INTRODUCTION State of the problem Climacteric is the transitional pe - PDF document

INTRODUCTION State of the problem ÒClimactericÓ is the transitional period from the pro-ductive to non-productive phase in the aging process.The climacteric symptoms include the following : hotflushes, sweating in the night time, insomnia, anxiety,hypersensitivity, memory disturbance, loss of concentra-tion, loss of confidence, atrophy of reproductive system,pain during sex, urinary problem symptoms, loss of sex-ual desire, atrophy of skin, arthralgia, uterus prolapse Developing an Instrument to MeasureClimacteric Symptoms among Korean andJapanese Women Purpose. Methods. 1. Professor, RN, Midwife, PhD, Department of Nursing, Jinju Health College, South of Korea 2. Professor, Midwife, PhD Department of Nursing, Nagasaki University, Japan 644 644 1. Professor, RN, Midwife, PhD, Department of Nursing, Jinju Health College, South of Korea 2. Professor, Midwife, PhD Department of Nursing, Nagasaki University, Japan and urinary incontinence and so on (Han, Park, Kim, &Cho, 1998; Korean Society of Menopause, 1994; KoreanSociety of Menopause, 2000). In addition to the abovephysical symptoms, climacteric women experience a roleloss in the family after the marriage of their children,and stress due to the sickness and death of parents, rela-tives and friends. Climacteric is also a period of crisis inwhich women experience various types of role ambigui-ty, role loss, crisis feeling, internal conflicts, and negativeself-concept (Lee et al., 1998). So, climacteric womenexperience various physical, mental and psychologicalstresses. If they donÕt maintain their health appropriatelyin this period, it will threaten the quality of their life inthe future. Therefore, the definitive measurement of cli-macteric symptoms becomes one of the very importantresearch tasks. In surveys of Korean women (Back, 1998; Ju et al.,2005; Korean Society of Menopause, 2000; Lee &Chang, 1992; Rhee, Shin, Chung, Shin, & Kim, 2001;Song, 2001), it was found that Korean climactericwomen had the following main symptoms; ÔI am tiredand in low spiritsÕ, ÔI have pains in the wristÕ, ÔI feelsharp pains and are numb in the arms and legsÕ, and ÔIhave short memory retentionÕ. Also Japanese climactericwomen had reported the symptoms (Igarashi et al.,2000; Kudo et al., 2005; Nishibayashi, 2004; Shima,2004), ÔI feel a stitch in the neck and shoulderÕ, ÔI have apain in the hands and feetÕ, ÔMy eyes feel tiredÕ, ÔI feel

tired easilyÕ, ÔI have a headacheÕ, and ÔI am forgetfulÕ. So,we found that the climacteric symptoms for both Koreanand Japanese women are very similar. For Korean cli-macteric women, mental symptoms were, sometimes,expressed as a physical symptoms and the relationshipwith husband affected the climacteric symptoms. Often,because of the Confucian life style, when a sexual prob-lem occurred during climacteric, the situation was notimproved but caused conflict, because of insufficientcommunication with her husband (Song, 1997).According to the Japanese survey utilizing in-depth in-terviews (Satoh, Takenoue, & Horiguchi, 2004),Japanese climacteric women thought as follows; ÔHus-bands arenÕt aware of menopause and they are not evenconcerned over itÕ, ÔEven though women work outsidelike men, husbands think that women must do all thehouse workÕ, ÔWomen work twice as much as menÕ, andÔClimacteric difficulties are not recognized as medicalproblems, but are treated as exaggerations or mental dis-turbancesÕ. Therefore, Japanese climacteric women hadnot only mental and physical pains, but also social pains.From these findings, it turned out that Japanese andKorean women live in a very similar socio-cultural envi-ronment. Therefore, we Korean and Japanese authors, thoughtthat there were many things in common for Korean andJapanese climacteric women, and made a decision to de-velop a measurement for climacteric symptoms to beused for both Korean and Japanese climacteric women.In collaboration with partners in the two countries, wereviewed literature(Back, 1998; Charles & Hammond,1997; Douglas & Jeffery, 2000; Han et al., 1998; Holte& Mikkelsen, 1991; Janette & Perz, 1997; Ju et al.,2005; Korean Society of Menopause, 1994; KoreanSociety of Menopause, 2000; Kudo et al., 2005; Lee etal., 1998; Lee, Chang, & Yoo, 2003; Mayer & Linscott,1995; Metka, Enzelsberger, Knogler, Schurz, &Aichmair, 1991; Nishibayashi, 2004; Park, Lee, & Cho,2002; Perz, 1997; Rhee et al., 2001; Satoh et al., 2004;Shima, 2004; Song & Chung, 1998; Song, 2001) andmade in-depth interviews with Korean and Japanese cli-macteric women in order to develop a valid instrumentin which socio-cultural environment and family relationsespecially with the spouse were reflected in Korea andJapan. Using this data and information, the instrumentfor climacteric symptoms was developed, and made itpossible to measure the climacteric

symptoms of Koreanand Japanese women. The purpose of this study was to develop an instru-ment (scale) for climacteric symptoms of Korean andJapanese women. For this, the following procedureswere considered: 1) Examine the reliability. 2) Examine the validity of the scale. Definition of Terms Climacteric symptoms refer to symptoms caused byoophorectomy, as well as symptoms accompanied bymenopause, which indicates the transition from repro-ductive to non-reproductive phase. The symptoms alsoinclude the change of physical, physiological, mental,psychological, social and endocrine symptoms, relatedto degeneration and gradual loss of ovaryÕsfunction(Korean Society of Menopause, 1994; KoreanSociety of Menopause, 2000; Lee et al., 1998). 638Journal of Korean Academy of Nursing Vol. 36, No. 4 Constructing a measurement instrument The process of developing an instrument to measureclimacteric symptoms among Korean and Japanesewomen was as follows. 1) Construction of a draft questionnaire through litera-From Dec. 12003 to March 302004, in-depth inter-views were made with 26 women (15 in Jinju, Koreaand 11 in Nagasaki, Japan)aged from 45 to 59 years whohad not taken hormone replacement therapy to relievethe climacteric symptoms. A draft questionnaire with 45items was constructed on the basis of the interview dataand literature review. 2) Examining the content validity of the draft question-Three obstetricians, three PhDs in nursing science, anda chief nurse who was exclusively in charge of climactericmanagement, one Korean PhD in Japanese philology,one Japanese PhD in Korean philology examined thedraft questionnaire to evaluate content validity. Theypointed out that uro-genital symptoms (6 items) might al-so appear due to the injury of delivery, infection and oth-er causes as well. Therefore, these 6 items were deleted.Those items included the following: ÔI feel itchy in thevaginaÕ, ÔI have a bad smell in the vaginaÕ, ÔI feel painwhen urinatingÕ, ÔI frequently need to urinateÕ, ÔI leak outurine when laughing, coughing, sneezing or taking hardexerciseÕ, ÔI urinate before arriving at a restroomÕ. Thus,the remaining 39 items constituted a preliminary ques-tionnaire. These items were scaled by utilizing Likertscaling method: 1 for ÔStrongly agreeÕ, 2 for ÔModeratelydisagreeÕ, 3 for ÔModerately agreeÕ, 4 for ÔStrongly agreeÕ.Thus, the higher the score of a climacteric symptom was,the

more serious was the climacteric symptom. A survey was conducted using a convenient samplingmethod in Jinju, Korea and Nagasaki of Japan duringthe period from April 1, 2004 to July 10, 2005. The re-spondents consisted of 380 climacteric women (256Korean and 124 Japanese). Their ages ranged from 45 to59 years. Respondents understood the research purposeand were willing to participate in the survey. In order tostudy climacteric symptoms accurately, responses from35 women (34 Koreans and 1 Japanese)were discardedbecause they had taken hormone replacement therapy.Eventually, 345 responses were used for statisticallyanalysis. Respondents were asked to complete the ques-tionnaires themselves, and it took about 20 minutes tocomplete it for each person. Statistical Analysis Data were analyzed using SPSS 12.0 version StatisticalDemographic Characteristics of the Samples(N = 345) VariablesCategoriesKorean women (N=222)Japanese women (N=123)Total (N=345)n (%)n (%)n (%)Age45 49146 (65.8)35 (28.5)181 (52.5) 57 (25.7)48 (39.0)105 (30.4) (8.6)40 (32.5)OccupationYes96 (43.2)88 (71.5)184 (53.3)No126 (56.8)35 (28.5)161 (46.7)Family number1 (3.6)32 (26.0) 90 (40.5)72 (58.5)162 (47.0) 6102 (45.9)18 (14.6)120 (34.8) Children number0 (5.0)20 3164 (73.9)87 (70.7)251 (72.8) 47 (21.2)16 (13.0)Economic statusUpper71 (32.0)25 (20.3)Middle138 (62.2)94 (76.4)232 (67.2)Perceived health statusGood61 (27.5)33 (26.8)Ordinary110 (49.5)63 (51.2)173 (50.1)51 (23.0)27 (22.0) Package. 1) The demographic characteristics were analyzed byusing descriptive statistics. 2) CronbachÕs alpha coefficient was obtained to testthe reliability of the constructed scale. 3) Factor analysis was used to test the validity of thescale. RESULTS Sample characteristics Among the respondent sample of 345 women used forstatistical analyses in this study, there were 222 Koreanwomen (64.3%) and 123 Japanese women (35.7%).More than half of the Korean women were of age 45 49 (65.8%), but the most frequent age class for Japanesewomen was 50 54 (39%). Most of the Japanese women(71.5%) had a job, but only 43.2% of Korean womenhad a job. Most of Korean sample had 3 5-6 family members (45.9%), but more than half ofJapanese women had 3 4 family members (58.5%).Most of Korean and Japanese women were of middleeconomic status (62.2% and 76.4%, respectively).Around half of the sample (49.5% for Korean, 51.2%640Journal of Korean Academy of

Nursing Vol. 36, No. 4Internal Reliability of the Preliminary Menopause Symptoms Instrument(N = 345) ItemItem ContentCorrected Alpha if item-total correlationitem deleted1. I am lonely because I donÕt have anybody who really understands me.591.9512. I have a feeling that I am mistreated by my husband, my husbandÕs family, and was mistreated by my maiden home family..647.9503. I feel empty, and I donÕt think that I am living well..686.950.708.950.575.9516. I have a feeling of being sacrificed for the benefit of the family..586.9517. I feel that I am being disregarded by my children..561.9518. I donÕt want to meet people..482.9519. I have reduced sexual desire..519.95110. I am not satisfied with my sexual life..586.95111. I am worried that my husband may have secret love affairs..347.95212. I donÕt like to have sex..423.95213. I avoid my husbandÕs intimate touch and cares..422.95214. Sometimes I want to die..605.951.619.95016. My skin became rough and dry..669.950.691.950.612.95019. I have twinges and dull pain in my extremities..712.950.623.95021. I have a short memory(amnesia).578.95122. My hands and feet are cold..480.951.091.954.461.95125. I have shoulder stiffness..507.95126. I am anxious or afraid..573.951.670.950.655.95029. I am hot without any reason, or I have hot flushes..595.951.737.95031. I have a feeling of suffocation or strangulation..590.95132. I canÕt sleep well at night (insomnia)..468.95133. I become sharp, and lose my temper easily..640.95034. I sweat during sleeping in the night time..520.951.652.950.491.95137. I sweat more nowadays than before..545.95138. I have reduced vaginal discharge..509.95139. I experience pain during sexual intercourse..536.951 for Japanese)evaluated their current health status as or-dinary (Table 1). Reliability The results of the internal reliability for the scale itemswere presented in Table 2. Among the 39 items in thepreliminary questionnaire, 1 item(ÔI gained weightÕ) waseliminated, because itÕs corrected item-total correlationwas lower than 0.3. The CronbachÕs alpha coefficient forthe remaining 38 items amounted to 0.953. Construct validity Construct validity focused upon theoretical validationby evaluating the relationship between the scale andeach constituent item. In this study, factor analysis wasused to evaluate construct validity. As the p-value of BarlettÕs test of sphericity was .000and KMO(Kaiser-Mayer-Olkin

)value (.936) was higherthan .06 (Table 3), our sample seemed to be adequatefor factor analysis (Child, 1990; Nho, 2003). On the basis of literature review, eigenvalues andchanges in scree plot(Child, 1990; Nho, 2003), 4 factorswere extracted. After factor rotation by varimax method,the percent of the explained variance of factors were13.938% for the 1st factor, 13.386% for the 2nd factor,10.750% for the 3rd factor and 8.812% for the 4th fac-tor, and thus total explained variance amounted to46.886% among total variance of the 38 items (Table 4). Principal axis factoring extraction method and vari-max method was used for factor extraction and factorrotation, respectively. After factor rotation, 2 items withfactor loading values lower than 0.4 were eliminated.Those items were ÔI am worried that my husband mayhave secret love affairsÕ and ÔMy hands and feet arecoldÕ. Finally, the scale developed consists of 36 items.For each 36 items, maximum factor loading valuesamong the 4 factor loadings are presented in Table 5.The 1factor containing 11 items was named as Ômentaland psychological symptomsÕ. The 2factor containing9 items was named as Ôphysical symptomsÕ. The 3fac-tor containing 10 items was named as Ôloss of autonomicnervous system symptomsÕ , and the 4factor containing6 items was named as Ôsexual symptomsÕ. Reliabilities of the measurement instrument Reliability of the four factors and total instrumentwere presented in Table 6. The CronbachÕs alpha of the1st factor Ômental and psychological symptomsÕ, the 2ndfactor Ôphysical symptomsÕ, the 3rd factor Ôloss of auto-nomic nervous system symptomsÕ, and the 4th factorÔsexual symptomsÕ were respectively .905, .829, .880,.821. Also, the CronbachÕs alpha of the total instrumentwas .953. Choosing a proper instrument with high degree of reli-ability and validity is very important in order to get thecorrect results. One of the problems found through theliterature review and in-depth interview was the distor-tion of the study findings resulting from the preconcep-tion about the different socio-cultural environment. Theclimacteric symptoms of Western women seemed to bedifferent from those of Korean and Japanesewomen(Charles & Hammond, 1997; Douglas & Jeffery,2000; Ju et al., 2005; Kudo et al., 2005; Nishibayashi,2004; Rhee et al., 2001; Shima, 2004; Song, 2001). ToExtracted Sum of Squares LoadingsRotated Sums of Squares Loading

sFactorEigen valuesTotal% of VarianceCumulative %Total% of VarianceCumulative %114.12613.62435.85435.8545.29613.93813.9383.96639.8205.08713.38627.3243.77643.5964.08510.75038.0743.29046.8863.3498.81246.886 Matrix(N = 345) KMO Measure of Sampling Adequacy.936Chi-Square5738.423BarlettÕs Test of Sphericitydf703Sig.000 measure the climacteric symptoms properly, all of thesocial, cultural, familial and psychiatric aspects should beconsidered. Also, instruments either constructed in theWest or measuring only physical symptoms do notseemed to measure correctly the menopause symptomsfor Korean and Japanese women. So, the instrument de-veloped in this study had a significance in two senses: 1)it was constructed multi-dimensionally, including themental and psychological symptoms, physical symp-toms, loss of autonomic nervous system symptoms, andsexual symptoms, and 2) it was constructed on the basis642Journal of Korean Academy of Nursing Vol. 36, No. 4Factor Loadings from the Rotated Factor Matrix : Principle Axis Factoring with Varimax Rotation(N = 345) 1. I feel empty, and I donÕt think that I am living well..6862. I feel gloomy..6293. I feel that I am being disregarded by my children..6164. Sometimes I want to die..6065. I am lonely because I donÕt have anybody who really understands me..5786. I am not confident..575family and was mistreated by my maiden home family..5528. I am anxious or afraid..5499. I donÕt want to meet people..53610. I have a feeling of being sacrificed for the benefit of the family..48311. I canÕt concentrate..47713. I have twinges and dull pain in my extremities..65314. My skin became rough and dry..63519. I have shoulder stiffness..52120. I have a short memory(amnesia)..43921. I sweat more nowadays than before..63722. I am hot without any reason, or I have hot flushes..59223. I sweat during sleeping in the night time..59025. I have a feeling of suffocation or strangulation..53927. I become sharp, and lose my temper easily..48230. I canÕt sleep well at night(insomnia)..40134. I avoid my husbandÕs intimate touch and cares..557 FactorMean SDCronbachÕs alphasymptoms1.87 7.13.905Physical symptoms2.52 6.71.829system symptoms1.93 6.52.880Sexual symptoms2.17 4.25.821Total2.11 21.09.953 of the in-depth interviews with Korean and Japanese cli-macteric women and literature reviews. In the study, our instrument was evaluated in the con-text of content validity a

nd construct validity.CronbachÕs alpha, which was the measure of the internalreliability for the 36 items, was .953. So, our instrumentseemed to be appropriate to measure climacteric symp-toms and can be contribute to easily finding women whoare suffering climacteric symptoms in Korea and Japan.The purpose of this study was to develop a valid andreliable instrument for climacteric of Korean andJapanese women. Through the literature review, in-depthinterview, and consultation with medical specialists, oneKorean PhD in Japanese philology, one Japanese PhD inKorean philology, 39 items were selected as a prelimi-nary questionnaire. Using the preliminary questionnaire,the survey was conducted in Jinju of Korea andNagasaki of Japan during the period from April 1st,2004 to July 10th, 2005. After discarding inappropriatecases, the final sample consisted of 345 women(222Koreans and 123 Japanese) aged 45-59 years and whohad never had hormone replacement therapy. The datawere analyzed by using SPSS 12.0 version. Reliabilityand validity of the instrument consisting of 39 itemswere examined. Also, by factor analysis and item analy-sis, the instrument finally developed consists of 36 items.Four factors were extracted from the 36 items by usingfactor analysis: 1) mental and psychological symptoms,2) physical symptoms, 3) loss of autonomic nervous sys-tem symptoms, and 4) sexual symptoms. The above 4factors explained 46.88% of total variance, andCronbachÕs alpha of the instrument amounted to .953.Therefore, we could conclude that the instrument hadthe authentic degree of reliability and validity, and thatthe instrument of climacteric symptoms was multidi-In this study, we have tried to construct a scale of cli-macteric symptoms that can be used both for Koreanand Japanese climacteric women and in the future, weare planning to retest and modify our instrument by us-ing larger random samples. References The essentials of factor analysisDouglas, R.M., & Jeffery, T.K. (2000). Management of the climac-symptoms : Life events, coping behavior, and severityLee, K.J., Chang, C.J., & Yoo, J.K. (2003). A study on the relation-Nho, H.J. (2003). Understandable multivariate data analysis bysymptoms, knowledge of?menopause, menopausal manage-ment in middle-aged women. K Shima, A. (2004). The relationship menopausal symptoms and. Unpublished doc-644Journal of Korean Academy of Nursing Vol. 36, No.