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Life satisfaction, loneliness and related factors during female midlife
Maturitas 72 (2012) 88–92
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Maturitas journal homepage: www.elsevier.com/locate/maturitas
Short Communication
Life satisfaction, loneliness and related factors during female midlife Ana M. Fernández-Alonso a , Martina Trabalón-Pastor a , Carmen Vara a , Peter Chedraui b , Faustino R. Pérez-López c,∗ , for The MenopAuse RIsk Assessment (MARIA) Research Group a b c
Obstetrics and Gynecology Department, Hospital Torrecárdenas, Almería, Spain Instituto para la Salud de la Mujer, Facultad de Ciencias Médicas, Universidad Católica de Guayaquil, Guayaquil, Ecuador Obstetrics and Gynecology Department, Universidad de Zaragoza, Hospital Clínico, Zaragoza, Spain
a r t i c l e
i n f o
Article history: Received 20 January 2012 Received in revised form 31 January 2012 Accepted 1 February 2012
Keywords: Midlife Life satisfaction index Menopause Loneliness UCLA loneliness scale Quality of life Menopause rating scale
a b s t r a c t Background: Studies assessing life satisfaction and feelings of loneliness in mid-aged women are scarce. Objective: To assess loneliness, life satisfaction and related factors in mid-aged Spanish women. Method: This was a cross sectional study in which 182 women aged 40 to 65 completed the menopause rating scale (MRS), the University of California at Los Angeles loneliness scale (UCLA-LS), the life satisfaction index A (LSI-A), and a general socio-demographic questionnaire containing personal/partner data. Internal consistency of each tool was also computed. Results: Median [interquartile range] age of the sample was 51 [9.0] years. A 55.5% were postmenopausal, 47.3% had increased body mass index (BMI) values, 57.7% were abdominally obese, 1.6% had hypertension and 86.3% had a stable partner. In addition, 4.9% used hormone therapy and 19.2% psychotropic drugs. Multiple linear regression analysis found that higher UCLA-LS scores (more loneliness) correlated with MRS psychological scores, partner alcohol abuse, living in urban areas, lower LSI-A scores (less life satisfaction) and not having a stable partner. Lower LSI-A scores (worse life satisfaction) correlated with severe female economical problems, BMI values and UCLA-LS and MRS psychological scores. Conclusion: Loneliness and life satisfaction in this mid-aged female sample was influenced by personal and partner issues which seem to play a much more relevant role than biological aspects. More research is warranted in this regard. © 2012 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Life satisfaction is not a univocal concept as it is used in many circumstances to collectively express the objective determinants of broad socio-economical well-being or quality of life (QoL), including a variety of factors such as economic level, non-market activities, human rights, social problems and support, or environmental pollution endpoints [1–3]. Human life satisfaction includes psychological well-being, feelings of happiness with everyday life, and achieved major goals [4,5]. It is also a major component of the World Health Organization definition of health, and a useful measure in health studies especially for individuals with physical disabilities. Reports indicate that life satisfaction may relate to
∗ Corresponding author at: Department of Obstetrics and Gynecology, University of Zaragoza Hospital Clínico, Domingo Miral s/n, Zaragoza 50009, Spain. Fax: +34 976 76 1735. E-mail addresses: [email protected], [email protected] (F.R. Pérez-López). 0378-5122/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.maturitas.2012.02.001
mortality, resilience, household income, partner relationships, lack of anxiety or depression, employment, positive self-esteem and religious beliefs [6–8]. Loneliness or feeling lonely is a frequent complaint in women during the menopausal transition. It is a distress produced when family and social relationships are perceived as less gratifying than expected [9]. In the general population, loneliness is a serious social problem related to the lack of emotional support, low self-esteem, depression, sleep disorders and also negative health outcomes [10–13]. Subjects who lack social support follow fewer healthy recommendations and engage in more risky behaviours [14]. Despite the aforementioned, loneliness is usually not assessed among midaged women or in relation to menopause related QoL or symptoms [15–19]. Mid-aged women are exposed to profound changes, not only linked to hormonal adjustments yet also social and emotional changes not included in conventional menopause-related QoL instruments. Data regarding life satisfaction and loneliness during the menopausal transition are still lacking. Hence, the objective of the present study was to assess these issues and related factors in mid-aged Spanish women.
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2. Method
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scores obtained for each subscale [25,17]. Higher MRS scores are indicative of QoL impairment.
2.1. Study design and participants This was a cross-sectional study carried out from November 2010 to June 2011 in which women (40 to 65 years) who were accompanying or visiting patients being attended for at gynaecological and obstetrical healthcare facilities of the Torrecárdenas Hospital, Almería, Spain, were requested to fill out the menopause rating scale (MRS), the University of California at Los Angeles loneliness scale (UCLA-LS), the life satisfaction index A (LSI-A), and an itemized questionnaire containing female/partner sociodemographic data. Women unable to understand the survey, not consenting participation or with psychological or physical incapacity imposing difficulties during the interview were excluded. Study research protocol was reviewed and approved by the Torrecárdenas Hospital Ethical Committee, Almería, Spain. All participants were informed of the study (objectives and used tools) and requested to voluntarily participate after providing written consent. 2.2. General socio-demographic questionnaire 2.2.1. Female data Female data included: age (years), parity, marital status, education (years), menopausal status (pre-, peri- or postmenopausal), time since menopause (years), current partner status (yes/no), body mass index (BMI), anthropometric measurements (neck, mid-arm, waist and hip circumference) and systolic and diastolic blood pressure (mmHg) values. Lifestyle and other personal factors included: smoking habit, regular exercise (yes/no), working and or economical problems (yes/no). Current drug use included: psychotropic drugs, oral contraceptives and hormone therapy (HT) or phytoestrogens for the menopause. Menopausal status was defined using criteria of the Stages of Reproductive Aging Workshop: premenopausal (women having regular menses), perimenopausal (irregularities > 7 days from their normal cycle) and postmenopausal (no more menses in the last 12 months either natural or surgical) [20]. Those with bilateral oophorectomy were also considered as postmenopausal. Women performing less than 15 min of physical activity (i.e. walking) two times per week were defined as sedentary [21] and those on medication or displaying blood pressure readings equal or above 140/90 were defined as hypertense [22,23]. Waist or abdominal, hip, neck and mid-arm circumferences were measured in centimetres (cm). A waist circumference greater than 88 cm was used to define abdominal obesity [22].
2.3.2. The University of California at Los Angeles loneliness scale The 10-item UCLA-LS validated in Spanish was used to measure general loneliness and the degree of satisfaction with subject’s social network [26,27]. Each item is rated on a scale of 1 (never), 2 (rarely), 3 (sometimes) and 4 (often). Scores may range from 10 to 40, with higher scores meaning greater loneliness [27–29]. 2.3.3. The life satisfaction index A The LSI-A is an instrument used to assess “successful aging”, a more complex process/phenomenon than the simple feeling good about oneself or the attainment of goals [4,5]. It is a construct that cannot be measured directly, and thus it should be indirectly assessed through its latent variables [30]. The present study used the original LSI-A validated in Spanish [31] which comprises 20 items that may be rated as agree (1 point), disagree (0 points), or uncertain (0 points) [4]. Possible total scores may range from between 0 to 20, with higher scores indicating higher life satisfaction. Neugarten et al. [4] have reported a mean score of 12.4 (SD 4.4) in their original study. 2.4. Statistical analysis Statistical analysis was performed using SPSS software package (Version 19.0 for Windows, SPSS Inc., Chicago, Illinois, USA). Data are presented as means, medians, interquartile ranges, percentiles (p25–p75), percentages, coefficients and 95% confidence intervals. The Kolmogorov Smirnov test was used to determine the normality of data distribution. According to this, non parametric data were compared with the Mann–Whitney (two independent samples) or the Kruskal–Wallis test (various independent samples). Rho–Spearman coefficients were calculated to determine correlations between scores of used tools and various numeric variables. Multiple linear regression analysis was performed to obtain a best model predicting total UCLA-LS and LSI-A scores (dependant variables). For this, first univariate analysis was performed to obtain potential independent variables (female and partner) with a 10% significance level to be entered into two models one including all studied women and the second only those with a stable partner. Variables were then entered into the model using a backward stepwise procedure. For all calculations a p value of <0.05 was considered as statistically significant. Internal consistency of used instruments was assessed computing Cronbach’s coefficient alphas for the MRS, the UCLA-LS and the LSI-A.
2.2.2. Partner data Women provided data related to partner including: age, educational level, regular exercising (yes/no), unfaithfulness (yes/no), alcohol abuse (yes/no), and the presence of sexual dysfunction (erectile dysfunction and or premature ejaculation). Definitions for alcoholism, erectile dysfunction, and premature ejaculation have previously been described [24].
Sample size calculation was based on the fact that 20% of midaged women would have increased life satisfaction [7]. Hence a minimal sample of 106 women was calculated considering a 10% desired precision and a 99% confidence interval.
2.3. Instruments
3. Results
2.3.1. The menopause rating scale The menopause rating scale is a health-related quality-of-life instrument composed of 11 items that assesses menopausal symptoms grouped into three subscales: somatic, psychological and urogenital. Women may grade each item from 0 (not present) to 4 (1 = mild; 2 = moderate; 3 = severe; 4 = very severe). For a particular individual, the total subscale score is the sum of each graded item contained in that subscale. The total MRS score is the sum of
During the studied period a total of 200 women were invited to participate, 9% (n = 18) denied participation, leaving 182 complete surveys for analysis. Median [interquartile range] age of the sample was 51 [9.0] years. A 55.5% were postmenopausal, 47.3% had increased BMI values, 57.7% were abdominally obese, 1.6% had hypertension and 86.3% had a stable partner. In addition, 4.9% used HT and 19.2% psychotropic drugs. Regarding their stable partner, median age was 55 years, an 11.5% had less than 7 years of formal
2.5. Sample size calculation
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education, 1.3% abused alcohol, 8.3% had erectile dysfunction and 5.7% premature ejaculation (Table 1). Scores for the MRS, the UCLA-LS and LSI-A are depicted on Table 2 (Descriptive analysis). Cronbach’s alphas for used tools were 0.89 for the MRS, 0.74 for the UCLA-LS and 0.90 for the LSI-A. Rho–Spearman coefficients between total UCLA-LS and LSI-A scores and various numeric variables are displayed on Table 3. Total UCLA-LS scores positively correlated (more loneliness) with female BMI and MRS scores (total and subscale) and an inversely with partner educational level. LSI-A total scores positively correlated with female and partner educational level and inversely with female BMI, neck and hip circumference, diastolic blood pressure, and scores for the MRS (total and subscales) and the UCLA-LS. Multiple linear regression analysis found (all women) that higher UCLA-LS scores (more loneliness) correlated with MRS psychological scores, partner alcohol abuse, living in urban areas, lower LSI-A scores (less life satisfaction) and not having a stable partner. Same trend was observed in the second model (only women with stable partners) in addition to finding a significant and positive correlation with partner alcohol abuse. Lower LSI-A scores (worse life satisfaction), in the first and second regression models, correlated with severe female economical problems, BMI values and UCLA-LS and MRS psychological scores (Table 4).
4. Discussion The menopausal transition is a period of endocrine, metabolic, psychological and social adjustments [32,33]. It is usually accompanied by the appearance of an array of individual symptoms or complaints and morbid conditions, sometimes aggravated by partner and social factors which impair overall QoL [15–19]. Midlife is also a time to make a general balance of life-time desires and projects. This balance may or not correlate in a high or low degree with life satisfaction. Due to these reasons we carried out this research in order to provide novel insights on life satisfaction and loneliness during the menopausal transition. The LSI-A was designed to assess global subjective life satisfaction [4]. Using this index we found positive correlations between LSI-A scores and educational level of both women and partners, and negative correlations with female measures (BMI, neck/hip circumference and diastolic blood pressure), UCLA-LS scores and menopauserelated QoL as measured by the MRS through total and subscale scores. These findings, although obvious, have not been previously reported and highlight how menopause-related QoL and loneliness may reduce life satisfaction; and vice versa lower life satisfaction may increase feelings of loneliness. Upon multivariate analysis in both regression models (all women and those with a stable partner), lower LSI-A scores (worse life satisfaction) were related to severe economical problems and higher BMI values and scores for the MRS (psychological) and the UCLA-LS, suggesting that problems appearing during midlife, independent of the type of partner relationship, may have a negative impact on life satisfaction which go beyond hormonal and age related changes typical issues observed during the menopausal transition. Indeed, our final
Table 1 General demographic data of surveyed women and their partners. Female data
n = 182
Age (years) 40–44 45–49 50–54 55–63 Parity 0 1–2 ≥3 Lives in urban area Marital status Married Single Widowed Divorced Co-habiting Educational level (years) 0–6 7–12 ≥13 Menopausal status Premenopausal Perimenopausal Postmenopausal Natural menopause Surgical menopause Hysterectomy after natural menopause Time since menopause onset (years) Body mass index Baseline BMI kg/m2 Normal (%) Overweight (%) Obese (%) Current smoking (%) Mid arm circumference Neck circumference Abdominal circumference (cm) Abdominal obesity (waist > 88 cm) Hip circumference Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Hypertension (blood pressure ≥140/90 mmHg) Engages in regular exercise (%) Severe working problems Severe economic problems Drug use Hormone therapy Phytoestrogens Psychotropics Oral contraceptive
51.0 [9.0] 14 (7.7) 55 (30.2) 60 (33.0) 53 (29.1) 2.0 [1.0] 25 (13.7) 107 (58.8) 50 (27.5) 169 (29.9) 137 (75.3) 10 (5.5) 6 (3.3) 13 (7.1) 16 (8.8) 13.5 [6.0] 12 (6.6) 68 (37.4) 102 (56) 50 (27.5) 31 (17.0) 101 (55.5) 95 (96.7) 6 (3.3) 0 5.0 [7.0] 24.8 [4.4] 96 (52.7) 64 (35.2) 22 (12.1) 67 (36.8) 29.0 [5.0] 35.0 [4.0] 90.0 [17.0] 105 (57.7) 104 [12.25] 120.0 [15.0] 70.0 [13.0] 3 (1.6) 41 (22.5) 9 (4.9) 7 (3.8) 9 (4.9) 7 (3.8) 35 (19.2) 5 (2.7)
Stable partner
n = 157
Age (years) Educational level partner (years) 0–6 7–12 ≥13 Engages in regular exercise partner (%) Alcohol abuse Erectile dysfunction Premature ejaculation Unfaithfulness
55.0 [10.0] 13.0 [7.0] 18 (11.5) 59 (37.6) 80 (51.0) 42 (26.8) 2 (1.3) 13 (8.3) 9 (5.7) 6 (3.8)
Data are presented as medians [interquartile ranges] or percentages n (%). Table 2 Scores for the MRS, UCLA and LSI-A among studied women (n = 182). MRS (0.89)a
Mean Median p25-p75 IQR a
A.
UCLA-LS (0.74)a
LSI-A (0.90)a
Total
Somatic
Psychological
Urogenital
Total
Total
10.3 8.5 4.0–16.0 12.0
4.1 4.0 1.0–7.0 6.0
3.8 3.0 1.0–6.0 5.0
2.4 2.0 0.0–4.0 4.0
18.4 17.0 12.75–23.25 10.5
12.5 13.0 10.0–15.0 5.0
Cronbach’s alpha; IQR: interquartile range; MRS: menopause rating scale; UCLA-LS: University of California at Los Angeles loneliness scale; LSI-A: life satisfaction index
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regression model did not include age and menopause status as factors influencing the degree of life satisfaction. Nevertheless psychological problems and feelings of loneliness did. The influence of BMI should be considered a general health problem rather than a specific menopause-related association, whereas having severe economical problems a social rather than a medical factor. Therefore in light of our results it seems that life satisfaction during mid life is not per se directly influenced by organic changes induced by ageing and the menopause. More research in this regard is warranted. Previous information regarding the menopause and life satisfaction is limited [8,34]. Dennerstein et al. [34] studied selected mid-aged, well educated, Australian women living in Melbourne using two self-reported measures of life satisfaction (a 13-item LSI and the Diener satisfaction with the life scale) without using any specific QoL instrument. They reported that life satisfaction was positively predicted by earlier attitudes and feelings for their partner and exercise and inversely related to daily complaints, stress, dysphoric symptoms and smoking. Beutel et al. [8] studied a German female population (18–92 years) using the questions on life satisfaction tool along with depression, anxiety, resilience and self-esteem. They reported that among aging women, life satisfaction was related to personal and social resources, and the absence of anxiety and depression. Our findings seem to correlate well with the latter data. Further studies are needed to increase knowledge regarding QoL and life satisfaction using more sophisticated approaches and tools. In this sense Cronbach’s alphas found for tools used in the present research were consistent with appropriate internal consistency. Feelings of loneliness may contribute as a determinant of QoL. Despite this, it is not specifically included in any of the conventional instruments used to measure menopause-related QoL and to date studies assessing feelings of loneliness during the menopausal transition are still lacking. The present study found that higher UCLA-LS scores (more loneliness) positively related to BMI values and MRS scores (total and subscale) and inversely to partner educational level. Upon multivariate analysis both regression models (all women and those only with stable partners) found that higher UCLA-LS scores (more loneliness) directly correlated with MRS
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Table 3 Rho Spearman coefficients between used tools and various numeric variables. Female (n = 182)
UCLA-LS
Age (years) Parity Educational level (years) Body mass index (Kg/m2 ) Abdominal circumference (cm) Mid arm circumference (cm) Neck circumference (cm) Hip circumference (cm) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) UCLA-LS total score Total MRS score Somatic MRS score Psychological MRS score Urogenital MRS score Partner (n = 157)
LSI-A
−0.012 (0.868) −0.041 (0.587) −0.117 (0.117) 0.160 (0.031) −0.012 (0.876) 0.093 (0.210) 0.085 (0.255) 0.117 (0.117) 0.013 (0.857) 0.047 (0.527) – 0.352 (<0.0001) 0.242 (0.001) 0.385 (<0.0001) 0.215 (0.003) UCLA-LS
Age (years) Educational level partner (years)
−0.028 (0.710) 0.003 (0.968) 0.226 (0.002) −0.265 (<0.0001) −0.050 (0.504) −0.140 (0.06) −0.186 (0.012) −0.172 (0.02) −0.130 (0.079) −0.157 (0.034) −0.660 (<0.0001) −0.392 (<0.0001) −0.302 (<0.0001) −0.455 (<0.0001) −0.166 (0.025) LSI-A
0.031 (0.695) −0.229 (0.004)
−0.013 (0.875) 0.310 (<0.0001)
Numbers in parenthesis are p values.
psychological scores, partner alcohol abuse, living in an urban area, lower LSI-A scores (less life satisfaction) and having a stable partner. Again important to mention is the fact that in both models loneliness feelings were neither associated to age nor menopausal status. The menopause is a phenomenon and a time for health, emotional and social adjustments. As already mentioned our data seem to favour psycho-social aspects as determinants of life satisfaction and loneliness in mid-aged women rather than endocrine-related changes. Finally as for the limitations of the study, one can mention its cross sectional design. Despite fulfilling sample size the present study only included women of one Spanish city without any specific sampling procedure and therefore data cannot be extrapolated to the rest of the Spanish or any other European population. This may also be seen as a potential limitation. Another identified drawback was not assessing changes in family structure in order to analyze
Table 4 Factors predicting UCLA-LS and LSI-A scores: multiple linear regression analysis. Factors
Beta coefficient
Standard error
95% CI
t
p value
UCLA-LS for all studied women (n = 182) Lives in urban area MRS psychological Has a stable partner LSI-A r2 = 0.46; adjusted r2 = 0.45, p < 0.0001
3.29 0.22 −2.58 −0.98
1.43 0.11 1.06 0.11
0.45 to 6.12 0.01 to 0.45 −4.69 to −0.47 −1.21 to −0.76
2.29 2.03 −2.42 −8.61
0.02 0.04 0.01 <0.0001
UCLA-LS for women with stable partner (n = 157) 3.76 Lives in urban area 0.26 MRS psychological 8.20 Partner alcohol abuse −0.88 LSI-A r2 = 0.45; adjusted r2 = 0.44, p < 0.0001
1.56 0.11 3.53 0.12
0.68 to 6.85 0.02 to 0.49 1.21 to 15.2 −1.11 to −0.64
2.41 2.22 2.32 −7.35
0.01 0.02 0.02 <0.0001
LSI-A for all studied women (n = 182) Severe economic problems BMI MRS psychological UCLA-LS r2 = 0.51; adjusted r2 = 0.50, p < 0.0001
−2.56 −0.17 −0.22 −0.28
1.04 0.06 0.05 0.03
−4.61 to −0.51 −0.29 to −0.04 −0.33 to −0.10 −0.35 to −0.22
−2.46 −2.64 −3.72 −8.93
0.01 0.009 <0.0001 <0.0001
LSI-A for women with stable partner (n = 157) Severe economic problems −2.54 −0.14 BMI −0.20 MRS Psychological UCLA-LS −0.27 r2 = 0.50; adjusted r2 = 0.49, p < 0.0001
1.09 0.06 0.06 0.03
−4.71 to −0.38 −0.27 to −0.01 −0.33 to −0.07 −0.34 to −0.19
−2.32 −2.10 −3.08 −7.29
0.02 0.03 0.002 <0.0001
CI: confidence intervals.
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the effect of relatives leaving home (especially siblings). Despite the aforementioned limitations, a strength can be mentioned for the study: it is to the best of our knowledge the first to assess life satisfaction and loneliness in mid aged women using validated tools including a menopause related QoL one. In conclusion, loneliness and life satisfaction in this midaged female Spanish sample was influenced by personal and partner issues. Social (living in an urban area or having economical problems) and partner factors contributed in a higher degree to loneliness and life satisfaction, regardless of age and the menopausal status. Further studies are warranted to support the findings of the present study and delineate the importance of social and general factors influencing several aspects of health of mid-aged woman. Contributors Faustino R. Pérez-López and Ana María Fernández-Alonso were involved in conception and design. Ana M. Fernández-Alonso, Martina Trabalón-Pastor and Carmen Vara were involved in data acquisition. Ana M. Fernández-Alonso and Peter Chedraui performed the statistical analysis. Faustino R. Pérez-López and Peter Chedraui did the drafting of the manuscript. All authors were involved in critically revising the manuscript for its intellectual content; and the final approval of the manuscript was done by all authors. Conflict of interest The authors declare no conflict of interests. Funding None Acknowledgement The authors would like to thank the support provided by Dr. Gabriel Fiol-Ruiz during the recruitment of the study participants. References [1] Borg C, Fagerström C, Balducci C, et al. Life satisfaction of older people in six European countries: findings from the European study on adult well-being. Geriatr Nurs 2008;29:48–57. [2] Uswitch PL. 2010 Quality of life index; 2010 [accessed 30.10.11] http://www.uswitch.com/news/money/uk-worst-place-to-live-in-europeuswitch-quality-of-life-index-890419/. [3] Mercer’s 2011 Quality of Life of living ranking highlights. Global. http://www.mercer.com/articles/quality-of-living-survey-report-2011, 2011 [accessed 30.10.11]. [4] Neugarten BL, Havighurst RJ, Tobin SS. The measurement of life satisfaction. J Gerontol 1961;16:134–43. [5] Life satisfaction index (LSI). https://instruct.uwo.ca/kinesiology/ 9641/Assessments/Psychological/LSI.html [accessed 30.10.11]. [6] Chida Y, Steptoe A. Positive psychological well-being and mortality: a quantitative review of prospective observational studies. Psychosom Med 2008;70:741–56. [7] Lacruz ME, Emeny RT, Baumert J, Ladwig KH. Prospective association between self-reported life satisfaction and mortality: results from the MONICA/KORA Augsburg S3 survey cohort study. BMC Public Health 2011;11: 579.
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Short Communication
Life satisfaction, loneliness and related factors during female midlife Ana M. Fernández-Alonso a , Martina Trabalón-Pastor a , Carmen Vara a , Peter Chedraui b , Faustino R. Pérez-López c,∗ , for The MenopAuse RIsk Assessment (MARIA) Research Group a b c
Obstetrics and Gynecology Department, Hospital Torrecárdenas, Almería, Spain Instituto para la Salud de la Mujer, Facultad de Ciencias Médicas, Universidad Católica de Guayaquil, Guayaquil, Ecuador Obstetrics and Gynecology Department, Universidad de Zaragoza, Hospital Clínico, Zaragoza, Spain
a r t i c l e
i n f o
Article history: Received 20 January 2012 Received in revised form 31 January 2012 Accepted 1 February 2012
Keywords: Midlife Life satisfaction index Menopause Loneliness UCLA loneliness scale Quality of life Menopause rating scale
a b s t r a c t Background: Studies assessing life satisfaction and feelings of loneliness in mid-aged women are scarce. Objective: To assess loneliness, life satisfaction and related factors in mid-aged Spanish women. Method: This was a cross sectional study in which 182 women aged 40 to 65 completed the menopause rating scale (MRS), the University of California at Los Angeles loneliness scale (UCLA-LS), the life satisfaction index A (LSI-A), and a general socio-demographic questionnaire containing personal/partner data. Internal consistency of each tool was also computed. Results: Median [interquartile range] age of the sample was 51 [9.0] years. A 55.5% were postmenopausal, 47.3% had increased body mass index (BMI) values, 57.7% were abdominally obese, 1.6% had hypertension and 86.3% had a stable partner. In addition, 4.9% used hormone therapy and 19.2% psychotropic drugs. Multiple linear regression analysis found that higher UCLA-LS scores (more loneliness) correlated with MRS psychological scores, partner alcohol abuse, living in urban areas, lower LSI-A scores (less life satisfaction) and not having a stable partner. Lower LSI-A scores (worse life satisfaction) correlated with severe female economical problems, BMI values and UCLA-LS and MRS psychological scores. Conclusion: Loneliness and life satisfaction in this mid-aged female sample was influenced by personal and partner issues which seem to play a much more relevant role than biological aspects. More research is warranted in this regard. © 2012 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Life satisfaction is not a univocal concept as it is used in many circumstances to collectively express the objective determinants of broad socio-economical well-being or quality of life (QoL), including a variety of factors such as economic level, non-market activities, human rights, social problems and support, or environmental pollution endpoints [1–3]. Human life satisfaction includes psychological well-being, feelings of happiness with everyday life, and achieved major goals [4,5]. It is also a major component of the World Health Organization definition of health, and a useful measure in health studies especially for individuals with physical disabilities. Reports indicate that life satisfaction may relate to
∗ Corresponding author at: Department of Obstetrics and Gynecology, University of Zaragoza Hospital Clínico, Domingo Miral s/n, Zaragoza 50009, Spain. Fax: +34 976 76 1735. E-mail addresses: [email protected], [email protected] (F.R. Pérez-López). 0378-5122/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.maturitas.2012.02.001
mortality, resilience, household income, partner relationships, lack of anxiety or depression, employment, positive self-esteem and religious beliefs [6–8]. Loneliness or feeling lonely is a frequent complaint in women during the menopausal transition. It is a distress produced when family and social relationships are perceived as less gratifying than expected [9]. In the general population, loneliness is a serious social problem related to the lack of emotional support, low self-esteem, depression, sleep disorders and also negative health outcomes [10–13]. Subjects who lack social support follow fewer healthy recommendations and engage in more risky behaviours [14]. Despite the aforementioned, loneliness is usually not assessed among midaged women or in relation to menopause related QoL or symptoms [15–19]. Mid-aged women are exposed to profound changes, not only linked to hormonal adjustments yet also social and emotional changes not included in conventional menopause-related QoL instruments. Data regarding life satisfaction and loneliness during the menopausal transition are still lacking. Hence, the objective of the present study was to assess these issues and related factors in mid-aged Spanish women.
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2. Method
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scores obtained for each subscale [25,17]. Higher MRS scores are indicative of QoL impairment.
2.1. Study design and participants This was a cross-sectional study carried out from November 2010 to June 2011 in which women (40 to 65 years) who were accompanying or visiting patients being attended for at gynaecological and obstetrical healthcare facilities of the Torrecárdenas Hospital, Almería, Spain, were requested to fill out the menopause rating scale (MRS), the University of California at Los Angeles loneliness scale (UCLA-LS), the life satisfaction index A (LSI-A), and an itemized questionnaire containing female/partner sociodemographic data. Women unable to understand the survey, not consenting participation or with psychological or physical incapacity imposing difficulties during the interview were excluded. Study research protocol was reviewed and approved by the Torrecárdenas Hospital Ethical Committee, Almería, Spain. All participants were informed of the study (objectives and used tools) and requested to voluntarily participate after providing written consent. 2.2. General socio-demographic questionnaire 2.2.1. Female data Female data included: age (years), parity, marital status, education (years), menopausal status (pre-, peri- or postmenopausal), time since menopause (years), current partner status (yes/no), body mass index (BMI), anthropometric measurements (neck, mid-arm, waist and hip circumference) and systolic and diastolic blood pressure (mmHg) values. Lifestyle and other personal factors included: smoking habit, regular exercise (yes/no), working and or economical problems (yes/no). Current drug use included: psychotropic drugs, oral contraceptives and hormone therapy (HT) or phytoestrogens for the menopause. Menopausal status was defined using criteria of the Stages of Reproductive Aging Workshop: premenopausal (women having regular menses), perimenopausal (irregularities > 7 days from their normal cycle) and postmenopausal (no more menses in the last 12 months either natural or surgical) [20]. Those with bilateral oophorectomy were also considered as postmenopausal. Women performing less than 15 min of physical activity (i.e. walking) two times per week were defined as sedentary [21] and those on medication or displaying blood pressure readings equal or above 140/90 were defined as hypertense [22,23]. Waist or abdominal, hip, neck and mid-arm circumferences were measured in centimetres (cm). A waist circumference greater than 88 cm was used to define abdominal obesity [22].
2.3.2. The University of California at Los Angeles loneliness scale The 10-item UCLA-LS validated in Spanish was used to measure general loneliness and the degree of satisfaction with subject’s social network [26,27]. Each item is rated on a scale of 1 (never), 2 (rarely), 3 (sometimes) and 4 (often). Scores may range from 10 to 40, with higher scores meaning greater loneliness [27–29]. 2.3.3. The life satisfaction index A The LSI-A is an instrument used to assess “successful aging”, a more complex process/phenomenon than the simple feeling good about oneself or the attainment of goals [4,5]. It is a construct that cannot be measured directly, and thus it should be indirectly assessed through its latent variables [30]. The present study used the original LSI-A validated in Spanish [31] which comprises 20 items that may be rated as agree (1 point), disagree (0 points), or uncertain (0 points) [4]. Possible total scores may range from between 0 to 20, with higher scores indicating higher life satisfaction. Neugarten et al. [4] have reported a mean score of 12.4 (SD 4.4) in their original study. 2.4. Statistical analysis Statistical analysis was performed using SPSS software package (Version 19.0 for Windows, SPSS Inc., Chicago, Illinois, USA). Data are presented as means, medians, interquartile ranges, percentiles (p25–p75), percentages, coefficients and 95% confidence intervals. The Kolmogorov Smirnov test was used to determine the normality of data distribution. According to this, non parametric data were compared with the Mann–Whitney (two independent samples) or the Kruskal–Wallis test (various independent samples). Rho–Spearman coefficients were calculated to determine correlations between scores of used tools and various numeric variables. Multiple linear regression analysis was performed to obtain a best model predicting total UCLA-LS and LSI-A scores (dependant variables). For this, first univariate analysis was performed to obtain potential independent variables (female and partner) with a 10% significance level to be entered into two models one including all studied women and the second only those with a stable partner. Variables were then entered into the model using a backward stepwise procedure. For all calculations a p value of <0.05 was considered as statistically significant. Internal consistency of used instruments was assessed computing Cronbach’s coefficient alphas for the MRS, the UCLA-LS and the LSI-A.
2.2.2. Partner data Women provided data related to partner including: age, educational level, regular exercising (yes/no), unfaithfulness (yes/no), alcohol abuse (yes/no), and the presence of sexual dysfunction (erectile dysfunction and or premature ejaculation). Definitions for alcoholism, erectile dysfunction, and premature ejaculation have previously been described [24].
Sample size calculation was based on the fact that 20% of midaged women would have increased life satisfaction [7]. Hence a minimal sample of 106 women was calculated considering a 10% desired precision and a 99% confidence interval.
2.3. Instruments
3. Results
2.3.1. The menopause rating scale The menopause rating scale is a health-related quality-of-life instrument composed of 11 items that assesses menopausal symptoms grouped into three subscales: somatic, psychological and urogenital. Women may grade each item from 0 (not present) to 4 (1 = mild; 2 = moderate; 3 = severe; 4 = very severe). For a particular individual, the total subscale score is the sum of each graded item contained in that subscale. The total MRS score is the sum of
During the studied period a total of 200 women were invited to participate, 9% (n = 18) denied participation, leaving 182 complete surveys for analysis. Median [interquartile range] age of the sample was 51 [9.0] years. A 55.5% were postmenopausal, 47.3% had increased BMI values, 57.7% were abdominally obese, 1.6% had hypertension and 86.3% had a stable partner. In addition, 4.9% used HT and 19.2% psychotropic drugs. Regarding their stable partner, median age was 55 years, an 11.5% had less than 7 years of formal
2.5. Sample size calculation
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education, 1.3% abused alcohol, 8.3% had erectile dysfunction and 5.7% premature ejaculation (Table 1). Scores for the MRS, the UCLA-LS and LSI-A are depicted on Table 2 (Descriptive analysis). Cronbach’s alphas for used tools were 0.89 for the MRS, 0.74 for the UCLA-LS and 0.90 for the LSI-A. Rho–Spearman coefficients between total UCLA-LS and LSI-A scores and various numeric variables are displayed on Table 3. Total UCLA-LS scores positively correlated (more loneliness) with female BMI and MRS scores (total and subscale) and an inversely with partner educational level. LSI-A total scores positively correlated with female and partner educational level and inversely with female BMI, neck and hip circumference, diastolic blood pressure, and scores for the MRS (total and subscales) and the UCLA-LS. Multiple linear regression analysis found (all women) that higher UCLA-LS scores (more loneliness) correlated with MRS psychological scores, partner alcohol abuse, living in urban areas, lower LSI-A scores (less life satisfaction) and not having a stable partner. Same trend was observed in the second model (only women with stable partners) in addition to finding a significant and positive correlation with partner alcohol abuse. Lower LSI-A scores (worse life satisfaction), in the first and second regression models, correlated with severe female economical problems, BMI values and UCLA-LS and MRS psychological scores (Table 4).
4. Discussion The menopausal transition is a period of endocrine, metabolic, psychological and social adjustments [32,33]. It is usually accompanied by the appearance of an array of individual symptoms or complaints and morbid conditions, sometimes aggravated by partner and social factors which impair overall QoL [15–19]. Midlife is also a time to make a general balance of life-time desires and projects. This balance may or not correlate in a high or low degree with life satisfaction. Due to these reasons we carried out this research in order to provide novel insights on life satisfaction and loneliness during the menopausal transition. The LSI-A was designed to assess global subjective life satisfaction [4]. Using this index we found positive correlations between LSI-A scores and educational level of both women and partners, and negative correlations with female measures (BMI, neck/hip circumference and diastolic blood pressure), UCLA-LS scores and menopauserelated QoL as measured by the MRS through total and subscale scores. These findings, although obvious, have not been previously reported and highlight how menopause-related QoL and loneliness may reduce life satisfaction; and vice versa lower life satisfaction may increase feelings of loneliness. Upon multivariate analysis in both regression models (all women and those with a stable partner), lower LSI-A scores (worse life satisfaction) were related to severe economical problems and higher BMI values and scores for the MRS (psychological) and the UCLA-LS, suggesting that problems appearing during midlife, independent of the type of partner relationship, may have a negative impact on life satisfaction which go beyond hormonal and age related changes typical issues observed during the menopausal transition. Indeed, our final
Table 1 General demographic data of surveyed women and their partners. Female data
n = 182
Age (years) 40–44 45–49 50–54 55–63 Parity 0 1–2 ≥3 Lives in urban area Marital status Married Single Widowed Divorced Co-habiting Educational level (years) 0–6 7–12 ≥13 Menopausal status Premenopausal Perimenopausal Postmenopausal Natural menopause Surgical menopause Hysterectomy after natural menopause Time since menopause onset (years) Body mass index Baseline BMI kg/m2 Normal (%) Overweight (%) Obese (%) Current smoking (%) Mid arm circumference Neck circumference Abdominal circumference (cm) Abdominal obesity (waist > 88 cm) Hip circumference Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Hypertension (blood pressure ≥140/90 mmHg) Engages in regular exercise (%) Severe working problems Severe economic problems Drug use Hormone therapy Phytoestrogens Psychotropics Oral contraceptive
51.0 [9.0] 14 (7.7) 55 (30.2) 60 (33.0) 53 (29.1) 2.0 [1.0] 25 (13.7) 107 (58.8) 50 (27.5) 169 (29.9) 137 (75.3) 10 (5.5) 6 (3.3) 13 (7.1) 16 (8.8) 13.5 [6.0] 12 (6.6) 68 (37.4) 102 (56) 50 (27.5) 31 (17.0) 101 (55.5) 95 (96.7) 6 (3.3) 0 5.0 [7.0] 24.8 [4.4] 96 (52.7) 64 (35.2) 22 (12.1) 67 (36.8) 29.0 [5.0] 35.0 [4.0] 90.0 [17.0] 105 (57.7) 104 [12.25] 120.0 [15.0] 70.0 [13.0] 3 (1.6) 41 (22.5) 9 (4.9) 7 (3.8) 9 (4.9) 7 (3.8) 35 (19.2) 5 (2.7)
Stable partner
n = 157
Age (years) Educational level partner (years) 0–6 7–12 ≥13 Engages in regular exercise partner (%) Alcohol abuse Erectile dysfunction Premature ejaculation Unfaithfulness
55.0 [10.0] 13.0 [7.0] 18 (11.5) 59 (37.6) 80 (51.0) 42 (26.8) 2 (1.3) 13 (8.3) 9 (5.7) 6 (3.8)
Data are presented as medians [interquartile ranges] or percentages n (%). Table 2 Scores for the MRS, UCLA and LSI-A among studied women (n = 182). MRS (0.89)a
Mean Median p25-p75 IQR a
A.
UCLA-LS (0.74)a
LSI-A (0.90)a
Total
Somatic
Psychological
Urogenital
Total
Total
10.3 8.5 4.0–16.0 12.0
4.1 4.0 1.0–7.0 6.0
3.8 3.0 1.0–6.0 5.0
2.4 2.0 0.0–4.0 4.0
18.4 17.0 12.75–23.25 10.5
12.5 13.0 10.0–15.0 5.0
Cronbach’s alpha; IQR: interquartile range; MRS: menopause rating scale; UCLA-LS: University of California at Los Angeles loneliness scale; LSI-A: life satisfaction index
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regression model did not include age and menopause status as factors influencing the degree of life satisfaction. Nevertheless psychological problems and feelings of loneliness did. The influence of BMI should be considered a general health problem rather than a specific menopause-related association, whereas having severe economical problems a social rather than a medical factor. Therefore in light of our results it seems that life satisfaction during mid life is not per se directly influenced by organic changes induced by ageing and the menopause. More research in this regard is warranted. Previous information regarding the menopause and life satisfaction is limited [8,34]. Dennerstein et al. [34] studied selected mid-aged, well educated, Australian women living in Melbourne using two self-reported measures of life satisfaction (a 13-item LSI and the Diener satisfaction with the life scale) without using any specific QoL instrument. They reported that life satisfaction was positively predicted by earlier attitudes and feelings for their partner and exercise and inversely related to daily complaints, stress, dysphoric symptoms and smoking. Beutel et al. [8] studied a German female population (18–92 years) using the questions on life satisfaction tool along with depression, anxiety, resilience and self-esteem. They reported that among aging women, life satisfaction was related to personal and social resources, and the absence of anxiety and depression. Our findings seem to correlate well with the latter data. Further studies are needed to increase knowledge regarding QoL and life satisfaction using more sophisticated approaches and tools. In this sense Cronbach’s alphas found for tools used in the present research were consistent with appropriate internal consistency. Feelings of loneliness may contribute as a determinant of QoL. Despite this, it is not specifically included in any of the conventional instruments used to measure menopause-related QoL and to date studies assessing feelings of loneliness during the menopausal transition are still lacking. The present study found that higher UCLA-LS scores (more loneliness) positively related to BMI values and MRS scores (total and subscale) and inversely to partner educational level. Upon multivariate analysis both regression models (all women and those only with stable partners) found that higher UCLA-LS scores (more loneliness) directly correlated with MRS
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Table 3 Rho Spearman coefficients between used tools and various numeric variables. Female (n = 182)
UCLA-LS
Age (years) Parity Educational level (years) Body mass index (Kg/m2 ) Abdominal circumference (cm) Mid arm circumference (cm) Neck circumference (cm) Hip circumference (cm) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) UCLA-LS total score Total MRS score Somatic MRS score Psychological MRS score Urogenital MRS score Partner (n = 157)
LSI-A
−0.012 (0.868) −0.041 (0.587) −0.117 (0.117) 0.160 (0.031) −0.012 (0.876) 0.093 (0.210) 0.085 (0.255) 0.117 (0.117) 0.013 (0.857) 0.047 (0.527) – 0.352 (<0.0001) 0.242 (0.001) 0.385 (<0.0001) 0.215 (0.003) UCLA-LS
Age (years) Educational level partner (years)
−0.028 (0.710) 0.003 (0.968) 0.226 (0.002) −0.265 (<0.0001) −0.050 (0.504) −0.140 (0.06) −0.186 (0.012) −0.172 (0.02) −0.130 (0.079) −0.157 (0.034) −0.660 (<0.0001) −0.392 (<0.0001) −0.302 (<0.0001) −0.455 (<0.0001) −0.166 (0.025) LSI-A
0.031 (0.695) −0.229 (0.004)
−0.013 (0.875) 0.310 (<0.0001)
Numbers in parenthesis are p values.
psychological scores, partner alcohol abuse, living in an urban area, lower LSI-A scores (less life satisfaction) and having a stable partner. Again important to mention is the fact that in both models loneliness feelings were neither associated to age nor menopausal status. The menopause is a phenomenon and a time for health, emotional and social adjustments. As already mentioned our data seem to favour psycho-social aspects as determinants of life satisfaction and loneliness in mid-aged women rather than endocrine-related changes. Finally as for the limitations of the study, one can mention its cross sectional design. Despite fulfilling sample size the present study only included women of one Spanish city without any specific sampling procedure and therefore data cannot be extrapolated to the rest of the Spanish or any other European population. This may also be seen as a potential limitation. Another identified drawback was not assessing changes in family structure in order to analyze
Table 4 Factors predicting UCLA-LS and LSI-A scores: multiple linear regression analysis. Factors
Beta coefficient
Standard error
95% CI
t
p value
UCLA-LS for all studied women (n = 182) Lives in urban area MRS psychological Has a stable partner LSI-A r2 = 0.46; adjusted r2 = 0.45, p < 0.0001
3.29 0.22 −2.58 −0.98
1.43 0.11 1.06 0.11
0.45 to 6.12 0.01 to 0.45 −4.69 to −0.47 −1.21 to −0.76
2.29 2.03 −2.42 −8.61
0.02 0.04 0.01 <0.0001
UCLA-LS for women with stable partner (n = 157) 3.76 Lives in urban area 0.26 MRS psychological 8.20 Partner alcohol abuse −0.88 LSI-A r2 = 0.45; adjusted r2 = 0.44, p < 0.0001
1.56 0.11 3.53 0.12
0.68 to 6.85 0.02 to 0.49 1.21 to 15.2 −1.11 to −0.64
2.41 2.22 2.32 −7.35
0.01 0.02 0.02 <0.0001
LSI-A for all studied women (n = 182) Severe economic problems BMI MRS psychological UCLA-LS r2 = 0.51; adjusted r2 = 0.50, p < 0.0001
−2.56 −0.17 −0.22 −0.28
1.04 0.06 0.05 0.03
−4.61 to −0.51 −0.29 to −0.04 −0.33 to −0.10 −0.35 to −0.22
−2.46 −2.64 −3.72 −8.93
0.01 0.009 <0.0001 <0.0001
LSI-A for women with stable partner (n = 157) Severe economic problems −2.54 −0.14 BMI −0.20 MRS Psychological UCLA-LS −0.27 r2 = 0.50; adjusted r2 = 0.49, p < 0.0001
1.09 0.06 0.06 0.03
−4.71 to −0.38 −0.27 to −0.01 −0.33 to −0.07 −0.34 to −0.19
−2.32 −2.10 −3.08 −7.29
0.02 0.03 0.002 <0.0001
CI: confidence intervals.
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the effect of relatives leaving home (especially siblings). Despite the aforementioned limitations, a strength can be mentioned for the study: it is to the best of our knowledge the first to assess life satisfaction and loneliness in mid aged women using validated tools including a menopause related QoL one. In conclusion, loneliness and life satisfaction in this midaged female Spanish sample was influenced by personal and partner issues. Social (living in an urban area or having economical problems) and partner factors contributed in a higher degree to loneliness and life satisfaction, regardless of age and the menopausal status. Further studies are warranted to support the findings of the present study and delineate the importance of social and general factors influencing several aspects of health of mid-aged woman. Contributors Faustino R. Pérez-López and Ana María Fernández-Alonso were involved in conception and design. Ana M. Fernández-Alonso, Martina Trabalón-Pastor and Carmen Vara were involved in data acquisition. Ana M. Fernández-Alonso and Peter Chedraui performed the statistical analysis. Faustino R. Pérez-López and Peter Chedraui did the drafting of the manuscript. All authors were involved in critically revising the manuscript for its intellectual content; and the final approval of the manuscript was done by all authors. Conflict of interest The authors declare no conflict of interests. Funding None Acknowledgement The authors would like to thank the support provided by Dr. Gabriel Fiol-Ruiz during the recruitment of the study participants. References [1] Borg C, Fagerström C, Balducci C, et al. Life satisfaction of older people in six European countries: findings from the European study on adult well-being. Geriatr Nurs 2008;29:48–57. [2] Uswitch PL. 2010 Quality of life index; 2010 [accessed 30.10.11] http://www.uswitch.com/news/money/uk-worst-place-to-live-in-europeuswitch-quality-of-life-index-890419/. [3] Mercer’s 2011 Quality of Life of living ranking highlights. Global. http://www.mercer.com/articles/quality-of-living-survey-report-2011, 2011 [accessed 30.10.11]. [4] Neugarten BL, Havighurst RJ, Tobin SS. The measurement of life satisfaction. J Gerontol 1961;16:134–43. [5] Life satisfaction index (LSI). https://instruct.uwo.ca/kinesiology/ 9641/Assessments/Psychological/LSI.html [accessed 30.10.11]. [6] Chida Y, Steptoe A. Positive psychological well-being and mortality: a quantitative review of prospective observational studies. Psychosom Med 2008;70:741–56. [7] Lacruz ME, Emeny RT, Baumert J, Ladwig KH. Prospective association between self-reported life satisfaction and mortality: results from the MONICA/KORA Augsburg S3 survey cohort study. BMC Public Health 2011;11: 579.
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