Exploring the Authentic Illness Experience and Health Management Needs of Patients with Moderate to Severe Menopausal Syndrome through the Lens of Social-Ecological Systems Theory: A Qualitative Study

doi:10.21203/rs.3.rs-4983047/v1

Background

Patients with moderate to severe menopausal syndrome often face significant physical and mental health challenges, yet their experiences are frequently overlooked in China. This study aims to explore the illness experiences and health management needs of these patients, focusing on their feelings, coping strategies, and demands for health services to address both physical and psychological symptoms, thereby promoting reforms in management programs.

Methods

A phenomenological approach was employed, with an interview guide developed based on socio-ecological systems theory. Twelve patients with moderate to severe menopausal syndrome were selected through purposive sampling for semi-structured interviews. Data were analysed using Colaizzi's seven-step method.

Results

Twelve women participated this research. Three primary themes and ten subthemes were emerged: (1) micro- cognitive limitations and reduced coping capacity (aging and confusion, self-regulation and health monitoring, delayed treatment, and divergent expectations); (2) meso- family silence and disappearing workplace care (ambiguous information, feeling of pain, isolation and helplessness, and workplace neglect and gossip); and (3) macro- misaligned healthcare (fleeting communication, absence of health promotion role, and enhancing management plan specificity and systemization).

Conclusion

The study found that patients with moderate to severe menopausal syndrome possess strong self-management awareness; however, their coping abilities require enhancement, particularly for atypical symptoms such as palpitations and joint pain. Developing effective and targeted health management plans relies on collaboration among families, communities, media platforms, medical institutions, and healthcare professionals to provide comprehensive support for patients.

Menopausal syndrome

Experience of illness

Social-ecological theory

Hierarchical health management

Perimenopause Syndrome (PMS) constitutes a cluster of complex symptoms prevalent among perimenopausal women. Statistical data indicate that the incidence of PMS in perimenopausal women in China approximates 61%¹. As age advances, the symptoms experienced by PMS patients tend to escalate, and the condition becomes more severe². Notably, patients with moderate to severe PMS frequently encounter multiple symptoms concurrently³. The likelihood of "physical and mental illness" is elevated compared to those with mild⁴, with the co-occurrence of dual symptoms reaching up to 80%^5–7. Of greater concern is that PMS not only impairs the quality of life for patients but also heightens the risk of cardiovascular events and mortality, which ranges from approximately 2–11%⁸. The risk of patients with moderate to severe PMS developing chronic conditions such as hypertension and diabetes is estimated to be between 22% and 40.1%^9,10, thereby imposing a significant burden on patients' families, society, and healthcare systems.

For an extended period, Perimenopause Syndrome (PMS) has been heavily stigmatized, often associated with negative and derogatory connotations. This adverse social and cultural public opinion climate has exacerbated the psychological stress experienced by patients, prompting some women to attempt to rationalize their experiences and the discomfort induced by PMS through shame and stigma¹¹. Such attitudes have impeded PMS patients' willingness to seek medical assistance.

In certain regions of China, Perimenopause Syndrome (PMS) is viewed as an ill-fated and sinful condition within family culture¹². Consequently, some afflicted PMS patients have endured prolonged mental humiliation from their spouses and children. This perception, to some extent, distorts the accurate understanding of PMS among perimenopausal women, undermining their sense of self-worth and self-identity. Moreover, it intensifies women's aversion towards PMS and perimenopause, thereby impacting the holistic health management of PMS. Dahlgren's¹³ research has indicated that psychosocial stress, genitourinary symptoms, and advanced age are significantly correlated with the level of stigma experienced by PMS patients. This observation underscores the urgent need for comprehensive and targeted intervention strategies to enhance the quality of life for these women who suffer from both physical and psychological symptoms.

The Social-Ecological Model (SEM) was proposed by Urie scholars¹⁴, which delves into the intricate connection between behaviour and cognition with the individual's environment. Within this framework, individuals and their relatives, social networks or workplace colleagues, and social culture or social organizations constitute micro, meso, and macro systems respectively, thereby forming a unique social ecosystem for individuals¹⁵. Currently, SEM has been extensively applied in various fields such as violence prevention¹⁶, nutritional support¹⁷, humanitarian assistance¹⁸, and chronic disease prevention¹⁹, yielding positive social impacts.

By leveraging this theory, it may facilitate an understanding of the interplay between patients with moderate to severe menopausal syndrome, their families, and society during their illness. It also aids in elevating societal awareness of PMS, rectifying misconceptions and prejudices, and concurrently offers a foundation for medical institutions to devise targeted management plans. However, the empirical evidence supporting this approach remains insufficient. In light of this, the present study investigates the authentic illness experiences and health management needs of PMS patients through the lens of SEM theory, aiming to provide a reference for the subsequent formulation of relevant health management plans.

Design

The phenomenological research method was used in in-depth semi-structured interviews. Adopting the slogan of "returning to things themselves," this method seeks to unveil the meaning of transcendental experiences and subsequently elucidate the nature of phenomena²⁰. It holds significant value in delving into the essence of specific groups or intricate and complex phenomena, as well as the sentiments of individuals within them. Consequently, selecting this approach aids researchers in concentrating on the authentic illness experiences of patients with moderate to severe PMS and in meticulously exploring their needs for health management strategies.

Participants

Purposive sampling method was used to obtain heterogeneous sample for exploring the experiences of patients with moderate to severe PMS and their needs for health management strategies. From April to June 2024, patients with moderate to severe PMS in gynaecological outpatient clinics of 2 public medical institutions in Guangzhou were selected for semi-structured interviews. Inclusion criteria: (1) Those who were diagnosed as "menopausal syndrome" by medical examination; (2) Those whose medical records complain that contain both physical symptoms and psychological symptoms of PMS; (3) Women aged 45 to 55 years; (4) Modified Kupperman Index (mKI) ≥ 16 points; (5) Those who have clear consciousness and can express and answer questions correctly; (6) Be informed about this study and voluntarily consent to participants. Exclusion criteria: (1) People with severe physical diseases or mental disorders (such as patients with advanced malignant tumours, mania, etc.); (2) People with severe hearing impairment. The mKI was used to evaluate PMS severity: 0-6 scores were normal, 7-15 scores were mild, 16-30 scores were moderate, and ≥ 31 scores were severe ²¹.

The sample size for the study is determined by the saturation of interview data and content, with no new topics emerging upon the addition of new interviewees or interview materials²². Ultimately, 12 patients aged between 45 and 55 years with moderate to severe PMS (5 moderate and 7 severe) were included. The majority of respondents were currently employed (n = 8), and co-residents primarily consisted of husbands and children (n = 6). The KI score results varied from 16 to 52 points (Table 1). In adherence to the principle of study confidentiality, the real names of respondents will be replaced with case numbers H1 to H12.

Ethical approval

This study received approval from the Ethics Committee of Guangdong Provincial Hospital of Traditional Chinese Medicine (ZE2024-038-01). The ethical protocol ensures the confidentiality of the research design and the interviewee's right to freely decline the interview or halt it at any point. All interviewees included in the scope of text analysis had provided informed consent.

Data collection

Based on the SEM theory, the interview outline for this study was devised. A nursing professor and a medical professor reviewed the interview outline and provided suggestions for revision. Two patients with menopausal syndrome who met the research criteria were selected for pre-interviews, and the outline was adjusted according to the interview results and the feedback from the interviewees. Ultimately, an interview outline comprising the following questions was established: (1) Can you tell me what you know about menopausal syndrome? (2) How has menopausal syndrome affected your daily life? (3) What specific strategies do you use to handle the symptoms of menopausal syndrome you're going through right now? (4) What do you think your family understands and focuses on when it comes to menopausal syndrome? (5) How much attention do you think your workplace gives to menopausal syndrome? What support measures are provided? (6) What kind of help are you looking for from doctors, community groups, or other organisations because of your menopausal syndrome symptoms? (7) If there was a plan to help manage health during menopause, what would you want it to cover? (8) If there was a system to manage menopausal syndromes differently based on your needs, what do you think about that?

The study employed semi-structured interviews, conducted by two female graduate nursing students who served as interviewers and recorders, respectively, within a quiet, private consultation room or lounge. Prior to the interview, the interviewer established rapport by inquiring about the interviewee's recent living circumstances, subsequently introducing the research objectives and the necessity for recording. Upon obtaining informed consent and executing the consent form, the interview commenced, with each session lasting between 19 to 38 minutes. To thoroughly explore the content of the interview outline, the researcher adeptly adjusted the questioning method and sequence, providing timely responses and confirmations to the patient's perspectives, and delving into topics of research value. The recorder meticulously documented the interviewee's distinctive intonation, micro-expressions, and bodily movements. Should the respondent exhibit avoidance or aversion towards a particular question, the researcher would either bypass the question or conclude the interview.

General data pertaining to the participants (age, educational background, co-occupant, work status, occupation, mKI score, PMS severity, etc.) were collected post-interview to minimize interference with the interview process.

Data analysis

Following each interview, the researcher responsible for questioning transcribed the recorded materials into textual form within 24 hours and subsequently provided feedback to the interviewees. Utilizing QRS Nvivo 12 pro software, two researchers applied Colaizzi's 7-step analysis method to conduct immersive reading and coding analysis of the transcribed materials: (1) Familiarization with the data; (2) Disjunctive statement; (3) Content coding; (4) Gathering of views; (5) Detailed description; (6) Discrimination and analysis of viewpoints; (7) Verification of the structure. Upon completion of each transcription, the entire study team reviewed the content for fluency and accuracy.

Through the analysis and synthesis of the interview data, in conjunction with the SEM model, the following three themes and ten sub-themes (Table 2) were extracted. These themes collectively encapsulate the illness experiences of patients with moderate to severe PMS and delineate the genuine and specific requirements for perimenopausal health management strategies.

Theme 1: Cognitive Limitations and ReducedCoping Capacity

Subtheme 1: aging and confusion

The cognition of menopausal syndrome in patients with moderate to severe PMS is relatively shallow. Under the general trouble of menstrual disorders, mood disorders, sleep disorders and other symptoms, its body image is characterized by aging, such as "irritability" and "no longer beautiful", rather than chronic diseases. Some patients think that PMS is a normal change in the perimenopausal stage, but it is customary to use the word "menopause" to obscure menopausal syndrome. "So, the skin starts to dry out and we lose collagen. Plus, our memory goes downhill. Some of my colleagues had a bit of a period in their forties and they said it was better to end it sooner. Because we're so busy with work and we've got kids anyway, there's no point in worrying too much about these things" (H1); "I don't see it as a disease. I think it's just a phase people go through after they hit their forties. You can't stay beautiful forever. Each age has its own charm. The key is to accept it and understand it"(H6)

Simultaneously, patients with moderate to severe PMS frequently experience nonspecific symptoms such as bone and joint pain and paroxysmal palpitations, yet they are perplexed and unable to comprehend the manifestation of these symptoms. Additionally, most participants exhibit limitations and misconceptions regarding the normal age of menopause. Some even hold the belief that "the later the menopausal event occurs, the better" and "it is ideal to menstruate until old age." "I really feel that it doesn't feel normal to me! I even asked my friend yesterday. She's still having periods at 50 and she also has insomnia, but she doesn't have my palpitations. Some people think it's normal. They say menopause is just like that, but I feel like something's not right, don't you think? How can palpitations be normal? I'm not just flustered, I'm the kind of scared that feels like I'm in danger" (H5); "I’m going crazy, I can't sleep at all, and I've got joint pain. My feet feel weak and my knees hurt, but I don't think these should count, right? It's like I've had this before" (H2)

Subtheme 2: self-regulation and health monitoring

Self-regulation by most patients with moderate to severe PMS is pivotal in the management of PMS health. As stated, following:

"I reckon personal adjustments are key. If you're feeling down, you might start noticing all sorts of niggles. And mentally, you need to give yourself a nudge, face up to it, and tweak things. Realize that even docs can only do so much to help" (H6); "Honestly, I would say that women in their 30s should start getting clued up. Maybe if you prepare early, you won't freak out so much later. Everyone's symptoms are unique, so it's wise to know what's coming" (H5)

PMS patients perceive that participation in a systematic health management program can motivate them to pay greater attention to PMS and other health issues. As in the following narrative: “I'm cool with that. I can keep tabs on it yearly, and I've got it covered in my mind” (H12); Other participant emphasized furtherly: “I'm all for proper health management for menopause. If there's a thorough, tiered approach, it can really help us figure out what's going on and what we need” (H5)

Subtheme 3: delayed treatment

Participants with moderate to severe PMS often encounter a prolonged waiting and hesitation period during the process of seeking medical treatment, and the delay in seeking medical attention is pronounced, which may be one of the significant factors contributing to the exacerbation of their symptoms. "I'm really snappy. Sometimes, I just don't know what to do. I'm clueless when it comes to picking a doctor. At night, I can't get comfy, my leg's all over the place. Even when I pinch it, I still don't bother seeing a doctor" (H3); "I wanted to get checked out earlier, but work got in the way. I'd been meaning to get help for ages, but my job kept pushing it back. The everyday hassles just kept piling up, so I finally had to head to the hospital for insomnia and others" (H5)

Additionally, one patient was readily influenced by the ambiguous and indifferent attitudes of family members during her hesitation period of seeking medical treatment. She tended to default to the belief that PMS is not associated with health threats, thereby neglecting her own discomfort symptoms: "I didn't think about going to the hospital back then. I told my husband about the dryness and bleeding, and he brushed it off. He said I could just pop into the clinic for a quick check, and it wouldn't kill me… After I took the meds and seemed to have nothing wrong, I just let it slide and never went back to the gynaecologist" (H7)

Subtheme 4: divergent expectations

Due to the unclear risks associated with menopausal hormone therapy and the varying personal expectations of treatment outcomes, participants tended to favour non-hormonal treatments or guidance on healthy lifestyles in their subjective preferences when making treatment decisions. "If I used hormones, I might think more about it. I might think: Why use hormones? What do you want? Because I think what kind of condition do you want me to recover from with hormones? Well...To my mind, I'm not too eager to fully recover." (H6)

Theme 2: Family Silence and Disappearing Workplace Care

Subtheme 1: ambiguous information dissemination

Because menopausal syndrome is closely linked to female reproductive function and organs, the primary sources of health information for participants are female relatives and friends. During the exchange of information, patients and their relatives and friends often harbour feelings of shame and taboo regarding PMS, which casts an ambiguous and vague hue over the dissemination of PMS health information.

"My husband's sister was anxious, and this happened to her at that time… I also accompanied her here to see a doctor, but a few years ago, my body didn't have these conditions at all, and I didn't understand (her) situation… I also have a friend who also had these situations. She also told me that she was very serious and even depressed. She said that she actually didn't know how to be anxious. We were all confused why we get it?" (H5); " There is no one to say in my hometown. I quietly asked my sister-in-law two years ago, and asked her what the process of menstruation was like. She said it was gone a little bit, a little bit anyway. Didn't say anything to me." (H7)

Subtheme 2: feeling of pain, isolation and helplessness

Patients interviewed considered both PMS and perimenopausal changes to be "private" and should not be discussed with others: "It's all about self-adjustment, because I consider these personal issues, and I don't want to or dare to tell others." (H2).

One interviewee exhibited significant emotional fluctuations upon hearing questions about family members' care for her. Despite her outward expression of indifference, her suddenly raised tone and faster speech conveyed the anguish of feeling ununderstood and uncared for: "I don't need to talk to others, just adjust it myself. Deal with your own affairs. These problems have nothing to do with your family, so you don't need to increase the burden on others." (H10)

Simultaneously, some interviewees felt they lacked the attention and companionship of their partners, and their inner distress sought an outlet, leading to a mix of "demands" and "expectations." One participant sighed helplessly while sharing: "Well, he simply advised me to rest more… If I expect him to be considerate, it might tire him out. It's good to care, but you can't ask for too much…" (H12)

Another clearly emphasized that the family care she received was insufficient to compensate for the trauma she experienced in family life, causing her psychological emptiness during the transition period to become more pronounced: "Honestly, not enough… Officially, due to the lack of family support or the influence of my childhood family environment, my slight depression is influenced by my family of origin. Therefore, after entering menopause, this feeling is even stronger. I think no one would deny that coupled with some private and unspeakable secrets, I can't talk to my husband, it just only make me more depressed and anxious." (H4)

Subtheme 3: workplace neglect and gossip

Currently, within China's workplace environment and social and cultural context, our participants still do not receive sufficient attention, understanding, and empathy. A teacher working at a medical university shared her sentiments with us: " Even though we work in a medical university, where you'd think it would be relatively easy to access this information, menopausal syndrome doesn't seem to be specifically highlighted for public awareness. I feel that the care for women in society now only remains at a relatively broad level. Perimenopause isn't regarded as an important and special period like pregnancy and childbirth, and we don't feel much attention." (H1) Another interviewee's perspective echoes this sentiment: " I would like to point out that the workplace, unless it's a particularly supportive one, otherwise I don't believe it pays much attention to menopausal syndrome, and the workplace might not give much thought to us during this period. Well, that’s true." (H2)

Furthermore, the public's prejudice and stigma towards menopausal syndrome have resulted in significant public opinion pressure on patients with moderate to severe PMS in the workplace. " It's less acknowledged. Seriously, society pays less attention and understanding to this stage. Moreover, I feel a kind of pressure, fearing that my colleagues and superiors will think I have something wrong all over, and I'm unsure what others might think of me or gossip about. Then I suppress myself, become very irritable, and worry that others will think I have… a terminal illness." (H5)

Theme 3: Misaligned Healthcare

Subtheme 1: fleeting communication

Due to the scarcity of medical resources and the high volume of patients, the medical atmosphere is characterized by tension and urgency during the diagnosis and treatment process. This environment prevents patients from engaging in in-depth communication with their attending physicians about their condition and personal health concerns, thereby exacerbating negative emotions such as "helplessness" and "hesitation" among patients with moderate to severe PMS. The following voices of several interviewees reflect this reality:

"The doctor doesn't pay enough attention to us, yet… They're always in a rush. They just ask what the issue is, then write out a prescription. Oh dear, it feels very assembly-line." (H8)

" The community doctor just tells me what to watch out for, and that's it. If there's any treatment (discussion), they don't go into specifics. Yes, the doctor didn't elaborate." (H5)

" How can the doctor find the time to listen to you and explain it in detail? Let alone, they've already written out a prescription. Can I even stay in the consulting room? Sometimes I really feel helpless, really." (H3)

Subtheme 2: absence of health promotion role

Owing to the insufficient transparency and openness of current publicity methods employed by medical institutions, participants reported difficulties in fully accessing professional health information. Among the existing social health service initiatives, perimenopausal women and PMS patients are infrequently targeted for intervention.

"The current health lectures in the community mainly target older people, and there are no specific projects for menopausal health or specialist clinics. It feels like no one has the time to support us. Maybe it would be hopeful to focus on this in the future." (H2);

"Well, I would say, if the hospital had those promotional materials, I would definitely take them, but I don’t know where to find them. Nobody knows, I guess." (H7);

" It seems to me that free clinics or consultations on menopausal syndrome are quite rare, and the information provided by hospitals is not clear or complete enough. Often, we don’t even know these activities exist." (H12)

This lack of focus contributes to the challenges faced by moderate to severe PMS patients who are aware of the need for medical treatment but struggle to obtain primary healthcare services and effective referrals. Consequently, this situation has become a significant contributing factor to the delays in the medical treatment of PMS patients.

Subtheme 3: enhancing management plan specificity and systemization

Participants in the interviews indicated that the current management measures implemented by medical staff are overly structured and universal, lacking the necessary flexibility and adaptability. These measures do not adequately consider the unique circumstances and individual differences within specific management dimensions, which adversely affects patients' willingness and compliance with health management intervention strategies: "If you ask me, after I realised that her advice was not specific, I lost interest in it. The focus needs to be improved… When seeing a doctor, I expect a professional medical plan that includes exercise, diet recommendations or something else. It would be helpful if the doctor could specify what we can and cannot eat, providing more detailed and targeted guidance" (H1); "The way I see it, doctors ought to take the initiative to offer advice, instead of we ask for it." (H2)

Given that the symptoms of perimenopause syndrome (PMS) involve multiple physiological systems, purely structured health education may fail to account for the overall health status of PMS patients. Those with moderate to severe PMS report a need to understand their current disease risk levels. It is essential for medical staff to develop transitional management plans for perimenopause based on risk assessment results, with a greater emphasis on mental health management.

"I think it is still necessary to carry out an overall management, breaking down specific symptoms and addressing them based on their severity. Serious and mild symptoms require different management approaches, right?" (H5)

Another participant also emphasized that: "Personally, if further improvement is needed, I think it would be beneficial to incorporate psychological assessments, similar to offering psychological counselling. Psychological support and guidance from you are very important for those of us experiencing emotional issues. Thank you." (H6)

Through 12 in-depth conversations with patients suffering from moderate to severe perimenopause syndrome, it has been observed that cultural or value-based constraints, such as "menstrual shame," "menopausal shame," and "age shame," significantly impact their emotional state. The global incidence of PMS has been on the rise in recent years, gradually emerging as a significant public health issue^23–25. Due to its complex pathogenesis and diverse clinical manifestations, PMS often leads to chronic conditions characterized by "physical and mental comorbidity."

The "Chinese Women's Development Outline (2021-2030)," reviewed and approved by the State Council of China, outlines key objectives for women's health, including the provision of comprehensive health services throughout their life cycle, the mitigation of rising trends in anxiety and depression among women, and the enhancement of women's health literacy. During the menopausal transition, it is essential to conduct thorough and scientific health risk assessments for perimenopausal women and to adjust their chronic disease management strategies accordingly^26,27. Thus, effective long-term health management for patients with menopausal syndrome is crucial for ensuring the quality of women's health throughout their life cycle. Given the prominent and complex symptoms experienced by patients with moderate to severe PMS, there is an urgent need for comprehensive health management solutions to address their specific health management requirements.

The study found that the disease cognition of patients with moderate to severe perimenopause syndrome can be classified into two categories: "natural state" and "disease state." Additionally, the interviewed patients expressed a clear desire to understand their overall health risks during perimenopause, as well as the data and outcomes of related risk assessments. Although these women demonstrated a strong willingness for self-management, their effective coping strategies were limited due to various factors related to their symptoms. This was particularly evident in their disease awareness, access to health information, and efforts to seek medical support.

Changes in menstrual rhythm, duration, and characteristics are typical manifestations of PMS; however, individual differences and the association between symptoms and "aging" can easily induce negative emotions in patients²⁸. Atypical symptoms of PMS, including palpitations, chest tightness, and bone and joint pain, were more pronounced in these participants, affecting their health and workplace value. To assist patients in successfully navigating perimenopause and improving their quality of life, general practitioners and specialist medical staff should guide patients, understand the timing and necessity of PMS treatment, and consider patients' wishes and expectations for treatment. In psychological counselling, doctors and nurses should alleviate patients' "menopausal shame" through empowerment, fostering the development of a correct self-image, enhancing self-management capabilities, and facilitating informed, personalized health decisions.

Our study also identified significant shortcomings in family support, work environments, and socio-cultural understanding among patients experiencing moderate to severe perimenopause syndrome (PMS). The finding following is slightly different to Chen's perspective²⁹, some respondents in this study delayed seeking medical treatment due to a lack of initiative, while others were influenced by inadequate family support or socio-cultural values, which suppressed their willingness to pursue medical attention. Socio-cultural prejudices against menstruation and perimenopause may, to some extent, restrict patients' ability to openly discuss symptoms and access information support¹².

Notably, patients with PMS continue to shoulder multiple social roles and bear responsibilities during perimenopause, facing pressures from work, childcare, and eldercare³⁰. If the cultural constraints that bind perimenopausal women are not dismantled over time, this may further diminish their courage to express their true feelings in family and workplace settings³¹. Emotional support for patients with moderate to severe PMS was primarily obtained from same-sex relatives or close friends, with children and male relatives, excluding husbands, rarely present during interviews. Additionally, discussions seldom addressed sexual dysfunction, genitourinary syndrome, and other symptoms directly related to reproductive health that are indicative of quality of life³². Furtherly, it was observed that the interviewees typically attended medical appointments alone, including women who were retired or on long-term leave. This may reflect a lack of adequate family or social support for patients with moderate to severe perimenopause syndrome from another perspective.

Based on the findings presented, it is proposed that the improvement of the social support system for patients with moderate to severe perimenopause syndrome relies on the collaborative efforts of medical and health institutions, media, and social organisations. These entities should provide relevant, accessible, and effective information while challenging outdated societal perceptions of menopause and PMS. The intergenerational family relationship is closely linked to the severity of PMS and the quality of life of affected individuals³³. Clinical doctors, particularly community general practitioners, should actively engage family support for patients with moderate to severe PMS and fulfil their professional roles in effectively disseminating accurate information about the condition. Furthermore, workplaces should foster a cultural atmosphere that values and respects women, recognising the significance of their contributions, and establish comprehensive care systems for perimenopausal women to enhance their professional satisfaction and success.

A key factor contributing to the stigma associated with menopausal syndrome is the inadequate information support provided by medical staff, which results in the neglect of symptoms in patients with moderate to severe perimenopause syndrome and their inability to access sufficient health management measures³⁴. This, in turn, exacerbates patients' misconceptions regarding menopausal hormone therapy and fosters negative attitudes towards menopausal syndrome³⁵.

In this study, patients with moderate to severe PMS generally reported that current health management protocols lacked relevance and had limited practical significance. Consequently, the promotion of the establishment of perimenopausal or menopausal specialist outpatient clinics is proposed, alongside the enhancement of training for general practitioners at the grassroots level and the facilitation of referral linkages and health management interactions between community health institutions and higher-level medical facilities³⁶. These measures aim to ensure continuous care and long-term health management for patients.

In the information age, digital interventions can effectively address deficiencies in time, space, and interactive experiences inherent in real-life settings³⁷. Leaders of medical and health institutions may consider utilising digital information technology to construct a health forum or management applet specifically for menopausal syndrome, or to develop management programmes suitable for wearable devices, serving as auxiliary tools for the linkage between community hospitals and superior medical institutions. Simultaneously, this approach can integrate health management models such as "triangle hierarchical management"³⁸, taking into account the supply capacity and needs of both managers and patients, thereby enriching and improving the structure of PMS health management schemes and enhancing patients' quality of life and self-management abilities. Additionally, scientific researchers should consider developing and implementing PMS screening and risk assessment guidelines, utilising risk stratification results to provide a foundation for formulating targeted management plans for patients with moderate to severe PMS.

To sum up, health management for patients with moderate to severe perimenopause syndrome in China currently faces several challenges, including limited self-awareness, inadequate family support, socio-cultural prejudices, and insufficient professional medical assistance. This study highlights the need to enhance the quality of life and services for these patients through initiatives such as health education, a two-way referral system, and the development of tailored health management programmes. Limitations of this study include the focus on urban samples; future research should expand the scope to include diverse populations and incorporate cross-sectional studies to better explore the quality of life and health management of patients with moderate to severe PMS, thereby providing a more comprehensive understanding of their circumstances and underlying causes.

FUNDING INFORMATION

This study was financially supported by Research Grant from the Guangdong Nurses Association (Grant No. gdshsxh2023ms20)

Jin Y, Cui F, WANG R, et al. Stress overload, influencing factors, and psychological experiences of nurse managers during early stages of the COVID-19 pandemic: a sequential explanatory mixed method study. Front Psychol. 2023;14:1187433

Author Contribution

YQQ and HQH were responsible for the conception and design of the article. YQQ, ZZJ, and HQH conducted the feasibility analysis. YQQ, SL, and ZKF contributed to the writing and revision of the paper. Data collection, collation, and result analysis were carried out by YQQ, ZZJ, and WXD. HQH oversaw quality control and proofreading of the article and was responsible for the overall integrity of the manuscript. All authors read and approved the final manuscript.

Acknowledgement

We extend our heartfelt gratitude to the 12 patients with moderate to severe menopausal syndrome who participated in the interviews, sharing their experiences, challenges, and aspirations for a healthy life. We also thank the clinical nurses who assisted in collecting patient information and recruiting participants for the study. This research reflects the collective efforts of all involved, and we sincerely appreciate everyone’ s contributions.

Data Availability

Due to the principle of scientific research confidentiality, we promised to keep participant’s information and data confidential, and the data used for this study will not be public, but available from the corresponding author on reasonable request.

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Table 1 Demographic information and mKI scores of participants (n=12)

Serial number	Age	Level of education	Living conditions	Working status	Occupation	mKI score	Severity
H1	45	Master's degree	Spouse	Be on the job	University teacher	16	Moderate
H2	45	Junior college	Spouse	Be on the job	Customer Service Staff	22	Moderate
H3	55	Primary school	Spouse, second-generation children	Retirement	Without	47	severe
H4	50	junior high	Spouse	Retirement	Without	48	severe
H5	47	Junior college	Spouse, generation of children	Be on the job	Finance staff	31	severe
H6	45	Regular college course	Spouse, generation of children	Be on the job	Administrative clerk	33	severe
H7	50	Primary school	Spouse	Long-term leave	Cleaning staff	52	severe
H8	50	Regular college course	Spouse	Be on the job	Finance staff	33	severe
H9	47	Junior college	Spouse, generation of children	Be on the job	Property Manager	20	Moderate
H10	46	Regular college course	Spouse, generation of children	Be on the job	Freelancing	18	Moderate
H11	50	Junior college	Spouse, generation of children	Retirement	Without	39	severe
H12	49	Junior college	Spouse, generation of children	Be on the job	Government workers	16	Moderate

Table 2 Themes and subthemes of illness experience and health management needs of patients with moderate to severe PMS in China

SEM system	Systematic implications	Subject matter	Subtheme
microscopic system	Seemingly separate individuals and their activities in a specific socio-ecological environment	Cognitive Limitations and Reduced Coping Capacity	Aging and confusion Self-regulation and health monitoring Delayed treatment Divergent expectations
mesoscopic system	Interrelationships between individuals and the various small-scale environments in which they participate, such as families, occupational groups, or other social groups	Family Silence and Disappearing Workplace Care	Ambiguous information dissemination Feeling of pain, isolation and helplessness Workplace neglect and gossip
macroscopic system	Large-scale environments that affect both micro-and meso-systems, including sociocultures, beliefs or values, social organizations or institutions	Misaligned Healthcare	Fleeting communication Absence of health promotion role Enhancing management plan specificity and systemization

No competing interests reported.

Exploring the Authentic Illness Experience and Health Management Needs of Patients with Moderate to Severe Menopausal Syndrome through the Lens of Social-Ecological Systems Theory: A Qualitative Study

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Abstract

Background

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Conclusion

Introduction

Methods

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Discussion

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Acknowledgement

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References

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