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Self‐care and menopause: Critical review of research a
Beverly J. McElmurry EdD, FAAN & Donna S. Huddleston RN, MS
a
a
University of Illinois , 845 So. Damen, Rm. 1126, College of Nursing, Illinois, 60612 Published online: 14 Aug 2009.
To cite this article: Beverly J. McElmurry EdD, FAAN & Donna S. Huddleston RN, MS (1991) Self‐care and menopause: Critical review of research, Health Care for Women International, 12:1, 15-26, DOI: 10.1080/07399339109515923 To link to this article: http://dx.doi.org/10.1080/07399339109515923
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SELF-CARE AND MENOPAUSE: CRITICAL REVIEW OF RESEARCH Beverly J. McElmurry, EdD, FAAN, and Donna S. Huddleston, RN, MS
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University of Illinois at Chicago College of Nursing Chicago, Illinois
Existing literature on self-care as it relates to menopause is examined to determine whether the knowledge base in this area reflects important tenets in women's health. One such tenet is that understanding the lived experience of women is critical in developing effective health care interventions. Few investigators acknowledge the lived experience of women in their studies of self-care and menopause.
INTRODUCTION An important goal of research in women's health is to develop knowledge that helps to prevent illness, prolong life, and promote and enhance well-being. To achieve this goal, researchers must design and conduct studies that will either create or discover interventions that promote, maintain, and enhance women's health. These interventions must be acceptable to women and must accurately reflect their lived experiences, that is, the biopsychosocial context of women's lives. These interventions must also be based on an understanding of what women do to take care of themselves and on an appreciation for cultural context. In this critical review of research on self-care and menopause, we evaluate the literature with respect to women's self-care activities as they relate to the natural menopause and as they take place in specific
This research project was partially supported by Grant No. HHS NU 01049: NRE/DPN; Grant No. NU 00455: PHS, HRSA; and Grant No. NR 06121: NIH, NCNR. Health Care for Women International, 12:15-26, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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Assumptions in the Health Care of Women The human body, mind, and spirit form a whole. Women have the capacity for self-care and self-healing. Events and interactions in the family, community, and world affect and shape the health of women. Health care is a shared responsibility. Health reflects integrity, flexibility, capacity to develop, and capacity to creatively transcend difficult situations. Control over one's body is a basic right. Lived experiences are the starting point for future action. Women's health settings vary. The health of all is improved by focusing on women's health. Source: "Concept Paper: Nursing Practice in Women's Health" by Chicago School of Thought in Women's Health, Nursing Research. 35.
cultural settings. Our evaluation is based on several assumptions about the health care of women developed by the Chicago School of Thought in Women's Health (1986). These assumptions are identified throughout our discussion. SELF-CARE Women have the capacity for self-care and self-healing (Chicago School of Thought in Women's Health, 1986), and self-care activities are one of the cornerstones of the women's health care perspective. However, only recently have researchers examined the day-to-day selfcare activities of women. Woods (1985) collected self-care activity diaries of 96 women 20 to 40 years old and found that vitamin ingestion, contraceptive use, and prescription medicines were the most common self-care activities reported by these women. Dorothy Orem, the most-cited nurse researcher in the development of the self-care concept (1980, 1981, 1985), defined self-care (1959, p. 5) as "The care which all persons require each day. It is the personal care which adults give to themselves, including attention to ordinary health requirements and the following of the medical directive of their physician." The definition has changed over the years. In 1985, Orem discussed self-care as "the production of actions directed to self or to the environment in order to regulate one's functioning in the interests of one's life, integrated functioning, and well-being" (p. 31). Other researchers have also defined self-care (Barofsky, 1978; Dean, 1981; Goldstein et al., 1983; Woods, 1985). Several of these definitions use the word behavior in relation to self-care and thereby add a cognitive
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dimension to the activity of self-care. Barofsky's definition emphasized self-care as a form of self-control and as a primary outcome of health care, and Dean viewed self-care as a response to illness. A second assumption (Chicago School of Thought in Women's Health, 1986) is that self-care is a responsibility shared by women and various health professions and is therefore not limited to the diagnosis and treatment of one's own problems. Seeking both traditional and nontraditional treatment should be seen as a part of self-care. In the popular use of the term self-care, health knowledge refers to traditional information handed down from generation to generation and used by the individual to identify and treat health problems. This self-care emphasis, common and necessary before medicine became institutionalized, was replaced as the medicalization of health problems occurred throughout most of the 20th century. The contemporary self-care movement in the United States, as evidenced by the great number of "treat-yourself' books on the market, can be viewed in part as dissatisfaction with modern health care as well as evidence of the increasing limitations on personal and social resources. In becoming more involved in their own health care, women are reassuming more responsibility for their own welfare. Of course, in many parts of the world women continue to engage in self-care activities without the help of institutionalized medicine. One of the leading consumer groups that arose during the 1970s was the Boston Women's Health Book Collective. These women met, explored their bodies, exchanged ideas, and shared their experiences. The immense popularity of this approach is evident in the success and growth of the publications Our Bodies, Ourselves (1973, 1976, 1979), The New Our Bodies, Ourselves (1981), and Ourselves Growing Older (1987). In addition, they have spurred other groups to publish books such as A New View of a Woman's Body (Federation of Feminist Women's Health Centers, 1981). The self-help groups have developed books with intricate drawings of the female anatomy, explained the known physiological processes of the body in simple language, and used women with a wide variety of physical characteristics in the illustrations. The self-help groups challenged health care professionals by naming and labeling female anatomic structures and physiologic processes that have not been thoroughly researched or examined by studies that make women active participants in the process. Many nurses have found that the concept of self-care provides a positive perspective for both research and nursing practice. This perspective focuses on the woman as a proactive consumer of health services. Ultimately, a woman should be able to make an informed selection of what
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Table 1. A Review of Selected Self-Care Studies Conducted by Nurse Researchers
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Author(s)
Perspective
Cultural sensitivity
Acknowledgment of context
Lakin (1988)
Biomedical
Cannot be determined
Yes
Rhodes, Watson, & Hanson (1988)
Biomedical
Cannot be determined
Yes
Woods (1985)
Biomedical
Cannot be determined
Cannot be determined
Hutchinson (1987)
Women's health
Identifies black/white women
Yes
Riesch (1988)
Women's health
Cannot be determined
Yes
Note. These self-care studies are not menopausal studies.
she needs from a wide variety of health care services and providers. The health providers who value self-care will assist women by teaching selfcare and related pertinent information as needed and by helping women to explore their options and choices. Another assumption (Chicago School of Thought in Women's Health, 1986) is that control over one's body is a basic right. This right should not only apply to reproductive freedom, but should also include all aspects and stages of women's lives, including menopause. Although research in self-care by nurses has not included menopause as a topic of study, nurse researchers (Lakin, 1988; Rhodes, Watson, & Hanson, 1988; Riesch, 1988) are using various self-care definitions and exploring self-care in various situations (Table 1). It is hoped that nurse researchers will broaden their research efforts in the area of self-care to include studies on menopause as a naturally occurring phenomenon in the lived experience of women. Furthermore, it is hoped that the selfcare perspective developed by nurse researchers will be used by other disciplines in their studies of menopause. In the following section, we discuss the research on menopause in light of the self-care and livedexperience concepts. NATURAL MENOPAUSE The natural menopause is a developmental marker or point of change in a woman's life; in medical and scientific terms, it is considered the endpoint of the reproductive option for women. Using this description of
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menopause, however, limits researchers to physiologic events and does not take into account all the experiences common to women during this time or phase in their lives. Some physiologic events that women may report around the time of menopause are vaginal dryness or painful sexual intercourse, changes in menstrual cycle regularity and flow, and hot flashes. The physiologic and experiential events that precede, occur at the time of, and continue for one full year past the natural menopause are referred to as perimenopausal phenomena. Perimenopausal phenomena have not been studied as an integrated whole. Furthermore, researchers have usually studied only selected aspects of menopause, rather than examining the context in which a woman experiences manopause. For example, there have been studies of age (Frere, 1971; Frommer, 1964; Goodman, Grove, & Gilbert, 1978; McKinlay, Jefferys, & Thompson, 1972; Neugarten & Kraines, 1965; Thompson, Hart, & Durno, 1973) and of attitudes (Bowles, 1986; Muhlenkamp, Waller, & Bourne, 1983). Other studies have investigated menopausal symptoms in relationship to sleep (Ballinger, 1976), life events (Cooke & Greene, 1981), culture (Flint & Garcia, 1979), outside work (Maoz et al., 1978), sexual activity (Bottiglioni & DeAloysio, 1981), mental health (Hallstrom & Samuelsson, 1985), and psychiatric morbidity (Ballinger, 1975). Hot flashes as a symptom of menopause (Greene, 1976; McKinlay & Jeffreys, 1974) and as an experience of menopause (Voda, 1981) have been investigated. In still other studies, age at menopause has been related to socioeconomic status and hormonal events earlier in a woman's life (Ernster & Petrakis, 1981), as well as to the risk of cardiovascular disease and death (Lapidus, Bengtsson, & Lindquist, 1985) and to smoking (McKinlay, Bifano, & McKinlay, 1985). Hormonal studies with postmenopausal women, most of which were conducted in conjunction with hormonal replacement therapy (HRT), have been given considerable coverage in the scientific literature and in research. In many of the cited studies (Blatt, Wiesbader, & Kupperman, 1953; Hammond, Jelovsek, Lee, Creasman, & Parker, 1979; Lindsay, 1981; Pratt & Thomas, 1937), research has focused on the "hormone deficiency state" that is assumed to exist in menopausal women. Recently, however, researchers have begun to question the view that menopause is a medical syndrome. This view is a biological reductionistic model that reduces a woman to a pair of ovaries, a uterus, and the related hormones. In an effort to free themselves of old assumptions, some researchers have begun to measure as many variables as they can without completely discarding the medical-syndrome model (Abe, Suzuki, Wada, Yamaya, & Moritsuka, 1985; Hagsted, Johansson,
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Wilhelmsson, & Janson, 1985; Leiblum, Bachmann, Kemmann, Colburn, & Swartzman, 1983). Biological reductionism, however, is not the only culprit in menopausal research; Lock (1986) observed that almost all research with menopausal women has been conducted from the "discipline's perspective." In a recent review of menopausal literature, Voda and George (1986) confirmed McKinlay and McKinlay's (1973) earlier concern that menopausal research was conducted using the biased perspectives of ageism, sexism, social (no-effect) models, biomedical models, and biological reductionism. The problem with using these biased perspectives in conducting research is that they limit the researcher's view of the woman's total experience of menopause. For example, ageism diminishes the value of the older woman mainly because she can no longer reproduce. Likewise, sexism diminishes women in that the male experience is viewed as the "norm." The social (no-effect) model discounts women's experiences of menopause, such as hot flashes, and the biomedical model assumes that menopause is a disease with specific symptoms. Furthermore, researchers have no common language for discussing menopause. Several terms have emerged over the years; one of these terms is the change of life, which is no longer acceptable for the modern woman. Women in the United States were thought to suffer an "empty nest syndrome" about the same time that they experienced menopause (Bart, 1973). With changing life-styles, this is no longer true for many women. The climacteric, another term used by researchers (Ballinger, 1975, 1976; Bottiglioni & DeAloysio, 1981; Cooke & Greene, 1981; Maoz et al., 1978; Uphold & Susman, 1981), is an ambiguous one that refers to a time span of 5-20 years. Exactly when the climacteric begins and when it ends is uncertain. In most instances, researchers define it as extending into the postmenopausal years. Regardless of its definition, this is a term that many women find too vague to be acceptable. Menopause has yet to be defined in an operational way. One of the characteristics of menopause is that it is not a time-limited event. The literature has often linked the postmenopausal period to a complete cessation of ovarian hormone production, but there is insufficient scientific evidence for such a link. Another problem with linking menopause to cessation of ovarian hormone production is that this linkage ignores the uterus, the main organ involved. Garcia and Cutler (1984) and Greenblatt, Colle, and Mahesh (1976) found that some of the definitions of menopause used in experimental studies lack support or explanation for the assumptions made about hormonal cessation. In some studies, researchers (Aleem, Weitzman, & Weinberg, 1984; Foster, Zacui, & Roch, 1985; Gerdes, Sonnendecker, & Polakow, 1982; Judd, Sha-
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monki, Frumar, & Lagasse, 1982; Meldrum et al., 1980; Talo & Pulkkinen, 1984) have grouped naturally and surgically induced menopausal subjects into the same categories. Knowledge about menopause is enmeshed in myths, misconceptions, and misinformation. Most hormonal studies are written in the technical language of a particular scientific discipline or include too few subjects (Custro & Scafidi, 1986; Greenblatt et al., 1976; Judd et al., 1982) to be considered scientifically generalizable by researchers. Much of the other research about menopause is biased by a disease-oriented or hormonedeficiency perspective. Women have little access to usable information about the experience of menopause. The lack of adequate information compromises the control that a woman has over her body. THE LIVED EXPERIENCE AND MENOPAUSAL STUDIES Although in reality self-care activities occur in many settings, much research with menopausal women has been conducted with physicianbased practices. Surveys of large numbers of women to determine age of menopause (Frommer, 1964) and symptoms (McKinlay & Jeffreys, 1974) have relied on lists drawn from physician-based practices. One novel sampling idea for identifying menopausal women was Feldman, Voda, and Gronseth's (1985) research of the hot flash; they used a cluster sample of telephone subscribers. Much of the research has focused on the signs and symptoms of menopause that could be relieved by HRT rather than on the menopausal woman and her experiences. There has been little attention to the benefits of the research for women or how the research could improve their health. The majority of menopausal studies are related to some aspect of HRT. Some nurses have developed seminars or written articles (Dosey & Dosey, 1980; McGuire & Sorley, 1978; Pearson, 1982) that "treat" menopausal women. Even the more recent efforts of researchers (Abe et al., 1985; Hagsted et al., 1985; Leiblum et al., 1983) to measure many variables relating to menopause lack an understanding of the development of women or the meaning of these variables in the context of women's lives. Nurse researchers have conducted some studies on menopause (Table 2). These studies have been conducted from several perspectives and are a necessary beginning for research in this area. More studies like these conducted by other disciplines need to be done. The anthropologists Flind and Garcia (1979) studied two American ethnic groups of Cuban and Jewish women and postulated that menopause varies from culture to culture. Kaufert and Syrotuik (1981) have
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Table 2. A Review of Selected Menopausal Studies Conducted by Nurse Researchers
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Author(s)
Perspective
Aspect studied
Cultural sensitivity
Acknowledgment of context
Frey (1981)
Biomedical
Symptoms
Cannot be determined
Yes
LaRocco & Polit (1980)
Biomedical
Knowledge of menopause
Cannot be determined
Partly
Polit & LaRocco (1980)
Biomedical
Symptoms
Cannot be determined
Yes
Uphold & Susman (1981)
Biomedical
Symptoms
Cannot be determined
Yes
Dosey & Dosey (1980)
Sociopsychological
Physical/ emotional
Cannot be determined
Yes
Bowles (1986)
Women's health
Attitudes
Yes
Yes
Feldman, Voda, & Gronseth (1985)
Women's health
Hot flashes
Yes
Partly
Muhlenkamp, Walker, & Bourne (1983)
Women's health
Attitudes
Cannot be determined
Yes
Voda (1981)
Women's health
Hot flashes
Cannot be determined
Yes
Note. These menopausal studies are not self-care studies.
discussed the probable bias in symptom perception and reporting across cultures. Cultural variables related to menopause have been included in Maoz et al.'s (1978) study sample of Jewish and Arabian women, Sharma's (1983) study of menopausal symptoms of Indian women, Beyene's (1985) focus on Mayan Indian and rural Greek women, and Frere's (1971) examination of the mean age of Bantu and White women in South Africa. Also, Wright (1981) has studied the menopausal symptoms of Navajo Indians, and Goodman et al. (1978) researched those of White, Japanese, Chinese, and part-Hawaiian postmenopausal women living in Hawaii. CONCLUSION The lack of consistency by researchers in defining self-care and menopause suggests that both concepts are in the early phases of re-
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search development. Thus, in both nursing research and clinical practice, a critical perspective is cultural sensitivity to menopausal women and the context of their health care. Like Dodd (1988), we find self-care to be an important concept for clinical practice. We would emphasize that it is a concept in need of measurement tools sensitive to the lived experience of women across the life span. Yet more than 14 years have passed since Daniels (1975) urged health and life-cycle issues for women as an area for research emphasis. This underscores the importance of finding ways to combine tenets of self-care with research on menopause in nursing research and practice. Such a combination will likely help to realize a research language consistent with such desired practice goals as helping women establish their health goals, adding to understanding of universal truths or knowledge of women's development, recognizing women as complex biopsychosocial beings who exist within a cultural context, and acknowledging that women own the menopause experience. REFERENCES Abe, T., Suzuki, M., Wada, Y., Yamaya, Y., & Moritsuka, T. (1985). Clinical endocrinological features of statistical clusters of women with climacteric symptoms. Tohoku Journal of Experimental Medicine, 146(1), 59-68. Aleem, F. A., Weitzman, E. D., & Weinberg, U. (1984). Suppression of basal luteinizing hormone concentrations by melatonin in postmenopausal women. Fertility & Sterility, 42(6), 923-925. Ballinger, C. B. (1975). Psychiatric morbidity and the menopause: Screening of general population sample. British Medical Journal, 3, 344-346. Ballinger, C. B. (1976). Subjective sleep disturbance at the menopause. Journal of Psychosomatic Research, 20, 509-513. Barofsky, I. (1978). Compliance, adherence, and the therapeutic alliance: Steps in the development of self-care. Social Science Medicine, 12, 369-376. Bart, P. B. (1973, September 10-12). Pioneers, professionals, returnees, Penelopes, and Portnoy 's mother. Paper presented before the 26th Annual Conference on Aging Women: Life Span Challenges, Ann Arbor, MI. Beyene, Y. (1985, May 3-5). Menopause: A biocultural event. Paper presented at the Sixth Conference of the Society for Menstrual Cycle Research, Galveston, TX. Blatt, M. H. G., Wiesbader, H., & Kupperman, H. S. (1953). Vitamin E and climacteric syndrome. American Medical Association Archives of Internal Medicine, 91, 792-799. Boston Women's Health Book Collective. (1973). Our bodies, ourselves: A book by and for women. New York: Simon & Schuster. Boston Women's Health Book Collective. (1976). Our bodies, ourselves: A book by and for women (2nd ed.). New York: Simon & Schuster. Boston Women's Health Book Collective. (1979). Our bodies, ourselves: A book by and for women (2nd ed. Revised and expanded). New York: Simon & Schuster.
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McKinlay, S. M., Bifano, N. L., & McKinlay, J. B. (1985). Smoking and age at menopause in women. Annals Internal Medicine, 103(3), 350-356. McKinlay, S. M., & Jeffreys, M. (1974). The menopausal syndrome. British Journal of Preventive & Social Medicine, 28, 108-115. McKinlay, S., Jeffreys, M., & Thompson, B. (1972). An investigation of the age at menopause. Journal of Biosocial Science, 4, 161-173. McKinlay, S. M., & McKinlay, J. B. (1973). Selected studies of the menopause. Journal
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of Biosocial Science, 5, 533-555. Meldrum, D. R., Tataryn, I. V., Frumar, A. M., Erlik, Y., Lu, K. H., & Judd, H. L. (1980). Gonadotropins, estrogens, and adrenal steroids during the menopausal hot flash. Journal of Clinical Endocrine & Metabolism, 50, 685-689. Muhlenkamp, A. F., Waller, M. M., & Bourne, A. E. (1983). Attitudes toward women in menopause: A vignette approach. Nursing Research, 32, 20-23. Neugarten, B. L., & Kraines, R. J. (1965). "Menopausal symptoms" in women of various age groups. Psychosomatic Medicine, 27, 266-273. Orem, D. (1959). Guides for developing curricula for the education of practical nurses. Washington, DC: U.S. Department of Health, Education, & Welfare. Orem, D. E. (1980). Nursing: Concepts of practice. New York: McGraw-Hill. Orem, D. E. (1981). Nursing: Concepts of practice (2nd ed.). New York: McGraw-Hill. Orem, D. E. (1985). Nursing: Concepts of practice (3rd ed.). New York: McGraw-Hill. Pearson, L. (1982). Climacteric. American Journal of Nursing, 82(7), 1098-1102. Polit, D. F., & LaRocco, S. A. (1980). Social and psychological correlates of menopausal symptoms. Psychosomatic Medicine, 42, 335-345. Pratt, J. P., & Thomas, W. L. (1937). The endocrine treatment of menopausal phenomena. Journal of the American Medical Association, 109, 1875-1877. Rhodes, V. A., Watson, P. M., & Hanson, B. M. (1988). Patients' descriptions of the influence of tiredness and weakness on self-care abilities. Cancer Research, 11(3), 188-194. Riesch, S. K. (1988). Changes in the exercise of self-care agency. Western Journal of Nursing Research, 10(3), 271-273. Sharma, V. K. (1983). The construction and development of a menopausal symptom checklist. Indian Journal of Clinical Psychology, 10, 63-70. Talo, A., & Pulkkinen, M. D. (1984). Electrical activity in the human oviduct after the menopause. Maturitas, 5, 185-191. Thompson, B., Hart, S. A., & Durno, D. (1973). Menopausal age and symptomatology in a general practice. Journal of Biosocial Science, 5, 71-82. Uphold, C. R., & Susman, E. J. (1981). Self-reported climacteric symptoms: A function of the relationships between marital adjustment and childrearing stage. Nursing Research, 30(2), 84-88. Voda, A. M. (1981). Climacteric hot flash. Maturitas, 3, 73-90. Voda, A. M., & George, T. (1986). Menopause. In H. H. H. Werley, J. J. Fitzpatrick, & R. L. Taunton (Eds.), Annual review of nursing research (4th ed.). New York: Springer. Woods, N. F. (1985). Self care practices among young adult married women. Research in Nursing and Health, 8, 227-233. Wright, A. L. (1981). On the calculation of climacteric symptoms. Maturitas, 4, 55-63.
Requests for reprints should be sent to B. J. McElmurry, 845 So. Damen, Rm. 1126, College of Nursing, University of Illinois, Chicago, IL 60612.
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Self‐care and menopause: Critical review of research a
Beverly J. McElmurry EdD, FAAN & Donna S. Huddleston RN, MS
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University of Illinois , 845 So. Damen, Rm. 1126, College of Nursing, Illinois, 60612 Published online: 14 Aug 2009.
To cite this article: Beverly J. McElmurry EdD, FAAN & Donna S. Huddleston RN, MS (1991) Self‐care and menopause: Critical review of research, Health Care for Women International, 12:1, 15-26, DOI: 10.1080/07399339109515923 To link to this article: http://dx.doi.org/10.1080/07399339109515923
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SELF-CARE AND MENOPAUSE: CRITICAL REVIEW OF RESEARCH Beverly J. McElmurry, EdD, FAAN, and Donna S. Huddleston, RN, MS
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University of Illinois at Chicago College of Nursing Chicago, Illinois
Existing literature on self-care as it relates to menopause is examined to determine whether the knowledge base in this area reflects important tenets in women's health. One such tenet is that understanding the lived experience of women is critical in developing effective health care interventions. Few investigators acknowledge the lived experience of women in their studies of self-care and menopause.
INTRODUCTION An important goal of research in women's health is to develop knowledge that helps to prevent illness, prolong life, and promote and enhance well-being. To achieve this goal, researchers must design and conduct studies that will either create or discover interventions that promote, maintain, and enhance women's health. These interventions must be acceptable to women and must accurately reflect their lived experiences, that is, the biopsychosocial context of women's lives. These interventions must also be based on an understanding of what women do to take care of themselves and on an appreciation for cultural context. In this critical review of research on self-care and menopause, we evaluate the literature with respect to women's self-care activities as they relate to the natural menopause and as they take place in specific
This research project was partially supported by Grant No. HHS NU 01049: NRE/DPN; Grant No. NU 00455: PHS, HRSA; and Grant No. NR 06121: NIH, NCNR. Health Care for Women International, 12:15-26, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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Assumptions in the Health Care of Women The human body, mind, and spirit form a whole. Women have the capacity for self-care and self-healing. Events and interactions in the family, community, and world affect and shape the health of women. Health care is a shared responsibility. Health reflects integrity, flexibility, capacity to develop, and capacity to creatively transcend difficult situations. Control over one's body is a basic right. Lived experiences are the starting point for future action. Women's health settings vary. The health of all is improved by focusing on women's health. Source: "Concept Paper: Nursing Practice in Women's Health" by Chicago School of Thought in Women's Health, Nursing Research. 35.
cultural settings. Our evaluation is based on several assumptions about the health care of women developed by the Chicago School of Thought in Women's Health (1986). These assumptions are identified throughout our discussion. SELF-CARE Women have the capacity for self-care and self-healing (Chicago School of Thought in Women's Health, 1986), and self-care activities are one of the cornerstones of the women's health care perspective. However, only recently have researchers examined the day-to-day selfcare activities of women. Woods (1985) collected self-care activity diaries of 96 women 20 to 40 years old and found that vitamin ingestion, contraceptive use, and prescription medicines were the most common self-care activities reported by these women. Dorothy Orem, the most-cited nurse researcher in the development of the self-care concept (1980, 1981, 1985), defined self-care (1959, p. 5) as "The care which all persons require each day. It is the personal care which adults give to themselves, including attention to ordinary health requirements and the following of the medical directive of their physician." The definition has changed over the years. In 1985, Orem discussed self-care as "the production of actions directed to self or to the environment in order to regulate one's functioning in the interests of one's life, integrated functioning, and well-being" (p. 31). Other researchers have also defined self-care (Barofsky, 1978; Dean, 1981; Goldstein et al., 1983; Woods, 1985). Several of these definitions use the word behavior in relation to self-care and thereby add a cognitive
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dimension to the activity of self-care. Barofsky's definition emphasized self-care as a form of self-control and as a primary outcome of health care, and Dean viewed self-care as a response to illness. A second assumption (Chicago School of Thought in Women's Health, 1986) is that self-care is a responsibility shared by women and various health professions and is therefore not limited to the diagnosis and treatment of one's own problems. Seeking both traditional and nontraditional treatment should be seen as a part of self-care. In the popular use of the term self-care, health knowledge refers to traditional information handed down from generation to generation and used by the individual to identify and treat health problems. This self-care emphasis, common and necessary before medicine became institutionalized, was replaced as the medicalization of health problems occurred throughout most of the 20th century. The contemporary self-care movement in the United States, as evidenced by the great number of "treat-yourself' books on the market, can be viewed in part as dissatisfaction with modern health care as well as evidence of the increasing limitations on personal and social resources. In becoming more involved in their own health care, women are reassuming more responsibility for their own welfare. Of course, in many parts of the world women continue to engage in self-care activities without the help of institutionalized medicine. One of the leading consumer groups that arose during the 1970s was the Boston Women's Health Book Collective. These women met, explored their bodies, exchanged ideas, and shared their experiences. The immense popularity of this approach is evident in the success and growth of the publications Our Bodies, Ourselves (1973, 1976, 1979), The New Our Bodies, Ourselves (1981), and Ourselves Growing Older (1987). In addition, they have spurred other groups to publish books such as A New View of a Woman's Body (Federation of Feminist Women's Health Centers, 1981). The self-help groups have developed books with intricate drawings of the female anatomy, explained the known physiological processes of the body in simple language, and used women with a wide variety of physical characteristics in the illustrations. The self-help groups challenged health care professionals by naming and labeling female anatomic structures and physiologic processes that have not been thoroughly researched or examined by studies that make women active participants in the process. Many nurses have found that the concept of self-care provides a positive perspective for both research and nursing practice. This perspective focuses on the woman as a proactive consumer of health services. Ultimately, a woman should be able to make an informed selection of what
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Table 1. A Review of Selected Self-Care Studies Conducted by Nurse Researchers
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Author(s)
Perspective
Cultural sensitivity
Acknowledgment of context
Lakin (1988)
Biomedical
Cannot be determined
Yes
Rhodes, Watson, & Hanson (1988)
Biomedical
Cannot be determined
Yes
Woods (1985)
Biomedical
Cannot be determined
Cannot be determined
Hutchinson (1987)
Women's health
Identifies black/white women
Yes
Riesch (1988)
Women's health
Cannot be determined
Yes
Note. These self-care studies are not menopausal studies.
she needs from a wide variety of health care services and providers. The health providers who value self-care will assist women by teaching selfcare and related pertinent information as needed and by helping women to explore their options and choices. Another assumption (Chicago School of Thought in Women's Health, 1986) is that control over one's body is a basic right. This right should not only apply to reproductive freedom, but should also include all aspects and stages of women's lives, including menopause. Although research in self-care by nurses has not included menopause as a topic of study, nurse researchers (Lakin, 1988; Rhodes, Watson, & Hanson, 1988; Riesch, 1988) are using various self-care definitions and exploring self-care in various situations (Table 1). It is hoped that nurse researchers will broaden their research efforts in the area of self-care to include studies on menopause as a naturally occurring phenomenon in the lived experience of women. Furthermore, it is hoped that the selfcare perspective developed by nurse researchers will be used by other disciplines in their studies of menopause. In the following section, we discuss the research on menopause in light of the self-care and livedexperience concepts. NATURAL MENOPAUSE The natural menopause is a developmental marker or point of change in a woman's life; in medical and scientific terms, it is considered the endpoint of the reproductive option for women. Using this description of
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menopause, however, limits researchers to physiologic events and does not take into account all the experiences common to women during this time or phase in their lives. Some physiologic events that women may report around the time of menopause are vaginal dryness or painful sexual intercourse, changes in menstrual cycle regularity and flow, and hot flashes. The physiologic and experiential events that precede, occur at the time of, and continue for one full year past the natural menopause are referred to as perimenopausal phenomena. Perimenopausal phenomena have not been studied as an integrated whole. Furthermore, researchers have usually studied only selected aspects of menopause, rather than examining the context in which a woman experiences manopause. For example, there have been studies of age (Frere, 1971; Frommer, 1964; Goodman, Grove, & Gilbert, 1978; McKinlay, Jefferys, & Thompson, 1972; Neugarten & Kraines, 1965; Thompson, Hart, & Durno, 1973) and of attitudes (Bowles, 1986; Muhlenkamp, Waller, & Bourne, 1983). Other studies have investigated menopausal symptoms in relationship to sleep (Ballinger, 1976), life events (Cooke & Greene, 1981), culture (Flint & Garcia, 1979), outside work (Maoz et al., 1978), sexual activity (Bottiglioni & DeAloysio, 1981), mental health (Hallstrom & Samuelsson, 1985), and psychiatric morbidity (Ballinger, 1975). Hot flashes as a symptom of menopause (Greene, 1976; McKinlay & Jeffreys, 1974) and as an experience of menopause (Voda, 1981) have been investigated. In still other studies, age at menopause has been related to socioeconomic status and hormonal events earlier in a woman's life (Ernster & Petrakis, 1981), as well as to the risk of cardiovascular disease and death (Lapidus, Bengtsson, & Lindquist, 1985) and to smoking (McKinlay, Bifano, & McKinlay, 1985). Hormonal studies with postmenopausal women, most of which were conducted in conjunction with hormonal replacement therapy (HRT), have been given considerable coverage in the scientific literature and in research. In many of the cited studies (Blatt, Wiesbader, & Kupperman, 1953; Hammond, Jelovsek, Lee, Creasman, & Parker, 1979; Lindsay, 1981; Pratt & Thomas, 1937), research has focused on the "hormone deficiency state" that is assumed to exist in menopausal women. Recently, however, researchers have begun to question the view that menopause is a medical syndrome. This view is a biological reductionistic model that reduces a woman to a pair of ovaries, a uterus, and the related hormones. In an effort to free themselves of old assumptions, some researchers have begun to measure as many variables as they can without completely discarding the medical-syndrome model (Abe, Suzuki, Wada, Yamaya, & Moritsuka, 1985; Hagsted, Johansson,
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Wilhelmsson, & Janson, 1985; Leiblum, Bachmann, Kemmann, Colburn, & Swartzman, 1983). Biological reductionism, however, is not the only culprit in menopausal research; Lock (1986) observed that almost all research with menopausal women has been conducted from the "discipline's perspective." In a recent review of menopausal literature, Voda and George (1986) confirmed McKinlay and McKinlay's (1973) earlier concern that menopausal research was conducted using the biased perspectives of ageism, sexism, social (no-effect) models, biomedical models, and biological reductionism. The problem with using these biased perspectives in conducting research is that they limit the researcher's view of the woman's total experience of menopause. For example, ageism diminishes the value of the older woman mainly because she can no longer reproduce. Likewise, sexism diminishes women in that the male experience is viewed as the "norm." The social (no-effect) model discounts women's experiences of menopause, such as hot flashes, and the biomedical model assumes that menopause is a disease with specific symptoms. Furthermore, researchers have no common language for discussing menopause. Several terms have emerged over the years; one of these terms is the change of life, which is no longer acceptable for the modern woman. Women in the United States were thought to suffer an "empty nest syndrome" about the same time that they experienced menopause (Bart, 1973). With changing life-styles, this is no longer true for many women. The climacteric, another term used by researchers (Ballinger, 1975, 1976; Bottiglioni & DeAloysio, 1981; Cooke & Greene, 1981; Maoz et al., 1978; Uphold & Susman, 1981), is an ambiguous one that refers to a time span of 5-20 years. Exactly when the climacteric begins and when it ends is uncertain. In most instances, researchers define it as extending into the postmenopausal years. Regardless of its definition, this is a term that many women find too vague to be acceptable. Menopause has yet to be defined in an operational way. One of the characteristics of menopause is that it is not a time-limited event. The literature has often linked the postmenopausal period to a complete cessation of ovarian hormone production, but there is insufficient scientific evidence for such a link. Another problem with linking menopause to cessation of ovarian hormone production is that this linkage ignores the uterus, the main organ involved. Garcia and Cutler (1984) and Greenblatt, Colle, and Mahesh (1976) found that some of the definitions of menopause used in experimental studies lack support or explanation for the assumptions made about hormonal cessation. In some studies, researchers (Aleem, Weitzman, & Weinberg, 1984; Foster, Zacui, & Roch, 1985; Gerdes, Sonnendecker, & Polakow, 1982; Judd, Sha-
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monki, Frumar, & Lagasse, 1982; Meldrum et al., 1980; Talo & Pulkkinen, 1984) have grouped naturally and surgically induced menopausal subjects into the same categories. Knowledge about menopause is enmeshed in myths, misconceptions, and misinformation. Most hormonal studies are written in the technical language of a particular scientific discipline or include too few subjects (Custro & Scafidi, 1986; Greenblatt et al., 1976; Judd et al., 1982) to be considered scientifically generalizable by researchers. Much of the other research about menopause is biased by a disease-oriented or hormonedeficiency perspective. Women have little access to usable information about the experience of menopause. The lack of adequate information compromises the control that a woman has over her body. THE LIVED EXPERIENCE AND MENOPAUSAL STUDIES Although in reality self-care activities occur in many settings, much research with menopausal women has been conducted with physicianbased practices. Surveys of large numbers of women to determine age of menopause (Frommer, 1964) and symptoms (McKinlay & Jeffreys, 1974) have relied on lists drawn from physician-based practices. One novel sampling idea for identifying menopausal women was Feldman, Voda, and Gronseth's (1985) research of the hot flash; they used a cluster sample of telephone subscribers. Much of the research has focused on the signs and symptoms of menopause that could be relieved by HRT rather than on the menopausal woman and her experiences. There has been little attention to the benefits of the research for women or how the research could improve their health. The majority of menopausal studies are related to some aspect of HRT. Some nurses have developed seminars or written articles (Dosey & Dosey, 1980; McGuire & Sorley, 1978; Pearson, 1982) that "treat" menopausal women. Even the more recent efforts of researchers (Abe et al., 1985; Hagsted et al., 1985; Leiblum et al., 1983) to measure many variables relating to menopause lack an understanding of the development of women or the meaning of these variables in the context of women's lives. Nurse researchers have conducted some studies on menopause (Table 2). These studies have been conducted from several perspectives and are a necessary beginning for research in this area. More studies like these conducted by other disciplines need to be done. The anthropologists Flind and Garcia (1979) studied two American ethnic groups of Cuban and Jewish women and postulated that menopause varies from culture to culture. Kaufert and Syrotuik (1981) have
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Table 2. A Review of Selected Menopausal Studies Conducted by Nurse Researchers
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Author(s)
Perspective
Aspect studied
Cultural sensitivity
Acknowledgment of context
Frey (1981)
Biomedical
Symptoms
Cannot be determined
Yes
LaRocco & Polit (1980)
Biomedical
Knowledge of menopause
Cannot be determined
Partly
Polit & LaRocco (1980)
Biomedical
Symptoms
Cannot be determined
Yes
Uphold & Susman (1981)
Biomedical
Symptoms
Cannot be determined
Yes
Dosey & Dosey (1980)
Sociopsychological
Physical/ emotional
Cannot be determined
Yes
Bowles (1986)
Women's health
Attitudes
Yes
Yes
Feldman, Voda, & Gronseth (1985)
Women's health
Hot flashes
Yes
Partly
Muhlenkamp, Walker, & Bourne (1983)
Women's health
Attitudes
Cannot be determined
Yes
Voda (1981)
Women's health
Hot flashes
Cannot be determined
Yes
Note. These menopausal studies are not self-care studies.
discussed the probable bias in symptom perception and reporting across cultures. Cultural variables related to menopause have been included in Maoz et al.'s (1978) study sample of Jewish and Arabian women, Sharma's (1983) study of menopausal symptoms of Indian women, Beyene's (1985) focus on Mayan Indian and rural Greek women, and Frere's (1971) examination of the mean age of Bantu and White women in South Africa. Also, Wright (1981) has studied the menopausal symptoms of Navajo Indians, and Goodman et al. (1978) researched those of White, Japanese, Chinese, and part-Hawaiian postmenopausal women living in Hawaii. CONCLUSION The lack of consistency by researchers in defining self-care and menopause suggests that both concepts are in the early phases of re-
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search development. Thus, in both nursing research and clinical practice, a critical perspective is cultural sensitivity to menopausal women and the context of their health care. Like Dodd (1988), we find self-care to be an important concept for clinical practice. We would emphasize that it is a concept in need of measurement tools sensitive to the lived experience of women across the life span. Yet more than 14 years have passed since Daniels (1975) urged health and life-cycle issues for women as an area for research emphasis. This underscores the importance of finding ways to combine tenets of self-care with research on menopause in nursing research and practice. Such a combination will likely help to realize a research language consistent with such desired practice goals as helping women establish their health goals, adding to understanding of universal truths or knowledge of women's development, recognizing women as complex biopsychosocial beings who exist within a cultural context, and acknowledging that women own the menopause experience. REFERENCES Abe, T., Suzuki, M., Wada, Y., Yamaya, Y., & Moritsuka, T. (1985). Clinical endocrinological features of statistical clusters of women with climacteric symptoms. Tohoku Journal of Experimental Medicine, 146(1), 59-68. Aleem, F. A., Weitzman, E. D., & Weinberg, U. (1984). Suppression of basal luteinizing hormone concentrations by melatonin in postmenopausal women. Fertility & Sterility, 42(6), 923-925. Ballinger, C. B. (1975). Psychiatric morbidity and the menopause: Screening of general population sample. British Medical Journal, 3, 344-346. Ballinger, C. B. (1976). Subjective sleep disturbance at the menopause. Journal of Psychosomatic Research, 20, 509-513. Barofsky, I. (1978). Compliance, adherence, and the therapeutic alliance: Steps in the development of self-care. Social Science Medicine, 12, 369-376. Bart, P. B. (1973, September 10-12). Pioneers, professionals, returnees, Penelopes, and Portnoy 's mother. Paper presented before the 26th Annual Conference on Aging Women: Life Span Challenges, Ann Arbor, MI. Beyene, Y. (1985, May 3-5). Menopause: A biocultural event. Paper presented at the Sixth Conference of the Society for Menstrual Cycle Research, Galveston, TX. Blatt, M. H. G., Wiesbader, H., & Kupperman, H. S. (1953). Vitamin E and climacteric syndrome. American Medical Association Archives of Internal Medicine, 91, 792-799. Boston Women's Health Book Collective. (1973). Our bodies, ourselves: A book by and for women. New York: Simon & Schuster. Boston Women's Health Book Collective. (1976). Our bodies, ourselves: A book by and for women (2nd ed.). New York: Simon & Schuster. Boston Women's Health Book Collective. (1979). Our bodies, ourselves: A book by and for women (2nd ed. Revised and expanded). New York: Simon & Schuster.
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Requests for reprints should be sent to B. J. McElmurry, 845 So. Damen, Rm. 1126, College of Nursing, University of Illinois, Chicago, IL 60612.
