The menopause representations questionnaire (MRQ)

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Cognitive appraisal of the menopause: The menopause representations questionnaire (MRQ) a

M. Hunter & I. O'Dea

a

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Department of Psychology, Adamson Centre, St Thomas' Hospital, London, UK Published online: 19 Aug 2010.

To cite this article: M. Hunter & I. O'Dea (2001) Cognitive appraisal of the menopause: The menopause representations questionnaire (MRQ), Psychology, Health & Medicine, 6:1, 65-76, DOI: 10.1080/713690224 To link to this article: http://dx.doi.org/10.1080/713690224

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PSYCHOLOGY , HEALTH & MEDICINE, VOL . 6, NO. 1, 2001

Cognitive appraisal of the menopause: the menopause representations questionnaire (MRQ) M. HUNTER & I. O’DEA Downloaded by [King's College London] at 01:32 19 July 2013

Department of Psychology, Adamson Centre, St Thomas’ Hospital, London, UK

Abstract This study describes the development of the Menopause Representations Questionnaire (MRQ), which, based on Leventhal’s self-regulation model (Leventhal et al., 1984), samples a range of cognitions about menopause, including identity, consequences, time frame and perceptions of control and cure. Items were derived from a qualitative interview study of 45 women aged 49–51. Identity included attributions of general symptoms as well as hot ushes and menstrual changes; positive and negative consequences were evident, as were both short and long time lines. The MRQ was given to a sample of 80 women aged 49–56 years. Internal consistency and test-retest reliability were reasonable. Perceptions of control/cure were negatively associated with depressed mood (Women’s Health Questionnaire, WHQ; Hunter, 1992), and perceptions of negative consequences were associated with medical help-seeking.

The term menopause refers literally to a woman’s nal menstrual cycle, although in common language it is used to describe the transition between reproductive and non-reproductive life stages. The menopause can be seen as a marker in a process of gradual physiological change (characterized by hormone changes and commonly by hot ushes) that happens concurrently with age and developmental changes, and which is ascribed meaning within a psychosocial and cultural context. While biomedical models of the menopause dominate the research literature, there is growing cross-cultural and sociological research that challenges a clear link between subjective experience of the menopause and biomedical indicators, such as menstrual changes or hormone measures (Avis et al., 1993; Kaufert, 1982). The biomedical model is based on the premise that the menopause is a cluster of physical and emotional problems that is caused by de ciency in reproductive hormones. While anxiety, depression, cognitive impairments and sexual problems are among the symptoms that have been reported by mid-aged women in clinical settings, general population studies suggest that menstrual irregularities and vasomotor changes are the only consistent indicators of menopause (Hunter, 1996; McKinlay et al., 1992; Nichol-Smith, 1996). Within a biomedical framework the treatment for menopausal problems, such as hot ushes, is hormone replacement therapy (HRT). Furthermore, there is evidence from case-control studies that HRT users may bene t from long-term health gains, such as Address for Correspondence: Dr Myra Hunter, Department of Psychology, Adamson Centre, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK. Tel: 1 44 0171 928 9292, ext 2284/3227; E-mail [email protected] ISSN 1354-8506 print/ISSN 1465-3966 online/01/010065-12 Ó DOI: 10.1080/13548500020021937

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M. HUNTER & I. O’DEA

reduced cardiovascular and osteoporosis risk, although the increased risk of breast cancer with long-term use is a concern for women considering long-term treatment (Grodstein et al., 1997). Thus, from this perspective the boundaries of the ‘disease’ have shifted from a transitory process to a more permanent postmenopausal condition. In contrast, sociocultural models propose that the menopause is a natural, developmental process having little or no effect upon women, and that menopausal problems are largely culturally constructed, for example being associated with negative stereotypes, attitudes towards aging and women’s social roles (Kaufert, 1982). This model has received support from anthropological studies (Avis et al., 1993; Flint, 1975). The biomedical and sociocultural models are both inadequate as models for the menopause, as they do not account for the variation in individual experience of the menopause and, by presenting women and doctors with polarized models, they have limited practical utility. Few psychological models have been developed. Greene (1984) formulated the ‘vulnerability model’, which is a variant of Brown and Harris’ (1978) life stress model applied to midlife, in which climacteric vulnerability is in uenced by both hormonal factors and life stresses, particularly bereavements. An alternative framework for studying menopause is a biopsychosocial model, where the focus is on a woman’s cognitive representations of the menopause. Women’s psychosocial and cultural context are taken into account, as well as their experience of physical changes, in determining the meaning and impact of menopause (Hunter, 1994). Cognitive factors have generally been neglected in menopause research, which is surprising since the nature of the menopause, being dif cult to de ne with vague parameters, and being imbued with cultural and historical meanings, can be seen as an interesting example of a physiological process which might be appraised in a variety of ways. When cognitions have been explored, associations have been found with experience of menopause. For example, previously held negative attitudes towards menopause have been found to predict reports of vasomotor symptoms upon reaching menopause (Avis & McKinlay, 1991). Similarly, in a prospective study of women across the menopause transition, those who, before the menopause, believed that menopausal women experience physical and emotional problems, were themselves more likely to report depressed mood when they were experiencing their own menopause (Hunter, 1992). Research on illness cognitions suggests that people construct their own representations of an illness in order to understand and deal with it. A dominant theoretical model in illness representations is the self-regulation model (Leventhal & Diefenbach, 1991; Leventhal et al., 1984), which proposes that people’s illness representations basically consist of ve components that determine emotional and behavioural reactions to illness. These components are identity, cause, time-line, consequences and cure/control. The identity component comprises the label given to the condition, the symptoms and the interaction between symptoms. The duration of the condition/illness is described by the time-line, which includes acute and chronic and cyclical/episodic time courses. Cause and control/cure describe the person’s ideas about why they have this condition and whether it is controllable or curable, and consequences involve the perceived severity and impact of the condition. While these ve components are distinct, they are not necessarily independent. These representations re ect a person’s cognitive responses to symptoms and Leventhal proposes that emotional responses are processed in parallel, and interact, with these cognitions (Leventhal et al., 1984). These ve components of illness representations have been con rmed for different illnesses using differing methodologies (Skelton & Croyle, 1991). More recently, the Illness Perception Questionnaire has been developed for use in a variety of illnesses (Weinman et al., 1996) and appears to be a useful tool, not only in predicting adjustment and coping behaviour in

MENOPAUSE REPRESENTATIONS QUESTIONNAIRE

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patients, but also in understanding/predicting adherence, emotional distress and illnessrelated disability (see Petrie & Weinman, 1997a). Although the menopause is a normal life stage and not an illness, the self-regulation model appears to be an appropriate framework with which to explore women’s cognitions about the menopause, which in turn may shed some light on individual differences in menopausal experience, help-seeking behaviour and adjustment. The aim of this study was to devise a menopause representations questionnaire to assess cognitive appraisal of the menopause. The study has two phases: a pilot study was carried out using in-depth semi-structured interviews, exploring the ve components of illness: identity, time, cause, consequences and control, in order to elicit women’s representations of the menopause. This qualitative information was used to devise the Menopause Representations Questionnaire (MRQ). Pilot study A qualitative semi-structured interview study of women’s representations of the menopause was carried out. Participants and methods Forty- ve women, aged 49–51, were recruited from the age/sex register of a general practice in North London that served a large socially mixed catchment area. Ninety-two women were initially contacted by letter and 45 responded to an invitation to talk to a researcher at the practice (a female health psychologist) about their health, wellbeing and lives. Semi-structured interviews were carried out, lasting 20–40 minutes, which began with several open questions about the women’s general life satisfaction and health in order to frame the menopause questions within a broader context of the women’s lives. The interviews were tape- recorded with the participants’ permission and transcribed verbatim. Women’s representations of the menopause were elicited from the accounts and were categorized into broad themes suggested by Leventhal et al. (1984). Results The women’s mean age was 50.04 (SD 5 0.74) years; 82% were married or cohabiting; 75% classi ed themselves as white British (9% as non-white British and 16% as white nonBritish); 56% left school at 16 years, while 44% continued education for a further one or more years. Fifty-one per cent felt that they were currently going through the menopause, 16% (11/45) were taking hormone replacement therapy (HRT), 20% were unsure as to their stage of menopause and 13% felt that they had not started yet. Only one woman reported having never heard of HRT. Identity of menopause The identity component is of particular relevance to the menopause as women in mid-age may attribute many symptoms to the menopause, including more general symptoms. Women’s reports of indications that they were in the menopause included vasomotor and menstrual symptoms; 59% reported hot ushes and night sweats and 61% irregular periods. General symptoms were also reported that are not necessarily associated with menopause; for

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example, anxiety (16%), loss of energy and memory loss (2%), being bloated (7%) and sleep problems (4%). Time frame There was great variation in the perceived time frame of the menopause, with many women acknowledging the dif culty in predicting duration, and others having either a long (up to 20 years) or short (one-year) time frame. The mean duration estimated for menopause was 5.7 years (SD 5 4.79).


Cause Few women spontaneously mentioned possible causes of their menopausal experience. When asked directly about cause, it appeared to be an unfamiliar and dif cult question to answer. Some women mentioned hormone changes but others felt that cause was less relevant to a process that affected all women. Consequences Consequences of the menopause included positive, negative and neutral impacts. The majority of women (n 5 26; 74%) did not see themselves as changing and talked about the menopause as having few or no consequences for them at all. For example: I had a few physical changes but nothing else; I’m still the same person. Nothing really, it’s part of life. For some women, however, the menopause was a negative experience (n 5 3; 9%), having emotional and physical consequences for their lives: … after my son was born I entered into a very rapid menopause … it started off with terrible night sweats. Waking up feeling very anxious. It was a horrible, horrible feeling … It was a loss of energy, self respect, fears of getting old, being there for my youngest child. For the rst time I had to face up to my own mortality … I think it [menopause] is awful. I don’t think it is fair that women should have this at all but there you are. Relief was expressed by many women (n 5 18; 40%) and the end of reproductive life was generally talked about in positive/neutral terms: It’s nice to get it over with and not have periods any more. I never really wanted to have children so it never really worried me in that way. I’ll be quite pleased in some ways. A smaller number of women included comments about ageing (n 5 5; 4%) in their accounts of the consequences of the menopause: I think once the menopause is over you feel as though you’re fast approaching retirement and it doesn’t seem so very long now to being old.


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Control/cure Women tended to refer to control or treatment of the menopause indirectly when discussing their experience. Few women reported feeling in control of the menopause. In fact, several women (n 5 18; 40%) spoke about not having any control over the menopause and having to come to terms with it: What control can you have over it? You’ve just got to accept it. Personally I don’t think there is a lot you can do about it. It’s going to happen and that’s it.


Some women mentioned that their own state of mind had a positive effect on their menopausal experience, perhaps by having positive or neutral expectations of menopause and also by not placing too much emphasis on it: I think I’ve been very lucky. I went all through, never had any trouble with my periods, never had any pain or any problems at all. Everything was plain sailing so, you know, it never occurred to me that this wouldn’t be any different. I work … may be that takes a lot of it away so that I’m not really thinking about it [menopause]. I think you can put these things out of your mind. If you’re at home maybe you think about things and get more depressed. Taking HRT (n 5 6; 13%), keeping active (n 5 5; 11%) and seeking help (n 5 3; 7%) in order to control the menopause were referred to by a small proportion of the women. Discussion The analysis suggests that the representations which emerged were broadly in keeping with Leventhal’s self-regulation model, and that components such as identity, consequences and control/cure appear to be applicable and meaningful with regards to a life stage, such as the menopause. However, some components appeared to be more relevant than others. For example, identity and consequences were most evident in discussion, cause and time-line less so. Overall, the women’s estimates of time duration of the menopause were reasonably accurate (McKinley et al., 1992), although there was considerable variation between women in their estimates of duration. Women had developed cognitive representations of the menopause, even though they were at various stages of it, and most women had categorized themselves in terms of the menopause without seeking medical help. Interestingly, many women saw the menopause as having some positive and neutral consequences. For example, relief from both periods and the end of their reproductive life stage were commonly reported, challenging stereotypes that the menopause is necessarily a source of distress for women. While these interviews provide a useful insight into how women appraise the menopause, this method is expensive and time-consuming and as such may only be appropriate for use with small samples. In keeping with previous questionnaire studies, a theoretically-based questionnaire was developed, items being generated from the data from this study. Development of the Menopause Representation Questionnaire (MRQ) The aim of this study was to develop a short scale to assess cognitive appraisals of the menopause.

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Participants and methods Statements were selected from women’s accounts for each component of identity, time-line, consequences and control/cure. Cause of menopausal experience was not included in the questionnaire, as women did not mention it spontaneously in the interview and when asked directly about cause needed prompting and appeared to nd the question unfamiliar. The identity scale included 20 items, experiences or symptoms referred to by the interviewed women. The items for the consequences, time-line and control/cure scales were those which re ected speci c representations and which were mentioned most frequently in the interviews. We aimed to include at least three statements that re ected each category. The nal version included 37 items in all: 20 identity items, nine items covering consequences, four items relating to time and four items relating to control/cure (see Appendix). The MRQ was piloted on ve women who completed it with one of the researchers and gave feedback. Following this, the wording of the identity instructions was made clearer. Questionnaires were then sent to all women aged 49–56 drawn from the age-sex register of a general practice. One hundred and eighty-nine women were sent a questionnaire and a covering letter inviting them to participate in a women’s health project and a stampedaddressed envelope was enclosed. The MRQ formed part of a larger questionnaire which included sociodemographic, menopausal status (de ned by the women themselves and by menstrual history—regular menstruation 5 premenopause, irregular menstruation within the past six months 5 perimenopause and no menstruation for 12 months 5 postmenopause), general health questions and the Women’s Health Questionnaire (WHQ; Hunter, 1992). A test-retest was carried out on 20 women recruited from the general public and at an outpatient menopause clinic. Mean age was 51.5 (SD 5 5.31). They completed the MRQ and repeated the exercise two–four weeks later. Scoring The identity scale is scored by summing the scores for all the items (0, 1 or 2) attributed to the menopause, the scores ranging from 0–40. Apart from the identity scale, the items are presented in a mixed order. Scoring is on a ve-point scale from strongly agree to strongly disagree (5–1) in concordance with scoring of the Illness Perception Questionnaire (Weinman et al., 1996), as follows: Consequences:

Negative impact 1, 4, 6, 10, 12 Relief 2, 11 New phase 9, 13

Time-line:

Short time 3, 15 Long time 7, 16

Control/cure

5, 8, 14, 17.

In order to provide comparison across sub-scales, the total scores from each were divided by the number of items per sub-scale, giving maximum scores of ve per sub-scale. Results Overall, 103 questionnaires were returned, giving a response rate of 54%; of these, 80 women completed the MRQ, since 23 women were premenopausal (de ned by menstrual history).


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Table 1. MRQ Scales: means with standard deviations in parentheses (N 5 80)


Identity Consequences Impact Relief New phase Control/cure Time—long Time-short

Mean

SD

11.58

(7.67)

2.42 3.78 3.18 3.60 3.33 2.58

(0.84) (0.91) (0.76) (0.58) (0.42) (0.63)

The mean age was 51.03 (SD 5 1.54); 65% of the women were married or cohabiting, 70% classi ed themselves as white British (6% as non-white British and 8% as non-British); 48% left school at 16 years, while 52% continued education for a further one or more years. Sixty-eight per cent felt that they were currently going through the menopause or had been through it and 17% were taking HRT. The means and standard deviations of the MRQ sub-scales are presented in Table 1. The most common menopausal symptoms reported within the identity sub-scale were: hot ushes and night sweats (65%), irregular periods (51%) and vaginal dryness (37%). However, other general symptoms were also attributed to the menopause (see Table 2). The MRQ included both positive and negative consequences of the menopause; the negative scale re ected the impact of the menopause upon a women’s sense of self, while positive items described menopause as a relief from periods and pregnancy and risk of pregnancy, as well as a new content phase of life. Time-line included both short and long time estimations. Table 2. Identity: frequencies of symptoms attributed to the menopause (N 5 80)

Hot ushes Night sweats Irregular periods Weight gain Bloated Vaginal dryness Mood Sleep Heavy periods Tiredness Stiff joints Loss libido Aches and pains Memory Headaches Anxiety Depression Skin problems Dizziness Breathlessness

n

%

51 47 38 34 33 26 25 25 24 25 23 19 18 18 14 14 13 11 9 7

(65) (64) (51) (47) (44) (37) (35) (33) (33) (32) (30) (26) (24) (24) (19) (19) (18) (15) (13) (10)

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Table 3. Internal consistency (Cronbach’s alpha) and retest reliability scores for MRQ scales Scale Identity Consequences Impact Relief New phase Control Time-long Time-short


*p ,

0.01; **p ,

Alpha

2–4 weeks

0.79

0.80**

0.78 0.63 0.60 0.63 0.60 0.72

0.84** 0.82** 0.90** 0.92** 0.55* 0.54*

0.001.

Inter-scale correlation and reliability The correlations between the MRQ scales were carried out. Women who perceived the menopause as having a negative impact also tended to believe that the menopause would last a long time (r 5 0.26, p , 0.05), and did not welcome it as a ‘new phase’ (r 5 0.32, p , 0.01). Having control over the menopause was signi cantly correlated with seeing the menopause as a positive change (r 5 0.23, p , 0.05) and lasting a short time (r 5 0.26, p , 0.05, p , 0.05). Women who had a broad menopause identity (attributed many symptoms) saw the menopause as having a greater impact (r 5 0.36, p , 0.01), and did not see it as lasting a short time (r 5 0.35, p , 0.01). Internal reliability of the MRQ scales was reasonably high, ranging from 0.6 to 0.79 and test-retest reliability was acceptable (see Table 3), although the test-retest reliability was considerably higher for the identity, consequences and control/cure sub-scales than for time-line. When the three consequences sub-scales and the two time-line sub-scales were initially combined, the internal consistency reduced markedly—suggesting that they are measuring different types of cognition and are best considered separately. Concurrent validity MRQ scores were correlated with sub-scales of the WHQ (Hunter, 1992) and medical help-seeking. Depressed mood (WHQ) was associated with lower perceptions of control/cure (r 5 2 0.33, p , 0.05), while reports of menstrual problems (WHQ) were associated with perceptions of a more negative impact of the menopause (r 5 2 0.33, p , 0.05) and beliefs that it will have a long duration (r 5 0.33, p , 0.05). Finally, women who perceived the menopause as having a negative impact on their lives were more likely to have visited their doctor within the past month (r 5 0.29, p , 0.01). Discussion This study describes the development and evaluation of a new questionnaire to assess cognitive appraisal of the menopause. The response rate of 54% is low, but typical of questionnaire studies. The sociodemographic data suggest that the sample represents a broad range of socio-economic status (assessed by educational level) and the proportion married and employed are similar to those found in previous studies of mid-aged women carried out in London (Hunter, 1992).



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The questionnaire was theoretically derived in accordance with Leventhal’s selfregulation model (Leventhal et al., 1984) and the items were selected from interview data. For menopause the identity, consequences and control/cure sub-scales were particularly salient. The consequences sub-scale formed three distinct scales: impact, relief and new stage, and time-line was separated into long and short time. It is possible that breaking down consequences and time in this way may enhance the discrimination of the MRQ. The internal consistency of all the sub-scales in the MRQ was reasonably high and the test-retest reliability (two–four weeks) was considered acceptable. The identity, control/cure and consequences scales (impact, relief and new stage) had the highest test-retest reliability; therefore these scales may be most useful in assessing cognitive appraisals of the menopause. Time-line appeared to be less reliable, which is perhaps understandable given the unpredictability and considerable variation in duration of menopause. Unlike the majority of symptom and mood measures used in menopause research, such as the WHQ (Hunter, 1992) and the Greene Climacteric scale (Greene, 1991), the MRQ was derived from interview data to assess cognitions speci cally about the menopause and hence may prove to be more useful in studies evaluating reactions to and coping speci cally with the menopause. Moreover, the inclusion of positive, neutral and negative cognitions means that the questionnaire does not collude with assumptions that the menopause is necessarily a negative experience. Concurrent validity was examined by comparing the MRQ scales with scores on the WHQ and help-seeking behaviour (visits to the doctor). The ndings suggest that cognitions of control/cure are associated with depressed mood, while reports of menstrual problems are associated with appraisal of the menopause as having negative consequences. It is possible that the marker of menstrual changes served as a trigger for focusing on the menopause as a potential cause of negative experiences. Alternatively, menstrual problems, such as heavy or unpredictable periods, might in themselves be seen as a negative consequence of the menopause. Women who visited their doctor within the past month also perceived the menopause as having greater negative impact. While cause and effect cannot be clari ed in this study design, these results are consistent with research on cognitions and depression, suggesting that depressed people report feeling more hopeless and having less control over their lives than non-depressed people (Abramson et al., 1989). The self-regulation model proposes that the representations re ect the cognitive responses to symptoms and that emotional responses are processed in parallel, and interact, with cognitions, as would appear to be the case. Although the majority of women have few problems during the menopause transition, many face the process with uncertainty. In addition, some women do seek help for anxiety and depression as well as menopausal symptoms at this time, and may be offered HRT or psychological interventions (Hunter & Liao, 1995; 1996). The MRQ might provide a useful focus for cognitive interventions and the evaluation of medical and psychological interventions. Future research could explore changes in MRQ pro les across the menopause transition, as well as testing out predictions about possible association between menopause cognitions and coping, help-seeking behaviour and use of medical services. For example, the MRQ is currently being used in a prospective study by the authors which attempts to predict 50-year-old women’s cognitive appraisals from sociodemographic variables and health beliefs assessed ve years earlier. Further exploration of control cognitions may prove interesting in explaining the relatively low uptake and adherence rates relating to HRT use (Cauley et al., 1990; Ryan et al., 1992). In summary, the MRQ is a short questionnaire designed to assess women’s cognitive

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representations of the menopause. It is hoped that this questionnaire will prove useful in explaining individual differences in menopause experience, for example help-seeking behaviour, uptake and adherence to preventive interventions, in keeping with other studies of illness representations (Petrie & Weinman, 1997b; Weinman, et al., 1996).


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Appendix Menopause Representations Questionnaire Please rate to what extent you think the following experiences are part of your menopause by ticking: Yes (part of my menopause), Uncertain (whether part of my menopause) or No (not part of my menopause).


YES Tiredness Hot ushes Aches and pains Headaches Sleep dif culties Dizziness Irregular periods Depression Feeling bloated Skin problems Mood swings Night sweats Memory loss Heavy periods Anxiety Breathlessness Vaginal dryness Decreased sexual interest Increased weight Stiff joints

UNCERTAIN

NO

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We are interested in your own personal views of how you see your menopause. Please indicate how much you agree or disagree with the following statements about your menopause by ticking: Strongly agree, Agree, Neither agree/nor disagree, Disagree, or Strongly disagree.

Strongly agree 1. Going through the menopause has an impact on my life. 2. It’s a relief to be free from the risk of pregnancy. 3. My menopause will last about a year. 4. The menopause has affected the way I see myself as a person. 5. Overall I feel I am coping reasonably well with my menopause. 6. I feel less con dent since the menopause. 7. My menopause will last a long time. 8. If I have problems during the menopause. I know what I can do to help myself. 9. I feel more content during this phase of life. 10. The menopause has affected the way others see me. 11. I am pleased that periods come to an end.

Agree

Neither agree/nor disagree

Disagree

Strongly disagree

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12. I feel more emotional than I did before the menopause. 13. It is good to be moving into a new phase of life. 14. I am con dent that I can deal with any changes that my menopause might bring. 15. My menopause will last a short time. 16. In time my menopausal symptoms will improve. 17. I feel I have the resources to manage my menopause well.

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