What is menopause?

Menopause literally means last period and is defined as ‘the permanent cessation of menstruation following loss of ovarian follicular activity’⁽¹⁸⁾. Ovarian production of oestrogens begins to decline in the fourth or fifth decade of life, marking the beginning of the menopausal transition with perimenopause. This is coupled with increases in follicular stimulating hormone and luteinising hormone as the body tries to stimulate the ovaries into reproductive action^{(Reference Weiss, Goldsmith and Taylor19)}, these two hormones control ovulation and reproductive oestradiol levels during the menstrual cycle^{(Reference Prior and Hitchcock20)}. These hormonal changes, including a decline in progesterone^{(Reference Allshouse, Pavlovic and Santoro21)}, lead to the emergence of menopausal symptoms such as hot flushes and night sweats^{(Reference Santoro, Allshouse and Neal-Perry22)}. Post-menopause is diagnosed retrospectively as 12 months of spontaneous amenorrhoea^{(Reference Rees, Abernethy and Bachmann14)}. Generally, women in the UK and Ireland are living longer with a life expectancy of about 83 years⁽²³⁾, meaning they will be post-menopausal for over one-third of their lives^{(Reference Malik, Sheoran and Siddiqui24)}.

In Ireland the mean age of menopause is 51 years, with most women experiencing their menopausal transition between 45 and 55 years^{(Reference Greendale, Lee and Arriola25,Reference Dravta, Real and Schindler26)} . For the majority of women it is a natural transition from the reproductive to the non-reproductive years in a woman's life. Natural menopause is regarded as a transition because fluctuations and changes in hormone levels can last on average for 4–5 years^{(Reference Harlow27)}, with some women experiencing persistent symptoms for 8–10 years into the post-menopause^{(Reference Santoro, Roeca and Peters28)}. Menopause for some women does not fit this pattern and can be defined in relation to when and how it occurs and includes premature, early and surgical menopause. Anyone experiencing menopause below the age of 40 years is regarded as going through premature menopause, affecting 3 % of women^{(Reference Lobo and Gompel29)}, and can be down to genetic or environmental factors. Early menopause occurs in women aged 40–44 years, affecting 10 % of this age range^{(Reference Leone, Brown and Gemmill30)}. Some women will experience induced menopause because of surgery, injury or disease. In surgical menopause women will have both ovaries removed prior to the onset of natural menopause, usually to combat diseases such as ovarian cancer^{(Reference Pillay and Manyonda31)}. The ovaries can become damaged because of chemotherapy or radio therapy in the treatment of some other forms of cancer and will stop functioning, so the patient will experience instant menopause^{(Reference Mauri, Gazouli and Zarkavelis32)}. A woman's experience of menopause is as individual as she is, and management of menopause needs to reflect diversity in this transition^{(Reference Talaulikar33)} and promote healthy ageing through positive lifestyle change^{(Reference Lobo and Gompel29)}.

Biopsychosocial changes during the menopause transition

Most menopausal symptoms or changes that occur during the menopause can be divided into vasomotor (hot flushes, night sweats, vaginal dryness), somatic (tiredness, muscle and joint pains), psychological (depression, anxiety and memory problems) and social (loss of fertility, empty nest, divorce and bereavement). Women will vary in their experience of these types of symptoms, but they have the potential to impact their quality of life and well-being^{(Reference Simpson and Fink9)}. More recently there has been a focus on looking at what types of symptoms women find most bothersome. The British Menopause Society recognise about thirty-eight menopausal symptoms in total, with hot flushes (79 %), night sweats (70 %), sleep problems (57 %), change in menstrual cycle (54 %), low mood (52 %), weight gain (47 %) and low-energy levels (47 %) being the top ones reported by menopausal women^{(Reference Hamoda, Panay and Arya34)}, and are comparable to more recent studies looking at the prevalence and severity of symptoms^{(Reference Nappi R, Siddiqui and Todorova7)}. There can be interactions and a domino effect for women experiencing multiple menopausal symptoms and they have potential to lead to a decline in quality of life and well-being^{(Reference Velasco-Téllez, Cortés-Bonilla, Ortiz-Luna, Irtelli, Durbano and Taukeni35)}. Hot flushes and night sweats may mediate the impact of some symptoms such as memory, mood and general well-being^{(Reference Furlong, Parr and Hodge36)} but more research is needed to fully understand the relationships between symptoms and how we can intervene to improve health and well-being during this time.

Menopause impact on health and the need for health promotion

The British Menopause Society in their mission statement ‘conditions associated with the menopause impact on all health care systems – not just gynaecology’^{(Reference Rees, Abernethy and Bachmann14)}. Health status declines across the lifespan and reduced oestrogen can lead to an increased risk of a range of health conditions for some women such as heart disease, stroke, metabolic syndrome, type 2 diabetes, osteoporosis, dementia and cognitive decline and some cancers such as ovarian and cervical (especially if exposed to additional oestrogens)^{(Reference Santoro, Roeca and Peters28,Reference Nappi, Cucinella, Petraglia and Fauser37)} . These long-term conditions may emerge 10–12 years following the last menstrual period^{(Reference Lobo and Gompel29)}, so it is important to identify mediating factors to enhance prevention^{(Reference Bermingham, Linenberg and Hall38)}. There is a need and a drive to better understand ageing in the female and how to maintain health, increase quality of later years and functional independence for longer. The National Institute for Clinical Excellence guidelines⁽¹³⁾ for menopause management sets out that women are entitled to advise about lifestyle and diet to manage their menopause more effectively. Increased symptoms and bodily changes may act as cues to action for some women and identify a need to promote their own health and well-being at this time^{(Reference Lum and Simpson11)} and making it an optimal for health promotion^{(Reference Rathnayake, Alwis and Lenora39,Reference Li, He and Wang40)} .

Lifestyle and behaviour change for menopause

Behaviour is central to health and well-being; health promotion and public health campaigns have focused on health-related behaviours as mediators of long-term conditions for many years^{(Reference Harris41)}. Health-related behaviours such as smoking, physical activity and diet are related to mortality and morbidity rates and longevity^{(Reference Ng, Sutradhar and Yao42,Reference Newman43)} , with women reporting poorer health in comparison to men, linked directly to chronic conditions^{(Reference Case and Paxson44)}. Lifestyle choices or health-related behaviour can be divided into two categories, those that are health promoting (such as eating five portions of fruit and vegetable daily or following a Mediterranean diet) and health compromising (such as high consumption of processed foods that are higher in fat, sugar and salt or alcohol above the recommended amount of fourteen units per week, spread out across three or more days per week)^{(Reference Morrison and Bennett45)}. Some health behaviours can be resistant to change such as smoking or reducing sugar intake. Very often people are aware of the harmful effects of some behaviours and what they need to do to promote their health, but do not follow through with a change in behaviour. There is a need to focus on how to bring about a more effective change in behaviour, and to establish what strategies are most effective in achieving behaviour change^{(Reference Rothman, Klein, Sheeran, Hagger, Cameron and Jamilton46)}. Health psychologists can be instrumental in supporting and informing the development and design of behaviour change interventions, through the application of theoretical frameworks that inform this process. Strategies aimed at changing attitudes and ultimately behaviour is more effective when guided by theory^{(Reference Abraham and Michie47)}.

Theories of behaviour change

Theories of behaviour change have been around for over 60 years and attempt to explain health-related behaviours by considering the cognitions or thoughts that are held by a person about the behaviour, the circumstances that make the behaviour more likely to occur and social influences on the behaviour. This information is used to manipulate these factors to bring about behaviour change. Theories of behaviour change can be divided into three main types. Continuum models which place the person along a range that reflects how likely they are to change their behaviour, based on the presence or absence of a number of predictor variables. These types of theories tend to focus on intention to engage or not with a particular behaviour, rather than looking at what predicts the actual behaviour^{(Reference Walsh and Simpson12)}. Examples of such theories include the health beliefs model^{(Reference Rosenstock48)} and the theory of planned behaviour (TPB)^{(Reference Ajzen49)}. Stage models of behaviour change suggest change occurs over a number of distinctive stages, thus depending on which stage of change (not thinking about changing a behaviour, considering a need to change, planning a change in behaviour) the person is at, will impact the likelihood of behaviour change and the strategies used to bring about change. Such theories suggest a person must move through the stages to bring about behaviour change. An example of a stage model is the transtheoretical model of behaviour change^{(Reference Grimley, Prochaska, Velicer, Brinthaupt and Lipka50)}. As a result of many of the issues with continuum and stage models of behaviour change, integrative models of behaviour change have been developed. Integrative models attempted to establish constructs that were common across a range of theories and combine these to better understand the underlying mechanisms that influence a particular behaviour. The capabilities, opportunities, motivation and behaviour (COM-B) model is an example of this type of theory^{(Reference Michie, Wood, Conner and Norman51)}.

All behaviour change theories attempt to explain or predict behaviour based on a range of constructs specific to each theory. The extent to which they succeed in this respect varies and it is worth noting that no one theory can explain 100 % of behaviour^{(Reference Conner and Norman52)}, even those based on integrative theories. It has been noted that some theories are more successful at explaining intentions to engage with a target behaviour but less so for the actual behaviour itself, sometimes referred to as the intention behaviour gap^{(Reference Conner and Norman52,Reference Sheeran53)} . Some improvements in accounting for the variance in behaviour has been achieved by combining theories^{(Reference Shanka and Gebremariam Kotecho54)} or adding and extending them to include additional variables^{(Reference Hamilton, Johnson, Hagger, Cameron and Hamilton55)} that may be relevant to engagement with a given behaviour such as past behaviour^{(Reference Wang and Zhang56)}, anticipated regret^{(Reference Abraham and Sheeran57)} or including sociodemographic variables^{(Reference Walsh and Simpson12,Reference Gray, Murphy and Gallagher58)} . It is also worth noting that theories are not always employed in the way that they should be to gain an understanding of behaviour and the main facilitators and barriers, which is essential for identifying what needs to change^{(Reference Timlin, McCormack and Kerr59)}. What is relatively new over the last 10 years is the drive to use this information to design more effective behaviour change interventions, also to standardise psychological intervention components and their description to better understand what the active agent of behaviour change are within an intervention and for this to translate into evidence-based policy and practice^{(Reference Hagger, Cameron and Hamilton60,Reference Wood, Richardson and Johnston61)} .

Using theories to design interventions: two worked examples

Interventions designed within a theoretical framework provide a basis for understanding the main facilitators and barriers to the target behaviour. It provides an opportunity to gain a better insight into the underlying mechanisms of action controlling the behaviour and to identify the most effective intervention components to bring about behaviour change^{(Reference Michie, Wood, Conner and Norman51,Reference Carey, Connell and Johnston62)} . There is some evidence to suggest that interventions designed using a theory are more effective^{(Reference Taylor, Conner and Lawton63)}; however, not all reviews support this^{(Reference Gardner64)} and others report mixed findings^{(Reference Bhattarai, Prevost and Wright65)}.

We have highlighted a need to address lifestyle modification at menopause, in order to promote health and well-being. Credence to this comes from the clinical guidelines that all menopausal women should receive advice and support on lifestyle change, and that theoretical models should be implemented for intervention design but there is a paucity of research on the effectiveness of such interventions. Also, there is a need to understand how to create lasting lifestyle change, where behaviour change becomes habitual^{(Reference Gardner, Arden and Brown66)}, running well beyond the duration of an intervention.

Interventions in relation to menopause management are starting to emerge, in response to the need for a greater understanding of menopause and how to support women with lifestyle changes^{(Reference Rees, Abernethy and Bachmann14)}. There is evidence from systematic reviews that the application of theories to behaviour change interventions at midlife is weak and inconsistent^{(Reference Timlin, McCormack and Kerr59,Reference Sediva, Cartwright and Robertson67)} . Some researchers have used theories as a framework for intervention design in menopause focusing on management of menopausal symptoms such as vaginal dryness^{(Reference Mohamady, Mohammed and Elheshen68)}, others have looked intentions to change lifestyle behaviours such as exercise and physical activity^{(Reference Godoy-Izquierdo, Ramírez and Díaz69,Reference Masoudy, Dehghani and Ansari70)} , and dietary intake^{(Reference Cowan, Jun and Tooze71,Reference Hajizadeh, Azar and Nadrian72)} . Some interventions target menopausal symptoms, diet and physical activity employing a health education approach^{(Reference Li, He and Wang40)}. More research is needed on what works best and the effectiveness and acceptability of such interventions for menopausal women.

The next section will explore in more detail how two theories of behaviour change were used to design interventions to promote physical activity in menopausal women and the promotion of the Mediterranean-dietary approaches to stop hypertension diet intervention for neurodegenerative delay (MIND) diet at midlife.

Example one: using the theory of planned behaviour to better understand engagement with the physical activity guidelines in pre-, peri- and post-menopausal women^{(Reference Doherty, Giles and Gallagher A10)}

Background and theory

This was in response to research findings that women tend to engage in less physical activity across the lifespan compared to men and that this declines further with age^{(Reference Simpson, O'Connor and Livingstone73)}. More recently, just over half of women are not meeting the recommended guidelines for moderate physical activity in Northern Ireland⁽⁷⁴⁾, even fewer (14 %) are engaging in muscle-strengthening activities^{(Reference Nuzzo75)}. Menopausal transition provided a good way to compare the difference between women pre, peri and post in relation to those meeting the physical activity guidelines. This example provides an overview of the methods employed to promote understanding of two target behaviours within the physical activity guidelines, 150 min of moderate physical activity per week and muscle strengthening activities on at least 2 days per week. It is the latter behaviour that formed the basis of the intervention outlined later.

The TPB^{(Reference Ajzen76)} enhances understanding of health behaviours and underlying cognitive decision-making processes, see Fig. 1. Attitudes to the behaviour (e-cigarette use) include the perceived benefits or risks of engaging in the behaviour. Subjective norms are the influence of important others such as family or friends in the decision to engage with a behaviour. Perceived behavioural control is the belief about how easy or difficult it is to engage with the behaviour. A consistent approach to the measurement of these constructs enables the TPB to explain or account for variation in intentions to use e-cigarettes (EC)^{(Reference Trumbo77,Reference Hershberger, Connors and Um78)} .

Fig. 1. Theory of planned behaviour (TPB) model^{(Reference Ajzen76)}.

The TPB proposes a sequential structure using mixed methodology (both qualitative and quantitative methods) for conducting research to inform intervention design, this is outlined in part in the manual for using the TPB to design research to understand a behaviour^{(Reference Francis, Eccles and Johnston79)} and Ajzen's website for designing interventions using this model. It involves three sequential stages.

Stage three

Stage three is feasibility and acceptability study on the design, implementation and evaluation of the intervention. Data gathered from stages one and two informed what needed to change and the predictors to be targeted to optimise behaviour change in the desired direction. Using this information to design an intervention is where the TPB becomes less clear on how to use this information to bring about behaviour change^{(Reference Fishbein and Ajzen80,Reference Michie and Abraham81)} . However, this research was guided by the Medical Research Council guidelines for developing and evaluating interventions^{(Reference Craig, Dieppe and Macintyre82,Reference Moore, Audrey and Barker83)} and the taxonomy of behaviour change^{(Reference Michie, Richardson and Johnston84)} to identify and standardise the reporting of the behaviour change techniques, thus the focus was on determining the acceptability and feasibility of an intervention to promote physical activity guidelines in women in the first instance, that could be further improved upon. In keeping with previous research, this involved a mixed methods approach^{(Reference Moitra, Madan and Verma85)}, first a randomised controlled feasibility trial and secondly, evaluation of process (behaviour change techniques) via interviews with participants, and outcome (pre- and post-intervention), changes in target behaviour and TPB constructs.

The intervention was a 4-week intervention, which included a leaflet to explain what muscle strengthening activities were and how to perform them and how many repetitions were required. Each week the participants met with the researcher, discussed progress and reviewed goals, were encouraged using the TPB constructs to complete the muscle strengthening activities each week and to build on this via a range of behaviour change techniques such as goal setting, self-monitoring, information provision, social support and rewards, these were mapped to key theoretical constructs identified in stages one and two as being important for the uptake of muscle strengthening activities, see Table 1 for some examples.

Table 1. Mapping the TPB onto intervention components and implementation examples

MSA, muscle strengthening activities; TPB, theory of planned behaviour.

Example two: developing a dietary intervention to encourage uptake of the Mediterranean-dietary approaches to stop hypertension diet intervention for neurodegenerative delay diet in healthy midlife adults, aged 40–55 years employing the behaviour change wheel^{(Reference Timlin, McCormack and Simpson86)}

Background and theory

The behaviour change wheel was developed to combat many of the issues and problems with early theories of behaviour change, to combine many of the constructs within the previous research, and to address issues with mapping theory into intervention design, standardising descriptions and components of intervention to aid replication and identify good practice^{(Reference Michie, Atkins and West87)}. It provides a theoretical framework for the research, again there are three stages, which will outline the methodology conducted using the theory in this worked example to determine facilitators and barriers to the uptake of the MIND diet^{(Reference Morris, Tangney and Wang88)} in adults at midlife.

The behaviour change wheel provides a research framework for designing, implementing and evaluating interventions, at its core is the COM-B model, which reflects capabilities (C), opportunities (O), motivation (M) and behaviour (B), see Fig. 2^{(Reference Michie, Atkins and West87)}. The model claims that opportunity and capability influences motivation, which then determines engagement with a target behaviour, thus opportunity and capability both have the potential to influence behaviour directly and indirectly. In order to change behaviour, according to the COM-B model, one of the constructs must be targeted, this will be dependent on an understanding of what is driving the behaviour, which is determined in stage one of the theoretical framework.

Fig. 2. Capabilities, opportunities, motivation and behaviour (COM-B) model^{(Reference Michie, Atkins and West87)}.

Stage three: identify content and implementation options

All six intervention functions were deemed suitable, and this marked the start of stage three, which involved identifying content and implementation options for the intervention. This was guided in part by the next step to select the most appropriate behaviour change techniques (BCT) for each of the intervention functions. Within the TDF, twelve domains and their corresponding intervention functions, have been linked to fifty-nine behaviour change techniques defined by the behaviour change techniques taxonomy v 1^{(Reference Michie, Richardson and Johnston84,Reference Cane, Richardson and Johnston91)} and the theory techniques tool^{(Reference Connell, Carey and de Bruin92)}. Prior research provided evidence to support the most frequently used behaviour change techniques to successfully target each intervention function, and their corresponding mechanism of action on the target behaviour^{(Reference Carey, Connell and Johnston62,Reference Johnston, Carey and Connell Bohlen93)} . In this study, twenty-four BCT were selected for the dietary intervention that could be mapped directly to the COM-B, using the taxonomy of behaviour change provided standardised descriptions of the components included in the intervention, making it more replicable in further studies, this approach is considered good practice^{(Reference Michie, Richardson and Johnston84)}. Table 2 shows how some BCT were mapped to the COM-B model.

Table 2. COM-B constructs mapped to examples of the BCT employed in the MIND diet intervention

COM-B, capabilities, opportunities, motivation and behaviour; MIND, Mediterranean-dietary approaches to stop hypertension diet intervention for neurodegenerative delay.

The implementation of the intervention was a 12-week feasibility randomised controlled trial (RCT) with adults aged 40–55 years living in Northern Ireland. There were three groups, a control group that received the current physical activity guidelines, MIND diet only group who were given information about the MIND diet and the MIND diet plus support group who had access to a website with additional resources based on data from stages one and two (educational material on benefits of MIND diet, recipes, self-monitoring resources and social support) to promote adherence to the MIND diet. An evaluation of the intervention, focusing on outcome and process was carried out in keeping with guidelines. This provided a very structured approach to intervention design and the evaluation of process provided an opportunity to determine what worked and didn't work in this sample and how this could be improved for a larger RCT.