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thesis entitled

PERCEIVED CONTROL OVER THE MENOPAUEE
EXPERIENCE AND EXPERIENCES,
EXPECTATIONS AND BEHAVIORS REGARDING
MENOPAUSE

presented by _
I

Jill (Walther) Kroll

has been accepted towards fulfillment
of the requirements for

M.A. degree in Psychology

 

 

 

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PERCENED CONTROL OVER THE MENOPAUSE EXPERIENCE AND
EXPERIENCES, EXPECTATIONS AND BEHAVIORS REGARDING
MENOPAUSE
By

Jill (Walther) Kroll
A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTER OF ARTS

Department of Psychology

1989

ABSTRACT

PERCENED CONTROL OVER THE MENOPAUSE EXPERIENCE AND
EXPERIENCES, EXPECTATIONS AND BEHAVIORS REGARDING
MENOPAUSE

By

1111 (Walther) Kroll

The purpose of this research was to determine the correlates of perceived
control relating to menopause for use in developing an educational interven-
tion to aid women in active involvement in their menopausal health care.

Two hundred sixty nine women age 45 to 55 responded to written ques-
tionnaires relating to menopause. High internal perceived control was found
to correlate -.24, (p_ < .05), with experienced symptoms, and -.35, (p_< .05), with
symptoms expected by those not yet experiencing menopause. Women whose
periods were still regular perceived more internal control relating to meno-
pause than women whose last period was 3 to 12 months ago, @(3, 263) = 4.92;
p < .05). Women who scored higher in knowledge of menopause perceived
more internal control related to menopause than did women who scored lower.
It was concluded that an intervention addressing women’s needs during meno-
pause should be sensitive to the variation in perceived control among women

as it relates to differing knowledge and symptoms experienced.

Dedicated to John
and

our sons, David and Thomas

ACKNOWLEDGMENTS

Special thanks to the chair of my thesis committee, Dr. William S.
Davidson, and my thesis committee members Dr. Esther Fergus, Dr. Raymond
Frankmann, and Dr. Marilyn Rothert.

Additional thanks to the Estrogen Replacement Therapy Study group at
Michigan State University.

iv

TABLE OF CONTENTS

Page
LIST OF TABLES .................................................................................................. ix
LIST OF FIGURES ................................................................................................. x
Chapter
1 Problem Definition: Menopause and the
Hormone Replacement Therapy Controversy .................... 1
Menopause ..................................................................................... 3
The Hormone Replacement Therapy
(HRT) Controversy .................................................... 6
Review and Critique of the Literature ........................................... 10
Criteria for Evaluation Of Research .......................................... 10
Search Method ............................................................................. 12
Locus Of Control and Menopause ............................................ 12
Health Locus of Control Scales ................................................. 19
Control Research Relating to Women ...................................... 21
2 Method ................................................................................................ 26
Hypotheses ................................................................................... 26
Subjects ......................................................................................... 27
Setting ........................................................................................... 30
Design ........................................................................................... 30

Chapter Page

2 Instruments .................................................................................. 31
Perceptions of Menopause ................................................... 31
Sociodemographic ................................................................. 36
Menopausal Symptoms ........................................................ 36
Management of Symptoms .................................................. 37
Menopause Information ....................................................... 38
Judgment Cases ..................................................................... 38

Procedure ........................................................................................... 39
Subject recruitment ..................................................................... 39

Data Collection ............................................................................ 4O

3 Results ................................................................................................. 43
Evaluation of Hypotheses .......................................................... 43
Hypothesis 1 .......................................................................... 43

Hypothesis 2 .......................................................................... 45

Hypothesis 3 ....................................................... . .................. .45

Hypotheses 4 8r 5 .................................................................. 49

Hypothesis 6 .......................................................................... 50

Hypothesis 7 .......................................................................... 50

Hypothesis 8 .......................................................................... 56

Hypothesis 9 .......................................................................... 56

Additional Analyses ................................................ : .................. 56
Summary ...................................................................................... 61

4 Discussion .......................................................................................... 63

Chapter Page

4 Limitations ......................................................................................... 68
Future Directions .............................................................................. 69
LIST OF REFERENCES ...................................................................................... 71
APPENDICES ...................................................................................................... 79
APPENDIX A
Instructions to Participants .............................................................. 79
APPENDIX B
Sociodemographic Instrument ........................ ' ................................ 8 2
APPENDIX C
Menopausal Symptoms Instrument ............................................... 89
APPENDIX D
Management of Symptoms Instrument ......................................... 98
APPENDIX E
Menopause Information Instrument ............................................ 103
APPENDIX F
Judgment Cases Instrument .......................................................... 107
APPENDIX C
Perceptions of Menopause Instrument ........................................ 127
APPENDIX I-I
Equations for Management Scales ................................................ 132
Example Calculations ..................................................................... 137
APPENDIX I
Menopause Information Instrument Key .................................... 138
APPENDIX I
Press Release and Media Requests for Participants ................... 139
APPENDIX K
Participant Recruitment Letters .................................................... 141

vii

Chapter Page

APPENDIX L

Participant Sign-up Sheet ............................................................... 143
APPENDIX M

Newsletter Example ........................................................................ 144
APPENDIX N

Additional Information Packet ..................................................... 145
APPENDIX 0

Consent Form .................................................................................. 148
APPENDIX P

Introduction Sheet and Results Request Form ........................... 149
APPENDIX Q

Example Thank-you Letters .......................................................... 150
APPENDIX R

Calculation of Omega-squared ((02): An Estimate Of

Treatment Effect Magnitude .................................................... 153

APPENDIX S

Calculation of Correction for Unreliability ................................. 154

LIST OF TABLES

Table Page
1 Locus of Control in Lien (1981) Study ....................................... 17
2 Description of the Participant Sample ....................................... 29
3 Perceptions Instrument Items ..................................................... 32
4 Interscale Correlations for Perceptions Instrument ................. 34
5 Education and Mean Score on Perceived Control ................... 45
6 Summary Statistics for Perceived Control and

Last Menstrual Period ............................................................ 47

7 Summary Statistics for Symptom Management and
Perceived Control ................................................................... 51
8 Medication Strategies and Frequencies ..................................... 52
9 Diet Strategies and Frequencies ................................................. 53
10 Vitamins and Minerals Strategies and Frequencies ................ 55
11 ”Other” Strategies and Prequencies......................- ..................... 55
12 Pearson Correlation CoeffiCient Matrix ..................................... 58

LIST OF FIGURES

Figure Page
1 Distribution of Scores on Control Scale .................................... 35
2 Mean Perceived Control By Last Period ................................... 48

Chapter 1
Prl fini'nzMen u nhHrmne
Replagmgnt Therapy Controversy
Because of an increased life span, 95% of women today will live beyond
menopause (Hamilton 8: Clements, 1982) making menopause a nearly univer-
sal experience for American women. Up to 88% Of women experience symp-
toms such as hot flashes (Feldman, Voda 8: Gronseth, 1985). Following meno-
pause, women may be more prone to debilitating fractures of the spine, hip or
wrist, due to accelerated loss of bone mass, (National Institutes of Health
Consensus Development Panel on Osteoporosis [NIH], 1984). Symptom
management and prevention of osteoporosis are therefore important issues for
middle years women (Kirkpatrick 8: Edwards, 1985; Hallal, 1985) but women
have been found to lack information regarding menopause (LaRocco & Polit,
1980). Since many of the issues surrounding management of symptoms and
prevention of osteoporosis are complex, support and information groups ad-
dressing the concerns of menopausal women have emerged in the United
States and Europe (Schmid—Heinisch, 1985; Caldwell, 1982; Drennan 8:
McGeeney, 1985; Staff, 1986), but no controlled studies Of the effectiveness of
such groups have been reported in the literature to date. Preparation for the
development of an educational intervention addressing the needs of meno-
pausal women involves an understanding of current perceptions and concerns
regarding the issues related to menopause today. One issue which may add to

our understanding of how women view menopause is perceived control.

2
Perceived control has been found to be related to a variety Of health related be-
haviors (Strickland, 1978) and may be an important variable to understand re-
lating to the experience of menopause for women. Duffy (1988) found that
health locus of control accounted for 16% of the variance observed in health
promotion lifestyle among a convenience sample of 262 middle years women.
Additionally, it has been found that individuals may differ in the level of con-
trol they desire to have in regard to their health care (W allston, Smith,
Wallston, King, Rye 8: Heim, 1987). In a review of locus of control and health
Wallston, Smith, Wallston, King, Rye and Heim (1987) concluded that health
education programs which tailor the orientation of the program to internally or
externally-oriented individuals were more effective in changing targeted health
behaviors.

In our youth-oriented society (Rosenthal, 1979) the period Of midlife has
often been overlooked in the study of the human life cycle (Upheld 8: Susman,
1981). Today, at the time of menopause a woman still has one third of her life
left to live (Schmid-Heinisch, 1985). Included in the period between the birth Of
a woman’s last child and old age, is the transition from the reproductive phase
of the woman's life to the nonreproductive phase (Rosenthal, 1979). This life
stage, which includes the menopause, is a time of physical and psychosocial
change which may be accompanied by uncomfortable physical or
psychological symptoms for some women (U phold 8: Susman, 1980). To fully
understand the context in which the issues related to menopause and the mid-
dle years are experienced it is necessary to understand the physical, psycholog-

ical and social changes occurring during this time.

Menopause
”Menopause" means the cessation Of menses (Rosenthal, 1979; Feldman et

al, 1985). The ”climacteric" has been described as ”that phase in the aging
process Of women making the transition from the reproductive stage of life to
the nonreproductive stage” (Rosenthal, 1970, p. 358), ” a natural life phase,
occurring in all women as the ovaries cease production and the estrogen level
decreases permanently” (Dosey 8: Dosey, 1980, p. 14). ”Climacteric symptoms”
were defined by Uphold 8: Susman (1981) as ”the common physiological and
psychological identifiable complaints associated with the gradual regression of
the ovarian hormonal function,” p. 85. A related term, ”menopause transition,”
has been described as ”a period of time marked by a progressive change in the
pattern of menstrual cyclicity indicated by unusually long or short menstrual
cycles, diminished menstrual flow, or intermittent menstrual cycles that
terminate in menopause” (Feldman et al, 1985, p.262). ”Perimenopausal” has
been defined as, ”a period of time surrounding the actual experience of meno-
pause” (Feldman et al, 1985, p. 262). Although some studies have included def-
initions Of menopause, many have not and a woman’s status in regard to meno-
pause is Often unclear leading to confusion in the menopause literature
(Alexander 8: Roberts, 1987). There are difficulties in determining a woman’s
menopausal status since menopause can only be diagnosed retrospectively
(after menstrual periods have ceased) without measurement of hormone levels
(World Health Organization [WHO], 1981).

The physical changes which occur at menopause have been postulated to

be due to ovarian aging. By the time a human female is born she has all of the

4

oocytes that she will have in her lifetime. These oocytes degenerate at various
stages of follicular development, beginning prenatally and continuing through-
out the woman’s lifetime, (less than .01% of oocytes in women are ovulated).
When all of the oocytes have either degenerated or been ovulated ovarian
failure occurs (Gosden, 1985). Since the somatic cells which surround an oocyte
and make up the follicle are the source of follicular oestradiol, when the store Of
oocytes and follicles is depleted, the ovary ceases to produce estrogen and
menopause occurs (Gosden, 1985). The mean age at natural menopause is
about 49.5 years, but 30 percent of women cease menstruating due to surgery
(Krailo 8: Pike, 1983). Estimates of the mean age of menopause vary from 46.7
to 50.1 (Batrinos, Panitsa-Faflia, Pitoulis, Pavlou, Piaditis, Alexandridis, 8:
Liappi, 1979; Van Keep, Brand, 8: Lehert, 1979; Feldman et al, 1985).

Menopausal symptoms vary greatly among women. For slightly less than
half of women, menses cease abruptly, while for others, cessation of menses
follows a period of menstrual irregularity (Batrinos et al, 1979). For women
who experience menstrual irregularity, the period of irregularity lasts less than
1 year for almost 90% of the women, but continues for up to 2 years for about
10% of the women, (Batrinos et al, 1979). Accompanying the changes in the
menstrual cycle are a variety Of symptoms including but not limited to hot
flashes, vaginal dryness, headaches, weight gain, aches in the back Of the neck
and skull, trouble sleeping, depression, forgetfulness, irritability and tiredness,
tingling in limbs, joint aches, night sweats, shortness Of breath, dizziness, palpi-
tations, loss of appetite, aching breasts, backache, bladder difficulties, and sexu-
al problems (Babuna, Aksu, 8: Erez, 1982; Feldman, Voda, 8: Gronseth, 1985;

5
Iaszmann, van Lith, 8: Zaat, 1969; Bungay, Vessey, 8: McPherson,, 1980, Dosey
8: Dosey, 1980).

The withdrawal of estrogen which was being produced by the ovaries prior
to menopause results in changes to estrogen-sensitive tissues like the vagina.
The vagina is gradually shortened and has reduced compliance to applied force
following the withdrawal Of estrogen (Gosden, 1985). The uterus, cervix and
vulva also show estrogen withdrawal related changes (Gosden, 1985). Among
the symptoms reported by women during the menopause, hot flashes has been
the most frequently reported complaint (Polit 8: LaRocco, 1980). The incidence
of hot flashes has been estimated to be between 40% and 90% (Batrinos et al,
1979; Iaszmann, van Lith 8: Zaat, 1969; Feldman et al, 1985). Hot flashes were
defined by Feldman et a1 (1985) as an experience associated with the
menopause transition, characterized as vasomotor instability, resulting in a
sudden sensation Of heat or a feeling as perceived and determined through the
self-report of women. Nonthermal body sensations may also be described
including sensations of tingling, throbbing, rush of blood, lightheadedness,
chills, and suffocation (Feldman et al, 1985).

Finally, in addition to experiencing physical and psychological symptoms
during menopause, many women are faced with social changes as well, such as
a changing family and marital role due to children achieving adulthood
(Bungay et al, 1980), financial difficulties, employment changes, and body
changes due to aging (Lien, 1981).

Which of the symptoms experienced by a woman are directly attributable

to menopause remains unclear (Greene, 1976). There is evidence that vasomo-

6
tor symptoms and symptoms associated with changes in estrogen sensitive tis-
sues may be directly attributable to the decline in estrogen associated with
menopause (Jaszmann et al, 1969; Bungay, et a1, 1980). Other symptoms may
be related to psychosocial changes which occur at midlife or may have other or-
igins and are not unique to menopause (Bungay, et al, 1980; Ballinger, 1985).
H rm n R l m n Th n

One of the most popular treatments for menopausal symptoms today is
hormone replacement therapy (HRT), also called estrogen replacement therapy
or ERT (National Center for Health Statistics, 1983; American Medical
Association Council on Scientific Affairs [AMA Council], 1983). Estrogen was
first prescribed for menopause-related symptoms in the United States in 1929
(Furuhjelm, 1977) and has usually been prescribed as one of two regimens: es-
trogen alone, or estrogen/ progestin combined (Upton, 1980).

Controversy exists regarding whether estrogen is an appropriate treatment
for the problems of menopause. It has been put forth that an alternative causal
explanation for osteoporosis in Older women is poverty-induced low-calcium
diets and fear of walking alone in a violent society (MacPherson, 1985, 1987).

Estrogen has been seen by some as contributing to the perception of meno-
pause as a deficiency disease, rather than an adaptive life event (Alington-
MacKinnon 8: Troll, 1981). Estrogen has also been seen as a beneficial
treatment for problems experienced by some women during menopause.
Estrogen replacement therapy has been found to be highly effective in reducing
the frequency of hot flashes (by 91 %) when compared with a placebo (Judd,
1987) and was concluded to be the single most effective modality for the

7
prevention of osteoporosis in women by the National Institutes of Health
Consensus Development Panel on Osteoporosis (1984). The issue is of concern
because of the severity of the problem of osteoporosis. Osteoporosis is an
age-related disorder characterized by decreased bone mass and increased
susceptibility to fractures in the absence of other recognizable causes of bone
loss (NIH, 1984). Osteoporosis has been estimated to affect as many as 20
rnillien individuals in the United States and about 1.3 million fractures per year
in people age 45 and older have been attributed to osteoporosis (NIH, 1984).
The cost of osteoporosis in the United States was estimated to be $3.8 billion
per year, in 1984 (NIH, 1984). A significant number of those who experience
fractures die from complications directly associated with the fracture (NIH,
1982). Ne laboratory tests for defining individuals at risk or those with mild
osteoporosis are available (NIH, 1984) so a decision regarding whether to take
estrogen replacement therapy must be made based on risk factors. It has been
clearly documented that unopposed pestrnenepausal estrogen use increases the
risk for endometrial cancer from 1 case per 1,000 women to between 3 and 7
cases per 1,000 women (Persson, et al, 1989; Gastel, Cerneni-Huntley 8: Brody,
1980; Hulka, Kaufman, Fowler, Crimson 8: Greenberg, 1980). The addition of
the hormone progesterone to the estrogen treatment regimen has been found to
reduce the risk of endometrial cancer to the rate for non-estrogen users
(Gambrell, 1987; Persson, et al, 1989; Gambrell, 1978) but when administered
cyclically in the dose believed to be required to provide protection from en-
dometrial cancer may promote a resumption of monthly bleeding or spotting

(Luciano, Turksoy, Carlee 8: Hendrix, 1988; Jones, Francis 8: Nerdin, 1982).

8
Estrogen replacement therapy may also provide protection from coronary heart
disease in women, by reducing serum levels of low density lipepretein (LDL)
cholesterol (Wolfe 8: Huff, 1989; Henderson, Paganini-Hill 8: Ross, 1988) and
increasing levels of high density lipepretein cholesterol (Fahraeus, 1988). The
addition of pregestins to the therapy may have the opposite effect however,
and may actually increase the risk for coronary heart disease (La Rosa, 1989).
Finally, evidence regarding the relationship between I-IRT and breast cancer re—
mains unclear and may be dose related (Dupent, Page, Rogers 8: Parl, 1989).
Studies of death from all causes have suggested that women who used estrogen
replacement therapy may be at less risk of death than women who did not
(Bush et al, 1983). In summary, the issues facing women today at the
menopause are complex, with risks as well as benefits inherent in the decision
regarding HRT. All of the factors discussed above, discomfort from hot flashes,
risk of fractures due to osteoporosis, risk of endometrial cancer, heart disease
risks and all-cause mortality risks combine to create a dilemma for the woman
as she approaches menopause. Should she rely entirely on the expert Opinion
of her health care provider as to decisions regarding her menopausal health
care, or should she take an active role in the decision making? If she chooses to
take an active role, how will she weigh the various risks and benefits? Many
women will want to take an active role in the decision making and will wish to
be inferrned regarding the risks and benefits associated with estrogen replace-
ment therapy. Other women will desire a lesser degree of involvement in the
decision making. Wallston, et al (1987) found that not all individuals desired

the same degree Of involvement in or ”control” regarding their health care.

9

Control relating to menopause may therefore be an important variable to
understand as it relates to the woman’s participation in her menopausal health
care.

Perceived control, also called locus of control was first described by
Rotter (1966). Locus of control was said to refer to an individual’s generalized
expectations about how reinforcement is controlled (Rotter, 1966). Individuals
who perceived events as occurring as the result of luck or powerful others, or
as unpredictable, were said to maintain an external locus of control (Rotter,
1966). Those who believed that an event was contingent upon their own be-
havior or characteristics maintained a generalized internal locus of control
(Rotter, 1966).

Control has been studied extensively in many different spheres or
situations and a variety of situation-specific scales to measure control have
been developed, including several particularly addressing health-related issues
(W allston, Wallston, Kaplan 8: Maides, 1976; Long 8: Haney, 1986; Labs 8:
Wurtele, 1986). Situation-specific measures of control have been found to
provide enhanced prediction of behavior in specific situations (W allston,
Wallston, Kaplan 8: Maides, 1976). Although many studies have addressed
control as it related to health care issues, few previous studies have examined
the relationship between control and experiences, expectations or behavior
relating to menopause. Of the studies reported, many were found to have
significant limitations or failed to address important issues relating to
menopause such as knowledge of menopause, menopausal status or symptom

management behavior.

10
Review and Critique of the Literature

This section reviews previous studies of control as it relates to menopause.
The conclusions of previous literature reviews will be described, along with
criteria for future research. Following this, the literature search methodology
will be described, and the studies will be discussed.

Criteria for Evaluation of Regargh

Several critiques of the general menopause literature have discussed the
limitations of past research and delineated criteria for future research (Barnett
8: Baruch, 1978; Koesk, 1982; Perlmutter 8: Bart, 1982).

Some research has been based on the assumption that menopause was a
psychosocial stresser which stirred up previous psychosexual adjustments and
produced turmoil and regression (the premorbid personality model). Research
based on this model has been criticized because it has drawn study subjects
from patient populations and used psychological testing, retrospective report
and clinical observation to study menopause (Koeske, 1982).

Research which could challenge such assumptions would draw study
participants from non-patient populations and employ means other than clini-
cal observation to gather data. Other research has been based on the
assumption that stresses on women during their middle years has predisposed
them to psychological difficulties (the coincidental stress model). Research
based on this model was primarily anecdotal and based on case reports
(Koeske, 1982).

A general recommendation for future research indicated that research

should involve aggregated data from multiple individuals. Additional

l l
difficulties with past research were discussed by Koeske (1982). Koeske (1982)
saw research which was based on the Behavioral Science models of menopause
as deficient because like the biomedical models, the research was usually
seeking to explain non-normative phenomena and posit a simple 1 to 1
relationship between hormone deficiency and behavior, social environment
(past or present) or social structure and experience. The recommendation to
break out of this pattern was that future research should look for multiple and
interacting variables as explanations for experience (Koeske, 1982).

Also ignored by most behavioral science research on menopause has been
the complex influence and interaction of biological factors (Woods, 1982;
Koeske, 1982) and the way in which social-environmental factors (pastor
present) can affect biology (Koeske, 1982).

Perlmutter and Bart (1982) suggested that future research should look at the
ways in which women understand and make sense of their experiences in
order to go beyond models of menopause which see women as passively vic-
timized by their hormones, psyches and society.

In summary, future research dealing with menopause should draw study
participants from non-patient pepulations, use other than clinical observations
as a means of data collection, report aggregated data collected from large
samples of women, look for multiple and interacting variables as explanations
for observed variation, consider ways in which social-environmental factors
can influence biology and examine the ways women themselves understand

and make sense of their experiences.

12

There have also been recommendations for future research addressing
locus of control. Rotter (1975) and Lowery (1981) suggested development of
locus of control scales specific to various situations. It was believed that a
measure of generalized expectancy would be less useful for making predictions
in specific situations than a control scale designed to measure expectancies in
that situation or a situation of the same subclass (Rotter, 1975) particularly if
one is seeking a practical application of the information (Rotter, 1975).
Search Methgd

A computer search in August, 1987 of five databases resulted in 6
documents including 1 duplication. The key words used were ”menopause”
combined with one of the following: ”internal-external-contrel,” or ”locus with
control.” Of the 5 non-duplicates, 2 were dissertations. The databases searched
were: Medline, (Index Medicus) (1), Dissertation Abstracts International (2),
Psychological Abstracts (3-1 repeat), Social Science Citation Index (0), and
Research in Nursing and Allied Health (0). The number in parentheses
represents the number of documents from the preceding source. Of the 5 non-
duplicated citations, one was irrelevant to the topic and 1 was a general review
of research on women in the middle years and reported no research findings.

Three relevant articles found through the search and an additional article
found since the computer search were reviewed. They were critiqued with
regard to the relationship between menopause and perceived control.
Locus of Control and Menopause

Collins, Hanson and Enereth (1983) examined the relationship between

climacteric symptoms, response to hormonal replacement therapy, personality

13
characteristics and masculine and feminine self-concept. Masculine and
feminine self-concept were measured by an instrument developed by the
researchers. Study participants were 17 post-menopausal women selected by
an unspecified means from among the patients attending an outpatient
gynecology clinic. The women’s post-menopausal state was verified by
measurement of FSH (follicle stimulating hormone) levels.

Self-reports of vasomotor, psychosomatic, psychological and sleep-related
symptoms were obtained using a graphic scaling technique with items adapted
from the Blatt Menopausal Index and the Neugarten and Kraines check list and
personality characteristics were measured by the Karelinska Scales of
Personality questionnaire. Internal-external locus of control was measured by a
questionnaire adapted from Rotter. The study sample scored higher on
W (p < .05) “W (p < .05) than a non-patient
sample of the same age did, but scores on masculinity / femininity were similar
to those obtained by the researchers from female university students. Internal-
external locus of control scores were higher than those obtained from female
university students, indicating highflpercejyegw. The magnitude
and statistical significance of the difference was not reported. After the
instruments were administered, study participants were placed on a regimen of
estregen/progestin on a 28 day cycle, and the same measures were
administered again at 4-6 weeks after the start of the hormone treatment.

memms Refer: treatment were found *9 correlated
significantly with external locus of control Q = .48, p < .05), but psychosomatic,

vasomotor and sleep-related symptoms were not. N one of the symptoms

l4
correlated significantly with control after treatment.

The authors warned that the results had to be interpreted with caution
because some of the symptoms and the personality variables could have been
measuring the same underlying dimension. Interpretation of these results was
also limited by the small sample size, lack of a comparable comparison group
and use of a patient sample with little descriptive information in regard to
relevant characteristics in relation to the general population of women in this
age group. Additionally, no explanation was given for the lack of findings post
treatment, increasing suspicion that the single significant finding before
treatment could have been due to chance.

Lind (1984) examined the relationship between menopausal symptoms, use
of estrogen replacement therapy and locus of control as measured by the Rotter
internal-external locus of control scale. One hundred volunteers between the
ages of 36 and 80 who were postmenopausal (reported that there had been no
spontaneous menses for 12 months or more) completed a symptom checklist,
the Rotter I-E scale and a sociodemographic questionnaira Sixty one percent
had not had a hysterectomy, 25% had undergone a partial hysterectomy (only
the uterus, not the ovaries had been removed) and 14% had undergone a
complete hysterectomy involving removal of uterus and ovaries.

Eifty percent of the participants were employed part or full-time and 80%
had at least some college. Forty percent of the participants had annual incomes
of $25,000 or more. .

Women were categorized as ”High Internal Locus of Control" or ”High
External Locus of Control” by splitting the scores on the LE scale at the median

l 5

point and placing women who scored below the mean into the ”High Internal”
group and those who scored above the mean in the ”High External” group.
Women were also categorized according to whether they used estrogen or not, I
producing 4 groups: High Internal Users of Estrogen, High Internal Non-users I
of Estrogen, High External Users of Estrogen and High External Non-users of /
Estrogen.

C There was a significant difference (p < .05) between the four groups
(Internal Non-users, Internal Users, External Non-Users and External Users) on
number of symptoms reported. gmmalfion-gers of Estrgggn reported the
most symptoms and IntemaLNen-JrserseLEstrogenreportedtheiemest

Widnd (1984) found that while there were no differences in
symptoms reported between estrogen users and non-users, there was a
Smyflsmnsmfimpofled betweenbish-exteraalw of
control subjects and highjntemallomseficontrel subjectsfy
Lind (1984) found no relationship between locus of com—Ire] and the use of

estrogen, (x2 = .002, p > .05). There was also no significant relationship

(a

between locus of control and age or income. ‘2. (.4 Li :4” (2') T I I {I
I? The conclusion in this study was that the results supported the premorbid
personality model of menopause-that menopausal symptomatology was
psychological in origin, rather than being an estrogen deficiency disease. It was
also concluded that Wntrol strgrglyinfluenced a woman’s reaction to
W-

While the Lind study used an adequate sample size, used a non-patient

sample, and reported adequate reliability of the control instrument, the

16

measure of control was not situation-specific and so had limited practical
application for drawing conclusions about women’s perceived control over
their menopause experience.

Lien (1981) studied the needs of middle aged adults in the Lutheran Church
in Texas. Seven hundred seventy five men and women, aged 35 to 64, from 31
Lutheran congregations in Texas were randomly chosen to participate in the
study. Of these, 218 agreed to participate. Data was collected by a written
questionnaire and a group interview, held during a workshop at the
participants’ church. Thirty four percent of the participants were aged 35 to 44,
43% were between the ages of 45 and 54, and 22% were between 55 and 64
years old. Sixty three percent (139) of the participants were women, and 91% of
the participants were married.

”Locus of Control” was measured by 21 items on the questionnaire
instrument. The origin of the items was unspecified. The internal consistency

of the scale was not reported, but the ”validity” of the instrument was
verified through pilot testing with middle aged adults and a panel of experts
over age 35. The experts included a PhD. in Science Education, clergymen and
lay people and ”members of the Christian community.”

The items comprising the ”Locus of Centre ” scale are shown in Table 1.

Lien (1981) used a non-patient sample of adequate size and developed a
control scale specifically for the purpose of the study, but no measure of scale
internal consistency was reported. Additionally, the construct validity of the
control scale could be challenged. While it was reported that the instrument
validity was addressed by having a panel of experts review the items, this

l 7
appeared to address the relevance of the items to middle aged adults rather

than to the construct of control.

Table 1
Locus of Control items in Lien (1981) study

 

Items

 

There has been a change in my social activities.

I have experienced the death of a close friend.

I have experienced difficulties in demonstrating academic ability.
I feel out of place in church activities.

I have worried about whether a decision I made was the right one.
I need someone to talk to.

I am alone more than I like to be.

I feel more at ease with people after I have an alcoholic drink.

I have considered suicide.

I have attempted suicide.

1 seem to dwell on the past.

I do not feel free to do things I want to do.

I feel free to do things I want to do.

I feel that I am a useful person.

I feel useless.

I feel effective.

I am not respected as an individual.

I feel depressed.

My life seems to have lost its meaning.

I am satisfied with life.

 

LDuffy (1988) studied 262 women (for a response rate of 44%) who
responded to a mailed questionnaire relating to midlife health. The women
ranged in age between 35 and 65, were predominantly white and 80% had

college or graduate degrees.7fwenty five percent of the variance observed in a

18
total health promotion score (from the Health-promoting Lifestyle Profile) was
explained by chance health locus of control, internal health locus of control
(both from the Multidimensional Health Locus of Control Scale), self-esteem
(from the Rosenberg Self-esteem Scale), current health, health worry/ concern,
and post-high-school education. It was concluded that the findings supported
Fender’s health promotion model which posited that individualpercepfions of
health locusQnggtrngelfresteemy and health status influence health
promotion behavior. It was concluded that highly educated midlife women
would not want to leave their health to chance. \I

The major short-coming of this study was the low response rate and
homogeneity of the sample. Since the sample was self-selected the results
could not be generalized to the population at large or to other women with
similar sociodemographic characteristics. It did indicate however, that for at
least some women, control was an important variable in relation to midlife
health concerns.

In summary, the literature to date suggested that there may be a
relationship between locus of control and symptoms during menopause, with
those experiencing more symptoms having an external locus of control. No
relationship between control and estrogen use has been detected. Nor was a
relationship found between control and any demographics studied. Some
findings indicated that there may be agafionshiphetmeeg 9M1 and Egg-

WEEIEYSE 91990859919: fiybglgllfifiMEsn-
An examination of selected studies of health locus of control and control

research relating to women provided information partially applicable to the

19

issue of control as it related to menopause.

l h f n l 1

In a study of control which used the Health Locus of Control [HLC] scale,
Wallston et al, (1976) found that high-value internals selected more pamphlets
relating to a health condition about which they knew nothing than did other
groups of individuals which suggested that health locus of control could be
used to predict health related behavior such as information seeking. (”High-
value” individuals ranked health as one of their top 4 terminal values).

[5:37 In a second study, Wallston et a1 (1976) found that overweight women who
attended an 8 week weightless program consistent with their expectancies as
measured by the HLC were significantly more likely to be satisfied with the
program than were women attending programs inconsistent with their expect-
ancies. This finding indicated that control may be an issue in health related
interventions such as a program addressing health care during menopause.

The HLC has been one of the most frequently used scales for application to
health-related situations. The HLC Scale consisted of 11 face-valid items in a 6
point Likert-type format with half of the items worded internally and half
worded externally. The alpha coefficient of reliability has ranged from .40 to
.72, depending on the sample and the test-retest reliability (8 week interval)
was .71. The scale correlated -.01 with the Marlowe-Crowne Social Desirability
Scale and .25 to .46 with Rotter’ 5 LE scale. Wallston et a1 (1976) found no sig-
nificant differences between males and females on the HLC scale. The HLC
scale has been found to be more predictive of health related behavior than the
Rotter I-E scale (Wallston et a1, 1976).

20

In a review of research examining control and health Strickland (1978) indi-
cated that measures specific to health such as the Wallston et a1 HLC scale were
better predictors of health-related behaviors than were non-specific measures
but concluded that the I-E variable (Internal-External) was only one of a num-
ber of complex factors that may converge to predict health attitudes and behav-
iors and that the variance that IE accounted for was fairly small in many situa-
tions. Strickland concluded that although results were not unanimous, the bulk
of the research suggested that internal individuals appeared to engage in more
adaptive responses when faced with health problems than did externals and
that development of an internal orientation could lead to improved health prac-
tices. Wallston and Wallston (1978) in a review of locus of control and health,
also concluded that health education programs should be tailored to locus of
control beliefs since some education programs had been found to be
differentially effective for internals and externals. They also concluded that
since internals appeared more likely to engage in positive health behaviors
health educators should train patients to hold more internal beliefs and that
internal locus of control could be used in conjunction with behavioral measures
to evaluate health education programs. This conclusion conflicted with the
findings of Wallston et a1 (1987) who studied patients scheduled for a barium
enema examination and found that low desire for control patients experienced
less distress in an information only condition as compared to choice or predict-
ability conditions. Contrary to prediction, high desire for control patients ex-
perienced less distress in the predictability condition compared to the choice or

information only conditions. It was hypothesized that this was due to reac-

2 l
tance. The choice condition failed to provide a true choice and instead was per-
ceived to be a travesty, providing a choice ”between poisons” (W allston et al,
1987). These results indicated that individuals differed in their desire for

control and suggested that ' t rven 'ons should be tailored to the W ingr-
m’gnals in regard to control.

While there was disagreement as to whether an internal orientation relating
to health should be encouraged or whether attempts should be made to accom-
modate the individual’s internal or external orientation (Strickland, 1978;
Wallston 8: Wallston, 1978; Wallston et al, 1987) there was general agreement
that control was an important variable in health related issues and for
application to health interventions.

Control Research Relating to Women

While Wallston et a1 (1976) reported no differences between men and
women on the HLC scale, research relating health locus of control to situations
specific to women’s health may be especially useful when considering control
in relation to an issue such as menopause because of potential greater similarity
between the situations.

A study of women's choice of prenatal health provider supported the find-
ing described above regarding differing desire for control. Women who had
selected a nurse midwife scored significantly higher on the internal locus of
control subscale of the Multidimensional Health Locus of Control [MI-ILC]
scale than did women who had chosen an obstetrician. Women who chose an
obstetrician scored more highly on the powerful other subscale. The two
groups of women (N = 244) did not differ significantly on other variables such

22
as demographic characteristics, how long they had been pregnant, when they
first sought prenatal care or rankings of life values (Aaronson, 1987). This sup-
ported experimental data which suggested that women differed in the amount
of control they desired over their health care.

Also supporting this concept was a study by Littlefield and Adams (1987)
which found that women who chose a conventional birthing method (versus an
alternative birthing center) scored significantly higher (p < .01) on the powerful
others subscale of the MHLC than did women who chose to birth at the alterna-
tive birthing center. Littlefield and Adams (1987) also found that women did
not score differently on the internal control subscale after delivery compared to
prior to delivery, which suggested that internal control was a stable personality
characteristic. Women in both birthing conditions did increase significantly in
powerful others scores post delivery, which suggested that experience may in-
fluence women’s perceptions regarding control relating to health. Since the
findings found change on one control dimension (powerful others) after
delivery but not on another dimension (internal control) it was unclear whether
control was a personality characteristic or a situation specific variable. Since
control may be situation specific or may change with experience, studies of
control as it related specifically to menopause may be needed for practical
application of the information. While this research may generalize to women
and health during menopause, there are some differences to consider. First,
while this research specifically examined control in relation to a health issue for
women, the data may not generalize from prenatal care to menopausal care

because the women belong to different age cohorts and some studies indicated

23
that some control dimensions were influenced by situation or experience.
Menopause is not only a different situation, but is experienced by women at a
different age than the women who were studied regarding childbirth. Both the
general research conducted using the HLC scale, which used college students
as subjects (W allston et al, 1976) and the studies related to childbirth health
providers (Aaronson, 1987; Littlefield 8: Adams, 1987) studied women under
the age at which menopause occurs. The Littlefield and Adams (1987) study
described above showed that score on the powerful others subscale can change
as a result of experience which also indicated that studies examining women at
one age may not generalize to women at a different age. Secondly, the measure
used (the MHLC) was a general measure of health locus of control. The more
situation-specific a measure is the better it is expected to predict behavior
(Rotter, 1975) suggesting that a measure developed specifically to measure con-
trol relating to menopause may be more appropriate for applied use. Labs and
Wurtele (1987) found that a measure developed specifically to assess control re-
lating to fetal health significantly predicted maternal behavior, while the
MHLC scale did not.

For this reason it is important to examine locus of control as it relates
specifically to menopause. Additional research is needed to verify the
relationship between symptoms and control using a situation-specific measure
and to look at the relationship between control and management of symptoms
with estrogen therapy and other strategies. Additionally, sociodemographics
should be examined using a situation-specific measure of control to determine

whether women of different backgrounds differ significantly on control

24
relating specifically to menopause. Another topic which has not been
addressed in the literature to date is whether a relationship exists between
control and knowledge regarding menopause. Do these who are more
knowledgeable about menopause perceive more or less control relating to
menopause? Ferguson, Hoegh and Johnson (1989) found that knowledge
regarding menopause issues was significantly related to likelihood of taking
ERT and that women who were more likely to take ERT were more likely to
view menopause as a medical condition and less likely to favor natural
approaches to menopause. Is the perception of control relating to menopause
dependent on a woman’s menopausal status as measured by last menstrual
period? Do women perceive more or less control relating to menopause while
they are actually experiencing the change in their menstrual pattern?

Addressing these questions requires an instrument designed to measure
perceived control which is situation-specific to menopause and has adequate
internal consistency. It requires a non-patient sample of adequate size and a
data collection measure other than clinical observation Aggregate data should
be the basis of any conclusions drawn.

The study described on the following pages aimed to describe one of the
key variables in the experience of menopause-perceived control-and to correct
some of the methodological flaws of past research on the menopause. The
instrument developed for the study was designed for use with a non-patient
sample and was designed to be situation-specific to the issue of control relating
to menopause. The data collection method was self-report rather than clinical

observation and a sufficiently large sample size was used to ensure adequate

25
statistical power in the analysis of the aggregate data. The methods,

procedures and hypotheses for the study follow.

26
Chapter 2
M91

The purpose of this research was to determine the correlates of perceived
control relating to menopause for use in developing an educational interven-
tion to aid women in active involvement in their menopausal health care.
Perceived control was examined in relation to demographic variables, symp-
toms, knowledge about menopause, symptom management behavior, and like—
lihood of taking hormone therapy.
Emothexs
1. Marital status, employment, household income, and education will
differentiate between individuals who are high in perceived control and those

who are low in perceived control.

2. Religious preference will differentiate between individuals who are high in

perceived control and those who are low in perceived control.

3. Menopausal status (as measured by time since last menstrual period-item 13
on Sociodemographic instrument) will differentiate between individuals who

are high in perceived control and those who are low in perceived control.

4. Women who indicate experiencing or expecting more symptoms on the
symptoms instrument will differ in perceived control from women who

indicate fewer symptoms.

27
5. Women who indicate experiencing or expecting more severe symptoms on
the symptoms instrument will differ in perceived control from women who

indicate less severe symptoms.

6. Women who indicate a higher mean number of symptom management
strategies on the management instrument will differ in perceived control from

women who indicate a lower mean number.

7. Symptom management strategy category will differentiate between
individuals who are high in perceived control and those who are low in

perceived control.

8. Overall knowledge regarding menopause as measured by the Menopause
Information Instrument will differentiate between individuals who are high in

perceived control and those who are low in perceived control.

9. Mean likelihood of taking estrogen replacement therapy will differentiate
between individuals who are high in perceived control and those who are low
in perceived control.
Subjects

Two hundred eighty three women between the ages 45 and 55 (inclusive)
completed instruments, of which 271 met the criteria for participation and had
usable data. To meet the criteria for inclusion in the study, women were

required to be between 45 and 55 years old, not presently taking estrogens and

28
not have had a hysterectomy. Twelve women were eliminated from data
analysis because either they did not meet these criteria, or they failed to
complete one or more entire instruments. The demographic characteristics of
the sample are shown in Table 2. Participants were volunteers recruited
through Lansing area churches, synagogues and women’s organizations and
through newspaper and newsletter articles requesting participants and a
television interview describing the study. Participants were also recruited
through an article in the Detroit Free Press which reached women in the Detroit
area and in other Michigan cities. Seventy of the participants attended a data
collection session in the Detroit metropolitan area, and 201 participants
attended sessions in the Lansing area. All of the participants were English-
speaking and able to respond to written material.

The sample consisted of women who volunteered to participate in this
study and were told that they would received information about estrogen
replacement therapy and menopause. The sample was not necessarily
representative of the population of women in this age range, but was
descriptive of a subsample who were interested in the topic and might be likely

to attend an informational program on ERT and menopause.

29

 

 

Table 2
WWW
Variable N %
Last Menstrual Period
Still Regular Periods 142 52.4%
Less than 3 Months Ago 34 12.6%
3 --12 Months Ago 35 12.9%
12 or More Months Ago 58 21.4%
Missing 2 .7%
Marital Status
Married 210 77.5%
Divorced 38 14.0%
Single 11 4.0%
Widowed 10 3.7%
Separated 1 .4%
Missing 1 .4%
Employment Status
Employed Full Time 136 50.2%
Employed Part Time 71 26.2%
Not Employed, Retired or Other 64 23.6%
Yearly Family Income
$50,000/ yr or More 105 38.7%
$35,000 - $49,999 55 20.3%
$30,000 - $34,999 33 12.2%
Less than $30,000 65 24.0%
Missing 13 4.8%
Education
Less than 12 years 4 1.5%
High School Graduate 61 22.5%
More than 12 yrs. but no degree 67 24.7%
Tech. School or Community College Degree or Other 21 7.8%
Bachelors Degree 68 25.0%
Masters Degree 42 15.5%
Ph.D or Professional Degree 8 3.0%
Race
White 254 93.7%
Black 7 2.6%
Hispanic 7 2.6%
Other 3 1.1%

30
em:

The questionnaires were completed during a meeting scheduled for the
purpose. The meetings were held at a location and time convenient to the
women, usually in the evenings, and took approximately 1 1 / 2 to 2 1 / 2 hours.
Meetings were held at churches, community centers, schools and at Michigan
State University. Usually the room used for the completion of the
questionnaires contained a table and chairs, though occasionally the women
simply sat in a circle in chairs. Five to 70 women, usually from several different
organizations, attended each session. Name tags and coffee were provided for
the discussion session with the nurses after completion of the questionnaires.
Sessions began with a brief description of the purposes of the study and
instructions regarding completion of the questionnaires. See appendix A for
instructions to participants. Following this, the women worked through the
questionnaires individually and then participated in the group question and
answer period with the nurse afterward, if they desired. Frequently the
question and answer period was held in another room and women joined the
discussion after they had finished with the questionnaires. Other times, it was
held in the same room and did not begin until all women in the group were
finished with the questionnaires.

Reign I

This study was a descriptive correlational study, with total on the perceived
control scale as the dependent variable. The independent variables were
marital status, employment status, yearly household income, educational level,
religious preference, and menopausal status all measured by self-report to

31

items on the Sociodemograpic Instrument (see appendix B). Additional
dependent variables were total symptom score, measured using the
Menopausal Symptoms Instrument (see appendix C), type of symptom
management strategies employed and mean number of strategies used,
measured with the Symptom Management Instrument (see appendix D),
knowledge of menopause, measured by the Menopause Information
Instrument (see appendix E), and likelihood of taking estrogen replacement
therapy, measured using the Judgment Cases Instrument (see appendix F). The
correlation between perceived control and the independent variables
(described for more fully under the instruments section) were examined using
the Pearson Correlation Coefficient and one-way Analysis of Variance.
Instruments

Perceptions of Menopause. The items forming the Perceived Control scale
were drawn from the Perceptions of Menopause Instrument (see appendix C)
developed by Rothert, et al (1986). The instrument consisted of 32 statements
reflecting subjective assessment of the experience or expectations of
menopause. One half of the items reflected positive and half reflected
negative perceptions. The response choices which formed a Likert-type scale
were "strongly agree,” ”agree," ”neither agree nor disagree," ”disagree," and
”strongly disagree." Responses were coded 1 through 5, with 5 indicating a
more positive perception or greater internal perceived control and 1 indicating
a negative perception or less internal perceived control. The Perceptions of
Menopause Instrument was constructed to have 5 scales, including Feelings,
Control, Attitudes Toward Hormone

32

Table 3
Perceptions Instrument Items

 

Item # Content

 

10
11
12
16
18
19

25

15

17
20

24

Menopause As Problem Scale
Menopause has been / will be an unpleasant experience for me.

The thought of menopause is disturbing to me.

I expect to (do) experience physical trouble during menopause.

I expect to (do) experience emotional trouble during the menopause.
Menopause will bring / has brought many changes to my life.

I have been/ will be able to experience menopause without problems.
Menopause will/ did cause me to be sick a lot.

Menopause probably will not/ did not have a negative effect on me.
Women are more tired than usual during menopause.

Menopause is associated with mood changes.

.Co_nt_r_o_l_S_c_ale

Menopause symptoms that I might have can be helped.

There are things I can do to feel good during the menopause other than
going to a health care provider.

There is little that an individual can do to control the symptoms of
menopause.

Menopause causes problems no matter what you do.

I believe that I can control menopausal symptoms.

Special diets 8: foods may help control some of the symptoms of
menopause.

Menopause is something I just have to put up with.

Hormones Help Scale
Hormones are necessary for the management of menopausal symptoms.

Taking hormones for menopausal symptoms can make me feel better.

Positive Emctations Scale
On the whole, I expect to feel better after the menopause than I did

before the menopause.
I welcome the menopause.

 

33

Therapy, Attitudes Toward Health Care Providers, and Activities of Daily
Living. Ten items formed the a priori Control scale: *6, 7, 8, '9, 13, ‘14, '20, 21,
’22, and 24. The items preceded by an asterisk were reflected (1 =5, 2:4, 5=1,

=2) so that a 5 on all of the items represented more internal perceived control.
Each scale was scored by adding up the code (1-5) for each item in the scale.

Cronbach’s alpha coefficient of internal consistency was .4531 for the a priori
scale. The corrected item-total correlations ranged from .0207 to 3014. Based
on item content the scale was revised. Items 7, 8, 13, and 21 were eliminated
from the scale and items 15 and 17 were added. Cronbach’s alpha for the new
scale was .6498. The corrected item-total correlations ranged from .1697 to
.5327 and the scale variance increased from 9.59 for the a priori scale to 10.53
for the new scale. Item 14 correlated least well with the scale (I = .1697) and
was eliminated to form the final scale which consisted of the following 7 items:
*6, *9, 15, 17, ‘20, ‘22 and 24. Cronbach’s alpha for the final Control scale was
.6580. The item content of the final scale is shown in Table 3. The Perceptions
of Menopause instrument yielded four internally consistent scales in their final
forms: Menopause As Problem, Control, Hormones Help, and Positive
Expectations. The content of each of these scales is shown in Table 3. Only the
Control scale was utilized in this study. The corrected item-total correlations
for each of the 7 items in the Control scale are shown in Table 4, along with the
item-scale correlations for the Control scale items with the other final
Perceptions instrument scales and the inter-scale correlations. Item 17
correlated highly with the Menopause As Problem scale as well as the Control
scale but was included in the Control scale based on content and because it

34
increased the reliability of the Control scale slightly by increasing the length of
the scale. The minimum score possible on the scale was 7 and the maximum
score possible was 35. The mean score on the scale was 2431 and the standard

deviation was 3.06. The distribution of the scores on the scale is shown in

Figure 1.

Table 4
Interscale Correletifls for Pergpfim Ipstggment

 

Control Men. As Prep. Horm. Help Pee. Eypee.

 

Control 1.00 0.4838 -.1107 .0968
(p<.001) (N.S.) (N .8.)
Men/ Prob. 1.00 .0956 .1046
(N .S.) (N .5.)
Her. Help 1.00 .1043
(N .5.)
Pos. Exp. 1.00

 

 

.................

Item-Total and Item-Scale Correlations fer Centre] Scale heme

 

Corrected Item-Scale Correlations
Item Item-Total Correlation Men/ Prob Her. Help Pos. E>_<p.
6 .3545 .1758 -.1775 .1387
9 .2387 .1221 .0380 .0245
15 .5350 .3636 -.0711 .0731
17 .4019 .5274 -.0219 -.0122
20 .4289 .3434 -.0548 .0609
22 .2066 .0650 -.0585 .0247

24 .4106 .2755 -.1148 .0713

 

35

Figure 1
Distribution of Scores on Control Scale

I

30 35 40

lllLJlllllJlll

Number of Women
15 20 25
l

10

5

 

 

llllllllllllllllLlllllll

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

n :- DTI-n

 

10 15 20 25 30 35
Score on Perceived Control Scale

36

§o_ciodemeg;aphic. The sociodemographic instrument was a 28 item
questionnaire which asked not only for sociodemographic information such as
age, race and income, but also included items relating to the health history of
the respondent, particularly menstrual history. See appendix B.

MW The Menopausal Symptoms instrument was
divided into 2 sections, color coded green and yellow. See appendix C.
Respondents read the 56 symptoms listed and for those symptoms they had
experienced, indicated whether they were, ”Not Bothered,” "Bothered a Little,”
”Bothered Somewhat,” or "Bothered a Lot" by the symptom. Women who
answered ”yes” to the question: ”Are you currently experiencing or have you
experienced symptoms in the past which you believe are or were caused by
menopause?” read the symptom list on the green pages. Women who
answered ”no” read the same list of symptoms on the yellow pages but their
responses choices were ”W ill Not Bother Me," "W ill Bother Me a Little,” "W ill
Bother Me Somewhat," and "Will Bother Me a Let." The instructions to the
women who answered on the yellow sheets were to answer only for those
symptoms meyexpected to experience due to menopause. After the women
checked how much each symptom they had experienced or expected to
experience bothered them , the instructions asked them to rank the 5 symptoms
which bothered them the most. The total symptom scale for each woman was
computed by totaling her bothersomeness ratings for all symptoms she
indicated. Cronbach’s alpha coefficient of internal consistency was .9475 for
the scale.

37

Management of Smptoms. This instrument was completed only by
women who answered ”yes” to question A on the Menopausal Symptoms
instrument . It had space for the respondent to list the five symptoms ranked
as most bothersome to her and four categories of symptom management
strategies. The four categories were Medications, Diet, Vitamin and Mineral
Supplements, and Other. The instructions directed the respondent to indicate
what strategies, if any, she used to manage each symptom she listed. I

The instrument consisted of four a priori scales made up of the strategies in
each of the management categories: Medications, Diet, Vitamin and Mineral
Supplements and Other. The rationally derived scales were developed by
Rothert, et a1 (1986). The Management instrument scales were coded by
scoring each strategy indicated by the respondent with a ”1” for each symptom
checked and scoring a ”0” for each symptom under each strategy which was
not checked by the respondent. For example, if the respondent indicated that
she took sleeping pills for symptoms 1 and 2 and tranquilizers for symptom 3
under medication and she had 4 symptoms listed, she received a "1” for
sleeping pills for symptom 1 and a ”1" for sleeping pills for symptom 2, and a
"0" for sleeping pills for symptoms 3 and 4. She would also receive a ”1” for
tranquilizers for symptom 3, and ”0’s" for tranquilizers for symptoms 1, 2, and
4. Each strategy checked for each symptom was counted as a "1." To obtain a
scale score for symptom management for each category, the number of ones
was added up for all of the items in each category, and divided by the number
of strategies listed in that category. This total was then divided by the number
of symptoms that were listed to obtain a mean number of strategies per

38
symptom score. The purpose was to make the measure equivalent across
strategy scales and subjects. See appendix H for equation and example.
Cronbach’s alpha coefficient of internal consistency for the Medications scale
was .4244. For the Diet scale, alpha = .8155. The alpha coefficient for the
Vitamin/ Minerals scale was .9185. The alpha coefficient for the Other scale
was .8429.

Menopause Information. This instrument was a 21 item questionnaire
designed to assess the respondent's knowledge about the physiology of
menopause and related issues. Its general intent was to assess knowledge of
factual information. Each item answered correctly was counted as a one and
the total score was tabulated as a measure of overall knowledge. One item for
which the correct answer was not dear-cut was excluded from the analysis
resulting in 20 possible points. Cronbach’s alpha coefficient of internal consis-
tency was .7721. See appendix I for answer key.

ludgment Cases. The Judgment Cases instrument was a series of 32 (16
replicated) systematically designed cases which presented three factors related
to the decision to take ERT. The factors represented in one of two levels were:
hot flashes (severe or minimal); risk of endometrial cancer (standard or high);
and risk of osteoporosis (standard or high). The factors were selected based on
the literature and interviews with nurses, physicians and women. All possible
combinations of the factors were included which resulted in eight cases. The
eight cases were randomly ordered and then replicated for a total of 16 cases in
each of two separately ordered sets. In the first set of cases the women were

asked how likely they would be to take estrogen replacement therapy

39
unopposed by progestogen and in the second set the women were asked to
indicate how likely they would be to take estrogen combined with progestin.
Each set of cases was preceded by an information sheet describing major risks
and benefits of the treatment and by two practice cases to help control for any
practice effect. The cases were orthogonally designed creating statistical
independence of the factors. The respondent was instructed to indicate
likelihood of taking hormone therapy on a scale of 1 to 5, from very certain she
would NOT take hormone therapy in that situation (1) to very certain that she
WOULD take hormone therapy (5), with (3) indicating may or may not take
hormone therapy. Probably would NOT and Probably WOULD take hormone
therapy are coded (2) and (4), respectively. Likelihood of taking estrogen was
computed by adding up the numbers (1-5) indicated by the respondent, as to
likelihood of taking hormone therapy. Cronbach’s alpha coefficient of internal
consistency was .9641 for the Average Likelihood of Taking Hormone Therapy
scale.
Procedure
Subject recruitment
Subjects were recruited from churches, synagogues, local women's
organizations, and through media requests for study participants (See
appendix J). When requesting participants through organizations, a contact
letter (see appendix K) was sent to the individual responsible for the group,
such as the clergyperson of a church or the president of an organization. The
letter described the study and requested an opportunity to come to a group

meeting and ask for volunteers to complete the questionnaires. The letter

40

indicated that a follow-up telephone call would be made to learn whether any
women from the organization would be interested in participating in the study
or whether the organization would be interested in hosting a session to
complete questionnaires and participate in the question and answer period
about menopause. During the telephone contact the study was described
further, and any questions answered. If there were women in the organization
who were interested in participating in the study but too few to schedule a
separate session for the organization, the women were contacted individually
and scheduled for a session already scheduled elsewhere. If the organization
was interested in the study, the contact person was provided with participant
sign-up sheets to distribute (see appendix L) and examples for newsletter and
bulletin board announcements (see appendix M). If the organization was
interested in hosting a session, a time and date were set and a letter confirming
the appointment was sent to the contact person. Organizations were told that if
they hosted a session to complete questionnaires, all women in the group were
welcome to participate in the question and answer discussion with the nurse
following the questionnaire period, even if they did not meet the criteria for
participation in the study. Women who were scheduled individually for
sessions were sent letters confirming their appointment. If additional
information regarding the study was requested, a packet of informational
materials (see appendix N) was sent to the contact person or individual.
Data Collection

Data was collected by having the women complete the written

questionnaires at data collection sessions conducted by the researcher. Each

41

data collection session began with an introduction to the study and a
description of its purpose (see appendix A). Verbal instructions for completing
the questionnaires briefly reviewed the written instructions included with each
instrument. Participants were informed that participation in the study was
completely voluntary and that they could terminate participation at any time.
The participants were encouraged to ask questions regarding the instructions if
needed while completing the instruments. They were also encouraged to
answer all questions and to indicate if they chose not to answer a particular
question so that it was clear that they had not inadvertently missed the item.

The women then signed the informed consent form (see appendix 0) and
completed the questionnaires. The instruments were completed in the
following order for most of the participants: Consent form (appendix 0),
Introduction sheet/ Results Request Form (appendix P), Sociodemographic
instrument (appendix B), Perceptions of Menopause instrument (appendix C),
Menopausal Symptoms instrument (appendix C), Symptoms Management
instrument (appendix D), Menopause Information instrument (appendix E),
Judgment Cases instrument (appendix F). Forty-nine participants completed
the Judgment Cases instrument following the Introduction sheet/ Results
Request Form and before the Sociodemographic instrument. The order of the
other instruments remained the same. The purpose in completing the
Judgment Cases before the other instruments was to determine whether there
were any instrument order effects on the Cases instrument. The importance
rank of hot flashes, osteoporosis risk and cancer risk was found to be the same

for those who completed the cases first as for those who completed them last.

42
No order effects were detected. Completion of the instruments took 45 minutes
to 1 1 / 2 hours for most women. Further instructions regarding specific
instruments were clarified to the group at intervals during the questionnaire
period.

After the women had completed all of the instruments they were invited to
join a question and answer discussion group lead by a member of the faculty of
the College of Nursing. The nurse answered questions raised by the
questionnaires and other concerns expressed by the women. The question and
answer group served as a debriefing period and attendance was voluntary but
almost all women participated in the discussions.

Following the data collection, each participant was sent a thank you letter.
Contact persons and organization leaders were also sent thank you letters

where appropriate. See appendix Q for example letters.

Chapter 3
£21.15.

The purpose of this study was to determine the correlates of level of
perceived control over the menopause experience. The data collected from the
six questionnaires described in the methods section was used to explore nine
hypotheses regarding the relationship of sociodemographics such as marital
status, employment status, and household income, and reported behavioral
and experiential characteristics such as symptomotolgy, knowledge about
menopause and symptom management behaviors, to level of perceived control.
Evaluep’on pf Hymthegs

Hymthesis 1. Null hypothesis I predicted that the sociodemographics
marital status, employment status, household income, and educational level
would not differentiate between individuals who were higher in perceived
control and those who were lower.

A one-way analysis of variance was performed to determine whether there
was a significant difference in marital status between those who were higher in
perceived control and those who were lower. There were no significant
differences in perceived control over the menopause experience between
women who were married, divorced, single, widowed, or separated, p>.05.

An Analysis of Variance was performed to determine the relationship
between employment status and perceived control over the menopause
experience. There were no significant differences in perceived control over the
menopause experience between women who were employed full-time,

employed part-time, retired, or not employed, p > .05.

43

44

The Pearson Correlation Coefficient was computed to determine whether
yearly household income correlated significantly with perceived control over
the menopause experience. A 2-tailed significance test showed that the
correlation between income and perceived control, was not significant at the .05
significance level.

The Pearson Correlation Coefficient was computed to determine whether
there was a relationship between educational level and perceived control over
the menopause experience. The correlation between educational level and
perceived control was found to be 1; = .1267, (p< .05, 2-tailed). The positive
correlation found indicated that more highly educated women perceived
greater control over the experience of menopause. The relationship was no
longer significant at below the .05 level however, when the group ”Other” (N =
5) was excluded. ”Other” included "beauty school,” ”registered med. tech.,"
”Associate degree in business and legal assistant,” and ”certified
graphoanalyst.” The hypothesis regarding educational level and control could
not be rejected at the .05 significance level. The means for each group are

shown in Table 5.

45

 

 

Table 5

Education and Mean Score on Perceived Control

Educational Level N Mean SD.
Less than 12 Years 4 24.00 2.45
High School Graduate 61 23.69 3.04
More than 12 Years / No Degree 67 24.34 3.40
Technical/ Community College Degree 16 23.70 2.71
Bachelor’ 5 Degree 67 24.51 3.06
Master's Degree 41 24.85 2.82
Ph.D. or Professional Degree 8 24.75 2.82
Other 5 25.60 2.07
Total 269 24.31 3.06

 

Since no significant correlations were found for demographic variables , Null
Hypothesis 1 could not be rejected.

Hymthesis 2 . Null hypothesis 2 predicted that individuals who indicated
a religious preference would not differ in perceived control from individuals
who did not.

An Analysis of Variance was performed to determine whether there was a
significant relationship between religion and perceived control over the
menopause experience. There was no significant difference in perceived
control between those who indicated no religion, Jewish, Protestant, Catholic,
or Other, 2) .05. Null hypothesis 2 was not rejected.

Hmthesis 3. Null hypothesis 3 predicted that individuals categorized as
menopausal according to question 13 on the sociodemographic instrument (last

menstrual period) would not differ in perceived control from individuals

46
categorized as premenopausal according to the same question. Table 6 shows
the means and standard deviations on the perceived control scale by last
period. A higher mean on the Control scale indicated greater or more internal
perceived control.

A one-way Analysis of Variance was performed to determined whether
menopausal women differed in perceived control over the menopause
experience from premenopausal women. As Table 6 shows, the omnibus F-test
for perceived control by menopausal status was statistically significant, 113,
263) = 4.9242, 2 < .05.

The Scheffe multiple range test indicated that the pair ”Still have regular
periods” and ”Last period 3 to 12 months ago” were significantly different at
beyond the .05 level. Women whose periods were still regular scored higher
(more internal) on perceived control over menopause than women whose last
period was 3-12 months ago. Figure 2 shows the mean and one standard
deviation for each of the four groups compared. An estimate of treatment
effect size ((02) was calculated (see appendix R) and found to be .042 which
indicated that Last Menstrual Period accounted for approximately 4.2% of the
variance in Perceived Control. Since the omnibus F-test as well as the Scheffe
multiple range test indicated that 2 groups differed significantly from each
other, null hypothesis 3 was rejected.

47

 

 

 

Table 6
umma a" frPriv n In Mns lPri

Last Menstrual Period N Mean SD.
Still Regular 140 24.91 2.93
Less than 3 mos. ago 34 24.29 3.22
3 to 12 mos. ago 35 22.89 3.34
12 or more mos. ago 58 23.90 2.67
Total 267 24.35 3.04

...........
.......................................

Analysis of Variance

 

Source D.F. Sum of Squares Mean Square F-Ratio F-Prob. a)

 

Between

Groups 3 130.5258 43.5086 4.924 .0024 .042
Within

Groups 263 2323.7738 8.8356

Total 266 2454.2996

 

Figure 2

Mean Perceived Control

28.0 _
27.0 _
26.0 _
25.0

24.0 _
23.0 _
22.0 _
21.0 _
20.0 _
19.0 -
18.0

Mean Perceived Control By Last Period

' (24.9)

 

1

 

(24.3)

1

 

(22.9)

‘ (23.9)

 

 

 

sun Regular

LessThan 3
Mos. Ago

:1 to 12
Mos. Ago

Last Menstrual Period

Mdre Than
12 Mos. Ago

49

Hmtheses 4 Q _5_. Null hypothesis 4 predicted that individuals who
indicated experiencing or expecting more symptoms on the symptoms
instrument would not differ in perceived control over the menopause
experience from women who indicated fewer symptoms. Null hypothesis 5
predicted that women who indicated experiencing or expecting more severe
symptoms on the symptoms instrument would not differ in perceived control
from those who indicated less severe symptoms. The total symptom score,
tabulated for each individual by summing the severity scores for all of the
symptoms, reflected both severity and number of symptoms reported. Severity
and number of symptoms were combined to provide a more complete picture
of the women’s responses. Simply counting the number of symptoms would
not have described the severity of the symptoms experienced by the woman,
and dividing the total symptom severity score by number of symptoms to
obtain a measure of severity per symptom was also thought to be a less useful
measure of symptomatology. The Pearson Correlation Coefficient was
computed to determine whether women who had a higher total symptoms
expected score were lower in perceived control over the menopause experience
than women who had a lower total symptoms expected score. Perceived
control was found to correlate -.3530 with the total symptoms expected score, 2
< .05, 2-tailed. Correcting the correlation for unreliability in the measures (see
Appendix S) increased the correlation to -.4471. This indicated that women
who reported expecting fewer symptoms perceived greater (more internal)
control relating to menopause than women who reported expecting more

symptoms. Null hypothesis 4 was rejected.

50

The Pearson Correlation Coefficient was also computed for women who
reported experiencing symptoms due to menopause (N = 207) to determine
whether women who had a higher total symptoms experienced score were
lower in perceived control over the menopause experience than women who
had a higher total symptoms experienced score. Perceived control was found
to correlate -.2353 with the total symptom score, 3 < .05, 2-tailed. The
correlation corrected for unreliability (see Appendix 5) was -.2980. This
indicated that women who reported experiencing fewer symptoms due to
menopause perceived greater (more internal) perceived control relating to
menopause than women who reported experiencing more symptoms. Null
hypothesis 5 was rejected.

Hmthesis 6. Null hypothesis 6 predicted that women who had a higher
mean for symptom management behaviors on the symptom management
instrument would not differ in perceived control over the menopause
experience from women who had a lower mean. The Pearson Correlation
Coefficient was computed for Control with Total Management Strategies.
There was no significant relationship between total management strategies
reported and perceived control (p > .05, 2-tailed). Null hypothesis 6 could not
be rejected.

Hmthesis 7. Null hypothesis 7 predicted that women who were higher in
perceived control would not differ in the symptom management strategies
used from women who were lower in perceived control. The means and
standard deviations on the perceived control scale for each management

strategy category are shown in Table 7.

51

Table 7
Summag Statistics for Smptom Management and Perceived Control

 

 

Management
War N Mean" SD. Pearson r P
Medications 205 .02 .02 -.0982 N .5.
Diet 204 .06 .08 .0673 NS.
Vitamins 205 .04 .10 -.0440 NS.
Other 205 .11 .12 .1930 .006

*Mean # of strategies per symptom per category

 

Pearson Correlation Coefficients were computed for each management
category with perceived control. Table 7 shows the correlations and 2-tailed
significance level for each category.

For the Medications category (see Table 8 for items), the Pearson
Correlation Coefficient shown in Table 7 indicated that there was no significant
difference in perceived control relating to menopause between women who
utilized more versus fewer medications to manage menopausal symptoms.

Table 8 shows each item listed under the symptom management category
Medications and the frequency (f) with which the item was checked. The
frequency indicates the total number of times the strategy was indicated. As
described previously, the Management instrument asked women to indicate
which strategies they used to manage their 5 most bothersome menopausal
symptoms. The women wrote each of their 5 symptoms in spaces on the .

instrument. Each participant could check each strategy from zero to five times.

52
If she did not use a given strategy for any of her top five most bothersome
symptoms, she would not check the item at all. If she reported that she used
the strategy for all 5 of her most bothersome symptoms, then she would have

Table 8
Medication Strategies and Frequencies

 

m

trae

Sleeping Pills
Tranquilizers

Blood Pressure Pills
Estrogen Alone

Progestin Alone
Estrogen and Progestin Combined
Pain Relievers

Sodium Fluoride Pills
Vaginal Lubricant
Estrogen Creams-Vaginal
Other

IFIO‘VUF

\0

OJ
IU'INOI

01
N

Total 200

 

checked the item 5 times. In Table 8 above, if a strategy has a frequency of
’5’,the number listed under '1’ could indicate that 5 women each used the
strategy for 1 symptom each, or that one woman used the strategy for all five of
her listed symptoms. The range possible for ’f’ for each strategy was therefore
0 (if not one woman used the strategy for any of her symptoms) up to NQ‘, ST)
where N was the number of women (205) and EST was the total number of
symptoms listed on the Management Instrument by all of the women (between

0 and 5 for each woman). For clarification of how the scale was scored see

53
appendix H. The estrogen and estrogen / progestin items were used only to
screen participants, since only women who were not presently taking ERT were
included in the study. The ”Other Medications" category included strategies
written in by participants such as Bellergal, Norpramin, Tagamet, and P.M.S
Tabs.

The Pearson Correlation Coefficient shown in Table 7 indicated that there
was no significant difference on perceived control between women utilizing
more versus fewer Diet strategies. Table 9 shows the strategy items listed
under the category Diet, and the total number of times each strategy was
checked. See discussion for Table 8 for explanation of frequency information.

Table 9
Diet Strategies and Frequencies

 

 

amiss)! f

Low Calorie ' 68
Low Fat 55
Low Salt 1 13
Low Cholesterol 42
High Calcium 46
Avoid Caffeine Products 144
Avoid Spicy Foods 17
Other 26
Total 511

 

The Pearson Correlation Coefficient shown in Table 7 indicated that women

who utilized more versus fewer strategies listed under the Vitamins and

54
Minerals category did not differ from each other in perceived control relating to
menopause. Table 10 shows the strategy items listed under the category
Vitamins and Minerals, and the total number of times each strategy was
checked. See discussion for Table 8 for explanation of frequency (f)
information.

The Pearson Correlation Coefficient shown in Table 7 was significant and
indicated that women who utilized more strategies listed'under the ”Other”
category perceived greater (more internal) control relating to menopause than
did women who utilized fewer ”Other” strategies. The significant correlation
increased to .2592 when corrected for unreliability in the measures (see
Appendix S). Table 11 shows the strategy items listed under the category
”Other” and the total number of times each strategy was checked. See

discussion for Table 8 for explanation of frequency (f) information.

55

Table 10
Vitamins and Minerals Strategies and Frequencies

 

 

 

Strategy f
Calcium Supplements 61
Vitamin E 45
Vitamin C 28
Vitamin D 13
Multivitamin 86
Iron 32
Other 37
Total 302
Table 1 1

”Other” Strategies and Frequencies

 

 

 

Strategy f

Walking 237
Exercising 210
Relaxation Techniques 135
Douche 7
Skin Creams 12
Keep Diary 32
Talk With Others 175
See Health Professional 167
Other 34

Total 1009

 

56

Hymthesis 8. Null hypothesis 8 predicted that women who were higher in
perceived control would not differ in score on overall knowledge regarding
menopause from women who were lower in perceived control. A Pearson
Correlation Coefficient was computed to determine whether the relationship
between knowledge and perceived control was significant. The correlation
between perceived control and total score on the Knowledge instrument was _i;
= .2365, _(p < .05, 2-tailed). The correlation corrected for unreliability (see
Appendix 5) was .3318. The null hypothesis was rejected. Women who scored
higher on the Knowledge instrument perceived greater (more internal) control
relating to menopause than women who scored lower.

Hymthesis 9. Null hypothesis 9 predicted that mean likelihood of taking
estrogen replacement therapy would not differentiate between individuals who
were high in perceived control and those who were low in perceived control.
The Pearson Correlation Coefficient was computed to determine whether there
was a relationship between likelihood of taking estrogen replacement therapy
and perceived control. Control was correlated .1271, (p < .05), with likelihood
of taking hormone replacement therapy. Corrected for unreliability (see
Appendix S), the correlation was .1596. Null hypothesis 9 was rejected.
Women who perceived greater (more internal) control relating to menopause
were more likely to take hormone therapy than women who perceived less
control.

Additional Analyses
In order to more completely examine the relationship of the variables

discussed above to perceived control, a stepwise regression analysis was

57
performed. The independent variables included in the analysis were Total
Symptom Severity Score, Average Likelihood of Taking Hormones, Knowledge
Score, Income, Education, Employment, Marital Status, and Last Menstrual
Period. The four symptom management strategy categories were not included
in the regression analysis because there was data only for women who reported
experiencing symptoms. Three variables entered the regression equation at or
below the .05 significance level. Total Symptom Severity Score entered the
equation first B= .2548; 32 change = .0649;£ change = 17.14, p < .0001). Last
Menstrual Period entered the equation second B= .3012; 18 change: .0258;£
change = 6.98, p = .0088) and Knowledge Score entered third Q: .3424; 32
change = .0265; F change = 7.36, p = .0071). To understand why only three
variables out of eight entered the regression equation the intercorrelations
between the variables were studied. Table 12 shows the Pearson Correlation
Coefficients and significance levels for the variables included in the regression

equation.

58

 

Table 12
Pear on rrel ' n ffi 'entM '

0—1 0 o

g a 8 E E '8 E 18

5 m m g 5 E3 {:1 2 a:
Cntrol 1.00 -.2699* .1271* .2365‘ -0442 .1267* -.0879 -.0334 -.1820*
Sym. 1.00 -.0752 -.0984 -.1171 -.1302* -.0055 -0314 -0359
ERT 1.00 2246* .0572* .1366‘ -.0656 .0316 -.1685‘
Know. 1.00 .1235* .2783‘ .0069 -.0248 .0304
Income 1.00 2293* -.0249 -.3502* -.0096
Educ 1.00 -.0782 .1039 -.1533‘
Empl. 1.00 -.1851‘ .1547‘
Marital 1.00 -.0617
Period 1.00

‘p< .05

 

Although most of the correlations were small in magnitude, some of them were

statistically significant. Education, for example was significantly correlated

with each of the other variables and highly significantly correlated (p< .001)

with the variable Knowledge, which had already entered the regression

equation. Likelihood of Taking Hormone Therapy was also highly significantly

correlated with the variable Knowledge and with the variable Last Menstrual

Period, both of which were already in the regression equation. The 3 variables

which entered the regression equation, Symptoms, Last Period and Knowledge

accounted for 12% of the variance in Perceived Control relating to menopause.

59

The variables relating to the Symptom Management instrument were not
included in the regression analysis nor in the correlation matrix because there
was data for these variables only for women who indicated that they were
experiencing symptoms due to menopause (N =207).

Other Management Strategies (”Other") was significantly correlated with
Knowledge score (1 = .25, p <.05), Education (L = .18, ,p_<.05) and Last Menstrual
Period (L = -.24, p <.05). A first order partial correlation controlling for Total
Symptom score increased the correlation between ”Other” and Control to _r; =
.29 (p < .05). First order partial correlations controlling for Knowledge,
Education, and Last Period each decreased the correlation between ”Other”
and Control slightly but the correlation remained statistically significant at
below the .05 level in each case. A partial correlation which simultaneously
controlled for Likelihood of Taking ERT, Knowledge score, Education, Total
Symptom score and Last Period increased the correlation between ”Other” and
Control to _r; = .23 (N =193, p_< .05).

First order partial correlations indicated that the correlation between
control and education was due to the correlation between education and the
variables Total Symptom Score, Likelihood of Taking Estrogen Therapy,
Knowledge score and Income. In order to examine the effect of Total
Symptom Score, Likelihood of Taking ERT, Knowledge score or Income on the
correlation between education and control, first order partial correlation
analyses were conducted. When first order partial correlations were computed
which controlled for Total Symptom Score, Likelihood of Taking ERT,

Knowledge score or Income the correlation between education and control

60
dropped to below .05 in each case and did not attain statistical significance.

When a first order partial correlation was computed which controlled for
Knowledge score the correlation between Control and Likelihood of Taking
ERT no longer attained statistical significance. First order partial correlations
which controlled for Education or Last Menstrual Period, resulted in
correlations of L = .12 (p<.05) and _r; = .11 (p< .05), respectively. When Last
Period, Knowledge score and Education were all partialled out (in that order)
the correlation between control and Likelihood of Taking ERT was no longer
statistically significant.

Partialling out the influence of Education (N =266) on the correlation
between Control and Knowledge score decreased the correlation observed only
slightly (from r = .24 to _1'. =21). The correlation was still significant at below the
.05 level. First order partial correlations controlling for Likelihood of Taking
Estrogen (N =249), and for Income (N =249) resulted in correlations of r = .16 (p_
< .05) and L = .20 (g < .05), respectively. Partialling out Likelihood of Taking,
Income and Education (in that order) resulted in a correlation of L = .16 (N =247;
p_< .05). The number of cases included in the third order partial correlation
analysis was 247, down from 266 when only Control, Knowledge and
Education were included in the analysis. Any case for which data was missing
for any one of the five variables in the third order analysis was eliminated.

Partialling out the influence of the variables Likelihood of Taking ERT,
Employment and Education decreased the correlation between Control and
Last Menstrual period from _r; = -.18 (N = 261; p< .05) to _r; = -.14 (N = 258; p =
.05).

61

A first order partial correlation controlling for Education only decreased the
correlation between Control and Total Symptom Score from ,r; = -.27 (N = 267; 2
< .05) to _r; = -.26 (N=266; p< .05).

mma

Of the 9 null hypotheses, 6 were rejected. Null hypotheses 1 and 2 could
not be rejected. The sociodemographic variables marital status, employment
status, income, education and religion were not significantly correlated with
perceived control relating to menopause. Sociodemographics did not predict
degree of perceived control rtelating to menopause.

Null hypothesis 3, which stated that there would be no relationship
between control relating to menopause and menopausal status as measured by
time since last menstrual period was rejected. The pair Still Regular Periods
and 3-12 Months Ago were significantly different at below the .05 level of
significance. Women whose periods were still regular perceived more internal
control relating to menopause than did women whose last period had been 3-
12 months ago.

Null hypotheses 4 and 5, that there would be no relationship between
perceived control and symptoms expected (hypothesis 4) or experienced
(hypothesis 5) were both rejected. Women who reported expecting or
experiencing more symptoms due to menopause perceived less control relating
to menopause than did those who reported fewer symptoms.

Null hypothesis 6 was not rejected. There was no significant relationship
between perceived control and number of symptom management strategies

reported.

62

Null hypothesis 7, which stated that women who differed in the category
(type) of symptom management strategies utilized would not differ in
perceived control relating to menopause, was rejected. Women who utilized
symptom management strategies categorized under ”Other” perceived
significantly greater control relating to menopause than did women who did
not.

Null hypothesis 8, that perceived control would not be related to
Knowledge score was rejected. Women who scored higher on the Knowledge
instrument perceived more control relating to menopause than did women
who scored lower.

Null hypothesis 9 was also rejected. Women who indicated a greater
likelihood of taking hormone therapy perceived greater control relating to
menopause than did women who indicated a lower likelihood. The observed
relationship between Control and Likelihood of taking ERT appeared to be
primarily due to differences in Knowledge score. A partial correlation
controlling for Knowledge score showed that the correlation between Control
and Likelihood of Taking ERT fell to less than .10 and was no longer
statistically significant at below the .05 level.

Women who expected or experienced fewer symptoms due to menopause,
who were still having regular menstrual periods, who scored more highly on
the Knowledge instrument and who utilized more symptom management
strategies categorized as ”Other" perceived more internal control relating to

menopause.

Chapter 4
Discussion

The purpose of the study was to determine whether there were significant
correlates of perceived control over the experience of menopause. Of particular
interest was examining the correlates of perceived control in light of their
application to designing an educational intervention for menopausal women to
help them in their decision making regarding estrogen and menopause. The
goal was to apply the knowledge to tailor the intervention to meet the needs of
women with different levels of perceived control over their menopausal
experience. Based on literature such as Duffy (1988) who found that health
locus of control accounted for 16% of the variance observed in health
promotion lifestyle among middle years women, the assumption was made
that control was an important variable in health-related behavior and that an
intervention tailored to the level of control a woman perceived to have over her
experience would be more successful in meeting the needs of that woman.

Self—administered questionnaires were used to gather information about
women’s sociodemographic characteristics, perceptions of menopause,
symptomatology, symptom management behaviors, knowledge of menopause
and decision making regarding estrogen replacement therapy. These variables
were then correlated with perceived control to form the basis of conclusions
about menopause and perceived control.

The finding that Control was not related to sociodemographics supported
previous research on locus of control and demographics (Lind, 1984; Lewis,

Morisky, & Flynn, 1978). The finding that religion was not related to perceived

63

64
control over the experience of menopause supported the study by Berrenberg
(1987) which found that God-mediated control differed from internal and
external personal control. The finding that women whose last menstrual
period was 3-12 months ago scored lower (more external) on perceived control
relating to menopause suggested that women who were in the perimenopause
perceived less internal control relating to menopause than women who were
premenopausal. This supported the findings of Littlefield 8: Adams (1987) who
found that experience influenced locus of control. Since this was a cross-
sectional sample it was impossible to conclude whether women perceived less
internal control relating to menopause due to their menopausal status (i.e.,
their locus of control changed as they began to actually experience the
menstrual changes related to menopause) or whether some other variable
accounted for the difference in perceived control observed between
perimenopausal women and premenopausal or postmenopausal women. A
longitudinal study of women as they progress from premenopause through the
perimenopause to postmenopause would be needed to clarify the relationship
observed.

It was unknown why the group ”Less Than 3 Months Ago” did not differ
significantly in perceived control from the group ”Still Regular Periods” when
the group ”3 to 12 Months Ago” did differ. The ”Less Than 3 Months Ago”
group conceivably included women who were not yet in menopause, but had
missed a period for other reasons (pregnancy, normal fluctuation in menstrual
cycle, etc). It was less likely that the reported change in periods for women in
the ”3 to 12 Months Ago” group was due to factors other than menopause since

64

65
more time had elapsed since the last period so women in this group were
perhaps more likely to actually be perimenopausal.

The finding that a higher symptom severity score was correlated negatively
with internal perceived control over menopause must be interpreted keeping in
mind that the direction of causation was unknown and that the data was
obtained from a cross-sectional sample. It was conceivable that women
experiencing more symptoms perceived less internal control relating to
menopause. It was also possible that those who perceived less internal control
reported more symptoms. The relationship observed may have been due to
variation in a variable other than expected or experienced symptoms since the
groups differed in other variables in addition to symptoms indicated. The
results supported the findings of Lind (1984) however, who found that internal
non-users of estrogen reported the fewest symptoms due to menopause and
that external non-users of estrogen reported the most symptoms.

Women who engaged in the general, health-conscious preventive strategies
listed under the ”Other” category perceived greater control over their
menopause than women who utilized fewer strategies listed under ”Other.”
This finding coincided with Duffy (1988) who found that women who scored
high on internal health locus of control and low on chance health locus of
control had high scores on nutrition and exercise.

The finding that women who were higher in perceived control had a higher
score on overall knowledge regarding menopause supported the findings of
Wallston and Wallston (1978) who reviewed five studies of health locus of

control and health knowledge or inforrnation—seeking and found that across

66
studies, individuals who were more internal on locus of control had more
knowledge regarding their illness or sought more knowledge than more
external individuals.

Again, it is important to note here that this research was correlational in
nature leaving not only the direction of causality unknown, but also leaving
open the possibility that the results could have been due to variation in a third
factor.

' The finding that perceived control and likelihood of taking ERT were
correlated indicated that women who perceived greater control over
menopause were more likely to take hormone therapy, possibly because the
action would relieve the symptoms of menopause and prevent osteoporosis.
The review of health locus of control literature by Wallston and Wallston (1978)
found that individuals who were more internal in health locus of control were
more likely to engage in behaviors that facilitated physical well-being.

A partial correlation controlling for Knowledge score showed that the
relationship between likelihood of Taking ERT and Control was due to the
correlation between Knowledge and Likelihood of Taking ERT Q = .23; p < .05).
The relationship observed between control, health knowledge and health
behavior suggested a path by which Control may be related to Likelihood of
Taking ERT. As before however, it should be noted that the correlational
nature of this study and the results of the partial correlation analysis prevented
conclusions regarding the presence of a direct causal relationship between

control and taking ERT.

67

Finally, the low to moderate correlations found and the fact that only three
of the variables which were significantly correlated with perceived control
entered the regression equation must be addressed. In previous studies of the
relationship between control and health-related behaviors, control consistently
emerged as a useful but weak predictor of health behavior (Lau, 1982;
Strickland, 1978). The findings of this study supported this general conclusion.
The relationship between control and the variables studied was small to
moderate, with the strongest relationship observed between control and
symptoms experienced or expected. It should be noted that several items on
the perceived control scale directly related to the symptoms of menopause,
which may have accounted for the strong correlation between the scale and
reported symptoms. In defense of including such items however, the data
indicated that women perceived menopause as defined by symptoms, not
necessarily by a change in their menstrual periods. Women who had not
experienced a change in their menstrual periods indicated that they were
experiencing symptoms they attributed to menopause. These findings
suggested that some women defined menopause according to the experience of
symptoms rather than change in periods.

While the relationship between last menstrual period and report of
experiencing symptoms due to menopause was correlated -.34 (p_ < .05), 33% of
those women whose periods were still regular reported that they were
experiencing symptoms which they attributed to menopause, and 38% indicat-
ed that they did not know if they were experiencing symptoms due to

menopause. Only about one third of the women indicated that they were not

68
experiencing symptoms they attributed to menopause.

In conclusion, several significant predictors of perceived control over the
experience of menopause were identified. The magnitude of the relationships
varied from L =.13 to L = -.27. The relationships identified have implications for
developing an educational program for women about menopause but caution
must be exercised in applying these findings due to their small magnitude and
correlational nature. The finding that perceived control relating to menopause
was a significant, though small aspect of the women’s experience of and
response to menopause indicated that an intervention addressing women’s
needs during menopause should be designed to be sensitive to the variation in
perceived control among women. Women with different levels of perceived
control may be experiencing or expressing different degrees of symptomatolo-
gy, may present with differing levels of knowledge and may be using different
strategies to manage symptoms. Most importantly they may approach their
menopausal health care differently and desire grater or lesser degrees of
participation in their menopausal health care decisions. It will be important to
measure perceived control preintervention and postintervention but the small
magnitude of the relationships observed in this study indicated that it should
not be expected that perceived control will be a major influencing factor in an
intervention addressing the needs of menopausal women.

m

The major limitations of this study included that the participants were self-

selected, that the data were cross-sectional rather than longitudinal and that the

correlational nature of the research prevented conclusions regarding causation.

69
Since the participants were self-selected, it was not known to what extent the
results could be generalized to another sample with similar sociodemograpic
characteristics, or to the population of women as a whole. Since the study was
cross-sectional in nature, it could not be determined whether the results
obtained were due to developmental factors. Finally since none of the variables
was manipulated experimentally, the direction and nature of causality was
unknown. An additional limitation was that the variables studied were all
measured through self-report. No concrete behavioral data was gathered
limiting the accuracy of the study to the accuracy of the self-reports. The
reliability of the control scale (r = .65) was weak, which attenuated the
treatment effects, contributing to the low correlations observed.
Future Directions
A longitudinal study examining women’s perceptions relating to
menopause within women and across menopausal status would clarify the role
of experience in perceptions of menopause. In addition, an experimental study
which manipulated knowledge relating to menopause would illuminate the
relationship between knowledge and perceived control relating to menopause.
Finally, applying the findings of this study to an educational intervention for
perimenopausal women in which perceived control was monitored across time
would clarify whether perceived control relating to menopause was useful in
understanding women's concerns regarding menopause and how they may be
best addressed. As described earlier, the low correlations between control and
the independent variables indicated that control was not a major influencing

factor for the women in regard to their menopausal experience. The correlation

70
between control and symptoms expected or experienced indicated that
perceived control may influence the experience or expression of symptoms (or
expectations regarding symptoms) or that those who experience or expect more
symptoms perceived less internal control relating to menopause. This finding,
combined with the finding that women whose periods were still regular
perceived more control relating to menopause than did women experiencing a
change in their periods, may have indicated that some women might desire an
intervention which provided information on issues relating to menopause as a
means of returning to a sense of internal control over their menopausal
experience. As pointed out earlier however, the findings of this study
indicated that variables other than control influenced the women's experience
of menopause and that it should not be expected that perceived control relating
to menopause would be influenced in any significant way by such an
intervention. An understanding of what factors influenced women’s
experience of menopause must be pursued through examining factors other
than control. Factors such as symptomatology experienced premenopausally
and perimenopausally and knowledge and attitudes about menopause may
provide more useful insights that further study of perceived control and

menopause.

LIST OF REFERENCES

71

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APPENDICES

APPENDIX A

79
APPENDIX A

Instructions to Participants

(Paraphrased)

Hello and welcome to the estrogen replacement therapy study. The purpose of
this study is to learn about what is important to women in making the decision
whether or not to take estrogen replacement therapy. We are asking women
who are between 45 and 55 years old, not presently taking estrogen, and who
have not had a hysterectomy to participate in the study. Even if you don’t
qualify to participate in the study you are welcome to look over the
questionnaires if you wish, and attend the question and answer period with the

nurse after the questionnaire session.

It will take approximately an hour to an hour and a half to complete the
questionnaires. When you are finished we will begin the question and answer

period.

Please complete the consent form on top of the packet. If you have any
questions please feel free to ask me at any time. Sometimes our instructions
aren’t as clear as they seem to us so please feel free to ask me to clarify them. If
you do not wish to answer a particular question, just indicate that you saw the
question but do not wish to answer it, by putting a mark or something by the

question. That way we will know that you did not just accidentally miss the

80
question. You do not have to answer any questions you do not wish to, but of
course the more questions you answer, the more information we get about

what is important to you about this issue.

Please complete the questionnaires in order. I will give additional instructions
later for some of the questionnaires. If you have any questions just let me

know.

-Later-
I’d like to clarify the instructions for the Symptoms instrument which is the
questionnaire with the green and yellow pages. If you are currently experienc-
ing symptoms which mbelieve are due to menopause, or have experienced
symptoms in the past, answer ”yes" to question A. If you have not experienced

I!

symptoms which you believe are due to menopause, answer ”no. If you an-
swered ”yes" to question A, complete the green pages, if you answered ”no,”
complete the yellow pages. On the green or yellow pages is a list of 56 symp-
toms. Not all women experience all or even most of these symptoms. This is a
very comprehensive list. If you are answering the green pages, indicate only
those symptoms which ygppersonally have experienced which yopbelieve
are due to menopause. If you have not experienced a symptom, leave it blank
If you have experienced a symptom but you believe it is due to something else,
leave it blank. We are interested in mopinion. If you are completing the
yellow pages, indicate only those symptoms which you expegto experience
due to menopause. If you do not expect to experience a symptom leave the

81
symptom blank. If you expect to experience a symptom, but believe it will be
due to something else, leave it blank. After you have checked each of the
symptoms and indicated how much it does or will bother you, go back and
rank the five symptoms which bother you the most, with 1 as the symptom
which is most bothersome and 5 as the 5th most bothersome symptom. If you

have any questions please don’t hesitate to ask.

-At the End-
I want to thank you all for helping us with this study. Thank you very much.
If you know of anyone who would be interested in participating in the study,

please have them give me a call, or I can call them.

APPENDIX B

12

TI

rev. h/l7/7

 

 

82
APPENDIX B s I u _____ ( “2;
° ° Pt. IO _____ (3-5
Socrodemographrc Instrument DATE ------ (6'1 I )
ERT STUDY

SOCIODEMOGRAPHIC

The following questions ask you to give some background Information about

yourself.
results.

This information will help us to understand and interpret the study's
The information will be kept completely confidential. Please answer

each question.

T3

1.

How old are you? YEARS.

(HRITE iN)

What is your present marital status? (CHECK ONE)

1. MARRIED

2. DIVORCED

3. SINGLE (never married)
1!. HIDOHED

5. SEPARATED

What is your principal employment status? (This question refers to
work which ypp are paid to do.) (CHECK ONE)

1. EMPLOYED FULL-TIME
2. EMPLOYED PART-TIME
3. RETIRED
0. NOT EMPLOYED

5. OTHER (specify )

If you are employed, what Job title best describes what you do? If
retired or unemployed, what Job title describes what you did?
(HRITE IN).

 

Hhat was your approximate total household Income (before taxes)
during the past year? (CHECK ONE

1. Under $9,999

2. $10,000 - $15,999
3e $15,000 - $190999
. $20,000 - $24,999
e $25,000 - $299999
$30,000 ' $349999
$359000 ' 5‘99999
. $50,000 or more

CD‘ICNUVJ'
e e

83
-2-

what was the highest grade or class you completed in school? (CHECK ONE)

1. LESS rHAH 12 YEARS
2. HIGH SCHOOL GRADUATE (INCLUDES 0.5.0.)

3. GREATER THAN 12 YEARS, our NO DEGREE

TECHNICAL TRADE/COHHUNITY COLLEGE ozone:

BACHELOR'S DEGREE

HASTER'S atone:

Ph.O./PROFESSIONAL ozone:

OTHER (specify )

a‘m”
eee

ON
0

”I
N
CH

10.

2|

8| 3|
8| 3’4
SI

Please indicate your religious preference.

I.
2.
3.
h.
5.

NONE
JEWISH

PROTESTANT (Baptist, Lutheran, Methodist, Presbyterian, etc.)

CATHOLIC

OTHER (specify

what is your race?

I.
2.

u
0

“Wk
0

BLACK
HISPANIC

AMERICAN INDIAN

NHITE

ASIAN/PACIFIC ISLANDER
OTHER (specify

 

(CHECK ONE)

 

How many pregnancies have you had?

How many people live in your household including yourself? (CHECK ONE)

NOWPWN—I

8 OR MORE

ll

(HRITE IN NUMBER)

How are those who live with you related to you? (Check all that apply.)

I. HUSBAND/SIGNIFICANT OTHER

2.
3.
h.

5.

PARENT(S)
CHILDREN

OTHER (specify

 

NOT APPLICABLE (live alone)

(CHECK ONE)

84

 

-3-
__ 12. A) Indicate the level of stress you are experiencing at this time.
30 (PLEASE CIRCLE THE NUMBER ON THE FOLLOWING LINE).
1 2 3 h 5 6 7 8 9
NO HIGH

STRESS STRESS

B) Please indicate your major source of stress. (CHECK ONE)

 

 

 

 

 

'3‘:
___ 1. WORK
___ 2. FAMILY (teenagers, caring for parents, re-marriage, etc).
___ 3. ILLNESS (family and/or self)
___ A. FINANCIAL
‘___ 5. COMBINATION OF AND (specify)
___ 6. OTHER (specify
The following questions ask about your menstrual cycle. All of your answers will be
kept confidential.
__ 13. How many months ago was your last menstrual period? (CHECK ONE)
32
___ i. STILL HAVE PERIODS REGULARLY
___ 2. LESS THAN 3 MONTHS AGO
____3. 3 TO 12 MONTHS AGO
___ h. 12 OR MORE MONTHS AGO
__ I“. On the following line, circle the number that best shows how bad
33 you think your menstrual problems are or were.
1 2 3 h S 6 7 8 9
H0 SEVERE
PROBLEMS PROBLEMS
15. Consider the following menstrual problems. Indicate whether you have
experienced or are experiencing each problem by marking a check by YES or
NO. Even if you experience(d) the problem occasionally, answer YES. For
each problem that you mark YES, circle the number on the line that follows
that best shows how severe you think the menstrual problems wus or Is for
you.
'__ A) CRAMPS NO
TE 35 "‘ its
1 2 3 H 5 6 1 8 2
NOT EXTREMELY

SEVERE SEVERE

‘81
ml
N

176767

I“?

85

15. (CONTINUED) Please Indicate yes or no for each symptom. For each symptom
you mark YES, circle the number which best shows how severe the symptom was or
is.

B) EXCESSIVE BLEEDING

 

 

 

 

 

 

(HEAVY rtov, H0
FLOODING) YES
I 2 3 A 5 6 ~I 0 9
H01 EXTREMELY
SEVERE SEVERE
C) srorrch H0
YES
I 2 3 A 5 6 7 0
NOT EXTREMELY
SEVERE SEVERE
0) IRREGULAR PERIODS H0
YES
1 2 3 A 5 6 7 8 9 ,
H01 EXTREMELY
SEVERE SEVERE
E) VATER RETENTION NO
' YES
L 2 3 A j 6 2 8 9
NOT EXTREMELY
SEVERE SEVERE
r) TENSION H0
YES
I 2 .3 A 5 6 7 O 2
NOT EXTREMELY
SEVERE SEVERE
c) HEADACHES NO
YES
1: z 3 h 5 6 la 8 9
NOT EXTREMELY
SEVERE SEVERE
H) 01HER H0
YES

1 2 .3 h as 6 7 B
Specify: NOT EXTREMELY
SEVERE SEVERE

 

831 EQI

VI
"J‘t‘i‘fll
claim

16.

17.

(specify)

86
-5-

Hhat do you do (or did you do) to relieve any discomfort you feel
or felt) Just before or during your period? (Check all that apply.)

I. PAIN RELIEVER (ex. Advil, aspirin, Excedrin, Tylenol)
2. REST

3. EXERCISE

HEATING PADS

DIET CHANGES (specify
OTHER MEDICATION (specify
OTHER (specify
NOTHING NEEDED

&
a

 

 

VVV

 

“NU‘UI
a a 0

Within the past five years have you ever sought medical help for
problems with your menstrual periods or menopause?

___ 1. YES ___ 2. NO - go to question 18.

If yes, what did the health care provider recommend?

 

18. Do you currently consider yourself to be experiencing menopausal
symptoms? (CHECK ONE)

‘90

20.

21.

: 3. H01 SURE

thch of the following responses best describes your mother's
menopausal experience? (CHECK ONE)

1. NO DIFFICULTIES

2. SOME OIPFICULTIES

3. SERIOUS DIFFICULTIES
A. DON‘T KNOH

Have you had a hysterectomy (an operation where the doctor removed all
or part of your uterus)? (CHECK ONE)

_1. YES _2. H0

Have one or both of your ovaries been removed? (CHECK ONE)
1. NO

: 2. YES, BOTH OVARIES REMOVED

3. YES, ONE OVARY REMOVED

A. NOT SURE

-87
-5-

22. A) Are you currently taking estrogens (female hormones) of any kind

 

 

6? (Including birth control pills)? If In doubt, please list the name of
your medication.
___ 1. YES ___ 2. NO - go to question 23
__ B. If yes, please specify the type by checking one of the following:
66 ____ estrogen pills alone
____estrogen pills and progestin pills
___ estrogen patch
____estrogen patch and progestin pills
___ birth control pills
23. Hhat would be your source of payment for any medicines you take which
67 are prescribed by a physician? (CHECK ONE)
___ Payment ls provided completely out of your pocket.
'___ Payment ls provided completely by a source other than you or your
family (ex, Insurance, government agency).
___ Payment Is provided partly out of your pocket and partly by another.
source (ex, insurance, government agency).
__ Don't know
The following questions are about your health history and your health care
behaviors. Again, they are to help us interpret the results of the study. All
answers will be kept confidential.
2A. A) How often have you seen a health care professional (doctor, nurse) In
8'8 ‘63 the last 12 months? TIMES
(HRITE IN)
70'77'72 B) What was the purpose of your vlsit(s) to a health care professional?
__ ___ (CHECK ALL THAT APPLY)
73 75 7s
___ I. ROUTINE CHECK-UP (INCLUDES INTERNAL CHECK-UPS)
76 _ 2. CHRONIC PROBLEMS (Ex. BURSITIS)
____3. MENSTRUAL PROBLEMS
____h. SICKNESS (Ex. COLDS, FLU)
_ S. INJURIES
___ 6. MENOPAUSAL SYMPTOMS
_ 7. OTHER (SPECIFY )
__ 25. A) Have you ever had cancer? (CHECK ONE)
77

_1. YES _2.Ho

 

-7-
‘8 26. Do you take any prescribed medications regularly? (CHECK ONE)
7
_ YES _ H0
__ 27. Do you take over-the-counter medications routinely? (CHECK ONE)
79
__ YES _ NO
3_ 28. Please check the birth control method you now use. (CHECK ONE)
0
__ 1. ORAL CONTRACEPTIVE
_ 2. INTRAUTERINE DEVICE (IUD)
_ 3. BARRIER METHOD (DIAPHRAGM, CREAM, CONDOM, SPONGE)
_ ‘I. STERILIZATION (YOU OR YOUR PARTNER)
_ 5. PERIODIC ABSTINENCE, (RHYTHM)
_ 6. NO BIRTH CONTROL METHOD USED
_ 7. OTHER (SPECIFY )
lsc
110:2

h/lS/87

APPENDIX C

6/15/87

 

 

89
APPENDD< C
Menopausal Symptoms Instrument
‘ . Pt. ID _ _ _ fi-fi
CARD __ _ (ls-5)
DATE ______ (6-11)
ERT STUDY

Menopausal Symptoms Instrument

A. Are you currently experiencing or have you experienced symptoms in
the past which you believe are or were caused by menopause?
___ 1. YES

If you answered [88, please answer questions on green pages,
indicating only those symptoms RELATED TO MENOPAUSE which
YOU are experiencing or have experienced.

_2. NO

If you answered ae, please answer questions on yellow pages,

indicating only those symptoms RELATED TO MENOPAUSE which
YOU expect to experience.

__(12)

If you answered £88:

Listed on the next few pages are a number of symptoms which sometimes occur in
women as they go through menopause. Please read the list and indicate which of
these symptoms yep have experienced or are experiencing. He are interested in
knowing only about those symptoms which ypg feel are caused by menopause or
which you feel are directly related to menopause. For each symptom you have
experienced indicate how bothersome that symptom has been for you, from "Does
not bother me" (or hasn't bothered me) to "Bothers(ed) me a lot."

Rank

91

If you have not experienced the symptom,
leave blank.

 

Does not bother me

Bothers me a little

Bothers me somewhat

Bothers are a lot

IL... ....

 

Height Gain (over 10 pounds)

 

Difficulty Sleeplpg

 

Crying Spells

 

 

Low Hork Performance

Muscle Stiffness or Aches

 

Egggetfulness
Confusion

Need for Npps
Headaches

Skin Disorders
Loneliness
Menstrual Crppps
Dizziness or Faintness

Desire to Avoid Social Activities
Anxiety

Baggaches

Cold Sweats (perspiration)

Poor Juggepent

Fatigge - Tigegpess

Nausea or Vgplting

Restlessness

Hot Flashes or Flushes

CONTINUE ON NEXT PAGE

 

_.__.-_-_-n_mh

Rank

92

If you have not experienced the symptom,
leave blank.

 

Does not bother me

Bothers me a little

Bothers me somewhat

Bothers me a lot

 

23.

Difficulty In Concentration

 

 

 

2h.

Painful or Tender Breasts

 

25.

Swelling or Fluid Retention

 

26.

Accident prone

 

27.

lrrltability

 

28.

Mood Swings

 

29.

Depression

 

_3Qe

Decreased Mental Efficiency

 

 

31.
_32.
33.
3h.
e35.
36.
237.
38.
39.
#0.
hi.
#2.

A3. Chest Pains

Decreased Motor Coordination
Tensiog_(nervousness)

Tingling Sensations, Numbness
Palpitations - Heart Pounding
Unwanted Growth of Hair
Irrpggiar Periods. Bleeding
Changes in Eating Habits
Floodipgi(heavy:penstrual flow)
Less Affectionate

Expiteable

Unusual Bursts of Energy, Activity

Feeling of Suffocation

CONTINUE ON NEXT PAGE

 

...--L.L....-.. -- -

L-

 

..- - ..._.).._ _ -.—

l
i
E

If you have not experienced the symptom, .
leave blank. '

Does not Bother Ime
8:)thers me a little
Bothers me some-what
Bothers are a lot

Rank

 

N

 

 

 

Ah. Ringlngyjn Ears .

 

#5. Blind Spots, Fgggy Vision I

 

A6. Seapal Desire increased
hZa_Sexual Desire Decreased
#8. Lack of Eneggy
#9. Lack of Confidence
SO. Difficulty Making Decisions
A51. Painful Intercourse
ySZ. Vaginal Infections
53. Vaginal Dryness
_59. Painful Urination
_55. Have to Urinate More Often

#56. Feeling of Crawling on Skin , , 44;

Now that you have gone through the list, go back and rank the five symptoms that are
most bothersome to you.

Assign a ”I" beside the symptom that has bothered you the most, a "2" beside the
next symptom, and so on, up to five symptoms. If you marked fewer than five
symptoms, rank only the symptoms you marked. (i.e., if you marked four symptoms,
you would rank them "I" to "A".) If you marked more than 5 symptoms rank only the S
which bother(ed) you the most. Rank the symptoms on the left of the page in the
spaces provided.

_(69)_(70) (71) (72) _(73)
_(7‘I)_(75) (76) .—

lsc
110:5
3/2h/87

If you answered 82:

Listed on the next few pages are a number of symptoms which sometimes occur In
women as they experience menopause. Think about the menopausal symptoms which
ypp expect to experience during that time. For each symptom which you expect to
experience, Indicate how ppthersome you believe that symptom will be for you,
from "will not bother me" to "will bother me a lot."

95

If you do not expect to experience the symptom,
leave blank.

 

VIII “bother me

till? bother me a little

VIII Bother ma MI

VIII bother me a let

 

1. Height Cain (over 10 ppunds)

 

.__a. Difficplty Sleeping

 

3. Crying Spells

 

A. Low Uork Performance

 

_AS. Npgcle Stiffness or Aches

 

6. Foggetfulness

 

2. Confusion

 

8. Need for ngs

 

2. Headaches

 

10. Skin Disorders

 

 

 

11. Loneliness

 

12. Menstrual Crgpps

 

13. Dizzlnggs or Fglntness

 

 

1h. Dgglre to Avoid Social Actlvltlgge

 

 

15. Anxiety

 

16. Backaches

 

12. Cold Sweats (perspiration)

 

18. Poor Jugggppnt

 

 

 

12. Fatigue - Tiredness

 

20. Nausea or meltlng

 

 

 

21. Restlessness

 

_88. Hot Flgghes or Flushes

CONTINUE ON NEXT PAGE

 

5

96

If you do not expect to experience the symptom,
leave blank.

 

 

til-II mot bother me

 

VIII bother me a little

 

W" yeti-er me ME

VIII Bother me a lot

 

 

2}. Difficulty In Concentration

 

2A. Pglnful or Tender Breasts

 

25. Swelling or Flgld Retgptlon

Mum

..- -o- b—

 

22. lrrltablllty

 

28. Mood Swings

 

 

_22e_222:2!si°n

 

m1-——L——4L—-. -.

 

30. Decreased Mental Efficiency

 

31. Decreased Motor Coordination

 

_333 Tension (pgrvousngpg)

 

 

33. Tingling Sensations, Numbness

 

at. Palpitations - Heart Peunding

 

35. Unwented Growth of Hair

 

 

36. Irregular Periods. Bleedlgg

 

32. Changes In Eating Habits

 

 

 

38. Flooding (heayy menstrual flow)

. Less Affe tionate

 

 

 

.522_§sslssatic

 

AI. Unusual Bursts of EnergyI pgtlvlty

 

 

A2. Feeling of Sggfocatlon
#3. Chest Pains

 

 

cares—oe— via—..-

 

 

CONTINUE ON NEXT PAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.. U
r: z
97 E m i m
g I I I
. .‘L .2“. 2. .1“.
If you do not expect to experience the symptom, 2 3 3 3
leave blank. 3: : : =
S 5 5 5
Rank
Ah. Ringing In Ears
£5. Blind SpgtsI Fuzzy Vision
‘6. Sexual Desire Increased
AZ. Sexual Desire Decreased
AB. Lack of Energy ,
I
AS. Lack of Confidence I
A50. Difficulty Making Decisions
51. Painful Intergourse .
52. Vaginal Infections at E .

 

____ 53. Vaginal Dryness f ,. I j I
____ 5h. Painful Urination

____ 55. Have to Urinate More Often
____. 56. Feeling of Crawling on Skin : i J

 

' -——-I p...—
—o—J—.— ..

 

i--. g... —... .

 

Now that you have gone through the list, go back and rank the five symptoms that you
expect to be most bothersome to you.

Assign a "1" beside the symptom that will bother you the most, a "2" beside the next
symptom, and so on, up to five symptoms. If you marked fewer than five symptoms,
rank only the symptoms you marked. (I.e., If you marked four symptoms, you would
rank' them "1" to "A".) If you marked more than 5 symptoms rank only the S which you
expect to be most bothersome to you. Rank the symptomslon the left of the page In
the spaces provided.

APPENDIX D

APPENDIX D
Management of Symptoms Instrument

 

 

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APPENDIX E

h/l7/87

 

 

103
IAPTOHQEHXFE
Menopause Information Instrument Pt. ID _ _ __ “-37
DATE ______ (5-9)
ERT STUDY

Menopause infonmation

The following questionnaire contains questions about menopause, (the change
of life) a time which signifies the end of the menstrual cycle. He are
interested in finding out what women know about menopause. Please answer
the following questions to the best of your ability.

1.

Between what ages does menopause usually begin (without hormone
therapy)? (Check one)

a. 35 TO “A YEARS.
b. 55 TO Sh YEARS.
c. 55 TO 6“ YEARS.

Ovulation frequently occurs for how many years after a women stops
menstruating? (Check one)

a. 0 YEARS (Not at all).
h. 1 YEAR.

c. 2 YEARS.

d. 3 YEARS.

e. A YEARS.

What can be said about birth control after menstruation stops?
(Check one)

I. BIRTH CONTROL SHOULD BE USED FOR 1 YEAR.

b. BIRTH CONTROL SHOULD BE USED UP TO 5 YEARS.

c. BIRTH CONTROL SHOULD BE USED AS LONG AS SEXUALLY ACTIVE.
d. BIRTH CONTROL IS NOT NECESSARY.

What causes the symptoms of menopause? (Check one)

I. THE PITUITARY GLAND STOPS FUNCTIONING.

b. THE UTERUS HILL NOT ALLOH ECG INPLANTATION.
c. THE FALLOPIAN TUBE BECOMES BLOCKED.

d. THE OVARIES PRODUCE LESS ESTROGEN.

0. ALL OF THE ABOVE

slaw-Al
alslal

104
-2-

5. Menopause increases the risk for which of the following? (Check all
that apply.)

a.
b.
c.
d.
e.
f.

 

LIVER DISEASE.

HEART DISEASE.

KIDNEY DISEASE.

LUNG DISEASE.

OSTEOPOROSIS (BRITTLE BONE DISEASE).
ALL OF THE ABOVE

NONE OF THE ABOVE

6. Hhat physical changes can occur In the vagina due to>menopause?
(Check one.)

a.
b.
c.
d.

IT BECOMES DRYER AND LESS ELASTIC.
IT BECOMES SHORTER AND MORE NARROH.
IT BECOMES THIN AND EASILY INJURED.
ALL OF THE ABOVE.

7. For how many years do menopausal symptoms without estrogen

treatment

a.
b.
c.
d.

usually last? (Check the best response.)

I TO 2 YEARS.

3 TO 5 YEARS.

6 TO 10 YEARS.

MORE THAN 10 YEARS.

8. By the end of menopause, which of the following occur? (Check all
that apply.)

a.
b.
c.
d.

THE OVARIES DECREASE FUNCTIONING.
MENSTRUAL BLEEDING HILL HAVE STOPPED.
OSTEOPOROSIS (BRITTLE BONES) OCCURS MORE.
ALL OF THE ABOVE.

9. Osteoporosis (brittle bones) may be treated by: (Check all that

.)

a.
b.
c.
d.

|||| -
'U
U
-
‘<

ESTROGEN PILLS.

SUFFICIENT CALCIUM INTAKE.
MODERATE PHYSICAL ACTIVITY.
ALL OF THE ABOVE.

Please answer the following questions with "true" or "false". (Circle
True or False for each question)

10. Hormone therapy (estrogen) after menopause increases the risk of
osteoporosis.

TRUE

FALSE

ll.

12.

13.

1“.

15.

l6.

17.

18.

105

-3-
Hormonal therapy can be used to help relieve the symptoms of
menopause.

TRUE FALSE

Estrogen therapy increases the risk of cancer of the uterus.

TRUE FALSE

Bleeding or spotting a year after a woman completely stops
menstruating (menopausal women) should be reported to your
physician.

TRUE FALSE

Symptoms most often reported during menopause are hot flashes
and night sweats.

TRUE FALSE
Once a woman is through menopause she no longer has to be concerned
with breast cancer or other female cancers.

TRUE FALSE

By the time of the last menstrual period, women can generally not
become pregnant.

TRUE FALSE

As long as a woman is ovulating she can still become pregnant.

TRUE FALSE

Ovulation may occur without menstrual bleeding occurring.

TRUE FALSE

Isc
110:1

106
-q-

19. To help reduce the uncomfortable feelings associated with hot
flashes, a person can...(Check one)

a. eat a balanced diet d. exercise daily
b. take extra vitamins e. estrogen replacement therapy
c. wear layered clothing f. all of the above

20. Vaginal dryness caused by menopause may lead to...(Check one)

a. painful intercourse

b. increased chance of infection
0. itching

d. all of the above

21. Vaginal dryness can best be relieved by...(Check one)

a. using a water soluble lubricant
b. using a vaseline lubricant

c. douching

d. estrogen replacement therapy

h/lS/87

APPENDIX F

 

Site __‘__ 44(145)

 

Pt. iO_____ (3-5)
107 Date ______ (8-13)
APPENDR F lI/28/87
Judgment Cases Instrument

INFORMATION SHEET

He are going to give you some written situations (cases) and ask you to
imagine yourself in that situation. You will be asked to read each case and
indicate how likely you would be in that situation to take hormone therapy.
There are two sets of 16 cases each, and it will probably take you about 30
minutes to complete all of the cases.

The purpose of asking you to tell us what you would do in these situations is
to find out what information is important to women in making these

decisions. He want to make sure that you have all the information you need
to make those decisions. Therefore, we have written down some of the facts
that we think would be helpful to you.

There are at least three important things to think about when you consider
whether to take estrogen therapy. These three factors are menopausal
symptoms, risk of fractures due to osteoporosis, and risk of endometrial
cancer. Information about each of these factors is given below. Also, there
is a paragraph about estrogen therapy and whether it would be expected to
help or make worse each of the three factors.

MENOPAUSAL SYMPTOMS-Somewhere in middle age, usually around fifty years of
age, women stop having monthly menstrual periods and are said to be going
through menopause or, "the change of life". One of the most common problems
that women mention related to menopause is hot flashes or the feeling of
warmth in the upper body. These hot flashes are usually mild, and even if
untreated, usually subside in a period of a few months or years. Some women
may have severe hot flashes accompanied by perspiration which cause them to
lose sleep or make it difficult or embarrassing to carry out their daily
activities.

RISK OF FRACTURES DUE TO OSTEOPOROSIS-You may have heard people talk about
having broken bones or fractures because they have brittle bones. Usually,
they are referring to osteoporosis, where the bones become weaker after
menopause. Thin, white women who smoke and do not exercise have the highest
risk of fractures due to osteoporosis, and black women, heavier women, and
those who exercise regularly have a lower risk. Assuming the usual life-span
of 85 years, for women presently 60-65 years old it is estimated that SO out
of 1,000 will have a fracture of the hip, spine, wrist or pelvis due to
osteoporosis each year. For many younger people fractures may not be
perceived as very serious, but in the older populations complications can
occur. One third of women over age 65 will have vertebral fractures. By
extreme old ago, one of every three women will have had a hip fracture. This
catastrophic type of fracture is fatal in l2 to 20 percent of cases and it
leads to long-term nursing home care for half of those who survive.

108

RISK OF ENOOMETRIAL CANCER-Endometrial cancer is cancer of the uterus or
womb. In women not takingiestro en, approximately 1 in l000 can be expected
to develop endometrial cancer each year. in most cases, if cancer develops,
it is detected early because it causes vaginal bleeding. it can be treated
with a hysterectomy (surgical removal of the uterus) and removal of the
ovaries with a 902 cure rate. However, if the cancer is advanced, it can
cause significant pain and not only require a hysterectomy, but also some
form of follow up radiation (X-Ray) therapy and perhaps anticancer drugs
(chemotherapy).

ESTROGEN REPLACEMENT THERAPY-You may have heard about other hormone
treatments for menopause, but this information is about estrogen alone. If
you were taking estrogen therapy, one plan is that you would take a pill once
a day for 25 days, then not take any pills for 5 days each month. There are
other plans and your doctor would prescribe the best one for you. The pills
cost approximately $5.50 per month. The physician would want you to come in
for an annual physical. Possible side effects other than those mentioned
include weight gain, nausea and vomiting, breast tenderness or enlargement.

ormone therapy with estrogen reduces or eliminates hot flashes, decreases
the chance of fracture due to osteoporosis, but increases the chances of
endometrial cancer. Estrogen therapy does not bring back monthly bleeding.

Fractures due to osteoporosis are much more common than endometrial cancer.
in numbers, for women who are not takin estro cn and who are presently 60-65
years old (assuming the usual life span of BS years) the occurance of
fractures and endometrial cancer is as follows. 50 out of every 1,000 women
can be expected to develop fractures of the hip, spine, wrist or pelvis each
year, and 1 out of every 1,000 women can be expected to develop endometrial

cancer each year. Most of the deaths due to complications of fractures and
most of the deaths due to endometrial cancer occur after age 75.

In women takin estro en who are presently 60-65 years old (assuming the
usual life span of BS years) 25 out of every 1,000 women can be expected to

develop fractures of the hip, spine, wrist or pelvis each year, and 6 out of
every l,OOO women can be expected to develop endometrial cancer each year.
The estrogen increases the risk of cancer from I per 1,000 to 6 per 1,000,
but cuts the osteoporosis fracture risk in half, from 50 per 1,000 to 25 per
1,000.

Not only is the occurrence of osteoporosis fracture greater than cancer, but
the death rate is also higher. Overall, approximately 3,000 women die of
endometrial cancer each year and 50,000 die due to complications associated
with fractures in the 0.5. each year. Again, these deaths occur mostly after
age 75.

Therefore, the woman in menopause is faced with a difficult decision: to
take the hormone therapy and run a higher risk of developing uterine cancer,
or not take it and run a higher risk of developing bone fractures. The
following graphs may be helpful in better understanding this information.

 

 

109

 

 

 

 

 

 

1,000-I WofVomenPeripOOVho 1,0001 NunberofVomenPerLOOOHho
/ / Experience fractures I / 0et Endometrial Cancer
Each Year Each Year
50 .. (5°) 50 _.
I Home Not Tm Hormones I
40 _ 4O _ Yemen Not Takhg Hormones
7" Vernon Taking Estrogen
so - 3° - Yemen Takhg Estrogen
(25)
20 ._ y 20 ..
10 4 '0 ‘ (6)
0 - /A 0 4A Ezzza
No Hormone Therapy Hith Estrogen Therapy No Hormone Therapy Vith Estrogen Therapy

I Number ofHomethoDieEach Year
I I Due to fractures and mum We

 

so - (50 000)
,000 I Death from Complications
‘0 00° of fractures
“11] Death from Endometrial

30,000- Cancer
20,”...
mm" (3 000)

0 _ IITIIIIIIII

 

 

Complications of Fractu'es Endometrial Cancer

*Host of the deaths related to both complications of fracttres
mdendcmetrtaloanceroccwafterage‘ls.

110
DEFINITIONS

h/l7/87

Now we want you to imagine yourself in a number of real situations and think
about how likely you would be to take estrogen therapy in each of those
situations. You will be given three kinds of information about each
situation. This information will include how bad the menopausal symptoms
are, chances of getting endometrial cancer, and chances of developing
osteoporosis. He ask you to think about what it would be like if you were in
this situation. Listed below are the definitions of several terms you will
need to know.

MENOPAUSAL SYMPTOMS-This refers to how bad your hot flashes are and whether
they are interfering with your sleep, social activities, work and daily
activities. He have defined two levels of menopausal symptoms.
High level means that you have very bad hot flashes which interfere with
your sleep, daily activities, and social life.

Standard level means that you have a few hot flashes which really don't
bother you or interrupt your daily life.

RISK OF FRACTURE DUE TO OSTEOPOROSIS-This refers to how likely it is that you
will develop fractures due to osteoporosis. Hith osteoporosis bones become
more porous and brittle and may break more easily. He have defined two
levels of risk. '
High level means that you have a greater than average chance of
developing fractures of the hip, spine, wrist or pelvis due to
osteoporosis. On the average, about 50 women out of 1,000 have such a
fracture but the high level defines you as having a greater than 50 out
of 1,000 chances of having a fracture.

Standard level means that you have an average chance of having a fracture
due to osteoporosis. Thus, your chances are about 50 out of 1,000 per
year.

RISK OF ENDOMETRIAL CANCER-This is a description of how likely it is that you
will develop endometrial cancer. Endometrial cancer is cancer of the lining
of the uterus, or womb. He have defined two levels:
High level means that you have a greater than average chance of
developing endometrial cancer. On the average, about one woman in 1,000
develops endometrial cancer each year but the high level defines you as
having a greater than i in l,OOO chance of having endometrial cancer.

Standard level means that you have an average chance of developing
endometrial cancer. Therefore, your chances of developing endometrial
cancer are about i in 1,000 per year.

As you read the cases please try to consider each one individually. The
cases may seem very similar, but it is important to consider each one. Do not
'worry about how you answered earlier cases, just consider each one as you
read it. The number of women who experience each problem on the average
(that is, the average risk) will be written in parentheses to help you.

h/20/87
111

DIRECTIONS

PLEASE REMOVE THIS PAGE FROM THE BOOKLET AND REFER TO THE DIRECTIONS AND
SCALE AS YOU READ AND MAKE JUDGMENTS ON EACH CASE.

Each of the following situations will ask you to Imagine that you are
experiencing hot flashes at a standard (average) or high level, that you are
at a greater or standard (average) risk than most women for developing
osteoporosis and endometrial cancer, and ask you how likely you would be in
that situation to take hormone pills.

Please read each case and decide how likely you would be to take hormone
pills in the situation described. Make your decision using the following
scale:

I. VERY CERTAIN THAT YOU HOULD NOT TAKE HORMONE THERAPY

2. PROBABLY HOULD NOT TAKE HORMONE THERAPY

3. MAY OR MAY NOT TAKE HORMONE THERAPY

h. PROBABLY HOULD TAKE HORMONE THERAPY

5. VERY CERTAIN THAT YOU HOULD TAKE HORMONE THERAPY
For each case, write down the number from this scale that represents your
decision as to how likely you would be to take hormone therapy In the

situation described. Continue until all cases are completed. The first 2
cases are practice cases followed by l6 cases.

112
PRACTICE CASE 1

You have frequent and severe hot flashes which interfere with your sleep and
make it difficult to carry out your daily activities.

You have been told by your physician that you have an average chance (50 out
of l,OOO women) of developing a fracture of the hip, spine, wrist or pelvis
due to osteoporosis.

Your chances of developing endometrigl cancer are greater than most women
(greater than i in a l,OOO) according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY HOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSHER:
aesassoeaaeeaaaoaeeetattoos*aeeeeeeoeeaeasoeeeaoeesaaaeaeeaeaaeeseeeeaeassess
Using the descriptions given, consider the level of hot flashes described,
your risk for fractures due to osteoporosis and risk for endometrial cancer
as described in the case. If you need to look back at the more detailed
descriptions of each, do so.

Hrite down your decision as to how likely you would be to take hormone
therapy in each situation. Hrite your decision on the line following the
word ANSHER. Refer to the "Directions" and choose the number on the 5 point
scale that most closely represents your judgment. For example, if you feel
you probably would not take hormone therapy in this situation, put a 2 on the

line as your answer.
aeeeeaeeeateoattestseeaeeseeaeaaeetetoterseatoesaseeaseeeeeoeeoaeaoeaaeeaseee

PRACTICE CASE 2

You sometimes have mild hot flashes but they do not keep you from sleeping or
bother you very much during the day.

Hhiie 50 out of 1,000 women on the average will develop a fracture of the
hip, spine, wrist or pelvis due to osteoporosis, you have been told by your
physician that your chances are higher than

average.

Your chances of developing endometrial cancer are greater than most women
(greater than i in'a 1,000) according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY HOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSHER:

113
CASE 1

You sometimes have mild hot flashes but they do not keep you from sleeping or
bother you very much during the day.

You have been told by your physician that you have an average chance (50 out
of i,000 women) of developing a fracture of the hip, spine, wrist or pelvis
due to osteoporosis.

Your chances of developing endometrial cancer are greater than most women
(greater than i in a l,OOO) according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSVER:
CASE 2

You have occasional mild hot flashes which do not Interfere with your sleep
or other daily activities.

Hhiie 50 women out of 1,000 on the average will develop a fracture of the
hip, spine, wrist or pelvis due to osteoporosis, you have been told by your
physician that your chances are higher than that average.

Your chances of developing endometrial cancer are about avera e, that is
about 1 out of 1,000 women according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSVER:
CASE 3

You have many severe hot flashes that keep you from sleeping well and
interfere with what you normally do during the day.

Your chances of developing a fracture of the hip, spine, wrist or pelvis due
to osteoporosis are about average (50 chances out of l,000) according to your
physician.

Your chances of developing endometrial cancer are greater than most women
(greater than i in a l,000) according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSVER:

114

CASE A

You have had some mild hot flashes but are able to sleep O.K. and they have
not kept you from doing your usual daily activities.

You have been told by your physician that you have a greater than gverggg
chance of developing a fracture of the hip, spine, wrist or pelvis due to
osteoporosis (odds greater than 50 out of 1,000).

You have been told by your physician that you have a greater than averagg
(that is, greater than i in a 1,000) chance of developing endometrial cancer
meaning you are at higher risk than most women.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN HORMONE
THERAPY?

ANSVER:
CASE 5

You have occasional mild hot flashes which do not interfere with your sleep
or other daily activities.

Your chances of developing a fracture of the hip, spine, wrist or pelvis due
to osteoporosis are about average (50 chances out of 1,000) according to your
physician.

You know that I out of I,OOO women on the average will develop endometrial
cancer, and your physician tells you that your chances are about average.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSHER:
CASE 6

You have manygsevere hot flashes which cause you to lose sleep and keep you
from doing your usual daily activities.

- You have been told by your physician that you have a greater than avergge
chance of developing a fracture of the hip, spine, wrist or pelvis due to
osteoporosis (odds greater than 50 out of 1,000).

Your physician tells you that you have an average chance, (i out of 1,000
women) of developing endometrial cancer.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY? .

ANSHER:

115

CASE 7

You have frequent and severe hot flashes which interfere with your sleep and
make it difficult to carry out your daily activities.

About 50 women out of 1,000 on the average will develop a fracture of the
hip, spine, wrist or pelvis due to osteoporosis, you have been told by your
physician that you have the an average chance of developing the problem.

You know that l out of 1,000 women on the average will develop endometrial
cancer, and your physician tells you that your chances are about average.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSHER:
CASE 8

You have many severe hot flashes that keep you from sleeping well and
interfere with what you normally do during the day.

Your chances of developing a fracture of the hip, spine, wrist or pelvis due
to osteoporosis are greater than the average (greater than 50 out of 1,000
women) according to your physician.

Hhiie I in 1,000 women on the average will develop endometrial cancer, you
have been told by your physician that your chances are higher than averag .

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSHER:
CASE 9

You have had some mild hot flashes but are able to sleep O.K. and they have
not kept you from doing your usual daily activities.

You have been told by your physician that you have a greater thanAgverage
chance of developing a fracture of the hip, spine, wrist or pelvis due to
osteoporosis (odds greater than 50 out of 1,000).

You have been told by your physician that you have a greater than average
(that is, greater than i in a 1,000) chance of developing endometrial cancer
meaning you are at higher risk than most women.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN HORMONE
THERAPY?

ANSVER:

116

CASE lO

You have occasional mild hot flashes which do not interfere with your sleep
or other daily activities.

Your chances of developing a fracture of the hip, spine, wrist or pelvis due
to osteoporosis are about average (50 chances out of 1,000) according to your
physician.

You know that 1 out of 1,000 women on the average will develop endometrial
cancer, and your physician tells you that your chances are about average.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSVER:
CASE 11

You have many severe hot flashes tfat keep you from sleeping well and
interfere with what you normally do during the day.

Your chances of developing a fracture of the hip, spine, wrist or pelvis due
to osteoporosis are gieater than the averggg (greater than 50 out of l,000
women) according to your physician.

Hhiie l in 1,000 women on the average will develop endometrial cancer, you
have been told by your physician that your chances are higher than avergg_.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSVER:
CASE l2

You have frequent and severe hot flashes which interfere with your sleep and
make it difficult to carry out your daily activities.

About 50 women out of i,OOO on the average will develop a fracture of the
hip, spine, wrist or pelvis due to osteoporosis, you have been told by your
physician that you have an average chance of developing the problem.

You know that 1 out of l,OOO women on the average will develop endometrial
cancer, and your physician tells you that your chances are about averag .

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSVER:

117
CASE 13

You have many severe hot flashes which cause you to lose sleep and keep you
from doing your usual daily activities.

You have been told by your physician that you have a greater than average
chance of developing a fracture of the hip, spine, wrist or pelvis due to
osteoporosis (odds greater than 50 out of 1,000).

Your physician tells you that you have an average chance (1 out of l,000
women) of developing endometrial cancer.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSVER:
CASE 1“

You have many severe hot flashes that keep you from sleeping well and
interfere with what you normally do during the day.

Your chances of developing a fracture of the hip, spine, wrist or pelvis due
to osteoporosis are about average (50 chances out of 1,000) according to your
physician. ‘

Your chances of developing endometrial cancer are greater than most women
(greater than i in a 1,000) according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSHER:
CASE l5

You have occasiongi mild hot flashes which do not Interfere with your sleep
or other daily activities.

Hhiie 50 out of 1,000 women on the average will develop a fracture of the
hip, spine, wrist or pelvis due to osteoporosis, you have been told by your
physician that your chances are higher than that average.

Your chances of developing endometrial cancer are about average, that is
about 1 out of 1,000 women according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSHER:

118
CASE l6

You sometimes have mild hot flashes but they do not keep you from sleeping or
bother you very much during the day.

You have been told by your physician that you have an average chance (50 out
of l,000 women) of developing a fracture of the hip, spine, wrist or pelvis
due to osteoporosis.

Your chances of developing endometrial cancer are greater than most women
(greater than I in a i ,000) according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
HORMONE THERAPY?

ANSVER:

119 lI/6/87
DIRECTIONS-SET 2

You will find the next set of cases very similar to the first set you just
completed. The one difference is the hormone treatment. You have been
thinking about whether to take estrogen, an example of which was one pill for
25 days followed by no pill for 5 days. The estrogen decreases the risk of
osteoporosis, relieves hot flashes, but increases the chance of endometrial
cancer.

There is another treatment program we would like you to think about now.

This hormone treatment would be estrogen and progestin. One plan would be on
a 30 day cycle, you would take on estrogen pill for 15 days, then take an
estrogen pill and progestin pill for the next 10 days, then no pills for five
days. The cost would be approximately $l2.50 per month. There are other
plans and your doctor would prescribe the best one for you. As the chart
below shows, adding the progestin takes away the problem of increasing the
risk of endomentriai cancer, that is, if you take this treatment program the
risk of endometrial cancer is no greater thgn if you did not take the

es t rogen e

Taking this treatment program does have one other side effect. You will
again start or continue to have vaginal bleeding or monthly periods. Thus,
estrogen with progestin will relieve hot flashes, reduce osteoporosis, have
no increase in risk of cancer, but will cause monthly periods.

Please turn the page and answer this set of cases by indicating how likely
you would be in each case to take the combined estrogenlprogestin hormone
therapy. Use the page you pulled out for the first set to refer to for the
response scale.

I pm -| Number of Vomen Per I ,000 th
/ Get Endometrial Cancer
/ Each Year
50...
1 Women Not Taking Hormones
40...
[:J‘MunuanfingEshmguiAmdPnunsWn
30___ ,
Homer) Taking Estrogen Only
20...
'° —' . (6)
o (l) (I) m
#—

 

 

 

NeikrnwneThwupy ‘VHhEsbegudanpan ‘fflhfigbmgflgom~

0/6/87

120
CASE 1

You sometimes have mild hot flashes but they do not keep you from sleeping or
bother you very much during the day.

Your chances of developing a fracture of the hip, spine, wrist or pelvis due
to osteoporosis are ggeater than the averagg (greater than 50 out of 1,000
women) according to your physician.

Your physician tells you that you have an average chance, (i out of l,000
women) of developing endometrial cancer.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSHER:
CASE 2

You have had some mild hot flashes but are able to sleep O.K. and they have
not kept you from doing your usual daily activities.

About 50 women out of 1,000 on the average will develop a fracture of the
hip, spine, wrist or pelvis due to osteoporosis, and you have been told by
your physician that you have an average chance of developing the problem.

You have been told by your physician that you have a greater than averggg
(that is, greater than i in 1,000) chance of developing endometrial cancer
meaning you are at higher risk than most women.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSHER:
CASE 3

You have many severe hot flashes that keep you from sleeping well and
interfere with what you normally do during the day.

Your chances of developing a fracture of the hip, spine, wrist or pelvis due
to osteoporosis are about average (50 chances out of l,000) according to your
physician.

Your chances of developing endometrial canceF are about the same as avera e,
that is I out of l,000 women according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE ESTROGEN
/PROGESTIN HORMONE THERAPY?

ANSVER:

121
CASE A

You have many severe hot flashes which cause you to lose sleep and keep you
from doing your usual daily activities.

You have been told by your physician that you have a greater than average
chance of developing a fracture of the hip, spine, wrist or pelvis due to
osteoporosis (odds greater than 50 out of l,000).

Your chances of developing endometrial cancer are greater thgn most women
(greater than i in a 1,000) according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSVER:
CASE 5

You have occasional mild hot flashes which do not interfere with your sleep
or other daily activities.

Hhiie 50 out of l,000 women on the average will develop a fracture of the
hip, spine, wrist or pelvis due to osteoporosis, you have been told by your
physician that your chances are higher than that average.

Hhiie i in 1,000 women on the average will develop endometrial cancer, you
have been told by your physician that your chances are higher than averag .

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSHER:
CASE 6

You sometimes have mild hot flashes but they do not keep you from sleeping or
bother you very much during the day.

You have been told by your physician that you have an average chance (50 out
of 1,000 women) of developing a fracture of the hip, spine, wrist or pelvis
due to osteoporosis.

Your chances of developing endometrial cancer are about avera e, that is I
out of 1,000 women according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSVER:

122
CASE 7

You have frequent and severe hot flashes which interfere with your sleep and
make it difficult to carry out your daily activities.

Hhiie 50 out of 1,000 women on the average will develop a fracture of the
hip, spine, wrist or pelvis due to osteoporosis, you have been told by your
physician that your chances are higher thgh that average.

You know that 1 out of 1,000 women on the average will develop endometrial
cancer, and your physician tells you that you chances are about average.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?"

ANSVER:
CASE 8

You have many severe hot flashes which cause you to lose sleep and keep you
from doing your usual daily activities.

You have been told by your physician that you have an average chance (50 out
of 1,000 women) of developing a fracture of the hip, spine, wrist or pelvis
due to osteoporosis.

You have been told by your physician that you have a greater than average
(that is, greater than i in 1,000) chance of developing endometrial cancer,
meaning you are at higher risk than most women.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSHER:
CASE 9

You have many severe hot flashes which cause you to lose sleep and keep you
from doing your usual daily activities.

You have been told by your physician that you have a greater than average
chance of developing a fracture of the hip, spine, wrist or pelvis due to
osteoporosis (odds greater than 50 out of 1,000).

Your chances of developing endometrial cancer are greater than most women
(greater than i in a l,000) according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSVER:

123
CASE 10

You have occasional mild hot flashes which do not interfere with your sleep
or other daily activities.

Hhiie 50 out of 1,000 women on the average will develop a fracture of the
hip, spine, wrist or pelvis due to osteoporosis, you have been told by your
physician that your chances are higher than that average.

Hhiie I in 1,000 women on the average will develop endometrial cancer, you
have been told by your physician that your chances are higher than average.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSVER:
CASE 11

You have many severe hot flashes which cause you to lose sleep and keep you
from doing your usual daily activities.

You have been told by your physician that you have an average chance (50 out
of 1,000 women) of developing a fracture of the hip, spine, wrist or pelvis
due to osteoporosis.

You have been told by your physician that you have a greater than average
(that is, greater than I in 1,000) chance of developing endometrial cancer,
meaning you are at higher risk than most women.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSHER:
CASE 12

You have frequent and severe hot flashes which interfere with your sleep and
make it difficult to carry out your daily activities.

Hhiie 50 out of l,000 women on the average will develop a fracture of the
hip, spine, wrist or pelvis due to osteoporosis, you have been told by your
physician that your chances are higher thgh that average.

You know that I out of l,000 women on the average will develop endometrial
cancer, and your physician tells you that you chances are about average.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?"

ANSVER:

124
CASE 13

You sometimes have mild hot flashes but they do not keep you from sleeping or
bother you very much during the day.

You have been told by your physician that you have an average chance (50 out
of 1,000 women) of developing a fracture of the hip, spine, wrist or pelvis
due to osteoporosis.

Your chances of developing endometrial cancer are about aver e, that is I
out of 1,000 women, according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSHER:
CASE IA

You have many severe hot flashes that keep you from sleeping well and
interfere with what you normally do during the day.

Your chances of developing a fracture of the hip, spine, wrist or pelvis due
to osteoporosis are about average (50 chances out of 1,000) according to your
physician.

Your chances of developing endometrial cancer are about the some as avera e,
that is 1 out of l,000 women, according to your physician.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSVER:
CASE 15

You have had some mild hot flashes but are able to sleep O.K. and they have
not kept you from doing your usual daily activities.

About 50 women out of 1,000 on the average will develop a fracture of the
hip, spine, wrist or pelvis due to osteoporosis, and you have been told by
your physician that you have an average chance of developing the problem.

You have been told by your physician that you have a greater than average
(that is, greater than I in 1,000) chance of developing endometrial cancer
meaning you are at higher risk than most women.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSVER:

125
CASE l6

You sometimes have mild hot flashes but they do not keep you from sleeping or
bother you very much during the day.

Your chances of developing a fracture of the hip, spine, wrist or pelvis due
to osteoporosis are greater than the average (greater than 50 out of 1,000
women) according to your physician.

Your physician tells you that you have an average chance, (1 out of 1,000
women) of developing endometrial cancer.

QUESTION: IN THIS SITUATION, HOV LIKELY VOULD YOU BE TO TAKE
ESTROGEN/PROGESTIN HORMONE THERAPY?

ANSVER:

1. Assuming equal benefits would result, how would you rate your preference
for each of the following ways of taking estrogen and progestin?

Much the preferred method
Preferred over some other methods
Probably not as preferred as other methods

I;
3
2
l Definitely not a preferred method

1. Injections taken every month

2. Skin implants that need to be changed periodically

3. Pills

A. Patch

 

2. Besides risk of osteoporosis and endometrial cancer, relief of hot
flashes, and resumption of monthly bleeding, are there any other factrors or
pieces of information that are important to you in deciding whether to take
hormone therapy for menopausal symptoms?

YES NO

 

If YES, please explain.

 

 

 

126

3. Please indicate on the scale provided how important each factor
was to you as you responded to the cases.

Hot Flashes

 

I 2 3 A 5 6
Not Important Extremely
At All important

Risk of Endometrial Cancer

 

i 2 3 II 5 ' 6
Not Important Extremely
At All important

Risk of Osteoporosis

 

I 2 3 A S 6
Not Important Extremely
At All Important

Resumption of Monthly Bleeding

 

I 2 3 A S 6
Not Important ' Extremely
At All Important -

Thank you for your help.

APPENDD( G

rev. A/l7/37

 

 

127 Pt. ID ___ (I-3)
oars Ih-si
ALPPTHVEMDIC; ”””
Perceptions of Menopause lnstmment
ERT STUDY

Perceptions of Menopause

Some of you will have not experienced menopause yet, and some of you are
experiencing menopause now. He are interested in finding out what your
perceptions are about menopause regardless of whether or not you are
experiencing menopause. In the questions that follow, please circle the
response that most represents how you feel about each statement.

1.

Menopause has been/will be an unpleasant experience for me.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

The thought of menopause is disturbing to me.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

My body may change during the menopause, but I will not change
personally.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

On the whole, I expect to feel better after the menopause than I did
before the menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

I welcome the menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

Menopausal symptoms that I might have can be helped.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

'00

ll.

12.

13.

IA.

128
-2-

Homen should be under a health provider's care during menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

Hormones are necessary for the management of menopausal symptoms.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

There are things I can do to feel good during the menopause other than
going to a health care provider.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

I expect to (do) experience physical trouble during the menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

I expect to (do) experience emotional trouble during the menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

Menopause will bring/has brought many changes to my life.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE . DISAGREE

I am confused about all of the controversy over hormone treatment and
menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

DeSpite what health care providers say, I believe I should make the
decisions about management of my menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

15.

i6.

17.

18.

19.

20.

21.

22.

129
-3-

There Is little that an individual can do to control the symptoms of
menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE
I have been/will be able to experience menopause without problems.
STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE
Menopause causes problems no matter what you do.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

Menopause will/did cause me to be sick a lot.
STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

Menopause probably will not/did not have a negative effect on me.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE
I believe that I can control menopausal symptoms.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE
Taking hormones for menopausal symptoms can make me feel better.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

Special diets : foods may help control some of the symptoms of
menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

23.

2h.

25.

26.

27.

28.

130
4,-

Homen are more tired than usual during menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

Menopause is something I Just have to put up with.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

Menopause is associated with mood changes.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

Most women make too much of menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

Health care providers don't really understand the problems women
experience with menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

There is a difference between male and female health care providers in
how they understand the problems that women experience with menopause.

STRONGLY NEITHER AGREE STRONGLY
AGREE AGREE NOR DISAGREE DISAGREE DISAGREE

131
-5-

Hhen I experience menopause I feel that...(PLEASE CHECK ONLY ONE ANSHER FOR
EACH QUESTION)

29. A) My sex life will be/is more satisfying.
B) My sex life will bells relatively the same.
C) My sex life will be/is less satisfying.

30. A) My sleep patterns will get/are better.
B) My sleep patterns will remain/are relatively the same.
C) My sleep patterns will get/are worse.

__ A) Participating in social activities will be/is much more enjoyable.

AD 1.. B) Participating in social activities will be/is no more or less
enjoyable.

C) Participating in social activities will be/is much less enjoyable.

32. __ A) It will be/is much easier for me to do the things that i normally
AT do during the day.
B) There will be/is little change in how I do the things that I
normally do during the day.
C) It will be/is more difficult for me to do the things that I
normally do during the day.

lsc
IIO:A
3/26/87

APPENDD( H

132
APPENDIX H
Equations for Management Scales

4.0.84 Emsmmoaoa wooed n M N

a. + game

 

 

N... u nemvosmo moo. gauges" 093881. 4.9. £30205 .4
on: u c on r o u Doom Son :me 05:09. 4.“ H .I. 008 new $385 .5
:4. n 88: :0. on E032: mpg—"350 .I. am
We u 90$— 50. 0». $568.30 580 - 00853 v.05 35.80 $35835 o:
$56880 Sages" .9. $58 ~85 H 8 m4

 

 

133

nus

30908505 moan wooed n M Na. Iv game

 

 

on... n 5000500 ..2. 5550505 03.089. .. mop. 05305 .4 a2. 0.: X... 5 0085—9. .5.
on... u c on r o n 6000 so» :00 0.5884 4." a n 6000 :00 0538‘ .3

35 u 85— :0. 0.. 553052: 0.0.3.500 5 509003050 omnomonv. u 3

m... u 85— :0. 0m 050850 :08“. - 065500 3.05 Baron 0253050 0:
053050 505505 Ame 5300 5.05 w 8 m4

 

 

134

F.”

OR» momma @256 n M Na. + Emma

 

 

N: u mam—x58 3.. 55mmn5a=n 5588‘ r m5. 3.5305 ._ m5. m: N: 5 awwnmog d.
on: u o 5. r o u anm 52 can mfimnnmw .5 H u doom :2" @585. .5

39 u 85. 5.. o». 55mma52: $5888 5 En» gamma—Q u m

ma u 88.— 50. o». m<5¢~o5m =33 - 3552— ».35 5589 $5685 a:
m5©85m 55552: .mq. <58 .35 H 8 m.

 

 

135

_n<

<fim55\§52.5 mow—m macaw u m Na. + 75mg.

 

X... n 85.58 ..2. 5955855" 9.585. r ..9. @5585 ._ ..5. m: x... 5 885$. .<.
om: u o 5. r o u 608 so» :8 $589. .5 a u Dog :8 2588‘ .5

Zr. n 85— 5a. 0.. 55558585" mgnmflnm 5 5555\5585 8853. u q

mg. n 85— 5a. 0.. $55.65,; :53 - 3553 ~35 5589 $5585 a:
m5vno5m 55555» Amq <58 ~35 H 8 m.

 

 

 

136

We

.095... mom—Hm macaw" Mum... IH<H owe

 

 

X... n 88888 «on 55.58559 8588. H. ..5. m5v85 . 3.. w: x: 5 358ch .c.
3.. u c 5. H" o u H58 non :8 8585. .5 H u 008 F8 8588. .5

So u 85H 5o. 5. 5558583 3.3898 5 .052... 88%—u. u 0

mg. n 83: 5o. 2. $5588 H889 - 06853 H.35 5585 855858 c:
3.56858 5.0.9555" .ma. <58 H.565 H 8 m5

 

 

137
Example Calculations

 

m n. fl EZOHus'Cg méadzw

$58 5 H85. 98 m5¢85m Iv \
H w w A m...

<H.H.>HSHZ >25 ’32ng mgvgzmza

H... H I' 65855 9558558 1 HH
5 u u IV 535:: m «up
A2555 0
5555 D

2553555
H35 . 4 4 A

058 5888 585.. n
0585558” pr u H“ XxHAW u H“ XmH u H“ me u H“ me u H“ 59.»: 058. Xu 0
m4u£§<u5MXau H+ H+ H+H+Hum

5555\3585 momma 298 u M X: + 349. u m + Q X 8 u .mwm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPENDIX I

1%

 

 

APPENDD< I
Menopause Information Instrument
Answer Key
Item Number Correct Answer
1 b
3 a
4 d
5 b & e
6 d
7 a
8 d-or-a&b&c-or-
a&b&c&d
9 dfina&b&cmn
a&b&c&d
1 0 false
1 1 true
1 2 true
1 3 true
14 true
15 false
1 6 true
1 7 true
1 8 true
1 9 c
20 d
21 d

APPENDIX 1

139
APPENDR I
fiesslhfleasearuihderhaihxpunnsflorlhutkipants

Contact: Marilyn Rothert. Nurein;
(517) 355-6525
or To- Oewald. Neva Bureau
(517) 355-2281

 

MSU ESTROGEN STUDY
SEEKS PAETICIPANTS

EAST LANSING - A Michigan State University etudy on Ienopauae and the uae
of estrogen ia in need of participante.

The atudy. which in being conducted by the HSU College of luraing. will
aurvey at least 200 wonen. gathering their thoughta on nanopauae and the uae
of eatrogen replacenent therapy.

To take part in the atudy. a wonan luet be between the agar of 45 and 55.
not preeently taking eatrogen. and not had a hyaterectony (eurgical renoval of
the uterua). Participante will apend about an hour completing a questionnaire
on their experiencea. All information will be kept confidential.

.An optional queation-and-anewer eeaaion with a nuree will follow and wonen
who chooae to attend will obtain infornation about the benefite and riaka of
eetrogen replacement therapy.

Henopauee ie the tine in a wouan'a life when her body reducea ita production
of the female her-one eatrogen. aaid Marilyn Rothert, aaeociate profeeeor of
nuraing at USU and principal investigator for the project. Iatrogen replacenent
_therapy in one nathod often ueed to deal with the phyaical diecolforte which nay
accolpeny nanopauae.

whether to uae eatroeen ie one of the hardeat deciaiona a wonan will lake.
Rothert said. While it doea offer lone relief for auch problena ea oateoporo-
eie (brittle bonea) and hot flaehee. there are none riaka ea well. euch ea the
threat of cancer of the uterus.

(lore)

     

'JICHIUAN THINK UNIV! HSITY 0 DIVISION ()I UNIVLH'SITY HI LAHONS 0 [ASI LAN‘HNG MICHIGAN 48834 ‘oU-M

MSUanJmm-Wm

Page 2 - Eatrogen Study HSU News Bureau

140

"Deciaion-making regarding eatrogen uae and menopauee hae been atudied from
the perspective of phyeiciana. but little in known about what ie important to
wonen ea they face this decieion." aaid Rothert.

The information gathered in thin atudy will be used to develop an educa-
tional program for wonen to help then become more inforned deciaion-makere about
eatrogen and menopeuae.

The project is funded by the National Center for Nuraing Research.

For more information. contact Rothert or Jill Kroll, USU College of Nuraing,
(517) 355-6744.

ltno!

APPENDIX K

141
APPENDIX K

Participant Recruitment Letters
MICHIGAN STATE UNIVERSITY

 

COLLEGE OF NURSING 0 DIVISION Of UFElONG EDUCATION 0 A230 mi Science: Budding 0 East laneeng. “It‘ll.“ “824-15" 0 Area Code “NBS-6525

Octal! 15, 1987

Me.JaneDoe
kzynuuninatimcmrda
1122mm

Lanaing,HI 99999
Denrlb.me:

maidugnnStateUnivu-aitymuegeofburaingiaMaetudyoffla
experimerrlexpectntimaofmregnrdhgmme,uauntie
Wmmmmmmmmmmmrqm
tlmpy(mr). 'meinfcrnmtimwillbetnedtodevelwducntimlmtetma
mulpmbmmmmfamddmidmmkuemmmmm
ERI‘. Weereamtacungwumprinmrilyflmaghlocnldmrdnsammldlike
tohmifmyminyourdumdxareintereatedinprticiptirginthe

stay.

sunyperticirmntaehouldhebetwmtlmegeaoffianISSyeeraoldm
Englieh—epealdng. witianlly.weereaakingtlntprticipntamtmvetmd
ehyaterectauymrlmtbetakingesu'ogma.mmprticiptewinrmdn
aeriea of written canes describing ficta'e related to muse, an! irritate
Imwlikelytluyuouldhetotakemmendiaae. 'meywillaleoenewer

otherqueetiaxaregnrdingtlmirperceptimofmexpu'imewith

mnamm, mmmm,mm. mums.
4824-1317. mitianlmeetiryawillbeadmuledintbfitm.

MSL u an Afflmumc Aunon Equal Opportunm lnsmunon

I42

Pagez

Ifymvnfldlikemeinfumtimtaxttheehfly,ortmvemflnvnuld
liketoparticipte.younnyantactJill,Suecm-nmatthemllegeof

Nureing at Hidtigan State Uruvereity. at (517) 355-6525.
Buloeedaremmfmtiamlmterialemmetudy. Pleaaehelfrme
tomanyoftheeenmtnialaanddiatrihatea'poettlm. Ifyouwould

likeadditianlapieaofthienmtedalpleaaecanJina'aieatthem
above.

Jinwinbeantactimyuibytelefiuninflmmrmtmtoleamm
thereareanyqaeatian.

Myoufa'yuxrhflp.

Simly.

Marilyn Ibthert
Associate Profeaecr arr!
Director for Lifelay Educatim

Jill Knoll
Renard: Aaaiatant

APPENDIX L

143
APPENDR L

Participant Sign-up Sheet
W W W

MIGHGAN emu: mm
m (P mm

The Michigan State University Cbllege of Nursing is mnducting a study of the
experimsudatpecutiomofwummgardmgmnpame,ardmtismportantm
thanindecidingwleflmerormttotakeestrogmreplacanmttlnnpy(m). 'lhe
infanmtionwinbemedtodevelopedwadormlmterialsmrelpmbeoamme
informed decision-nexus regarding unmopause and m.

mmmipeteinflestmycanetoametingmsperdMIrar
outpletingthequestiorruires. Afterthisthereisaninfcrnmlqnstimarflanswer
periodwithamrsetoansweryuxquestionsaboutmmopause. Studyparticipants
stmldbebetweentheages of 45am55 years oldandEnglish-speaking.
Additionally, we are asking that sttrly participants mt be presently taking any
MotestrogmsamthVehadahysterectany.

Hanan who participate in the study will read a series of written cases describing
fictorsmlatedtomanpause.ammicatemwlikelytlwymumumtakemm
eachcase. Ihaywinalsoanmoflaerquestiomregardingtheirperceptionsof
andexperiencewithmempame. 'mosewl'oduoosetoprticipatewillalsobeasked
tosignaaansent form.

mmmnmmpammpamrwmmgemmmwmmm
MORGANSMTEWITYAT3SS-67MQWMMMWWHTO:
WWW, mwwasm, DEGIIGAN SET! tmvmsm, 421

wasrmm.aasrmrsm.m48824.

Ifymhaveanyquestimsregardingthe stdyyounmycnntactaiemmineauorm
at the College of Nursing at Michigan State University, at (517) 355-6525.

thank you for your interest.
Marilyn Ibthert. R.N.. Ph.D.
Associate Professor and
Director fcr Lifelcng Education

Please cmtactnnabwtpmflicipatimintheflfl‘stulybeingaxdwtedbythe
college of Nursing at Michigan State University.

 

 

 

 

Nam: Session you wish to attamd:
Telephone: (my) __ Them, Dec. 1, '7-9 pan.

(mung) _ Wed., Dec. 9. 12-2 p.m.
Address: _ Mar... Dec. 14, 7-9 pan.

 

mes" Dec. 15, 7-9 pan.

 

Medidwanarabomzthemsuxly? Other:

 

 

 

 

 

Additional dates will be edueduled in the future. Please call 355-6744 for
infatuation.

APPENDIX M

144

APPENDIX M

Newsletter Example

WWWW
MOHGANSETEWITY
mmmrm

The Michigan State University (bilege of Ntn'sing is oa'ducting a stuiy of the
experiencesandexpectations ofunmrsgardingmernpause,ammat is
hlportanttomanindscidingvheflierormttotakeestrogmreplacamt
therapy (HIT). Tm infmnation will be mod to develop educational materials
tohelpmbecanemre infmnsd decision-nekers regarding menopause and
Estrogen Replacanent Therapy. We are looking for English-speaking when
bebueentheagesofIISandSSyearsoldvd'nhavemthadahysterectanyard
wlnaremttakingestrogen.toparticipateinthestuiy. Marlenwln
participate in the study will be asked to read a series of written cases
describing factors related to nenopause, and indicate how likely they would
bemtakemineachcase. 'Iheywillalsobeaskedtoanswerother
questions regarding their perceptions of and experience with mpause. Nam
interestedinparticiptirginthesttfiymuldmtoaneetirgandspafi
aboitllnircarpletingquestiomaires. Afterthistherewmldbean
infomalquestimmfiansverperiodvdthamrsetoanswerqiestimsabwt
mnpause.
mmumummmcmmmmwammmormmm
MICHIGAN 5mm LNIVERSITY AT 355-6744 (1! mm o
'lI-IECINMPERSNEORYOURGW.

APPENDIX N

145

 

APPENDR N
Additional Information Packet
MICHIGAN STATE UNIVERSITY
COLLEGE OF NURSING 0 DIVISION Of LIIEIONG EDUCATION 0 A250 Life Sciences Building 0 Fan taming. Michigan «cu-m? 0 Am Code “hiss-6525

Septamer 17, 1987

Dear Interested Participant:

mmmanStatemuveraitymllegotmdmiaaxductimaeuflyofflm
experiencesandexpsctatimaofwumrsgardingmmmanifintis
totlunindecidingmcrmttotake replacanmt
therapymm'). ‘meinfounatimwillhemedtodevelopedwatiomlunterials
tohelpmbeouneminfanmddecisiaHmket-sregardimmuseam
ERI‘. Wearecxntactimwunenprinmrilythrmghlocalm'sgroups. m
mmawymightheinterestedinpnrdciptingintlnstudymuMue
toameetingandspendahoutlrnurcmpletingthequestiamaires. After
armlcpestimarxlmperiodwithamseto
myun'questimaahoutmuse. Sttflyprticipuutsslmldhebebdem
tlieagesofllSarrlSSyearsoldarflErglislr-spakirg. Adiitianlly.weare
askingtlutetmyprticipmmtsmtbepresmtlytakingmykirflofestrogun
and hysterectauy. luminymrgmpvdnareinterestedin
theetudy mtfitthesecriteriaareweloanstojoinmemseting
andparticipateinfltequsstimelflmperind.

a
I
E
E

gs
3E
89

theatudywillreuaseriesofwrittencases
srelatdtomme.am1rdicateluw1ike1ytluyvnfld
Eminenchcase. 'Iheywillalsoanswerotherqaestims
rsgardimmirperceptimaofatrieatperiencewithmuse. 'Ihe
infometionaheetattadtedexplainetheatudymanpletely. 'nneeuho
dwosetoprticipatewinaleoheaskedtosignacmserrtfcnnmu

IfywtmveanyqxstimsregrdingthsetuIyywneyantactJinKron,an
ofqrreeeardmuaistante.a'matflmmllegeofmin;atmdxigan8tate
Ihiversity, at (517) 355-6744.

'lhankyouforyourhelp.

I;
g:

%

MSL‘ us an Affitmamr Action Equal Opportunm lmmunon

146

information Sheet

This research, sponsored by Hichigan State University College of Nursing,
studies the judgments of women regarding estrogen replacement therapy (ERT) as they
anticipate and experience menopause. The decision to take or not to take the
hormone therapy is complex. For example, while the use of ERT relieves hot flashes
and decreases the risk of brittle bones (osteoporosis) it may also increase the risk
of endometrial cancer. As such, women need to be fully informed of the risks,
benefits and implications of ERT for the relief of menopausal symptoms so that they
can make informed decisions.

in this particular study, we are interested in what women feel are important
factors and considerations in taking ERT and what decisions they would make given
various hypothetical situations. He are also interested in the relation of various
factors to decisions regarding menopause. These factors include previous health
behaviors, perceptions, management and knowledgement of menopause, and expectations
and experience with menopause. Ultimately it is the intention of the research team
to use the information in designing an educational program for nurses so that they
can help women make informed decisions regarding ERT.

During the study, care will be take to ensure confidentially of all participants
answers, and women who choose to participate will be free to discontinue their
participation at any time during the study. A nurse will be on hand to answer any
questions women may have about the study and about menopause. Finally, results from
the study will be made available to all those who request it.

147

Consent Form - Phase I Survey

One option for dealing with some menopausal symptoms is taking hormones
or estrogen replacement therapy. The College of Mrsing at Michigan State
University is conducting a study to better understand how women make decisions
about whether or not to use estrogen. The results fran this study will be
used to design materials which can be used to help wanen make informed deci-
sions about whether or not to take estrogen replacement therapy.

In this survey. you will be asked a number of questions about your
perceptions. expectations and experience with menopause and what you would
decide about estrogen replacement therapy given some hypothetical situations.
You will also be asked to give information about such things as your marital

status, age and education.

By signing this form I understand that:-
l. I have freely consented to take part in this study.

2. The study has been explained to me. Furthermore, I understand
the explanation that has been given to me and what my participa-
tion will involve.

3. I am free to discontinue my participation in the study. at any.
time without penalty.

4. My responses will be treated with strict confidence and all
participants will remain anonmws.

S. I will be responding to written information.

6. It will take approximately 60 minutes to couplets the
questionnaires .

7. I am not guaranteed any beneficial results from my participation
in this study.

8. i may be contacted at a *later time to participate in a later
phase of the research. Based on preliminary analysis of responses
from the initial study, a second study will be done-with selected
representatives of participants frm the original study. If I'
am contacted at a later time, I will be under no obligation to
participate further in the study.

9. Results of the study will be made available to me at my request.

figned :

Date:

APPENDIX 0

I48
AJTHBVEHXKD

(kxuwnuifixmn
Consent Form - Phase I Survey,

One option for dealing with some menopausal syumtoms is taking hormones
or estrogen replacement therapy. The College of Nursing at Hichigan State
University is conducting a study to better understand how women make decisions
about whether or not to use estrogen. The results from this study will be
used to design materials which can be used to help women make informed deci-
sions about whether or not to take estrogen replacement therapy.

In this survey. you will be asked a number of questions about your
perceptions, expectations and experience with menopause and what you would
decide about estrogen replacement therapy given some hypothetical situations.
You will also be asked to give information about such things as your marital
status, age and education.

 

By signing this form I understand that:
l. I have freely consented to take part in this study.

2. The study has been explained to me. Furthermore, I understand
the explanation that has been given to me and what my participa-
tion will involve.

3. I am free to discontinue my participation in the study at any_
time without penalty.

4. My responses will be treated with strict confidence and all
participants will remain anonymous.

5. I udll be responding to written information.

6. It will take approximately 60 minutes to cmplete the
questionnaires.

7. I am not guaranteed any beneficial results from my participation
in this study.

B. I may be contacted at a later time to participate in a later
phase of the research. Based on preliminary analysis of responses
from the initial study, a second study will be done with selected
representatives of participants from the original study. If I'
am contacted at a later time, I will be under no obligation to
participate further in the study.

9. Results of the study will be made available to me at my request.

Address: §190€d§

 

Date:

Phone:

APPENDD< P

149
AKPPEHQEHJI IP

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The Michigan State University College of Nursing is trying to
better understand what is important to women when they decide
whether or not to take estrogen (hormone) replacement therapy for
menopausal symptoms. He know that some women decide that they went
hormonal therapy as they approach menopause, others decide that
they do not, and others are undecided or don't feel they have
enough information.

Our goal is to better understand how women make this decision. At
the completion of this project, we will use what we have learned to
develop materials to help women have the information they need to
make the best decision regarding hormonal or estrogen therapy.

He are asking you to help us with the project by answering some
questions and giving us your thoughts about some written
situations. We are asking women who are between hS-SS years of age
who have not had a hysterectomy (removal of the uterus or womb) to
participate in the study. This will include women who are
approaching menopause and women who are now experiencing menopause.

The information you give us will be used only for this study. All
information obtained will be treated with strict confidence.
People will remain anonymous, that is, the information collected
will be identified only by a code number and the researchers will
be the only ones who know which number is assigned to whom.

Your decision to participate or not to participate in this study
has nothing to do with the health care you receive. You have the
right to withdraw from the study at any time without penalty.
Hhiie we appreciate you answering all of the questions, you have
the right not to answer a question if you choose.

This task is estimated to take about 1 hour. first you will be
asked to answer some written questions about menopause. Then you
will be asked to read some situations and tell us how likely you
would be to take hormone therapy in those situations.

The results of the study, while not of direct benefit to you, will
help us find weys to help women have the information they need to
make the best decision for themselves regarding estrogen
replacement therapy. Without your help we could not do this study,
and we greatly appreciate your cooperation. if you would like a
report of the study when completed, please indicate it on the
enclosed form.

Thank you for your help.

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Please send me a copy of the results of this study.

Name
Street _,
City in

 

APPENDIX Q

150

 

APPENDR Q
Example Thank-you letters
NHCJHCLKNISTATETUhHVERSFFY
COLLEGE Of NURSING 0 DIVISION Of LIFELONG EDUCA‘DON 0 A230 Life Sciences Building 0 ha unsung. Michigan 48824-13!” 0 Area Code “7655-6525

threater’ls, 1987

He. Jane Doe
1212 State Street

Lansing, MI 99999

Dear Ms. Doe:

Thank you very much for your‘help in coordinating theemeeting for the
estrogen replacement therapy study. we appreciate your‘help and thank you
for the use of for participating. The information your group»prowided
‘will he need toilearnimore about:menopauee and about‘what is important to
erneriirnneking the decision regarding estrogen therapy. ‘Ultimately, the
infermaticn your group and other participants have provided will be used
t0>develop»educational materials for women, tijrovide the information
they need aboutimenopauee and to‘help themlmake informed decisions about
estrogen therapy and other health care issues.

If participants completed the formnrequeating a copy of the results<of
this etudy'when it is completed, we*will sand themlwhen they’become

available. nesults‘may be available in 6 to 10 months.

Again, thank you very'murhifcr your'helpu and if in the future»you‘hear of
any individuals or group-.ct'woneniwholmay be interested in participating

in the Estrogen Replacement Therapy Study please final free to contactiJill
Kroll or myeelf at 355-6744, or tc»ahare this telephone number with them,

and encourage themlto»contact us.

Sincerely,

lurilyn.nothert, stun, Ph.D.
.Aeeociate Professor and
Director of Lifelong Education

MSL' u an Affirmative Amen Equal Opponunm lnsmuan

151

MICHIGAN STATE UNIVERSITY

 

COLLEGE Of NURSING 0 DIVISION Of LIFEIONG EDUCATION 0 A230 Life Sciences Building 0 Last Isms-mg. Much-gen 48824-15” 0 Area Code ”71399-6323

Jarmary 4, 1988

Ms. Jane Doe
4444 City Road
West Bloanfield, MI 48322

Dearbb.lbe:

'I'hankymverynuzh forparticipating in the estrogen replacement therapy
study being conducted by the Cbllege of Nursing at Michigan State
University. 'me infatuation you provided will be used to learn sure about
nernpeuseandaboutwhatisinportanttovmeninnakingthedecisim
regarding estrogen therapy. Ultimately, the intonation you and other
participants have provided will be med to develop educational naterials far
yum, toprovidet‘ne infmrationtheyneedaboutmmeandtolelptlm
make infmned decisions about estrogm therapy and other health care issues.

Ifyoucalpletedtheformreguestingaapyoftheresultsofthisstudym

it is carpleted, we will send them when they became available. Results my
be available in 6 to 1a maths.

Again, thank you verynuch for your help.
Sincerely,

Marilyn Rothert, R.bl., Ph.D.
Associate Professor and
Director of Lifelong nitration

MSL‘ u an Afflifl‘lllfl't Aaron/Equal Opportunm lnsmuuon

152

MICHIGAN STATE UNIVERSITY

 

COLLEGE Of NURSING 0 DIVISION Of UfEiONG EDUCATION 0 A230 Life Sciences Building 0 he! Loafing. Michigan 48824-15” 0 Area Code 517855-6525

Octdaer 9, 1987

Any Giurch of Lansing
3333 (Jim-ch Street
Iansing, MI 99999

Dear Pastor:

'Ihank you very and: for your diurdi's participation in the estrogai
replacenent therapy study being conducted by the Cbllege of Nursing at
Michigan State University. We appreciate your help in putting in in mntact
with your mnen's group and thank the grow for participating. 'lhe
infomatimprovidedbytlewuminyurchurcharxiomerdmrdieswillbe
usedtoleammreabaitnernpauseandaboutmtisinportanttovnnmin
making the decision regarding estrogen therapy. Ultinately, the information
will be used to develop educational materials for warren, to provide the
informationtheyneedabwtmmcpauseandtohelpthemuake infa'med
decisions about estrogen therapy and other health care issues.

Iftheparticipantsfranyoxdmrdianpletedfluformrequestmgacopyof

theresultsofthis studywhenit isompleted,wewilleendtlmtheresults
whentheybecaneavailable. knitsnaybeavailable in6 to lflmnths.

Again, thank you very m fer your help.
Sincerely,

Marilyn Rothert, R.N., Ph.D.
Associate Professor and
Director of lifelong Edination

MSL' is an Affirmative Amon‘Equai Opporlumn lnsmunon

APPENDIX R

153
Appendix R
Calculation of Omega-squared ((02)
An Estimate of Treatment Effect Magnitude

From Kepple (1982):

(02 = ssbn - (a-1)(MSwi)

 

SST + MSWi

where:
SSbn = Sum of Squares Between Groups

SST = Sum of Squares Total
Mswi a Mean Square Within Groups
a = Number of Groups

APPENDIX 5

154
Appendix 5
Calculation of Correction for Unreliability

 

1" = 1‘
xytrue xy obt
«xx NEYY
where:
r - True correlation
"ytrue
r - Observed correlation
xy obt
«En - Reliability of measure x
«5”, - Reliability of measure y
From : Edwards, A. L. (1954). W

New York: Holt, Rinehart and Winston.

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