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This is to certify that the

thesis entitled
THE RELATIONSHIP OF LEVEL OF WOMEN'S KNOWLEDGE
OF MENOPAUSE TO LEVEL OF ADHERENCE TO PLAN FOR
EXERCISE, CALCIUM SUPPLEMENTATION, AND
HORMONAL REPLACEMENT THERAPY

presented by

Ann N. Fowler

has been accepted towards fulfillment
of the requirements for

Master of Science degree in Nursing

 

. 97/444477 Xd/d/Zé/W

Major professor

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THE RELATIONSHIP OF LEVEL OF WOMEN'S KNOWLEDGE OF MENOPAUSE
TO LEVEL OF ADHERENCE TO PLAN FOR EXERCISE, CALCIUM
SUPPLEMENTATION, AND HORMONAL REPLACEMENT THERAPY

BY

Ann W. Fowler

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree

MASTER OF SCIENCE IN NURSING

College of Nursing

1996

ABSTRACT
THE RELATIONSHIP OF LEVEL OF WOMEN'S KNOWLEDGE OF MENOPAUSE

TO LEVEL OF ADHERENCE TO PLAN FOR EXERCISE, CALCIUM
SUPPLEMENTATION, AND HORMONAL REPLACEMENT THERAPY

BY

Ann W. Fowler

Women desire information about menopause. Failure to
obtain this information may affect their capability for
self-care. This study utilized a convenience sample of 201
women age primarily between 40 to 55 years of age to examine
the relationship between knowledge of menopause and
adherence to plans for exercise, calcium supplementation,
and hormonal replacement therapy (HRT). A self-care
framework was used. The women scored 88% on the knowledge
instrument. Those who planned to exercise did so 59% of the
time, those who planned to take calcium supplements did so
77% of the time, and those who planned to take HRT did so
95% of the time. There was no relationship between
knowledge and level of adherence to plan for exercise,
calcium supplementation, or HRT. Implications include
continued client education about menopause and further

research to determine what influences adherence to self-care

measures .

To Bob, Rob, and Dan for their loving support.

iii

ACKNOWLEDGMENTS

To Dean Marilyn Rothert, Brigid Warren, and Georgia
Padonu, I wish to express my deepest gratitude for their
participation in the development and completion of my
thesis. Their guidance and professional insight as thesis
committee members was most appreciated.

Many thanks to Dean Rothert who served as the chair of
my thesis committee. She took time out from her very hectic
schedule to answer my questions, find the right resources,
and provide positive feedback. Her encouragement and
realistic perspective on the entire thesis process promoted
a sense of optimism that this project could and would be
accomplished.

I also wish to thank Jill Kroll who spent many hours
helping me to develop a thesis question, determine what data
to look at, and how to make sense of it all. Her knowledge

of the parent study was invaluable.

iv

TABLE OF CONTENTS

LIST OF TABLES . . . . . . . . . . . .
LIST OF FIGURES . . . . . . . . . . .
INTRODUCTION . . . . . . . . . . . .
THEORETICAL FRAMEWORK . . . . . . . . . .
CONCEPTUAL DEFINITIONS . . . . . . . . .
REVIEW OF LITERATURE . . . . . . . . . .
METHOD 2 . . . . . . . . . . . . . .

De51gn . . . . . . . . . . . . . . .

Operational Definitions of Variables

Instrumentation . . . . . . . . . .
Sample . . . . . . . . . . . . .

Data Collection Procedure .
Data Analysis . . . . . . . . .
Protection of Human Subjects . . .

RESULTS 0 O O O O O O I O O O O O O O 0
Analysis by Research Question . . .

DISCUSSION . . . . . . . . . . . . . . .
Research Questions . . . . . . . . .

and

Implications for Advanced Practice Nursing

Primary Care . . . . . . . . . . . .
Recommendations for Future Research
Limitations of Secondary Analysis .
SUMMARY . . . . . . . . . . . . . . . . .
LIST OF REFERENCES . . . . . . . . . . .

APPENDICES O O O 0 O O O 0 O O O O O O O

22
22

24
26
28
28
28

28
28

32
33

36

47

47

49

54

LIST OF TABLES

Table Page

1 Sociodemographic Characteristics of Sample . . . . . . 25

vi

LIST OF FIGURES

Figure Page
1 A Conceptual Framework for Self-Care of the Menopausal
Woman . . . . . . . . . . . . . . . . . . . . . . . . . 7
2 Frequency Distribution of Knowledge Scores . . . . . . 30
3 Frequency Distribution of Adherence to Exercise . . . . 30
4 Frequency Distribution of Adherence to Calcium . . . 31
5 Frequency Distribution of Adherence to HRT . . . . . . 32

vii

INTRODUCTION

As women enter midlife they begin to experience
menopausal symptoms. This normal phase of the life cycle is
unique for each woman. Menopause has been viewed negatively
by society which places high value on the reproductive
ability of women (Frey, 1981). Rather than look at
themselves in a negative fashion women are seeking
information regarding menopause, its symptoms, and
indications for self-care. With roughly half of their lives
before them, women want quality of life in the
postmenopausal period. Menopause is an integral part of
women's health.

The advanced practice nurse (APN), with experience as
an educator, has the ability to fill in the educational gaps
that exist for the majority of middle-aged and younger women
concerning menopause. By sharing scientific knowledge and
providing access to primary care, the APN can collaborate
with female clients to meet their identified needs.
According to Pender (1987), client education for health
promotion emphasizes higher levels of wellness, fulfillment,
and life satisfaction. The health of women can be
actualized at any phase of the life cycle when these

outcomes are reached: "physical fitness, good nutritional

2
status, creative relaxation, self-awareness, enhanced self-
esteem, expanded social support systems, and attainment of
important life goals"(Pender, 1987, p.209).

Primary care is the setting in which the APN can
collaborate with women to see that these outcomes do occur.
All women deserve access to healthcare. As healthcare is
changing, women's health programs are being developed to
meet the specific needs of women throughout the lifecycle.
Research funds are increasingly being allocated for women's
health issues (Hickey, Ouimette,& Venegoni, 1996).

In determining client teaching priorities, Futrell et
al. (1980) have identified two goals for improving self-
care: to determine what issue is most important to the
client and what area of knowledge will contribute the most
to improving the client's health. The APN tailors health
education to focus on the topic that is currently most
relevant to the client. The maintenance or enhancement of
the health of the client can be achieved as the APN provides
the client with the knowledge base that is necessary to meet
the client's needs. Continual assessment of the client's
knowledge level and ability to incorporate what has been
learned into daily self-care measures is necessary to
individualize education for the client.

In an educational intervention study conducted by
Rothert (1990) women who volunteered for the study made the
topic of menopause a priority through their self-selection

for the study. These women decided what was on their minds

3
by answering the media advertisement to participate in the
study. In the year that followed, the women kept track of
their self-care measures for exercise, calcium
supplementation, and hormonal replacement therapy (HRT).
They decided on a daily basis what self-care measures they
would implement.

The purpose of this study is to determine the
relationship between the level of women's knowledge of
menopause and their adherence to their plan for exercise,
calcium supplementation, and HRT. As an educator, the APN
needs to understand what impact knowledge of menopause has
on women's self-care strategies.

ResearcLQusstions

The research questions for this study are: Is level of
knowledge of menopause associated with adherence to
exercise? Is level of knowledge of menopause associated
with adherence to calcium supplementation? Is level of
knowledge of menopause associated with adherence to HRT?
Wage

The results of this study have the potential to provide
the APN with a stronger understanding of the impact of
education on the menopausal woman. This study will yield
information showing whether providing appropriate knowledge
required for self-care measures has the potential to improve

adherence to self-care. The APN works in partnership with

4
the menopausal woman to maximize her health for the
perimenopausal and postmenopausal period of the life cycle.
THEORETICAL FRAMEWORK

The self-care deficit theory of nursing (S-CDTN)
developed by Dorothea Orem (1980) will serve as the
theoretical framework for this study. Orem's theory
consists of three interrelated theories: self-care, self-
care deficit, and nursing systems. Self-care is defined as
behavior that has been learned through interaction and
communication in larger social groups. Self-care is
considered to be deliberate and is performed in response to
a known need. It is not instinctive or reflexive.
According to Orem, individuals possess the ability and
motivation to provide care for themselves and dependents.
Unfortunately, not all individuals will seek knowledge or
act (Orem, 1980).

Self-care deficit acknowledges the fact that
individuals may periodically experience limitations that
prevent them from meeting their self-care needs. These
limitations may arise from internal or external factors. If
a legitimate need exists, then the nurse may address the
self-care deficit of the individual (Orem, 1980).

The purpose of the nursing system is to increase the
client's capabilities to meet a need or to decrease the
demand. The nursing system is composed of the nurse and the
patient. If a family member is involved in the care of the

client, then this person is also part of the nursing system.

5
Together the actions of the nurse, client, and family
caregiver make up the nursing system (Orem, 1980).

Orem (1991) views self-care as deliberate, learned
behavior. She sees self-care as goal-directed behavior with
a specific purpose. Self-care occurs in phases. Prior to
performing a specific self-care action, knowledge of the
action and its relationship to continued life, health, and
well-being are required. The phases of seeking knowledge
and decision-making must take place prior to self-care
action. As new life events such as pregnancy and menopause
occur, individuals seek out information. One way that
individuals learn to understand about their individual needs
and the self-care actions necessary to meet these identified
needs is through interaction with healthcare professionals.
Such an interaction allows the intermingling of scientific
knowledge from the healthcare professional with the personal
knowledge of the individual (NDCG, 1979).

In the educational intervention study conducted by
Rothert (1990), the research team functioned in a
supportive-educative capacity as the women performed all the
self-care activities (Orem, 1991) over the twelve month
intervention period. By volunteering for the study the
women sought knowledge about menopause and received
education in the form of the study's intervention. As they
continued to participate in the study, these women
continually made decisions about their self-care activities.

They documented whether or not they performed the self-care

6
measures of exercise, calcium supplementation, and/or HRT.
According to Orem (1990) these women had the right and
capability to be knowledgeable participants in their own
health care. The researchers supported and facilitated the
self-care measures of these menopausal women through the
educational intervention (Orem, 1990).

For the purpose of this study only the concept of self-
care as it pertains to menopausal women will be considered
(Figure 1). The model presents a bidirectional relationship
between the menopausal woman and the APN. With each
interaction, there is an opportunity for an exchange of
information between the APN and the woman.

Women's self-care deficits with regards to menopause
are not being studied at this time. In this research
setting, the women possessed primary responsibility for
their personal health. The researchers functioned in a
consultative capacity (Orem, 1985).

CONCEPTUAL DEFINITIONS
W

According to Webster's Ninth New Collegiate Dictionary
(1986), knowledge is the fact or condition of knowing
something with familiarity gained through experience or
association; the acquaintance with or understanding of a
science, art, or technique; and the sum of what is known:
the body of truth, information, and principles acquired by

mankind (p. 665).

Menopausal Woman ‘ § Advanced Practice Nurse

 

(Personal Knowledge) + Supportive/Educative _.>(Scientific Knowledge)

\

Performs Self-care

Figure 1. A Conceptual Framework for Self-Care of the

Menopausal Woman

Menopause is the cessation of menstruation due to the
loss of ovarian function as a result of surgery or natural
process. The menses must be absent for at least twelve
months. The perimenopausal period, also called the
climacteric, is the period of diminishing ovarian activity
before menopause and the first few years of amenorrhea.
Postmenopause is the span of life after actual menopause. A
normal developmental phase, menopause takes place between 50
to 51 years of age for women who have not undergone surgical
removal of their ovaries. Menopause occurs roughly at the
same time for each woman regardless of menses, childbearing,
socioeconomic factors, weight, or race. Each woman can plan
on spending about one-third of her life in the:
postmenopausal period (McCance & Huether, 1994).

This author defines knowledge of menopause as the
understanding of the physiology, symptomatology, and
treatment measures/options/risks related to menopause.

Failure to have adequate information about menopause

8
threatens the control a woman has over her own body
(McElmurray & Huddleston, 1991). Unfortunately, women's
knowledge of menopause seems to be defined by what they do
not know. Women have been tested to ascertain their
understanding of this natural event. Even when a woman
feels well-informed about menopause, this is not always the
case when tested (LaRocco 8 Polit, 1980). According to Cook
(1993) some of the problems associated with perimenopause
can be lessened and potentially disabling problems avoided
through education concerning aging, menopause, osteoporosis,
sexuality, self-esteem, and treatment alternatives.
Adherence

Webster's Ninth New Collegiate Dictionary (1986)
defines adherence as a steady or faithful attachment, an
act, action, or quality of adhering (to bind oneself to
observance) (p. 56). The medical literature frequently
interchanges compliance with adherence. Sackett and Haynes
(1976) define compliance as the extent to which a person's
behavior coincides with medical advice. In the spirit of
developing a partnership with clients rather than a
paternalistic relationship, this author would prefer to
refer to client behavior as adherent.

These two variables have been chosen as a means to
understand what may influence how a menopausal woman
performs self-care. Each woman brings personal knowledge to
her own experience of menopause. The APN provides

scientific knowledge that the woman may or may not possess.

9

Women require both personal and scientific knowledge to make
decisions about menopause (Rothert, Padonu, Holmes-Rovner,
Kroll, Talarczyk, Rovner, Schmitt, & Breer, 1994). By
looking at level of knowledge of menopause and adherence to
plans for self-care after the women have undergone an
educational intervention, this study hopes to find that the
supportive-educative interaction that the research team had
with study participants made a difference in the women's
adherence to plans of self-care.

REVIEW OF LITERATURE
Was

Within the healthcare literature the dissatisfaction of
women with their knowledge of menopause is documented
(Andrews, 1995). A recent Gallup poll of North American
women in the 40 to 60 age bracket showed that only 44% were
satisfied with the knowledge that they received from their
physicians regarding menopause (Utian & Stiff, 1994). This
sends a clear message that the information regarding
menopause is not reaching the people to whom it is most
relevant: women.

LaRocco and Polit (1980) studied the relationship
between a woman's level of knowledge and her background
characteristics. Using a mailed questionnaire, data were
collected from 167 women from 40 to 60 years of age, in an
urban setting. The results indicated that younger women,
women who were employed, and women with higher levels of

education were more knowledgeable about menopause than

10
older, unemployed, and less well-educated women. The
authors noted that what the women feared most about
menopause was not knowing what to expect. LaRocco and Polit
concluded that this gave nurses the opportunity to play a
supportive and educative role in helping women cope with
menopause and any potential problems (1980).

Johnson and Snow (1979) compared the concerns,
attitudes, and beliefs about menopause and menstruation of
31 patients in a prenatal clinic serving low-income
clientele with 24 students from a nearby university. The
data were gathered as part of a larger study about the
knowledge and beliefs of women regarding reproductive life.
The results demonstrated that young women of the same age
group living in the same geographic area can possess very
different knowledge about menopause and menstruation. No
assumptions could be made on the level of knowledge of
menopause simply on the basis of amount of education a woman
possessed. Anxiety and a deficiency of knowledge of
menopause exist for many women.

Millette (1981) surveyed the attitudes and knowledge of
menopause among 130 professional and blue collar employees
of a community hospital and local school system. A
difference was noted in the relationship between income
level and knowledge for the two groups of women. The women
from the upper income level demonstrated higher knowledge

scores .

ll

Frey (1981) studied women's perceptions of menopause
and their relationship to physical symptoms, psychological,
and sociocultural variables. The survey of 78 women, aged
40 to 60 years, investigated attitudes, symptoms,
demographic characteristics, mother's experiences with
menopause, age of menarche, number of children, and
socioeconomic status. The relationship among the
demographic.variables, physical symptoms, and attitudes
toward menopause was explored. The results demonstrated
that in general the women did not possess an illness
orientation toward menopause. Rather than devising a
treatment program focused on drug therapy or surgical
intervention, Frey recommended using support techniques,
teaching coping skills, and providing health-oriented
information to meet the needs of menopausal women.

The body of the literature pertaining to women's
knowledge of menopause is clearly lacking. More literature
regarding symptoms and symptom management can be found than
information about what women actually know about menopause.
In McElmurray and Huddleston's (1991) meta-analysis of self-
care and menopause, it was found that women have little
access to usable information regarding the menopausal
experience. Much of the literature at the time the meta-
analysis was conducted was written in technical language or
biased by either a disease-oriented or hormone-deficiency

perspective. McElmurray and Huddleston concluded that

12
without sufficient information, women are thwarted in their
attempts to control their own bodies.

The limited published research concerning women and
their knowledge of menopause underscores the important role
of the APN as an educator and researcher. Further studies
are necessary to determine what women currently know about
menopause. Then interventions can be devised to promote,
maintain, and enhance women's health (McElmurray &
Huddleston, 1991).

Wise

The following is a review of the literature related to
adherence to exercise. This author did not find studies
related specifically to knowledge of menopause and adherence
to exercise. Exercise has been discussed as a form of
symptom management in menopause. The exercise literature
discusses adherence to plans for exercise. Within the
osteoporosis literature, many articles recommend that women
in midlife should exercise to decrease the risk of
osteoporosis (Bond, 1991; Gregory, 1982; MacPherson, 1985; &
Wark, 1993). Appropriate exercise contributes to good
health and decreases the risk of disease (Bouchard,
Shephard, Stephens, Sutton, & McPherson, 1990).

Robertson and Keller (1992) developed a model to
identify the relationships between variables that explained
adherence to an exercise regimen for clients who had
undergone coronary artery bypass graft surgery (CABG) or

percutaneous transluminal angioplasty (PTCA). Thirty-one

13

percent of the variance in exercise adherence was explained
by perceived barriers, benefits, severity, self-efficacy,
and type of surgery. Perceived barriers contributed the
largest amount of variance, followed by self-efficacy and
type of surgery. The study findings suggested the
importance of self-efficacy and health beliefs in describing
exercise adherence in this particular cardiac population.
It should be noted that 75% of the 51 subjects were male.

Jensen and Lorish (1994) surveyed physical therapists
and patients to create a database regarding barriers
experienced in the implementation of exercise programs in
clinical practice. The questionnaires from 568 physical
therapists and 305 rheumatic disease patients were analyzed.
Patient survey results indicated that the difference between
patients who continued an exercise program from those who
did not were: patient beliefs about consequences, judgments
of consequences as positive or negative, and the importance
of the consequences. To enhance patient cooperation with
exercise programs, inquiry into the patient's belief system,
problem solving, and negotiation between patient and
therapist were recommended.. The authors did not
specifically state whether the survey measured the patients'
knowledge of their rheumatic disease as it looked at their
belief systems.

Wilbur, Holm, and Dan (1992) identified the
relationship between menopausal status, physical and

psychologic symptoms, and energy expenditure. Two hundred

14

and seventy-nine women, age 37 to 64, were included in this
second wave of a longitudinal study of midlife women's
health. Physical activity was explored as a means of
menopausal symptom management. Leisure activity energy
expenditure appeared to have a positive effect on decreasing
menopausal symptoms. Occupational activity energy
expenditure had a negative effect on menopausal symptoms.

Dzewaltowski, Noble, and Shaw (1990) compared the
theory of reasoned action, theory of planned action, and
social cognitive theory in the prediction of physical
activity participation. Two hundred and fifty-four
undergraduates self-administered a 7-day recall
questionnaire about the previous week's physical activity
participation. Then for each of the next four weeks, the
participants again completed the 7-day recall questionnaire.
The results demonstrated that self-efficacy was the better
predictor of exercise behavior than intention.

Lee (1993) conducted a telephone survey of attitudes
and behavior related to the adoption of exercise by 286
Australian women, age 50 to 64 years. The study identified
psychological variables that distinguished stages of change
related to exercise. The purpose of the study was to
identify possible targets for intervention. A multivariate
analysis of variance was performed for the three change
categories: precontemplators, contemplators, and
action/maintenance. Forty percent of the subjects reported

regular exercise. Precontemplators of change were

lS
distinguished from the action group by exercise knowledge,
perceived family support, and perceived psychological
barriers. The precontemplators were older, possessed lower
levels of exercise knowledge, viewed their families as less
supportive of their exercise activity, expected less
psychological benefits from exercise, and rated avoidance of
smoking as more important than exercise. Contemplators and
the action group were distinguished from each other by
perceived barriers. One third of all respondents expressed
a reluctance to go out alone to exercise and a reluctance to
use public changing facilities. More than half the women in
the sample viewed gyms and fitness centers as the domain of
younger people. The study found that there was a need for
basic information about safe and effective levels of
exercise activity for women in this age group. .Finally the
study identified attitudes and knowledge as potential areas
for future interventions with middle-aged women.

Bernhard and Sheppard (1992) conducted a cross-
sectional survey of 101 menopausal women who were over 40
years of age, menopausal, had not used hormones during the
last six months, and had an intact uterus. The study tried
to determine the relationship among menopausal symptoms,
perceived health, and self-care responses in perimenopausal
and postmenopausal women. The authors concluded that health
was related to self-care and menopausal symptoms.

The health-promoting behaviors of African-American

women were surveyed by Ahijevych and Bernhard (1994). The

16
187 women ranged from 19 to 69 years. The Health-Promoting
Lifestyle Profile (HPLP) instrument was used to assess the
health promotion activities of these women. Self-
actualization and interpersonal support subscales had the
highest means. The exercise scale had the lowest mean.
Dulberg (1992) also found that black women practiced
exercise less than white women.

Hartweg (1993) studied 153 black and white women
ranging from age 40 to 59. The study attempted to describe
specific health actions performed by middle-aged women for
health promotion. The relationship between self-care
actions to age, sociocultural orientation, work patterns,
and family system factors was explored. The activity
category identified walking as the most frequent physical
activity used to promote physical well-being. Higher levels
of formal education were related to more self-care actions
of social interaction, normalcy, activity, solitude and
hazards. The women with higher education also undertook
more activities associated with developmental change and
self-care demands related to alterations in health status.

Further study is necessary to determine what
relationship exists between knowledge of menopause and
adherence to exercise. Little research was found in this
area. Lee's (1993) study emphasized the need to provide
middle-aged women with more information about exercise.
Hartweg (1993) found that more educated women engage in more

self-care activities. Perceived barriers to exercise cannot

17
be ignored when examining the exercise behavior of
individuals. The APN can help the menopausal woman to make
appropriate decisions related to menopause as the woman
learns about of the effects of exercise. Every woman has
the right to individualized care that addresses needs and
risk factors.
£11 I : 1 . S J l l'

The review of the literature did not reveal data
related to knowledge of menopause and women's use of calcium
supplements. Instead the data focus on the role of calcium
in the prevention of osteoporosis with or without HRT (Bond,
1991; Christiansen, 1994; Larson & Shannon, 1984; Ravnikar,
1993; & Wark, 1993). Larson and Shannon (1984) developed an
osteoporosis health risk assessment form designed to solicit
information from the client population regarding exercise,
calcium in the diet, calcium supplementation, family risk
for osteoporosis, and knowledge of osteoporosis. No data
collection using this tool was found in the literature
search conducted by this author.

The Women's Health Initiative (WHI) was developed to
determine whether or not long-term preventive measures would
decrease the incidence of certain cancers, cardiovascular
disease, and fractures. The WHI was also designed to find
better predictors of future disease and health in older
women. Part of the clinical trial and observational study
will include a component related to the prevention of

osteoporotic fractures. Forty-five thousand women will be

18
involved in the trial to determine the effect of calcium and
vitamin D supplementation on the prevention of colorectal
cancer and osteoporotic fractures. It is predicted that the
information from the WHI will be available by 2007 (Rossouw,
Finnegan, Harlan, Pinn, Clifford, & McGowan, 1995). This
data will have the opportunity to increase the body of
knowledge regarding women's health.

As little information is available concerning the way
that adherence to calcium use relates to knowledge of
menopause, further research is warranted. Women may be
taking calcium supplements for various reasons. If the goal
of the menopausal woman is to promote her health through
self-care activities, then she needs to be well-informed as
to what type of calcium supplement she should take, the
correct amounts, reasons for, and the possible adverse side
effects of the specific supplement.

W

As previously noted, the majority of the literature
relating to women's continued HRT use is referred to in
terms of compliance, not adherence. Perhaps this comes from
the paternalistic medical frame of reference regarding
prescriptions and the Client's reaction to this form of a
medical command. In any case, the manner in which women
have chosen to take or not take HRT will be discussed.

Ryan et al. (1992) assessed the compliance of 400
postmenopausal women in taking HRT after they were screened

for osteoporosis. This screening lead to increased use of

19

HRT for women who were identified as being at greatest risk
of osteoporosis. After 8 months, 40% of the women with low
bone density stopped taking HRT. The two main reasons for
cessation of HRT were weight gain and withdrawal bleeding.

Coope and Marsh (1992) used education and screening to
determine if these two factors could improve HRT compliance.
A clinic was designed to provide education and screening of
British women aged 40 to 60. Of the 1322 women who were
identified by the medical practice's age-sex register and
sent a postal invitation to attend the screening, 681 women
responded and attended the health education clinic. The
weekly clinic was run by a doctor and a nurse. The
education process included information about calcium dietary
intake, HRT for eligible individuals, sunlight for vitamin D
synthesis, smoking cessation, and exercise. Advice about
health, cardiac diet, aerobic exercise, smoking cessation,
and the advantages of HRT for osteoporosis and
cardiovascular disease were given. Compliance with HRT was
measured by repeat prescriptions for the medication. This
data was collected by an audit of the patient's records and
a computerized list of repeat prescriptions for HRT.
Compliance for HRT over a one to five year period ranged
from 84% to 92%. Reasons given for stopping HRT were: fear
of breast cancer, dislike of bleeding, anxiety over possible
thrombosis, and side-effects such as painful breasts.

Groeneveld et al. (1995) tried to determine the

cumulative incidence of first HRT prescription and what

20

predicts its prescription. The study also looked at the
influence of women's well-being, attitude toward menopause,
menopausal status, and other variables on first HRT
prescription in the sample during the nine month follow up
period. The sample consisted of 1689 Dutch women from age
45 to 60. The researchers found that within 21 months, the
majority of the women who had been prescribed HRT had
discontinued the medication. For women who did not have
typical menopausal complaints, physicians prescribed HRT
five times more frequently to those women who demonstrated
lower levels of well-being. For women who had typical
menopausal complaints, the HRT prescription was mainly
related to the women's attitude toward the medical treatment
of menopause. Thus it appeared that most HRT prescriptions
were given to the women for therapeutic rather than
preventive reasons.

Cano (1995) followed 331 postmenopausal women for 1 to
5 years. Compliance was defined as taking the medication
for 1 year. Nine percent never filled the prescription, 15%
interrupted treatment, and 14% demonstrated sporadic
compliance. The variables of progestins and oral route of
administration of HRT determined lower levels of compliance.
Source of referral and severity of menopausal symptoms did
not influence compliance in the study. Cano concluded that
women who understood why HRT was prescribed were more

compliant in taking the medication.

21

Wren and Brown (1991) reviewed HRT use in 101
postmenopausal women 1 year after the initiation of
treatment. Sixty-one percent continued therapy. Twenty-
seven percent ceased to take HRT. No data were available on
12% of the subjects. The main reason for cessation of HRT
was the return of bleeding. Fear of adverse reaction to HRT
was also common in compliant and non-compliant groups. The
researchers strongly recommended followup visits, monitoring
of the client's response to HRT, and the individualization
of HRT for each client. Stumpf and Trolice (1994) also
stressed the importance of education and individualization
in HRT to enhance compliance.

This literature review demonstrates the need for
further research regarding women's knowledge of menopause
and their adherence patterns to methods of self-care.

Though not the focus of this study, the areas of self-
efficacy and perceived barriers to action warrant further
research with regards to menopausal women. As the research
is compiled, the APN will be in a position to provide women
with the access to the knowledge that they desire. When
uncertainty about menopause is replaced with usable
knowledge, women will be better prepared to make sound

decisions (Andrews, 1995) and implement individualized self-

care measures .

22
METHOD

Design

This study is a secondary analysis of the data from the
"Decision Making in Menopause" study conducted by principal
investigator Rothert (1990) (Appendix A) and funded by the
National Center for Nursing Research (NR01245). The purpose
of the original study was to design an educational
intervention to aid women to become more effective decision-
makers regarding menopause and HRT.

Dgsgriptign_gf_zazent_3tndy. In the original study,
the convenience sample of 379 women age 40 and over was
recruited through the media of radio, television, and
newspaper requests. Women were not excluded from the study
because of menopausal status, current medication taking
behavior, or hysterectomy. Sociodemographic data about the
participants was collected in the following areas: age,
race, education, employment, household income, religion, and
time since last menstrual period. The subjects ranged from
40 to 65 years of age. Forty-six percent of the sample fell
between the ages of 46 to 50. Ninety-four percent of the
sample was Caucasian, more than half were married and
employed full-time. Almost half of the sample had a
household income between $50,000 to $99,999. Forty-nine
percent had earned a bachelor's degree or more. More than
half the sample still reported having menstrual periods,
14.3% had had a hysterectomy, and one-tenth had had one or

both ovaries removed. Half the women reported that they

23
were currently experiencing menopausal symptoms, while 24%
were not sure if they were having symptoms. More than half
the women were not sure if they would take HRT (Rothert,
1990).

Following recruitment, the women were randomly assigned
to one of three groups. Group A received a written brochure
about menopause. Group B received the brochure and
participated in a lecture/discussion group. Group C
received the brochure and was given interactive decision
support (Rothert, 1990).

Data was collected at pre-intervention (Time 1), three
weeks later/post intervention (Time 2), six months post-
intervention (Time 3), and 12 months post-intervention (Time
4). Data collection took place in a classroom setting on a
large Midwestern university campus. At the three different
classroom sites, two members of the research team were
present to offer consistent instruction to the participants.
Instruments used in the study included sociodemographic,
perceptions of menopause, menopausal symptoms, symptom
management and self-care, knowledge of menopause,
satisfaction with interaction with health professional, and
self-care efficacy. Adherence to a plan for self-care was
measured using a calendar format (Rothert, 1990).

The researchers found no differences in the level of
adherence between the three groups. A small, but
statistically significant difference was noted in the level

of knowledge between the three groups post-intervention.

24
Although the women were assigned to three different
treatment groups, the data for the three groups was pooled
for this study.

In terms of attrition, of the 379 women who registered
for the study, 300 (79%) women participated in Session 1.
Two hundred and fifty-two women participated in the
additional sessions. Two hundred and one (80%) women
completed the entire twelve month study.

new This study used a
descriptive correlational design to determine if a
relationship existed among the identified variables. These
variables were: level of knowledge of menopause and
adherence to plan for exercise, calcium supplementation, and
HRT.

The sociodemographic characteristics for the 201 women
who participated in the study at time 4 are given in Table
1. These women were primarily 40 to 55 years of age,
married, employed full-time, earned a household income of
$50,000 or greater, college-educated, Protestant, Caucasian,
and more than half still had natural menstrual periods.

00- . e9. 0- ... e.‘ e . ..e - ..e g‘ 11‘. . e.

For the purpose of this study the knowledge of
menopause scale and the calendar self-report measure were
utilized from the research developed by Rothert (1990).
Only the data collected at month 12 (Time 4) was used. As
with all the instruments, these two instruments were

developed and reviewed by a multidisciplinary team of

25

 

 

Table 1

S . i l' :1 l . l' E 5 J lT' I}

(N = 201)

Characteristic n %
Ass_1¥earsl

40-45 62 (24.6)
46-50 94 (33.3)
51-55 49 (19.0)
56-60 5 (2.0)
61-65 2 (0.9)
BEER

African-American 3 (1.2)
Hispanic 1 (0.4)
American Indian 1 (0.4)
White 194 (77.0)
Other 2 (0.9)
Marital_Status

Married 137 (54.4)
Divorced 47 (18.7)
Single 15 (6.0)
Widowed 2 (0.8)
Full-time 126 (50.0)
Part-time 40 (15.9)
Retired 12 (4.8)
Not employed 19 (7.5)
Other 4 (1.6)
Income

< $14,999- 9 (3.60)
515,000-529,999 21 (9.3)
$30,000-$49,999 54 (21.4)
$50,000-$99,999 92 (36.5)
$lO0,000-$200,000 18 (7.5)
>$200,000 4 (1.6)
Education

High school graduate 16 (6.3)
> 12 years 53 (21.0)
Technical trade/community college 25 (9.9)
Bachelors degree 52 (20.6)
Masters degree 37 (14.7)
PhD/Professional degree 16 (6.3)
Other 2 (0.9)

26

Table 1 (continued)

 

 

Characteristic n %
E 1. .

None 27 (10.7)
Jewish 3 (1.2)
Protestant 110 (43.7)
Catholic 49 (19.4)
Other 12 (4.8)
WhenJasLnenodZ

Still have natural period 111 (44.0)
Less than three months ago 5 (2.0)
3 to 12 months ago 20 (7.9)
More than 12 months ago 65 (25.8)

 

nurses, physicians, menopause researchers, psychologists,
and lay representatives. This group assessed the
instruments for validity, conceptual definition, and
clinical relevance (Rothert, 1990).

Semi:

Knowledge. Level of knowledge of menopause was
measured using a 24 item scale which assessed the subjects'
knowledge regarding risk factors associated with HRT,
menopausal symptoms, and self-care strategies related to
menopause. The questions were comprised of 11 multiple
choice and 13 true-false items. Items were coded "1" or "0"
for correct or incorrect/missing and are summed. A higher
level of knowledge of menopause was reflected in a higher

number of correctly answered items. A lower level of

27
knowledge of menopause was demonstrated by a lower number of
correctly answered items (Appendix B: Knowledge Scale).

The internal consistency of the knowledge scale was
measured by computation of an alpha coefficient. In the
original pilot study of 120 women recruited from faculty and
staff of a large Midwestern university, an alpha coefficient
of 0.77 was produced. During a process of modification to
improve the clarity of the scale, several items were either
deleted or rewritten. Following the administration of the
scale to 251 women, the knowledge scale produced a
coefficient alpha of 0.85. Factor analysis of the knowledge
scale revealed a unidimensional scale (Rothert, 1990). No
test-retest reliability has been done.

Adhgrgnge_nea§nremgnt. This study looked at the
calendar data for month 12. To measure adherence to plan
for exercise, calcium supplementation, and HRT use, the
subjects agreed to keep a record of their activities on a
calendar (Appendix C: Calendar). The calendar data was
returned monthly for 12 months. Each woman devised a
personal plan for intended exercise, calcium
supplementation, and HRT. At the end of each month, the
planned activity frequency (i.e., exercise three times per
week) was divided by the actual frequency (i.e., exercised
two times per week). Only the mean adherence scores for
exercise, calcium supplementation, and HRT for month 12 were

used in this study.

28
E l : J] l' E i

This study considered data that was collected at month
12. The knowledge scale was administered in the classroom
setting of a large Midwestern university. Participants
mailed the calendar data for month 12 to the research office
as they had done for the previous 11 months.

I l E 1 .

Data analysis was conducted using the SPSS computer
software. Pearson's correlation coefficient was used to
analyze the relationship between level of knowledge and
exercise adherence, the relationship between level of
knowledge and adherence to HRT, and the relationship between
level of knowledge and adherence to calcium supplementation.
E l l' E H 5 l' l

Individual rights of subjects were protected according
to the University Committee on Research Involving Human
Subjects (UCRIHS) guidelines. Application for approval to
conduct this secondary analysis was made prior to data
analysis.- Confidentiality was protected by giving an
identification code number to each participant in the study.
Each person signed a consent form prior to participation in
the study. All responses throughout the study remained
confidential. Data results were collectively reported.

RESULTS
E J . l E l : l'
Question 1. The purpose of this research was to answer

three questions about menopausal women. The first was: What

29
is the relationship between level of knowledge of menopause
and adherence to plan for exercise?

The mean knowledge score from the 24 item scale is 20.8
with a standard deviation of 2.7 and a range from 11 to 24
(Figure 2). A mean score of 21 indicates that the women on
average correctly answered 87.5 percent of the questions.

The mean adherence to plan for exercise score for month
12 is .59 with a standard deviation of .39 and a range of
.00 to 1.00 (Figure 3). A mean score of .59 indicates that
women adhered to a plan for exercise 59 percent of the time.

Pearson's correlation coefficient indicates that there
is a very weak relationship between level of knowledge and
adherence to exercise in this sample, rs.06. The results
are not generalizable to the population as the probability
is .25.

Questign_z. The second question was: Is there a
relationship between level of knowledge of menopause and
adherence to plan for calcium supplementation?

The mean adherence to plan for calcium supplementation
is .77 with a standard deviation of .38 and a range of .00
to 1.00 (Figure 4). A mean score of .77 indicates that the
women adhered to a plan for calcium supplementation 77% of
the time.

Pearson's correlation coefficient indicates that there
is weak negative relationship between level of knowledge of

menopause and calcium supplementation, r=-.09. This result

Frequency

30
40 -

30-

20-

1O -

 

v- N m V ID (0 N on O) O F N (‘9 V
1- 1- v- v- v- v- r- ‘- e- N N N N N

Knowledge=4; Mean=20.8; Standard Deviation=2.7; H=201

Figure 2- Ereuuencx_Distributinn_9f_Kn9wledge_Scores

Frequency

 

 

Adherence to Exercise, Month 12
Mean=.59; Standard Deviation=.39;.u=139

Figure 3- Ereduenc1_Distribution_9f_Adherence_to_Exercise

Frequency

31

 

 

 

90W
70-
805
60-
4o.
30.
201
1.] l
0* s. 3
° 3‘: '4’: 9! 5". 5. E. 2 3. "
906000 6

Adherence to Calcium, Month 12
Mean=.77; Standard Deviation=.38; N:117

Figure 4. ' ° '

 

is not generalizable to the population as the probability is
.18.

Questign_1. The third question was: Is there a
relationship between level of knowledge of menopause and
adherence to plan for HRT?

The mean adherence to plan for HRT is .95 with a
standard deviation of .21 and a range of .00 to 1.00 (Figure
5). The variance for this group is very low at .043. A
mean score of .95 indicates that women adhered to a plan for
HRT 95 percent of the time.

Pearson's correlation coefficient indicates that there
is a weak negative relationship between level of knowledge

of menopause and adherence to plan for HRT, r=-.08. The

Frequency

32

50
.01

3O -
20 -
1O -

 

 

 

 

O 086 1

Adherence to HRT, Month 12
Mean=.95; Standar Deviation=.21; N=46

Figure 5 . WW

results are not generalizable to the population as the
probability is .30.
DISCUSSION

Study findings are reviewed in this section. First, an
overview of findings is given, second the three research
questions are discussed, and third, implications of study
findings in terms of self-care and the APN as a primary care
provider are reviewed. Finally the limitations of the study
are presented with suggestions for future research.

The women who participated in this study were recruited
through convenience sampling methods. The sociodemographic
characteristics indicated that this was a fairly homogeneous
group. The majority of the women were Caucasian (77%),
married (54.4%), employed full-time (50.0%), and over half

of the sample reported an income of $50,000 or more. Almost

33
half of the women had earned a degree at a bachelor's level
or greater.

In comparing the characteristics of the women who chose
to take follow plans for exercise, calcium supplementation,
and/or HRT versus the entire sample of 201 women at time 4,
differences are noted in the subsample that took HRT.
Analysis of variance for each subsample and each of the
sociodemographic variables demonstrates that the women who
took HRT were older (F-ratio 5.37, F-probability .0215),
less educated (F-ratio 4.41, F-probability .037), and had a
greater lapse of time since last period (F-ratio 50.0, F-
probability .0000) than those women in the sample who chose
not to take HRT.

The findings of this study will serve as a starting
point in looking at a menopausal woman, her knowledge of
menopause, and how she adheres to plans for self-care.
Future inclusion of more diverse populations and cultures of
women would provide more information to increase the body of
knowledge.regarding the menopausal woman.

Researchfiuestinns

W. The weak
relationship found between level of knowledge of menopause
and adherence to plan for exercise in month 12 of this study
raises new questions. What other factors affect the daily
adherence to exercise? A look at the reviewed literature

may provide direction for issues to be pursued.

34

After reviewing the results of the study by Jensen and
Lorish (1994), one would ask what perceived barriers to
exercise existed for the women in this study. Health
beliefs and self-efficacy are also factors to consider to
determine how these women viewed exercise. Did those who
followed a plan for exercise have differences in their
beliefs regarding the consequences of exercise? If so, did
they see these consequences as positive or negative? Were
the consequences of exercise important to them?

Dzewaltowski et al. (1990) concluded that self-efficacy
was a better predictor of exercise than intention. If this
study had looked at self-efficacy related to the subjects
and their exercise plans would a strong relationship been
found? What about intention?

Lee (1993) concluded that women who were classified as
precontemplators of exercise were older, possessed less
exercise knowledge, and perceived less family support for
exercise. This study found no age difference between those
women who followed a plan for exercise and those who did
not. Exercise knowledge and family support were not
measured. In future studies exercise knowledge of
menopausal women could be measured along with general
knowledge of menopause. Researchers might ask menopausal
women whether they viewed their families as supportive of
exercise and if they perceived any barriers to exercise.

Dulberg (1992) noted that black women exercise less

than white women. This study was too homogeneous in terms

35
of its ethnic makeup to look at this issue. A more diverse
sample would be necessary to compare exercise
characteristics of menopausal women. Sociodemographic
characteristics, exercise knowledge, self-efficacy, and
perceived barriers are areas that could provide information
about the menopausal woman and her exercise profile. Choice
of exercise type, environment, and ease of exercise are also
factors to consider.

W.

The weak relationship found between level of knowledge of
menopause and adherence to plan for calcium supplementation
in month 12 of the study illustrates the lack of information
about menopausal women and calcium use. What other factors
affect the daily ingestion of a calcium supplement? Cost,
choice of supplement type, sense of risk of osteoporosis may
influence the decision. The information from the WHI study
may yield information about women and calcium use (Rossouw
et al., 1995).

KnQWledge_and_Adherence_tg_HBT. The weak relationship
between level of knowledge of menopause and adherence to
plan for HRT at month 12 suggests that other factors affect
adherence besides knowledge. Previous research has shown
that side effects such as bleeding and breast tenderness
along with fear of cancer are reasons women give for ceasing
to take HRT (Cano, 1995; Coope et al., 1992; Natchingall,
1990). Cano (1995) concluded that women who understand why

they take HRT are more compliant than those who do not.

36
This study looked at only the last month of the entire 12
month plan. To examine knowledge and adherence to HRT over
the entire 12 month period might demonstrate a more
significant relationship. The sample size in this study for
the HRT group consisted of only 46 women.

Groenewald et al. (1995) noted that most HRT
prescriptions were written for therapeutic rather than
preventative reasons. Did this mean that women wanted to
take HRT for symptom management rather than for the long-
term benefits? Would these women be planning only short
term use of HRT? In parent study (Rothert, 1990), the
brochure that the women were given addressed the long-term
benefits of HRT. Did these women who followed a plan for
HRT do so for symptom management, long-term benefits, or
both? A longitudinal study of greater than one year might
yield more information about a long-term adherence to plan
and how women dealt with the side effects and fears that so
often influence women to stop taking HRT. Do women who take
HRT for preventative reasons view coping with HRT side
effects in the same way as women who choose HRT for
preventive reasons? Are side effects a greater predictor of
non-compliance in one group more than another?

He . e. e ;e .g -e ' . . - \ I! ..e ' 1:.

Though this study did not show a relationship between
the selected variables, there is still much to consider in
terms of primary care issues for menopausal women and women

in general. As Pender (1996) notes, physical fitness,

37
adequate nutrition, effective relaxation methods, self-
awareness, increased self-esteem, expanded social systems,
and fulfillment of life goals are all important issues for
women. All women have a right to good health. Knowledge
about their bodies is part of self-care for women.
Menopausal women need health-oriented information to meet
their own needs not just information about drug therapy and
surgical interventions (Frey, 1981). Healthcare
professionals who value self-care can assist women by
teaching them self-care measures and relevant information
and assisting them to explore choices (McElmurray et al.,
1991).

Hartweg (1993) found that women with higher levels of
education undertook more self-care actions as they
experienced developmental changes and self-care demands.
This study did not find any difference between the women who
followed plans for self-care versus those who did not. The
women who followed a plan for HRT were actually slightly
less educated than the women who did not. However the small
sample size and homogeneity of this group must be considered
as there was little variance among the 46 women who chose to
follow a plan for HRT.

Millete (1981) supported the need to look at the
differences in levels of knowledge of menopause for women
with lower economic means. This underscores the importance
of including women of diverse educational and economic

levels in research studies to obtain a better understanding

38
of menopausal women. Economic means and access to
healthcare are important issues to take into account when
trying to provide comprehensive healthcare to menopausal
women. Not all menopausal women are aware of the
appropriate screening measures they should be receiving or
what options exist for menopausal symptoms. Even if women
do possess the understanding of these pertinent healthcare
issues, they may not possess the resources to obtain
adequate care. The APN can serve as an advocate for such
women by providing access to primary healthcare.

The APN should never assume that clients who are
articulate and well-educated are knowledgeable about the
basic facts regarding basic physiological function of
menstruation or its cessation at menopause (Johnson 8 Snow,
1979). A higher economic status and educational level do
not guarantee a fuller understanding of menopause.
Assessment of every client's knowledge level is necessary.

The APN has the opportunity to assess the client's
understanding of her body during visits to the primary care
setting. When the adolescent comes to the APN for
healthcare, this is when a holistic approach to self-care
can be initiated: the need for exercise on a lifelong basis
and its implications throughout the life cycle, the
importance of calcium in dietary and supplemental forms for
bone growth, a knowledge of the crucial periods of bone
formation and loss, osteoporosis risk factors, hormonal

replacement therapy, cardiac health, etc. Health promotion

39
and prevention are ongoing. Having established a working
collaborative relationship with individuals, the APN is in a
position to take advantage of every encounter to reinforce
health teaching to promote the health and self-care of
clients.

Though this study did not support the model for self-
care for the menopausal woman that was proposed (Figure 1),
it does not mean that knowledge of menopause does not play a
role in self-care activities of middle-aged women. The
schematic drawing is perhaps too simplistic. Further
research is needed to look at what other factors influence a
menopausal woman to carry out a plans for self-care.

The model depicts a bidirectional relationship between
the menopausal woman and the APN. The menopausal woman
provides the APN with new information with each interaction.
The APN, in a supportive/educative role, has the potential
to influence the health outcomes of the woman. As the
menopausal woman seeks to meet her self-care demands by
performing self-care measures, it is at this point that the
APN can serve as'a resource to maximize the responsible
health-seeking behaviors of her client.

Pender (1996) states "Adequate attention to self-care
during the young and middle-aged years promotes optimal
productivity and life satisfaction and lays the groundwork
for a healthy and productive retirement and old age rather
than one fraught with discomfort, disability, and

compromised quality of life" (p. 102). There is no better

40
health legacy that an APN could encourage a menopausal woman
to invest in. Health promotion for the menopausal woman is
a plan that focuses on health and will save the individual
and society healthcare dollars as well. This long-term plan
for health needs to begin in adolescence, not with the first
hot flash.

A knowledge assessment tool is a starting point. By
determining what women know and do not know the APN has some
sense of how to assist the client to meet her self-care
needs. A menopause questionnaire would provide the woman
with an opportunity to focus on herself to assess her own
health needs. Such a knowledge assessment would stimulate
new questions and heighten self-awareness (Gendler, 1979).
The exchange of information about menopause should be
formalized in the manner similar to the preconception visit
with specific guidelines and recording keeping tools
(Andrews, 1995).

According to Orem (1971), the first step in self-care
is for the client to come to understand her health status,
capabilities, and level of functioning. Once a knowledge
questionnaire has been completed, the APN and menopausal
client have the opportunity to assess and review together
what the client does and does not know. This is also a time
to identify what strengths and weaknesses may affect the
self-care actions of the client (Gendler, 1979). Together
the APN and client can collaborate to set goals for self-

care. Assessment of clinical outcomes for the

41
individualized self-care plan of the client must be
incorporated into the mutually-defined plan of care.
Through assessment of outcomes, both the client and the APN
are given feedback about the success of the plan.

The APN can use the following self-care education
components (Carporael-Katz, 1983): allow time for expression
of feelings, reinforce client self-esteem, provide open
access to healthcare, foster immediate practice of self-care
skills, present alternative health care views, and
critically evaluate traditional and alternative therapies.
The APN can help the woman to systematically plan to
incorporate health promotion activities into her busy home
and work routines. Not only will this enhance the client's
health in a busy lifestyle, but it will also model a healthy
lifestyle for other family members and co-workers (Pender,
1996).

As a primary care provider the APN is in a position to
act as a counselor and educator of women. Andrews(1995)
recommends that an in-depth counseling session be offered to
women at age 45 or sooner. At this time a personal risk
assessment should be performed, including family history.
Any myths or fears the woman has about menopause should be
replaced with factual knowledge about signs and symptoms of
menopause, immediate and long-term effects of estrogen
decline, and treatment options with associated benefits and
risks. At this and future visits, the APN can teach the

woman about health promotion and prevention practices that

42
are appropriate for her lifestyle and personal needs. As a
primary healthcare provider, the APN is responsible for
insuring that the client is given the opportunity to have
the recommended screening tests such as Papanicolaou smear,
pelvic exam, breast exam, and mammogram according to the
current practice guidelines (Andrews, 1995).

With each transitional period in a woman's life an
opportunity arises for that woman to pause and assess where
she has been and where she is going in terms of her health
and lifestyle. At the time of the menopause transition she
presents with a bone mass that is a consequence of her
lifestyle before menopause. After documentation of the
client's lifestyle habits, nutrition, and any alternative
medical methods, the APN can present options for a
multifaceted approach for optimum bone mass: HRT, exercise,
and calcium (dietary and supplemental). Estrogen is
important for maintenance of bone mass postmenopausally and
for prevention of decreasing bone mass that leaves
postmenopausal women prone to fractures. HRT should be
offered to all women for whom it is not contraindicated.
The adverse effects of smoking, alcohol, lactose
malabsorption, a vegetarian diet, and caffeine on bone loss
should also be presented (Ravnikar, 1993).

For those women who chose to take HRT, Natchigall
(1990) suggests the following strategies to enhance
compliance: education with clear discussion, booklets, and

books; communication of need for continued surveillance of

43
client even after HRT has been started; provision of printed
prescriptions and handouts; emphasis on the ease of taking
medication; utilization of appropriate measures to decrease
nuisance factors such as breast tenderness, breakthrough
bleeding, vaginal irritation or local skin irritation;
endometrial biopsy when warranted; and demonstration of
results/benefits through cholesterol levels, vaginal exam,
and bone density measurement. The last strategy is a means
of positive reinforcement for taking HRT.

Measurement of self-care and clinical outcomes is
important for determination of the quality and success of
the menopausal woman's self-care plan. For the women who
choose to take HRT, the following self-care behaviors can be
measured: type, frequency, and duration of weight-bearing
exercise; frequency and type of dietary and/or supplemental
calcium intake; monthly self-breast exams; yearly
mammograms, scheduling and completion of annual history and
physical exam appointments; actual HRT use; side effects of
HRT experienced; and effectiveness of interventions in
relieving side effects (Uphold 8 Graham, 1994). The APN and
client can work on ways to individualize the HRT for the
client. The goal is for the client to feel that she has
ownership of this plan and is responsible for carrying it to
fruition.

The same can be said for a plan of self-care developed
for the woman who decides not to take HRT. Her self-care

performance will be evaluated for exercise, calcium intake,

44
interventions for menopausal symptoms, monthly self-breast
exams, annual mammograms, annual physical with emphasis on
menopausal, osteoporotic, and cardiac changes, and risk
behaviors such as smoking, heavy caffeine use, and alcohol
intake (Uphold et al., 1994).

The APN assists the menopausal woman to decide whether
or not to take HRT by providing the necessary scientific
knowledge. The woman is empowered to perform self-care.
She determines whether or not she will adhere to the plan of
self-care individualized to meet her needs. She has
ownership of her self-care plan and determines on a daily
basis whether she will alter, adhere to, or abandon her
personal plan.

WW

According to McElmurray et al. (1991), the goal of
research in women's health is to develop knowledge that
helps to prevent illness, prolong life, and promote and
enhance well-being. Through such research, interventions
are created and discovered that promote, maintain, and
enhance health. These interventions are to be based on an
understanding of the ways in which women take care of
themselves and with an appreciation for cultural context in
which these self-care measures are to be carried out
(McElmurray et al., 1991).

This study hoped to increase the understanding about
the relationship between women's level of knowledge of

menopause and their adherence to plan for exercise, calcium

45
supplementation, and exercise. The results did not provide
the information expected. Therefore it would appear that
adherence to these particular plans for self-care were
influenced by factors other than knowledge. The lack of
significant results in this study does not mean that
knowledge does not bear a relationship to adherence to plan
for self-care. Rather the flaw in the study may be the fact
that it looked at these variables only in the twelfth month
of the study.

Future research may ask if a significant level of
exercise adherence is more likely for women who have
exercised at a similar rate prior to menopause? What about
women who have been sedentary? Can their behavior pattern
for exercise change if they come to view exercise as a self-
care activity that has meaning for them?

In terms of calcium supplementation, further dietary
information is needed to determine why some women chose to
take supplements and why others did not. How many women in
the study chose to increase dietary intake of calcium alone
or in conjunction with other supplements? Are women who
feel that they are at greater risk for osteoporosis more
likely to take supplements? Had any of the women in the
study had bone density studies performed? According to the
data, only one woman in the study had experienced fractures.
What influences what supplements women chose to take?
Pharmaceutical advertising, women's magazines, and provider

information are sources to consider.

46

HRT adherence is a complex issue. Why did 90% of the
women who had chosen a plan for HRT follow through and
adhere to it? Considering the poor levels of compliance to
HRT that are found in the literature (Hammond, 1994;
Natchingall, 1990), it is worthwhile to determine why these
46 women had a 90 percent success rate for adherence? What
were the characteristics of these 46 women? How many of
them were hysterectomized? Of those with an intact uterus,
were they afraid of cancer? Had any of them taken birth
control pills in the past? Did they experience side effects
from HRT?

Future research will continue to ask questions to
increase understanding of menopausal women and their
healthcare needs. Such studies must include more diverse
populations to determine how different women perceive the
menopausal experience, their symptoms, and self-care
practices related to menopause. What self-care measures do
they employ? What place does diet, exercise, and HRT have
in their lives?

Menopausal women of lower educational and income levels
warrant further study. Do women with lower educational
levels require more information about menopause than the
well-educated women in this study? What other types of
educational interventions might be necessary for these adult
learners? Are women with lower income levels as concerned
about menopause as much as women with greater financial

resources for healthcare and intervention measures?

47

In doing the secondary analysis certain limitations
existed. First, the questions posed in this study were
limited by the questions and data gathered by the parent
study. Second, no information was given as to what
influenced the women to adhere to their plans for exercise,
calcium, and HRT. Third, this study looked at knowledge
level and adherence post-intervention. Would a relationship
between level of knowledge of menopause and adherence to
exercise, calcium, and HRT been found if examined over the
entire 12 month course of the parent study?

SUMMARY

This study did not demonstrate that a relationship
exists between level of women's knowledge of menopause and
adherence to plan for exercise, calcium supplementation, and
HRT. The study showed menopausal education and did not
impact adherence to plans for self-care. The study was
unable to conclude whether provision of appropriate
knowledge for the menopausal woman had the potential to
improve adherence to the three self-care measures. This
does not mean that knowledge of menopause is not important
for women to perform self-care activities. Rather further
research is necessary to determine why some women adhere to
particular plans for self-care and others do not. Also,
women may use other aspects of their personal knowledge to
come to decisions to adhere to self-care. As a primary care

provider, the APN is obligated to assist women to become as

48
knowledgeable as possible about their bodies and how to care
for them. The APN must use clinical skills, current

practice standards, and research to provide high quality

care to all menopausal women.

LIST or REFERENCES

LIST OF REFERENCES

Andrews, W. C. (1995). The transitional years and

beyond Qbstetrics_8_£¥nec9199¥1_85(1). 1- 5-

Ahijevych, K. 8 Bernhard, L. (1994). Health-promoting
behaviors of African-American women. Nursing_Resgargh1
11(2), 86- 89.

Bernhard, L. A. 8 Sheppard, L. (1992). Health,

symptoms, self-care, and dyadic adjustment in menopausal
women.

Nursing1_22(5), 456-460.

Bond, K. (1991). Osteoporosis. NAACQGLS_Q11n1:a1
Issuesi_2(4). 498-507-

Bouchard, C. J., Shephard, R. J., Stephens, T., Sutton,
J.R., 8 McPherson, B. D. (Eds. ) (1990). Exercise1_fitness1
and_health1_A_consensus_of_current_kncwledce

' . Champaign,
IL: Human Kinetics.

Cano, A. (1995). Compliance to hormone replacement
therapy in menopausal women controlled in a third level

academic center. Matnr1tas1_zg, 91-99.

Carporael-Katz, B. (1983). Health, self-care, and

power: Shifting the balance. T9n1cs_1n_Clinical_Nursin91_5.
31-41.

Christiansen, C. (1994L The different routes of
administration and the effect of hormone replacement therapy

on osteoporosis. Eertilitx_and_Sterilitxi_62(suPpl 2). 6.
1525-1555.

Cook, M. J. (1993). Perimenopause: An opportunity for
health promotion. '

Neonatal_Nursing1_22(3), 223-229.

Coope, J. 8 Marsh, J. (1992L Can we improve
compliance with long-term HRT? Maturitas1_1§, 151- -158.

Duelberg, S. (1992). Preventive health behavior among
(black and white women in urban and rural areas. Social

Science_and_uedicinel_34. 191- -198-

49

SO

Dzewaltowski, D.A., Noble, J.M., 8 Shaw, J.M. (1990).
Physical activity participation: Social cognitive theory
versus the theories of reasoned action and planned behavior.
1ournal_cf_Sncrt_8_Exercise_Esxch9199¥1_12 388-405.

Frey, K.A. (1981). Middle-age women's experience and
perceptions of menopause. Homen_§_flga1§h1_§,(1-2), 26-35.

Gendler. P-A- (1979). Ths_relationshin_between_the

O 0
e‘ ‘e e. e e‘ 7 7 e. g- e‘ equ.. ‘ e e

11fe_agtixities1 Unpublished master' 8 thesis, Michigan
State University, East Lansing, MI.

Gregory, C. A. (1982). Possible influence of physical
activity on musculoskeletal symptoms of menopausal and
postmenopausal women.

and_Neonatal_Nursing March-April 103-107-

Groeneveld, F.P.M.J., Bareman, F.P., Barensten, R.,
Dobter, H.J., Drogenijk, A.C., 8 Hoes, A.W. (1995).
Determinants of first prescription of hormone replacement
therapy. A follow-up study among 1689 women aged 45- 60
years. Mdtnzitasi_29 81- 89-

Hammond, C. B. (1994L Women' 5 concerns with hormone
replacement therapy-compliance issues. £er;111;y_and
SteriliL¥1_§2(6). 157$ 160$-

Hartweg, D.L. (1993). Self-care actions of healthy

middle-aged women to promote well-being. Nnr51ng_3gsgazgh1
12(4), 221-227.

Hickey, J.V., Ouimette, R.M., 8 Venegoni, S.L. (1996).
applications. Philadelphia: Lippincott.

Jensen, G.M. 8 Lorish, C.D. (1994). Promoting patient
cooperation with exercise program. ' '
1(4), 181-189.

Johnson, S.M. 8 Snow, L. F. (1979). What women do not

know about the menOPause. Tne_Qstennathic.2h¥sician1_2. 28-
37.

LaRocco, S. A. 8 Polit, D. F. (1980). Women's knowledge
about the menOPause- Nursing_Besearch1_22(1). 10-13-

Larson, K. A. 8 Shannon, S. C. (1984L Decreasing the
.incidence of osteoporosis-related injuries through diet and
exercise. Eublic_Health_BenQrtsi_22(6). 609- 613-

51

Lee, C. (1993). Attitudes, knowledge, and stages of
change: A survey of exercise patterns in older Australian
women. Healih_25¥QthQQ¥1_12(6)v 475'430-

McCance, K.I. 8 Huether, S.E. (1994). Reenoohye1o1ooy1

. . .. . . . - . 2 . . - .
o . 0 ' . . '

O ‘ .
ed11. St. Louis, MO: Mosby.

McElmurray, B.J. 8 Huddleston, D.S. (1991). Self-care
and menopause: Critical review of research. Heel;h_geze_for
Nomen_1nternationali_12. 15-26.

MacPherson, K.I. (1985). Osteoporosis and menopause: A
feminist analysis of the social construction of a syndrome.
Adxances_in_Nursins_Science1_l(4), 11-22.

Millette, B.M. (1981). Menopause: A survey of

attitudes and knowledge. Issues_1n_Health_Care_of_flomen1_3.
263-276.

Natchingall, L.E. (1990). Enhancing patient compliance
with hormone replacement therapy at menopause. Qbete§r1o§_§
Gxnecologxl_15(4), 773-905.

Nursing Development Conference Group (1979). gonoeot

° (2nd ed.),
D.E. Orem (ed.). Boston: Little, Brown.

Orem. D-E- (1980). Nursinci_Concents_in_nractice (2nd
ed.). New York: McGraw-Hill.

Orem. D-E- (1985). Nursin91.99ncsnts_of_nractice (3rd
ed.). New York: McGraw-Hill.

Orem. 0.3- (1991). Nurs1n91.99ncents_of_nractice (4th
ed.). St. Louis: Mosby-Year Book, Inc.

Pender, N.J. (1996). ' '
pzeoe1oe (3rd ed.). Norwalk, CT: Appleton 8 Lange.

Pender. N-J- (1987)- Health—promotion_in_nursing
ozeoeioe (2nd ed.). Norwalk, CT: Appleton 8 Lange.

Ravnikar, V.A. (1993). Diet, exercise, lifestyle in

preparation for menOpause. Qbstetrics_8_§¥necolngy_911nics
of_North_America1_ZQ(2). 365-376.

Robertson, D. 8 Keller, C. (1992). Relationship among
health beliefs, self-efficacy, and exercise adherence in

patients with coronary artery disease. Heert_fi_Lnno1_z1(1),
56-63.

52

Rothert, M. (1990). Women's judgements of estrogen
replacement therapy. (Research Grant No. NR1245-04A2).
Washington, D.C.: D.S. Department of Health and Human
Services, National Center for Nursing Research.

Rothert, M. Kroll, J., Breer, L., Rovner, D., Holmes-
Rovner, M., Schmitt, N., Talarczyk, G., 8 Padonu, G. (1994).
Communicating risks and benefits to mid-life women.

Commun1cat1nu_R1sks_tn_£atients. United States Pharmacooeial

Convention, Reston, VA.

Rossouw, J.E., Finnegan, L.P., Harlan, W.R., Pinn,
V.W., Clifford, C., 8 McGowan, J.A. (1995). The evolution
of the Women's Health Initiative: Perspectives from the NIH.

I I .

(2).
50-5.

Ryan, P.J., Harrison, R., Blake, G.M., 8 Fogelman, I.
(1992). Compliance with hormone replacement therapy (HRT)
after screening for post menopausal osteoporosis.

° , 325-328.

Sackett, D.L. 8 Haynes, B. (1976). '
theranentio_regimene. Baltimore, MD: Johns Hopkins

University Press.

Stumpf, P.G. 8 Trolice, M.P. (1994). Compliance
problems with hormone replacement therapy. Qbe;e;zioa_end
G¥necolnsx_c1inics_of_North_America1_21(20). 219-229.

Uphold, C.R. 8 Graham, M.V. (1994). Clinioel
Guidelines_in_£am11¥_£ractice (2nd ed.) Gainesville, FL:

Barmarrae Books.

Utian , W.H. 8 Stiff, I. (1994). North American
Menopause Society-Gallup survey of women's knowledge,
information sources and attitudes to menopause and hormone

replacement theraPY- Menopause1_Jnurnal_nf_North_American
Menopause_Snciet¥1_1. 39-48-

Wark, J.D. (1993). Osteoporosis: Pathogenesis,
' I

diagnosis, prevention, and management. Beill1ere_s_£1inigal
Endocrinolos¥_and_uetabnlismi_l(1). 151-181-

. (1986).
Springfield, MA: Merriam-Webster.

Wilbur, J., Holm, K., 8 Dan, A. (1992). The
relationship of energy expenditure to physical and

psychologic symptoms in women at midlife. Nore1no_9n§1ook1
An(6), 269-276.

53

Wren, B.G. 8 Brown, L. (1991). Compliance with
hormonal replacement therapy. Mennr11351_11, 17-21.

APPENDICES

APPENDIX A

Research Team

APPENDIX A

Research Team

Marilyn Rothert, RN, PhD, FAAN
Principal Investigator
College of Nursing
Geri Talarczyk, RN, EdD
Co-investigator
College of Nursing
Georgia Padonu, RN, DrPH
Co-investigator
College of Nursing
David Rovner, MD
Co-investigator
College of Human Medicine
Margaret Holmes-Rovner, PhD
Co-investigator
College of Medicine
Neal Schmitt, PhD
Co-investigator
College of Social Science
Jill Kroll, PhD
Co-investigator

Research Associate

54

APPENDIX B

Knowledge Instrument

DECISION MAKING IN MENOPAUSE STUDY
Men0pause Information

The following questionnaire contains questions about men0pause, (the change of
life) a time which signifies the end of the menstrual cycle. In this section we are
interested in your knowledge about the process of menopause. Answers to some of
the questions will depend on whether or not a woman has a uterus. Please answer
all questions assuming the woman has a uterus.

68. What can be said about birth control after menstntation stops?

1 a Birth control should be used for 1 year

2 = BirthcontrotshouldbeuseduptoSyears

3 a Birth control should be used as long as sexually active
4 = Birth control is not necessary

5 as Don't know

69. What causes the symptoms of menopause?

l :- The pituitaryglandstopsfunctioning

2 a'Iheuteruswillnotalloweggimplantation

3 -'I'hefallopiantubebecomesblocked

4 a The ovaries produce less estrogen (female hormone)
5 - Allot'theabove

6 = Don’tltnow

70. Menopause increases the risk for which of the following?

l=Liverdisease
2=Eyediseese
3-Kidneydiseese
4=Lungdiseese
S-Osteoporosis
6-Allot'theabovc
7=Noneoftheabove
8=D0n’tlrnow

° 1992 Michigan State University
College of Nursing
13

55

Check your answer sheet. You should now be filling in row number 71

71.

74.

75.

What physical changes can occur in the vagina due to menopause?

l = It becomes dryer. shorter and less elastic

2 I- It becomes leg; easily injured

3 - The vagina remains the same following men0pause
4 1: Don't know

Risk of osteoporosis (brittle bones) can be reduced by:

l B Vitamin C

2 - Estrogen pills

3 - Relaxation exercises
4 a Don't know

To help reduce the uncomfortable feelings associated with hot flashes, a person can...

I =- Increase caffeine intake

2 - Take vitamins above recommended daily allowance
3 =- Wearseverallightwrapssooneeanberemoved

4 - Increase spices and seasoning in food

5 I- Don't know

Vaginal dryness caused by menopause may lead to...

l - Increased chance of vaginal infection

2 1- Decreased chance of vaginal infection

3 - Nochangeinchanceofvaginalinfection
4 a Don't know

Vaginal dryness an best be relieved by...

l - Using a petroleum jelly lubricant (Vaseline')
2 1- Estrogen replacement therapy '

3 - Using cold cream

4 - Don't know

° 1992 Michigan State University
College of Nursing
14

56

Check your answer sheet. You should now be filling row number 76

76.

After menopause, a woman's risk of heart disease:

I = Decreases

2 =- Increases

3 Is the same as before menopause
4 = Don‘t know

Estrogen replacement therapy:

I - lncreasesawoman's risk of heart disease
2=Decreasesawoman'sriskofheartdisease
3-Hasnoeffectonaw0man'srisk0fheartdisease
4=D0n'tknow

Please answer questions 78-90 using the following scale:

1 = True

2 - False

3 - Don’t Know
Although many women have menopausal symptoms, approximately 20% not: medical relief.
Hormone therapy (estrogen) after menopause increases the risk of osteoporosis.

Hormonal therapy (estrogen) can be used to help relieve the symptoms of menopause.

. Estrogen therapy without progestogen increases the risk of cancer of the uterus.

Ifa menopausal woman unexpectedly bleeds or spots a year after she completely stops
menstruating she should report this to her physician.

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

Onceawomanisthroughmenopauseshenolongerhastobeconcernedwithbresstcancerorother
femalecancers.

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

Ovulation may occur without menstrual bleeding occurring.

° 1992 Michigan State University
College of Nursing
15

57

Check your answer sheet. You should now be filling in row 87

87. The addition of a progestational agent (Provera') to estrogen replacement therapy frequently results
in monthly menstrual flow.

88. The addition of a progestational agent (Provera’) to estrogen replacement therapy increases the risk
of cancer to the uterus.

89. The most common cause of death among women is breast cancer.

90. A woman's chance of dying from cancer of the uterus is greater than her chance of experiencing
osteoporosis fractures.

° 1992 Michigan State University
College of Nursing
16

58

Check your answer sheet. You should now be filling in row 97

91. Choose the graph below which correctly'shows the number of women who die each year from
these medical problems. Darken the circle on your answer sheet corre5ponding to the correct
graph. Use the following scale:

1 = Graph 1 400300

2 = Graph 2 g

4 = Don t Know § 300.000
‘0

2 250.000

 

 

400.000 C's" D‘s-s
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0 i
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Graph 3

° 1992 Michigan State University
College of Nursing
17

59

APPENDIX C

Calendar Instrument

ACTIVITY‘RECORD CALENDAR

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60

ACTIVITY. RECORD CALENDAR

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64

APPENDIX D

UCRIHS Approval

 

RESEARCH
AND
GRADUATE
STUDIES

runways-away
mun-sum
mam

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MICHIGAN STATE
u N l v E R s I T Y

 

June 3. 1996

To: Ann w. Fowler
10849 Hildon Way
Grand Ledge. HI 4883?

RB: IRBC: 96-334
TITLB: THE RELATIONSHIP OF THE LEVEL OF WOMEN'S
KNOWLEDGE OF MENOPAUSE TO LEVEL OP ADHERANCB TO
PLAN FOR EXERCISE, USE OF CALCIUM AND VITAMIN
SUPPLEMENTS AND HORMONAL THERAPY

REVISION RSOUBSTED: g]:
APPROVAL DAIB: 05/31/96

The University Cousittee on Research Involving Human Sub ects' (OCRIRS)
review of this project is complete. I am pleased to adv as that the
rights and welfare of the human subjects appear to be a tely
tected and methods to obtain informed consent are appropriate.
gherefore. the UCRIBS approved this project and any rev sions listed

allluabi UCRIBS approval is valid for one calendar year. beginning with
the approval date shown above. Investigators pl to
continue a project beKond one year must use the green renewal
form (enclosed with t e original a proval letter or when a
2::1::: is renewed) to seek ugdate certification. There is a

of four such expedite renewals ssible. Investigators

wishi to continue a project beyond the time need to submit it
again or complete reView.

srvrsrous: UCRIRS must review any changes in procedures involving human
subjects, prior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. ro
revise an ap roved protocol at any other time during the year
send your written request to the CRIRS Chair. requesting revised
approval and referencing the project's 1R3 I and title. Include
in your request a description of the change and any revised
ins ruments. consent forms or advertisements that are applicable.

ssosnsus/
cnhlclli Should either of the following arise during the course of the
work, investigators must noti UCRIHS promptly: I) roblems
(unexpected side effects comp aints, e c.) involv ng uman'
subjects or (2) changes in the research environment or new
information indicating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future help, lease do not hesitate to contact us
at (517)355s2180 or FAX (Sl?)4 2- 171.

Sincerely.

  
  

 
  

avid B. Wright. Ph.D.
UCRIHS Chair

cc: Marilyn Rothert

65

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