Menopause: a Qualitative Study of Women’s Perception in the Monteverde Region

Menopause: a Qualitative Study of  Women’s Perception in the Monteverde Region

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Menopause: a Qualitative Study of Women’s Perception in the Monteverde Region
Translated Title:
La menopausia: un estudio cualitativo de la percepción de las mujeres en la region de Monteverde
Lopez, Bernice K. McGinnis, Kara Gottfredson, Lauren Valenti, Michaela Fish, Nathalie
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Women--Health ( lcsh )
Health--Education ( lcsh )
Menopause ( lcsh )
Costa Rica--Puntarenas--Monteverde Zone ( lcsh )
Costa Rica--Puntarenas--Zona de Monteverde
Community Health 2010
Salud Comunitaria 2010
Reports ( lcsh )


The report describes how women in two towns of the Monteverde region of Costa Rica view menopause, its relationship to aging and what educational and traditional resources are available for women in menopause.
El informe describe como las mujeres en dos pueblos de la region de Monteverde en Costa Rica, ven la menopausia, su relacion con el envejecimiento y ven que recursos educativos y tradicionales estan disponibles para las mujeres en la menopausia.
Text in English.
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M38-00025 ( USFLDC DOI )
m38.25 ( USFLDC Handle )

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Lopez, Bernice K. McGinnis, Kara Gottfredson, Lauren Valenti, Michaela Fish, Nathalie
La menopausia: un estudio cualitativo de la percepcin de las mujeres en la region de Monteverde
Menopause: a Qualitative Study of Womens Perception in the Monteverde Region
c 2010-08
Born Digital
3 520
The report describes how women in two towns of the Monteverde region of Costa Rica view menopause, its relationship to aging and what educational and traditional resources are available for women in menopause.
El informe describe como las mujeres en dos pueblos de la region de Monteverde en Costa Rica, ven la menopausia, su relacion con el envejecimiento y ven que recursos educativos y tradicionales estan disponibles para las mujeres en la menopausia.
Text in English.
Costa Rica--Puntarenas--Monteverde Zone
Costa Rica--Puntarenas--Zona de Monteverde
Community Health 2010
Salud Comunitaria 2010
t Monteverde Institute : Community Health
M38-00023, Qu es la
Un librito sobre menopausia; M38-00024, Menopausia; M38-00026, Menopause : a qualitative study of womens perceptions in Santa Elena and San Luis
i Related document;


Menopause: a Qualitative Study of WomenÂ’s Perception in the Monteverde Region Bernice Lopez Kara McGinnis Lauren Gottfredson Michaela Valenti Nathalie Fish Globalization and Community Health Field School 201 0 Faculty and Staff Dr. David Himmelgreen Dr. Nancy Romero-Daza Patricia Jimnez Jenny Pea Daniel Vargas Charlotte Noble


INTRODUCTION Menopause is a stage in a woman’s life that has imp lications for both health and social roles. As such, menopause is culturally constructed in dif ferent societies with different understandings of symptoms and coping strategies. Many menopausal sym ptoms are attributed to biomedicine and modern lifestyles. It is thus important to examine the cultural constructs of menopause in daily lives especially with the increasing connections of globa lization. Our objective is to determine how women in two towns of the Monteverde region of Cost a Rica view menopause, its relationship to aging and what educational and traditional resource s are available for women in menopause. This is especially intriguing in Costa Rica, where the univ ersal health care system is internationally acclaimed. However, this system has its challenges and thus it is important to investigate what the system offers women in terms of knowledge and treat ment of menopause. As community health researchers, we want to understand menopause from w omen’s points of view and provide information to help women if we find that it is nee ded. Our research takes place in the Monteverde zone in Costa Rica, a region known for its beautiful cloud forest. We focus on an urban town, Santa Elena, and a rural town, San Luis. Both are developing towns that have been affected by globali zation, especially through the tourism industry. We partnered with a community group, the Monteverde Institute, to help us integrate into the community. Additionally, we lived in homestays to b ecome culturally immersed and to know the people more intimately. LITERATURE REVIEW Defining menopause in the literature has been diff icult. Medically, menopause is considered to be the specific moment when menstruation ceases (Locklear et al. 2008; Leidy Sievert 2006; Lock and Kaufert 2001); however, to many women menopause is a longer period of hormonal change and irregular menstruation patterns (Locklear et al. 20 08; Leidy Sievert 2006; Lock and Kaufert 2001). Investigators looking into how women approach and d eal with menopause have found varying cultural understandings of menopause that are great ly affected by culture, class and social setting. For example, Lock and Kaufert (2001) found signific ant differences in symptom occurrence in a comparison study of Japanese, Canadian and US women (See APPENDIX A). Additionally, rural Mayan women see menopause as a natural process to b e treated with herbs and teas, and they report fewer and less severe symptoms than women in urban areas of Mexico and Guatemala and in the US (Locklear et al. 2008). Also, middle class women in the US, while having negative symptom experiences, view the overall process as a positive aging event that ushers in a period of less sexual responsibility, more confidence and new social resp onsibilities that generally equated to more freedom (Dillaway 2005). Thus, this period of aging referred to medically as “perimenopause” and in some cultures as “climacteric,” has different so cial, physical and medical implications for women based on their culture. Few studies have looked at menopause in Costa Rica Locklear et al. (2008) noted that Costa Rica is an interesting case study, as it has a univ ersal health care system, a focus on women’s health and high education rates. Costa Rica is also reachi ng its epidemiologic transition, including increasing cardiovascular diseases, obesity and cha nging lifestyles. This is interesting, as there is evidence that the medical risk factors associated i n biomedicine with changes from menopause, like osteoporosis, might actually be more associated wit h lifestyle and environment than medical illness (Locklear et al. 2008; Lock and Kaufert 2001). Thus looking at how women in Costa Rica experience menopause is an important addition to th e literature as well as an opportunity to inform women in Costa Rica of what menopause is and how th ey can alleviate symptoms medically and traditionally in the context of a changing society.


METHODS In order to determine how women understand menopau se in Costa Rica, as well as what they know and want to know, qualitative data was collect ed through structured interviews and focus groups. Structured interviews were conducted with 2 7 women 20 to 81 years of age living in rural San Luis, Monteverde region during a Feria de Salud a Health Fair, organized by the researchers and their colleagues. Interviews collected occupati on, education level, religion and age and consisted of four questions (See APPENDIX D, E, and H). There were two different interview guides, one for the theme edad age (n=14), and one for menopausia menopause (n=13). These interviews allowed us to collect preliminary data on how women in San Luis, view menopause, aging, their relationship, and how women alleviate symptoms. Two focus groups were done after the preliminary d ata. The first group consisted of premenopausal and perimenopausal women and the seco nd group consisted of solely postmenopausal women. The groups were conducted in Spanish by a n ative Spanish-speaking researcher, while a second researcher took notes. The focus groups were also audio recorded to aid translation. The questions assessed what these women currently know, what they expect, how they find out about menopause and how to relieve or cope with menopausa l symptoms. The questions for the second group also asked specific experiences these women h ad with menopause, and what information or treatments they would have liked in retrospect (See APPENDIX F, G and I). RESULTS Structured Interviews: Women in San Luis ranged from ages 20-81. In regard s to aging, women under 55 thought it was a normal process while midd le aged women, 55-65 years of age, were unhappy about aging and expressed it as “getting ol der and that the years are passing by.” Women over 65 agreed that it was normal, added it is “Un tiempo de experiencia y un tiempo de preocupaciones” (a time of more experiences and more worries). When the same women were asked to list the changes that signify aging, younger wom en listed physical changes like whitening of hair, wrinkles and loss of energy. Older women included b oth physical and emotional responses often based on their own experiences. These included an i ncrease in sickness, pain, wrinkles, a lack of appetite, not being able to work as hard and less s exual desire. In the “menopause” survey, we did not find age diff erences in defining menopause, but we did in the knowledge of symptoms. Five of the 13 wo men defined menopause by symptoms like “calores” (hot flashes) and “frios” (chills). Other women used medical terms, such as t he women that said that menopause is the loss of menstruatio n and a change in hormones. When listing changes that indicate menopause, women over 39 listed hot f lashes and chills, irregular menses, bleeding, body pain and sicknesses. Women younger than 39 did not express knowledge of the topic, commenting “I haven’t experienced it yet, so I don’t know much .” During an Illness Recall activity at the Health Fair, women 40 to 60 reported feeling similar symptoms to women in Japan, US, and Canada (Lock and Kaufert 2001; APPENDIX A). Regardl ess of whether these symptoms can be attributed to aging, menopause or lifestyle, women in San Luis are feeling symptoms of ill health similar to women in other countries who are the sam e age. Questions three and four were asked to all women an d answers did not vary based on the first two questions. Twelve women, most under 40, said th at menopause and aging are different. As one woman said, “Menopausia es una etapa… el envejecer es continual ” (Menopause is a stage…aging is continual). Another twelve, almost all over 40, believe menopause and aging are the same, one claiming, “porque es la entrada a la edad mayoridad, este mo mento no le da la menstruacin” (Because it’s the entrance of old age, this moment when you don’t have menstruation). The remaining three women were unsure and there was no real correlation between those three women’s ages. It is important to note that younger women an d older women again had different responses,


perhaps reflecting those who are already personally knowledgeable about menopause and aging, and those who have yet to experience these stages. Seven of the 27 women surveyed expressed that they did not know how to answer “What do women do in response to menopause?” All of these wo men were under 50 years old. Some ways women reported to alleviate symptoms were walking, sleeping and just waiting to pass through it. It is apparent that younger women have only limited kn owledge of menopause, and in regards to specific symptoms and alleviation of symptoms they report having no knowledge. Older women, those of ages where it is likely they have experien ced menopause, are more knowledgeable about symptoms, and are able to tell personal techniques they and their friends used for alleviating symptoms. The difference in knowledge between women who have experienced menopause and those that have yet to go through it needs to be ex plored further. Focus Groups : Focus groups were used to get a more in-depth und erstanding of how women understand, learn about and alleviate menopause sym ptoms, as well as what information might be lacking in the community. Our questions were design ed after looking at the interviews. Our first group was four perimenopausal and three premenopaus al participants (n=7) and our second group was four postmenopausal participants (n=4). There w ere not many differences between responses of women in each group, and future research will have to include more premenopausal women to determine what women really know before they begin the experience. First, we further clarified “What is Menopause?” Li ke our San Luis informants, the focus group participants noted medical definitions such a s, “cuando la menstruacin para,” (when the menstrual cycle stops) and “hay cambios en las hormonas ” (hormones change); symptom definitions like, “tener calores y fros,” (to have hot flashes and chills) and a few women as sociated it with natural life changes, “Cambios en la salud y la vida que son inevitables” (changes in the health and life are inevitable). However, a common theme was c onfusion around when menopause starts and its duration. One woman’s concern was that “ No s cuando la menopausia comienza y cuando termina…siento que muchas mujeres no saben…y debemo s de tener informaccin sobre eso ”(I don’t know when menopause starts and finishes…and feel ma ny women don’t know…we should have information regarding this). In relation to aging, women in the focus groups gen erally separated menopause and aging, explaining that aging was longer and menopause was more specifically associated with menstruation and symptoms like hot flashes. “ Menopausia es una etapa y el envejecer es un proces o continuo” (menopause is a stage and aging is a continual proc ess). Yet as the woman above mentioned, menopause and aging are inevitable changes, and one woman exclaimed, “ Tener la menopausia significa ser viejo” (to have menopause means to be old). Thus, there ap pears to be no culturally accepted relationship between the two and may refle ct age. Women generally learned about menopause through the education system, from their own mothers or by accident. What they learned about was not uniform. For example, one woman explained, “Mi mam y yo tenamos una relacin abierta y ella me contaba todo lo que me esperaba” (My mother and I have an open relationship and she told me all I wished to know), while another simply said, “ Mi mam describa los calores y sangrados” (My mom would describe hot flashes and bleeding). Most women knew of women who learned about menopause thought they were pregnant. “Cuando fui al doctor y pens que estaba embarazada lo que realmente tena era la menopausia” (When I went to the doctor and I thought I was preg nant, actually I had menopause). Unfortunately, women reported that doctors at the EBAIS (public clinic) do not supply premenopausal women with information. A visit to th e clinic confirmed that no literature was available. Some women also reported that a private gynecologist discusses menopause more than the public doctors, but women need to actively seek the information. Menopause symptoms reported by our participants we re similar to symptoms found in Western countries and included hot flashes, chills, stress, irregular periods, worries, bad moods, lac k


of sex drive and pain in the ovaries. An additional symptom described by many women was hemorrhages, or heavy periods, which occur during t he irregular menstruation period. Women reported emotional symptoms such as, “Prefiero quedarme en la casa” (I prefer to stay in the house), “Me precupo ms por mi familia” (I worry more for my family), and “Ya los platos ya estn guardado” (The plates are put away) – referring to a lack of sex drive. More research is needed to investigate the occurrence and duration of symptoms in women of this region, and if they vary based on rural or urban lifestyles, diets, occupations, o r habits. Women also described how they alleviate symptoms. Techniques that emerged included taking estrogen pills, natural supplements, teas li ke chamomile, eating more vegetables and fruits, soaking feet in hot water, waking, running and exer cising more, joining women’s groups and getting hobbies. These individual coping mechanisms could p rovide examples for others, and women liked talking about their own methods. Using their favori te foods we organized a chart explaining which foods help which symptoms (See APPENDIX B). Many wo men expressed gratitude to get the opportunity to discuss menopause with other women. This need for a space to talk could be fulfilled by women’s organizations, groups at the clinic, or other creative ways women come up with. Finally, women discussed how menopause affects rela tionships. A few women commented that they had “una relacin muy bonita” (a beautiful relationship) where they and their hus bands talked about issues. But other women expressed loca l beliefs such as women “ya no sirven para nada” or become useless after menopause. Another joked t hat, “ya se sac todo el motor,” (they already took out my motor). Women also reported tha t there were men locally known as “viejos verdes” (green old men) who are older men who leave their wives to date you nger women. Finally, a woman said that this was a time of increased divorc es and relationship change. When discussing how some couples fight for years and that children move out around the time menopause starts, one said, “Cuando no hay ms hijos, no hay nada que los manti enen unidos” (When there are no more children, there is nothing to maintain [couples] to gether). While this was attributed to the time peri od of menopause, this seems to reflect underlying fami ly issues that emerge during this period of change in life. One tip a woman gave for having a better r elationship with her husband, was that they each found activities that they enjoyed doing separately and it enabled them to have their own spaces. Looking at changing relationships as couples’ age i s a potential topic for important future research. Women expressed what they hoped to see in the futur e. This included receiving information about menopause younger, having information availab le at the clinic, and having more women’s groups unite women who share interests and provide a place to create and talk. DISCUSSION From our assessment of menopause in Monteverde, Co sta Rica, it is apparent that menopause is a confusing time period for women and a topic th at remains taboo to discuss. For most women, their first introduction to menopause is when they begin to experience symptoms, and most women cannot discuss menopause well until they are going through it. Although women turn to family members or doctors for answers, the education is li mited and often reserved for women who actively seek it. In the meantime, women have found many per sonal ways to cope with negative symptoms, including trying to be healthier, enjoying personal time and seeking natural remedies. In Monteverde, while some women reflected that menopause was natur al and expected, it is still a time of uncertainty, new social roles and lifestyle changes Thus, women expressed a desire for more information for women before, during, and after men opause to better prepare for and deal with symptoms. They hoped to learn more about how to all eviate symptoms, talk with their family and be healthier in general. As one focus group participan t expressed, “la juventud est en el corazn no en la piel o nada ” (your youth is in your heart not your skin or any thing else); adopting this attitude may be the best prevention of negative aging and menopa usal symptoms available to date. Breaking through the taboo of talking about menopause might provide women with the opportunity to more


openly discuss how they are feeling as well as give them courage to discuss what is going on with their families. While it is difficult at this stage in research to discuss the implications that globalization and changing lifestyles and attitudes are specifically having on womenÂ’s perceptions of aging and of symptoms, it will be interesting to fo llow-up and see how these changes are influencing womenÂ’s experiences of menopause and aging both neg atively and positively. CONCLUSION Due mainly to time constraints, there were many lim itations to our investigation. First, our samples were small and not representative of the co mmunity as a whole, as most women were involved with the Institute. Language barriers prev ented some investigators from taking part in the interviews and focus groups. Also, the young age of the researchers and the lack of anonymity between focus group participants may have hindered women from feeling comfortable. As preliminary researchers into the topic, it was diff icult to know immediately if we could ask women certain questions and some questions had to be rewo rded to better help some women understand the questions. However, despite the short length of tim e, we believe the research we were able to conduct is great preliminary data of womenÂ’s experiences of menopause in Monteverde, Costa Rica. We hope this data can provide the framework for additional research. Important themes would be occurance and severity of symptoms in urban and rural women, a better understanding of younger womenÂ’s impressions of menopause, and a better understandin g of how women talk to each other and spouses about personal issues. Also, Akahoshi et al. (2002) found a positive correlation between high body mass index (BMI) and later age of menopause in Japa nese women. As BMIs in Costa Rica have been increasing (Locklear et al. 2008), seeing if there is a correlation between BMI and menopause onset in Costa Rica would be interesting. Future research could also explore further womenÂ’s sexual wishes, problems, and changes during this time of t heir lives. In conclusion, we found that menopause is somethin g that women in Monteverde go through fairly quietly and unprepared for. Many things cont ribute to this including a lack of available educational materials, misconceptions about what is normal or not normal for a woman going through menopause, no discussion of the topic befor e women begin menopause and the lack of an available public space where women feel comfortable discussing and learning about menopause. Because of the taboo nature of menopause in Monteve rde, many women are left with confusion about how to deal with this period of life medicall y, socially, and personally, especially younger women. However, women have successfully found indiv idual solutions for alleviating menopausal symptoms and for finding answers. We recommend the following: doctors should bring up menopause with women before they begin to have symp toms, resources need to be available in the clinics that are both culturally competent and low literacy, more womenÂ’s groups need to be available with different activities, resources need to be developed to aid women in discussing menopause and its effects with family members and s chools should educate students on the entire reproductive history of women and men. In order to help women learn about the change s that they can expect or what to do while they are going throu gh changes, we have created a mini book. In it a woman entering menopause talks with friends, doctor s, and herbalists to learn about how she can alleviate menopause symptoms and find answers to he r questions. Some suggestions are modifying the womanÂ’s diet, exercising more, creating persona l time to relax and enjoy hobbies and talking with friends, family, and medical professionals whe n they feel confused or overwhelmed. We hope that this research provides a foundational understa nding of how menopause is lived in the Monteverde region of Costa Rica, and that it provid es an example of what people can due to increase womenÂ’s competency when going through menopause and major life changes. By increasing womenÂ’s knowledge of local resources and local reme dies, women can be empowered to make healthier choices and successfully navigate an unpr edictable time in their lives.


LITERATURE CITED Akahoshi, M., Soda, M., Nakashima, E., Tominaga, T. Ichimaru, S., Seto, S., Yano, K. (2002). The Effects of Body Nass Index on Age at Menopause. International Journal of Obesity 26(7):961-968. Center for Disease Control and Prevention. “Women's Reproductive Health: Menopause.” July 01, 2009. nsRH/Menopause.htm (accessed July 12, 2010) Dillaway, H. E. (2005). Menopause Is the "Good Ol d": Women's Thoughts about Reproductive Aging. Gender and Society 19(3): 398-417. Fries, W. C. “8 Natural Ways to Ease Menopause Symp tom.” 2003. -to-ease-menopause-symptoms. (accessed July 12, 2010). Herbal “Menopause and Exercise.” htt p:// (accessed July 12, 2010) Lock, M. and Kaufert, P. (2001). Menopause, Local Biologies, and Cultures of Aging. American Journal of Human Biology 13(4):494-504. Locklear, T. D., Doyle, B. J., Huang, Y., Perez, A. L., Caceres, A., Mahadyl, G. B. (2008). Menopause, A Universal Female Experience: Lessons f rom Mexico and Central America. Current Womens Health Reviews 4(1):3-8. “Menopause and Hormonal Changes.” (accessed July 12, 2010) Sievert, L. L. (2006). Menopause: A Biocultural Per spective. Introduction (pp. 1-31) and Methods of Study (pp. 49-81). Rutgers University Pr ess: New Brunswick, NJ


APPENDIX A: Menopause Symptoms Symptom Japan Canada USA Costa Rica Diarrhea/Constipation 24.5 12.8 21.4 45.4 Upset Stomach 6.3 5.2 10.1 45.5 Shortness of Breath (Difficulty Breathing) 3.1 8.2 15.6 36.4 Sore throat 10.5 9.1 10.7 36.4 Backaches 24.2 26.8 29.6 54.4 Headaches 27.5 33.8 37.2 90.9 Aches/Stiffness in joints (Muscle Aches) 14.5 31.4 38.6 27.3 Dizzy spells 7.1 12.3 11.1 27.3 Lack of Energy (tiredness) 6.0 39.8 38.1 72.7 Irritability 11.5 17.1 29.9 27.3 Feeling blue/depressed (cry, little interest, boredom) 10.3 23.4 35.9 54.5 Lack of appetite 4.6 4.0 5.4 18.2 Hot flashes 12.3 31.0 34.8 45.5 Total People 1,225 1,307 7,802 11 N=11 DOB between 1950 and 1970 (ages 39.5-59.5) as oppos ed to ages 45-55 Questions asked for last 30 days, as opposed to 2 w eeks Not asked specifically in regards to menopause, but illness recall in general APPENDIX B: Menopause Diet Recommendations Foods Contains Alleviates Symptom Chamomile Tea Isoflavonoids Ne rvousness, tension, fatigue Avocados Vitamin E Hot flashes and night sweats Bananas Vitamin B6 Hormone Imbalance and fatigue Soya Phytoestrogens Hot flashes Bee Pollen Vitamin B1 Hot flashes Flaxseed Omega-3 Fatty Acid Joint Pain Spinach and Broccoli Calcium Bone Density Loss Milk, Yogurt, Cheese Calcium Bone Density Loss Fruits, Vegetables and Whole Grains Fiber Digestive Issues


nEvening Primrose Oil Omega-6 Fatty Acid Depression and fatigue Eggplant, rice, corn, shrimp, almonds, beans, spinach Magnesium Anxiety, insomnia, irritability Sweet red pepper, oranges, cooked cabbage, tomato, spinach and broccoli Vitamin C Hormone Imbalance and collagen loss Eggs, Canned Salmon Vitamin D Bone Density Loss


APPENDIX C: Consent Form Somos estudiantes del curso de Salud del Instituto Monteverde y estamos realizando un proyecto sobre ___________ Nos gustara hablar con Ud. sobre este tema. Si U d. est de acuerdo en participar, le haremos una entrevista que durar ap roximadamente 30 minutos (o tomar parte de una discusin de grupo, que durar aproximadamente una hora). La informacin que recojamos ser usada para el proyecto final del curso, y pres entaremos los resultados a la comunidad y al Instituto. Sin embargo, queremos asegurarle que no usaremos su nombre ni ningn otro dato que permita identificar sus respuestas. Sus opiniones s on muy importantes para nosotros y esperamos que se sienta cmodo/a compartindolas con nosotros . Su participacin en este proyecto es completamente voluntaria, y puede dejar de participar cuando Ud. quiera. Desafortunadamente, no podemos d ar ningn pago por la participacin. El participar en este proyecto no implica ningn riesg o fsico o emocional para Ud., sin embargo, es posible que Ud. se sienta incomodo/a al hablar de a lgunos temas. Si este es el caso, Ud. tiene derecho a no contestar esas preguntas. Este curso se lleva a cabo bajo la coordinacin de Jenny Pena del Instituto Monteverde. Si tiene alguna pregunta sobre el proyecto, por favor comun quese con ella al 2645-5053; ____ Certifico que he ledo o me han ledo esta inf ormacin y que estoy de acuerdo en participar. ____________________________ ____________________ ________ __________ Nombre Firma Fecha (Remember that you could just ask the respondent to mark with an X instead of signing, but in that case, you also need a witness) Affirmation of the Investigator I have carefully explained to the participant the m eaning of the above document. I affirm that to my best understanding, the signed participant under stands the nature, expectations, risks and benefits associated with participating in this stud y. ____________________________ __________ Signature of Investigator Date


APPENDIX D: Age Questionnaire Interviewer:___________________ Hola. Soy una estudiante de los Estados Unidos, y e stoy trabajando con el Instituto Monteverde. Vamos a hacer un proyecto sobre la salud de las muj eres, y queremos aprender un poco ms. Puedo preguntarle unas preguntas para aprender ms? No necesita contestar nada que no quiera. [Hi. IÂ’m a student from the US, and IÂ’m working wit h the Monteverde Institute. WeÂ’re doing a Project about womenÂ’s health, and we want to learn more. May I ask you questions to learn more? You donÂ’t need to answer anything you donÂ’t w ant.] Qu significa la el envejecimiento para las mujere s en el rea de Monteverde? [What signifies aging for women in the Monteverde area?] Por favor, liste todos los signos que usted puede p ensar que indican que una mujer envejece. [Please list all of the signs you can think of that indicate a woman is aging.] Las mujeres aqu consideran la menopausia y el enve jecimiento la misma cosa? [Do women consider menopause and aging the same thing?] Cul es su edad? _______________ Cul es el ltimo ao de su educacin? ____________ Cul es su religin? _______________ Cul es su ocupacin? _____________


APPENDIX E: Menopause Questionnaire Interviewer:___________________ Hola. Soy una estudiante de los Estados Unidos, y e stoy trabajando con el Instituto Monteverde. Vamos a hacer un proyecto sobre la salud de las muj eres, y queremos aprender un poco ms. Puedo preguntarle unas preguntas para aprender ms? No necesita contestar nada que no quiere. [Hi. IÂ’m a student from the US, and IÂ’m working wit h the Monteverde Institute. WeÂ’re doing a project about womenÂ’s health, and we want to learn more. May I ask you questions to learn more? You donÂ’t need to answer anything you donÂ’t w ant.] Que es la menopausia para una mujer en la regin de Monteverde? [What signifies menopause for women in the Monteverde area?] Por favor liste todos los signos que usted puede p ensar que indican que una mujer est llegando a la menopausia. [Please list all of the signs you can think of that indicate a woman is having menopause.] Las mujeres aqu consideran la menopausia y el enve jecimiento la misma cosa? [Do women consider menopause and aging the same thing?] Cul es su edad? _______________ Cul es el ltimo ao de su educacin? ____________ Cul es su religin? _______________ Cul es su ocupacin? _____________


APPENDIX F: Focus Group Question: Premenopausal and Perimenopausal Women Qu es la menopausia? What is menopause? (Probe: Que sabe usted acerca de la menopausia? W hat do you currently know about menopause..when doe s it occur, when does it stop?) Cuales son algunas de las experiencias que Ud. Han oido de otras mujeres que tienen o estan pasando por la menopausia? What are some of the experiences that you have hear d from other women (familial or non-familial) who have/or are go ing through menopause? Ustedes quieren llegar a la menopausia? Are you looking forward to menopause? (Probe: En caso afirmativo, por que? Si no, por qu no ? If yes, why ? If not, why not? Han visto o saben de informacion disponible sobre la menopausia? Have you seen or know of any available information about menopause? Que informacion especifica les gustaria ver en un folleto sobre la menopausia dirigido a mujeres como ustedes que todavia no han pasado por eso? What specific information would you like to see in a brochure regarding menopause for women like yourselves who have yet to go through it? Ustedes cual creen que sea la manera mas efectiva de dar informacin sobre la menopausaid a mujeres de su edad? What do you think is the most effective way to rela y information regarding menopause to women of your same age? Qu les gustara a Ustedes que fuera el producto f inal de este proyecto? What would you wish to see come out of this project ? (Flyer form, poster form, womenÂ’s group) Hay algo mas que quieran decir sobre la menopausia ? Is there anything else that youÂ’d like to know abou t menopause? Tienen preguntas para mujeres que ya pasaron por la menopausia? Do you have any questions for women who have alread y gone through menopause?


APPENDIX G: Focus Group Question: Postmenopausal Wo men Qu es la menopausia? What is menopause? (Conversation—probing is it a pa rt of aging/symptom) when does it occur…. when does it stop? Cunto sabias ustedes acerca de la menopausia ante s de que les empezara? (Probe: Dnde aprendieron eso?) How much did you know about menopause prior to star ting it? (Probe: Where did you learn that from? E.g. from mother/sisters/family?(were you tau ght or did you just observe) Como le describirian Ud. la menopausia a una mujer que todavia no lo ha tenido? How would you describe Menopause to a woman who is not going through it yet? Que hizo para aliviar los sintomas? Por ejemplo pl antas o hierbas, remedies naturales, etc.? (Probe : Hay algo que les hubiera gustado tener di sponible?) Was there anything you did or used to alleviate sym ptoms? For example plants/herbs/natural remedies? (Probe: Was there anything you wish you h ad?) Hay algun consejo que le puedan ofrecer a las muje res que estan pasando por la menopausia? (Probe: Que funcion para ustedes, Que han aprend ido a travs de esa experiencia?, Cree usted que la menopausia afecta/o afecto a su famili a (si es as por qu / por qu no?) Is there any advice you can offer to women who are going through menopause? Ustes creen que la menopausia afecta/ a su familia (si es asi por que/ por que no?) Do you feel that menopause affected your family (if so why/why not)? Ustedes como creen que vaya ser la experiencia de l as mujeres que apenas se estn acercando a la menopausia, ser parecida o diferente a las expe riencias de ustedes? Por que? What do you think will be like the experience of wo men that are just approaching menopause, will it be similar to or different from your experi ences? Why? Qu le gustara a ustedes que fuera el producto fi nal de este proyecto? What would wish to see come out of this project? (F lyer form, poster form, women’s group) Ya hablamos con unas mujeres que ya no han llegado a la menopausia. Como las contestan Uds. Estas preguntas? We already spoke to some women who have not gone th rough menopause and they have some questions. How would you answer these?


APPENDIX H: San Luis Participant Demographics Identification Age Religion Highest Education Occupation 1 65 Catholic None Housewife 2 81 Catholic None Housewife 3 63 Catholic 2nd Housewife 6 20 Evangelical University Housewife 8 39 Catholic 6 th Housewife 9 35 Evangelical 6 th Housewife 10 55 Catholic 3 rd Housewife 11 63 Catholic None Housewife 12 ---------------------Catholic None Housewife 13 59 Catholic 4 th Housewife 15 29 Mormon University Group coordinator 17 30 Catholic 6 th Housewife 19 45 Mormon None Monteverde Institute Staff 20 24 Catholic 5 th Housewife 21 26 Catholic 6 th Housewife 22 66 Evangelical 6 th Cook 23 45 Catholic 6 th Housewife 24 74 Catholic None Housewife 26 26 Catholic 6 th Store 27 61 Catholic None Housewife 28 68 Evangelical None Housewife 31 56 Catholic 5 th Housewife 33 39 Catholic 6 th Housewife 34 41 Catholic 6 th Housewife 36 34 Catholic 6 th Housewife 45 55 Catholic 3 rd Housewife 46 46 Catholic 6 th Works for University of Georgia


APPENDIX I: Focus Group Demographics Focus Group 1 Participants: Identification Age Religion Highest Education Occupation 1 48 JehovahÂ’s Witness Sixth grade Tourism 2 49 Catholic Sixth grade Housewife 3 50 Catholic Twelfth grade Housewife 4 44 Catholic Sixth grade Housekeeping at a hotel 5 40 Catholic University (BachelorÂ’s degree) Hair Stylist 6 42 Catholic Third grade Housewife 7 41 Christian University Research coordinator Focus Group 2 Participants: Identification Age Religion Highest Education Occupation 1 53 Catholic Tenth grade Housewife Artesian Administrator 2 52 Catholic Twelfth grade Housewife Artesian 4 63 Evangelical No school Housewife 7 50 Catholic University (BachelorÂ’s degree) Artesian Costume maker in CASEM Coop 6 41 Christian University Research coordinator


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