1) What is already known about the topic?
a) Sources of menopausal information are underexplored in the African region.
b) Information sources are consulted by menopausal women in the African region, but there is little information on the preferred sources of such information for the management of menopausal symptoms.
2) What this paper adds
a) Our systematic review and meta-analysis identified only fourteen eligible papers from the five African countries that were involved in the research on information sources consulted by menopausal women in the African region during 2000-2017.
b) Meta-analysis revealed six preferred information sources, with friends as the most frequently reported source of menopause information, followed by relatives; medical providers; television and radio; books, magazines, journals; and religious sources being the lowest.
Despite an abundance of information regarding menopausal women in western society, African women have been almost overlooked in menopausal research   . In most African states, research on menopause and how its symptoms are understood and dealt with in public policy and public health education is minimal   . Several studies conducted in the African region confirm that awareness of information about menopause in African women was low      .
Additionally, issues of menopause such as sources of information are under explored  . However, inexperience and inadequate health-related knowledge on menopause negatively affects understanding and coping with menopause and related symptoms. Equally, African menopausal women need support systems from all relevant stakeholders, including health care providers, family and society to effectively manage menopause   . Hence, it is important to determine where women in Africa obtain information about menopause  .
1.2. The Purpose of the Review
This systematic review aimed at identifying and analysing information sources consulted by menopausal women in the African region regarding the management of menopausal symptoms. The goal was to enable medical/health service providers to provide their clients with correct information from reliable sources and empower menopausal women to alleviate suffering during menopause. Furthermore, evidence from this review will allow policy makers, such as the ministry of health to devise appropriate interventions that will enable all women, particularly menopausal women, to receive correct information.
The specific objectives of this systematic literature review were to: review relevant African studies since 2000 to date, regarding the sources of information in the management of menopausal symptoms among pre-, peri-, menopause-, and post-menopausal women aged 35 - 90; assess the validity of the findings of the included studies and systematically analyse the relevance of information sources across the African region.
Menopause is characterised by absence of menstrual period for 12 consecutive months without biological or physiological cause    . Such absence of menstrual period signifies the end of fertility and childbearing years   . The end of fertility in a woman’s life is characterised by several symptoms brought about by decreased hormonal activity  . The most common symptoms associated with menopause are hot flashes, decreased libido, vaginal dryness, insomnia, and bone or joint disorders       .
Pre-menopause is the stage that leads up to peri-menopause. This stage affects most women in their late thirties and early forties. During this period, women are still menstruating regularly, but the estrogen and progesterone levels may begin to change  .
Peri-menopause is the stage that occurs before menopause. At this stage, women have a significant drop in estrogen levels, which signifies the end of fertility in a woman’s life, coupled by some troublesome symptoms, such as hot flashes, vaginal dryness and slowed metabolism. During this stage, the menstrual period becomes irregular, and women may experience missed periods, shorter menstrual cycles or suffer from longer cycles   .
Post-menopause refers to the time after a woman’s menstrual periods have ceased for 12 consecutive months. During the postmenopausal stage, many troublesome symptoms a woman may have experienced during peri-menopause gradually decrease  .
2.2.1. Review Question
A systematic review of the literature was conducted to answer the following question:
What information sources are consulted by pre-, peri-, menopause-, and post-menopausal women between ages 35 - 90 in the African region in the management of menopausal symptoms since 2000 according to literature obtained from Embase (OVID), Google Scholar, MEDLINE (OVID), MEDLINE in Process (OVID), Pub Med, Scopus plus African specific databases: https://www.africabib.org/, African Index Medicus; http://indexmedicus.afro.who.int/, and African Journals Online (AJOL) https://www.ajol.info/. This review was registered on 12 May 2017 in PROSPERO; the international prospective register of systematic reviews as: PROSPERO 2017 CRD42017065866 and is available from http://www.crd.york.ac.uk/PROSPERO/display_record.phd?ID=CRD42017065866
A systematic literature review was conducted according to the PRISMA statement and guidelines  .
1) Search strategy
Six databases were searched in April 2017: PubMed, BioMed Central, Embase, Google Scholar, Medline and Medline in Process and Scopus.
2) Search terms
The search strategy was designed in PubMed. In brief this comprised a combination of three sets of search terms:
Menopaus* [in title or abstract] OR Menopause as a Medical Subject Heading
(Information OR experience* OR perception* OR health seeking behav* OR knowledge) [In title or abstract] OR Information Seeking Behavior as a Medical Subject Heading
A search filter of title/abstract terms to identify research carried out in Africa OR Africa as a Medical Subject Heading
Following testing for its ability to identify known relevant studies, the search was then adapted and run in the following additional databases: Embase (OVID), Google Scholar, Medline (OVID), Medline in Process (OVID), Scopus, www.Africabib.org, African Index Medicus; http://indexmedicus.afro.who.int/, and African Journals Online (AJOL) https://www.ajol.info/ in April 2017. The databases were chosen to provide good coverage of the African healthcare literature by including both the major global and Africa-specific resources. Complete search strategies, including combinations of text words (from title/abstract) and indexer-provided subject headings (where available), are listed in Appendix 1.
Supplementary searching was also employed: reference lists of included studies were checked for additional studies; citation tracking was used to identify more recent publications; authors of included publications were contacted to ask about unpublished and in-press studies.
2.3. Inclusion and Exclusion Criteria
To assure modern-day relevance, this study was limited to literature published from January 2000 to April 2017, when searches were completed. As this review aimed at identifying and analysing the information sources consulted by menopausal women in the Africa region, only studies that incorporated women from the African region were included. Pre-, peri-, menopause-, and post-menopausal women between ages 35 - 90 were included in this review. Complete inclusion and exclusion criteria are described in Table 1.
2.4. Data Selection
The results of all database searches were imported into Reference Manager 12 http://www.adeptscience.co.uk/products/refman/reference and duplicates removed. Records potentially meeting the inclusion criteria were screened by two researchers, independently, first at title/abstract stage then at full text stage. Additional studies obtained from cross referencing and reviews met the inclusion criteria and were included in the full text review. Data were then independently coded by two researchers based on the sources of information used by the menopausal women.
2.4.1. Quality Assessment
Two researchers firstly independently reviewed different appraisal tools and then agreed on the Center for Evidence-Based Management (CEBMa) critical appraisal tools, designed for qualitative and cross-sectional studies
(https://www.cebma.org/resources-and-tools/what-is-critical-appraisal). The CEBMa critical appraisal tools have 10 (qualitative) and 12 (quantitative) yes/no questions depending on the type of study to help guide the assessment of the quality of the literature being critiqued. Quantitative studies were critiqued,
Table 1. Inclusion and exclusion criteria for the review.
based on the following criteria: focused question, study design, selection of participants, selection bias, representativeness, sample size by power calculation, response rate, question reliability, statistical significance, confidence intervals, confounders, relevance to African population, while qualitative studies were critiqued on: focused question, study design, study context, fieldwork, evidence inspected, procedure reliability, analysis reliability, results credibility, conclusions justified, findings transferable. (See comments in Table 2) Thereafter, eligible studies (14) were independently appraised by two researchers. The researchers had one Skype call and one in-person meeting and discussed appraised articles. Two disagreements in the scores were discussed until consensus was reached.
2.4.2. Data Extraction
Tables were used to extract author name, year of publication, country of origin, aim of study, study design, sample characteristics, data collection instruments and data collection procedure, results and limitations identified via the quality assessment process, as shown in Table 3.
Prevalence information was pooled with random effects meta-analysis where appropriate. Results are presented with the associated fixed effect estimates and 95% confidence interval as well as the i-square statistic. All analysis was conducted using the R programming language and environment implementing the meta and metafor packages    .
Our initial search yielded 794 studies (Figure 1). Twelve additional studies were
Figure 1. Flow diagram of reviewed studies.
identified from cross referencing and reviews. After 443 duplicates were deleted from the initial search, the remaining 351 studies together with the twelve records through other sources were then imported into Reference Manager 12. Three hundred and thirty (330) studies were excluded because they were conducted primarily among African American menopausal women in America. The 21 full text review records plus the twelve additional records were retained. Thirty three full-text articles were assessed for eligibility (Appendix 2), and 19 records excluded, with reasons including: not providing sources of information, HIV related, not a study of women’s views, or an educational interventional study. The eligibility criteria were then reapplied to the remaining 14 full texts for thematic synthesis to illustrate the key information sources, used by menopausal women in the African region. Of the 14 reviewed studies, 12 employed quantitative and 2 qualitative approaches. Resultant studies are summarised in Table 2.
The majority of the studies (12) employed a quantitative cross-sectional design: two (2) studies were qualitative in nature. The information from the cross-sectional studies was collected with structured questionnaires, using close and open ended questions, while interviews were used for qualitative studies. Response rates were between 75-100%. The fourteen eligible studies reporting on the information sources used by menopausal women in the African region were from Nigeria (7), South Africa (3), Ethiopia (2), Namibia (1) and Ghana (1). Meta-analysis was conducted to pool the prevalence of six different information sources: friends, relatives, medical providers, books/magazines/journals, TV/radio and religious sources.
Friends were the most frequently reported source of menopause information with a point prevalence estimate of 0.44 (95% CI: [0.35, 0.54], number of studies = 7), followed by relatives with a point prevalence estimate of 0.35 (95% CI: [0.22, 0.50], number of studies = 5). Medical providers were next, prevalence 0.30 (95% CI: [0.15, 0.50], number of studies = 9), followed by TV and radio, prevalence 0.20 (95% CI: [0.06, 0.48] number of studies = 5), then books, magazines, journals prevalence 0.19 (95% CI: [0.10, 0.33], number of studies = 9), with religious sources being the lowest, prevalence 0.06 (95% CI: [0.02, 0.14], number of studies = 5). It must be noted however that all of the above analyses exhibited high levels of heterogeneity (i2 all above 94%).
3.2. Quality Assessment
Fourteen studies were appraised. Each of the critiqued studies had 10 - 12 components needed to constitute a strong study, out of 10 - 12 possible criteria (see Table 2). According to the results of the critical appraisals, studies were overall of good quality. Survey instruments were rarely piloted or validated however, and studies did not generally assess statistical significance intervals because these studies were mostly addressing perceptions, attitudes and or behaviour of the
Table 2. Summary of quality assessment based on CEBMa tools.
African menopausal women.
This review synthesised the data regarding information sources consulted by
Table 3. Included studies and data extraction.
menopausal women in the African region. The available literature was of high quality, despite the heterogeneity of the methodologies and sample characteristics and assessment tools.
Based on the findings and consistent with previous reports  , African menopausal women are more likely to learn about the menopause from their friends and relatives, rather than from professional assistance. Religious sources were the lowest of all that were consulted by women in the African region about the menopause.
The meta-analyses revealed high heterogeneity indicating that it is unlikely that the studies were all measuring the same quantities in exactly the same way. This is perhaps unsurprising given the wide geographical area covered by this study, encompassing many different cultures. The results must therefore be interpreted carefully.
Although women experience menopause in a universal manner due to decline in ovarian function leading to different menopausal symptoms, the actual experiences of the most common symptoms such as hot flushes, night sweats and low libido are individual      . Menopausal women may also experience challenges such as: anxiety, poor-self-image, low self-esteem, sleeplessness, panic  , due to the multidimensional nature of menopause, which is influenced by biological, psychological, social and cultural dimensions  . Therefore, lack of professional awareness may contribute to silent suffering of menopausal women   . This is particularly true in the majority of African states where discussion of reproductive health issues are considered taboo, private and sensitive and therefore not easily shared amongst others   .
It is equally desirable that women have access to information on the menopause from health care providers regarding current treatment options    and associated risks and benefits of menopause. Medical professionals are best placed to provide menopausal women with individualised care to improve quality of life. Regarding some common menopausal symptoms, such as reduced sexual functioning, health care workers should advise women that pharmacological and non-pharmacological therapies are available to treat atrophic vaginitis and relieve pain during intercourse  . With over three quarters of women not citing medical professionals as an information source there is clearly room for improvement.
Given how many women access menopause information through friends and relatives, it may be helpful for health care providers to design special programmes to inform them about menopause; as partners or family members, men also may benefit from education as they experience menopausal symptoms alongside these women without prior knowledge or understanding. Such awareness will help family and friends to be sensitive to menopausal women during this period and provide adequate support  . The public health systems should also mobilise adequate resources to improve the awareness and knowledge of the women about menopause and menopausal symptoms to promote active and healthy living during the period of menopause  . Moreover, clinical research regarding menopause and understanding of menopausal symptoms should be done in the African region to guide public health policy and education.
Although a comprehensive search was undertaken, we cannot guarantee that all relevant research studies were identified. All the papers that discussed lack of knowledge/information in general but with no description of information sources were excluded. These criteria might have limited the scope of available literature on the information sources in the African region.
Women in African countries experiencing menopause are more likely to have gained information about their condition from friends and relatives than from health professionals. Consequently, while relatives and friends might support them during this uncertain period, there is a clear opportunity for medical professionals to play a greater role in the education of women experiencing the menopause.
Special thanks are extended to Writing to Improve Nursing Science (WINS) Program (Columbia University, School of Nursing) who provided us with fundamental information throughout the course of this paper, with special reference to Dr Carolyn Sun (Associate Research Scientist), who mentored this review. We also acknowledge the support of the Phoenix Project (a University of Namibia and Cardiff University partnership, led by Professor Judith Hall) for this international collaboration.
As this was a review of existing literature, no ethical approval was required.
Appendix 1: Search Strategies
PubMed 7 April 2017 259 hits
Menopaus*: as a text word (ie word in title or abstract) OR Menopause: as a MeSH term (including all more narrow terms).
(Information OR experience* OR perception* OR health seeking behave* OR knowledge): as a text word OR Information Seeking Behaviour: as a MeSH term (there are no more narrow terms).
(Africa* OR Algeria OR Angola OR Benin OR Botswana OR “Burkina Faso” OR Burundi OR Cameroon OR “Canary Islands” OR “Cape Verde” OR “Central African Republic” OR Chad OR Comoros OR Congo OR “Democratic Republic of Congo” OR Djibouti OR Egypt OR “Equatorial Guinea” OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR Guinea OR “Guinea Bissau” OR “Ivory Coast” OR “Cote d’Ivoire” OR Jamahiriya OR Jamahiryia OR Kenya OR Lesotho OR Liberia OR Libya OR Libia OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mayote OR Morocco OR Mozambique OR Mocambique OR Namibia OR Niger OR Nigeria OR Principe OR Reunion OR Rwanda OR “Sao Tome” OR Senegal OR Seychelles OR “Sierra Leone” OR Somalia OR “South Africa” OR “St Helena” OR Sudan OR Swaziland OR Tanzania OR Togo OR Tunisia OR Uganda OR “Western Sahara” OR Zaire OR Zambia OR Zimbabwe OR “Central Africa” OR “Central African” OR “West Africa” OR “West African” OR “Western Africa” OR “Western African” OR “East Africa” OR “East African” OR “Eastern Africa” OR “Eastern African” OR “North Africa” OR “North African” OR “Northern Africa” OR “Northern African” OR “South African” OR “Southern Africa” OR “Southern African” OR “sub Saharan Africa” OR “sub Saharan African” OR “subSaharan Africa” OR “subSaharan African”): as text words
OR Africa: as a MeSH term (there are no more narrow terms)
BioMed Central 19 April 2017 85 hits.
Menopause AND information seeking AND (South Africa* OR Namibia*)
As text words
Sorted by “relevance” and browsed for studies since 2000. No relevant studies.
Continent specific databases: 7 April 2017.Search strategy: Search for menopaus* in the title. One additional hit, not identified in other databases (Saka 2011)
African Index Medicus; http://indexmedicus.afro.who.int/
African Journals Online (AJOL) https://www.ajol.info/ =======================================================
Embase 19 April 2017 250 hits.
Database(s): EMBASE 1947-Present [OVID] Search Strategy:
Key to terms used:
/ = indexer-provided subject heading
kw = author keyword
tw = word in the title or abstract
Database(s): Ovid MEDLINE(R) without Revisions 1996 to April Week 1 2017, Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations April 18, 2017 Search Strategy:
Key to terms used:
/ =indexer-provided subject heading
kw = author keyword
tw = word in the title or abstract
Scopus 19 April 2017 54 hits.
(TITLE-ABS-KEY (menopaus*)) AND (TITLE-ABS-KEY (information OR experience* OR perception* OR health AND seeking AND behave* OR knowledge))
Appendix 2: PRISMA 2009 CHECKLIST
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 Hofnie-Ho?bes, K., Matengu, K. and Iipinge, S. (2009) An Investigation and Assessment of Knowledge of Menopause, Menopausal Symptoms and Issues among Women and Men in Namibia. University of Namibia, Multidisciplinary Research Centre Social Sciences Division. (Unpublished)
 Ama, N.O. and Ngome, E. (2013) Menopauseal Perceptions and Experiences of Older Women from Selected Sites in Botswana. Advances in Sexual Medicine, 3, 47-59.
 Makuwa, G.N., Rikhotso, S.R. and Mulaudzi, F.M. (2015) The Perception of African Women Regarding Natural Menopause in Mamelodi, Tshwane District. Curationis, 38, 1531.
 Saka, M.J., Akande, T.M., Saka, A.O., Odusolu, P.O., Latinwo, A.W.O., Jimoh, A.A.G. and Raji, H.O. (2014) Assessment of Expectation, Knowledge and Adjustment Behaviour of Menopausal Women in North Central Nigeria. The Tropical Journal of Health Sciences, 18, 59-64.
 Osinowo, H.O. (2003) Psychosocial Factors Associated with Perceived Psychological Health, Perception of Menopause and Sexual Satisfaction in Menopausal Women and Controls. West African Journal of Medicine, 22, 225-231.
 Odiari, E.A. and Chambers, A.N. (2012) Perceptions, Attitudes and Self-Management of Natural Menopausal Symptoms in Ghanaian Women. Health Care for Women International, 33, 560-574.
 Maharaj, N.R., Gangaram, R. and Moodley, J. (2007) The Menopause, Hormone Replacement Therapy and Informed Consent: Are Women in an Under-Resourced Country Adequately Aware? Journal of Obstetrics and Gynecology, 27, 300-304.
 Bello, A.B. and Daramola, O.O. (2016) Attitude to the Menopause and Sex amongst Middle-Aged Woman in a Family Medicine Clinic in Ibadan, Nigeria. Obstetrics and Gynecology International, 2016, Article ID: 203105.
 Dienye, P.O., Judah, F. and Ndukwu, G. (2013) Frequency of Symptoms and Health Seeking Behaviour of Menopausal Women in an Out-Patient Clinic in Port Harcourt, Nigeria. Global Journal of Health Science, 5, 39-47.
 Mbu, R.E., Abauleth, Y.R., Koffi, A., Keita, N., Dolo, A. and Lankoande, J. (2014) Effect of Daily Supplementation of Soy Isoflavones on Hot Flashes and Night Sweats in African Menopausal Women. Open Journal of Obstetrics and Gynecology, 4, 42-46.
 Ikeme, A.C.C., Okeke, T.C., Akogu, S.P.O. and Chinwuba, N. (2011) Knowledge and Perception of Menopause and Climacteric Symptoms among a Population of Women in Enugu, South East, Nigeria. Annals of Medicine and Health Sciences Research, 1, 31-36.
 Ibraheem, O.M., Oyewole, O.E. and Olaseha, I.O. (2015) Experiences and Perceptions of Menopause among Women in Ibadan South East Local Government Area, Nigeria. African Journal of Biomedical Research, 18, 81-94.
 Anolue, F.C., Dike, E., Adogu, P. and Ebirim, C. (2011) Women’s Experience of Menopause in Rural Communities in Orlu, Eastern Nigeria. International Journal of Gynecology and Obstetrics, 118, 31-33.