Palestinian Menopausal Women In the West Bank: A Needs Assessment Shiraz Nasr, Sawsan Imseeh, Doaa Hammoudeh, Niveen Abu Rmeileh, Rita Giacaman (supervisor) Institute of Community and Public Health, Birzeit University (ICPH/BZU) A study conducted on behalf of and in cooperation with The Palestinian Ministry of Health March 2014 1 RESEARCH TEAM Shiraz Nasr, Research Assistant Sawsan Imseeh, Research Assistant Doaa Hammoudeh, Research Assistant Researcher and Supervisor: Professor Rita Giacaman Consultant statistician: Dr. Niveen Abu Rmeileh Field workers: Palestinian Ministry of Health nursing staff Data analysis: Shiraz Nasr, Sawsan Imseeh, Professor Rita Giacaman with consultations from Dr. Niveen Abu Rmeileh Report writing: Shiraz Nasr, Sawsan Imseeh, Doaa Hammoudeh, Professor Rita Giacaman 2 ACKNOWLEDGEMENTS We would like thank our partners at the Palestinian Ministry of Health (PMoH) represented by Dr. Asaad Ramlawi, Head of the Primary Health Care Directorate, Ms. Siham Shamasneh, Head of Nursing at the PMoH and Ms. Amal al-Haj and Ms. Taghreed Abdulrahman at the Primary Health Care Directorate. We also we would like to express our gratitude to all PMoH nurses who conducted the field work for the study. These nurses include: Alaa’ abu Rmeileh, Amal Rami, Samar Sawalha, Yasmeen Abdulraheem, Ghadeer Awad, Shireen Bani Odeh, Fatima Ja’far, Khuloud Isa, Intisar Damrah, Basma Hamshari, Izdihar Masoud, Zaher Abdullatif, Huda Ala’sa, Khitam Abu Sharar, Majdoleen Diebes, Kariman Ayesh, Lubna Abdulqader, Zeinab Sa’d, Nada Turkman, Adala Radi. Finally, we would like to thank Dr. Ali Shaar, UNFPA, for reading and making important comments on the study instrument. This study was conducted by faculty and research assistants from the Institute of Community and Public Health at Birzeit University on behalf of and in cooperation with the Palestinian Ministry of Health with financial support from UNFPA represented by Dr. Ali Shaar. 3 CONTENTS RESEARCH TEAM ................................................................................................................................ 2 ACKNOWLEDGEMENTS ...................................................................................................................... 3 LIST OF TABLES .................................................................................................................................. 5 LIST OF ACRONYMS ............................................................................................................................ 6 1. EXECUTIVE SUMMARY .................................................................................................................... 7 2. INTRODUCTION ............................................................................................................................ 14 3. LITERATURE REVIEW ..................................................................................................................... 15 4. METHODS ..................................................................................................................................... 18 4.1. Design ....................................................................................................................................... 18 4.2 Questionnaire construction ........................................................................................................ 18 4.2. Sample selection ....................................................................................................................... 20 4.3. Training of field workers ............................................................................................................ 21 4.4. Interviews.................................................................................................................................. 21 4.5. Statistical analyses ..................................................................................................................... 22 5. RESULTS........................................................................................................................................ 25 5.1. Sample description results ......................................................................................................... 25 5.2. Post-menopausal women .......................................................................................................... 30 5.3. Peri-menopausal Women .......................................................................................................... 37 6. DISCUSSION .................................................................................................................................. 40 BIBLIOGRAPHY ................................................................................................................................. 48 APPENDIXES ..................................................................................................................................... 51 4 LIST OF TABLES Table 1: PMoH selected clinics .............................................................................................................21 Table 2: Socio-demographic characteristics of the study sample .......................................................26 Table 3: Reported medical problems by menopausal group and total percentages ...........................27 Table 4: Reported menopausal symptoms by menopausal group and total percentages ..................28 Table 5: Quality of life responses by menopausal group and total percentages .................................29 Table 6: Reported menopausal symptoms and associated demographic and socioeconomic factors – Post-menopausal women .....................................................................................................................31 Table 7: Menopausal symptoms by selected associated factors – Post-menopausal women.............32 Table 8: Psychosocial health by selected associated factors – Post-menopausal women ..................33 Table 9: Psychosocial health and associated factors– Post-menopausal women ...............................34 Table 10: Fear of divorce and associated factors– Married post-menopausal women .......................36 Table 11: Reported menopausal symptoms and associated factors – Peri- menopausal women ......37 Table 12: Psychosocial health and associated factors – Peri-menopausal women .............................39 LIST OF APPENDIXES Appendix 1: Qualitative pilot study report ..........................................................................................51 Appendix 2: English version of developed questionnaire ...................................................................67 Appendix 3: Arabic version of developed questionnaire .....................................................................86 5 LIST OF ACRONYMS BZU Birzeit University DM Diabetes Mellitus HBP High Blood Pressure HRT Hormone Replacement Therapy ICPH Institute of Community and Public Health MRS Menopause Rating Scale NAMS The North American Menopause Society NCDs Non-communicable Diseases oPt occupied Palestinian territory PMoH Palestinian Ministry of Health QoL Quality of Life UNFPA The United Nations Fund for Population Activities UQoL Utian Quality of Life Scale WB West Bank 6 1. EXECUTIVE SUMMARY Introduction Most Palestinian women’s healthcare services and programs are geared toward pre-natal care and childbirth, with little attention paid to the needs of women during the menopausal or other periods. Calls for the inclusion of menopausal women’s needs in the primary healthcare system have extended over 20 years. A recent initiative by the United Nations Fund for Population Activities (UNFPA) entailed requesting the Institute of Community and Public Health at Birzeit University (ICPH/ BZU) to investigate the needs of menopausal women on behalf of the Palestinian Ministry of Health (PMoH). It was agreed to conduct the assessment on a sample drawn from women attending PMoH clinics in the West Bank (WB) excluding the Gaza Strip due to constraints related to accessibility to the Strip. This assessment aims to achieve equity in health care provision for menopausal women and to make their needs visible to policymakers. Menopause, the permanent cessation of ovarian activity, or the ending of a woman’s ‘periods’, is part of normal aging and is a universal event, experienced by all women at midlife [1,2]. There has been marked progress in shifting out of the medicalized paradigm towards a more integrative and holistic approach to understanding menopause and redefining it as a perfectly natural life event [3]. It should therefore be stressed that menopause is not a disease but rather a stage encompassing various biological and physiological events and may bring about a range of health complaints and increase some risks of illnesses. Given current knowledge, we know that symptoms at menopausal age have a significant relation to culture and society and may influence how menopause is perceived [1]. In most parts of the world, menopause is associated with both social and biological changes. Moreover, while virtually all societies associate menopause with unpleasant symptoms, the implications of the cessation of periods vary enormously, depending upon attitudes 7 towards ageing in general, and attitudes towards older women and their place in society in particular. [14, 15] Thus, menopause is a complex phenomenon experienced within a socio-cultural context. While there are number of cross-cultural qualitative studies of the midlife