Quality of life of Jordanian menopausal working and retired women and its associated factors: a cross-sectional study

Jordanian women at menopausal age

Bustami et al.,²⁵ conducted a cross-sectional study to assess factors associated with onset of premature/early menopause among 409 Jordanian women. Findings revealed that the mean age of natural menopause (ANM) is 48.5±5.0, and 2.7% of the women experienced premature menopause (ANM <40) and 7.8% early menopause (ANM 40–44). Smoking was highly associated with early/premature menopause, chronic diseases or combinations of diseases were associated with average (45–52 years) or late menopause (>52 years). BMI, arthritis pain, hot flushes and inconsistent urination were significantly higher in the early and regular menopause than in premenopausal and perimenopause women.

Jaber et al. (2017) examined patterns and severity of menopausal symptoms among 359 women between the age of 45-65 years. The Arabic version of Menopause Rating Scale (MRS) was used. Results showed that the mean age at menopause was 49.4 years, a total of 105 women had regular menstruation (premenopausal), 49 experienced irregular cycles, and 205 had reached menopause. Women who were still menstruating regularly were found to be 1.5 times more likely to suffer from irritability, while women experiencing irregular cycles but were still menstruating, were found to be 1.63 times more likely to suffer from hot flushes, approximately 2 times more likely to suffer from physical and mental exhaustion and more likely to have sexual problems, vaginal dryness, and joint and muscular discomfort.

Severity of menopausal symptoms of Jordanian women was examined by Gharaibeh et al., (2010) who recruited 350 women between the ages of 45 to 55 years. Authors used the Greene Climacteric Scale to measure the severity of menopausal symptoms. The scale consists of domains of vasomotor symptoms, somatic symptoms, psychological symptoms and sexuality symptoms. Results showed that the mean age of menopause was 48.7 years. A positive association between severity of menopausal symptoms and both educational level and menopausal status; the mean score for severity of menopausal symptoms in perimenopausal women was higher than that for premenopausal women. The scores for the psychological, somatic, vasomotor and sexuality subscales were significantly higher among the perimenopausal, and postmenopausal groups compared to the premenopausal group. Perimenopausal women’s scores for all clusters were higher compared to those of postmenopausal women except for the vasomotor and its symptoms of sweating at nights, and the sexuality and its symptoms of loss of interest in sex, vaginal dryness and pain during intercourse.

An earlier study by Al-Qutob (2001) investigated types and magnitude problems associated with menopausal using exploratory study with 317 of Jordanian women between 18 and 49 years old and 185 women older than 50 years. The mean and median age of onset of menopause were 47.5 and 49 years. Chronic diseases were found to be present among menopausal women such as urinary tract infection, hypertension, diabetes, iron deficiency anemia, reproductive tract prolapse.

In Jordan life expectancy at birth has increased for females to 78.6 in 2020.²⁶ However the retirement age for women in Jordan is 55 for women where women can ask for early retirement at early age between 50 and 52 years old and can still benefit from the governmental pension.²⁷

It is clear from the review of the available studies that there is a gap in studies from Jordan that addressed the quality of life of menopausal working women. Therefore, the study comes to fill the gap by assessing the quality of life of Jordanian working and retired women and its associated factors. The importance of the study comes from the fact that the life expectancy at birth of Jordanian women has increased from 61.98 years in 1971 to 76.45 years in 2019,²⁸ indicating that the numbers of women in perimenopause, transitional phase and postmenopausal ages will increase and we are expected to see more working, active women involved in the society and enjoy a positive QoL. Findings of this study will help women live a productive life, and health care professionals who can provide supportive services that enhance working women’s QoL.

Ethics

The study was approved by the Institutional Review Board (IRB) of Applied Science Private University, Jordan. The informed participant consent was obtained along with the data collection with maintaining participant privacy, confidentiality, and anonymity which was built into the design and the process of the instrument. The cover letter included with the questionnaire stated the study purpose and that the completion and submitting of the questionnaire was indication of consenting to the study.

A cross-sectional study was conducted with 200 Jordanian women during the period from 5^th January to 5^th March 2021. Sample size was determined using power analysis software for the following parameters: alpha 0.05, power of 95%, moderate effect size 0.3. The needed sample size was 196 participants; 200 questionnaires were completed and submitted. The main inclusion criteria were working and retired women between the age of 45 to 60 years old. The women were excluded if they suffered from any mental disorders since these will impact the QoL. The women were recruited from main authors or research assistants who were employed from the main authors. These women were recruited based on information provided on leaflets, which were distributed in health centers and hospitals. The leaflets included information on the researchers and how to contact them.

Women were recruited using social media and emails. This research utilized Google Forms for data collection; a link was sent by the authors to participants via social media, such as Facebook, Instagram. Google forms is an application in the form of a template or worksheet that can be used independently or together for the purpose of obtaining information. Google form is very easy to understand and use and is available in the Arabic language. The form took 15 minutes to fill out.

Measurement tool

The questionnaire consisted of three parts; the demographic part which consisted of seven questions on age in years, employment status (employed, retired), social status, level of education, chronic diseases, menopausal stage (pre, menopausal and postmenopausal), and finally number of children. All variables were categorical except for age and number of children, which were continuous. The second part was the menopausal information and preventive measures, which consisted of the perceived menopausal health related information, (very good, moderate, know some, not good), sources of menopausal information (social media, family/friend, TV, health personnel) and health promotion and disease prevention measures (BSE, monogram, pap smear, routine checks). The third part was the QoL measures, the study used the Utian QoL developed by Utian et al. (2018). The tool consists of 23 items divided into four main domains: occupation domain (7 items), health domain (7 items), emotional domain (6 items) and sexual domain (3 items). The original tool was validated with a diverse sample of peri- and postmenopausal women using the Short Form-36²⁹ (well established inventory of QoL). For the QoL domains, confirmatory factor analyses were conducted with a second sample of 270 women. The original scale is in the English language and showed to be valid and reliable. Cronbach’s alpha for the 23-item scale as a whole was 0.830, occupational domain was 0.83, health domain 0.73, emotional domain 0.64 and for the sexual domain 0.79.²⁹

For our study, the scale was translated to the Arabic language using the World Health Organization standard (translation and back translation process).³⁰ This method consisted of the following steps: forward translation; expert back-translation; pretesting and cognitive interviewing and producing the final version. A panel of three experts in psychiatry, mental health nursing, nursing education and women’s health from Jordan University of Science and Technology and Applied Science University. These experts were chosen based on their experience and were tasked with checking the content validity and the process of translation and back translation. The Arabic version was then pilot tested with 25 menopausal women, which were not included in the sample. These women were recruited by research assistants and have the same inclusion and exclusion criteria of the participants of this study and were not entered into the main data of the project. Results of the pilot testing revealed that it is simple to read, and completion of the tool required approximately 10 minutes. The Cronbach reliability coefficients for the translated version for the total scale was 0.85, it was 0.80 for the occupational domain, 0.69 for the emotional domain, 0.62 for the health domain, and 0.50 for the sexual domain.

Data analysis

Data was analyzed using the SPSS software for Windows version 25 (IBM Corp, USA, RRID:SCR_016479). Descriptive statistics including means, standard deviation, numbers, and frequencies were used to describe the sample characteristics. Means and standard deviation were used to describe each domain and the total QoL. The t-test was used to show the differences in the four domains for working and retired women. Frequencies and percentage were used to describe the response for each item of QoL. Chi-square test was conducted to show the difference in each item for QoL for working and retired women. Multiple regression was conducted to determine predictors for QoL for the whole sample and for each group of working and retired women.

Demographic and health background characteristics

Table 1 presents the demographic characteristics of the sample as the mean age of women was 50.5±4.8 years old. Employed women were 117 (58.5) and retired women were 83 (41.5).

Information and preventive measures

Women reported acceptable information level regarding the menopausal stages and changes 134 (67%). The majority receive their information from social media, rather than their health care providers, 61 (30%). For preventive measures, self-examination breast checks that were done regularly the previous year, was 63 (31.5) and those who had a Mammogram examination once during the previous year was 40 (30.0). As shown in Table 2.

Domains of QoL

The total QoL for women was 77.5±14.4, which is higher than the average total universal quality of life (UQoL).¹⁹ There is a significant difference (p=.023) in total QoL between working (80.5±12.7) and retired women (73.4±15.7). The highest domain mean score was for the occupational domain 25.9±6.4, followed by the emotional domain 22.3 ±4.8, and health domain 21.5±5.0, while the lowest mean score was among the sexual domain 7.6±2.6. There was a significant difference in occupational health (p=.003) between working (27.2±5.3) and retired women (24.1±7.4), see Table 3.

Description of QoL among menopausal women

Descriptive statistics was used to describe the women's response to the QoL tool. The highest response was for “I am currently experiencing physical discomfort or pain during sexual activity with my partner” 141 (71%), “I think my work benefits society” 129 (65%), and “I'm not happy with my appearance” 124 (62%). However, the lowest score response was reported for “I do exercise at least 3 times a week” 15 (8%), “I feel like I'm not satisfied with my sex life” 21 (11%), and “I feel in good shape” 38 (19%).

There was a significant difference in QoL between working and retired women in seven questions. Items were, “I am able to control the important things in my life” (p=.024), “I think my work benefits society” (p=.007), “I am satisfied with my romantic life” (p=.007), “I get anxious frequently” (p=.003), “I am proud of my professional achievements” (p=.006), “I keep setting personal goals for myself” (p=.006), and “I keep setting professional goals” (p=.001) (Table 4).

Predictors of QoL for whole sample of menopausal women

Multiple regressions test was conducted to determine the predictors of QoL among menopausal women. The model was significant (F= 3.5, p<. 001). This means that many factors predicted QoL among women; these were employment status/currently employed (B=.175, p=.046, r²=.34), number of chronic diseases (B=-.198, p=.004, r²=-.260), and using preventive measures (B=.177, p=.011, r²=.222). Employed women with fewer chronic diseases and using frequent preventive measures had higher QoL compared to others. The three variables explained 54% in the variance of QoL. See Table 5.

Predictors of QoL for working and retired menopausal women

Multiple regression tests were conducted to determine the predictors of QoL among working and retired menopausal women. These models were significant for working women (F=4.45, p=.001) and retired women (F=6.52, p<.001). The only significant predictors for QoL for working women were number of chronic diseases (B=-.206, p=.006, r²=-.267) and using of preventive measures (B=.196, p=.003, r²=.194) and income (B=0.204, p=0.037, r²=0.134). This means working women with less chronic diseases and using preventive measures had higher QoL compared to retired women. The only significant predictors for QoL for retired woman were education (B=.199, p=.04, r²=.231), menopausal status (B=.199, p=.04, r²=.222), and using of preventive measures (B=.217, p=.045, r²=.194). This means retired women with higher education, who reached postmenopausal, and using preventive measures had higher QoL compared with other women. See Table 6.

Implications

Health care providers can pay more attention towards the menopausal changes, chronic disease health promotion and disease prevention for working women, to increase their work productivity and achievements. Policy makers should pay more attention towards improving the working conditions that support the transitional period for menopause, to increase women’s productivity and improve their health status during these important life stages.

Increasing the Jordanian women life expectancy would suggest adding more working years for women, as retired women seem to perceive a lower QoL than working women, therefore this study’s results might be used as a valid indicator for revisiting the retirement age law.

It’s recommended for further research on women’s perception of the best retirement age and the influence of their menopausal stage on their work productivity.

Limitations

This study has limitations that rise from the convenience nonprobability sample that limited the generalizability of the findings. The fact that the study used Google Form for data collection has eliminated women with poor reading comprehension and those who are not familiar with the use of technology or do not have access to computers or mobiles. Findings are also limited to the use of a translated scale developed for women from western cultures, which may not have captured the cultural aspects of the QoL of Jordanian women.

Underlying data

Figshare: Data Set Menopause Women.xlsx. https://doi.org/10.6084/m9.figshare.20822032.v2.⁵⁰

This project contains the following underlying data:

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).