|Year : 2021 | Volume
| Issue : 2 | Page : 46-50
Quality of life scale among perimenopausal and postmenopausal women in a rural area of Delhi: A facility-based study
Saurav Basu1, Ruchira Pangtey1, Bratati Banerjee1, Saurabh Kumar2
1 Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
2 Office of the Deputy Medical Superintendent, Maharishi Valmiki Hospital, New Delhi, India
|Date of Submission||20-Dec-2020|
|Date of Decision||21-Jan-2021|
|Date of Acceptance||23-Jan-2021|
|Date of Web Publication||26-Jul-2021|
Dr. Saurav Basu
Department of Community Medicine, Maulana Azad Medical College, New Delhi
Source of Support: None, Conflict of Interest: None
Background: The average Indian woman has early onset menopause compared to the global average. Assessment of the quality of life (QOL) among Indian women with perimenopause or postmenopause at health facilities using a rapidly administered, validated instrument is required. Objective: To assess the QOL among perimenopause and postmenopausal women in India and to ascertain the factors influencing their QOL using a brief instrument suitable for clinical use. Methods: A cross-sectional study was conducted during August to October 2019 in the medical outpatient department at a government secondary care hospital in a rural area of Delhi, India. We enrolled women in the age group of 40–59 years. Results: We recruited 136 participants with a response rate of 92%. The mean (standard deviation) age of the participants was 49.2 (6.1) years. A majority (51.2%) of the participants were illiterate, and only 22 (16.6%) were employed. The Cronbach's alpha of the Utian QOL was 0.824, indicating good reliability. The QOL scores of the participants were below average for the occupational and emotional domains, but higher for the health and sexual domains. On bivariate analysis, we found education not more than primary school, not being employed, and having more than two children were associated with lower QOL scores. Conclusion: Women with greater education, employment, with up-to two children and without depressive symptoms reported a better QOL, but it did not differ significantly between perimenopausal and postmenopausal women.
Keywords: India, menopause, quality of life, Utian quality of life
|How to cite this article:|
Basu S, Pangtey R, Banerjee B, Kumar S. Quality of life scale among perimenopausal and postmenopausal women in a rural area of Delhi: A facility-based study. J Public Health Prim Care 2021;2:46-50
|How to cite this URL:|
Basu S, Pangtey R, Banerjee B, Kumar S. Quality of life scale among perimenopausal and postmenopausal women in a rural area of Delhi: A facility-based study. J Public Health Prim Care [serial online] 2021 [cited 2022 Jan 16];2:46-50. Available from: http://www.jphpc.com/text.asp?2021/2/2/46/322306
| Introduction|| |
Menopause is a natural phenomenon marking the end of a woman's reproductive capacity with cessation of ovarian function and a fall in the levels of the hormones, estrogen and progesterone that is reflected in the absence of periods for 12 months or a time equivalent to three menstrual cycles. Compared to Western societies, Indian women are more likely to experience early menopause, especially in case of women without formal education, low socioeconomic status (SES), marital breakdown, and absence of use of oral contraceptive pills or when not sterilized. It is well-established that the onset of menopause is causally associated with physical or psychological symptoms that may decrease their quality of life (QOL) and consequently their health status. The World Health Organization has defined QOL as an 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. Previous research has shown that postmenopausal QOL apart from medical outcomes (such as osteoporosis) is dependent on the sociocultural factors prevalent in the local communities. Furthermore, the period of transition to menopause or the perimenopause period can present with menopause like symptoms due to fluctuations in the level of the estrogen hormone that cause abnormalities in the menstrual cycles. Symptoms such as hot flushes, sleep problems, night sweats, and vaginal and bladder problems are typically experienced by women during this phase as they progress toward eventual menopause. There is growing recognition that the QOL among women in perimenopause should also be assessed just like in the postmenopausal women.
There exist a paucity of studies that have assessed QOL among perimenopause and postmenopausal women in Northern India, especially when the women predominantly have risk factors related to poor literacy, rural habitation, and low SES. With this background, we conducted this facility-based study in a rural area in the outskirts of Delhi, the Indian capital city. Our objective was to assess the QOL among perimenopause and postmenopausal women in India and to assess the factors influencing their QOL using a brief instrument suitable for clinical use.
| Methods|| |
A cross-sectional study was conducted during August to October' 2019. We enrolled women with perimenopause or those having attained menopause in the age group of 40–59 years. The women previously diagnosed with any malignancy, any obvious mental illness, or any serious acute health event were excluded.
The study was conducted among women outpatient attendees in the medicine department of a government secondary care hospital in the North-western district of Delhi, India. Most of the patients reporting to the hospital resided in nearby urban slums and some rural areas in the outskirts of Delhi and were socioeconomically disadvantaged.
Women who were having any of these symptoms: Menstrual irregularities, hot flashes, sleep disturbances, or mood swings in the previous 3 months.
Women who had undergone at least 12 consecutive months without a menstrual period.
The QOL in the women was ascertained using the Utian QOL Scale (UQOL) scale consisting of 23 items., The UQOL was translated into the local language Hindi using a back and forth translation method fulfilling cross-cultural validation requirements. Items 8, 9 assessed dietary behavior, item 10 assessed frequency of exercise, item 11 assessed depressive mood, item 12 assessed anxiety and items 21, 22 assessed physical fitness. For individual items, we dichotomized responses as agreement or disagreement, with a score <3 considered as disagreement.
The UQOL measured QOL in four domains through their respective subscales, including occupational, health, emotional, and sexual QOL. Response to each of the items of the questionnaire was coded on a 5-point continuous rating scale with 1 (not true) and 5 (very true of me). The UQOL score was calculated by summing up the individual item scores. The items 4, 7, 8, 11, 12, 13, 15, and 16 were reverse coded. The expected mean scores for the total QOL, occupational QOL, health QOL, emotional QOL, and sexual QOL were 74, 25, 21, 20, and 8, respectively.
According to a previous study, 37.5% of Indian women are expected to have a low QOL. At 95% confidence levels, and 8% margin of error, the sample size was calculated to be 141 using OpenEpi software.
The SES of the participants was assessed by calculating their per capita income and classifying it through the BG Prasad scale, updated as per the consumer price index for industrial workers.
Outpatients waiting in the queues of the medicine outpatient department were assessed consecutively for eligibility, and on meeting, the selection criteria were invited to participate in the study. We collected the data using a pretested patient interview schedule. The UQOL is usually self-administered, but it was verbally administered to the participants by a trained female resident doctor due to poor literacy in the majority of the participants.
The data were analyzed with IBM SPSS version 25 (IBM Corp., Armonk, NY:). The results were expressed as frequency and proportions for the categorical variables and mean and standard deviation (SD) for the continuous variables. The independent samples t-test was used to compare the difference in means. Correlation between the continuous variables was assessed by calculating the correlation coefficient.
The Institutional Ethics Committee of the hospital approved the study. Written and informed consent was obtained from all the study participants.
| Results|| |
Sociodemographic and clinical characteristics
We recruited 136 participants with a response rate of 92%. The mean (±S. D.) age of the participants was 49.2 (±6.1) years. A majority (51.2%) of the participants were illiterate. Only 22 (16.6%) participants were employed. The average (±S. D) number of children borne by the participants was 3.7 (±1.4), of whom 126 (92.64) had at least one male child. Diabetes mellitus was previously diagnosed in 18 (13.2%) participants. None of the participants reporting tobacco smoking or alcohol consumption, whereas 4 (2.94%) participants reported smokeless tobacco use. The mean (SD) age of onset of menopause was 47.4 (±5.02) years among the postmenopausal women participants (n = 82).
Quality of life
The Cronbach's alpha of the UQOL was 0.824, indicating good reliability [Table 1]. Furthermore, the Cronbach's alpha for the occupational, sexual, emotional, and health domains were 0.867, 0.298, 0.508, and 0.521, respectively.
|Table 1: Utian quality of life scale scale with reliability, means, and standard deviation|
Click here to view
Only 16 (11.8%) participants had above-average expected total QOL scores, 77 (56.6%) participants had low QOL, (between mean and-1SD) scores, while 43 (31.6%) participants had very low QOL (below-1SD) scores. The participants reported above-average QOL scores across health and sexual domains, below average for the emotional domain and the lowest for the occupational domain [Table 2].
|Table 2: Utian quality of life scale domain scores of the study participants|
Click here to view
Mental health, physical, and dietary behaviors
Forty-six (33.8%) participants reported the presence of generally depressive mood and 39 (28.67%) reported frequently experiencing anxiety. A total of 48 (35.3%) participants reported engaging in active exercise for three or more times per week, whereas 71 (51.2%) participants perceived themselves to be physically fit. However, most (85.3%) participants considered their routine diet to be nutritious.
Predictors of suboptimal quality of life
On bivariate analysis, we found limited education restricted up to primary school, not being employed, and having more than two children were associated with lower UQOL scores [Table 3].
|Table 3: Distribution of factors associated with quality of life in the study participants|
Click here to view
Construct validity of the UQOL: Health-related QOL was positively correlated with the total, occupational, and sexual QOL, but negatively correlated with the emotional QOL [Table 4].
|Table 4: Construct validity of the Utian quality of life scale among Indian women with perimenopause or post-menopause (n=136)|
Click here to view
| Discussion|| |
The present study conducted among Indian women in their mid-life years found the observed QOL scores were suboptimal and below the expected average QOL scores. Furthermore, the QOL scores were below average for the occupational and emotional domains, but higher for the health and sexual domains. However, the reference scores were obtained for the original scale that had not been assessed in an Indian population previously.
Women who were employed and had no more than two children had a significantly better QOL compared to women lacking any specific employment and mothers having more than two children, respectively, which suggested that the UQOL had good discriminant validity. However, the presence of diabetes comorbidity in the women did not significantly lower the QOL compared to previous studies, probably due to the relatively younger age profile of the participants. A major finding of the present study was the lack of a significant difference in the QOL score between the perimenopause and postmenopausal women, probably due to the early onset of menopause among Indian women.,
Depression and anxiety are the significant predictors of poor QOL. Our study found that 46 (33.8%) participants reported the presence of generally depressive mood and 39 (28.67%) frequently experiencing anxiety. In contrast, another study from Southern India reported nearly half the postmenopausal women experiencing symptoms of depression or anxiety. A study in the Northern state of Uttar Pradesh reported most peri- and postmenopausal women experiencing physical (100%) and psychosocial (94.5%) symptoms.
We found nearly one in three participants (31.6%) had very low QOL, while good QOL was seen in just over one in ten participants (11.8%). Previous studies in Southern India reported poor QOL in 37.2% and 40% postmenopausal women. Another study from the Eastern state of West Bengal observed poor QOL in 75% of postmenopausal women. Furthermore, a study among slum dwelling postmenopausal women in Odisha reported impaired QOL in 67.3% participants. Nevertheless, the validity of the comparisons is limited by the methodological heterogeneity between the studies due to the use of varying study instruments for the assessment of QOL with different items and scoring criteria.
In comparison with a previous study among Indonesian postmenopausal women assessed with the UQOL, the reliability parameters in this study were more robust. However, a similar lack of reliability and validity was observed for the emotional QOL domain.
The strength of this study is that it was conducted mostly among women who are presumed to be at higher risk of lowered QOL due to factors such as poor literacy, high fertility, and low SES. Furthermore, it included women in their mid-life years among both women having menopause and women making the transition to menopause, and excluded geriatric women who are more likely to have reduced QOL due to multiple comorbidities. The study also contributes to the sparse knowledge on QOL among perimenopausal and postmenopausal women in Northern India.
| Conclusion|| |
Women with greater education, employment, having up-to two children and without depressive symptoms reported a better QOL, but it did not differ significantly between perimenopause and postmenopausal women. The Hindi UQOL is a reliable and valid tool with regard to the occupational and health domains but shows poor convergent validity for the emotional domain and lacks reliability for the sexual domain. This could be because of the local community's cultural norms that inhibited disclosures of personal sexual histories to people outside their families. Future studies should develop and evaluate a modified UQOL which accounts for these deficiencies with inclusion of more relevant items in the existing scale for appropriately identifying issues related to the women's emotional and sexual health.
We did not assess sleep quality and urogenital symptoms which are known determinants of QOL. Medical conditions such as osteoporosis that contribute to significant lowering of the QOL among postmenopausal women was not assessed in this study. Since the UQOL was verbally administered, there was increased likelihood of the social desirability bias which could result in over-reporting of healthy and underreporting of unhealthy behaviors by the participants, inflating their QOL scores. Nevertheless, it also ensured completeness of data. Furthermore, due to the cross-sectional study design, any causal association between the predictor variables and QOL scores could not be ascertained. Finally, the present study was conducted at a single facility-based site, limiting the generalizability of its findings.
We would like to thank the North American Menopause Society for the use of the Utian Quality of Life Scale.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Report of WHO Scientific Group on the Menopause in the 1990. WHO Technical Report Series 866. Geneva: World Health Organization; 1996.
Whelan EA, Sandle DP, McConnaughy DR, Weinberg CR. Menstrual and reproductive characteristics and age at natural menopause. Am J Epidemiol 1990;131:625-32.
Pallikadavath S, Ogollah R, Singh A, Dean T, Dewey A, Stones W. Natural menopause among women below 50 years in India: A population-based study. Indian J Med Res 2016;144:366-77.
] [Full text]
Lock M. Ambiguities of aging: Japanese experience and perceptions of menopause. Cult Med Psychiatry 1986;10:23-46.
Karmakar N, Majumdar S, Dasgupta A, Das S. Quality of life among menopausal women: A community-based study in a rural area of West Bengal. J Mid-life Health 2017;8:21-7.
] [Full text]
Utian WH, Janata JW, Kingsberg SA, Schluchter M, Hamilton JC. The Utian Quality of Life (UQOL) Scale: development and validation of an instrument to quantify quality of life through and beyond menopause. Menopause 2002;9:402-10.
Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: A clear and user-friendly guideline. J Eval Clin Pract 2011;17:268-74.
Krishnamoorthy Y, Sarveswaran G, Jayaseelan V, Sakthivel M, Arivarasan Y, Bharathnag N. Assessment of quality of life based on psychological, somatovegetative, and urogenital health problems among postmenopausal women in Urban Puducherry, South India: A cross-sectional observational study. J Mid-life Health 2018;9:173-9.
] [Full text]
Sharma R. Revision of Prasad's social classification and provision of an online tool for real-time updating. South Asian J Cancer 2013;2:157.
Mathew DJ, Kumar S, Jain PK, Shukla SK, Ali N, Singh DR. A cross-sectional study to assess the quality of life of perimenopausal and post-menopausal women in rural Etawah, Uttar Pradesh, India. J Midlife Health 2020;11:161-7.
Jayabharathi B, Judie A. Severity of menopausal symptoms and its relationship with quality of life in postmenopausal womena community based study. Int J Pharm Clin Res 2016;49:2-71.
Ray S, Dasgupta A. An assessment of QOL and its determining factors of post-menopausal women in a rural area of West Bengal, India: A multivariate analysis. Int J Med Public Health 2012;2:12-9. [Full text]
Kumari A, Panigrahi A, Roy A, Panda J. Impaired Quality of life and its determinants among postmenopausal women of slum communities in Bhubaneswar, India. J Midlife Health 2020;11:149-55.
Baernholdt M, Hinton I, Yan G, Rose K, Mattos M. Factors associated with quality of life in older adults in the United States. Qual Life Res 2012;21:527-34.
Wulandari P, Soeroso Y, Maharani DA, Rahardjo A. Validity and reliability of a modified utian quality of life scale for Indonesian postmenopausal women. J Int Dent Med Res 2018;11:232-7.
Singh N, Kumar D, Yadav G, Srivastava MK, Mishra SR, Gupta AK, et al
. Comparison of quality of life and bone mass density among postmenopausal women: A cross-sectional study. J Mid-life Health 2020;11:224-30. [Full text]
[Table 1], [Table 2], [Table 3], [Table 4]