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CLINICAL RESEARCH

A Psycho-Educational Program for

Improving Womens Attitudes and
Coping With Menopause Symptoms
Mina Rotem, Talma Kushnir, Ruth Levine, and Mally Ehrenfeld

Objective: To examine the impact of participation in a psycho-educational program on womens

attitudes toward menopause, the perceived severity of
their symptoms, and the association between the two.
Design: Quasi-experimental. Data were gathered at baseline and 3 months after termination of the
program.
Setting: Two health maintenance organization
clinics.
Participants: Eighty-two healthy 40- to 60-yearold women who chose to participate in the study.
Thirty-six women participated in the program, and 46
women comprised the control group.
Intervention: Program participants met for 10
weekly sessions to receive information from a professional team on subjects related to menopause and to
share and discuss their experiences.
Main Outcome Measures: Attitudes toward
menopause and severity of menopause symptoms.
Results: The more negative the attitudes, the
higher was the severity of symptoms. Participants
reported significant improvements in attitudes and
reductions in symptom severity compared to their own
baseline scores and compared with the control group.
Conclusions: Participation in a program that
combines delivery of information and processing of
experiences on the cognitive, emotional, and social
levels may improve womens attitudes toward
menopause and ease the perceived severity of their
symptoms, thereby increasing quality of life. JOGNN,
34, 233240; 2005. DOI: 10.1177/0884217504274417
Keywords: AttitudesMenopauseProgram
SymptomsWomens groups
Accepted: December 2003

March/April 2005

Menopause is a transitional developmental period

in a womans life. It is associated with natural
processes of aging, decline of ovarian functioning,
and anatomic changes. Menopause is accompanied
by different symptoms and changes in social roles,
and the social and cultural connotations accompanying this period define its significance (Im &
Meleis, 2000; Kowalcek, Rotte, Painn, Schmidt &
Diedrich, 2003).
At the beginning of the 20th century, the life span
of women in Western countries was about 40 years,
and only a few of them experienced menopause. At
the beginning of the third millennium, however,
womens life spans have been prolonged to 80 to 84
years (Schaad, Bonjour, & Rizzoli, 2000). This
extension of the life span has affected the social perceptions of advanced age and the concept of aging.
Women in their 50s and 60s in Israel, like other
Western countries, are active in different areas.
Many of them work outside the home. Eighty percent of these women report unpleasant symptoms
occurring close to menopause, such as headaches,
sexual problems, tachycardia, hot flushes, perspiration, and insomnia, that significantly reduce their
quality of life (Blumel et al., 2000; Dennerstein,
Alexander, & Kotz, 2003).
Very few researchers have studied the menopause
experience in Israeli women. In a review of these
studies, Flescher (1998) stated that the menopause
experiences of Israeli women are similar to those of
women in Western Europe and the United States.
This experience is influenced by social role and status. Differences have been found between different
ethnic groups and between religious and nonreligious women. Religious women accepted

JOGNN 233

menopause as a natural phase of life, whereas nonreligious women expressed negative attitudes toward
menopause. Blumberg et al. (1996) found that Israeli
women born in North African and Middle Eastern countries (other than Israel) had negative attitudes toward
menopause compared to native-born Israelis or to women
of European and North American origin.
One of the most debated subjects in industrial countries is the treatment for menopause symptoms, in particular, hormone replacement therapy (Pines, 2004). The
effectiveness of the hormonal treatment in reducing most
of the symptoms is debated, and the controversy regarding the effectiveness of preventing serious diseases while
increasing risks to health has not been settled yet (Casper,
2000; Gregory, 1999).
Lately, the abundance of popular books and publications and the increased promotion of womens health
have caused women to reexamine menopause, request
more up-to-date information, and be more involved in
decisions concerning their health (Perez, 2004; Walter,
Emery, Rogers, & Britten, 2004). In 1990, Bowles developed a model claiming that a womans attitude toward
her own menopause is one of the most significant factors
that influence her menopausal experience. This model
predicts that women who are positive about menopause
will experience no special suffering, whereas women with
negative attitudes will experience more and stronger
symptoms. Despite the recognition that womens attitudes
toward menopause tend to influence their menopausal
experiences (Adler et al., 2000; Chornesky, 1998; Mercer,
1999; Ulacia et al., 1999) and that negative attitudes and
expectations predict distress and reduced quality of life
for menopausal women (Chornesky, 1998; Sievert &
Espinosa, 2003; Ulacia et al., 1999), physicians still
emphasize medical treatment instead of promoting a
healthy lifestyle, behavioral changes, and positive attitudes toward this period in life (Grisso, Freeman, Maurin,
Garcia-Espana, & Berlin, 1999; Ulacia et al., 1999; Will
& Fowles, 2003).
A combination of four main factors increases interest
in alternative treatments to hormonal therapy and underscores the importance of the present research:
1. The rate of hormone replacement therapy in most
countries remains low (Casper, 2000).
2. Hormone replacement therapy remains controversial mainly because of the possibility of an increase
in breast cancer risk (Rackley, 2004; Willett,
Colditz, & Stampfer, 2000) and doubts as to its
effectiveness in preventing cardiovascular diseases
(Cutson & Meuleman, 2000; Harmam et al., 2004;
Hulley & Grady, 2004).
3. Research findings show that there is no direct connection between the reduction in hormones and
occurrence of symptoms and that menopausal
234 JOGNN

symptoms are mediated by social and cultural factors (Obermeyer, 2000).

4. Some of the symptoms may be related to psychological factors such as the need of women to change
their self-image during menopause (Standing, 1996).
Bogge and Rosenthal (2000) suggested that health care
professionals should provide women with information
and help them create support groups to adopt positive
attitudes and healthy perceptions of menopause. Women
participating in such groups help each other through discussions by sharing of personal experiences and current
information on menopause. Furthermore, the supportive
atmosphere in such groups encourages participants to
take responsibility for their well-being.

here is increased interest in alternative

treatments for menopause symptoms.

Yalom (1995) suggested that participating in a group

can influence values, attitudes, learning, habits, achievements, performances, and well-being of members. These
factors are influenced by emotional disclosure, the sharing of universal human experiences, the introduction of
behavioral alternatives, and availability of feedback from
the other members. The cohesiveness of the group facilitates the formation of interpersonal relations and bonds
among the participants and enables them to attain higher
levels of awareness of their difficulties in daily life. Individuals in the group relieve emotions, look together into
what happens in the present, and discover what hinders
them from functioning as they would like to.
The literature survey revealed a limited number of articles describing several programs for women in
menopause. Some articles examined changes in knowledge among women, and others examined changes in
health habits, attitudes, or symptoms. For example, Liao
and Hunter (1998) examined health habits, knowledge,
and attitudes toward menopause. The program provided
information about menopause and coping methods, and
the women discussed menopause as a natural transitional
period in their lives. At the end of the program, knowledge levels among the participants were higher than their
own baseline scores and in comparison with the levels in
the control group. The attitudes were also more positive
compared with baseline. No significant changes were
found in health behaviors.
Hunter and ODea (1999) found that women who participated in a menopause educational program had better
knowledge and health habits than the women in the control group did: Seventy-five percent reported that particiVolume 34, Number 2

pating in the program helped them to cope emotionally

with menopause, and 87% reported that the group helped
them cope with practical aspects of menopause. Participants in the control group attributed more symptoms to
menopause, reported more sexual problems, and had a
higher prevalence of hormonal replacement therapy than
the participants in the educational program. Ueda (2004)
found significant improvement in menopause symptoms
among women enrolled in an educational and exercise
program. No significant improvement was found in quality of life and attitudes toward exercise.
The literature survey did not reveal studies that examined the impact of psycho-educational programs on all
outcomes: attitudes, perception of symptoms, and the
association between the two. The present research examines the impact of a structured psycho-educational program on womens attitudes toward their menopause, the
perceived severity of their symptoms, and the association
between attitudes and symptoms.

Method
Participants
The sample included 82 healthy married women
(clients of one health maintenance organization) aged 40
to 60 years, whose last period had occurred at least 12
months before the beginning of the study. A maximum
limit was not set. All participants graduated from high
school or had academic degrees. All lived in Israel for
more than 7 years and read and wrote Hebrew. The
research was not limited to women who did not use hormone replacement therapy but excluded women who
started this treatment during the research period. Participants resided in two neighboring towns located in the
northern part of Israel. The populations of the two towns
are similar in terms of socioeconomic status, number of
new immigrants, and cultural diversity. The program was
advertised in the local newspaper, on billboards, and in
the health maintenance organization clinics. Thirty-six
women requested to participate in the program (the
research group). Concurrently, 46 healthy women aged
40 to 60 years were chosen randomly by the directors of
nursing in the two womens health care clinics in these
towns to form the control group. The women in the control group arrived at the womens health care centers
accompanying other patients but not as a response to the
ads concerning the program or to get medical treatment
for themselves. This group did not participate in the
psycho-educational program.
Seventeen women did not fit the inclusion criteria for
the following reasons: menopausal status (3 women), partially filled or missing questionnaires (10 women), not
participating in all meetings of the program (3 women),

March/April 2005

and started hormone replacement therapy during the

research period (1 woman). These participants were not
included in the data analysis.
Twenty-five percent of the participants in the program
and 28.1% of the women in the control group had been
taking hormone replacement treatments, but there were
no statistically significant differences between the two
groups in this or in any of the other research variables at
baseline.

Measures
The Menopause Attitude Scale (MAS; Bowles, 1986).
This semantic differential instrument measures womens
attitudes toward menopause and consists of 20 bipolar
adjective scales (e.g., ugly-beautiful; clean-dirty). Each
scale ranges from 1 (most negative) to 7 (most positive),
with 4, the center position, indicating neutrality toward
both adjectives. Women were asked to mark how, in their
opinion, a woman in menopause felt. Cronbachs alpha
reliability coefficient of the tool was .96. Convergent
validity was demonstrated by r = .63 and a discriminant
validity of r = .42.
The Menopause Specific Quality of Life Questionnaire
(Hilditch et al., 1996). This questionnaire included 29
items assessing vasomotor, physical, psychological, and
sexual problems and general quality of life. The participants were asked to indicate (yes/no) if they suffered from
various symptoms. For each yes mark, they were asked
to indicate the level of disturbance on a scale ranging
from 0 (not at all) to 6 (very much). Test-retest reliability
interclass correlation coefficients were .81 for the physical
domain, .79 for the psychological domain, .70 for the sexual domain, and .55 for the quality-of-life domain. Two
items concerning fast pulse and uncertainty and concern
for the future were added to the measure based on findings from the pilot study.
A personal data questionnaire. Sociodemographic
details were added to examine how the participants fit the
criteria for inclusion in the study: education, age, date of
occurrence of last period, medications, and health habits
such as smoking and physical activity.

Procedures
The program coordinators were nursing directors in
the health maintenance organization, with undergraduate
or graduate levels of education. Before the beginning of
the research, the instructors were trained in interviewing
skills and in the core contents of the program. The coordinators formed four groups of women. Two research
groups (one for each town) consisted of women who were
interested in participating in the program for women in
menopause. Two control groups were also formed, one
for each town, consisting of women who agreed to fill out

JOGNN 235

the questionnaires and did not participate in the program

(the control group).
The program was psycho-educational in nature. It consisted of 10 weekly meetings, 2 hours each. The meetings
took place during early evening hours in health care centers located in the two towns. The program was structured and included information and discussions about
biological and physiological processes as well as psychological, emotional, and social aspects of midlife. Treatments of both conventional and complementary medicine
were pointed out. Menopause as a natural part of life was
emphasized, focusing on factors that prevent illness and
promote a physical, emotional, and social well-being. The
1st hour of each of the meetings was dedicated to the
cognitive level. During this period, professionals from the
medical and paramedical areas presented current information, and the women had the opportunity to raise general questions relating to the issue discussed. The 2nd
hour was dedicated mainly to the social and the emotional aspects. The dynamics within the group were used to
enhance personal awareness and produce the advantages
that a group has in modifying attitudes. Thus, roleplaying and group tasks were used to encourage women
to share their personal experiences with the others. The
participants were encouraged to respond in an empathic,
nonjudgmental way and to give each other feedback, support, and active listening. Throughout the meetings, positive thinking and introspection were encouraged.

Program Outline
1. Introduction and group forming
2. Lecture: The menopausal experience in a sociocultural perspective
Activity: Follow-up discussions and group support
3. Lecture: The menopausal experience from a biomedical perspective
Activity: Follow-up discussions and group support
4. Lecture: Alternative treatments for menopause
symptoms
Activity: Follow-up discussions and group support
5. Activity: Physiotherapy, exercise, and relaxation
6. Facilitated group discussion: Conducting a healthy
life style during menopausediet, physical activity,
personal responsibility for health
7. Lecture: Elder care and the resulting changes within
the nuclear family
Activity: Follow-up discussions and group support
8. Facilitated group discussion: The meaning of midlife
and its impact on need of change, couplehood,
intimacy, and sexuality
Activity: Physiotherapy, exercise, and relaxation
9. Summary, conclusions, and feedback

236 JOGNN

TABLE 1

Correlations Between Attitudes and Perceived

Severity of Symptoms at Baseline in the Total
Sample
Psychological
Symptoms
Physiological symptoms
Psychological symptoms
Social symptoms

.79***

Social
Symptoms Attitudes
.53***
.60***

.36***
.53***
.24*

*p < .05. ***p < .001.

Data were collected in two rounds: The first questionnaire was completed by the research and control groups
separately before the program started. Three months after
the completion of the psycho-educational program, both
groups were invited to attend an event that included a lecture. Here, they were asked to complete the follow-up
questionnaire.

Results
Associations Between Attitudes and Symptoms
Pearson correlations were computed to examine the
linear association between attitudes toward menopause
and perceived severity of symptoms at baseline (before
participation in the program). Table 1 presents the correlations in the total sample. All the correlations were statistically significant. The more negative the attitudes
toward menopause, the higher the perceived severity of all
symptoms: physiological, social, and psychological.
Attitude Change
Table 2 shows the mean scores of participants attitudes at the beginning of the research and at follow-up, as
well as the change scores in womens attitudes after participation in the program. In both groups, there were
higher scores at the end of the research than at the beginning. However, the extent of the change in the research
group was higher than the change in the control group.
Table 3 presents the results of the statistical analysis of
the impact of the program on the participants attitudes
toward menopause. This impact was examined by a twoway analysis of variance with repeated measures (at the
beginning of the program and at follow-up). The independent variables were timing of assessment and type of
group (research and control group). The dependent variable was attitudes toward menopause. The interaction
term (Group Time of Measurement) was examined as

Volume 34, Number 2

TABLE 2

Attitudes Toward Menopause and Change Scores in the Two Groups

Research Group (n = 32)
Beginning
M
SD

5.30
0.99

Control Group (n = 33)

Follow-Up

Change

Beginning

Follow-Up

Change

5.91
1.14

0.61

5.94
1.04

6.05
0.99

0.11

TABLE 3

TABLE 4

Results of Analysis of Variance of Attitudes in the

Different Groups, at the Beginning of the Study
and at Follow-Up
Factor
Time
Group
Time Group

12.2
2.69
5.9

.001
.10
.018

well. There was a significant improvement in attitudes

from baseline to follow-up among all participants (p <
.001), but there were no significant overall differences
between the two groups. However, there was a significant
effect of interaction between the group and time of assessment factors, F(1, 63) 5.90, p < .018. This indicates that
the significant improvement in attitudes toward menopause occurred in only one group.
Changes in the Symptoms
Table 4 shows the mean scores of the perceived severity of the physiological, psychological, and social symptoms at the beginning of the research and at follow-up in
the two groups. In the research group, the perceived
severity of all symptoms was reduced. In the control
group, the perceived severity of the psychological and
social symptoms increased slightly while the perceived
severity of the physiological symptoms decreased slightly.
Table 5 presents the analysis of the changes (shown in
Table 4) in the perceived severity of the symptoms as a
result of participation in the program. Because of the correlations between the severity of the various symptoms, a
multifactor analysis of variance with repeated measures
was conducted to examine the significance of the changes.
The independent variables were time of assessment
(beginning and follow-up) and the type of group (control
or research group). The dependent variables were the
perceived severity of the psychological, physiological,
and social symptoms. The interaction terms were also
examined.
The results indicate that from baseline to the follow-up
measurements, there was a statistically significant overall
reduction in physiological and psychological symptoms
March/April 2005

Perceived Severity of Symptoms in the Two Groups

at the Beginning of the Study and at Follow-Up
Control
(n = 33)
M
Physiological symptoms
Beginning
2.38
Follow-up
2.24
Change
0.14
Psychological symptoms
Beginning
2.27
Follow-up
2.56
Change
+0.29
Social symptoms
Beginning
2.12
Follow-up
2.33
Change
+0.21

Research
(n = 32)

SD

SD

1.06
1.05

2.39
1.67
0.72

0.94
0.92

1.43
1.76

2.37
1.46
0.91

1.64
1.32

1.76
1.67

1.68
0.87
0.81

1.68
1.06

but not in the social symptoms. Overall, the two groups

differed significantly only in terms of the social symptoms
(social symptoms were lower in the research group). All
interactions were significant. This means that there was a
statistically significant reduction of perceived severity of
the physiological, psychological, and social symptoms
only in the research group but not in the control group. In
the control group, the psychological and social symptoms
somewhat increased, but the physiological symptoms
were slightly reduced.

Discussion
Participants in a 10-week psycho-educational program
for menopausal women reported a considerable impact
on their attitudes toward menopause. Three months after
completing the program, the women expressed more positive attitudes toward menopause compared to their own
attitudes at baseline. They felt more confident, stronger,
and more valuable. These results are consistent with
Lemaire and Lenzs (1995) findings that after group counseling, women in menopause experience an increase in

JOGNN 237

TABLE 5

Multivariate Analysis of Variance on the Changes

in Perceived Severity of Symptoms in the Two
Groups
Source of Variation
F(Time)
Physiological symptoms
Psychological symptoms
Social symptoms

F(Group) F(Time Group)

22.15*** 1.5
4.77*
1.95
3.31
7.2**

10.19**
17.36***
9.77**

*p < .05. **p < .01. ***p < .001.

levels of confidence and sense of control. The findings

also indicate that the participants felt more lively, successful, and needed. These findings support Hunter and
Liaos (1995) conclusions that women who participated
in a group program reported an increase in life satisfaction and lower measures of anxiety, depression, and
insomnia.
One of the possible explanations for the improvement
in the participants attitudes toward menopause is based
on the integrative model, or dual-mode processing model
of the processes of persuasion (Petty & Wegener, 1998).
This model suggests that it is impossible to separate cognitive from emotional processes because of the reciprocal
influence existing between emotions and cognitions in
learning processes, decision making, and attitude change.
Thus, when women experience increased quality of life
throughout the program, their attitudes may also
improve.
Actual participation in a supportive group may also
provide a partial explanation to these findings. Yaloms
(1995) theory emphasizes the power of the social group
on modifying attitudes through processing on the socioemotional level. Indeed, this program focused on the cognitive, emotional, and social levels of functioning.
The participants in the research group reported a significant reduction in the perceived severity of the physiological symptoms: hot flushes, nocturnal perspiration,
fatigue, and insomnia. A similar reduction also occurred
in the perceived severity of social and psychological symptoms, such as impatience toward others, rejection of intimacy, and feelings of uncertainty, depression, and anxiety.
The research results also support the findings in
Hunter and ODeas (1999) research, in which the participants in the group received information about
menopause, had group discussions, and learned stress
management skills and in which healthy habits (physical
activity, nutrition, and smoking cessation) were reinforced. It was assumed that the sharing process within the
group contributed to the sense of normalization by which

238 JOGNN

participants realized that other women faced similar difficulties. Participation in the program enabled women to
receive information, empower each other, and reduce
stress levels. During the weekly meetings, women found
relief from the pressures and stresses with which they
struggled by themselves before joining the program. It is
possible that the program had a direct impact on the perception of symptoms through additional mechanisms
such as conveying information, feedback, and relief from
stress.

sycho-educational programs led by nurses

may affect participants well-being and improve
their knowledge and attitudes toward
menopause.

In contrast with the improvement in attitudes toward

menopause in the research group, the positive change
found in the control group was not statistically significant. The small change in this group can be attributed to
the Hawthorne effect, by which the mere participation in
a study may incur some changes in behavior. An insignificant increase was also found in the perception of the
severity of the psychological and social symptoms. It is
possible that the exposure to the questionnaire concerning womens quality of life during their menopause somewhat enhanced awareness of this subject, which may have
caused the women in the control group to be more attentive to their bodies and seek information on the meaning
of menopause. In addition, the women who did not participate in the program were still exposed, as all women
are, to messages embedded in the written and electronic
media and those held by health maintenance organizations, which tend to regard women in the biomedical
approach (Chornesky, 1998; Gannon & Stevens, 1998;
Shoebridge & Steed, 1999). It is possible that mere exposure to such messages is responsible for the more negative
assessment of their symptoms.
Further research is warranted to develop, assess, and
compare the effectiveness of different types of intervention programs. In addition, using a larger sample and a
wider geographical distribution could help separate the
effects of age, use of hormone replacement therapy, and
socioeconomic and demographic status. These variables
may have had significant impact on the results. In addition, it is recommended to extend the research over a
longer period of time as the impact of psycho-educational
programs may decline over time.

Volume 34, Number 2

psycho-educational program on
menopause may be used either as a sole
therapeutic tool or as adjunct to other
therapeutic measures.
The present findings support the claim that although
hormonal and alternative treatments are still under medical debate and the percentage of women using them regularly remains low, the nursing team has the potential to
influence the quality of life of women in menopause
through modifying their attitudes toward menopause.
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Mina Rotem, RN, MA, is in the Department of Nursing, School

of Health Professions, Faculty of Medicine, Tel-Aviv University, Israel.
Talma Kushnir, PhD, is in the Department of Nursing, School
of Health Professions, Faculty of Medicine, Tel Aviv University, Israel.
Ruth Levine, PhD, is in the Department of Health System Management, Emek Yezreel College, Israel.
Mally Ehrenfeld, RN, PhD, is in the Department of Nursing,
School of Health Professions, Faculty of Medicine, Tel-Aviv
University, Israel.
Address for correspondence: Mina Rotem, RN, MA, Department of Nursing, School of Health Professions, Faculty of Medicine, Tel-Aviv University, P.O. Box 39049, Tel-Aviv 69978,
Israel. E-mail: mina_rotem@yahoo.com.

Volume 34, Number 2