RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

ANNEXURE –II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 Name of the candidate and BINU PAULOSE address FIRST YEAR M. SC. NURSING SAHYADRI COLLEGE OF NURSING (in block letters) FALNIR ROAD, KANKANADY, MANGALORE

2 Name of the institution SAHYADRI COLLEGE OF NURSING FALNIR ROAD. KANKANADY MANGALORE -02

3 Course of study and subject M.Sc. NURSING, COMMUNITY HEALTH NURSING

4 Date of admission to course 5.6.2009

5 Title of the study: A COMPARATIVE STUDY TO ASSESS THE QUALITY OF LIFE OF POST-MENOPAUSAL WOMEN RESIDING IN SELECTED RURAL AND URBAN COMMUNITIES WITH A VIEW TO CONDUCT AN AWARENESS PROGRAMME ON POST MENOPAUSAL HEALTH.

1 6. BRIEF RESUME OF INTENDED WORK

Introduction

Menopause is a complex time in a woman’s life leading to both physical and emotional challenges. Menopause currently affects the lives of millions of women globally and will be an issue of increasing concern as the population ages over the next few decades. The word menopause literally means the permanent physiological or natural cessation of menstrual cycle. In other words, menopause means the natural and permanent stopping of monthly reproductive cycles, which is usually manifest as a permanent absence of monthly periods or menstruation. Post menopause refer to the period of life after menopause has occurred. It is generally believed that the postmenopausal phase begins when 12 full months have passed since the last menstrual period. From then on, a woman will be postmenopausal for the rest of her life1.

According to IMS (Indian Menopause society) research, there are about 65 million Indian women in the age group of 45 years. Average age of menopause is around 48 years but it strikes Indian women as the age as 30-35 years. So menopausal health demands even higher priority in Indian Scenario.2

6.1. Need for study

Menopause is an important time in women’s life. Declining levels of the hormones i.e., oestrogen and progesterone produced by the ovaries bring about many changes in the female .The historical and social construction of the menopause experience has significant implications for menopausal women. Persistent stereotypes imply that menopause is a time associated with a loss of youth and sexuality. Further influencing the way in which menopause is perceived and understood is the fact that the medical discipline has largely defined menopause as a negative experience filled with a variety of undesirable physical and emotional symptoms (Winterich & Umberson, 1999). Menopause is an inevitable milestone in the reproductive life of every woman. Technically, it refers to a woman’s last periods; a woman can be said to have reached menopause when she had one year without menstruating. Menopause

2 as a change in hormonal levels can conceal the social context in which it occurs as a change of life marked by many life stages.3

Women play an important role in replenishing the earth but her reproductive capacity is not permanent; it ceases one day which is coined as menopause. Menopause, especially in a rural woman brings in lot of changes which she has to tackle to get rid of chronic illnesses especially psychosomatic problems. The efficient and effective means of preventing and controlling these problems is through improving social support, self-esteem, and empowerment.

A research study measured on 56 middle-aged rural Indian women of selected villages of Chennai, Tamilnadu reported correlations were statistically significant with P < 0.01 in a two tailed test. Self-esteem was positively associated with social support (r=0.044), empowerment (r=0.354), and self-efficacy (r=0.566). The highest absolute correlation was found between loneliness and stress (r=716), depression and stress (r^0.701) and social support with loneliness (r=0.646). The study concluded that social support, self-esteem, empowerment, and psychosocial indicators have a correlation.4

Menopause is accompanied by biological and psychological changes that affect a women’s health and sense of well being. Menopause is the time in a woman’s life, usually occurs naturally, often after 45 years. Menopause happens because the woman’s ovaries stop producing the hormones oestrogen and progesterone. Changes and symptoms can start several years earlier. They include changes in periods – shorter or longer, lighter or heavier with more or less time in between hot flushes and/or night sweats, trouble sleeping, vaginal dryness, mood swings, trouble focussing and less hair on the head, more on the face, women as to men, experience an age-related decline of physical and mental capacity. They observe symptoms such as periodic sweating or hot flushes, depression, insomnia, impaired memory, lack of concentration, nervousness, and bone and joint complaints. These symptoms more seen in rural communities. Quality of life different from rural and urban communities.5

3 The investigator during her community health field experience observed as well as listened to menopausal women complaining about various minor problems that interfere in their day to day life. These complaints can be overcome to improve the quality of life. Due to illiteracy Indian women are ignorant about the changes taking place in their reproductive system. Religion and culture of our society also inhibits to express these changes. So awareness programme need to be conducted to overcome these issues. But there is a lack of awareness of cause, effect and management pertaining to it. A wide gap in the knowledge has been documented on the women from developed and developing countries. And this gap is even wider in women from rural and urban communities. So the investigator felt that there is a need to improve the quality of life of post menopausal women through an awareness programme.

6.2 Review of Literature

A study was conducted to evaluate the factors influencing the quality of life (QOL) of Moroccan postmenopausal women with osteoporosis. Forty-three post menopausal women aged 48-60 yrs participated in this study. Questionnaire was used to assess the quality of life of post menopausal women. The independent factors were associated with poor quality of life, low educational level (p=0.01), vertebral fractures (p=0.03) and a history of peripheral fracture (p=0.006). Worse QOL was observed in the group with fractures in all domains except “pain,” namely, physical functioning (p=0.002), fear of illness (p=0.00), and psychosocial functioning (p=0.007). The number of fractures was a determinant of a low QOL, as indicated by an increased score in physical functioning (p=0.001), fear of illness (p=0.007), and total score (p=0.01) after adjusting on age and educational level. Patient with higher score had low quality of life in these two domains too (p=0.002, p=0.001 respectively) and in the total score (p=0.01) after adjusting on age and educational level.6

A study was conducted among women in age after 45 years from Poland, Belarus, and Greece. The menopause rating scale (MRS) was used. It consists of and letter of 11 symptoms which had been answered. The respondents have and choice among 5 categories – no symptoms, mild, moderate, marked, and severe. Mild and no complaints in similar degree were reported by all women from these three countries.

4 The investigator also found that almost 14.4% of women from Greece had marked complaints in menopause rating scale compared to complaints of 9% respondents from Belarus and 9.5% from Poland. These differences were significant (P < 0.001). Moderate complaints were reported more frequently by women from Poland (32.56%) and Belarus (34%) compared to women from Greece 28.5%). Severe complaints were noted more rarely in 1.6% Greek women compared to 2.6% Belarusian and 3% Polish respondents. These findings were not significant. Furthermore, a half of the respondents from Poland, Belarus, and Greece reported hot flushes (in moderate degree). In contrast 70% of Greek women declared hot flushes from, 54.4% from Poland, and 60% from Belarus. Insomnia was reported more frequently by women from Poland (34.6%) and Belarus (36%) than by respondents from Greece (17.6%). No significant differences between no complaints, mild, moderate, marked and severe were found between women from Belarus, Poland and Greece.7

A study was conducted on health related Quality of Life of post menopausal women. The age group 45-60 yrs was selected. A randomized lifestyle intervention trial of diet, physical activity was included in the study. Analysis focused on the women who lost ≥5lb during the initial phase of the study, baseline to 6 months (n=248). This cohort was divided into 3 groups based on sub sight weight change between 6 & 18 months : weight loss (WL; ≥lb loss), wt stable (WS; <±5lb change) & weight regain (WR; ≥5lb gain) of the 248 women studied, 5, (21%) continued to loss weight after initial weight loss, while 127 (51%) maintained & stable weight & 70 (28%) regained weight. Between baseline & 6 months, women in weight regain group had deceased mental health & social functioning scores, while the weight loss and weight stable groups improved in those subscales. Between baseline & 18 months, energy improved most significantly in those with continued weight loss (P=0.0003).8

A study was conducted in Chandigarh, India. Systematic random sampling was used. The study population comprised of women above 40 years and resident of study area. Out of total 528 women interviewed, 302 (56%) were residing in urban area and rest were the resident of slums. 78.8% urban 60.2% from slums had attained menopause. Majority (70.3%) of urban residents had heard about menopause as compared to 30.9% in slums. The most common menopausal symptoms were vaginal

5 irritation /discharge (47.7%) less than half of females (38.7%) took treatment for menopausal symptoms. Calcium supplements were taken by majority 63%. 7.7% female complained of post menopausal bleeding out of which 13(14.8%) had it after intercourse. Only 2(28.6%) women had their pap smear done after being suggested by doctor and they were from urban area only. The study highlights that there is lack of awareness regarding menopause and related aspects especially post menopausal bleeding in both urban and slum population.9

A study was conducted on Quality of Life impairment among postmenopausal women living in urban areas. In this study women aged 40-50 years participated in a cross-sectional study filling out the Menopause Rating Scale (MRS) and a general questionnaire. A total 579 women were included. 153 Hispanic, 295 indigenous and 131 Afro-descendent. Hispanci Women had an average age of 55.3+/- 3.3 years. Indigenous and balck women were less educated than the Hispanic ones (2.2+/- 1.8 and 4.6+/--4.4 vs. 6.4+/- 3.5 years, p<0.0001). Hispanic women displayed lower total MRS score (better QoL) when compared to indigenous and black women. Urogenital scoring was worse among indigenous women compared to Hispanic and black women. Black women presented higher MRS psychological and somatic scorings than Hispanic and indigenous women. After adjusting for confounding factors, indigenous and black women continued to display a higher risk for impaired QoL, total menopause rating scale score >16 which was significantly higher among indigenous women due to urogenital symptoms and black women due to psychological and somatic symptoms.10

A study was conducted on the effects of physical exercise on the quality of life of post-menopausal women. Forty-eight menopausal women aged 55-72 years were recruited at a primary care centre as voluntary participants in a quasi experimental study. They were randomly assigned to one of the two groups – control (n = 24) and experimental (n=24). The experimental group participated in a 12-month programme of cardiorespiratory, stretching, muscle-strengthening, and relaxation exercise carried out during two fully supervised exercise sessions per week (total 3 hours weekly). Health-related quality of life was assessed by using the Quality of Life Profile for Chronically Ill Patients, a generic questionnaire widely used in epidemiological and clinical studies to measure the wellbeing and function, incorporating as an optional module, the Kuppeman Index of Menopausal Symptomatology. There was a

6 statistically significant improvement in health-related quality of life of the experimental group, whereas the health-related quality of life of the control group significantly worsened. Menopausal symptoms also significantly improved in the experimental group and significantly worsened in the control group over the 12- month study period.11

6.3 Problem Statement

A comparative study to assess the quality of life of post-menopausal women residing in selected rural and urban communities with a view to conduct an awareness programme on post menopausal health.

6.4 Objectives of the Study

1. To assess the quality of life of postmenopausal women residing in selected rural and urban communities. 2. To compare the quality of life of post menopausal women residing in selected urban and rural communities. 3. To find out an association between quality of life of postmenopausal women and selected demographic variables such as age, income, occupation.

6.5 Operational definitions

1. Quality of life: According to the World Health Organization, Quality of Life can be defined as “Individual’s perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns.

In this study, quality of life refers to the way a woman overcomes significant physical, physiological, emotional, and psychological changes taken place due to menopause which may affect interms of health.

a. Physical changes such as weight gain, ageing process, skin changes, dryness of vagina and painful intercourse. These changes can be managed by physical exercises like jogging, walking and cross legging. b. Physiological changes such as low back pain, joint ache, hot flushes, night sweats, and dryness of vagina, and sexual changes. These changes can be handled by meditation, pranayama, yoga, and nutritious diet containing Calcium, Vitamin E, C and A.

7 c. Psychological changes refer to mood swings, irritability, anxiety, depression and sexual problems. These changes can be managed by recreational therapies like reading books, music, picnics, and spiritual gathering.

d. Emotional changes are irritation, nervousness, headache, and feelings of fear, sadness, and loneliness. These changes can be managed by family support and social support.

2. Postmenopausal women: According to Webster New World medical dictionary “It is the time after which a women has experienced 12 consecutive months of amenorrhoea.

In this study, postmenopausal women refer to married, unmarried, employed or unemployed women in the age group of 45-60 years, who have experienced 12 consecutive months of amenorrhoea and who are not on hormone replacement therapy (HRT)

3. Rural: Rural are large and is isolated areas of a country, often with low population density (Wikipedia).

In this study, it refers to the selected villages which comes under selected primary health centre.

4. Urban: Urban area is characterized by higher population density and vast human features in comparison to areas surrounding it (Wikipedia).

In this study, it refers to the selected areas which comes under selected urban family welfare centre.

5. Awareness Programme on post menopausal health: In this study it refers to the individual health education and selected demonstration such as breast self examination, yogas and calcium preparation which will be provided to postmenopausal women of selected areas with the use of charts to improve the quality of life.

8 6.6 Assumptions The study assumes that:

 Post-menopause is a period in which women will have some health problems which contribute to having changes in the quality of life.

 There will be difference in the quality of life of urban and rural communities.

6.7 Delimitations The study is delimited to:

 Postmenopausal women in the age group of 45-60 years.

 Postmenopausal women who are not on hormone replacement therapy

 Selected areas of Mangalore.

6.8 Hypotheses

H1: There will be significant difference between the mean quality of life score of postmenopausal women in rural and urban areas.

H2: There will be significant association between the quality of life of postmenopausal women and selected demographic variables such as age, income and occupation. 7. MATERIALS AND METHODS

7.1 Source of data

Post menopausal women in the age group of 45-60 years in selected urban and rural areas in Mangalore.

7.1.1 Research design

Comparative survey.

Phase 1 Phase 2 Phase 3  Quality of life of Prepare and validate Conduct awareness postmenopausal women awareness programme programme on of rural area on post menopausal postmenopausal health. health.  Quality of life postmenopausal women of urban area 7.1.2 Setting

9 The study will be conducted in selected rural and urban communities of Mangalore.

7.1.3 Population

Post menopausal women who have experienced 12 consecutive months of amenorrhoea living in rural and urban communities.

7.2 Method of data collection

7.2.1 Sampling procedure

The purposive sampling technique will be used to select the sample.

7.2.2 Sample size

Sample size consists of post menopausal women 40 from rural and 40 from urban communities.

7.2.3 Inclusion criteria for sampling

 Those who have experience one year of amenorrhoea in the age group of 45- 60 years.

 Those who are willing to participate in the programme.

7.2.4 Exclusion criteria for sampling

 Those who have been diagnosed with critical medical, surgical and gynaecological problems.

 Those who are on Hormone replacement therapy.

7.2.5 Instrument intended to be used

 Demographic proforma.

 Modified Menopause Rating Scale to assess the quality of life

10 7.2.6 Data collection method

 Permission will be obtained from concerned authorities.

 The purpose of the study will be explained to postmenopausal women and informed consent will be obtained from them.

 Pilot study will be conducted prior to the study.

 Quality of life of post menopausal women will be assessed using modified menopause rating scale.

 Awareness programme to improve quality of life will be given to the post menopausal women residing in selected rural and urban communities.

7.2.7 Data analysis plan

Data will be analysed using descriptive and inferential statistics.

7.3 Does the study require any investigation or intervention to be conducted on patients or humans or animals? If so please descriptive briefly?

No.

7.4 Has ethical clearance been obtained from institution in case of 7.3?

Yes, ethical clearance will be obtained from concerned authority.

11 8. LIST OF REFERENCES

1. Tamilmani. Menopause and hormone replacement therapy. Nightingale Nursing Times. 2006; 2(1): 24-27.

2. Puri S, Bhatia V, Mangat C. Perceptions of menopause and post menopausal bleeding in women of Chandigarh. The Internet Journal of Family Practice. 2008; 6(2): 601-608.

3. Sharon D, Wonshik C. Menopausal symptom experience : an online forum study. Journal of Advanced Nursing 2008; 60(7): 541-548.

4. Sharadha R. Social support system in menopause. Nightingale Nursing Times. 2009; 5 (6): 12-15.

5. Dutta DC. Text book of gynaecology. 3rd edition, New central book agency (P) Ltd. 2004; 46.

6. Sabbah. Quality of life in rural and urban population in Lebanon using Sf-36 health survey. Health quality of life outcomes. 2003; 1(10): 477-498.

7. Isaac S. The benefits of regular exercise for post menopausal women. Alternative medicine for menopause. 2004; 5 (10): 90-97.

8. Robert P. Exercise boosts quality of life in post menopausal women. Jama archives journals. 2007; 28 (12): 34-39.

9. Alvaro M, Juan B, Peter C. Quality of life impairment among post menopausal women. Gynaecological Endocrinology. 2008 ; 25 (8): 491-497.

10. Sanat B. Effect of physical exercise on the quality of life of menopausal women. Journal of Advanced Nursing 2009; 54 (1): 54-58.

11. D’souza S, Melba. Health promoting quality of life of post menopausal women. Journal of Advanced Nursing Sciences 2009; (66)2:142-146.

12 13 8. Signature of the candidate

9. Remarks of the guide

10. Name and designation of (in block letters)

10.1 Guide

10.2 Signature

10.3 Co-guide (if any)

10.4 Signature

11 11.1 Head of the department

11.2 Signature

12. 12.1 Remarks of the Chairman and Principal

12.2 Signature

14 15