Youth Health Services. Part 4
Data and Methods
Births by age of mother, city, and year are extracted from the Birth Public Use file, an electronic data file available for 1990 through 2002 as of this writing from the California Center for Health Statistics (2004), Department of Health Services. Populations by sex and age for each of California’s 55 largest cities (all of those with populations of 100,000 or more in 2000), as well as racial and Latino ethnic composition, poverty rates, population size, labor force participation, educational attainment, income, marital status, and home ownership are taken from the Bureau of the Census (2005). These show that in 2002, California’s 55 largest cities had a total of 1.1 million teen women ages 10-19 who had 27,400 live births, and 3.1 million adult women ages 20-44 who had 247,300 live births. Adult birth rates are calculated for each city as a measure of background norms for childbearing and to provide a control variable against which to assess levels of and changes in teenage birth rates (Appendix A).
Rankings of each city according to its level of programs, services and opportunities for youth are taken from Get Real’s and the California Adolescent Health Collaborative’s (2004) “Reality Check” report. The report evaluated “six variables covering access to health services and seven youth development opportunity variables.” The health services variables included the number of clinics and health centers (both those receiving and not receiving Title X funding), school based clinics and health centers, family PACT (Planning, Access, Care and Treatment, a federally subsidized family planning program) providers, pharmacies providing emergency contraception, and additional “health and well being services for teens.” The youth development opportunity variables included scorings of youth involvement in decision making at the city and school district levels and the presence of Boys’ and Girls’ Clubs, YMCAs and YWCAs, mentoring programs, and federally- and state-funded after-school programs. Each city’s services were assigned a quartile score of 1 (lowest 25%), 2 (26%-50%), 3 (51%-75%) or 4 (highest 25%) on each of the variables. The scores were summed, and each city was assigned rankings for health services, development programs, and total score (Appendix A).
Several correlation and regression analyses were conducted to assess the associations of each city’s rate of births among teen mothers with other relevant variables, including poverty, adult birth rates, and the indexes of youth health services and development opportunities. The statistical significance threshold used here, p < 0.01, is more stringent than that used in most analyses (0.05).
Levels of Teen Birth Rates
California’s 55 largest cities show immense variation in rates of births by teenage mothers. The highest rate (108.9 births by mothers under age 20 per 1,000 females ages 15-19) in 2002, found in Bakersfield, is more than 30 times higher than the lowest (3.3, in Irvine). The variation in teen birth rates is considerably more extreme than the variation in adult birth rates, which ranges four-fold from highest (134.6 per 1,000 females ages 20-44, also in Bakersfield) to lowest (35.8, in Berkeley) (see Appendix A).
As these congruencies suggest, the rate of births by teens is strongly correlated with the rate of births by adults, and youth poverty rates are strongly correlated both with rates of births by teenage mothers and by adult mothers. The strongest correlation was between youth poverty rates and the net teen birth rate, that is, the ratio of the teen birth rate to the adult birth rate. The adult birth rate is associated with 75% of the variation in teen birth rates across the 55 cities; together, the adult birth rate and the youth poverty rate are associated with 89% of the variation in teen birth rates.
Youth Health Services. Part 3
Nevertheless, a number of groups claim programmatic approaches can be credited with the low rates of teen births in European countries, variations in teen birth rates in certain American cities, and the large decline in teen births in the United States from 1991 to 2003. For example, in September 2004, Los Angeles’s Get Real! and the San Francisco Bay Area’s CAHC (2004) issued a “Reality Check” report ranking California’s 55 largest cities (all those with populations of more than 100,000) in providing services to teens and in preventing teen births. The report rated Berkeley as “California’s most teenager-healthy city” for providing teens with the greatest access to health and prevention services, including “a health center that readily hands out advice and condoms” to youths, credited with producing “the state’s lowest birth rate among teen mothers” (Bender, 2004, p B1). In “Berkeley High: A Sex Ed Success Story,” Planned Parenthood also argues that Berkeley’s “comprehensive sex education programs that are proven to work” (as opposed to abstinence education) and “web of support” has resulted in the fact that “for eight years running, Berkeley has had the lowest teen pregnancy rate in the state” (Lambert, 2005).
A factual problem with Get Real!, CAHC, and Planned Parenthood’s statements is that California Center for Health Statistics’ (2004) natality reports for 2002 and the Bureau of the Census’ (2005) census of population by age for 2000 show that Berkeley does not rank lowest, but fifth, from the lowest, in teen birth rates among California’s cities of more than 100,000 population. In fact, Berkeley has a higher teen birth rate (16.2 births by mothers under age 20 per 1,000 females ages 15-19) than three cities ranked as among the worst in youth services (Irvine, Glendale, and Santa Clarita). In particular, the city with the state’s lowest teen birth rate, Irvine (3.3 per 1,000), ranks second worst in services to youth and teaches a “family life” curriculum stressing conservative, “universal moral values,” anchored by such films as, “Why Abstinence? The Price Tag of Casual Sex” (Irvine Public Schools, 2003). If only programmatic approaches are compared and other factors are ignored, the opposite conclusion could be argued from Get Real!’s “Reality Check” data: that teaching abstinence from sex rather than providing teens with services produces lower teen birth rates.
While the National Campaign and other groups involved in the teen sexuality debate advocate expanded investment in education curricula and programmatic measures, none that I can find proposes redistributive policies, such as stronger social insurance programs to boost incomes of low income families, as a strategy to reduce teen birth rates. The question of whether educational and programmatic strategies can significantly reduce births by teenagers in the absence of significant, economic reforms is an important public policy question, especially given weak and diminishing efforts by authorities in the United States to reduce high rates of poverty among youth. If only major social investments to reduce the high rates of poverty suffered by American youth will bring down the birth rate among teens in the long term, over promotion of educational and program solutions as the answer to teen pregnancy inadvertently gives policy makers an easy way to avoid politically difficult economic reforms to reduce the poverty and related disadvantages that contribute to poorer teens’ higher birth levels. This paper proposes to examine these issues on a multi-city basis by correlating variations in teen births rates with variations in the availability of health and development programs, teenage poverty rates and other economic variables, and adult birth rates in California’s 55 largest cities.
Youth Health Services. Part 2
Similarly, Advocates for Youth (2005) concedes that, “most teenage mothers come from socially and/or economically disadvantaged backgrounds,” but credits only “easy access to sexual health information and services” as the cause of “better sexual health outcomes” in European nations. The Sexuality Information and Education Council of the United States (2005) cites coming from “low-income families” as only one in a lengthy list of risks leading to higher odds of giving birth as teens. SIECUS states: “Young people who become infected with HIV, contract a STD, or face an unintended pregnancy often lack opportunities to receive accurate information and build critical skills,” leading to its recommendation for “youth development programs” that include “sexuality and sexual/reproductive health education components that prepare young people to lead sexually healthy lives.”
Likewise, the Public Health Institute and the California Wellness Foundation note that “one of the best predictors of teen birth rates are poverty rates,” neither advocates any measures to reduce adolescent poverty. Instead, PHI credits only “state funded reproductive health… and teen pregnancy prevention programs” and “program and policy grant initiatives funded by philanthropic foundations in California, led by the California Wellness Foundation” as “the solution” for reducing births by teenage mothers (Constantine & Nevarez, 2002, pp. 5, 7). Wellness itself emphasizes “grants to outreach activities for reproductive health care; access to contraceptive services; and comprehensive programs for pregnant teens,” emphasizing “peer-provider clinics and other reproductive health organizations that work with high-risk, sexually active, underserved teen populations” (California Wellness Foundation, 2005).
Even those, such as the Alan Guttmacher Institute, that cite a combination of socioeconomic and programmatic factors in research papers (Darroch et al., 2001) typically recommend only programmatic solutions: “Societal assistance to teenagers in their transition to adulthood, combined with acceptance of teenage sexual relationships, clear expectations for responsible sexual behavior and access to sexual and reproductive health services leads to lower rates of teenage pregnancy” (Alan Guttmacher Institute, 2001, press release). The National Campaign to Prevent Teen Pregnancy’s (2005) prevention initiative, called “Putting What Works to Work,” advocates a variety of education, service, and program initiatives. California’s Get Real! About Teen Pregnancy (2005, campaign materials) urges adults to “recognize the need to encourage healthy behaviors and activities for teens as a way to help reduce unplanned pregnancies.”
Given the hundreds of studies now available, individual findings favorable to one point of view can be selected to show any effect, but only one intensive program, the National Adolescent Sexuality Training Center at The Children’s Aid Society (2005), has consistently produced positive results. However, taken as a whole, the large body of research on the effectiveness of various sexuality, abstinence, and contraceptive education and programs in reducing births to teen mothers has been inconsistent and inconclusive (see reviews by Kirby, 2001, 2002). Even the studies that find significant results typically suffer from flaws in method such as selection biases between test and control groups, low sample retention, lack of replication of results for programs found effective in single studies, and failure to explain why similar programs have not shown similar results in other communities or time periods.
Youth Health Services
Many advocacy groups depict sexuality education, abstinence education, health services, and development services to teenagers as pivotal factors in their birth rates. Data from California’s 55 largest cities for 1990-2002 allow regression analyses of the associations between levels of health and development services to youth, socioeconomic factors such as poverty, and environmental factors such adult birth rates on rates of and changes in births to teenage mothers. The analysis found teenage birth rates vary 30-fold from California’s richest to poorest city. Socioeconomic and environmental factors, chiefly adult birth rates and youth poverty rates, are associated with nearly 90% of the variance in teen birth rates. Contrary to assertions by many advocates, lower-income teens have greater access to health, sexuality education, and development services, and the availability of these services is not associated with lower rates of or greater reductions over time in teenage birth rates.
Considerable controversy surrounds the factors underlying the higher rates of birth among American teenage mothers of poorer socioeconomic classes compared to more affluent populations. High birth rates among populations suffering high rates of poverty are the chief reason U.S. teen birth rates exceed those of similarly affluent Western nations by a wide margin (Darroch et al., 2001).
Some observers take a socioeconomic view: that poorer young women have higher birth rates because of the conditions imposed by poverty itself, including the lack of financial assets necessary to pursue higher education and career options (Musick, 1993), extended-family structures that provides more caregivers for children of poorer young mothers (Luker, 1996), and economic advantages to poorer women of having children earlier in life (Hotz et al., 1997, 2000). In this view, teen mothers’ birth rates are a function of social inequality and are directly related to the sexual behaviors of adults of similar socioeconomic status.
However, the predominant view expressed by major American teen-pregnancy prevention groups might be called “programmatic:” that is, teenagers’ sexual behaviors constitute a “social problem” defined by their young age and can be treated separately from those of adults, and high teen birth rates result largely from poorer youths’ lack of access to abstinence and sexuality education, contraceptive services, and youth development programs. For example, the California Adolescent Health Collaborative (2005) acknowledges that, “teen births are more prevalent among populations of lower socio-economic status,” but none of its policy recommendations include measures to reduce poverty among youths. Instead, CAHC’s “strategies to reduce teen pregnancy and STIs [sexually transmitted infections]” are: “Provide teens with the information, skills, and support they need to practice safe sexual behavior, including abstinence... increase access to reproductive health care... increase the role males play in preventing adolescent pregnancy... decrease glamorization of irresponsible sexual behavior in the media.”
Menopause Knowledge and Attitudes of English-Speaking Caribbean Women. Part 7
Causes of secondary amenorrhea include anxiety, drastic weight reduction, obesity, and endocrine disorders such as under- or over-functioning thyroid disease. Even with this knowledge, physicians do not routinely evaluate thyroid function in menopausal women. Drugs prescribed for other conditions can also cause the cessation of menstruation for example the psychiatric drug phenothiazide, and narcotics. As already mentioned, weight gain can result in amenorrhea, because excess fat interferes with the menstrual cycle.
Depression during menopause that women in this study said was a symptom of menopause is an area about which there is still controversy. Studies have linked estrogen deficit with depression. Women, who are prescribed estrogen, report an enhanced sense of self. Some experts suggest that the estrogen mood elevating effect is due to the hormone’s ability to reduce hot flashes and night sweats allowing for more REM sleep (Shaver, et al., 1988). Others say that depression during menopause has more to do life events than with hormones, so treatment or therapy is unnecessary.
The focus of health promotion and disease prevention should include “self efficacy” and the legitimizing of symptoms by educating women in the use of non-prescriptive alternatives if they are unwilling to seek medical care.
Thirty three percent of the respondents in the study identified hot flashes as a symptom they were experiencing at the time the questionnaire was completed. Most researchers report that women will experience this symptom at some time during menopause and for some menopausal women hot flashes can be debilitating. The mechanism of hot flashes is not clearly understood but is thought to be controlled by the hypothalamus in the brain. The rate of estrogen withdrawal changes the “hypothalamic set point”, resulting in temperature changes. Others suggest hot flashes are due to a surge in the Gonadotropin Releasing Hormone (GnRH) in the brain that directly controls the heat regulating center of the body. This mechanism creates changes in blood vessels causing them to expand rapidly in an attempt to reduce vasodilatation. Still others say that an alteration in brain glucose availability act as the trigger for hot flashes (Dormire, 2003). Hot flashes is said to deplete the body of Vitamin B, magnesium and potassium. A randomized controlled trial using the dietary supplement red clover blossom and a placebo in a double blind study with symptomatic menopausal women, found at the end of a two week intervention period, no clinically important effect from the treatment of their hot flashes or for any other menopausal symptoms (Tice et al., 2003).
In spite of the yet unclear understanding of the physiology of menopause, women including English-speaking Caribbean women are part of the 75% of menopausal women who experience debilitating symptoms and need pertinent information on how to address their situation.
Conclusion
In contrast with “African American” or “Black” women in other studies, the English-speaking Caribbean women in this preliminary study have incomplete and inaccurate information about menopause, a lack of resources for obtaining relevant information and a resistance to seeking and complying with recommended treatments. There is a need for health educators to seek out and/or develop ways of keeping these women informed, as they do not seem to have a reference point for menopause information. A lack of knowledge about menopause, and lifetime risks of heart disease, would suggest that English-speaking Caribbean women irrespective of education need better information sources for decision making about what they can do to prevent disease and promote their own well being.
Recommendations
There is an urgent need to inform English-speaking Caribbean women about the risk of heart disease and the contributions of poor nutrition to disease in a culturally sensitive manner so that they can be assisted to take measures to reduce a major preventable cause of morbidity that arise during menopause. For all women, estrogen declines with menopause and is an added factor in increasing the risk for heart disease. However, some phyto-estrogen rich foods once present in the diet of the English-speaking Caribbean population should be encouraged. These food sources include sweet potatoes, pumpkins and soy products that are not only rich in phyto-estrogens but have the added benefits of fiber-rich carbohydrates, that contribute to the reduction of LDL cholesterol and cardio-vascular disease. Excess sodium in the diet has also been associated with an increased risk of morbidity and mortality from hypertension. Traditional foods of the English-speaking Caribbean population favor high sodium content. The promotion of exercise, a low fat diet, and low salt are vital to the prevention of hypertension and heart disease. Given the limited identified resources for menopause information, places most commonly frequented by English-speaking Caribbean women, such as places of worship, need to be cultivated as resource centers for information. Therefore, a liaison with leaders of faith-based communities is probably one of the most efficient ways of reaching this population of women, who are without the necessary information to make informed decisions. There is a need for health educators to seek out and develop other ways of keeping English-speaking Caribbean women informed, as they do not seem to have culturally sensitive resources about menopause.
Menopause Knowledge and Attitudes of English-Speaking Caribbean Women. Part 6
Presenting symptoms reported included hot flashes, weight gain, difficulties or discomfort during intercourse, mood swings, heart palpitations and memory loss. Although participants reported seeking advice from physicians and gynecologists, only n=11, (17%) reported being given a physical examination.
Different treatment options were discussed with health care providers, although more than half of the volunteers (52%) neither sought treatment nor complied with prescribed treatment. Fourteen (22%) indicated that as a health measure recommended by the health care provider they had stopped smoking and were eating healthier and taking vitamin supplements. Fifty-one of the sixty-three volunteers (81%) recognized osteoporosis as a major health risk associated with menopause, and 43% associated menopause with depression. Sixteen (25%) recognized cardio-vascular disease as an associated risk.
All respondents claiming a “significant other” n=14, (22%) reported receiving encouragement to talk about their menopause symptoms and to visit a healthcare provider for treatment. Twenty five (40%) reported that treatment was prescribed for menopause related symptoms but only twelve (19%) indicated that they followed the prescribed treatment. For those who complied with the prescribed treatment the reported benefit was the relief of symptoms. Nineteen (30%) indicated that any treatment, including home remedies, went against “nature.”
In contrast to the African American and Caucasian women interviewed by Pham, Freeman, and Grisso (1997) who chose family members as the most frequently chosen source of menopause information, the main source of menopause information for the respondents in this study was books n=26, (41%) Physicians as health care providers were the second most frequently chosen resource n=15, (24%). Only two respondents used the Internet as a source of information, even though 56% of the volunteers were college educated. Neither the church nor television was a significant source of information.
Discussion
This study is a first step in identifying the knowledge of and attitudes toward menopause held by English-speaking Caribbean women. Informed decisions cannot be made without knowledge, and the replies to the questionnaire clearly indicate a lack of such knowledge. Awareness of risk factors is critical to any approach to health promotion and disease prevention. Similar to African Americans, the English-speaking Caribbean women in this study lack awareness of some of the life threatening risks of menopause.
There was a clear underestimation of such menopause related risk factors as cardio-vascular disease and cancer. In previous research studies, the underestimation of cardiovascular risks of “Blacks” or “African American” women has been noted. The same results were found for English-speaking Caribbean women. As race and ethnicity are important variables, English-speaking Caribbean women like their counterparts of African descent, are more likely to develop hypertension at an earlier age than Whites, and are 1.5 times more likely to die from heart disease as estimated by the Centers for Disease Control and Prevention (National Center for health statistics, 2004). At the American Stroke Association annual conference on cardiovascular disease epidemiology and prevention, Carol Derby (2003) suggested the need for sustained efforts to modify risk factors resulting from a high cholesterol levels should include decreasing the accumulation of fat in the abdomen, reducing hypertension prior to menopause as a way of modifying the need for more drastic measures in the post menopausal period.
Menopause Knowledge and Attitudes of English-Speaking Caribbean Women. Part 5
Instrument
The instrument used in this study was the Assessment of the Menopause Knowledge and Attitudes of English- Speaking Caribbean Women: Implication for Health Education Questionnaire. The questionnaire was in the form of a checklist determined by pre-test to take no more than thirty minutes to complete. Nine of the thirty-three questions focused on knowledge about menopause. Volunteers were asked to select the one of the seven definitions that most accurately defined menopause. Questions were also asked about menopause status, sources of knowledge about menopause and its health risks, visits to a healthcare provider in response to menopause symptoms and whether treatment, prescriptions and discussions of health risks was part their encounter with the health care provider.
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Seven questions addressed the volunteer attitudes toward menopause, seeking medical services for their symptoms, and reasons for compliance or non-compliance with provider instructions or therapy. Questions addressing the expected benefits from the use of alternative therapies such as herbs, vitamins, dietary modifications and home remedies were also asked. Nine questions focused on partner perception and support. Women who indicated that they did not carry out the prescribed treatment or remedies were asked to check their reasons for not doing so. Demographic questions related to island of origin, marital status, education, income and menopause status completed the questionnaire. The questionnaire was distributed and collected upon completion by the investigator and a trained assistant who were present at each site to assist the respondents. The data were analyzed using SPSS descriptive statistics.
Findings
There were 63 usable questionnaires for analysis. Seventy four women volunteered to participate in the study. Of these volunteers, eleven questionnaires were not included in the data analysis because: 1) six participants had either had surgically induced menopause or did not feel comfortable giving information even though they were told that the questionnaire was anonymous, 2) three participants were not from an English-speaking Caribbean country, 3) two participants had agreed to complete the questionnaire but their appointment at the Women’s Center took much longer than expected and so they declined completion of the questionnaire.
Demographics
Thirty-seven (59%) of the volunteers identified themselves as Jamaicans and the other twenty four (38%) came from other English-speaking Caribbean islands. The reported average annual income was $20,000. Twenty four women (38%) reported being currently married. Sixteen women (25%) reported four years of college education, and only 5% of the respondents had not completed high school.
All volunteers were above 30 years of age and below 60, from an English-speaking Caribbean country, and had had no surgical reproductive intervention. The final sample consisted of 63 menopausal and peri-menopausal respondents. Knowledge of the nature of menopause was mediocre, and definitions varied widely.
Menopause Knowledge and Attitudes of English-Speaking Caribbean Women. Part 4
In all the studies reviewed the issue of diversity and other important factors necessary to provide guidelines for recognizing and addressing differences among cultural groups, were lacking or absent. Several studies made comparisons of menopause knowledge and attitudes along racial lines, for example, race was correlated with hormone replacement therapy (HRT) use. Black women were less likely to use HRT than white women (Brett & Madans, 1997). Low income Blacks were also compared with low income than Latino women (Saunders-Philips, 1996). When seeking to identify sources of information, African Americans were found to be ten times more likely than Latinos to rank family first as their source for menopause related information. Neither income nor education was found to significantly correlate with information source (Pham et al., 1997).
Often menopause is symptomatic for women. The respondents preferred dietary modifications, herbs and vitamins to treat menopausal symptoms. Many viewed the symptoms of menopause as “normal” and “something all women go through.” They believed that the symptoms would pass without treatment and are not unduly perturbed by menopausal discomforts (Kaufert, Boggs, Ettinger, Fugate-Woods, & Utian, 1998).
Barriers to seeking treatment for symptoms of menopause included the un-sympathetic nature of men in general (including male physicians) (Pham et al., 1997). Some of the more recent approaches to managing menopause do not reach African Americans and most English-speaking Caribbean women. Barriers of income and education continue to leave some women frustrated by the seemingly lack of and conflicting information encountered. African American women appear to under-estimate the risk of cardio-vascular disease and osteoporosis, putting greater emphasis on cancer when making health decisions (Pham et al., 1997). Some African American women are suspicious of pharmacological treatment and may prefer non-pharmacological treatment. Helping women feel comfortable with uncertainty but still able to progress based on the best available information, is most essential (Holmes-Rovner, Padonu, Kroll et al., 1996; Maslow, 1994).
Due to the lack of research about menopausal women from the English-speaking Caribbean, it is uncertain whether the findings for “African-American,” “Black” or “Caribbean women” can be generalized to this group. This study is a first step in addressing the need to gather culture data on these women, as a basis for providing relevant and appropriate menopause related health promotion and disease prevention strategies. It is hoped that this exploratory research will trigger additional research.
Method
A sample of seventy four English-speaking Caribbean women in New York City between the ages of 35-64 years, volunteered to complete a menopause knowledge and attitude questionnaire. Data were collected from a total of seventy-four females based on age 35 years and older and who declared their peri-menopause status. Each volunteer was given verbal explanation of the questionnaire with anonymity emphasized. A consent form was signed by each volunteer and was placed in a sealed envelop in their presence. The questionnaire was then distributed and assistance given as requested. Data were collected at three sites, an urban Community College, a center for Caribbean women, and a local Protestant Church in the Borough of Brooklyn. Data collection took six months.
Menopause Knowledge and Attitudes of English-Speaking Caribbean Women. Part 3
The English-speaking Caribbean culture itself comprises segments with subjectively divergent sub-cultural patterns of behavior. Internally, there are distinctive differences of race, ethnicity, parlance and religion. Bi-racial societies represent countries such as Barbados, Antigua, Jamaica, St. Lucia, Trinidad, and St. Vincent, and they differ in their cultural, political, and economic structures. According to the 2000 census, the terms Black or African-American is used for people having origins in any of the Negroid racial groups of Africa. This description makes extracting data about those from the English-speaking Caribbean difficult and inclusive.
The sample of respondents included women from Jamaica, Barbados, Grenada, Trinidad, Guyana, St. Kitts, Tortola, St. Vincent, and Nevis. Because the majority (59%) of the respondents to this study was Jamaicans, the overview focuses on Jamaican immigrants. Emigration from Jamaica to the United States has been heavy and steady, with approximately 20,000 migrants to the U.S. annually. New York has a significant population from the Caribbean that resides in the neighborhoods of Flatbush, Canarsie and Flatlands of the Borough of Brooklyn. According to the 2000 census, one in two from Flatbush was born outside the U.S. Residents from Jamaica and Trinidad and Tobago form approximately 60% of this population. In Canarsie and Flatlands, two out of five residents are born outside of the U. S., with Jamaicans forming the largest part of the 51% of African Americans. People from the English-speaking Caribbean reside in all the boroughs of the city, but the concentration is highest in those three neighborhoods.
In the 2000 census, residents were asked to rate their state of health: approximately 17% of those living in these neighborhoods did not consider themselves to be in good health. The leading cause of death in Canarsie, Flatlands and Flatbush reflects the national trend showing heart disease as the number one killer, and the number one cause for hospitalization. Depression was found to be major cause of ill health but often it was not diagnosed, even though treatable. There is poor access to medical care. Thirteen percent of the population reported no health coverage, 22% had no personal physician and 10% needed care but did not receive it (Centers for Disease Control & Prevention, 2004). The Borough of Brooklyn identified ‘Targets for Prevention’ did not directly include menopause even though heart disease is one issue being targeted for other reasons.
Review of the Literature
A review of the literature from 1993-2004 was conducted to identify studies providing information on menopause knowledge and attitudes. Of the studies identified, most (90%), focused on the general experience of “Black” women and/or “Afro-American” women. (Brett & Madans, 1993). No studies on menopause were found that specifically addressed the knowledge and attitudes of English-speaking Caribbean women. One study used the word ‘Black’ to include women who were not “African-American” but were from non-English speaking Caribbean countries (Brett & Madams).
Menopause Knowledge and Attitudes of English-Speaking Caribbean Women. Part 2
The physiological fact of menopause may be universal, but how women experience menopause differs by ethnicity, culture, and socio-economic status. Given the definitions of low income and poverty in the Department of Health and Human Services guidelines, many women from the English-speaking Caribbean are low-income. Like many other immigrants, they are attempting to improve their economic position with little thought to preventive health strategies. Studies of low-income peri-menopausal African-American women have concluded that there are culturally based expectations for disease risk. Utian & Schiff (1994) suggested the need for “efficacy based prevention strategies” to meet the needs of a diverse group of menopausal women.
Self-efficacy has been defined as the beliefs individuals hold about personal capabilities to exercise control over their own level of functioning and over events that affect their lives. A strong personal efficacy belief enhances motivation and performance. High levels of motivation enhance self-efficacy beliefs and therefore strengthen the commitment for achieving goals. Those with high levels of motivation are less likely to become frustrated when threatened by personal difficulties and are motivated to take action rather than feel threatened. Those who do not exercise self-efficacy are less likely to master challenges and to achieve their goals. (Bandura, 1993). Thus building strong efficacy beliefs is one of the primary objectives if menopausal women are to take actions that will improve their health enhancing practices. Self-efficacy imparts thought, beliefs, feelings and behavior through the individual’s cognitive, motivational, affective and selective processes (Bandura, 1993).
Much has been written about the impact of health promotion and disease prevention and the behaviors of low income women. (Saunders-Philips, 1996). Differences in the perception of health status and the value of health and healthcare providers are often mediated by income and education, as well as acculturation and cultural background. Lack of access to knowledge and care, as well as poverty per se, may result in unhealthy behaviors.
The identified lack of knowledge about menopause in our participant population suggests the need for a more culturally focused, relevant education as a pre-requisite for developing successful preventive strategies. The purpose of this research is to determine English-speaking Caribbean women’s knowledge and attitudes toward menopause as the potential basis for the development of culturally relevant health promotion interventions.
Significance
This study represents a landmark venture into the area of English-speaking Caribbean women’s menopausal health. It is expected to provide valuable information for determining areas of health education need, as no relevant data has so far been identified.
The study involved the administration of a questionnaire to English-speaking Caribbean women to identify their knowledge and attitudes toward menopause and the cultural issues relevant to health promotion and disease prevention. Menopause related education of all women including English-speaking Caribbean women need to be highlighted. The intention is two folded, to identify particular educational, attitudinal and cultural differences that might influence health behavior, and to rectify the paucity of menopause related information available about this population. Lack of information prevents optimal use of available preventive and medical care services and limits the effectiveness of new initiatives.