Qual Life Res
DOI 10.1007/s11136-013-0464-z
Predictors of psychological well-being and stress
among Jordanian menopausal women
Rania Y. Abdelrahman • Lubna A. Abushaikha •
Mohammad A. al-Motlaq
Accepted: 19 June 2013
Ó Springer Science+Business Media Dordrecht 2013
Abstract
Purpose The aim of this study was to investigate purpose
in life, self-acceptance, perceived stress levels, and men-
opausal symptoms among Jordanian women.
Methods A descriptive, correlational design with a con-
venience sample of 193 women aged 40–55 years was
employed.
Results The average age at menopause for the current
sample was 47.4 years, and menopausal status did not
significantly affect purpose in life, self-acceptance, or
perceived stress levels. Negative correlations were found
between purpose in life and perceived stress, and between
self-acceptance and perceived stress (r = -0.49; p = 0.01
and r = -0.58; p = 0.01, respectively). Menopausal
symptoms were found to be a strong negative predictor of
purpose in life, self-acceptance, and perceived stress levels.
In addition, higher health rating was significantly associ-
ated with higher psychological well-being and lower per-
ceived stress levels. Perimenopause was found to be a
vulnerable stage for severe menopausal symptoms partic-
ularly psychological complaints. However, vasomotor
symptoms and loss of sexual interest became more intense
among postmenopausal women. Although women in the
current study had low psychological well-being and high
perceived stress, these were not affected by their meno-
pausal status.
Conclusion The study showed the importance of includ-
ing both physical and psychological symptoms during
R. Y. Abdelrahman
M. A. al-Motlaq (&)
Hashemite University, Zarqa, Jordan
e-mail: mohammada_m@hu.edu.jo
L. A. Abushaikha
Jordan University, Amman, Jordan
encounters with health professionals, besides considering
women’s expectations about menopause to help ease their
menopausal transition and improve their well-being.
Keywords Jordan
Menopause
Perceived stress

Purpose in life
Self-acceptance
Introduction
Perimenopause, also called the menopausal transition,
refers to woman’s natural transition toward permanent
infertility (menopause). As a developmental stage, meno-
pause involves physical, psychological, and social changes,
which have an impact on the way women think about
themselves and their expected roles [1, 2]. Consequently,
some women experience a sense of loss during menopausal
transition such as the loss of their maternal role and ulti-
mately loss of purpose in life [3]. Having purpose, self-
acceptance, and meaning in life have been addressed as
important protective factors that facilitate psychological
well-being and positive adaptation in different situations
[4, 5]. Therefore, perceiving self as living a meaningful life
is argued to be related to physical health and general well-
being [4, 6]. Besides, having a sense of positive self-worth
and self-acceptance were also considered essential for a
meaningful life [7, 8]. A Danish study found both positive
and negative aspects of menopause, where the positive
aspects such as becoming experienced and having more
freedom and time for more personal development over-
weighed the negative aspects [9]. Another study described
the experience of Jordanian menopausal women during
menopausal transition, where also many positive aspects
for menopause were found including a time of no more
reproductive obligations, transition from reproductive
123

responsibilities to freedom, relief and rest, a time for
growing into a wise woman, and acceptance of aging as
part of life [2]. However, a study from Australia found that
women’s sense of their role and purpose in life have
changed, and their self-acceptance has decreased as they
became older [1]. Therefore, some investigators considered
menopause a stressful event and a risk for psychopathology
or poor mental health [10–12]. This stress was evaluated in
many studies by measuring actual psychological com-
plaints that accompany menopausal transition, though few
studies have investigated women’s perceived stress. In a
study of premenopausal and postmenopausal women with
vasomotor symptoms, results revealed lower levels of well-
being compared to women without symptoms, though no
difference in well-being levels was found for perimeno-
pausal women (i.e., still going through menopause) [13].
Another study revealed that the level of stress, psycho-
logical distress, and severity of menopausal symptoms
were attributed to the perceptions and attitudes of women
toward menopause [14]. The investigators concluded that
women who hold negative perceptions or attitudes toward
menopause have experienced worse physical health and
higher stress levels [14]. Two other studies, one from
Jordan [15] and one from the USA [16], found a negative
impact of menopause on women’s quality of life. The
Jordanian study explored the severity of menopausal
symptoms in relation to menopausal status and found a
significant relationship between menopausal symptoms and
women’s perceived health status [15]. The US study found
a negative impact of menopause on women’s health-related
quality of life regardless of their menopausal symptoms
[16]. Given these differences and given the dearth of
related studies, it is important to examine each group
separately to determine the differences that ethnicity and
culture play in psychological well-being and stress levels
among menopausal women. The aim of this study was to
measure purpose in life, self-acceptance, and perceived
stress levels among Jordanian menopausal women. In
addition, the study investigated factors affecting psycho-
logical well-being of Jordanian menopausal women.
Materials and methods
Measures
Measures included demographic information sheet, the two
subscales of the Psychological Well-Being Inventory
(PWI), the Green Climacteric Scale (GCS), and the Per-
ceived Stress Scale (PSS) [4, 17, 18]. The PWI includes six
distinct components of positive psychological well-being,
of which the Purpose in Life and the Self-Acceptance
subscales were used [4]. On a 6-point Likert scale ranging
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Qual Life Res
from 1 strongly disagree to 6 strongly agree, the 14-state-
ment Purpose in Life subscale asked women about their
goals in life and the 14-statement Self-Acceptance subscale
asked women about attitudes toward themselves. Higher
scores indicated that participants hold beliefs that give life
a purpose and possess a positive attitude toward self. The
reported internal consistency for the Purpose in Life and
the Self-Acceptance subscales was 0.88 and 0.91, respec-
tively [4]. The GCS measured the severity of menopausal
symptoms and consists of 21 symptoms divided into four
main domains: vasomotor (2 items); psychological (11
items); somatic (7 items); and sexuality symptoms (1 item).
The total score of GCS ranges between 0 (asymptomatic)
and 63 (highest degree of complaints). Cronbach’s alpha
reliability of 0.87 was reported for the GCS [17]. The PSS
includes 14 questions that measured the degree of appraisal
of stressful situations using a 5-point Likert scale ranging
from 0 never to 4 very often, and the highest possible score
is 56, with a reported alpha coefficient reliability of 0.84
[18]. Instruments were translated to Arabic and back
translated by three experts and evaluated by another three
experts in the fields of women’s health and mental health
nursing for face and content validity. Instruments were
initially live tested for readability and reliability of the
measures on a convenience sample of 30 women. The
Cronbach’s alpha coefficient was above 0.80.
Procedure
Approval to conduct the study was obtained from the ethical
committees of Jordan University and the Ministry of Health.
A convenience sample of 203 menopausal women in dif-
ferent menopausal stages from four selected comprehensive
healthcare centers in Amman and Zarqa cities was invited to
participate in the study. Participants completed the study
questionnaires in the waiting rooms of the health centers,
where only three women refused to participate. Seven
women suffering from malignancies or had a hysterectomy
were excluded from the analysis. All women with hyster-
ectomy were on hormone replacement therapy and were not
included in the study. Anonymity, data confidentiality, and
participants’ right to refuse participation were maintained
throughout the study. The remaining 193 women responses
were coded and entered for analyses using SPSS 14.0.
Descriptive statistics were used to examine participants’
purpose in life, self-acceptance, and perceived stress levels.
To assess the relationship between these variables, Pear-
son’s product moment correlation was employed. ANOVA
and t tests were used to examine differences in participants’
characteristics in relation to purpose in life and self-accep-
tance. A stepwise multiple regression was used to explore
predictors of study variables. A P value of less than 0.05 was
considered significant.
Qual Life Res

Results Table 2 Percentage of respondents who indicated strongly agree or

agree on the Purpose in Life Scale (N = 193)
Descriptive results Agreement
(%)
Table 1 shows the demographic characteristics of the 193
Positively-worded itemsa
women participated in the study. The mean age of partic-
I have a sense of direction and purpose in life 88.0
ipants was 45 years (SD = 4.5) ranged between 40 and
Some people wander aimlessly through life but I am 87.0
55 years. Their average age at menarche was 13.3 years not one of them
(SD = 1.3) and at menopause was 47.4 years (SD = 4.3). I enjoy making plans for the future and working to 85.0
The majority of participants were premenopausal (69.4 %), make them a reality
married (88.6 %), first wives (88.6 %), unemployed I am an active person in carrying out the plans I set 84.0
(73.6 %), non-smokers (87.6 %), and educated to high for myself
school level or below (63.7 %). The families had an My aims in life have been more a source of 83.0
average of 5 children with total monthly income of 514 satisfaction than frustration to me
$US. Negatively-worded itemsa
Table 2 presents percentage of respondents who indi- I tend to focus on the present, because the future 35.5
nearly always brings me problems
cated strongly agree or agree with each item on the Purpose
I used to set goals for myself, but that now seems like 29.0
in Life Scale. Positively worded items were rated higher
a waste of time
than negatively worded items. The highest rated item was
My daily activities often seem trivial and 28.5
‘‘I have a sense of direction and purpose in life’’ (88 %), unimportant to me
while the lowest rated item was ‘‘I live life 1 day at a time I don’t have a good sense of what it is I’m trying to 26.0
and don’t really think about the future’’ (25 %). The mean accomplish in life
score of Purpose in Life Scale for the total sample was 60.6 I live life one day at a time and don’t really think 25.0
(SD = 9.1). Although no significant difference was found about the future
by menopausal stage, premenopausal and perimenopausal a
Items were grouped based on content (positive or negative)
women (60.7 and 61.5, respectively) reported higher mean
score than postmenopausal women (59.5). Acceptance Scale. Results revealed that positively worded
Table 3 presents percentage of respondents who indi- items were rated higher than negatively worded items. The
cated strongly agree or agree with each item on the Self- mean score on the scale was 55.9 (SD = 10.3), with no
significant difference found by menopausal stage.
Perceived stress levels were high among participants
Table 1 Sample characteristics and valid percentage of each sub- with over 62 % reporting severe stress levels. Although not
category (N = 193) significant, perimenopausal women reported higher level of
Variables Subcategory N (%) stress (M = 27.3) compared to premenopausal (M = 27.0)
and postmenopausal (M = 26.1) women.
Menopausal status Premenopause 134 (69.4 %)
A significant difference (F = 3.92, df = 2, p \ 0.05) in
Perimenopause 35 (18.1 %)
severity of menopausal symptoms was found by meno-
Postmenopause 24 (12.4 %)
pausal stage with perimenopausal women reporting more
Employment Yes 51(26.4 %)
severe symptoms. Particularly, psychological and somatic
No 142 (73.6 %)
symptoms were significantly higher in perimenopausal
Smoking Yes 24 (12.4 %)
women, while vasomotor symptoms and sexual dysfunc-
No 169 (87.6 %)
tion were significantly higher in postmenopausal women.
Medical problems Yes 101(52.3 %)
No 92 (47.7 %) Factors affecting the studied variables
Type of medical problems Hypertension 46 (23.8 %)
Diabetes mellitus 14 (7.3 %) Table 4 shows the results of correlation among purpose in
Othersa 133 (68.9 %) life, self-acceptance, symptoms, and perceived stress
Health rating Weak 10 (5.2 %) scores. Results revealed medium to large correlation
Average 108 (56 %) between variables. The highest correlation was between
Very good 63 (32.65) self-acceptance and purpose in life scores (r = 0.6,
Excellent 12 (6.2 %) p \ 0.01). Participants’ characteristics were also examined
a
Rheumatism, urinary tract infections, osteoporosis, depression, high in relation to purpose in life and self-acceptance. Women
cholesterol, asthma who had less than secondary education had significantly

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Table 3 Percentage of women who indicated strongly agree or agree symptoms (B = -0.1, p \ 0.03). In addition, three pre-
on the Self-Acceptance Scale (N = 193) dicting variables explained 39 % of the self-acceptance
Agreement variance including perceived stress (B = -0.6, p \ 0.001),
(%) smoking (B = -5.0, p \ 0.005), and menopausal symp-
toms (B = -0.2, p \ 0.007).
Positively-worded items
In general, I feel confident and positive about myself 93.0
When I compare myself to friends and acquaintances, 91.0
it makes me feel good about who I am
Discussion
I like most aspects of my personality 86.5
Menopause is a normal process in women’s life where many
Given the opportunity, there are many things about 86.0
myself that I would change physical and psychosocial changes occur and impact their
For the most part, I am proud of who I am and the life 83.0 sense of well-being [13, 19]. Given the dearth of studies on
I lead menopause in Jordan, the current study examined the psy-
Negatively-worded items chological well-being (purpose in life and self-acceptance),
My attitude about myself is probably not as positive 48.5 perceived stress, and menopausal symptoms among Jorda-
as most people feel about themselves nian menopausal women. Generally, most women in the
Everyone has their weaknesses, but I seem to have 45.0 sample provided positive responses to the psychological
more than my share well-being subscales, indicating that participants held beliefs
In many ways, I feel disappointed about my 45.0 that give life a purpose and possessed a positive attitude
achievements in life
toward self. These results match those of a Jordanian study
Many days I wake up feeling discouraged about how 41.5
I have lived my life
where women positively pointed to their transitional expe-
I envy many people for the lives they lead 21.5
rience as a time of no more reproductive obligations and
accepting aging as a part of life [2]. Comparative analyses
* Items were grouped based on content (positive or negative) identified no significant differences between women in dif-
ferent stages of menopause; hence, menopausal transition
lower scores on purpose in life (F = 2.7, df = 4, did not affect their psychological well-being. Others repor-
p \ 0.05). Similar results were found with their husband’s ted similar results, suggesting that the stage of menopause
education (F = 4.1, df = 5, p \ 0.01). Smokers had lower does not affect feelings about purpose in life and self-
purpose in life (t = -2.10, df = 198, p \ 0.05) and self- acceptance at any point in women’s lives [1, 20]. However,
acceptance scores (t = -3.3, df = 198, p \ 0.01), while the cross-sectional nature of these studies might be a factor
participants who positively rated their health had signifi- limiting the generalizability of these conclusions to the
cantly higher purpose in life (F = 5.8, df = 3, p \ 0.01) general menopausal women population.
and self-acceptance scores (F = 4.5, df = 3, p \ 0.01). No Although the current study did not confirm a significant
significant difference was found between women based on association between purpose in life and age, the postmen-
their medical problems. opausal women lower ratings of their purpose in life
Stepwise multiple regression was used to explore pre- compared to premenopausal women could be a result of the
dictors of study variables. The variables analyzed via mul- aging process and not the effect of menopausal transition.
tiple regression included menopausal status, employment, This claim is supported by findings from other studies,
smoking, medical problems, level of education, husband’s where feeling of purpose in life declined with age [21].
education, health rating, and the studied dependent variables. This might also be explained by including only women
Three predicting variables explained 27 % of purpose in life younger than 55 years old (middle-aged), where the pur-
variance including perceived stress (B = -0.4, p \ 0.001), pose in life is still strong and valued among them.
husband’s education (B = -3.2, p \ 0.01), and menopausal A Jordanian study [2] revealed that women realized that
their roles were changing during menopause but they still
Table 4 Correlations between women’s self-rated purpose in life, self- valued their lifetime contributions hence considered men-
acceptance, perceived stress, and menopausal symptoms (N = 193) opause a positive motivation to growing older. Deeks and
Variables Self-acceptance Perceived Menopausal McCabe [1] clarified this by claiming that negative events
stress symptoms appear while women move from one stage to another but
are replaced with positive events that enable them to grow
Purpose in life 0.62** -0.49** -0.35**
and develop. For example, women who experienced bodily
Self-acceptance – -0.58** -0.42**
changes achieved balance by doing things (e.g., participa-
Perceived stress – – 0.48**
tion in religious practices); they were unable to do because
** Pearson’s correlation coefficient significant at a = 0.01 of their past reproductive obligations.

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Although results indicated that women in the sample had
high stress levels, neither psychological complaints nor
stress was associated with menopausal status. Therefore, the
high stress level and psychological symptoms could be an
influence of other psychosocial factors such as the burden of
occupying multiple social roles in life and social support.
According to the role strain hypothesis, occupying multiple
roles in life could have negative psychological conse-
quences [22]. Being a mother, a wife, an employee, and an
active member in the society, women in Jordan play vital
roles inside and outside their homes besides their repro-
ductive obligations. Although postmenopausal women
reported lower level of stress compared to premenopausal
women, this difference was not significant. Similar results
were reported by others [10] who suggested that the stage of
menopause does not contribute to women’s stress level.
Other physical and social factors could also affect women’s
evaluation of their stressful daily life than their menopausal
status. Therefore, when assessing women’s psychological
distress, it is important to examine their psychosocial
environment besides their menopausal status.
Although perimenopause is the most stressful stage
during the menopausal transition [11, 23–25], results of the
current study revealed that women in this stage had the
highest scores on the Purpose in Life and Self-Acceptance
scales. These findings are supported by other studies, where
menopause had no contribution to women’s psychological
well-being [1, 20]. This might be explained by the age
group of participants (M = 45.4 years), where middle-
aged persons were reported to have higher scores on most
psychological well-being dimensions [4].
As self-acceptance has been found to be a source for
meaningful life [8], the findings revealed that women who
had higher ratings of purpose in life also had higher ratings
for self-acceptance. Cramer and Jones [26] suggested that
denial might be used as a protective mechanism to keep
individuals from greater loss of self-acceptance and that
denial could be achieved by removing unpleasant thoughts
or affects from consciousness. In this sense, postmeno-
pausal women in our study might hold positive perceptions
about menopause and aging that protected them from a
greater loss of self-acceptance during menopausal transi-
tion. Results also revealed a negative association between
perceived stress and psychological well-being. Similar
association was established in other studies where higher
stress levels were associated with lower health status and
well-being, suggesting that stress is an important predictor
of negative health outcomes [27, 28].
The effect of many factors on women’s psychological
well-being was elaborated in previous studies [1, 20, 29].
For example, Dennerstein et al. [20] found that women’s
psychological well-being was influenced by their current
health status, history of premenstrual complaints, and
interpersonal stress. Bauld and Brown [14] also associated
women’s well-being with high psychological distress,
menopausal symptoms, and poor physical health. In the
current study, decreased health self-rating and the presence
of menopausal symptoms have negatively affected
women’s purpose in life and self-acceptance. Similar to a
previous study [30], menopausal symptoms were found to
be bothersome and affecting women’s sense of well-being.
Although 87.6 % of women in this study were not smokers,
smoking also had a significant negative association with
psychological well-being particularly feeling of self-
acceptance. These results confirmed findings of Denner-
stein et al. [20], where the negative impact of smoking on
general health affected women’s sense of well-being.
Similarly, lower educational level for women and their
husbands negatively associated with their purpose in life,
confirming results of a previous study [31].
On the other hand, many factors affected women’s
perceived stress during the menopausal transition including
their age, education, working status, husband’s education,
health status, and menopausal symptoms. While working
women were more likely to perceive higher stress level
than non-working women, higher education level for
women and their husbands was associated with lower stress
levels. The job stress resulting from demands of work and
the benefits of education of providing greater chances to
access resources might explain this [10, 31]. Age was also
negatively associated with perceived stress. Hvas [9] con-
cluded that growing older makes women feel more com-
petent and experienced, but when considering physical
problems that appear as a result of aging process, then age
might be a source of stress. Using self-rated health measure
to measure women’s perceived health, the study found that
women who rated their health status to be average or poor
were more likely to have severe stress [20]. This was
previously explained by presence of medical problems
[19].
Because of the cross-sectional nature of the study and
the criteria for exclusion, there might be a weakness in
interpreting women’s self-assessment of their quality of
life as their menopausal symptoms might overlap with their
medical symptoms. However, three points refute such
claim. First, a Jordanian study found a significant rela-
tionship between menopausal symptoms and women’s
perceived health status [15]. Second, the used GCS is
intended specifically to be a standard measure of core cli-
macteric symptoms and not other medical symptoms.
Third, the analysis found no significant difference in terms
of perceived stress, purpose in life, or self-acceptance
between women based on their medical problems.
Although hindered by some limitations, the results of
the current study have multiple implications including
changing practices to involve the psychosocial aspects
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when providing examination to women in menopause.
Health education programs with interventions focused on
stress reduction should be designed at community levels,
and special services such as menopausal clinics should be
integrated to meet the needs of menopausal women.
Healthcare providers can consider transferring these results
to other Middle Eastern countries as they share the same
culture with Jordan.
Conclusion
Although women in the current study had low psychological
well-being and high perceived stress, these were not affected
by their menopausal status. The study also found that many
socio-demographic and lifestyle factors significantly associ-
ated with women’s psychological well-being and stress levels.
Importantly, psychological symptoms had no relationship
with menopausal status, indicating no organic (hormonal
changes) origin of these complaints during menopausal tran-
sitions. Practices should be changed to include women’s
psychological symptoms besides their physical symptoms
during encounter with health professionals.
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