Specialist referral framework for nulliparous women. Conclusion
Conclusions
Wehave identified the most important clinical risk factors for pre-eclampsia in healthy nulliparous women and provided new information on the level of risk associated with specific combinations of risk factors. The predictive performance of the algorithm is modest, but offers a considerable improvement on current practice in healthy nulliparous women. As all known risk factors were included in this large prospective cohort, it shows the expected performance and limitations of using clinical phenotype to predict pre-eclampsia. The algorithm serves as a prototype that requires alidation in other nulliparous populations. If validated, it might provide a personalised clinical risk profile for nulliparous women to which biomarkers could be added.
We thank the pregnant women who participated in the SCOPE study, Claire Roberts for her contributions in establishing the SCOPE study in Adelaide, Denise Healy for coordinating the Australian SCOPE study, Annette Briley for coordinating the UK MAPS (SCOPE) study, Nicolai Murphy for coordinating the Cork SCOPE study, the SCOPE research midwives, and Steven Wu for his assistance with data imputation. Contributors: RAN was responsible for conception and design, analysis and interpretation of data, and drafting the article and revising it critically for important intellectual content. LMEMcC, GAD, LP, JJW, and PNB were responsible for conception and design and interpretation of data, and critical revision of paper for important intellectual content. EHYC, AWS, and MAB were responsible for statistical analyses and interpretation of data, and revising the article critically for important statistical content. RST was responsible for study design, coordination of clinical study, and revising the article critically for important intellectual content. LCK was responsible for conception and design, interpretation of data, drafting the article, and critical revision of paper for important intellectual content. All authors had full access to all of the data (including statistical reports and tables) in the study, can take responsibility for the integrity of the data and the accuracy of the data analysis, and approved the final version to be published. RAN is guarantor.
Funding: This study was funded by New Enterprise Research Fund, Foundation for Research Science and Technology; Health Research Council (04/198); Evelyn Bond Fund, Auckland District Health Board Charitable Trust; Premier’s Science and Research Fund, South Australian Government; Guy’s and St Thomas’ Charity, Tommy’s the baby Charity; Biotechnology and Biological Sciences Research Council (GT084), UK National Health Services (NEAT grant FSD025), University of Manchester Proof of Concept Funding, NIHR; Health Research Board, Ireland (CSA/ 2007/2). The study sponsors had no role in study design, data analysis or writing this report. MAB received consultancy fees from the SCO PE Study, University of Auckland, which were funded by the New Zealand Health Research Council and the New Enterprise Research Fund, foundation for Research Science and Technology.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; RAN and PNB have had consultancy relationships with Pronota in the previous three years; RAN has a consultancy relationship with Alere; LCK and PNB declare a US Provisional Patent Application in the name of University College Cork, Ireland (Louise Kenny and Philip Baker) “Detection of risk of preeclampsia” Application No USSN 61/288,465; RAN and MAB declares the following patent, which to date has not been licensed to a company: Blumenstein M, North RA, McMaster MT, Black MA, Kasabov NK, Cooper GJS. Biomarkers for prediction of pre-eclampsia and/or cardiovascular disease, PCT number WO/2009/108073. LP has a consultancy relationship with Tate and Lyle Research Advisory Group and is chairing a working party with ILSI Europe; both are outside the area of the submitted work.
Ethical approval: This study was approved by local ethics committees (New Zealand AKX/02/00/364, Australia REC 1712/5/2008, London and Manchester 06/MRE01/98, and Cork ECM5 (10) 05/02/08), and all women provided written informed consent.
Specialist referral framework for nulliparous women. Part 4
Confirming the results of a case-control study, a lower maternal birth weight was associated with an increased risk of pre-eclampsia, with an even greater risk when low maternal birth weight coexisted with other key risk factors. Prolonged vaginal bleeding in early pregnancy was associated with a twofold increase in risk of pre-eclampsia. As reported by others, most of these bleeds were mild in severity, suggesting that a discrete bleeding pattern could be associated with later pre-eclampsia. Several factors were associated with a reduced risk of pre-eclampsia. A single early miscarriage with the same partner, eating a lot of fruit, and smoking were protective, again reassuringly consistent with previous reports. The protective influence of cigarette smoking in our cohort was less than previously reported, and cigarettes did not remain in the model when we added uterine artery Doppler indices. Alcohol use in the first trimester was protective but requires confirmation in other cohorts. Obese women are reported to drink less alcohol, possibly because food fulfils their addictive behaviour. Obesity is unlikely to be the only explanation, however, as the protective effect of alcohol is retained with BMI in the model, and there was no interaction between BMI and alcohol. A recent series of publications reported algorithms to predict pre-eclampsia based on clinical risk factors in a general population comprising high risk women (previous pre-eclampsia and medical conditions), nulliparous women, and low risk women (multiparas with previous uncomplicated pregnancies). A model is fitted to the population in which it was developed, using the available candidate predictors. A general antenatal population constructed of subgroups with different risk profiles is difficult to replicate and future “general populations” are likely to comprise a different case-mix. The importance of population differences is evident in the failure of one proposed algorithm to validate in a high risk population, raising questions as to more general applicability to other populations such as “healthy” nulliparous women. Poor performance on validation might also occur because key predictors are missing from the model. When the list of candidate predictors includes strongly predictive factors, such as previous pre-eclampsia, renal disease, and chronic hypertension, these will take precedence, replacing other factors that might be more relevant to healthy nulliparous women. In contrast, in SCOPE, we investigated candidate predictors applicable to healthy nulliparous women.
Clinical relevance
The new information on the rate of pre-eclampsia in the presence of combinations of specific risk factors could be used by clinicians to improve current guidelines for specialist referral in nulliparous women. When we applied the criteria proposed in the NICE guidelines to the SCOPE cohort, 16.5% of nulliparous women would be referred for a specialist opinion of whom 10% would develop pre-eclampsia. This included 31% of the 186 women who developed preeclampsia and 38% of the 47 of those who developed preterm pre-eclampsia. If we included only first pregnancy, as in the NICE guidelines, 52 12% would be referred and 23% and 28% cases of pre-eclampsia and preterm pre-eclampsia, respectively, would be detected. Our proposed framework for specialist referral based on the algorithm, along with uterine artery Doppler screening of a subpopulation, performed better than the NICE guidelines but requires validation. Among the referred women (9% of nulliparas), the rate of pre-eclampsia was 21%. Thirty four per cent of cases of pre-eclampsia and 53% of cases of preterm preeclampsia were identified. This framework has the potential to identify a subgroup of nulliparous women at high risk of pre-eclampsia who could benefit from low dose aspirin and more intensive antenatal surveillance. It does not, however, provide additional information for the rest, whose risk is similar to an unscreened nulliparous population. Hence a negative “test” result would not modify current clinical care. The algorithm requires external validation, followed by assessment of the impact of increased surveillance, the false positive and false negative results, and a health economics analysis. If externally validated, this algorithm could help to inform future NICE guidelines for specialist referral. It could be made accessible, including via the web, as a support for risk stratification of healthy nulliparous women in low resource settings. To improve overall accuracy and detection of cases, the clinical algorithm will require the addition of biomarkers.
Specialist referral framework for nulliparous women. Part 3
Comparisons with other studies
Previous studies investigating risk factors for preeclampsia have used birth registries or hospital databases,634 randomised trials with negative results (that is, no treatment effect shown), and, in a few studies, prospective cohorts (usually general obstetric populations) designed to investigate outcomes of pregnancy. Consistent with other contemporary studies, the women who developed pre-eclampsia were younger, more obese, and more likely to have lower socioeconomic status. Many of the risk factors included in the algorithm presented here are associated with a similar degree of risk to that previously reported, giving confidence regarding the potential applicability of the algorithm to other populations. Higher blood pressure within the normal range, a higher BMI, and a family history of pre-eclampsia had similar predictive characteristics to those observed in other studies. In our algorithm, blood pressure was the most important risk factor driving the estimated probability of pre-eclampsia. Mean arterial pressure, rather than systolic or diastolic blood pressure blood, was selected by stepwise logistic regression and included in the model.8 If it was implemented into clinical practice, the clinician would derive the mean arterial pressure from systolic and diastolic blood pressure entered into the algorithm. A history of coronary artery disease in the woman’s father was associated with a 1.9-fold increase in the risk of preeclampsia, consistent with a previous report and the association between pre-eclampsia and subsequent.
Comparisons with other studies
Mexican pharmacy online
Previous studies investigating risk factors for preeclampsia have used birth registries or hospital databases,634 randomised trials with negative results (that is, no treatment effect shown), and, in a few studies, prospective cohorts (usually general obstetric populations) designed to investigate outcomes of pregnancy. Consistent with other contemporary studies, the women who developed pre-eclampsia were younger, more obese, and more likely to have lower socioeconomic status. Many of the risk factors included in the algorithm presented here are associated with a similar degree of risk to that previously reported, giving confidence regarding the potential applicability of the algorithm to other populations. Higher blood pressure within the normal range, a higher BMI, and a family history of pre-eclampsia had similar predictive characteristics to those observed in other studies. In our algorithm, blood pressure was the most important risk factor driving the estimated probability of pre-eclampsia. Mean arterial pressure, rather than systolic or diastolic blood pressure blood, was selected by stepwise logistic regression and included in the model. If it was implemented into clinical practice, the clinician would derive the mean arterial pressure from systolic and diastolic blood pressure entered into the algorithm. A history of coronary artery disease in the woman’s father was associated with a 1.9-fold increase in the risk of preeclampsia, consistent with a previous report and the association between pre-eclampsia and subsequent.
Specialist referral framework for nulliparous women. Part 2
The concept of a personalised clinical risk estimate for disease, to which biomarkers can be added, is established in several areas of medicine. The algorithm to predict pre-eclampsia reported here provides a first step towards a personalised risk score for pre-eclampsia among nulliparous women. It is inevitable the model will be overfitted to our population and external validation of the algorithm in other nulliparous populations is essential.Weplan to evaluate its performance in the next 3000 women recruited into SCOPE, nearly all of whom will be recruited in different centres than the initial 3500 women. Validation should also be performed in other study populations of nulliparous women.
Strengths and weaknesses
A major strength of this study is its large multicenter prospective design with excellent follow-up. As the focus of the SCOPE study is development of tests to predict pregnancy outcome with potential to translate into clinical care, we recruited a clearly defined population of nulliparous women, enabling identification of similar populations for external validation. This is critical for generalisability of a risk assessment algorithm; the population in which the algorithm is developed needs to be identifiable if a screening test is to be used in clinical care.
We obtained high quality data for all known risk factors for pre-eclampsia from questionnaires administered at interviews, along with detailed standard operating procedures. Use of a real time database, with automated checking procedures, reduced data entry errors and transcription errors. For a dataset of this size, the rate of missing data was minimal. The intensive two stage data monitoring adds confidence in data integrity. Potential measurement errors, such as in self reported family history, could have occurred, but as the goal was to develop a prototype algorithm ultimately for clinical use, this limitation was accepted. Principal investigators reviewed outcome data for cases, ensuring accurate diagnosis. One of the challenges when predicting rare events in prospective cohorts, such as SCOPE, is the relatively low numbers of cases compared with studies based on huge epidemiological databases. While the latter might have a substantially greater number of events, their interpretation is restrained by less accurate diagnosis. There is no consensus as to the best method for selection of variables. Given the rich dataset of potential predictors for pre-eclampsia, we used a pruning step based on significance testing and then selected a subset of candidate variables on a priori knowledge. This could have introduced variable selection bias, but it is reassuring that the clinical risk factors and their strength of association with pre-eclampsia are consistent with the literature. While we could undertake only internal validation at this stage, external validation is planned.
Clinical risk prediction for pre-eclampsia in nulliparous women. Part 2
In prospective studies of general obstetric populations, the reported performance of a limited number of clinical risk factors to predict pre-eclampsia is modest, with an AUC (area under the curve) in the order of 0.66 to 0.79. These cohorts included high risk women and the best predictors of pre-eclampsia (underlying medical conditions that predispose to preeclampsia or a history of pre-eclampsia4616) are not applicable to healthy nulliparous women. Before preventive treatment and stratified antenatal care can be offered to nulliparous women, we need to identify those at high risk of pre-eclampsia. At present there is no method to accurately stratify healthy nulliparous women according to their risk profile for preeclampsia. This study is part of the SCOPE (Screening for Pregnancy Endpoints) study, a prospective, multicenter cohort study of “healthy” nulliparous women with the primary aim of developing screening tests to predict pre-eclampsia, infants who are small for gestational age, and spontaneous preterm birth. The study design incorporates prospective collection of information on all known clinical risk factors for pre-eclampsia. The objectives are to develop multivariable predictive models for pre-eclampsia (based on clinical risk factors present in early pregnancy alone or in combination with ultrasound estimates of uteroplacental perfusion and fetal measurements at 19-21 weeks’ gestation) and determine their performance to predict pre-eclampsia as a baseline for future external validation; identify the rate of pre-eclampsia associated with specific combinations of clinical risk factors and ultrasound scan variables; and develop a proposal for risk stratification of “healthy” nulliparous women, based on combinations of key clinical risk factors and scan indices, to identify a subgroup at increased risk of pre-eclampsia for whom specialist referral might be indicated.
METHODS
Five centres (Auckland, New Zealand; Adelaide, Australia; London and Manchester, UK; and Cork, Ireland) recruited nulliparous women with singleton pregnancies to the SCOPE study between November 2004 and August 2008. Women (n=4961) attending hospital antenatal clinics, obstetricians, general practitioners, or community midwives before 15 weeks’ gestation were invited to participate. Exclusion criteria included recognized as high risk of pre-eclampsia, small for gestational age baby or spontaneous preterm birth because of underlying medical conditions (chronic hypertension requiring antihypertensive drugs, diabetes, renal disease, systemic lupus erythematosus, antiphospholipid syndrome, sickle cell disease, HIV), previous cervical knife cone biopsy, three or more abortions or three or more miscarriages, current ruptured membranes; known major fetal anomaly or abnormal karyotype; or intervention that could modify the outcome of pregnancy (such as aspirin, cervical suture). A research midwife interviewed and examined women at 14-16 and 19-21 weeks’ gestation. Women underwent an ultrasound scan at 19-21 weeks. At the time of interview, data were entered on an internet accessed central database with a complete audit trail (MedSciNet). At 14-16 weeks’ gestation the following data were collected: demographic information including age, ethnicity, immigration details, education, work, socioeconomic index, income level, living situation; the woman’s birth weight and gestation at delivery and whether it was a singleton or multiple pregnancy; previous miscarriages, abortions, or ectopic pregnancies and whether these pregnancies were with the same partner as the current pregnancy or not; history of infertility, use of assisted reproductive technologies, duration of sexual relationship, and exposure to partner’s sperm; gynaecological (including polycystic ovarian syndrome) and medical history, including hypertension while taking combined oral contraception, asthma, urinary tract infection, inflammatory bowel disease, thyroid disease, and thromboembolism; and family history (in mother and sisters) of obstetric complications (miscarriage, pre-eclampsia, eclampsia, gestational hypertension, spontaneous preterm birth, any preterm birth, gestational diabetes, stillbirth, and neonatal death) and family history (mother, father, sibling) of medical conditions (hypertension, coronary artery heart disease, cerebrovascular accident, type 1 and 2 diabetes, and venous thromboembolism).
Clinical risk prediction for pre-eclampsia in nulliparous women
Abstract
Objectives To develop a predictive model for pre-eclampsia based on clinical risk factors for nulliparous women and to identify a subgroup at increased risk, in whom specialist referral might be indicated.
Design Prospective multicentre cohort.
Setting Five centres in Auckland, New Zealand; Adelaide, Australia; Manchester and London, United Kingdom; and Cork, Republic of Ireland.
Participants 3572 “healthy” nulliparous women with a singleton pregnancy from a large international study; data on pregnancy outcome were available for 3529 (99%).
Main outcome measure Pre-eclampsia defined as ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, or both, on at least two occasions four hours apart after 20 weeks’ gestation but before the onset of labour, or postpartum, with either proteinuria or any multisystem complication. Preterm pre-eclampsia was defined as women with pre-eclampsia delivered before 37+0 weeks’ gestation. In the stepwise logistic regression the comparison group was women without pre-eclampsia.
Results Of the 3529 women, 186 (5.3%) developed pre-eclampsia, including 47 (1.3%) with preterm pre-eclampsia. Clinical risk factors at 14-16 weeks’ gestation were age, mean arterial blood pressure, body mass index (BMI), family history of pre-eclampsia, family history of coronary heart disease, maternal birth weight, and vaginal bleeding for at least five days. Factors associated with reduced risk were a previous single miscarriage with the same partner, taking at least 12 months to conceive, high intake of fruit, cigarette smoking, and alcohol use in the first trimester. The area under the receiver operating characteristics curve (AUC), under internal validation, was 0.71. Addition of uterine artery Doppler indices did not improve performance (internal validation AUC 0.71). A framework for specialist referral was developed based on a probability of pre-eclampsia generated by the model of at least 15% or an abnormal uterine artery Doppler waveform in a subset of women with single risk factors. Nine per cent of nulliparous women would be referred for a specialist opinion, of whom 21% would develop pre-eclampsia. The relative risk for developing pre-eclampsia and preterm pre-eclampsia in women referred to a specialist compared with standard care was 5.5 and 12.2, respectively.
Conclusions The ability to predict pre-eclampsia in healthy nulliparous women using clinical phenotype is modest and requires external validation in other populations. If validated, it could provide a personalised clinical risk profile for nulliparous women to which biomarkers could be added.
Introduction
Pre-eclampsia is a multisystem complication that occurs after 20 weeks of pregnancy and can cause considerable maternal and fetal morbidity and mortality. This complex condition is characterised by suboptimal uteroplacental perfusion associated with a maternal inflammatory response and maternal vascular endothelial dysfunction. One of the main reasons for serial clinical assessment in antenatal care is the early detection of signs (raised blood pressure and proteinuria) indicative of evolving pre-eclampsia. Recent guidelines from the National Institute for Health and Clinical Excellence (NICE) also recommend routine screening for specific risk factors for pre-eclampsia (nulliparity, older age, high body mass index (BMI), family history of pre-eclampsia, underlying renal disease or chronic hypertension, multiple pregnancy, more than 10 years between pregnancies, and a personal history of pre-eclampsia). The expected rate of pre-eclampsia when any one of these risk factors is present ranges from 3% to more than 30%, and many women have several risk factors. The absolute risk for an individual will be determined by the presence or absence of these and other predisposing or protective factors not incorporated in the NICE guidelines. Currently, because of a paucity of large prospective studies, we cannot accurately estimate the risk of pre-eclampsia from combinations of clinical risk factors.
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.
Online pharmacy Mexico
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.