this research along side other academic activities such as attending lectures and other educational activities required of her.

Finance: The researcher incurred more financial expenses in carrying out this study such as typesetting, printing, sourcing for relevant materials, literature, or information and in the data collection process.

Availability of Materials: The researcher encountered challenges in sourcing for literature in this study. The scarcity of literature on the subject due to the nature of the discourse was a limitation to this study

1.10 Definition of terms

Knowledge:

Knowledge refers to the awareness, understanding, and familiarity that older women possess regarding menopause, its physiological processes, associated symptoms, and potential management strategies. This includes factual information, acquired through various sources such as healthcare providers, literature, personal experiences, and cultural beliefs.

Attitude:

Attitude pertains to the psychological predisposition or perspective of older women towards menopause and its challenges. It encompasses their feelings, beliefs, opinions, and emotional responses regarding menopausal experiences, including their perceptions of its impact on their physical health, emotional well-being, social interactions, and overall quality of life.

Menopausal Challenges:

Menopausal challenges denote the array of physiological, psychological, and social difficulties encountered by older women during the transition into menopause and the postmenopausal period. These challenges may encompass a spectrum of symptoms such as hot flashes, mood swings, sleep disturbances, vaginal dryness, changes in libido, cognitive changes, osteoporosis, cardiovascular risks, and challenges related to body image, self-esteem, and identity. They may also include broader societal attitudes, cultural perceptions, and healthcare-related issues impacting women's experiences of menopause.

1.11 Area of the study

Ibadan is the capital and most populous city of Oyo State, in Nigeria. It is the third-largest city by population in Nigeria after Lagos and Kano, with a total population of 3,649,000 as of 2021, and over 6 million people within its metropolitan area. It is the country's largest city by geographical area.

CHAPTER TWO

REVIEW OF LITERATURE

INTRODUCTION

Our focus in this chapter is to critically examine relevant literatures that would assist in explaining the research problem and furthermore recognize the efforts of scholars who had previously contributed immensely to similar research. The chapter intends to deepen the understanding of the study and close the perceived gaps.

2.1 CONCEPTUAL FRAMEWORK

Menopause

Menopause is the cessation of menstruation – defined retrospectively after one year without a menstrual period (National Institute on Aging [NIA], 2018). On average, women reach menopause at age 51 (NIA, 2018). However, the menopausal transition, or perimenopause, is a years-long process marked by hormonal fluctuations and changes in the menstrual cycle. The word menopause is commonly used to refer to the entire transition rather than used in its more technically appropriate sense. A set of guidelines for evaluating the entire transition was developed by researchers at the Stages of Reproductive Aging Workshop + 10 (STRAW + 10), and these guidelines are widely accepted as the standard (Harlow et al., 2012). The primary criteria used to define STRAW + 10 stages are changes in the menstrual cycle. Hormones, including follicle stimulating hormone, luteinizing hormone, estrogen, and progesterone, fluctuate regularly during the menstrual cycle, unpredictably during 2 perimenopause, and stabilize during postmenopause (NIA, 2018). These variations, combined with the relative expense of testing hormone levels, make menstrual cycle changes a much more convenient parameter for estimating menopausal phase. 

Under the STRAW + guidelines, perimenopause lasts from the beginning of the menopausal transition to one year after menopause. The early menopausal transition is marked by a persistent difference in the length of cycles of seven days or more. The late menopausal transition is marked by the absence of menstruation over a 60-day time period, and often the emergence of vasomotor symptoms. After 12 months without menstruation, menopause has been achieved; postmenopause refers to the entire time span after menopause(Jack et al, 2016). This series of stages is typical of natural menopause, but does not describe the experiences of all women. Women may experience menopause differently for several reasons, such as undergoing a bilateral oophorectomy. These women’s experiences are usually quite different from those of women who go through natural menopause.

Menopause is a natural transition all women experience as natural as adolescence. How a woman experiences menopause is determined by many factors: attitude, diet, overall health, genetics and cultural group. But the fact remains that menopause is a universal female midlife transition that remains poorly understood (Hardy,  Griffiths and Hunter, 2017). In the same vein, Dobson,  Szeto and Knaak  (2019) concedes that menopause is multidimensional influenced by biological, psychological and sociocultural factors and requires responses that are equally multidimensional. Jung and Takeuchi, (2018) investigated the degree to which attitudes toward menopause and aging vary across ethnic groups and menopausal status. A sample of more than 16,000 women indicated women’s attitudes toward menopause ranged from neutral to positive; with African American women indicating significantly more positive attitude to menopause. 

Nevertheless, Ali, Ahmed, & Smail, (2020) had observed that positive attitudes toward menopause are associated with positive experiences of menopause whereas negative attitudes are associated with both negative symptoms and negative experiences. In furtherance of this Ali, Ahmed, & Smail (2020) maintained that attitudes influence menopausal experience. This contention implies that the attitude of the woman towards menopause will invariably influence her experience of menopause. Therefore, women should be encouraged to develop positive attitude towards menopause. In addition, much of how a woman’s life is affected by menopause depends to a great extent on how she views herself (Ali, Ahmed, & Smail, 2020). 

Because women are often judged on the basis of their appearance and youthfulness, those who have used their glamour to attract men and enhance their self-esteem may find aging particularly painful (Ali, Ahmed, & Smail, 2020). From the foregoing, it becomes clear that women are concerned about aging and its implications for them especially psychologically. But the key issue is acceptance of the inevitability of the aging process. Acceptance can lead to more positive feelings about self and to a high level of satisfaction with one’s life circumstances (Saucier, 2004). Women can therefore be guided to begin to think of midlife as a time for reevaluation, not crisis. In fact, they should be encouraged to become more realistic and to reappraise their goals and their ability to meet such goals (Ali, Ahmed, & Smail, 2020).

Symptoms Of Menopause

The natural menopausal experience varies widely between individuals, and across cultures. Some women experience many symptoms; some women experience almost none. No universal menopause syndrome has been found to occur either across or within ethnic groups (Arseneau et al., 2021). Women living in non-Western cultures report fewer symptoms than those in Western cultures (Etikan  & Bala, 2017). Whereas women report a wide range of symptoms while going through the menopausal transition, and many of these symptoms are perceived to be caused by menopause, very few can be definitively attributed to menopause. Some commonly reported symptoms of menopause include hot flashes, night sweats, sleep disturbance, vaginal atrophy, vaginal dryness, urinary leakage, forgetfulness, heart pounding or racing, irritability, stiffness or soreness, feeling tense or nervous, and feeling depressed or blue (Etikan  & Bala, 2017). Of these symptoms, hot flashes are probably the most stereotypically associated with menopause; hot flashes are also one of the few well-validated symptoms of menopause (Etikan  & Bala, 2017). 

Hot flashes and night sweats are jointly referred to as vasomotor symptoms. In one study of almost 4,000 United States women of multiple ethnic and racial backgrounds, vasomotor symptoms increased throughout the menopausal transition – 25.2% of those aged 40-43 reported hot flashes or night sweats, and 46.4% of those aged 52-55 reported them (Faubion et al., 2015). It is interesting to note that not even half of the women surveyed reported hot flashes, the most widely accepted symptom of menopause. Psychosocial symptoms, such as depression and irritability, are also difficult to attribute entirely to menopause. In a longitudinal study of over 2,000 women, the best predictor of depression during menopause was prior depression; women who spent longer in the perimenopausal phase experienced more depression during that phase, although postmenopausal women’s depression scores improved (Faubion et al, 2015). 

Stratton (2021) suggests that increased depression during the menopause transition may be the result of symptoms, particularly more disruptive ones such as sleep disturbance. Perimenopausal women experience significantly more sleep disturbance than premenopausal women (Stratton, 2021). Vasomotor symptoms are connected to both increased sleep disturbance and a more negative mood, but sleep disturbance only explains a small portion of this relationship, suggesting that sleep disturbance caused by vasomotor symptoms is not one of the primary causes of menopausal women’s negative moods (Thapa  & Yang, 2022).

Nevertheless, Avis and colleagues (2019) found that increased symptomatology was associated with more depression, so another mechanism or set of symptoms may be 4 explaining the connection. At any rate, depression and other psychological symptoms may be a correlate of menopause, rather than a result of it (Deeks, 2003). Menopause often coincides with life changes and events that may influence mental health, such as children leaving the home, parents passing away, job changes or retirement (Thapa  & Yang, 2022). It can be difficult to establish a causal relationship between menopause itself and many of the commonly reported symptoms of menopause, whether in psychosocial or physiological realms. Menopause and its associated symptoms do not require treatment unless they are troublesome or interfere with a woman’s quality of life. The medical community is now shifting to this perspective, but in times past menopause was viewed as a ―deficiency disease.‖ Instead of a natural change in hormonal levels that occurs over time, it was seen as an absence of something that should be there – an unnatural, abnormal development that should be cured(Thapa  & Yang, 2022). When symptoms do negatively affect quality of life, hormone replacement therapy is frequently an effective treatment for some issues, such as hot flashes (Thapa  & Yang, 2022). Even when menopause is not viewed as a deficiency disease, women have difficulty communicating with medical professionals about their concerns; doctors can be dismissive and fail to fully explain issues related to menopause (Thapa  & Yang, 2022). Communication between doctors and patients is essential to help women understand and effectively treat any symptoms they may experience.

Stereotypes and Taboos Towards Menopause

In the past, menopausal women were regarded as emotionally unstable; the end of fertility was seen as devastating, and almost a death knell – although shorter life expectancies made the latter somewhat accurate (Zhang, Ruan, Cui,  Gu, & Mueck, 2020). While perceptions of menopause have improved in modern times, stereotypical views of 5 menopause and menopausal women still abound. In two studies examining stereotype content, Agarwal,  Kiron,  Gupta & Sengar, (2019) found that compared to both midlife women and men, menopausal women are seen negatively – particularly in terms of having more negative emotions, not having positive traits, and not being active. Additionally, they found that men have more negative perceptions of menopausal women than do women. 

Agarwal,  Kiron,  Gupta & Sengar, (2019) asked college students to describe menopausal women, and students most frequently chose words or phrases such as irritable, old, moody, and having hot flashes. Male and female students did not differ in their overwhelmingly negative perception of menopausal women. These views are reinforced by depictions of menopause in the popular media. One study, by Ahmad, Mahmoud, and Ahmad, (2019), reviewed articles published in popular sources between 1981 and 1994. They found that the vast majority of articles discussed negative aspects of menopause, emphasized a need for medical treatment, and minimized or dismissed the impact of other factors on the menopausal transition, such as diet and exercise. Many of the articles offered incorrect or contradictory information, such as stating that hormone replacement therapy both caused and treated several conditions (Ali, Ahmed &Smail,  2020). 

On a mildly encouraging note, the number of articles on menopause did increase over time. Unfortunately, the number was still far below the number of articles on other topics that affect a far smaller number of women. Ali, Ahmed &Smail (2020) concluded that the advice given in the articles they reviewed was representative of the medical view of menopause as an unnatural and negative experience that should be treated, especially with hormone replacement therapy. Ali, Ahmed &Smail (2020) agree with Gannon and Stevens’ perspective, arguing that the way menopause is depicted in the media is a result of the medical view of 6 menopause, which has in turn been shaped by our negative cultural view of aging women, creating a circular influence that continually reinforces the perception of menopause as a miserable time for all women. Stereotypes both represent our understanding of the world and set the norms for how members of certain groups should behave (Ali, Ahmed &Smail,  2020). They exert a powerful influence. Menopause is a ubiquitous experience for women, yet the popular view of menopause remains limited and inaccurate; even women tend to accept this depiction. This discrepancy between stereotype and reality may be partially the result of women’s unwillingness to share their own experience of menopause with others. Ali, Ahmed &Smail (2020) interviewed women and found that those who tried to reach out to others for information during menopause were often rejected - not only by their friends who were also going through menopause, but even their own mothers, who are traditionally an important source of information about bodily changes for women. This lack of communication between mothers and daughters concerning menopause seems to be common (Ali, Ahmed &Smail, 2020).

Women’s Attitudes toward Menopause

Unlike the limited research on men’s attitudes, studies of women’s attitudes abound. The topic has been repeatedly studied since at least the early 1960s, when Amitha, Malathi,  Nayak, Pratibha (2020) published an influential study. Generally, women’s attitudes toward menopause range from neutral to positive, which is particularly reassuring in light of the influence attitudes may have on the menopause experience. In a systematic review of research on women’s attitudes, 13 out of 16 studies found that women who reported more negative attitudes reported experiencing more symptoms (Ayers, Forshaw, & Hunter, 2010). All but one of these studies were crosssectional, limiting conclusions about the direction of the relationship between attitudes and experiences; those who have more negative experiences would presumably have more negative attitudes after the fact. The sole longitudinal study, however, did support 9 a causal relationship between attitudes and experiences. Women who had more negative attitudes prior to menopause reported more symptoms during menopause (Essa, Hafez, Kandeel, 2020). 

Women who had negative attitudes before menopause also tended to report improvements in attitude toward the end of the menopausal transition, with their attitudes becoming neutral or even positive, suggesting that personal experience may lead to more positive attitudes. Several different factors have been explored as predictors of menopause attitudes, although few have been shown to reliably account for a great deal of variance in attitudes. Age is one of the few factors that has consistently predicted menopause attitudes. Starting with Essa, Hafez, Kandeel,(2020), younger women have been shown to have more negative attitudes than older women. This finding has been replicated repeatedly. Some studies conflate age and menopause status, but although age and menopause status are highly positively related, age is not an exact determinant of when women go through menopause. In large samples of women ranging from 45 to 60 years of age, it is possible to tease apart these two characteristics (Essa, Hafez, Kandeel,, 2020). 

When menopause status is determined separately from age, postmenopausal women tend to have more positive attitudes than premenopausal women. Younger and premenopausal women may have more negative attitudes because they have less knowledge of the menopausal transition. Considering the lack of communication from other women, and the stereotypical depiction of menopause as time when women are crazy and constantly experiencing hot flashes, it is not surprising that women without personal experience would have a negative view of menopause. Education has also been linked to attitudes, although results are inconsistent. 

Essa, Hafez, Kandeel, (2020) found that higher levels of education were associated with both higher ratings of positive dimensions of menopause attitudes and higher ratings of negative dimensions, such that women with lower education levels had more neutral attitudes toward menopause than women with higher education levels. 

Gebretatyos, Ghirmai,  Amanuel,  (2020) noted that more educated women had more positive attitudes toward menopause, but Stratton  (2019) reported that more educated women had more negative attitudes. Several studies have found no relationship between education and attitudes. These contradictory results indicate that more research is needed to clarify the relationship between education levels and attitudes toward menopause.

Facets of Menopause Attitudes

Most literature addresses menopause attitudes solely from a valence perspective, on a spectrum from negative to positive. This can be limiting, as menopause is a complex and multi-layered phenomenon and menopause attitudes are no different (Etikan, & Bala, 2017). Women may have vastly different perspectives on different elements of menopause attitudes, particularly if their experience, or the information they have received from others, was more negative in one area and more positive in another. Parsing out aspects of attitudes can provide a more nuanced understanding of how individuals perceive menopause.

Fertility. 

The loss of fertility is a primary feature of the menopausal transition. Depending on the importance of fertility to a woman, her intimate partners, her close others, and her culture, this can be a momentous occasion or simply a blip on the radar. In traditional cultures, where fertility is often highly valued, menopause may have more negative connotations (Etikan & Bala, 2017). From an evolutionary perspective, fertility also plays an important role in men’s perceptions of women,particularly for younger men who are more focused on reproductive success. Some women feel that their lack of ability to reproduce does limit their attractiveness to potential mates and might reduce their femininity. Despite this view, most women retrospectively reported feeling relieved at their last menstrual cycle, and very few reported feeling regret. Menopause does indicate the end of fertility, but it is also the end of the hassles of monthly menstruation and brings freedom from worries about contraception or pregnancy (Etikan & Bala, 2017).

Attractiveness

Physical attractiveness is closely linked with fertility and youth in evolutionary history (Etikan & Bala, 2017). Visual cues that are considered attractive are typically indicative of potential fertility and good health, such as smooth skin and full lips (Etikan & Bala, 2017). As men and women age, these features tend to fade away, but the consequences of this transition are more acute for women. Women’s attractiveness is perceived as declining at a faster rate than men’s with age. Some women report feeling less attractive after menopause (Etikan & Bala, 2017), but postmenopausal women are less concerned about attractiveness compared to premenopausal women. Women may develop different relationships with their bodies during the menopausal transition.

Personal growth.

Menopause is stereotypically depicted as a solely negative time, and researchers typically focus on negative aspects of menopause. In contrast to this approach, many women experience menopause as a time of personal growth. Jung, and Takeuchi, (2018) noted that some women reported positive feelings after menopause, such as having more energy and being in better spirits; another study found that postmenopausal women reported reduced inhibitions and an improved understanding of themselves. Menopause can overlap with several life transitions, such as children leaving home and changing or reduced responsibilities in other realms, leaving women feeling more free to pursue their own interests and with more time for themselves (Jung and Takeuchi, 2018). Postmenopausal women’s more positive attitudes when compared to premenopausal women may be reflective of these positive elements.

Emotional stability

Women’s emotional experiences and mood changes are often attributed to hormone-triggered mood swings no matter which phase of reproductive life they happen to be in, and menopause is no exception (Jung and Takeuchi,, 2018). For centuries, emotional lability has featured heavily in views of menopausal women. Women do report experiencing emotional lability during menopause (Jung, Y. and Takeuchi,  2018), but again, a direct causal relationship between menopause and mood swings has not clearly been established. For some women, changes in hormone levels may cause mood changes, but this has not been widely established. Depression and mood changes that do occur during menopause may be the effect of symptoms or of other concurrent situations.

Sexuality

Women frequently experience changes in sexual functioning and desire, including increased vaginal dryness and decreased desire for sex, during the menopausal transition (Brewis,  Beck, Davies, and Matheson, 2017). Some of these changes are attributable to decreased estrogen levels, but some may be more accurately attributed to other sources, such as aging itself or individual and societal expectations. Some research has found that menopausal women report decreased desire for and enjoyment of sex, but other studies have found that some menopausal women experience an increase in desire for and enjoyment of sex. Some aspects of menopause, such as the end of concerns about pregnancy, even led to a more positive view of sex. 

Post-menopausal women who communicated clearly with their partner about sex continued to have fulfilling and enjoyable sex lives after menopause (Brewis,  Beck, Davies, and Matheson, 2017). These women typically acknowledged that there were changes in how their bodies responded, including drops in libido and increased time to orgasm, but reported adapting to their changing bodies and continuing their sex lives much as before (Brewis,  Beck, Davies, and Matheson, 2017). These contrasting findings again serve to illustrate the range of variability in individual women’s experiences of menopause.

2.2 THEORETICAL FRAMEWORK

The Theory Of Reasoned Action (Tra) By Ajzen And Fishbein (1975 & 1980)

The theory of reasoned action (TRA) was propounded by Ajzen and Fishbein (1975 & 1980) to show how attitude impact on behaviour. TRA suggests that a person‟s behaviour intention depends on the person‟s attitude about the behaviour and subjective norms. To put the definition into simple terms, a person‟s volitional (Voluntary) behaviour, is predicted by his or her attitude toward the behaviour and how he or she thinks other people would view them, if they performed the behaviour (Ajzen & Fishgerbein, 1975).

According to Taylor (2003), TRA stresses that one‟s attitudes toward a particular behaviour are influenced by belief outcome of the behaviour and one‟s evaluation of the potential outcome. This theory, by extension, can be used to analyze the attitude of women towards modern family planning methods. Women of reproductive age who develop negative attitude to particular methods of modern family planning are likely not to use such methods, whereas those who believe that using certain methods of modern family planning protect them against unplanned pregnancies and sexually transmitted infections will likely use such methods. On this basis, the knowledge, attitude and practices of women towards family planning services will be anchored on the theory of reasoned action (TRA).

Application Of The Theory To The Topic

The Theory of Reasoned Action (TRA) can be applied to understand and address the knowledge, attitudes, and effects of menopausal challenges among older women in several ways:TRA posits that individuals' behavioral intentions are influenced by their attitudes toward the behavior and subjective norms. In the context of menopausal challenges, understanding women's beliefs and attitudes toward menopause and its associated challenges is crucial. Surveys and interviews can be conducted to gauge women's perceptions of menopause, its symptoms, and its effects on their lives(Ajzen & Fishgerbein, 1975). 

By understanding these attitudes, healthcare professionals can tailor interventions to address misconceptions and promote positive attitudes toward menopause. TRA emphasizes the role of subjective norms, which refer to perceived social pressures to perform or not perform a behavior. In the case of menopausal challenges, social norms regarding discussing menopause openly, seeking help for symptoms, and coping mechanisms can significantly impact women's experiences. Interventions aimed at changing social norms, such as support groups or community education programs, can provide a platform for women to share their experiences, seek support, and challenge stigmatizing attitudes surrounding menopause.

TRA suggests that behavioral intentions are strong predictors of actual behavior. By understanding women's intentions regarding managing menopausal challenges, healthcare providers can tailor interventions to promote positive health-seeking behaviors. This may include providing information about available treatment options, encouraging regular health check-ups, and promoting self-care practices such as exercise and healthy eating to alleviate menopausal symptoms. TRA emphasizes the importance of effective communication in shaping attitudes and behavioral intentions(Ajzen & Fishgerbein, 1975). Healthcare providers can use communication strategies grounded in TRA principles to provide accurate information about menopause, address misconceptions, and promote positive attitudes toward seeking help for menopausal challenges. This could involve using clear and empathetic language, providing educational materials tailored to different literacy levels, and involving family members or social networks in the communication process to strengthen social support. 

TRA recognizes that attitudes and subjective norms may vary across individuals and cultural contexts. In the context of menopausal challenges, it's essential to consider cultural beliefs and practices surrounding menopause, as well as individual differences in coping styles and health behaviors. Interventions should be culturally sensitive and personalized to meet the specific needs of diverse groups of women, taking into account factors such as ethnicity, socioeconomic status, and educational background(Ajzen & Fishgerbein, 1975). By applying the Theory of Reasoned Action to the topic of menopausal challenges among older women, healthcare providers and researchers can gain valuable insights into the factors influencing women's experiences and develop targeted interventions to promote positive attitudes, enhance social support, and improve health outcomes during the menopausal transition.

The Theory of Planned Behaviour (Tpb)

Similarly, the theory of planned behaviour (TPB) was also propounded by Ajzen and Fishbein (1975). The TPB is another theory about the link between attitudes and behaviour. The TPB states that people‟s evaluation of, or attitudes toward behaviour are determined by their accessible belief about the behaviour, where a belief is defined as the subjective probability that the behaviour will produce a certain outcome. Specifically, the evaluation of each outcome contributes to the attitude in direct proportion to the persons subjective possibility that the behaviour produces the outcome in question. 

Ogdem, Karim, Choudry and Brown (2007) concurred that the intention to perform a behaviour can be translated into actual behaviour. For example, the intention to use modern contraceptives, predicts contraceptive use. The intention to exercise correlates with this behaviour, and the intention to go for cervical or breast screening practices predicts actual attendance. Therefore, the cognition „I intend to…‟ seems to translate into I did. When a person intends not to do it, it translates into no performance or no action. 

Application Of The Theory To The Topic

TPB suggests that attitudes influence behavioral intentions. In the context of menopausal challenges, attitudes refer to how older women perceive menopause and its associated symptoms (such as hot flashes, mood swings, etc.). By assessing attitudes through surveys or interviews, researchers can gauge whether women view menopause positively or negatively, and how these attitudes may impact their coping strategies and health-seeking behaviors(Ajzen & Fishgerbein, 1975). TPB emphasizes the importance of social influences on behavior. Subjective norms in the context of menopausal challenges refer to perceived social pressures or expectations from significant others (e.g., family, friends, healthcare providers) regarding how women should deal with menopause. Understanding these norms can help identify potential sources of support or barriers to seeking help or information about menopausal symptoms. TPB suggests that perceived behavioral control, or the perceived ability to perform a behavior, influences behavioral intentions and actual behavior. In the context of menopausal challenges, this could involve assessing women's beliefs about their ability to manage menopausal symptoms effectively. Factors such as access to healthcare, knowledge about available treatments, self-efficacy beliefs, and previous experiences with managing health issues can influence perceived behavioral control. TPB does not explicitly include knowledge as a component, but it can be integrated into the model as an influencing factor. Knowledge about menopause, including its physiological changes, symptoms, and available treatment options, can impact attitudes, subjective norms, and perceived behavioral control. Higher levels of knowledge may lead to more positive attitudes toward menopause and better coping strategies for managing symptoms. Similarly, according to TPB, behavioral intentions are strong predictors of actual behavior. By understanding older women's intentions regarding managing menopausal challenges (e.g., seeking medical help, adopting lifestyle changes), healthcare providers and policymakers can design interventions to promote positive health behaviors during the menopausal transition. Finally, TPB can help researchers and healthcare providers understand the effects of menopausal challenges on various aspects of women's lives, including physical health, mental well-being, social relationships, and quality of life. 

By identifying factors influencing behavioral intentions and actual behavior, interventions can be tailored to mitigate the negative effects of menopausal symptoms and improve overall health outcomes for older women. In summary, the Theory of Planned Behavior provides a comprehensive framework for understanding the knowledge, attitudes, and effects of menopausal challenges among older women, and it can inform the development of interventions to support women during this life transition.

The Health Belief Model (Irwin M. Rosenstock, Godfrey M. Hochbaum, S. Stephen Kegeles,and Howard Leventhal 1950s)

The Health Belief Model is a theoretical model that can be used to guide health promotion and disease prevention programs. It is used to explain and predict individual changes in health behaviors. It is one of the most widely used models for understanding health behaviors.  Key elements of the Health Belief Model focus on individual beliefs about health conditions, which predict individual health-related behaviors (Ogdem, Karim, Choudry and Brown, 2007). The model defines the key factors that influence health behaviors as an individual's perceived threat to sickness or disease (perceived susceptibility), belief of consequence (perceived severity), potential positive benefits of action (perceived benefits), perceived barriers to action, exposure to factors that prompt action (cues to action), and confidence in ability to succeed (self-efficacy).

A typical instance of the Health Belief Model is the Michigan expedient elaboration, as he considers  Health Belief Model as a curriculum designed for implementation in the society. It targets social and emotional health challenges including transmission, nutrition, physical activity, alcohol and drug use, safety, and personal health, among other topics(Ogdem, Karim, Choudry and Brown, 2007). This model adapts components of the Health Belief Model related to knowledge, skills, self-efficacy, and environmental support. Hence this theory is considered best and suitable for this study as depicts individuals knowledge, perceptions, actions and behaviours as relations to disease occurrence.

Application Of The Theory To The Topic

This aspect of the HBM focuses on an individual's perception of their susceptibility to a particular health condition. In the context of menopausal challenges, older women may perceive themselves as susceptible to various symptoms such as hot flashes, mood swings, and changes in libido. Understanding how women perceive their susceptibility to these challenges can help in designing interventions aimed at increasing awareness and promoting preventive behaviors. Perceived severity refers to the individual's perception of the seriousness of a health condition and its potential consequences(Ogdem, Karim, Choudry and Brown, 2007). For menopausal challenges, older women may perceive symptoms such as osteoporosis and cardiovascular risks associated with hormonal changes as severe. This perception can influence their attitudes towards seeking medical help, adopting healthy lifestyle behaviors, and adhering to treatment regimens. In addition, this aspect focuses on the individual's belief in the effectiveness of a recommended health action in reducing the threat of a health condition. Older women may perceive benefits from adopting healthy behaviors such as regular exercise, balanced nutrition, and hormone replacement therapy (HRT) in alleviating menopausal symptoms and reducing associated health risks(Ogdem, Karim, Choudry and Brown, 2007). Highlighting these benefits can motivate women to take proactive steps towards managing their menopausal challenges. Perceived barriers refer to the obstacles that individuals perceive in adopting a recommended health behavior. In the context of menopausal challenges, barriers may include concerns about the safety and side effects of hormone therapy, financial constraints in accessing healthcare services, and cultural stigma surrounding menopause. Identifying and addressing these barriers are crucial in promoting positive health behaviors among older women.

2.3 REVIEW OF EMPIRICAL STUDIES

Sifa Marie Joelle Muchanga (2019) aimed to evaluate the knowledge, attitudes and practices of middle-aged women towards menopause. In this cross-sectional study, data collected using a multistage clustered random sampling from 54 health centres in the Democratic Republic of Congo were used. Participants filled a questionnaire derived from the menopause rating scale and from local beliefs. The knowledge, attitudes and practices towards menopause were evaluated among pre- and postmenopausal women of the 353 women, both pre- and postmenopausal women knew the definition of menopause but for the symptoms, postmenopausal women were more informed than premenopausal. For the attitudes and practices towards menopause, while both had equally positive attitudes, the premenopausal women did not know which practices to adopt. Congolese women had limited knowledge, positive attitudes and unconventional practices towards menopause. Health-care providers, therefore, need to dispense appropriate advice to middle-aged women before the advent of menopause.

Hatice İkiışık1, Güven Turan1, Feyza Kutay, Defne Cansu Karamanl, Elif Güven, Ezgi Özdemir, Mustafa Taşdemir1, & Işıl Mara (2016) investigate the awareness of menopause and strategıes to cope wıth menopausal symptoms of the women aged between 40 and 65 who consulted to a tertiary care hospital and among those who were postmenopausal, to measure the severity of symptoms and to determine the strategies and choice of resources to cope with menopausal symptoms. From a total of 292 women 272 (93%) were available to participate in the study. A questionnaire and the Menopause Rating Scale (MRS) was during face-to-face interviews. The mean age was 50.1±6.5 years. The mean total MRS score of non-menopausal women was 16.6±8.9. The mean scores: 6.2±3.5 for somatic subscale, 6.5±3.7 for psychological subscale and 3.8±2.7 for urogenital subscale. The most common menopausal symptom was physical and mental exhaustion (84.0%). Severe menopausal symptoms were identified in 79 (46.7%) women completing the MRS scale. The women with an average monthly income of 2000 TL or less and chronic illness had a higher frequency of severe menopausal symptoms. The most commonly preferred coping strategy was visit to a medical doctor or a healthcare center (n=103, 60.9%). In order to raise awareness about menopause, structured education programs should be prepared and implemented

Yael S. Edler (2023) aims at assessing the moderating role of age on the relationship between attitudes towards menopause and well-being in women aged 30 to 50 years. A mixed-methods study design with open and closed questions was implemented. The dataset consisted of 89 middle-aged women from the Netherlands, Germany, and Poland, using convenience and snowball sampling. During the research, the participants could qualitatively elaborate on their perspectives about menopause in an open question on menopause. In addition, the Mental Health Continuum – Short Form and the Attitudes Towards Menopause scale were used to quantitatively assess well-being and attitudes towards menopause, respectively. The results showed no significant moderating effect of age on the relationship between attitudes towards menopause and well-being. However, this study has shown that education about menopause is crucial for women and their attitudes towards menopause. Therefore, society and the media must portray more realistic pictures of menopause and highlight its positive consequences. It is important to appropriately educate women about this major life challenge and provide them with information on where to seek help and support. Moreover, further studies are needed to assess the relationship of attitudes towards menopause with menopausal status rather than age.

Ensieh Noroozi, Nayereh Kasiri Dolatabadi, Ahmad Ali Eslami, Akbar Hassanzadeh, Soheila Davari (2015) investigate the knowledge and attitude of women toward the menopause phenomenon. This cross-sectional study was conducted on 400 healthy and non-menopaused women aged 40–45 years. The stratified sampling method was used and participation in this study was based on obtaining informed consent. The data collection instrument was a questionnaire consisting of three parts: demographic information, questions to assess knowledge and attitude investigation questions. The results showed that the average knowledge score of subjects was 63.57 ± 10.79, and their average attitude score was 61.21 ± 12.73. In this study, 8% of the subjects had poor knowledge, 68% had moderate knowledge and 38.5% had good knowledge. Meanwhile, 81.5% of the women had a positive attitude toward menopause. The correlation test showed that knowledge and attitude are meaningfully related to economic status and education level. But, the relationship between knowledge and attitudes of women under study was not significant. Conclusion: Identifying the quality of women’s subjective perception of menopause has an essential role in the development of accurate and appropriate programs to promote women’s health during menopausal years.

Nülüfer Erbil (2017) investigate attitude towards menopause, body image and depression level of Turkish women in menopause.  The data of this descriptive and cross-sectional study were collected via questionnaire form, Attitude towards Menopause Scale (ATMS), Body Image Scale (BIS) and Beck Depression Inventory (BDI). 54.1% of women held negative attitudes towards this transition. The rate of women who fit the borderline evaluation for depression was 27.5%. Women with low depressive symptom severity and positive attitudes towards menopause had higher positive body image scores. Women with positive attitudes towards menopause had a more positive body image and they experienced lower depressive symptoms. ATMS, BIS and BDI scores of women in naturally menopause who had not had menstruation for at least one year or who had entered menopause due to surgery were compared; menopause attitude scores and body image scores of women in naturally menopause was significantly more positive. There was a significant positive correlation between ATMS and BIS scores of women in menopause, also there was a significant negative correlation between MAS and BDI scores of women. Conclusions: Women with an optimistic attitude towards menopause tend to have a more positive body image and their depression level is lower.

Ogunleye (2015)examined the attitudes of women to menopause. A total of 300 married female teachers made up the sample for the study. Data was collected using the modified Attitude Towards Menopause (ATM) checklist. The responses of the participants were analyzed using simple percentages. The results showed that an overwhelming majority of the respondents indicated concern about how their husbands will feel about them after menopause (98%); women should see a doctor at menopause (91%); menopause is an unpleasant experience (83%) among others. The implications these findings have for counselling and counsellors were discussed. The focus was on the key strategies the counsellor should adopt in helping women to cope with menopause and also develop positive attitudes toward it.

Melissa M. Pope (2017)examined men’s and women’s attitudes toward several facets of menopause, including fertility, attractiveness, personal growth, emotional stability, and sexuality, using an Amazon Mechanical Turk sample of 194 females and 151 males. Results revealed that women and men differed significantly in their attitudes toward fertility, attractiveness, personal growth, and sexuality, with women having more positive attitudes on every dimension except sexuality. For females, age was a significant positive predictor for fertility, personal growth, and emotional stability; knowledge was a significant positive predictor for personal growth; and education was a significant positive predictor for emotional stability. For males, age was a significant positive predictor for fertility, and knowledge was a significant negative predictor for fertility. These results indicate that men typically have more negative attitudes toward menopause than do women, and that more potential predictors of menopause attitudes should be explored in future work to provide insight into the reasons for this difference.

2.4 APPRAISAL OF LITERATURE REVIEW

According to Thapa, R., & Yang (2022) women have a greater population and their average age and life expectancy is more than men, but their imperfection and disability is higher and they face special issues resulting from their natural and physiological conditions; one of these issues is the menopausal transition period or final years of pregnancy. Menopause is one of the natural and important processes of women’s life, where its main feature is fertility and menstruation ending. 

The average age of menopause onset is 51 years (from 47 to 53 years), but, in Iran, menopausal age is lower and is about 47.8 years. Regarding life expectancy in Iran, women spend about one-third of their life in this period [Stratton, 2021]. In 1990, 467 million women were at the age of 50 or more, where 40% lived in industrialized countries and 60% in developing countries. By 2030, this number will reach one billion and two hundred million people, respectively. Despite this overall increase, the ratio of menopaused women in industrialized countries will decrease to 24%, while this number will reach 76% in developing countries[Stratton, 2021]. 

In our country, by investigating health and disease in 1385 by the Iran Statistical Center, there are 5854763 40–65-year-old women [Agarwal,  Kiron, Gupta,  & Sengar, 2019]. Women during the menopause period experience certain physical and psychological changes and face various problems such as urogenital, psychological–social,[Etikan & Bala, 2017] cardiovascular and neurological problems, etc. These problems not only cause great distress and disability for the person but also impose a lot of pressure on the limited resources of the countries’ health care system. Familiarity with these changes and understanding their reasons are essential in the life of all women, and helps them enter this stage of their life with adequate knowledge and a positive attitude [Etikan & Bala, 2017] 

Studies by Jung and Takeuchi, (2018) performed in Iran in the field of investigating the level of women’s knowledge and attitude toward menopause indicate inadequate knowledge and negative attitude toward this phenomenon among Iranian women.  “knowledge is a basic condition for the use of health services and

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