Women & Health
ISSN: 0363-0242 (Print) 1541-0331 (Online) Journal homepage: http://www.tandfonline.com/loi/wwah20
Premenstrual Distress Among Japanese High School Students: Self-Care Strategies and Associated Physical and Psychosocial Factors Hiroko Otsuka-Ono PhD, RN, RNM, Iori Sato PhD, RN, PHN, Mari Ikeda PhD, RN, PHN & Kiyoko Kamibeppu PhD, RN, PHN To cite this article: Hiroko Otsuka-Ono PhD, RN, RNM, Iori Sato PhD, RN, PHN, Mari Ikeda PhD, RN, PHN & Kiyoko Kamibeppu PhD, RN, PHN (2015) Premenstrual Distress Among Japanese High School Students: Self-Care Strategies and Associated Physical and Psychosocial Factors, Women & Health, 55:8, 859-882, DOI: 10.1080/03630242.2015.1061089 To link to this article: http://dx.doi.org/10.1080/03630242.2015.1061089
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Date: 05 November 2015, At: 17:10
Women & Health, 55:859–882, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2015.1061089
Premenstrual Distress Among Japanese High School Students: Self-Care Strategies and Associated Physical and Psychosocial Factors HIROKO OTSUKA-ONO, PhD, RN, RNM, IORI SATO, PhD, RN, PHN, MARI IKEDA, PhD, RN, PHN, and KIYOKO KAMIBEPPU, PhD, RN, PHN
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Department of Family Nursing, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
This study aimed to identify self-care strategies and assess physical and psychosocial factors associated with premenstrual distress among high school students. A cross-sectional survey of 217 adolescent girls aged 15 to 18 years was conducted in October 2009. Most (84.3 percent) had at least one or more symptoms of premenstrual distress. Premenstrual distress interfered with normal school activity in 51.2 percent. Most participants (57.1 percent) did not perform any self-care strategies for premenstrual distress. A hierarchical multiple linear regression analysis was conducted. Comprehension of one’s own physical and mental states during premenstrual phases mediated the relationship between neuroticism and premenstrual distress. Activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during premenstrual phases and premenstrual distress. Findings suggest that, even if girls have neuroticism, it will be important to teach them to address the comprehension of one’s own physical and mental states so that perceptions of both premenstruation and menstruation become more positive. Findings also suggest that the family’s understanding was associated with alleviation of premenstrual distress. This study suggests the need for education to help adolescent girls and
Received October 27, 2013; revised September 8, 2014; accepted September 25, 2014. Address correspondence to Kiyoko Kamibeppu, PhD, RN, PHN, Department of Family Nursing, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-0033, Japan. E-mail: [email protected] 859
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their families manage premenstrual distress and increase awareness of the benefit of managing its associated symptoms. KEYWORDS adolescent, health education, premenstrual syndrome (PMS), self-care, women’s health
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INTRODUCTION Premenstrual distress may be severe enough to have a substantial negative impact on the woman’s daily life activities and relationships with family members (Borenstein et al. 2003), absenteeism (Heinemann et al. 2010), academic performance, social and personal functions, and work performance (Halbreich et al. 2003; Robinson and Swindle 2000). In this study, physical and mental symptoms during the premenstrual phase were operationally defined as “premenstrual distress.” Medications and non-drug therapies are available for the treatment of premenstrual distress (Freeman 2010; Thangaratinam, Ismail, and O’Brien 2006). In terms of non-drug therapy, education regarding self-care includes self-monitoring, self-modification, self-regulation (such as changing negative thought patterns) and environmental modifications (Taylor 2005). Healthcare professionals need to assist women with self-care activities and refer them to other providers if necessary (Taylor 2005). However, in Japan, education about premenstrual distress is not often provided after education about menarche, which occurs in elementary schools. Therefore, adolescent girls may have inadequate self-care strategies regarding premenstrual distress. Although a relationship has been found in high school students between premenstrual distress and the time since menarche and between premenstrual distress and neuroticism (Kayashima et al. 1984; Kimura, Kayashima, and Maehara 1986), other associated factors are still not clear. Neuroticism is defined as the propensity to experience negative emotions, represented by emotional instability, anxiousness, feelings of guilt, low selfesteem, hypersensitivity, tension, shyness, and emotionalism (Eysenck, Eysenck, and Barrett 1985). Neuroticism has clearly influenced premenstrual distress; however, it is difficult to change because it is a personality trait (Mor et al. 2008). Therefore, if factors that mediate the relationship between premenstrual distress and neuroticism can be identified, they can become a target of interventions. In this study, we focused on comprehension of one’s own physical and mental states during premenstrual phases. We defined the comprehension of one’s own physical and mental states during the premenstrual phase as comprehensive perception of one’s premenstrual changes. It is useful to address in education the appropriate mediating factor so that comprehensive perception of one’s premenstrual changes may become more positive.
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Negative emotions induced by neuroticism could be associated with the comprehension of one’s own physical and mental states during the premenstrual phase. Moreover, comprehension of one’s own physical and mental states during the premenstrual phase could be associated with premenstrual distress. If this comprehension is associated with premenstrual distress, interventions that work on one’s comprehension may relieve one’s premenstrual distress. We planned to examine the possibility that comprehension of one’s own physical and mental states during the premenstrual phase mediated the relationship between neuroticism and premenstrual distress (Figure 1). We also examined the possibility that activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress. Premenstrual distress has been correlated with menstrual distress (Rizk et al. 2006). Therefore, we considered that activity restrictions due to menstrual distress might promote the family’s understanding of premenstrual and menstrual distress. Understanding factors associated with premenstrual distress and self-care strategies for premenstrual distress may help improve women’s quality of life and decrease suffering from premenstrual distress. Thus far, no studies of which we are aware have examined the factors associated with premenstrual distress and self-care strategies for premenstrual distress among high school students. The purposes of this study were: (1) to identify self-care strategies, and (2) to assess variables that mediate the relationship between neuroticism and premenstrual distress, variables that mediate the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress, and the physical and psychosocial factors associated with premenstrual distress among high school students.
Comprehension of one’s own physical and mental states during premenstrual phases
Neuroticism
Premenstrual distress
FIGURE 1 Proposed model of comprehension of one’s own physical and mental states during premenstrual phases as a mediator between neuroticism and premenstrual distress.
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METHODS Participants Participants were female students at two full-time coeducational public high schools in the suburbs of Kyoto Prefecture in Japan. We distributed questionnaires to all female students at A high school (239 first through third years) and B high school (142 third years). Japanese high schools have three grades with student ages ranging from 15 to 18 years.
Procedure
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Students were recruited through high school teachers to complete an anonymous self-reported questionnaire survey in school or at home. The high school teachers distributed questionnaires. If girls did not want to answer, they could submit a blank questionnaire. After completing the questionnaires, each student sealed the envelope herself and handed it to the high school teacher. Data were collected in October 2009.
Measures MENSTRUAL DISTRESS QUESTIONNAIRE Premenstrual distress and menstrual distress were assessed using Form A of the Japanese version (Kayashima et al. 1995) of the Moos Menstrual Distress Questionnaire (MDQ) (Moos 1968, 1977). Form A is a retrospective symptom questionnaire that allows a woman to describe the menstrual cycle symptoms of the most recent menstrual cycle (Moos 1977). Each symptom is scored from 1 to 6, with 1 being “no experience of the symptom” and 6 being “extremely severe.” The total MDQ score has forty-one items and ranges from 41 to 246 with higher values indicating worse symptoms. One item (change in eating habits) of the Total MDQ score could not be located consistently on any subscale (Moos 1977). The main outcome measure was premenstrual distress, which was summarized using six scales that measured impairment (pain, impaired concentration, behavior changes, autonomic reactions, water retention, negative effects) and the arousal scale, which measures activation perception. The Cronbach’s alpha coefficients in this study were: 0.86 for pain, 0.84 for impaired concentration, 0.80 for behavior changes, 0.74 for autonomic reactions, 0.67 for water retention, 0.90 for negative effects, 0.63 for arousal scale, and 0.96 for total MDQ score during premenstrual phases. SELF-CARE STRATEGIES Thirteen self-care strategies used to relieve symptoms of premenstrual distress were identified from various literature sources (Taylor 2005; Kirkpatrick, Brewer,
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and Stocks 1990; Kirkpatrick and Grady 1985) and from a panel of experts and provided to participants. These strategies included getting moderate exercise, cheering oneself up, cutting down on sugar, cutting down on salt, staying away from caffeine, keeping a record of one’s menstrual cycle, recording symptoms during the premenstrual phase, measuring basal body temperature, telling a familiar person that you have uncomfortable symptoms, taking an over-thecounter pain reliever, visiting the doctor, taking the medicine prescribed by the doctor, and following one’s own solution. Participants were asked to indicate which self-care strategies (behaviors or habits) they usually used to alleviate symptoms of premenstrual distress. In addition, participants were asked to write down any self-care strategy that did not appear on the list. We measured the presence (1) or absence (0) of reported self-care measures in this study.
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COMPREHENSION OF ONE’S OWN PHYSICAL PREMENSTRUAL PHASES
AND
MENTAL STATES DURING
The comprehension of one’s own physical and mental states during the premenstrual phase was measured using the Semantic Differential (SD) method devised by Osgood (1969). Based on the measurement procedure using the SD method (Iwashita 1983), several items were selected from previous studies (Jacobson and Lentz 1998; Watanabe and Kita 2007) and preliminary research for thirteen women aged from 20 years to their early 40s was conducted. Twenty opposite adjective pairs (good, bad; fair, unfair; comfortable, uncomfortable; clean, filthy; kind, unkind; reliable, unreliable; safe, anxious; glad, sad; strong, weak; light, heavy; easy, difficult; shallow, deep; clarified, obscure; bright, dark; soft, hard; simple, complicated; sharp, bleary; quick, late; active, inactive; positive, negative) were tested. Three apposite adjective pairs (fulfilling, empty; calm, fidgety; healthy, unhealthy) were created and tested. To check the “semantic stability,” which is the basis for selection of terms, we checked whether a positive and negative directionality would be in agreement with a candidate for each adjective pair. Only items with semantic stability were selected for this study. Participants were asked to respond to ten adjective pairs that were opposite in meaning and to rate their applicability from 1 to 7 (easy, difficult; fulfilling, empty; safe, anxious; calm, fidgety; comfortable, uncomfortable; light, heavy; bright, dark; sharp, bleary; active, inactive; healthy, unhealthy). The higher the score was, the more positive the perception was of the premenstrual period.
NEUROTICISM Neuroticism was measured using the subscale of the Japanese version (Hosokawa and Ohyama 1993) of the Short-Form Eysenck Personality
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Questionnaire Revised (EPQ-R) (Eysenck, Eysenck, and Barrett 1985). The questionnaire consists of 12 items that are rated on a 2-point scale (0 to 1). The total score ranges from 0 to 12, with higher scores representing a greater degree of neuroticism. The Cronbach’s alpha coefficient for this scale was 0.77. The EPQ-R has been validated among respondents aged 17 to 70 years (Eysenck, Eysenck, and Barrett 1985) and among high school girls (Mor et al. 2008). The Japanese version of the EPQ-R has been validated among college students and adults. Previous studies (Kayashima et al. 1984; Kimura, Kayashima, and Maehara 1986; Slade and Jenner 1980) and the Menstrual Distress Questionnaire Manual (Moos 1977) state that neuroticism should be considered when using the MDQ.
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ORAL CONTRACEPTIVE USE To control for potential confounding by use of oral contraceptives, current oral contraceptive use was assessed using a single question graded as 0 (absence) or 1 (presence).
SOCIAL SUPPORT To explore whether social support was related to premenstrual distress, we used the Scale of Expectancy for Social Support (Hisata, Senda, and Migti 1989), which measures the degree of the expectation of receiving support from the father, mother, siblings, teachers, and friends, and so forth for potential future problems. The questionnaire consists of sixteen items measuring each source of support. Items are rated on a four-point scale (1 to 4), and total scores range from 16 to 64. The higher the score, the more support the participant received. With the scale developer’s permission, we created a classification called “family other than mother” instead of “father.” Because one’s family is believed to affect premenstrual distress, we measured the support of “family other than mother,” “mother,” “teachers,” and “friends” in this study. The Cronbach’s alpha coefficients for these measurements were 0.96, 0.97, 0.97, and 0.96, respectively.
FREQUENCY
OF
CONVERSATIONS ABOUT MENSES WITH MOTHER
To explore the relation of conversations with mothers about menses, the frequency of such conversations was rated on a five-point scale (1 to 5) ranging from “does not talk at all” to “always talking.” The higher the score, the more frequent the mother/daughter conversations.
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FAMILY’S UNDERSTANDING
OF
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ONE’S BEHAVIOR DURING PREMENSTRUAL PHASES
The degree of the family’s understanding of one’s behavior during the premenstrual phase was rated using a single question graded on a four-point scale (1 to 4). The higher the score, the lower the family’s understanding of one’s behavior. ACTIVITY RESTRICTIONS DUE
TO
MENSTRUAL DISTRESS
The degree to which menstrual distress interfered with normal activities was rated using a single question graded on a five-point scale (1 to 5). The higher the score, the more menstrual distress interfered with the respondent’s daily life.
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IMPACT
OF
PREMENSTRUAL DISTRESS
ON
DAILY ROUTINE
Participants were asked about the impact of premenstrual distress on their daily routine (multiple answers were permitted). Responses included missed school/school absence, missed class, missed work, missed physical activity or sports participation, and sternness with friends or family. We measured the presence (1) or absence (0) of these impacts. In addition, participants were asked to write down any experiences that did not appear on the list. MENSTRUAL HISTORY/REPRODUCTIVE HEALTH Questions were asked regarding the presence or absence of menarche, age at menarche, usual length of menstrual cycle, and usual number of days of bleeding. PERCEPTION
OF
PMS
Premenstrual syndrome (PMS) is diagnosed in cases in which premenstrual distress occurs cyclically and recurrently (American College of Obstetricians and Gynecologists 2000; Halbreich et al. 2007). Participants were asked whether they had ever heard of PMS, regardless of whether symptoms actually existed. Participants were then briefed on the definition of PMS, that is, a variety of physical, emotional, behavioral, and cognitive symptoms, such as headache, irritability, and decreased concentration that occurs during the week before menses and remits shortly after menses begin. INFORMATION ABOUT PMS Participants who had heard of PMS were asked about their sources of information. The list of sources included their mother, father, sister, grandmother,
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peers (female friend), male friends, boyfriend, school nurses, homeroom teacher, health and physical education teachers, physician, nurse, public health nurse, midwife, magazines, technical books, radio and TV, and the Internet. Multiple answers were permitted, and participants could also indicate that they could not recall the sources. In addition, participants were asked to write down any sources of information that did not appear on the list. INFORMATION NEEDS ABOUT PMS
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Participants were asked what information they wanted to know about PMS (multiple answers were permitted), including treatments, signs and symptoms, self-care strategies, indications for consulting a healthcare professional, consultation place, and how to acquire information. In addition, participants were asked to write down any information needs that did not appear on the list.
Human Subjects Approval Before this study was performed, the protocol was approved by the institutional review board of the University of Tokyo and by the principals of the participating schools. We explained the purpose of the study to the students and their guardians in a letter, and received the written consent from both the participants and their guardians. Surveys completed by students who did not provide consent were excluded from analyses. We also produced a pamphlet designed to deepen high school students’ understanding of PMS and self-care. The pamphlets were distributed after the collection of questionnaires, regardless of whether or not the participants cooperated in the research.
Data Analysis All reported p values are two-tailed, and a p value < .05 was considered significant. The Statistical Package for Social Sciences (IBM SPSS, Armonk, NY, USA), Windows version 21.0, was used for all analyses. Descriptive statistics were computed for the demographic, physical, and psychosocial characteristics of participants, impact of premenstrual distress on daily routine, information about PMS, information needs about PMS, and selfcare strategies during the premenstrual phases in accordance with the first aim of the study. A paired t-test was conducted to compare distress of participants during the premenstrual phases and menstrual phases of MDQ, during the premenstrual phases and inter-menstrual phases using the MDQ. To check factor composition as a procedure of measurement by the SD method, an explanatory factor analysis of ten items regarding “comprehension of one’s own physical and mental states during the premenstrual phase” was
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conducted. Using the non-weighted least squares method in factor extraction, we established characteristic values of one or more standards for the number of factors and performed promax rotations. A hierarchical multiple linear regression analysis was then performed in accordance with the second aim of the study, i.e., to assess variables that mediated the relationship between neuroticism and premenstrual distress, and variables that mediated the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress, and assess the physical and psychosocial factors associated with premenstrual distress among high school students. To take into account variance in premenstrual distress due to time since menarche, the weighted least squares method was applied, using time since menarche as a weighted factor. Factors that were associated with premenstrual distress in bivariate analyses (Spearman’s rank-correlation coefficient ≥0.3) and that were important in previous studies (Kayashima et al. 1984) were considered independent variables. These independent variables were chosen after consideration of multicollinearity. Four regression models were tested: the first model contained menstrual history/reproductive health (time since menarche, oral contraceptive use) and personality trait (neuroticism). The second model contained all of the variables included in the first model plus social support (perceived social support, frequency of conversations about menses with the mother, and the family’s understanding of one’s behavior during premenstrual phases). The third model contained all of the variables included in the second model plus activity restrictions due to menstrual distress to test whether activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress. When we tested whether activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during premenstrual phases and premenstrual distress, we observed: a mediating effect in cases in which (1) activity restrictions due to menstrual distress were statistically significant, (2) the effect of the family’s understanding of one’s behavior during premenstrual phases became smaller than the effect in the former model, and (3) the F change was also statistically significant. The fourth model contained all of these variables plus the comprehension of one’s own physical and mental states during the premenstrual phase to test whether comprehension of one’s own physical and mental states during the premenstrual phase mediated the relationship between neuroticism and premenstrual distress. When we tested whether comprehension of one’s own physical and mental states during premenstrual phases mediated the relationship between neuroticism and premenstrual distress, we observed: a mediating effect in cases in which (1) comprehension of one’s own physical and mental states during the premenstrual phase was statistically significant, (2) the effect of neuroticism became smaller than the effect in the former model, and (3) F changes were also statistically significant.
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RESULTS
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A total of 298 questionnaires were collected from 381 girls (78.2 percent response rate); of these, 226 (overall 59.3 percent participation rate) also had the students’ and parents’ consent to participate in the study. Seven participants (3.1 percent) answered less than half the questions on the MDQ, and five participants (2.2 percent) answered less than half the questions regarding comprehension of one’s own physical and mental states during premenstrual phases; these participants were excluded from the analyses. Missing values were removed. Therefore, the final sample included 217 students. Although lessons about menses were included in health and physical education classes at both schools, no lessons were provided regarding premenstrual distress at either school. Because the distributions of each independent variable used in the hierarchical multiple linear regression analyses did not differ in the third-year students at A high school and B high school, results were analyzed using the total sample combined.
Demographic and Menstrual History The 217 participants had a mean age of 16.5 years, and all participants had already experienced menarche (Table 1). The average age of menarche was 12.3 years. Most participants (94 percent, n = 204) usually bled for 3 to 7 days. Participants were a mean of 4.2 years postmenarche, and many of them were beyond 3.4 years postmenarche. A total of twenty-nine participants reported current use of oral contraceptive (13.4 percent), one of whom took contraceptive pills specifically for premenstrual and menstrual symptoms. To control for the potential confounding by oral contraceptives, “current oral contraceptive use” was considered a control variable in the hierarchical multiple linear regression analyses.
Premenstrual Distress We compared premenstrual and menstrual distress (Table 2) and found that arousal was comparable in both phases, whereas pain, impaired concentration, behavior changes, autonomic reactions, and negative effects were all significantly lower in the premenstrual phase than in the menstrual phase (p < .001). Report of water retention was significantly lower in the premenstrual phase than in the menstrual phase (p = .011). Furthermore, we compared premenstrual and inter-menstrual distress (Table 2) and found that all of the scales were significantly lower in the inter-menstrual phase than in the premenstrual phase (p < .001). However, 150 participants who replied to all the questions on the MDQ (84.3 percent) had at least one or more symptoms of premenstrual distress. Moreover, 173 participants who
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Demographics Class year First-year Second-year Third-year Family type Intact family No-parent family Single-father family Single-mother family Medical history Regular doctor’s visits for chronic disease Steady dose of medicationa (not oral contraceptives) Menstrual history/reproductive health Age at menarche (years) Time since menarche (years) Oral contraceptive users Timing of menarche (age in years) Early menarche ( 0.04 are in bold. Exploratory factor analysis: nonweighted least squares method/promax rotation.
Physical and Psychosocial Factors Associated With Premenstrual Distress in Multivariable Models The dependent variable was premenstrual distress. The independent variables that were important in previous studies were time since menarche (years), oral contraceptive use, neuroticism, perceived social support from the mother, perceived social support from family other than the mother, perceived social support from teachers, perceived social support from friends, frequency of conversations about menses with the mother, the family’s understanding of one’s behavior during premenstrual phases, activity restrictions due to menstrual distress, and comprehension of one’s own physical and mental states during premenstrual phases. Variables that correlated (Spearman’s rank-correlation coefficient ≥0.3) with the dependent variable were neuroticism, comprehension of one’s own physical and mental states during premenstrual phases, and activity restrictions due to menstrual distress. A hierarchical multiple linear regression analysis was then performed to test mediating effects. The proposed model was that comprehension of one’s own physical and mental states during the premenstrual phase mediated the relation between neuroticism and premenstrual distress (Figure 1). Results from the final model, testing whether comprehension of one’s own physical and mental states during the premenstrual phase mediated the relationship between neuroticism and premenstrual distress, were significant (R2 = 0.377, adjusted R2 = 0.342) (Table 6). The final model explained 38 percent of the variance in premenstrual distress. Variables that correlated with the dependent variable were comprehension of one’s own physical and mental states during the premenstrual phase (B = –1.446, β = –0.332, t = 4.695, p < .001) and
875 0.104 0.086
0.058 0.119 0.282
β 0.461 0.130 0.000
p value
Model 1
0.142 0.107 0.038 2.170
0.059 0.123 0.256 −0.128 0.013 −0.170
β 0.460 0.114 0.001 0.110 0.868 0.036
p value
Model 2
0.282 0.247 0.139 28.140
0.087 0.128 0.176 −0.069 −0.015 −0.132 0.391
β
***
0.237 0.075 0.018 0.354 0.841 0.076 0.000
p value
Model 3
0.377 0.342 0.095 22.042
0.100 0.073 0.142 −0.069 0.019 −0.095 0.308 −0.332
β
***
0.145 0.283 0.043 0.321 0.792 0.173 0.000 0.000
p value
Model 4
Note: N = 183. β: Standardized partial regression coefficient. Weighted least-squares method: To take into account the variance in premenstrual distress due to time since menarche, the weighted least squares method was applied using time since menarche as a weighted factor. ***p < .001.
Time since menarche Oral contraceptive use Neuroticism Perceived social support from mother Frequency of conversations about menses with mother Family’s understanding of one’s behavior during premenstrual phases Activity restrictions due to menstrual distress Comprehension of one’s own physical and mental states during premenstrual phases R2 Adjusted R2 R2 change (step) F change (step)
Independent variables
TABLE 6 Hierarchical Multiple Linear Regression for Premenstrual Distress
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activity restrictions due to menstrual distress (B = 10.132, β = 0.308, t = 4.332, p < .001). The model showed that activity restrictions due to menstrual distress mediated the relation between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress. Results from the third model, testing whether activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress, were also significant (R2 = 0.282, adjusted R2 = 0.247). The effect of the family’s understanding of one’s behavior during the premenstrual phase in the second model disappeared in the third model. We also found that activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress. The increment in R-square in the third model (0.14) was statistically significant. The effect of neuroticism in the third model had a small effect in the final model. We also found that comprehension of one’s own physical and mental states during premenstrual phases mediated the relationship between neuroticism and premenstrual distress. The increment in Rsquare in the final model (0.095) was statistically significant.
DISCUSSION To our knowledge, this is the first study to identify self-care strategies for premenstrual distress among high school girls in Japan and also the first to examine physical and psychosocial factors associated with premenstrual distress in this group. Most participants’ usual number of days of bleeding was in the normal range. Participants were a mean of 4.2 years postmenarche, and many of them had passed 3.4 years or more. A previous study has indicated that adolescents at 3.4 or more years postmenarche have reported more intense premenstrual distress compared to adolescents at less than 3.4 years (Cleckner-Smith, Doughty, and Grossman 1998). Many participants in our study were 3.4 years postmenarche and thus might have had more intense premenstrual distress. Among adolescent girls in this study, menstrual distress was stronger than premenstrual distress, which supports findings in previous studies (Wong 2011; Wilson and Keye 1989). Wilson and Keye (1989) found that premenstrual distress in girls (86 percent) was as prevalent as symptoms of dysmenorrhea (91 percent), and most of the girls were unaware of the causes and treatments of these symptoms. The fact that only one participant in this study who reported having premenstrual distress consulted a physician may indicate poor treatmentseeking behavior for menstrual-related matters and poor self-care. Alternatively, girls may perceive premenstrual distress as completely normal; hence, they did not want to seek professional treatment. Based on our findings,
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adolescent girls did nothing or eventually ended up relying on their own premenstrual distress management. As reported in other studies (Wong 2011), girls may not be inclined to seek treatment for these symptoms. Nevertheless, such attitudes are potentially amendable through educational interventions (Robinson and Swindle 2000). Therefore, incorporating an educational program on menstrual-related matters into the regular school curriculum for adolescent girls would seem appropriate (Robinson and Swindle 2000; Wong 2011). Although the perception of PMS was low, more than half of the participants reported that premenstrual distress had interfered with daily life or school life during the premenstrual phase, a result that matched results of previous studies (Wong 2011; Sagara, Kuwabara, and Mizuno 1991). In previous studies (Wong 2011), 63.1 percent of female adolescents reported premenstrual distress, but only 34.9 percent reported it as PMS. Our study showed a lower perception of PMS than in previous studies. Therefore, health education on effective management of premenstrual distress is potentially important, especially for high school students, to prevent absence from school and loss of interest in school due to concentration impairments (Wong 2011). As the key resource for PMS and reproductive health information was school nurses, peers, and mothers, increasing the involvement of these groups in reproductive education is important.
Physical and Psychosocial Factors Associated With Premenstrual Distress Activity restrictions due to menstrual distress were associated with premenstrual distress in this study, which supports findings in other studies. Premenstrual distress and menstrual pain were positively associated (Wong 2011; Shye and Jaffe 1991), and premenstrual distress has been shown to be correlated with dysmenorrhea (Kitamura et al. 2012; Rizk et al. 2006; Freeman, Rickels, and Sondheimer 1993). Though further investigation is needed to clarify why premenstrual distress and dysmenorrhea are positively correlated, one factor that is associated with premenstrual distress is the degree of activity restrictions due to menstrual distress. We also found that comprehension of one’s own physical and mental states during the premenstrual phase mediated the relationship between neuroticism and premenstrual distress. These findings imply that even if adolescent girls have neuroticism as a personality trait, it will be important to address this factor in the education of high school students so that perceptions of both premenstruation and menstruation become more positive. Morse (1997, 1999) conducted a longitudinal study for adult women with PMS using a quasi-experimental research design and reported that positive reframing was effective in reducing perimenstrual impairment. Reframing was the
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intervention that helped women to frame their premenstrual perception in a more positive light (Morse 1997, 1999). Therefore, we believe that Morse’s positive reframing would be useful for high school girls. We also found that activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress. These findings suggest that activity restrictions due to menstrual distress promoted the family’s understanding of premenstrual and menstrual distress, as the family’s understanding of one’s behavior during premenstrual phases had an inverse relationship to premenstrual distress. The findings suggest that the family’s understanding was associated with alleviation of premenstrual distress. In this study, girls received information regarding PMS from school nurses, health and physical education teachers, peers, and mothers. Information obtained from mothers was relatively scarce in this study compared with data from a previous study in which 31.3 percent of girls obtained information from their mothers (Wong 2011). It appears that school-based written educational materials related to menstrual problems are needed. At the same time, it is necessary to encourage parental involvement in education and management activities (Wong 2011). Furthermore, the fact that a considerable proportion of students acquired information from peers suggests that a youth peer educator may be a practical way of tackling sensitive issues like menstruation (Wong 2011).
Implications for the Support and Education of High School Students The results of the study suggest the need for educational intervention programs regarding self-care for premenstrual distress in high school students. High school students who have already experienced premenstrual distress may find it manageable through positive reframing. It is important in the education of high school students who have not experienced premenstrual distress to approach such education in a way in which the “comprehension of one’s own physical and mental states during premenstrual phases” may become positive, rather than having to be reframed.
Strengths and Limitations The findings of this study must be interpreted in the context of its limitations. First, as this study was a small survey conducted in two schools in a single region, generalizing the results requires prudence. Second, as we performed a cross-sectional survey, no temporal and thus causal relationships could be determined. Third, although three menstrual cycles need to be recorded for the diagnosis of PMS, studies of adolescents that use prospective daily symptom ratings are limited. Because this survey, which
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used the MDQ, was conducted via a retrospective method in consideration of high school students’ burden, the diagnosis of PMS was not ascertained. Fourth, the measurement of the MDQ did not include any positive symptom experiences and positive changes. It is necessary to use measures that can assess the positive side of the menstruation cycle in future investigations. Finally, some of the measures may not have had criterion-related validity, in particular the neuroticism measure, and had modest internal validity, as indicated by moderate values for Cronbach’s alpha, and thus may have misclassified some participants. However, this study can provide basic data for future studies simply by having clarified the self-care strategies and the relevant factors for premenstrual distress among high school students. Moreover, according to high school students’ stage of development, it is necessary to discuss how it might be effective to approach education so that the “comprehension of one’s own physical and mental states during premenstrual phases” may become positive. Henceforth, we believe that it would be useful to measure the “comprehension of one’s own physical and mental states during premenstrual phases” before and after an intervention. The “comprehension of one’s own physical and mental states during premenstrual phases” can measure educational (intervention) secondary effects, even when high school students have not experienced or are not aware of their own premenstrual distress. A further prospective intervention study needs to be done for high school students. To develop sufficient measurement tools, a wide range sampling would be required.
CONCLUSION These findings suggest the need for education to help adolescent girls and their families manage premenstrual distress and increase awareness of the benefit of managing these symptoms.
ACKNOWLEDGMENTS We are grateful to the students who participated in this research and the staff members of the high schools, who cooperated with us during this research. From the onset of our research, we received guidance from Professor Kimiko Kayasima of the Jikei University School of Medicine.
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ISSN: 0363-0242 (Print) 1541-0331 (Online) Journal homepage: http://www.tandfonline.com/loi/wwah20
Premenstrual Distress Among Japanese High School Students: Self-Care Strategies and Associated Physical and Psychosocial Factors Hiroko Otsuka-Ono PhD, RN, RNM, Iori Sato PhD, RN, PHN, Mari Ikeda PhD, RN, PHN & Kiyoko Kamibeppu PhD, RN, PHN To cite this article: Hiroko Otsuka-Ono PhD, RN, RNM, Iori Sato PhD, RN, PHN, Mari Ikeda PhD, RN, PHN & Kiyoko Kamibeppu PhD, RN, PHN (2015) Premenstrual Distress Among Japanese High School Students: Self-Care Strategies and Associated Physical and Psychosocial Factors, Women & Health, 55:8, 859-882, DOI: 10.1080/03630242.2015.1061089 To link to this article: http://dx.doi.org/10.1080/03630242.2015.1061089
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Date: 05 November 2015, At: 17:10
Women & Health, 55:859–882, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2015.1061089
Premenstrual Distress Among Japanese High School Students: Self-Care Strategies and Associated Physical and Psychosocial Factors HIROKO OTSUKA-ONO, PhD, RN, RNM, IORI SATO, PhD, RN, PHN, MARI IKEDA, PhD, RN, PHN, and KIYOKO KAMIBEPPU, PhD, RN, PHN
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Department of Family Nursing, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
This study aimed to identify self-care strategies and assess physical and psychosocial factors associated with premenstrual distress among high school students. A cross-sectional survey of 217 adolescent girls aged 15 to 18 years was conducted in October 2009. Most (84.3 percent) had at least one or more symptoms of premenstrual distress. Premenstrual distress interfered with normal school activity in 51.2 percent. Most participants (57.1 percent) did not perform any self-care strategies for premenstrual distress. A hierarchical multiple linear regression analysis was conducted. Comprehension of one’s own physical and mental states during premenstrual phases mediated the relationship between neuroticism and premenstrual distress. Activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during premenstrual phases and premenstrual distress. Findings suggest that, even if girls have neuroticism, it will be important to teach them to address the comprehension of one’s own physical and mental states so that perceptions of both premenstruation and menstruation become more positive. Findings also suggest that the family’s understanding was associated with alleviation of premenstrual distress. This study suggests the need for education to help adolescent girls and
Received October 27, 2013; revised September 8, 2014; accepted September 25, 2014. Address correspondence to Kiyoko Kamibeppu, PhD, RN, PHN, Department of Family Nursing, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-0033, Japan. E-mail: [email protected] 859
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their families manage premenstrual distress and increase awareness of the benefit of managing its associated symptoms. KEYWORDS adolescent, health education, premenstrual syndrome (PMS), self-care, women’s health
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INTRODUCTION Premenstrual distress may be severe enough to have a substantial negative impact on the woman’s daily life activities and relationships with family members (Borenstein et al. 2003), absenteeism (Heinemann et al. 2010), academic performance, social and personal functions, and work performance (Halbreich et al. 2003; Robinson and Swindle 2000). In this study, physical and mental symptoms during the premenstrual phase were operationally defined as “premenstrual distress.” Medications and non-drug therapies are available for the treatment of premenstrual distress (Freeman 2010; Thangaratinam, Ismail, and O’Brien 2006). In terms of non-drug therapy, education regarding self-care includes self-monitoring, self-modification, self-regulation (such as changing negative thought patterns) and environmental modifications (Taylor 2005). Healthcare professionals need to assist women with self-care activities and refer them to other providers if necessary (Taylor 2005). However, in Japan, education about premenstrual distress is not often provided after education about menarche, which occurs in elementary schools. Therefore, adolescent girls may have inadequate self-care strategies regarding premenstrual distress. Although a relationship has been found in high school students between premenstrual distress and the time since menarche and between premenstrual distress and neuroticism (Kayashima et al. 1984; Kimura, Kayashima, and Maehara 1986), other associated factors are still not clear. Neuroticism is defined as the propensity to experience negative emotions, represented by emotional instability, anxiousness, feelings of guilt, low selfesteem, hypersensitivity, tension, shyness, and emotionalism (Eysenck, Eysenck, and Barrett 1985). Neuroticism has clearly influenced premenstrual distress; however, it is difficult to change because it is a personality trait (Mor et al. 2008). Therefore, if factors that mediate the relationship between premenstrual distress and neuroticism can be identified, they can become a target of interventions. In this study, we focused on comprehension of one’s own physical and mental states during premenstrual phases. We defined the comprehension of one’s own physical and mental states during the premenstrual phase as comprehensive perception of one’s premenstrual changes. It is useful to address in education the appropriate mediating factor so that comprehensive perception of one’s premenstrual changes may become more positive.
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Negative emotions induced by neuroticism could be associated with the comprehension of one’s own physical and mental states during the premenstrual phase. Moreover, comprehension of one’s own physical and mental states during the premenstrual phase could be associated with premenstrual distress. If this comprehension is associated with premenstrual distress, interventions that work on one’s comprehension may relieve one’s premenstrual distress. We planned to examine the possibility that comprehension of one’s own physical and mental states during the premenstrual phase mediated the relationship between neuroticism and premenstrual distress (Figure 1). We also examined the possibility that activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress. Premenstrual distress has been correlated with menstrual distress (Rizk et al. 2006). Therefore, we considered that activity restrictions due to menstrual distress might promote the family’s understanding of premenstrual and menstrual distress. Understanding factors associated with premenstrual distress and self-care strategies for premenstrual distress may help improve women’s quality of life and decrease suffering from premenstrual distress. Thus far, no studies of which we are aware have examined the factors associated with premenstrual distress and self-care strategies for premenstrual distress among high school students. The purposes of this study were: (1) to identify self-care strategies, and (2) to assess variables that mediate the relationship between neuroticism and premenstrual distress, variables that mediate the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress, and the physical and psychosocial factors associated with premenstrual distress among high school students.
Comprehension of one’s own physical and mental states during premenstrual phases
Neuroticism
Premenstrual distress
FIGURE 1 Proposed model of comprehension of one’s own physical and mental states during premenstrual phases as a mediator between neuroticism and premenstrual distress.
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METHODS Participants Participants were female students at two full-time coeducational public high schools in the suburbs of Kyoto Prefecture in Japan. We distributed questionnaires to all female students at A high school (239 first through third years) and B high school (142 third years). Japanese high schools have three grades with student ages ranging from 15 to 18 years.
Procedure
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Students were recruited through high school teachers to complete an anonymous self-reported questionnaire survey in school or at home. The high school teachers distributed questionnaires. If girls did not want to answer, they could submit a blank questionnaire. After completing the questionnaires, each student sealed the envelope herself and handed it to the high school teacher. Data were collected in October 2009.
Measures MENSTRUAL DISTRESS QUESTIONNAIRE Premenstrual distress and menstrual distress were assessed using Form A of the Japanese version (Kayashima et al. 1995) of the Moos Menstrual Distress Questionnaire (MDQ) (Moos 1968, 1977). Form A is a retrospective symptom questionnaire that allows a woman to describe the menstrual cycle symptoms of the most recent menstrual cycle (Moos 1977). Each symptom is scored from 1 to 6, with 1 being “no experience of the symptom” and 6 being “extremely severe.” The total MDQ score has forty-one items and ranges from 41 to 246 with higher values indicating worse symptoms. One item (change in eating habits) of the Total MDQ score could not be located consistently on any subscale (Moos 1977). The main outcome measure was premenstrual distress, which was summarized using six scales that measured impairment (pain, impaired concentration, behavior changes, autonomic reactions, water retention, negative effects) and the arousal scale, which measures activation perception. The Cronbach’s alpha coefficients in this study were: 0.86 for pain, 0.84 for impaired concentration, 0.80 for behavior changes, 0.74 for autonomic reactions, 0.67 for water retention, 0.90 for negative effects, 0.63 for arousal scale, and 0.96 for total MDQ score during premenstrual phases. SELF-CARE STRATEGIES Thirteen self-care strategies used to relieve symptoms of premenstrual distress were identified from various literature sources (Taylor 2005; Kirkpatrick, Brewer,
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and Stocks 1990; Kirkpatrick and Grady 1985) and from a panel of experts and provided to participants. These strategies included getting moderate exercise, cheering oneself up, cutting down on sugar, cutting down on salt, staying away from caffeine, keeping a record of one’s menstrual cycle, recording symptoms during the premenstrual phase, measuring basal body temperature, telling a familiar person that you have uncomfortable symptoms, taking an over-thecounter pain reliever, visiting the doctor, taking the medicine prescribed by the doctor, and following one’s own solution. Participants were asked to indicate which self-care strategies (behaviors or habits) they usually used to alleviate symptoms of premenstrual distress. In addition, participants were asked to write down any self-care strategy that did not appear on the list. We measured the presence (1) or absence (0) of reported self-care measures in this study.
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COMPREHENSION OF ONE’S OWN PHYSICAL PREMENSTRUAL PHASES
AND
MENTAL STATES DURING
The comprehension of one’s own physical and mental states during the premenstrual phase was measured using the Semantic Differential (SD) method devised by Osgood (1969). Based on the measurement procedure using the SD method (Iwashita 1983), several items were selected from previous studies (Jacobson and Lentz 1998; Watanabe and Kita 2007) and preliminary research for thirteen women aged from 20 years to their early 40s was conducted. Twenty opposite adjective pairs (good, bad; fair, unfair; comfortable, uncomfortable; clean, filthy; kind, unkind; reliable, unreliable; safe, anxious; glad, sad; strong, weak; light, heavy; easy, difficult; shallow, deep; clarified, obscure; bright, dark; soft, hard; simple, complicated; sharp, bleary; quick, late; active, inactive; positive, negative) were tested. Three apposite adjective pairs (fulfilling, empty; calm, fidgety; healthy, unhealthy) were created and tested. To check the “semantic stability,” which is the basis for selection of terms, we checked whether a positive and negative directionality would be in agreement with a candidate for each adjective pair. Only items with semantic stability were selected for this study. Participants were asked to respond to ten adjective pairs that were opposite in meaning and to rate their applicability from 1 to 7 (easy, difficult; fulfilling, empty; safe, anxious; calm, fidgety; comfortable, uncomfortable; light, heavy; bright, dark; sharp, bleary; active, inactive; healthy, unhealthy). The higher the score was, the more positive the perception was of the premenstrual period.
NEUROTICISM Neuroticism was measured using the subscale of the Japanese version (Hosokawa and Ohyama 1993) of the Short-Form Eysenck Personality
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Questionnaire Revised (EPQ-R) (Eysenck, Eysenck, and Barrett 1985). The questionnaire consists of 12 items that are rated on a 2-point scale (0 to 1). The total score ranges from 0 to 12, with higher scores representing a greater degree of neuroticism. The Cronbach’s alpha coefficient for this scale was 0.77. The EPQ-R has been validated among respondents aged 17 to 70 years (Eysenck, Eysenck, and Barrett 1985) and among high school girls (Mor et al. 2008). The Japanese version of the EPQ-R has been validated among college students and adults. Previous studies (Kayashima et al. 1984; Kimura, Kayashima, and Maehara 1986; Slade and Jenner 1980) and the Menstrual Distress Questionnaire Manual (Moos 1977) state that neuroticism should be considered when using the MDQ.
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ORAL CONTRACEPTIVE USE To control for potential confounding by use of oral contraceptives, current oral contraceptive use was assessed using a single question graded as 0 (absence) or 1 (presence).
SOCIAL SUPPORT To explore whether social support was related to premenstrual distress, we used the Scale of Expectancy for Social Support (Hisata, Senda, and Migti 1989), which measures the degree of the expectation of receiving support from the father, mother, siblings, teachers, and friends, and so forth for potential future problems. The questionnaire consists of sixteen items measuring each source of support. Items are rated on a four-point scale (1 to 4), and total scores range from 16 to 64. The higher the score, the more support the participant received. With the scale developer’s permission, we created a classification called “family other than mother” instead of “father.” Because one’s family is believed to affect premenstrual distress, we measured the support of “family other than mother,” “mother,” “teachers,” and “friends” in this study. The Cronbach’s alpha coefficients for these measurements were 0.96, 0.97, 0.97, and 0.96, respectively.
FREQUENCY
OF
CONVERSATIONS ABOUT MENSES WITH MOTHER
To explore the relation of conversations with mothers about menses, the frequency of such conversations was rated on a five-point scale (1 to 5) ranging from “does not talk at all” to “always talking.” The higher the score, the more frequent the mother/daughter conversations.
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OF
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ONE’S BEHAVIOR DURING PREMENSTRUAL PHASES
The degree of the family’s understanding of one’s behavior during the premenstrual phase was rated using a single question graded on a four-point scale (1 to 4). The higher the score, the lower the family’s understanding of one’s behavior. ACTIVITY RESTRICTIONS DUE
TO
MENSTRUAL DISTRESS
The degree to which menstrual distress interfered with normal activities was rated using a single question graded on a five-point scale (1 to 5). The higher the score, the more menstrual distress interfered with the respondent’s daily life.
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IMPACT
OF
PREMENSTRUAL DISTRESS
ON
DAILY ROUTINE
Participants were asked about the impact of premenstrual distress on their daily routine (multiple answers were permitted). Responses included missed school/school absence, missed class, missed work, missed physical activity or sports participation, and sternness with friends or family. We measured the presence (1) or absence (0) of these impacts. In addition, participants were asked to write down any experiences that did not appear on the list. MENSTRUAL HISTORY/REPRODUCTIVE HEALTH Questions were asked regarding the presence or absence of menarche, age at menarche, usual length of menstrual cycle, and usual number of days of bleeding. PERCEPTION
OF
PMS
Premenstrual syndrome (PMS) is diagnosed in cases in which premenstrual distress occurs cyclically and recurrently (American College of Obstetricians and Gynecologists 2000; Halbreich et al. 2007). Participants were asked whether they had ever heard of PMS, regardless of whether symptoms actually existed. Participants were then briefed on the definition of PMS, that is, a variety of physical, emotional, behavioral, and cognitive symptoms, such as headache, irritability, and decreased concentration that occurs during the week before menses and remits shortly after menses begin. INFORMATION ABOUT PMS Participants who had heard of PMS were asked about their sources of information. The list of sources included their mother, father, sister, grandmother,
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peers (female friend), male friends, boyfriend, school nurses, homeroom teacher, health and physical education teachers, physician, nurse, public health nurse, midwife, magazines, technical books, radio and TV, and the Internet. Multiple answers were permitted, and participants could also indicate that they could not recall the sources. In addition, participants were asked to write down any sources of information that did not appear on the list. INFORMATION NEEDS ABOUT PMS
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Participants were asked what information they wanted to know about PMS (multiple answers were permitted), including treatments, signs and symptoms, self-care strategies, indications for consulting a healthcare professional, consultation place, and how to acquire information. In addition, participants were asked to write down any information needs that did not appear on the list.
Human Subjects Approval Before this study was performed, the protocol was approved by the institutional review board of the University of Tokyo and by the principals of the participating schools. We explained the purpose of the study to the students and their guardians in a letter, and received the written consent from both the participants and their guardians. Surveys completed by students who did not provide consent were excluded from analyses. We also produced a pamphlet designed to deepen high school students’ understanding of PMS and self-care. The pamphlets were distributed after the collection of questionnaires, regardless of whether or not the participants cooperated in the research.
Data Analysis All reported p values are two-tailed, and a p value < .05 was considered significant. The Statistical Package for Social Sciences (IBM SPSS, Armonk, NY, USA), Windows version 21.0, was used for all analyses. Descriptive statistics were computed for the demographic, physical, and psychosocial characteristics of participants, impact of premenstrual distress on daily routine, information about PMS, information needs about PMS, and selfcare strategies during the premenstrual phases in accordance with the first aim of the study. A paired t-test was conducted to compare distress of participants during the premenstrual phases and menstrual phases of MDQ, during the premenstrual phases and inter-menstrual phases using the MDQ. To check factor composition as a procedure of measurement by the SD method, an explanatory factor analysis of ten items regarding “comprehension of one’s own physical and mental states during the premenstrual phase” was
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conducted. Using the non-weighted least squares method in factor extraction, we established characteristic values of one or more standards for the number of factors and performed promax rotations. A hierarchical multiple linear regression analysis was then performed in accordance with the second aim of the study, i.e., to assess variables that mediated the relationship between neuroticism and premenstrual distress, and variables that mediated the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress, and assess the physical and psychosocial factors associated with premenstrual distress among high school students. To take into account variance in premenstrual distress due to time since menarche, the weighted least squares method was applied, using time since menarche as a weighted factor. Factors that were associated with premenstrual distress in bivariate analyses (Spearman’s rank-correlation coefficient ≥0.3) and that were important in previous studies (Kayashima et al. 1984) were considered independent variables. These independent variables were chosen after consideration of multicollinearity. Four regression models were tested: the first model contained menstrual history/reproductive health (time since menarche, oral contraceptive use) and personality trait (neuroticism). The second model contained all of the variables included in the first model plus social support (perceived social support, frequency of conversations about menses with the mother, and the family’s understanding of one’s behavior during premenstrual phases). The third model contained all of the variables included in the second model plus activity restrictions due to menstrual distress to test whether activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress. When we tested whether activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during premenstrual phases and premenstrual distress, we observed: a mediating effect in cases in which (1) activity restrictions due to menstrual distress were statistically significant, (2) the effect of the family’s understanding of one’s behavior during premenstrual phases became smaller than the effect in the former model, and (3) the F change was also statistically significant. The fourth model contained all of these variables plus the comprehension of one’s own physical and mental states during the premenstrual phase to test whether comprehension of one’s own physical and mental states during the premenstrual phase mediated the relationship between neuroticism and premenstrual distress. When we tested whether comprehension of one’s own physical and mental states during premenstrual phases mediated the relationship between neuroticism and premenstrual distress, we observed: a mediating effect in cases in which (1) comprehension of one’s own physical and mental states during the premenstrual phase was statistically significant, (2) the effect of neuroticism became smaller than the effect in the former model, and (3) F changes were also statistically significant.
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RESULTS
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A total of 298 questionnaires were collected from 381 girls (78.2 percent response rate); of these, 226 (overall 59.3 percent participation rate) also had the students’ and parents’ consent to participate in the study. Seven participants (3.1 percent) answered less than half the questions on the MDQ, and five participants (2.2 percent) answered less than half the questions regarding comprehension of one’s own physical and mental states during premenstrual phases; these participants were excluded from the analyses. Missing values were removed. Therefore, the final sample included 217 students. Although lessons about menses were included in health and physical education classes at both schools, no lessons were provided regarding premenstrual distress at either school. Because the distributions of each independent variable used in the hierarchical multiple linear regression analyses did not differ in the third-year students at A high school and B high school, results were analyzed using the total sample combined.
Demographic and Menstrual History The 217 participants had a mean age of 16.5 years, and all participants had already experienced menarche (Table 1). The average age of menarche was 12.3 years. Most participants (94 percent, n = 204) usually bled for 3 to 7 days. Participants were a mean of 4.2 years postmenarche, and many of them were beyond 3.4 years postmenarche. A total of twenty-nine participants reported current use of oral contraceptive (13.4 percent), one of whom took contraceptive pills specifically for premenstrual and menstrual symptoms. To control for the potential confounding by oral contraceptives, “current oral contraceptive use” was considered a control variable in the hierarchical multiple linear regression analyses.
Premenstrual Distress We compared premenstrual and menstrual distress (Table 2) and found that arousal was comparable in both phases, whereas pain, impaired concentration, behavior changes, autonomic reactions, and negative effects were all significantly lower in the premenstrual phase than in the menstrual phase (p < .001). Report of water retention was significantly lower in the premenstrual phase than in the menstrual phase (p = .011). Furthermore, we compared premenstrual and inter-menstrual distress (Table 2) and found that all of the scales were significantly lower in the inter-menstrual phase than in the premenstrual phase (p < .001). However, 150 participants who replied to all the questions on the MDQ (84.3 percent) had at least one or more symptoms of premenstrual distress. Moreover, 173 participants who
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Demographics Class year First-year Second-year Third-year Family type Intact family No-parent family Single-father family Single-mother family Medical history Regular doctor’s visits for chronic disease Steady dose of medicationa (not oral contraceptives) Menstrual history/reproductive health Age at menarche (years) Time since menarche (years) Oral contraceptive users Timing of menarche (age in years) Early menarche ( 0.04 are in bold. Exploratory factor analysis: nonweighted least squares method/promax rotation.
Physical and Psychosocial Factors Associated With Premenstrual Distress in Multivariable Models The dependent variable was premenstrual distress. The independent variables that were important in previous studies were time since menarche (years), oral contraceptive use, neuroticism, perceived social support from the mother, perceived social support from family other than the mother, perceived social support from teachers, perceived social support from friends, frequency of conversations about menses with the mother, the family’s understanding of one’s behavior during premenstrual phases, activity restrictions due to menstrual distress, and comprehension of one’s own physical and mental states during premenstrual phases. Variables that correlated (Spearman’s rank-correlation coefficient ≥0.3) with the dependent variable were neuroticism, comprehension of one’s own physical and mental states during premenstrual phases, and activity restrictions due to menstrual distress. A hierarchical multiple linear regression analysis was then performed to test mediating effects. The proposed model was that comprehension of one’s own physical and mental states during the premenstrual phase mediated the relation between neuroticism and premenstrual distress (Figure 1). Results from the final model, testing whether comprehension of one’s own physical and mental states during the premenstrual phase mediated the relationship between neuroticism and premenstrual distress, were significant (R2 = 0.377, adjusted R2 = 0.342) (Table 6). The final model explained 38 percent of the variance in premenstrual distress. Variables that correlated with the dependent variable were comprehension of one’s own physical and mental states during the premenstrual phase (B = –1.446, β = –0.332, t = 4.695, p < .001) and
875 0.104 0.086
0.058 0.119 0.282
β 0.461 0.130 0.000
p value
Model 1
0.142 0.107 0.038 2.170
0.059 0.123 0.256 −0.128 0.013 −0.170
β 0.460 0.114 0.001 0.110 0.868 0.036
p value
Model 2
0.282 0.247 0.139 28.140
0.087 0.128 0.176 −0.069 −0.015 −0.132 0.391
β
***
0.237 0.075 0.018 0.354 0.841 0.076 0.000
p value
Model 3
0.377 0.342 0.095 22.042
0.100 0.073 0.142 −0.069 0.019 −0.095 0.308 −0.332
β
***
0.145 0.283 0.043 0.321 0.792 0.173 0.000 0.000
p value
Model 4
Note: N = 183. β: Standardized partial regression coefficient. Weighted least-squares method: To take into account the variance in premenstrual distress due to time since menarche, the weighted least squares method was applied using time since menarche as a weighted factor. ***p < .001.
Time since menarche Oral contraceptive use Neuroticism Perceived social support from mother Frequency of conversations about menses with mother Family’s understanding of one’s behavior during premenstrual phases Activity restrictions due to menstrual distress Comprehension of one’s own physical and mental states during premenstrual phases R2 Adjusted R2 R2 change (step) F change (step)
Independent variables
TABLE 6 Hierarchical Multiple Linear Regression for Premenstrual Distress
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activity restrictions due to menstrual distress (B = 10.132, β = 0.308, t = 4.332, p < .001). The model showed that activity restrictions due to menstrual distress mediated the relation between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress. Results from the third model, testing whether activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress, were also significant (R2 = 0.282, adjusted R2 = 0.247). The effect of the family’s understanding of one’s behavior during the premenstrual phase in the second model disappeared in the third model. We also found that activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress. The increment in R-square in the third model (0.14) was statistically significant. The effect of neuroticism in the third model had a small effect in the final model. We also found that comprehension of one’s own physical and mental states during premenstrual phases mediated the relationship between neuroticism and premenstrual distress. The increment in Rsquare in the final model (0.095) was statistically significant.
DISCUSSION To our knowledge, this is the first study to identify self-care strategies for premenstrual distress among high school girls in Japan and also the first to examine physical and psychosocial factors associated with premenstrual distress in this group. Most participants’ usual number of days of bleeding was in the normal range. Participants were a mean of 4.2 years postmenarche, and many of them had passed 3.4 years or more. A previous study has indicated that adolescents at 3.4 or more years postmenarche have reported more intense premenstrual distress compared to adolescents at less than 3.4 years (Cleckner-Smith, Doughty, and Grossman 1998). Many participants in our study were 3.4 years postmenarche and thus might have had more intense premenstrual distress. Among adolescent girls in this study, menstrual distress was stronger than premenstrual distress, which supports findings in previous studies (Wong 2011; Wilson and Keye 1989). Wilson and Keye (1989) found that premenstrual distress in girls (86 percent) was as prevalent as symptoms of dysmenorrhea (91 percent), and most of the girls were unaware of the causes and treatments of these symptoms. The fact that only one participant in this study who reported having premenstrual distress consulted a physician may indicate poor treatmentseeking behavior for menstrual-related matters and poor self-care. Alternatively, girls may perceive premenstrual distress as completely normal; hence, they did not want to seek professional treatment. Based on our findings,
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adolescent girls did nothing or eventually ended up relying on their own premenstrual distress management. As reported in other studies (Wong 2011), girls may not be inclined to seek treatment for these symptoms. Nevertheless, such attitudes are potentially amendable through educational interventions (Robinson and Swindle 2000). Therefore, incorporating an educational program on menstrual-related matters into the regular school curriculum for adolescent girls would seem appropriate (Robinson and Swindle 2000; Wong 2011). Although the perception of PMS was low, more than half of the participants reported that premenstrual distress had interfered with daily life or school life during the premenstrual phase, a result that matched results of previous studies (Wong 2011; Sagara, Kuwabara, and Mizuno 1991). In previous studies (Wong 2011), 63.1 percent of female adolescents reported premenstrual distress, but only 34.9 percent reported it as PMS. Our study showed a lower perception of PMS than in previous studies. Therefore, health education on effective management of premenstrual distress is potentially important, especially for high school students, to prevent absence from school and loss of interest in school due to concentration impairments (Wong 2011). As the key resource for PMS and reproductive health information was school nurses, peers, and mothers, increasing the involvement of these groups in reproductive education is important.
Physical and Psychosocial Factors Associated With Premenstrual Distress Activity restrictions due to menstrual distress were associated with premenstrual distress in this study, which supports findings in other studies. Premenstrual distress and menstrual pain were positively associated (Wong 2011; Shye and Jaffe 1991), and premenstrual distress has been shown to be correlated with dysmenorrhea (Kitamura et al. 2012; Rizk et al. 2006; Freeman, Rickels, and Sondheimer 1993). Though further investigation is needed to clarify why premenstrual distress and dysmenorrhea are positively correlated, one factor that is associated with premenstrual distress is the degree of activity restrictions due to menstrual distress. We also found that comprehension of one’s own physical and mental states during the premenstrual phase mediated the relationship between neuroticism and premenstrual distress. These findings imply that even if adolescent girls have neuroticism as a personality trait, it will be important to address this factor in the education of high school students so that perceptions of both premenstruation and menstruation become more positive. Morse (1997, 1999) conducted a longitudinal study for adult women with PMS using a quasi-experimental research design and reported that positive reframing was effective in reducing perimenstrual impairment. Reframing was the
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intervention that helped women to frame their premenstrual perception in a more positive light (Morse 1997, 1999). Therefore, we believe that Morse’s positive reframing would be useful for high school girls. We also found that activity restrictions due to menstrual distress mediated the relationship between the family’s understanding of one’s behavior during the premenstrual phase and premenstrual distress. These findings suggest that activity restrictions due to menstrual distress promoted the family’s understanding of premenstrual and menstrual distress, as the family’s understanding of one’s behavior during premenstrual phases had an inverse relationship to premenstrual distress. The findings suggest that the family’s understanding was associated with alleviation of premenstrual distress. In this study, girls received information regarding PMS from school nurses, health and physical education teachers, peers, and mothers. Information obtained from mothers was relatively scarce in this study compared with data from a previous study in which 31.3 percent of girls obtained information from their mothers (Wong 2011). It appears that school-based written educational materials related to menstrual problems are needed. At the same time, it is necessary to encourage parental involvement in education and management activities (Wong 2011). Furthermore, the fact that a considerable proportion of students acquired information from peers suggests that a youth peer educator may be a practical way of tackling sensitive issues like menstruation (Wong 2011).
Implications for the Support and Education of High School Students The results of the study suggest the need for educational intervention programs regarding self-care for premenstrual distress in high school students. High school students who have already experienced premenstrual distress may find it manageable through positive reframing. It is important in the education of high school students who have not experienced premenstrual distress to approach such education in a way in which the “comprehension of one’s own physical and mental states during premenstrual phases” may become positive, rather than having to be reframed.
Strengths and Limitations The findings of this study must be interpreted in the context of its limitations. First, as this study was a small survey conducted in two schools in a single region, generalizing the results requires prudence. Second, as we performed a cross-sectional survey, no temporal and thus causal relationships could be determined. Third, although three menstrual cycles need to be recorded for the diagnosis of PMS, studies of adolescents that use prospective daily symptom ratings are limited. Because this survey, which
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used the MDQ, was conducted via a retrospective method in consideration of high school students’ burden, the diagnosis of PMS was not ascertained. Fourth, the measurement of the MDQ did not include any positive symptom experiences and positive changes. It is necessary to use measures that can assess the positive side of the menstruation cycle in future investigations. Finally, some of the measures may not have had criterion-related validity, in particular the neuroticism measure, and had modest internal validity, as indicated by moderate values for Cronbach’s alpha, and thus may have misclassified some participants. However, this study can provide basic data for future studies simply by having clarified the self-care strategies and the relevant factors for premenstrual distress among high school students. Moreover, according to high school students’ stage of development, it is necessary to discuss how it might be effective to approach education so that the “comprehension of one’s own physical and mental states during premenstrual phases” may become positive. Henceforth, we believe that it would be useful to measure the “comprehension of one’s own physical and mental states during premenstrual phases” before and after an intervention. The “comprehension of one’s own physical and mental states during premenstrual phases” can measure educational (intervention) secondary effects, even when high school students have not experienced or are not aware of their own premenstrual distress. A further prospective intervention study needs to be done for high school students. To develop sufficient measurement tools, a wide range sampling would be required.
CONCLUSION These findings suggest the need for education to help adolescent girls and their families manage premenstrual distress and increase awareness of the benefit of managing these symptoms.
ACKNOWLEDGMENTS We are grateful to the students who participated in this research and the staff members of the high schools, who cooperated with us during this research. From the onset of our research, we received guidance from Professor Kimiko Kayasima of the Jikei University School of Medicine.
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