Health Education Research, Vol. 14, No. 6, 817-830,
December 1999
© 1999 Oxford University Press
Effects of an educational programme on adolescents with premenstrual syndrome
Department of Nursing, Sino Building, Chung Chi College, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
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Abstract |
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An education program was developed and evaluated to determine its efficacy in increasing knowledge and decreasing the severity of symptoms of premenstrual syndrome (PMS). Participants from a sample of 94 schoolgirls aged between 14 and 18 years from four secondary schools in Hong Kong were assigned to either the experimental or control group. Immediately following the education program, the schoolgirls in the experimental group had significantly increased knowledge scores as measured by the Premenstrual Syndrome Knowledge Questionnaire. Three months following the education program, schoolgirls in the experimental group reported having a significant reduction in total PMS scores and three of the subscale scores as measured by a translated version of Abraham's Menstrual Symptom Questionnaire. In addition, no significant differences were found for the control group on pre-test and post-test PMS scores suggesting that the education program could have been the source of the reduction in PMS symptoms of the experimental group of young adolescents girls.
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Introduction |
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Premenstrual syndrome (PMS), which occurs 7–14 days before the onset of menstruation and subsides with the commencement of menstrual flow, affects women during their reproductive age, and is associated with physical, psychological and behavioral changes (Reeder and Martin, 1987
). More specific approaches to defining PMS are based on the clustering of symptoms as reflected in the various instruments for measuring PMS. Moos (Moos, 1968) developed the Menstrual Distress Questionnaire (MDQ) which categorizes 47 perimenstrual symptoms into eight scales including pain, water retention, negative affect, autonomic reaction, impaired concentration, behavioral change, arousal and control. Abraham (Abraham, 1983) modified Moos' MDQ and included only the 19 symptoms that were found to have the greatest changes premenstrually. Thus Abraham's Menstrual Symptom Questionnaire (MSQ) had four common subgroups of PMS: PMT-A consisting of behavior changes, PMT-H associated with symptoms of water and salt retention, PMT-C characterized by craving, and PMT-D includes symptoms of depression. The Premenstrual Assessment Form (PAF) developed by Halbreich et al. (Halbreich et al., 1982) comprises 95 symptoms which are grouped into premenstrual physical, mood and behavioral changes. Eighteen categories could be identified including major and minor depression, withdrawn, agitated/anxious, irritable, hostile, impulsive, increased well-being, general discomfort, water retention, fatigue, autonomic physical, impaired social functioning, and organic mental features.
The reported prevalence of about 20–40% shows that a significant group of women may be affected by PMS (Logue and Moos, 1986). Reports of PMS among adolescents in Western countries indicate a prevalence ranging from 14 to 30% (Hargrove and Abraham, 1982; Raja et al., 1992). Some of the PMS symptoms may create serious negative consequences for the adolescents, their families and their social relationships, including low self-esteem, low tolerance to stress and feelings of inadequacy (Halas, 1987; Wilson and Keye, 1989). The consequences necessitate the development of effective educational programs and their implementation to facilitate the adolescents' learning to control their PMS symptoms, rather than letting the symptoms control them (Milius, 1988).
Few studies have been reported in relation to PMS experience in Chinese women of any age. PMS has been studied in a group of 153 secondary school students in Hong Kong (
= 15.21 years) where the prevalence rate was 19% (Chau et al., 1998). In adults, 92% of the Chinese women (n = 86) were found by Chang et al. (Chang et al., 1995) to experience some PMS symptoms as compared with approximately 40% in Moos's (Moos, 1991) study of English-speaking women. Fatigue was found to be the most prevalence physical symptoms and pain also featured highly in Chang et al.'s study.
In a study that examined the association between tea consumption and PMS in China by Rossignol et al. (Rossignol et al., 1989), for 124 nursing students aged between 15 and 33 years ( = 22.3 years), the most common symptoms reported were breast swelling and tenderness (51%), tiredness (49%) and anxiety (34%). In Chinese medicine, not much has been reported that specifies the treatment or intervention for PMS. Chinese herbs like Chinese Angela roots, Rehmannia = Radix et Rtizoma Rehmanniae and Placenta Hominis that contain zinc, copper and iron are frequently cited and used as menses-regulating drugs (Liu et al., 1985).
In Hong Kong, about 10% of the secondary schools were found to have no sex education on the topic of menstruation (The Family Planning Association of Hong Kong, 1989). Less than half of the secondary schools in Hong Kong who responded to a survey (n = 348 schools) indicated that the schools had formulated an overall policy in the implementation of sex education (Hong Kong Education Department, 1994). Thus when these adolescent girls approach puberty, those with lack of support or education may not be well prepared to handle all the associated changes accompanying their menstruation.
Although the etiology of PMS is uncertain, a major emphasis in the treatment, apart from pharmapeutic management, is educating women to practice self-care measures to reduce the severity of symptoms (Kirkpatrick et al., 1990). In studies that examined the effects of educational programmes, the findings reflected a significant improvement in the outcome measures.
Seideman (Seideman, 1990) studied the effect of an education program on premenstrual symptomatology on 47 women ( = 33.6 years) employed in an industrial setting. The results showed a significantly reduced occurrence of anxiety and craving symptoms among subjects in the experimental group as well as a significant decrease in the severity of edema symptoms. In another study, Kirkpatrick et al. (Kirkpatrick et al., 1990) evaluated the efficacy of education interventions in raising the number of self-care measures practiced by the 84 women ( = 33.5 years) and the alterations in the symptoms of PMS. A significant increase in the self-care measures was found post-test among both experimental groups and a significant decrease was found in relation to the total PMS scores of one of the experimental groups.
However, in determining the effectiveness of the proposed self-care measures, most studies have focused on the efficacy of a single intervention for the relief of PMS. Examples include cognitive-behavioral therapy (Morse et al., 1991), relaxation response (Goodale et al., 1990) and nutritional intervention (Abraham and Rumley, 1987). Few attempts have been made to study the effectiveness of a combination of self-care measures on helping women with PMS (Kirkpatrick et al., 1990; Seideman, 1990) and most of these studies recruited adult women as the major participants.
A health education package was therefore developed in this study, and was evaluated in terms of (1) increasing adolescent girls' PMS and menstrual knowledge, and (2) decreasing the incidence and severity of premenstrual and menstrual symptoms. Gaining knowledge has been regarded as an important goal towards improving an individual's health status (Posavac, 1980). It also helps to gain a means of controlling feelings of powerlessness (Rankin and Stallings, 1990). Conversely, a lack of knowledge can contribute to a variety of responses including anxiety and self-care deficit (Carpenito, 1997). Although knowledge has not been measured in previous studies, it was chosen as one of the outcome measures for the education program in this study in order to determine whether there is a link between knowledge and health outcomes.
Nowadays, there is more effort in evaluating education programs in terms of improvement in individuals' health status (Posavac, 1980) including physical and psychological well-being. A major goal in health education is also to promote better health. Some scholars argue that when PMS in adolescents is ignored, it can cause an impact on the adolescents' health and quality of life (Halas, 1987; Wilson and Keye, 1989). An adolescent may develop an altered body image, a decrease in self esteem, lack of self confidence and subsequently affect their relationships with significant others. On reaching adulthood, these effects may give rise to broken engagement, marital distress, difficulty in pursuing education goals or becoming withdrawn and socially isolated (Wilson and Keye, 1989). Thus improvements in physical and psychological well-being were the main concerns of the educational program, and were evaluated as longer-term goals.
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Method |
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In order to fulfill the purposes of the study, the following hypotheses were formulated and tested.
- Adolescent girls who receive the educational program on PMS will demonstrate a reduction in total PMS and four subscale scores as compared to a group of adolescent girls who do not receive the educational program.
- Adolescent girls who receive the educational program on PMS will demonstrate an increase in knowledge about PMS and related self-care strategies after the educational program.
Design
A quasi-experimental, non-equivalent pre-test–post-test control group design was used to determine the efficacy of a PMS educational program. A non-equivalent control group design was used because students from the same school would have known each other. If students in each school were randomly assigned to experimental and control groups, there may have been a chance that students in the experimental group would discuss the intervention with students in the control group, and thus confound the post-test PMS and knowledge scores. Therefore, the experimental and control groups were from different schools.
There was one experimental group and one control group. The experimental subjects received two educational sessions on PMS and related self-care measures. The control group subjects received the same educational sessions after the collection of post-test data. Both groups completed pre- and post-tests for PMS, trait-anxiety and PMS knowledge. Power analysis using the findings from the pilot study demonstrated that a total of 44 subjects was needed to achieve a significance of 0.05 and a power of 0.8 for a 40% reduction in the total PMS scores.
Sampling procedures
Letters were sent to eight secondary schools located in the New Territories, an urban sub-region in Hong Kong, to ask for the participation of their students in a research study on adolescent girls' health. This process of recruiting sample subjects continued until four schools had agreed to participate. For those schools who showed interest, a short discussion between the schoolteachers and the researcher was held to provide further explanations of the study rationale and procedures. The initial contact also allowed the researcher to find out whether their students had been previously exposed to similar topics or content as in the present study. None of these schools had been previously exposed to similar topics or content. The first two groups of students that gave consent to participate in the study were assigned as the subjects of the experimental group and the subjects from the other two schools were assigned to the control group. The other four schools had refused to participate because they had too many research studies in progress.
Four-hundred and eighty-four schoolgirls from the four different schools were invited to participate in the study. Two-hundred and two (42%) students showed interest and individual as well as parents' consent were given before the education sessions together with a clear explanation of activities involved. Fifty-seven students in the experimental group attended all teaching sessions, completed an initial interview, and all pre-test and post-test questionnaires on PMS, trait-anxiety and PMS knowledge. Fifty-seven students in the control group completed the interview and all questionnaires, and the same education interventions were offered to all the students interested after completion of the study.
Criteria for inclusion in the final analyses were that schoolgirls had experienced at least two or more PMS symptoms during their last menstrual period and were not receiving any hormonal therapy or taking regular drugs. They had a regular menstrual cycle around 15–45 days. Thus three students were excluded from the final analyses because they were taking regular drugs including vitamins and Chinese herbs for regulating their menses. Another 17 students were excluded because they had either no experience or had experienced less than two premenstrual symptoms during their last menstrual cycle.
The final study sample included a sample of 94 Chinese, secondary school female students with ages ranging from 14 to 18 ( = 15.51 years, SD = 1.09). There were 49 schoolgirls from the two schools assigned as the experimental group and there were 45 from the other two schools assigned as the control group. The subjects' grade of studies ranged from Form 2 to Form 6.
Method of data collection
Instrument to assess PMS
A Chinese version of the Abraham's MSQ was used to assess PMS. The students were asked to rate 19 symptoms commonly found in PMS on a four-point scale with responses ranging from: 0 = no effect; 1 = mild, present; 2 = moderate; and 3 = severe disabling with regard to the degree of interference and disruption to usual family, school and social activities. Abraham used four subscales to categorize the 19 symptoms into: PMT-A, for behavioral changes; PMT-H, indicating water and salt retention; PMT-C, manifestations of craving; and PMT-D, characterizing depression. The MSQ also measured the occurrence and severity of two menstrual pain symptoms including cramp and backache experienced during the first 2 days of the subjects' last menstrual period. These items were for the purpose of distinguishing between menstrual and premenstrual symptoms. Subjects were also asked to grade the effects of PMS on their marital, familial, social and work-related performance for their last cycle. Minor modifications were made to suit the age of subjects, thus the item on marital performance was deleted and the item on work-related performance was replaced with school performance.
A previous study using the Chinese version of the MSQ showed that Cronbach's 
coefficient for the MSQ was 0.87 (Chau et al., 1998). The coefficient for the Chinese MSQ in this study was 0.82.
Instrument to assess trait-anxiety
Trait-anxiety, the students' relatively stable individual differences in anxiety proneness, was measured by Spielberger et al.'s (Spielberger et al., 1983) Trait-anxiety Inventory (STAI Form Y-2), using a four-point scale (almost never, sometimes, often and almost always) on 20 items. The inventory includes 11 anxiety-present (e.g. I wish I could be as happy as others seem to be) and nine anxiety-absent items (e.g. I feel satisfied with myself). The previous version of the STAI (Form X-2) had been translated into Chinese, and the validity of the tool and subscales had been supported by Shek (Shek, 1988) using factor analysis. The new items in STAI (Form Y-2) were translated into Chinese and back translated. The test–re-test reliability coefficient for the English and Chinese versions of STAI Form Y-2 was 0.96 (Chau et al., 1998) and in this study, the coefficient was 0.87. The inventory was used in this study to rule out one of the confounding factors of individual differences in the interpretation of threatening situations among experimental groups and the controls. It was also used to identify any significant correlation between the incidence of PMS and the level of students' trait-anxiety.
Instrument to assess knowledge
The Premenstrual Syndrome Knowledge Questionnaire (PMSKQ) was developed for this study to measure the students' knowledge regarding PMS and related self-care strategies. It was used primarily as an outcome measure to demonstrate one aspect of intervention efficacy in increasing the knowledge of the subjects. It was also used to rule out any significant difference in the pre-test knowledge among experimental and control groups that might confound any treatment effects.
Formulation of the items was based on the objectives of each education session. The development of objectives was established through an extensive review of the PMS literature. The PMSKQ required students to answer questions concerning three aspects of learning outcomes. These aspects included general knowledge regarding menstruation, knowledge of terminology, etiologies, aggravating factors of PMS and knowledge of self-care measures relating to PMS. Three sections were included in the PMSKQ. Part one consisted of seven cluster-type true–false items (Gronlund and Linn, 1990) with three statements in each cluster item. The students were asked to choose whether each statement in the cluster was true or false and a correct answer was given 1 point. Therefore a total of 21 points was allocated for this section. Part two included four true and false items with a maximum score of 4 points. The content and face validity of the questionnaire were determined by two experts who have studied PMS extensively and have published related articles.
The PMSKQ was also translated, blind back-translated, reviewed and modified by independent bilingual persons. The translated version of PMSKQ was then pre-tested on a sample of five secondary schoolgirls to identify potential problems in data collection and no problem was found. The reading level of the instrument was found to be appropriate and easy to understand.
Interview
Short telephone interviews were conducted before the educational sessions to find out additional information on nutritional habits, usual dietary pattern and dietary preferences of the subjects. The information was used as a basis for devising dietary guidelines for this group of Chinese adolescent girls.
Intervention
A health education package was designed and reviewed by two experts in this area. The criteria for assessing the validity of the health education package includes the adequacy of the content, the accuracy of the background information, the relevance in relation to the topic and appropriateness of the methodologies used. The general orientation to the educational materials was to use those previously developed and readily available whenever possible. The development of the educational package was based on an extensive review of the literature. Material relating to self-care strategies to relieve the symptoms of PMS were selected from available materials developed in other research projects such as `Total Dietary Programs for Premenstrual Syndrome' by Haid and Abraham (Haid and Abraham, 1992) and `Premenstrual Blues' by Abraham (Abraham, 1991). Some of these materials were modified to fit into the Chinese culture, such as the incorporation of Chinese food and individual preferences as obtained during the interviews into the dietary program with the help of a dietician. Various teaching methodologies were used to add interest and aid memory. Pilot teaching was performed by the author to a group of 32 secondary school students in another school not in the main study in order to obtain feedback from them about the appropriateness of teaching methodologies used. Students in this pilot group also helped in determining the readability of MSQ and helped in identifying potential problems in data collection.
There were a total of two health education sessions with the first session lasting for 45 min and the second session lasting for 90 min. The objectives and content outline for each session were as follows.
Session 1: content outline
- Review structure and function of female reproductive organs.
- Explain the physiology of menstruation.
- Discuss and clarify myths and misconceptions about menstruation.
- Introduce PMS, and discuss how it affects the physical and psychological states of adolescence.
- Provide a summary of prevalence of PMS symptoms among adolescence in Hong Kong.
- Discuss the causes of PMS.
- Provide information on different categories of PMS symptoms and their impact on various aspects of life.
Session 2: content outline
- Discuss stress and provide information on sources of stressor.
- Discuss relationship between stress and PMS.
- Introduce progressive relaxation exercise.
- Learn and practice progressive relaxation technique.
- Discuss self-help measures to manage stress including learning to deal with own emotional symptoms, scheduling activities, using Menstrual Symptom Diary, and maintaining positive attitudes towards PMS.
- Discuss self-care measures related to dietary change.
- Review dietary habit of schoolgirls.
- Provide a list of recommended diet menu.
- State the importance and benefits of regular exercise.
- Discuss the harmful effect of smoking in relation to PMS.
- Discuss measures to deal with menstrual cramps.
Data collection procedures
Experimental group
The actual intervention sessions were delivered by the author and took place in the students' regular classroom after school hours. This intervention lasted for a total of 135 min and was conducted on 2 days within 1 week. Before the first education session began, each student was asked to complete the pre-test MSQ, Trait-anxiety Inventory and the PMSKQ. After finishing all the teaching sessions, the subjects were asked once again to complete the PMSKQ. Three months after the educational interventions, the subjects were sent the post-test MSQ and Trait-anxiety Inventory with cover letters and return envelopes, and they were encouraged to return them by mail.
Control group
The students in the control group were invited to complete two pre-test questionnaires (MSQ and Trait-anxiety Inventory). Three months after the initial data collection period, the students were asked to complete both the post-test MSQ and Trait-anxiety Inventory. The same education sessions were offered to all the students interested and, before the first educational intervention, they were asked to complete the PMSKQ. Only those students with complete sets of pre-test and post-test data and who met the inclusion criteria were included in the final analysis.
Method of data analysis
All data were analyzed using the computer program SPSS. Normal distribution of data was checked to ascertain the appropriate inferential statistical tests for this study. Tests of all dependent and independent variables indicated that most of the normal distribution null hypotheses were rejected with P < 0.05 except for trait-anxiety scores (P > 0.20) and height (P > 0.20). Thus a conservative approach using non-parametric statistics was employed when the data did not meet assumptions of parametric tests (Siegel, 1956).
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Results |
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Demographic findings
The mean age of all 94 schoolgirls in the final sample was 15.51 years with a minimum age of 14 and maximum age of 18 years. The majority was Form 4 (grade 9) secondary schoolgirls (77.7%). All the schoolgirls reported that the duration of their menstrual cycle was from 25 to 45 days (
= 30.52, SD = 3.86) and that the length of menstrual flow for the most recent cycle was from 3 to 8 days ( = 5.56, SD = 1.14). The mean age of menarche was 12.05 (SD = 1.24). Two schoolgirls started their menarche as early as 9 years (2.1%) while another two schoolgirls started at the age of 15 (2.1%). The mean number of postmenarche years at the time of the data collection was 3.46 (SD = 1.51) (with a range of 1–8) and was calculated by subtracting the year of menarche from their age.
The height of students in both groups ranged from 145 to 180 cm ( = 159.54, SD = 6.41) and weight ranged from 35 to 73 kg ( = 47.59, SD = 6.96). The height and weight of the schoolgirls were converted to a single unit of measurement [body mass index (BMI)] and was also used for subsequent analyses. The mean BMI was 18.80 (SD = 2.93) for the experimental group and 18.88 (SD = 2.59) for the control group, with a range of 14.1–28.9.
The types of exercise commonly performed by the study population were categorized into light, moderate, heavy, very heavy and unduly heavy using Durnin and Passmore's (Durnin and Passmore, 1967) classification of work according to energy expenditure (kcal/min/kg) for an 8 h workday. Exercise commonly performed included: light exercise (20.8%) such as walking, sit-ups, press ups; moderate level of exercises (37.6%) included volleyball, badminton, cycling, dancing; heavy exercise (1.3%) included jogging or playing tennis; very heavy exercise (20.8%) included basketball or swimming; and unduly heavy exercise (19.5%) included handball or running. Most commonly schoolgirls performed a moderate level of exercise (37.6%). Seven schoolgirls (7.7%) indicated that they did not perform any regular exercise at all. For those schoolgirls who did perform exercise, the average length of exercise was approximately 1 h per week ( = 59.65 min, SD = 60.12). The frequency of doing exercise ranged from 0 to 9 times per week ( = 2.06, SD = 1.68).
Effectiveness of the educational program
Group comparability
Comparisons were made between experimental and control groups to detect any significant group differences on baseline demographic characteristics and other variables being studied. Mann–Whitney U-test results indicated that the mean rank scores on age, weight, duration of last menstrual cycle, days of flow of last cycle, year of menarche, years postmenarche, duration of exercise and frequency of exercise per week had no significant group differences with all P > 0.05. Independent t-tests also indicated that the mean scores on height had no significant pre-test differences between the two groups.
Comparisons were made between the experimental and control groups on trait-anxiety scores and the total PMS knowledge scores. Mann–Whitney U-test results indicated no significant differences between the two groups on PMS knowledge scores. Independent t-test results also indicated no significant group differences on pre-test trait-anxiety scores with P > 0.05.
The experimental and control groups were further compared for differences in the incidence and severity of premenstrual and menstrual symptoms. Mann–Whitney U-test results indicated no significant group differences when the total PMS scores, the four PMT subscale scores and menstrual pain scores were compared. Mann–Whitney U-tests were also performed to compare the group differences on the subjective accounts of the effects of PMS symptoms on various aspects of activities and no statistical significant differences were found (see Table I).
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The results showed that the mean difference was not significant with t = 1.10 (P = 0.14) indicating that trait-anxiety was not a confounding variable in this study. On the other hand, the pre-test and post-test trait-anxiety scores for the control group subjects were similar (t = 0.11, P = 0.91) when compared using the paired t-test. In summary, as there were no significant differences in any group characteristics or variables being studied, the group equivalence was established.
Effects of educational program on the incidence and severity of PMS
As shown in Table II, the total PMS scores and three of the subscale scores of the experimental group showed significant post-test differences with: total PMS scores (Z = –2.57, P < 0.001), PMT-A subscale scores (Z = –1.85, P < 0.05), PMT-C subscale scores (Z = –2.78, P < 0.01) and PMT-H subscale scores (Z = –1.98, P < 0.05) that indicated a decrease in PMS symptom severity among these variables. The schoolgirls in the experimental group also reported less but not significantly less PMT-D symptoms (Z = –1.52, P = 0.06) and menstrual pain (Z = –1.58, P = 0.06).
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The effects of PMS on activities after the education intervention were significantly reduced for familial interactions (Z = –2.11, P < 0.05), social activities (Z = –2.92, P < 0.01) and school performance (Z = –2.79, P < 0.01).
PMS findings for the control group
No significant differences were found among control groups on pre-test and post-test total PMS scores, all four PMT subscale scores, and menstrual pain scores (see Table III). Additionally, no significant differences were found for the subjective accounts of PMS symptoms on various activities.
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Effects of education program on PMS knowledge
Wilcoxon matched-pairs signed-rank tests (see Table IV
) indicated a significant increase in post-test PMSKQ scores for the experimental group when compared with pre-test PMSKQ scores (Z = 4.68, P < 0.0001). Significant differences were also noted in all three aspects of PMS knowledge.
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Discussion |
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Overall benefits of education
The benefits of the PMS educational program employed in this study provide support for the use of a multifactoral approach to interventions where biological and psychosocial factors were addressed within the program (Ussher, 1992
). As well as a decrease in the total PMS scores there was also a reduction in the experimental group's premenstrual symptoms of anxiety, water retention and craving. The schoolgirls in the experimental group reported less PMS symptoms 3 months after the educational program, while no significant changes were found in the control group. Group comparability and similarity were established using the pre-test scores of both experimental and control groups to improve the effectiveness of the control in the research design (Campbell and Stanley, 1963). Thus it could be claimed that the reduction in PMS scores was not due to natural changes which might have affected both conditions equally, but is most likely due to the treatment effect (Greene and D'Oliverira, 1982). Additional support for the benefits of the educational program for the experimental group comes from the control group findings of no significant differences between pre- and post-test total PMS scores, all four PMT subscale scores, and menstrual pain scores. This supports previous findings that the incidence of premenstrual and menstrual symptoms is quite stable across time (Rosen et al., 1990; Metcalf et al., 1992). The stability of PMS experience was further evidenced in this study as there were no significant differences in the pre- and post-test subjective accounts of PMS on various aspects of life, including family interaction, social activities and school performance for the control group.
The positive outcomes of the program in this study were evident by the significantly reduced numbers of negative comments about the impact of PMS symptoms on adolescents' various activities in the post-test MSQ measurement. All three aspects of activities including family interaction, social activities and school performance had significantly decreased in mean rank scores when compared with pre-test baseline data. While improving the quality of life of adolescents is a major concern for care (Halas, 1987; Wilson and Keye, 1989), it was encouraging to find a significant reduction in symptoms together with a decrease in self reported impact on adolescents various aspects of life. The reasons why nurses could be well placed to promote health and facilitate self-care are that parents and teachers are often seen as authority figures, whereas nurses are seen as independent health professionals (Cohen, 1994). Nurses are also well equipped and already prepared with the knowledge base for both the content and process of health education. Thus not only is their knowledge of the behavioral, biological and nursing sciences helpful in teaching, but nurses are also able to design learning packages that account for the entry level of the learner and style of teaching needed for this age group (Redman, 1993).
The positive findings of the present study are consistent with the assumption that education programs benefit individuals with PMS. The importance of education in the management of PMS, which has been well documented (O'Brien, 1982; Keye, 1988), was supported by the positive outcomes found for the adolescents in this study. The findings that the educational program had positive effects on premenstrual symptoms of anxiety, water retention and craving are consistent with the findings of Seideman (Seideman, 1990). A similar finding was observed in Kirkpatrick et al.'s study that reported a significant decrease in total PMS scores in one of the experimental groups of adult women (Kirkpatrick et al., 1990). The present study differs from the above as additional variables were included: menstrual history information, controlling for individual differences related to anxiety traits, exercise and dietary patterns. The inclusion of these variables increased the rigor of the study by controlling these intervening variables that could create threats to the internal validity of the study (Nieswiadomy, 1987). These variables were compared using the pre-test scores for both the experimental and control groups, and the results showed group similarity in relation to the above personal characteristics.
While considerable benefits of the educational program have been demonstrated, there were two areas where no improvement was found. These two areas were premenstrual symptoms of depression and menstrual symptom pain.
One possible explanation for the non-significant difference found between pre- and post-test depression subscale scores may be the high anxiety trait among this group of adolescents. A mean trait-anxiety score of 48.25 (SD = 7.87) was found for the experimental group. The mean score is relatively higher when compared with 41–45 for the New York adolescent sample (Golud and Harrington, 1981) and 40.97 in the normative US sample of senior high students (Spielberger et al., 1983). The mean age of 15.51 in this Hong Kong study corresponded with the mean age of the New York and normative sample of senior high students. The mean trait-anxiety scores of the schoolgirls in this study were at the 76–77th percentile (Spielberger et al., 1983) when compared to the percentile range from the US normative samples. Persons with high levels of trait-anxiety as described by Spielberger and Sarason (Spielberger and Sarason, 1975) tend to perceive greater danger in situations that threaten self-esteem than do persons with lower levels of trait-anxiety. This tendency may in turn lessen the ability of adolescents to manage the premenstrual depression symptoms. Another possible explanation for there being no improvement in the depression subscale may be the association found between age and the incidence of PMS symptoms in this study. Age was found to be significantly negatively correlated (rs = –0.25, P < 0.05) with the depression subgroup. This inverse association differs from the findings of Hargrove and Abraham (Hargrove and Abraham, 1982) and Huerta-Franco and Malacara (Huerta-Franco and Malacara, 1993) that older women tend to report more premenstrual symptoms and experience increased depression.
A relatively early onset of menstruation may also account for a finding of increased confusion in the depression subscale for the experimental group. Female adolescents in Hong Kong are having earlier sexual maturation and by the age of 12.5 years old, half of the girls would have started menstruation, that is at least half a year earlier than children in Western countries and earlier than children in Hong Kong 30 years ago (Leung, 1994). A few schoolgirls in this study even started their menarche as early as the age of 9. Lack of sex education on the topic of menstruation (The Family Planning Association of Hong Kong, 1989) at this critical stage in life when striving for a sense of identity (Erikson, 1965) means that adolescents may find it hard to cope with any adjustment. Such adjustment is needed because of the cyclic physical and psychological changes associated with puberty (Waechter et al., 1985).
The complexity of decision-making skills as proposed by Tones et al. (Tones et al., 1994) may render a slight increase in the level of confusion for the implementation of suggested self-care practice. Thus although information on different alternatives of self-care measures was provided during the educational program, the instructions on the decision-making skills may have been insufficient. This may have increased the confusion of the schoolgirls when appraising the information given and trying to make their own choice. A longer program and with a wider range of activities for enhancing schoolgirls' decision-making skills therefore would be needed in future studies.
In summary, although age and trait-anxiety accounted for significant correlations with PMS scores for the experimental group, they might not be the strongest factors contributing to the non-significant findings of the depression subscale in this study. A further evaluation of the content of the educational program with a larger group of schoolgirls would be beneficial to identify any inadequacy of the program in helping adolescents to manage their depression symptoms.
There are a number of possible reasons for there being no significant reduction in menstrual pain. Menstrual pain consists of menstrual cramps and backache. When these two items were examined separately, mean menstrual cramp scores had decreased from 1.12 pre-test to 0.90 post-test, while menstrual backache had an even smaller reduction from 0.55 to 0.41. The relatively small improvements found in the experimental group for backache were most likely due to the fact that the measures for managing backache were less emphasized in this educational program. More specific interventions for menstrual cramps and backache should be included to emphasize this aspect of self-care management.
Thus although the education program was mainly beneficial it was not able to significantly reduce the depression symptoms or menstrual pain. While further development of the education program may help to improve these outcomes, other factors which may have influenced the findings needed to be examined. Such factors include anxiety, age and exercise.
Apart from the overall decrease in the incidence and severity of PMS symptoms, improvement in knowledge was also used to evaluate the efficacy of the educational program. As expected, overall knowledge of PMS had significantly increased as well as the three main aspects of PMS knowledge. The schoolgirls' performance on: general concepts of menstruation; terminology, etiology, aggravating factors of PMS; and PMS self-care measures in the post-test PMSKQ were similar. However, further examination of each item indicates that there were a few poor performance items in the post-test PMSKQ. These items include: the identification of relationships between the level of sex hormone with the etiology of PMS, whole-grain food being recommended for girls with PMS and high caloric food is not appropriate dietary advice for girls with PMS. Improvement to emphasize these aspects of information in future health educational activities is warranted.
In summary, as the Hong Kong students in this study generally lacked basic knowledge regarding PMS, the education program has been of value in helping them to obtained a better understanding of health-related issues and PMS self-care measures. This information may also be necessary to develop a positive self-concept and positive attitude towards menstruation-related symptoms. Such attitudes are necessary for the subsequent adoption of self-care measures to improve general well-being (Halas, 1987). Thus incorporating information on menstruation, PMS and self-care measures as a regular subject and starting the education early in junior secondary schools would be helpful. Through adequate education, young schoolgirls could learn more effective means to manage their physical and psychological changes associated with puberty.
Limitations
A number of limitations have been suggested along with the above discussions of the findings. Additional limitations in this study include the response rate of 56% that reduced the ability to generalize the findings of this study. However, when the number of assessments and the inclusion criteria for this study are taken into consideration, the response rate is considered satisfactory. Further, the use of a convenience sample in this study also limits the ability to generalize the findings. An additional limitation in this study is that the self-care behavior of the adolescents before and after the educational program was not measured. It would be helpful to have a measure of self-care to provide baseline information and to help in identifying behavioral changes after the educational program.
Implications and recommendations for further research
It is encouraging that positive outcomes were found even though minimum interventions were delivered to students. Further investigation using longitudinal studies with continual assessment and evaluation of education interventions for adolescent girls with PMS would be of great value in primary health promotion. A lack of general knowledge related to menstruation as reflected in the findings and reviewed by students themselves indicates a need to extend the education. More effective and appropriate interventions to help adolescents manage symptoms of depression and menstrual pain should be incorporated in further programs.
During the process of delivering the health education program, it was interesting to find out that schoolgirls reported special interest in most of the topics, including basic concepts and etiologies of PMS, self-care measures related to exercise schedule, dietary advice, and measures to relieve menstrual cramps. The willingness to learn to be a responsible individual was observed in most of the schoolgirls participating in the study. High motivation and enjoyment were also observed during and after the educational program. Other observations included the concern for physical fitness, the appearance that symbolized femininity and identity were highly valued among this group of schoolgirls. The concern for academic achievement also was expressed by some schoolgirls who were especially worried about the difficulties in English comprehension and learning English subjects. A lack of trusting relationships with family and teachers, and a lack of basic understanding of anatomy, terminology and sex education were also expressed by the schoolgirls. All these worries and concerns could intensify during their premenstrual phase that in turn could generate further stress and aggravate the symptoms of PMS. However, the degree of this influence could not be determined with the limited information in this study. Further research that helps in identifying the physical and psychosocial health needs of adolescent girls would be of great value to their long-term health.
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Acknowledgments |
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We would like to thanks Dr Guy E. Abraham for his advice and generous help throughout the refinement of the MSQ used in this study. Special appreciation also goes to Mr C. H. Kwok, Miss V. Wong, Miss K. F. Yau, Mrs H. Y. Wai, Miss T. H. Hui and Miss S. F. Chow, who were the principals and teachers of the secondary schools participating in the study. Their support and cooperation contributed to the smooth progress of the study. We would like to express our appreciation to all the students who took part in the study and who continue to inspire us with their enthusiasm and energy.
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Received on October 7, 1997; accepted on October 15, 1998
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