Menopause: The Journal of The North American Menopause Society Vol. 22, No. 1, pp. 79/87 DOI: 10.1097/gme.0000000000000256 * 2014 by The North American Menopause Society
Menopausal symptoms among British Pakistani women: a critique of the standard checklist approach Mwenza T. Blell, PhD Abstract Objective: This study aims to identify problems with the standard menopause symptom checklist method previously used to study variations in menopause symptoms and to explore data collected using an alternative approach. Methods: As part of a biosocial study of menopause, 257 British Pakistani women aged 39 to 61 years and living in West Yorkshire, UK, were interviewed. Participants reported and rated any menopause-associated changes (positive or negative) they had experienced. Participants also reported whether they associated with menopause each of the 34 symptoms on a standard checklist. Responses were analyzed using factor analysis, and factor scores from five factors were used to assess predictors of the attribution of symptoms to menopause. Results: Women reported a wide range of symptoms, most of which are not on symptom checklists. Attribution of symptoms to menopause was associated with menopause status, age, and migration status. Women’s beliefs about which experiences were attributable to menopause did not correspond to those of the checklist developers. Women interpreted some items on the standard checklist in ways other than originally intended based on local ideas; however, because of the use of a more open approach, this produced useful data. Conclusions: Symptom checklists have serious limitations as a tool for understanding symptom experience, and prior justifications for their use leave much to be desired. The use of a more open approach generates useful data; moreover, research participants’ understanding of changes attributable to menopause may accurately reflect biological changes and may have a relationship with population-specific disease risk. Key Words: UK Y Climacteric Y South Asian Y Migration Y Muslim Y Pakistani women.
M
enopause is both a universal biological phenomenon in women and a personal experience shaped by biology, culture, and society. It has long been considered to be associated with physical and psychological changes, either transient or permanent, often called Bsymptoms of menopause.[ Although this term has been associated with a tendency to pathologize menopause,1 it is the term most often used in menopause literature. Studies have shown differences in reported menopause symptom experience between ethnic groups/populations.2,3 Studies have also found that beliefs about menopause and its symptoms vary considerably cross-culturally.1,4,5 This study provides an overview of some problematic issues in prior research on menopause symptoms, suggests alternative approaches, and investigates the usefulness of new types of data to the study of variations in menopause experience using data collected from women of Pakistani origin.
Received November 14, 2013; revised and accepted March 18, 2014. From the Department of Archaeology and Anthropology, University of Bristol, Bristol, UK. Funding/support: This research was supported by a Parkes Foundation PhD Fellowship, a UK Overseas Research Student Award, and a Durham University Doctoral Fellowship. Financial disclosure/conflicts of interest: None reported. Address correspondence to: Mwenza T. Blell, PhD, Department of Archaeology and Anthropology, University of Bristol, 43 Woodland Road, Bristol BS8 1UU, UK. E-mail: [email protected]
Several approaches have been used to assess the prevalence of menopausal symptoms in different groups/populations. Some studies have produced their own checklists of symptoms,6 whereas others have used standardized instruments such as the BlattKupperman index,7 Menopause Symptom Checklist,8 Greene Climacteric Scale,9 Menopause-Specific Quality of Life Questionnaire,10 and Everyday Complaints Symptom List.11 Each of these lists includes a different number of symptoms. However, there is overlap among them; notably, all include vasomotor symptoms and depression (or metaphors/indicators of depression such as Bfeeling blue[), and most include an indication of the severity of symptom experience. Several of the lists were derived from clinical experiences of and interviews with women living in New York or Chicago in the middle 20th century,7,8 including the Blatt-Kupperman index, Menopause Symptom Checklist, Greene Climacteric Scale, and Menopause-Specific Quality of Life Questionnaire. In contrast, the Everyday Complaints Symptom List developed by Kaufert and Syrotuik12 in 1981 combines experiences that they considered to be unrelated to menopause and experiences that they considered to be potential symptoms of menopause (based on a 1977 review of clinical literature by the International Health Foundation13). Kaufert and Syrotuik12 developed the checklist in this manner to prevent Bcultural stereotypes[ of menopause from interfering with research, and the administration of the checklist avoids mentioning menopause while inquiring about the recent Menopause, Vol. 22, No. 1, 2015
Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
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experience of each symptom. Kaufert and Syrotuik12 stated that informing research participants that the research is about menopause will create bias in reporting because of local ideas about menopause. Other authors who used the Everyday Complaints Symptom List also justified its use, reasoning that it avoids limiting researchers to symptoms associated with the Western biomedical model of menopause.14 However, the addition of several items without any known connection to menopause to a Western biomedically derived checklist would seem to be a somewhat arbitrary way to expand the set of symptoms under consideration for an association with menopause. Other researchers have combined these closed-question quantitative approaches with more open-ended qualitative methods and with attempts to discover understanding of menopause in different societies.1,5 Although quantitative approaches facilitate the use of statistical inference, the use of symptom checklists has several limitations. To begin with, most of these tools, particularly the Everyday Complaints Symptom List, attempt to bypass women’s understanding of their experiences at midlife. In appraising this approach, two questions arise: (1) What are the potential problems with bypassing women’s understanding of their experiences and only asking about symptoms already on symptom checklists? (2) To what extent might women’s ideas on menopause actually restrict their self-reporting of menopause symptoms if their understanding is not bypassed?
Limitations of bypassing women’s knowledge about their experiences In interpreting the results of menopause checklists, researchers seek to determine which reported (usually recent) experiences are attributable to menopause; this is performed specifically without reference to any other information from the participants. It is therefore possible that a symptom may be understood by a participant to be related to something other than menopause. The currently prevailing approach seeks to keep this information out of the study’s data, presumably because women may be wrong. However, it is plausible that women may be correct in their attribution of symptoms for two reasons: (1) Women may be aware that the frequency of symptom experience has not changed in middle age (eg, a woman who has been experiencing sleep problems since her 20s, which have not worsened, would be incorrectly interpreted as experiencing menopausal insomnia using a 2-wk recall checklist). (2) Women may be aware that their experience of a symptom is more likely to be related to another condition or circumstance (eg, sweating at night in the previous 2 wk may have been caused by a viral infection). Furthermore, these errors may be systematic and related to differences between populations or ethnic groups, especially those that are related to health conditions (because these often vary by population) or social circumstances. Bypassing women’s knowledge about their experiences allows researchers to conflate causes and, in some cases, to assume that changing levels of any nonvasomotor symptom experience during the menopausal transition may be a result of other transient morbidities.15
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Limitations of asking only about the symptoms on checklists Use of symptom checklists contributes to what has become a somewhat closed system of investigation. Despite a lack of agreement between researchers about which symptoms should be included on a menopause symptom checklist, a lack of openness seems to keep research focused on a list of potential symptoms similar to the list of symptoms that Europeans and North American participants and researchers originally identified. Although it makes sense that the ideas with which researchers have been most familiar are those on which they have performed most prior research, the extent to which investigation has focused on a small number of symptoms is surprising. Perhaps even more surprising is the fact that the experiences and understanding of non-Westerners have been almost entirely excluded from scientific investigation in favor of this small number of symptoms. Vasomotor symptoms had been identified in Western medical literature to be a result of menopause as early as 1870.1 Many studies have tried to assess the relationship between vasomotor symptom experience and either menopause status or hormone levels, including estradiol, estrone, sex hormoneYbinding globulin, follicle-stimulating hormone (FSH), luteinizing hormone, dehydroepiandrosterone sulfate, androstenedione, testosterone, and free testosterone.16
Menopausal symptoms among British Pakistani women: a critique of the standard checklist approach Mwenza T. Blell, PhD Abstract Objective: This study aims to identify problems with the standard menopause symptom checklist method previously used to study variations in menopause symptoms and to explore data collected using an alternative approach. Methods: As part of a biosocial study of menopause, 257 British Pakistani women aged 39 to 61 years and living in West Yorkshire, UK, were interviewed. Participants reported and rated any menopause-associated changes (positive or negative) they had experienced. Participants also reported whether they associated with menopause each of the 34 symptoms on a standard checklist. Responses were analyzed using factor analysis, and factor scores from five factors were used to assess predictors of the attribution of symptoms to menopause. Results: Women reported a wide range of symptoms, most of which are not on symptom checklists. Attribution of symptoms to menopause was associated with menopause status, age, and migration status. Women’s beliefs about which experiences were attributable to menopause did not correspond to those of the checklist developers. Women interpreted some items on the standard checklist in ways other than originally intended based on local ideas; however, because of the use of a more open approach, this produced useful data. Conclusions: Symptom checklists have serious limitations as a tool for understanding symptom experience, and prior justifications for their use leave much to be desired. The use of a more open approach generates useful data; moreover, research participants’ understanding of changes attributable to menopause may accurately reflect biological changes and may have a relationship with population-specific disease risk. Key Words: UK Y Climacteric Y South Asian Y Migration Y Muslim Y Pakistani women.
M
enopause is both a universal biological phenomenon in women and a personal experience shaped by biology, culture, and society. It has long been considered to be associated with physical and psychological changes, either transient or permanent, often called Bsymptoms of menopause.[ Although this term has been associated with a tendency to pathologize menopause,1 it is the term most often used in menopause literature. Studies have shown differences in reported menopause symptom experience between ethnic groups/populations.2,3 Studies have also found that beliefs about menopause and its symptoms vary considerably cross-culturally.1,4,5 This study provides an overview of some problematic issues in prior research on menopause symptoms, suggests alternative approaches, and investigates the usefulness of new types of data to the study of variations in menopause experience using data collected from women of Pakistani origin.
Received November 14, 2013; revised and accepted March 18, 2014. From the Department of Archaeology and Anthropology, University of Bristol, Bristol, UK. Funding/support: This research was supported by a Parkes Foundation PhD Fellowship, a UK Overseas Research Student Award, and a Durham University Doctoral Fellowship. Financial disclosure/conflicts of interest: None reported. Address correspondence to: Mwenza T. Blell, PhD, Department of Archaeology and Anthropology, University of Bristol, 43 Woodland Road, Bristol BS8 1UU, UK. E-mail: [email protected]
Several approaches have been used to assess the prevalence of menopausal symptoms in different groups/populations. Some studies have produced their own checklists of symptoms,6 whereas others have used standardized instruments such as the BlattKupperman index,7 Menopause Symptom Checklist,8 Greene Climacteric Scale,9 Menopause-Specific Quality of Life Questionnaire,10 and Everyday Complaints Symptom List.11 Each of these lists includes a different number of symptoms. However, there is overlap among them; notably, all include vasomotor symptoms and depression (or metaphors/indicators of depression such as Bfeeling blue[), and most include an indication of the severity of symptom experience. Several of the lists were derived from clinical experiences of and interviews with women living in New York or Chicago in the middle 20th century,7,8 including the Blatt-Kupperman index, Menopause Symptom Checklist, Greene Climacteric Scale, and Menopause-Specific Quality of Life Questionnaire. In contrast, the Everyday Complaints Symptom List developed by Kaufert and Syrotuik12 in 1981 combines experiences that they considered to be unrelated to menopause and experiences that they considered to be potential symptoms of menopause (based on a 1977 review of clinical literature by the International Health Foundation13). Kaufert and Syrotuik12 developed the checklist in this manner to prevent Bcultural stereotypes[ of menopause from interfering with research, and the administration of the checklist avoids mentioning menopause while inquiring about the recent Menopause, Vol. 22, No. 1, 2015
Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
79
BLELL
experience of each symptom. Kaufert and Syrotuik12 stated that informing research participants that the research is about menopause will create bias in reporting because of local ideas about menopause. Other authors who used the Everyday Complaints Symptom List also justified its use, reasoning that it avoids limiting researchers to symptoms associated with the Western biomedical model of menopause.14 However, the addition of several items without any known connection to menopause to a Western biomedically derived checklist would seem to be a somewhat arbitrary way to expand the set of symptoms under consideration for an association with menopause. Other researchers have combined these closed-question quantitative approaches with more open-ended qualitative methods and with attempts to discover understanding of menopause in different societies.1,5 Although quantitative approaches facilitate the use of statistical inference, the use of symptom checklists has several limitations. To begin with, most of these tools, particularly the Everyday Complaints Symptom List, attempt to bypass women’s understanding of their experiences at midlife. In appraising this approach, two questions arise: (1) What are the potential problems with bypassing women’s understanding of their experiences and only asking about symptoms already on symptom checklists? (2) To what extent might women’s ideas on menopause actually restrict their self-reporting of menopause symptoms if their understanding is not bypassed?
Limitations of bypassing women’s knowledge about their experiences In interpreting the results of menopause checklists, researchers seek to determine which reported (usually recent) experiences are attributable to menopause; this is performed specifically without reference to any other information from the participants. It is therefore possible that a symptom may be understood by a participant to be related to something other than menopause. The currently prevailing approach seeks to keep this information out of the study’s data, presumably because women may be wrong. However, it is plausible that women may be correct in their attribution of symptoms for two reasons: (1) Women may be aware that the frequency of symptom experience has not changed in middle age (eg, a woman who has been experiencing sleep problems since her 20s, which have not worsened, would be incorrectly interpreted as experiencing menopausal insomnia using a 2-wk recall checklist). (2) Women may be aware that their experience of a symptom is more likely to be related to another condition or circumstance (eg, sweating at night in the previous 2 wk may have been caused by a viral infection). Furthermore, these errors may be systematic and related to differences between populations or ethnic groups, especially those that are related to health conditions (because these often vary by population) or social circumstances. Bypassing women’s knowledge about their experiences allows researchers to conflate causes and, in some cases, to assume that changing levels of any nonvasomotor symptom experience during the menopausal transition may be a result of other transient morbidities.15
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Menopause, Vol. 22, No. 1, 2015
Limitations of asking only about the symptoms on checklists Use of symptom checklists contributes to what has become a somewhat closed system of investigation. Despite a lack of agreement between researchers about which symptoms should be included on a menopause symptom checklist, a lack of openness seems to keep research focused on a list of potential symptoms similar to the list of symptoms that Europeans and North American participants and researchers originally identified. Although it makes sense that the ideas with which researchers have been most familiar are those on which they have performed most prior research, the extent to which investigation has focused on a small number of symptoms is surprising. Perhaps even more surprising is the fact that the experiences and understanding of non-Westerners have been almost entirely excluded from scientific investigation in favor of this small number of symptoms. Vasomotor symptoms had been identified in Western medical literature to be a result of menopause as early as 1870.1 Many studies have tried to assess the relationship between vasomotor symptom experience and either menopause status or hormone levels, including estradiol, estrone, sex hormoneYbinding globulin, follicle-stimulating hormone (FSH), luteinizing hormone, dehydroepiandrosterone sulfate, androstenedione, testosterone, and free testosterone.16
