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Dysmenorrhea and related factors in Taiwanese adolescent girls

Dissertation
Author: I-Chen Lu
Abstract:
The purpose of this cross-sectional, correlational study was to validate the factors that are related to dysmenorrhea in Taiwanese adolescents. The specific aims were to describe the perceived dysmenorrhea pain symptom experience (SE), related self-care strategies (SCS), and perceived effectiveness of self-care strategies (PESS); to explore the relationships between SE, SCS, and PESS; and to explore the influence of contextual factors on SE, SCS, and PESS. A conceptual framework based on the revised Symptom Management Model was developed and guided this study. A nonprobability sample of 165 adolescent participants was recruited from a technology university located in southern Taiwan. Inclusion criteria for participants were: (1) Taiwanese female adolescent, (2) age 15-19 years old, and (3) willing to participate in this study. All participants and their parents completed the consent forms and completed the questionnaires in their classrooms during free studying time. Five instruments were used and data was analyzed by using the SPSS Version 14.0 including descriptive statistical techniques, Pearson's correlations, ANOVA, and multiple regression analysis. The findings showed the prevalence of dysmenorrhea in this sample was 87.3%. There were 82.4% of participants who reported dysmenorrhea had influenced their daily activity, and 12.7% of participants who reported school absenteeism because of dysmenorrhea. Most of participants used self-care strategies for dysmenorrhea including avoiding cold food or drinks, drinking brown sugar and ginger soup, etc. The most frequently used self-care strategies and their effectiveness were described. Age, age of the first period, total menstrual years, eating cold food or drinks, self-care strategies, and mother's perceived support of self-care strategies were significantly related to the log of symptom experience of dysmenorrhea. Total menstrual years and self-care strategies were identified as significant predictors of dysmenorrhea. This study added to the body of nursing science regarding dysmenorrhea in Taiwanese adolescents. In particular, the findings supported the existence of relationships between self-care strategies and perceived effectiveness of self-care strategies. Building on these findings, future research should be conducted to design interventions that reduce the pain associated with dysmenorrhea for this population.

Table of Contents List of Tables ...................................................................................................... xii List of Figures .................................................................................................... xiv Chapter 1 Introduction ..........................................................................................1 Purpose ..........................................................................................................2 Background and Significance .......................................................................2 Conceptual Framework ...............................................................................5 Research Questions ...................................................................................11 Definitions .................................................................................................12 Assumptions ..............................................................................................14 Summary ...................................................................................................14 Chapter 2 Literature Review ...............................................................................16 Overview of Dysmenorrhea ..........................................................................16 Experience of Dysmenorrhea in Adolescent Girls........................................18 Self-Care strategies for Dysmenorrhea .......................................................21 Effectiveness of the Self-Care Strategies for Dysmenorrhea ...................26 The Influence of Multiple Factors Related to Dysmenorrhea ................26 Knowledge Gaps in the Studies Related to Dysmenorrhea in Taiwan .....31 Limitations of Reviewed Studies ..............................................................32 Summary and Conclusion .......................................................................34 Chapter 3 Methodology ....................................................................................35 Research Design ..........................................................................................35 Population and Sample ...............................................................................36 Procedure for Protection of Human Subjects ............................................36 Data Collection Method ............................................................................37 Instrumentation .........................................................................................38 Data Analysis ............................................................................................47 Pilot Study .................................................................................................49

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Summary ...................................................................................................52 Chapter 4 Results ..............................................................................................54 Findings of the Main Study .......................................................................54 Demographic Characteristics of Participants ...................................54 Body Mass Index (BMI) ..................................................................57 Menstruation Characteristics .........................................................57 Dysmenorrhea Characteristics .......................................................60 Health Habits .................................................................................63 Exercise Habits ..............................................................................64 Data Analysis to Answer Research Questions ..........................................66 Research Question 1 ......................................................................66 Research Question 2 ......................................................................71 Research Question 3 ......................................................................73 Research Question 4 ......................................................................76 Research Question 5 ......................................................................78 Research Question 6 ......................................................................86 Summary ...................................................................................................88 Chapter 5 Interpretations and Discussions ........................................................91 Discussions of Findings ............................................................................92 Finding Related to Symptom Experience of Dysmenorrhea ...........92 Finding Related to Self-Care Strategies for Dysmenorrhea ............92 Finding Related to Perceived Effectiveness of Self-Care Strategies .....................................................................................................94 Finding Related to Mother’s Perceived Support of Self-Care Strategies .....................................................................................................95 Findings regarding to the Relationship between Contextual Factors and Dysmenorrhea .....................................................................96 Issues related to Conceptual Model ..........................................................98 Implications and Recommendations .......................................................100 Limitations ..............................................................................................103 Summary of the Study ..........................................................................104

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Appendix A Instruments (English/Chinese) ...................................................107 Appendix B Consent Form (English/Chinese) .................................................132 Reference .............................................................................................................154 Vita .. ....................................................................................................................161

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List of Tables Table 1: Conceptual links Between the Symptom Management Model, Study Variables and Measurement Tools ..................................................40 Table 2: Demographic Characteristics of Participants ..................................56 Table 3: Distribution of BMI in the participants ...........................................57 Table 4: Menstruation Characteristics ..........................................................59 Table 5: Dysmenorrhea Characteristics ........................................................62 Table 6: Health Habit Characteristics ...........................................................64 Table 7: Exercise Habit Characteristics ........................................................66 Table 8: Distribution of Short Form McGill Pain Questionnaire (SF-MPQ).68 Table 9: Distribution of Visual Analogue Scale (VAS)..................................70 Table 10: ADSCS Scores of the Participants ..................................................72 Table 11: The Top Five Items of Self-Care Strategies Mostly Used by Participants ......................................................................................73 Table 12: PESSQ Scores of Participants (Sorted by Effectiveness Order) .......75 Table 13: MPSSQ Scores of Participants (Sorted by Support Order) ............77 Table 14: Pearson’s Correlations among Personal Factors and SE, SCS, PESS ...........................................................................................................79 Table 15: Spearman’s rho Correlations among Personal Factors and SE, SCS, PESS .................................................................................................80 Table 16: ANOVA Test on Symptom Experience of Dysmenorrhea (SE) by Personal Factors ..............................................................................81 Table 17: ANOVA Test on Self-Care Strategies for Dysmenorrhea by Social Economic Status................................................................................82

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Table 18: Pearson’s Correlations among Health and Illness factors and SE, SCS, PESS ...............................................................................................82 Table 19: Spearman’s rho Correlations among Health and Illness Factors and SE, SCS, PESS ................................................................................83 Table 20: ANOVA Test on Symptom Experience of Dysmenorrhea (SE) by Health and Illness Factors .................................................................84 Table 21: Pearson’s Correlations among SE, SCS, PESS, and MPSS ...........85 Table 22: Spearman’s rho Correlations among SE, SCS, PESS, and MPSS ..86 Table 23: Hierarchical Multiple Regression of Predictors on SE ...................88

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List of Figures Figure 1: Conceptual Framework for Symptom Management of Dysmenorrhea ...........................................................................................................10 Figure 2: Symptom Experience of Dysmenorrhea .........................................69 Figure 3: Visual Analogue Scale ..................................................................71

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CHAPTER ONE INTRODUCTION Some reproductive age women experience significant pain with menstruation, a phenomenon called dysmenorrhea (Helms, 1987). Primary dysmenorrhea is the most prevalent menstrual health problem in childbearing age women. Adolescents have the highest prevalence of dysmenorrhea with approximately 90 percent experiencing the problem (Coco, 1999; French, 2005). Dysmenorrhea is also a common health problem in the female adolescent population in Taiwan, with estimates ranging from 73.3 to 89.4 percent in adolescent girls in Taiwan (Chiou & Wang, 2004; Chiou & Wang, 2008; Ko & Kao, 2004). However, the factors associated with dysmenorrhea are not well defined. A better understanding of factors associated with dysmenorrhea in adolescent girls should facilitate development of clinical evaluation strategies as well as development of prevention and treatment strategies (EI-Gilany, Badawi, & EI-Fedawy, 2005; Ko, & Kao, 2004; Sundell, Milsom, & Andersch, 1990; Lee, Chen, Lee, & Kaur, 2006). Dysmenorrhea can significantly affect the individual’s ability to perform daily activities affecting productivity and role performance with the associated stress (Davis and Westhoff, 2001; Woods, 1985). In the United States, school absenteeism for adolescent girls is commonly as a result of dysmenorrhea; in addition, dysmenorrhea significantly alters academic performance and sporting activities for symptomatic adolescents (Banikarim, Chacko, & Kelder, 2000). Similarly, Taiwanese adolescents with dysmenorrhea reported the consequences of dysmenorrhea in Taiwan include inability to

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concentrate in class (64.6 %), to attend physical training class (33.8%), to attend extracurricular activities (25 %) and to attend school (8.8%) (Chiou, & Wang, 2008). However, dysmenorrhea is so common that many women do not report it to health providers even when their daily activities are restricted (Coco, 1999). Chiou & Wang (2008) found that only 4.1% of symptomatic Taiwanese adolescents report their dysmenorrhea to either physicians or school nurses. Most symptomatic Taiwanese adolescents endure dysmenorrhea and its impact on their lives because they believe dysmenorrhea is a normal phenomenon (Yang, 2006). Consequently, most adolescent girls with dysmenorrhea used self-care strategies to manage their discomfort instead of seeking interventions prescribed by health care professionals (Chiou, & Wang, 2008). However, there is a knowledge gap regarding the relationship between these culture- based self-care strategies and their perceived effectiveness in Taiwanese adolescents. Purpose The purpose of this study was to validate the factors that are related to dysmenorrhea in Taiwanese adolescents. The specific aims were to describe the perceived dysmenorrhea pain symptom experience (SE), related self-care strategies (SCS), and perceived effectiveness of self-care strategies (PESS); to explore the relationships between SE, SCS, and PESS; and to explore the influence of contextual factors on SE, SCS, and PESS. Background and Significance Dysmenorrhea is a common heath problem in Taiwan as well as in the United States affecting the daily lives of symptomatic adolescents. Studies in Taiwan indicate that the consequences of dysmenorrhea include failure to concentrate in class (64.6 %), failure to

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attend physical training class (33.8%), failure to attend extracurricular activities (25 %) and failure to attend school (8.8%) (Chiou, & Wang, 2008). Unlike studies conducted in the United States, descriptive research in Taiwan indicates that adolescents with dysmenorrhea report emotional behavior including weeping, expressing strong feelings, and asking help from their family members and intimate friends as characteristics of dysmenorrhea experience (Chen, Lin, Heitkemper & Wu, 2006). Previous studies have reported that dysmenorrhea significantly affects the symptomatic Taiwanese adolescents’ lives in terms of emotional status, school absenteeism, academic performance, and social and sporting activities (Banikarim, et al., 2000; Chen, et al., 2006). A direct relationship between the severity of menstrual distress and its impact on daily lives has been demonstrated in Taiwan (Chen & Chen, 2005). Few adolescents discuss dysmenorrhea with their gynecologic health care provider; most choose to “suffer silently” (Durain, 2004). In the United States, only 37 percent of symptomatic adolescents sought the advice of a health care professional regarding management of the condition (Houston, Abraham, Huang, & D'Angelo, 2006). In contrast, less than 5% of symptomatic Taiwanese adolescents sought the advice of a health care professional (Chiou, & Wang, 2008). The important issue here is “normalization” of this health problem. When adolescents normalize dysmenorrhea, they might ignore symptoms that can indicate health problems like pelvic inflammatory disease and endometriosis (Houston, et al., 2006) Adolescents with dysmenorrhea do seek guidance from their mothers. In previous studies, adolescents in Taiwan identified their mothers as the most important persons they

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turned to for answers regarding dysmenorrhea or menstruation (Lee, et al., 2006; Chiou, & Wang, 2008; O’Connell, Davis, & Westhofk, 2006). However, the influence of the mother’s input has not been examined for either content or effectiveness of the advice and relevance to self-care strategies used. The mother’s influence on the adolescents’ management of dysmenorrhea has not been clearly examined in Taiwanese mother adolescent pairs. Self-care strategies for dysmenorrhea are defined as behaviors to enhance comfort and prevent or respond to the condition (Hsieh, Gau, Mao, & Li, 2004). Various culturally relevant self-care strategies have been identified as significant for management of dysmenorrhea (Chen, et al., 2006; Chiou &Wang, 2008; EI-Gilany, et al., 2005; O’Connell et al., 2006; Campbell & McGrath, 1999). Adolescents in Canada use non-pharmacologic method (e. g., heat, distraction) to manage menstrual discomfort (Campbell et al., 1999), while adolescents in Taiwan diminish physical activity, change their diet, use herbal remedies or medication, use supplementary therapies, express their emotions, sleep and apply heat, or use over-the-counter medication (Chen, et al., 2006; O'Connell, Davis, Westhoff, 2006). The effectiveness of these culture-based self-care strategies for dysmenorrhea has not been explored. It is important to understand the efficacy of the strategies so that nurses can help symptomatic adolescents determine the best intervention to manage their distress. Reports from recent studies indicate conflicting results regarding factors associated with dysmenorrhea. Dysmenorrhea has been reported significantly associated with age, mother’s occupation, the duration of menstrual flow, age at menarche, body

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mass index (BMI), attitude toward menstruation, skipping breakfast, exercise frequency, cigarette smoking, depression, anxiety, and health education (Chiou, and Wang, 2004; Chen, and Chen, 2005; Fujiwara, 2003; Hirata, Kumabe, & Inoue, 2002; Ko, & Kao, 2004; Sundell, et al., 1990; Lee, et al., 2006). In other studies, dysmenorrhea was not associated with current age, height, weight, length of menstrual cycle, smoking, alcohol use, exercise behaviors, or number of stressors reported (Alonso, & Coe, 2001; Jarret, Heitkemper & Shaver, 1995; Sundell, et al., 1990). The findings are conflicting regarding relationship with BMI, exercise frequency, and length of menstrual cycle. Because findings are equivocal regarding associated factors, additional research is needed to clarify the relationship between multiple factors and the experience of dysmenorrhea. This study examined factors related to dysmenorrhea in a sample of Taiwanese adolescent girls; described the perceived dysmenorrhea pain symptom experience (SE), related self-care strategies (SCS), and perceived effectiveness of self-care strategies (PESS); explored the relationships between SE, SCS, and PESS; and explored the influence of contextual factors on SE, SCS, and PESS. These data will guide the development of nursing intervention strategies to support symptomatic adolescents. Conceptual Framework The revised Symptom Management Model (Dodd et al. 2001) guided this study of dysmenorrhea and the associated factors in Taiwanese adolescents. The model is built on the premise that effective symptom management “has three interrelated dimensions: the symptom experience, symptom management strategies and symptom outcomes” (UCSF, 1984, p. 273). As a nursing model, the basic concepts of nursing science (person,

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health/illness, and environment) are integrated into and influence core dimensions in the Symptom Management Model (Dodd et al., 2001). Symptom Experience Dodd et al (2001) defined the symptom experience holistically as the interplay of an individual’s awareness of significance attributed to, evaluation of, and response to a symptom. Because of the reciprocal relationships between components of the symptom experience, health care professionals must value the interaction of these dimensions in order to manage symptoms efficiently (Dodd et al., 2001). Symptoms experience by adolescents with dysmenorrhea may include crampy pelvic pain (menstrual pain) and some associated symptoms like gastrointestinal responses (nausea, change in bowel movement) or lightheadedness (French, 2005; McEvvoy, et al., 2004). While these symptoms have been described in various studies, the significance of the symptoms, the adolescent’s interpretation and management of the symptoms have not been reported. Symptom Management Strategies Symptom treatment strategies could include either those prescribed by health care professions or self-care strategies used by the individual. Treatment is aimed at reducing or protecting adverse outcomes (Dodd et al., 2001). A basic presumption in the Symptom Management Model is “that all troublesome symptoms are in need of management, and symptom management should influence or control the symptom experience, not just symptom outcomes” (UCSF, 1994, p. 274). Symptom management strategies for adolescents with dysmenorrhea include information seeking, medicine use, and non-pharmacological interventions such as staying resting, applying heat, diversion or

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changing diet (Chiou, et al., 2008; O’Connell et al., 2006; Campell & McGrath, 1997; Hillen et al., 1999). Outcomes Outcomes arise from both the perception of the symptom and the treatment strategies (Dodd et al., 2001). Ten aspects of outcomes identified “including: symptom status, self-care ability, financial status, morbidity, and comorbidity, mortality, quality of life, health service utilization, emotional status, and functional status” (UCSF, 1984, p. 275). Outcome in analysis of dysmenorrhea is in terms of perceived effectiveness of the self-care strategies for dysmenorrhea in this proposed study. Person Domain Personal variables are those developmental, physical, physiological and social factors that might influence the three core components of this model (Dodd et al. 2001). Personal variables are the context within which the symptoms occur but they affect the symptom, and could be affected by the symptom (UCSF, 1994). Demographic variables include age, sex, ethnicity, marital status, and social economic status, and more. Symptoms can be influenced by any or all of these factors. The physiological variables that come into play “are rest, activity patterns, and physical capacity” (USCF, 1984, p. 274). Psychological variables are “personality trait, cognitive capacity, and motivation” (UCSF, 1984, p. 274). The sociological variables include family connection, and faith. Finally, psychosocial development and maturity are components of developmental variables in this model (Dodd et al., 2001). In this proposed study, variables in the person domain will include age, mother’s occupation, mother’s educational level, parental

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social-economic status, and exercise frequency. Health and Illness Domain The health and illness category focuses on an individual’s state of health or illness, including health status, risk factors, and disease or injury status (UCSF, 1994). These factors have an influence on each dimension of the model. Structural, functional and physiological aspects of the individual together define one’s health status (UCSF, 1994). Risk factors related to the symptom can be either genetic or behavioral, such as sedentary lifestyle, drug use or cigarette smoking (UCSF, 1994). Health and illness domain variables in this study are BMI, length of period, length of menstruation cycle, and age at menarche. Environment Domain In the Symptom Management Model, environment is viewed as the situation within which the symptom is experienced. Environment factors are “physical, social, ethnic, and cultural variables” (UCSF, 1984, p. 274), which have an influence on every dimension of the model (Dodd et al., 2001). The researchers also stated, “The physical environment includes home, work, and play. The social environment is one’s social support network. Cultural aspects of the environment are beliefs, values, and practices” (UCSF, 1984, p. 274). The environment variable in this study is mother’s perceived support of self-care strategies. The Symptom Management Model is a nonspecific model that can be used to guide both symptom care and research (UCSF, 1994). The model is not limited to symptom type. For example, this model was illustrated in various studies in people in various

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background including midlife women with menopausal symptoms (Lee & Taylor, 1996), premature babies having pain with insufficient treatment (Frank & Miaskowski, 1998), patients with dyspnea (Janson & Carrieri, 1986), patients with Type I and Type II diabetes mellitus (Hunt et al. 1998, Rankin, 1998) and etc. Conceptual Framework for the Proposed Study Based on the Symptom Management Model, a conceptual framework was designed to explain the relationships among some selected factors regarding dysmenorrhea management in Taiwanese adolescents and guided the present study (see Figure 1).

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Figure 1: Conceptual Framework for symptom management of dysmenorrhea

*Personal factors in this study include age, mother’s occupation, mother’s educational level, parental social-economic status and exercise frequency. *Health and illness factors include BMI, length of period, length of menstruation cycle, age at menarche. *Environmental factors include mother’s perceived support of self-care strategies.

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Research Questions The research questions for the study are: 1. What is the perceived pain symptom experience of dysmenorrhea in Taiwanese adolescents? 2. What self-care strategies for dysmenorrhea are used by Taiwanese adolescents? 3. What is the perceived effectiveness of self-care strategies for dysmenorrhea are reported by Taiwanese adolescents? 4. What is the mother’s perceived support of self-care strategies for dysmenorrhea as reported by Taiwanese adolescents? 5. What are the relationships among the symptom experience of dysmenorrhea (SE), self-care strategies for dysmenorrhea (SCS), perceived effectiveness of self-care strategies (PESS), and contextual factors including personal, health and illness, and environmental factors? 6. What are the predictors of symptom experience (SE) of dysmenorrhea among Taiwanese adolescent girls?

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Definitions The definitions of variables in the present study are categorized by symptom experience of dysmenorrhea, self-care strategies for dysmenorrhea, and perceived effectiveness of self-care strategies for dysmenorrhea, personal factors, health and illness factors, and environmental factors. Pain Symptom Experience of Dysmenorrhea The pain symptom experience of dysmenorrhea in the present study is defined as any perceived menstrual pain sensations that the symptomatic adolescents felt. The Short Form McGill Pain Questionnaire (SF-MPQ) (Melzack, 1987) was used to measure the perceived pain symptom experience of dysmenorrhea. Self-care Strategies for Dysmenorrhea Self-care strategies for dysmenorrhea are defined as the individual decisions, actions or interventions an adolescent takes to cope with or manage the symptoms of dysmenorrhea. The adolescent dysmenorrhea self-care scale (ADSCS) (Hsieh, Gau, Mao, & Li, 2004) was used to measure the self-care strategies for dysmenorrhea. Perceived Effectiveness of Self-Care Strategies for Dysmenorrhea Perceived effectiveness of self-care strategies is defined as the perceived power to bring about a change or affect the extent to which an intervention does what it is intended to do. The Perceived Effectiveness of Self-care Strategies Questionnaire (PESSQ) that is adapted from ADSCS was used to measure the perceived effectiveness of self-care strategies for dysmenorrhea.

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Personal Factors Personal factors in this present study include: age, mother’s occupation, mother’s educational level, parent social-economic status and exercise frequency. Age is the participant’s age. Mother’s occupation is defined as whether the participant’s mother is working outside of home. Mother’s educational level is defined the level mother has been educated. Parent socio-economic status is estimated from the parents' education and occupation(s)

using a socio-economic status index. Five

social classes were defined (class I = highest, V = lowest) (Lin, 1978). Exercise frequency is defined the number of hours per week that the participant exercise. Data of these variables were collected using the background data questionnaire. Health and Illness Factors Health and illness factors to be included in this study are BMI, length of period, length of menstruation, and age at menarche. Body mass index (BMI) is defined as a gauge of body fat determined by calculating the ratio of weight to height (National Heart Lung and Blood Institute, 2010). Body mass index is calculated from self-reported weight (Kg)/height 2 (M). Length of period is defined as how many days the participant’s period continued. Length of menstruation is defined how many days the participants’ menstruation cycle continued. Age at menarche is defined as when an individual experienced her first period. Data for these variables were collected by using the background data questionnaire. Environmental Factors One only environmental factor was examined in this study: mother’s perceived

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support of self-care strategies as a social environment factor in this study. Mother’s perceived support of self-care strategies is defined as the participants’ perception of support regarding self-care strategies for dysmenorrhea from their mothers. The Mother’s Perceived Support of Self-care Strategies Questionnaire (MPSSSQ) adapted from ADSCS, was used to measure this variable. Assumptions The following assumptions have been made for this study: 1. Dysmenorrhea is painful for symptomatic adolescents. 2. Participants are the best evaluators of their own symptom experience of dysmenorrhea. 3. Symptom management is an iterative process with management strategies changing with the evolving symptom experience and changing context of person, environment and health. 4. Participant will answer questions honestly and accurately. Summary Dysmenorrhea is the most common gynecologic problem for adolescent girls. It can significantly affect the individual’s ability to perform daily activities affecting productivity and performance with the associated stress. The purposes of this study were to validate the factors that are related to dysmenorrhea in Taiwanese adolescents; to describe the perceived dysmenorrhea pain symptom experience, and the self-care strategies used as well as their perceived effectiveness; to explore the relationships between the symptom experience, the self-care strategies used and the perceived

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effectiveness; and to explore the influence of contextual factors on these variables. The conceptual framework for this study was developed based on the Symptom Management Model. Health care providers in Taiwan can use the findings from this study to develop strategies to guide effective nursing assessment and interventions aimed at helping Taiwanese adolescents with dysmenorrhea.

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CHAPTER TWO LITERATURE REVIEW Dysmenorrhea is a common condition associated with menstruation, particularly for adolescent girls. Dysmenorrhea can significantly affect daily lives and activities of affected adolescents resulting in absenteeism, impaired academic performance and restricted activities. Available evidence indicates that adolescents typically do not seek medical advice for management of dysmenorrhea; self-care management strategies for symptomatic adolescents are the norm. However, the effectiveness of various self-care strategies has not been examined. In addition, available evidence generally focuses on dysmenorrhea in Western populations. Therefore, this review will provide an overview of literature regarding the dysmenorrhea experience, the relationships between dysmenorrhea and associated factors, and self-care strategies used by Western and Taiwanese symptomatic adolescents. Overview of Dysmenorrhea Primary dysmenorrhea is defined as menstrual pain in otherwise healthy women with normal pelvic structures and regular ovulation. It usually begins during adolescence with an onset between 6 to 12 months after menarche. Primary dysmenorrhea is described as cramping pelvic pain before or during the menstrual period (French, 2005). Symptoms were reported as spastic pain in the lower abdomen. Some adolescents also had related symptoms such as gastrointestinal changes or faintness (McEvoy, Chang, & Coupey, 2004).

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Primary dysmenorrhea is thought to be caused by the release of prostaglandins by the endometrium after ovulation, causing painful uterine contractions. The dysmenorrhea experience is also believed to be affected by levels of vasopressin since it leads to both increased uterine contractility and vasoconstriction resulting in ischemic pain (French, 2005). In contrast, secondary dysmenorrhea is the result of pathological conditions including endometriosis, salpingitis, congenital anomalies of the reproductive system, or other pelvis organ pathology (French, 2005; McEvvoy, Chang, & Coupey, 2004). Only primary dysmenorrhea is the focus of this study since it is common in the adolescent population. Medical management goals for primary dysmenorrhea focus on relief from symptom. The major management goals focus on pain management and control of menstruation. The two most efficient treatments are prostaglandin synthesizing enzyme inhibitions and oral contraceptives. The most usual prostaglandin enzyme inhibitors used are nonsteroidal anti-inflammatory medicine (NSAIDs) like ibuprofen, naproxen sodium, and mefenamic acid (Zhang & Li, 1998). The key in effectiveness is timing and frequency of use. The medicine should be initiated as soon as dysmenorrhea symptoms begin. Medications are generally needed for the first three days in the period (McEvvoy, et al., 2004). The suggested dose is 400 mg PO every 4 hours. If NSAIDS are contraindicated, aspirin or acetaminophen may be useful. Combination oral contraceptive pills may be used if NSAIDs are ineffective in treating severe dysmenorrhea during three to four menstrual cycles. These treatment strategies reduce symptoms by suppressing ovulation and reducing endometrial growth,

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which in turn reduces both menstrual flow and prostaglandin release (Cholst & Carlon, 1998). Proctor (2006) found that 65% of women using oral contraceptives provided against pain from dysmenorrhea. Experience of Dysmenorrhea in Adolescent Girls Dysmenorrhea is an age-associated condition with adolescents experiencing the highest prevalence. In a longitudinal study, Sundell, Milsom, & Andersch (1990) found the highest rate of dysmenorrhea in adolescents (90% at age 19) and decreased to 67% when the participants reached age 24. Burnett, et al., (2005) found similar result in a cross-sectional in design study with the adolescents (age 18-19) reporting prevalence of dysmenorrhea at 70%, adult women (age 25-34) reporting prevalence of dysmenorrhea at 58%, and middle-age women (age 35-49) reporting 49% prevalence of dysmenorrhea. The incidence of dysmenorrhea is similar for adolescents in Taiwan. Studies revealed that dysmenorrhea is an important health issue for Taiwanese adolescents with a prevalence rate between 73.3% to 89.4% in Taiwanese adolescents (Chiou, & Wang, 2004; Chiou, & Wang, 2008; Ko, & Kao, 2004). Globally the reported dysmenorrhea rate is between 67.2 % to 91% demonstrating that dysmenorrhea is a universal health issue affecting more than two third of all female adolescents. Associated Symptoms Adolescents who are symptomatic for dysmenorrhea not only experience a painful period, but also some other associated symptoms. Cramps and backache are two most common symptoms. The symptoms associated with dysmenorrhea have been found to vary by culture. Chen and Chen (2005) conducted a descriptive, cross-sectional study

Full document contains 176 pages
Abstract: The purpose of this cross-sectional, correlational study was to validate the factors that are related to dysmenorrhea in Taiwanese adolescents. The specific aims were to describe the perceived dysmenorrhea pain symptom experience (SE), related self-care strategies (SCS), and perceived effectiveness of self-care strategies (PESS); to explore the relationships between SE, SCS, and PESS; and to explore the influence of contextual factors on SE, SCS, and PESS. A conceptual framework based on the revised Symptom Management Model was developed and guided this study. A nonprobability sample of 165 adolescent participants was recruited from a technology university located in southern Taiwan. Inclusion criteria for participants were: (1) Taiwanese female adolescent, (2) age 15-19 years old, and (3) willing to participate in this study. All participants and their parents completed the consent forms and completed the questionnaires in their classrooms during free studying time. Five instruments were used and data was analyzed by using the SPSS Version 14.0 including descriptive statistical techniques, Pearson's correlations, ANOVA, and multiple regression analysis. The findings showed the prevalence of dysmenorrhea in this sample was 87.3%. There were 82.4% of participants who reported dysmenorrhea had influenced their daily activity, and 12.7% of participants who reported school absenteeism because of dysmenorrhea. Most of participants used self-care strategies for dysmenorrhea including avoiding cold food or drinks, drinking brown sugar and ginger soup, etc. The most frequently used self-care strategies and their effectiveness were described. Age, age of the first period, total menstrual years, eating cold food or drinks, self-care strategies, and mother's perceived support of self-care strategies were significantly related to the log of symptom experience of dysmenorrhea. Total menstrual years and self-care strategies were identified as significant predictors of dysmenorrhea. This study added to the body of nursing science regarding dysmenorrhea in Taiwanese adolescents. In particular, the findings supported the existence of relationships between self-care strategies and perceived effectiveness of self-care strategies. Building on these findings, future research should be conducted to design interventions that reduce the pain associated with dysmenorrhea for this population.