Participants discussed three barriers to seeking or continuing osteopathic management, including lack of knowledge, embarrassment, and financial constraints. Participant 3 described that her main barrier was her family's apprehension regarding osteopathy, as they did not understand how osteopathy would help, “My family didn't really understand how it could help. There was a lot of misunderstanding and not knowing about how it works”. She also added that “My first osteopath clicked my neck and back and it spasmed for over a week, so at the start I had a really bad first impression of it”. Due to some of the participants' lack of knowledge about their first consultation, they had different viewpoints. For example, some participants found osteopathy to be, “Weird, voodoo magic”, “Airy fairy nature”, or “Apprehensive because of previous disbelief in other alternative medicines [naturopathy].”
Embarrassment was another barrier mentioned by some participants. For instance, Participant 8 discussed how her main barrier towards seeking osteopathic management was embarrassment because dysmenorrhea is not regularly spoken about. In fact, it was uncomfortable for her to bring up the topic with her GP or close family and friends, “You don’t really want to tell people you have a period.” Similarly, Participant 7 mentioned, “It is a shameful part of development and life in general.”
The most common barrier declared by women in this study was financial constraints. For example, Participant 1 indicated, “It [osteopathy] is not covered under ACC.” Additionally, Participant 2 said, “The hardest part is you have to mentally prepare for the amount you’re going to spend.”
Despite these barriers, participants continued with osteopathic management because they were pleased with their treatments and how osteopathy had worked for them. Participant 4 stated, “I will break down any barriers that prevent me from going.”
57 The participants of this study were recommending osteopathic care to other women with dysmenorrhea. Participant 2, for instance, suggested, “Try it, try osteo [osteopaths], or chiro [chiropractors]. It takes 3 sessions to work, do not expect a quick fix, even though it is expensive, do it.” Additionally, Participant 6 advised, “Just find a really good osteopath and continue going back. Some sessions I have I think, Oh, I don't feel like she’s done anything, and then the next couple are really good and it’s just all trial and error and to keep at it.” Some participants encouraged other women to seek help. For example, Participant 5 said, “It’s not normal to have excruciating periods, you’re not supposed to be in that much pain. Start talking about it. Seek help.
You shouldn’t be scared to talk about it.” Similarly, Participant 8 mentioned, “Don’t be embarrassed to seek help.”
Common advice that some participants wanted to share with other women was to discourage them from going only through the medical system for treatment. Participant 3 emphasised, “Have an open mind, don’t go straight down the medical route, just because the medicine doesn’t work, doesn’t mean something else won’t.” A similar response was given by Participant 4,
Don’t trust what a surgeon says. Do your own research, seek other opinions, try alternative therapies, even if they’re not presented to you. It was just, "You need surgery."
And there was nothing else. So, I had to go to them and say, "Well, what about a Mirena?",
"Well, it probably won't work." And it has. So, don't trust doctors, really, is my message.
Furthermore, Participant 2 mentioned how she was recommended to exercise by her doctor, “How can you exercise if you can’t walk?” and “When you’re in so much pain you want help. Doctors don’t know what to do. Women need to know there are other options. I tell my experiences to other women because if you don’t, no one knows.”
58
DISCUSSION
This study explored women’s experiences with the osteopathic management for dysmenorrhea.
Three key themes emerged: impact of dysmenorrhea on women’s QOL, osteopathy as an effective strategy for managing dysmenorrhea, and barriers to beginning osteopathic management.
The results of this study showed that dysmenorrhea had a negative impact on women’s QOL. For instance, the participants found walking, studying, and socialising challenging. Similar findings were reported by previous studies conducted on women with dysmenorrhea. Previous research has reported high scores for pain, low scores for physical and general health perception and vitality (Unsal et al., 2010) as well as low QOL scores in 14 of 16 domains including physical health (Iacovides et al., 2015). The current study found that almost half the participants were in pain for at least half of their menstruation each month. Similarly, Berkley & McAllister (2011) reported that dysmenorrhea affected women not only on the days of menstruation but also throughout the entire month. All participants in the current study reported that they could not accomplish any sort of daily activities without experiencing pain. This may be because more than half of the participants disclosed before or during the interviews that they had a form of secondary dysmenorrhea, which may have impacted their pain levels (Osayande & Mehulic, 2014).
Participants in this study explained how dysmenorrhea psychologically impacted their lives, causing shamefulness and isolation. Similarly, Iavocides et al. (2014) found that women with dysmenorrhea had overall lower contentment and satisfaction towards life during their menstrual cycle. Additionally, Li et al. (2020) described how their participants were socially isolated, and that potentially limited their ability to discuss their problems with other women. Both of the above mentioned studies also concluded that dysmenorrhea can significantly affect multiple areas of an individual’s life (Iacovides et al., 2014; Li et al., 2020).
The current study’s participants indicated that lack of knowledge, embarrassment and financial constraints were barriers to beginning osteopathic management. Nearly half of the participants mentioned that they felt their condition is misunderstood and they had to explain to people their experience of living with dysmenorrhea. This may be because, for those who have never experienced this condition, it is difficult to fully comprehend the impact that it can have on
59 women’s lives. Existing literature seems to support these findings. Chen et al. (2018) suggested that women view dysmenorrhea as a normal part of life, and therefore, they have a lack of knowledge about the condition itself, and potentially about available treatment options. However, based on the comments from Chen’s study participants, it appeared that many women may be apprehensive as they view health providers as unhelpful. Half of the participants in the current study were worried about visiting an osteopath before their first appointment. This apprehension may also be due to their lack of knowledge and past negative experiences, visiting inexperienced practitioners, or their GP not recommending an osteopath as the best choice for management. This could also indicate a lack of knowledge among medical professionals about osteopathy, possibly because osteopaths find it challenging to provide evidence-based health care (Leach et al., 2019).
In the current study, over half of the women were not aware of osteopathy until it was recommended to them.
Embarrassment was mentioned by one participant as a barrier because dysmenorrhea was not regularly spoken among people in society. Participants in the current study thought their condition was not taken seriously, and they felt unsupported and isolated. Furthermore, some participants mentioned that they did not feel their condition was considered to be a legitimate health concern.
This may stem from the fact that few women seek the care they need. Fernandez-Martinez et al.
(2019) found that 66% of their participants never sought medical advice for their dysmenorrhea.
Reasons for this included feeling embarrassed or afraid to seek care (Fernández-Martínez et al., 2019). Comparatively, in 2017, Chen et al. also found that some women were afraid to seek health care for dysmenorrhea because they were embarrassed or afraid of being laughed at or being seen as a whiner. Similarly, Li et al. (2020) found their participants’ dysmenorrhea contributed to their negative thoughts of themselves based on other people’s perceptions about dysmenorrhea. This is similar to half of the participants’ reports in the current study as they felt they needed to, “Harden up”, “Get over it”, and “Deal with the fact there is a lack of support among my peer group”.
Furthermore, some participants in this study believed that dysmenorrhea is still considered taboo in some circles, and some medical practitioners do not know what to do or do not even have awareness of alternative therapies such as osteopathy. This may suggest that women have a difficult time dealing with their dysmenorrhea as it may be disregarded, making them feel less validated by society.
60 Financial difficulties were commonly mentioned among most of the participants in the current study. Previous research reported that their participants did not seek treatment for dysmenorrhea due to their limited resources such as the absence of health insurance and treatment expenses (Chen et al., 2018). However, despite the financial barriers, participants in this study continued having regular treatment because they believed that osteopathy was an effective management tool for dysmenorrhea-related symptoms.
All participants in the current study found osteopathy to be effective in reducing the pain related to the condition. Osteopathy provided a multi-faceted approach and experience which reduced dysmenorrhea symptoms. Almost half of the participants mentioned that they do not use the same dosage of their pain medication anymore. Similarly, Boesler et al. (1993) and Pirritano’s (2004) research found that osteopathic manipulations were effective in reducing the intake of pain medications consumed by women for their dysmenorrhea.
Various osteopathic techniques are used within the profession to treat dysmenorrhea. In the current study, osteopathic techniques used on the participants were either cranial, visceral, or structural.
These could be applied directly or indirectly on each patient. This was similar to Pirritano’s (2004) findings as their treatment of dysmenorrhea patients included visceral and structural techniques.
Schwerla et al. (2014) used a variety of techniques including high-velocity low amplitude thrusts, muscle energy techniques, myofascial release, balanced ligamentous tension, functional, visceral, and cranial techniques and maintained similar results. The combination of osteopathic techniques decreased participants' pain intensity, indicating that several techniques may be more effective than a single technique for managing dysmenorrhea (Pirritano, 2004; Schwerla et al., 2014).
Participants in the current study also felt greater relief from symptoms with a combination of techniques.
All participants in the current study recommended osteopathic management to other women with dysmenorrhea. This may be because some women prefer to not seek medical intervention, which is supported by the Chen et al.’s (2018) study. Reasons some women do not believe in seeking medical treatment may show hesitancy around current treatment options. For example, participants are wary of pharmaceutical (Paracetamol or contraceptive pills) or surgical options (Chen et al.,
61 2018). Osteopathic management provides a holistic patient-centred approach and seems to be a good alternative for women to incorporate into their management plan as discussed earlier in this research. However, there is a need for more research on this topic to enhance the care that is provided to women who are suffering from dysmenorrhea.
Limitations
There were a few limitations to this study. Firstly, it was not clarified whether the participants experienced primary or secondary dysmenorrhea. Due to the two types of dysmenorrhea stemming from different causes, women with primary and secondary dysmenorrhea may respond to treatment differently. Knowing which form of dysmenorrhea participants had would enable the researchers to explore if there was any distinction. However, the results provided the foundation for further research on dysmenorrhea. Secondly, due to the small sample size, caution is required when interpreting the findings of this study. However, smaller sample sizes are common in qualitative methodology in order to allow for more in depth and detailed data to be collected through the interview process. Lastly, despite advertising recruitment posters around New Zealand, all participating women were recruited from Auckland; therefore, these findings may possibly reflect the experiences of other women of similar age living in Auckland.
CONCLUSION
Dysmenorrhea is a common debilitating condition that affects women’s QOL worldwide. This research contributes to the currently limited literature on women’s experiences of osteopathic management for their dysmenorrhea. The main themes that were identified were the impact of dysmenorrhea on women’s quality of life, osteopathy as an effective strategy for managing dysmenorrhea, and barriers to beginning osteopathic management. The findings of this research show that while osteopathy cannot cure dysmenorrhea, it can be an effective management tool for controlling the symptoms that accompany this condition. Furthermore, alternative therapies such as osteopathy should be recommended to more women who are suffering from this condition.
Recommendations for future research should look into conducting a nationwide study, investigating specific cohorts including adolescent girls, older women, and the transgender and
62 non-binary community. Additionally, researching primary and secondary dysmenorrhea separately could allow for greater transferability and specificity of the findings.
Conflict of Interest Statement
No conflict of interest has been declared by the authors.
63
REFERENCES
Attride-Stirling, J. (2001). Thematic networks: An analytic tool for qualitative research: 1(3), 385–405. https://doi.org/10.1177/146879410100100307
Aziato, L., Dedey, F., & Clegg-Lamptey, J. N. A. (2015). Dysmenorrhea management and coping among students in Ghana: A qualitative exploration. Journal of Paediatric and Adolescent Gynaecology, 28(3), 163–169. https://doi.org/10.1016/J.JPAG.2014.07.002
Benoot, C., Hannes, K., & Bilsen, J. (2016). The use of purposeful sampling in a qualitative evidence synthesis: A worked example on sexual adjustment to a cancer trajectory. BMC Medical Research Methodology, 16(1), 1–12. https://doi.org/10.1186/S12874-016-0114- 6/TABLES/5
Berkley, K. J., & McAllister, S. L. (2011). Don’t dismiss dysmenorrhea! In Pain (Volume 152, Issue 9, pp. 1940–1941). Elsevier B.V. https://doi.org/10.1016/j.pain.2011.04.013
Boesler, D., Warner, M., Alpers, A., Finnerty, E., & Kilmore, M. (1993). Efficacy of high- velocity low-amplitude manipulative technique in subjects with low-back pain during menstrual cramping. The Journal of the American Osteopathic Association, 93(2), 203-214 https://pubmed.ncbi.nlm.nih.gov/8432669/
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706QP063OA
Carr, A. J., Gibson, B., & Robinson, P. G. (2001). Is quality of life determined by expectations or experience? BMJ, 322(7296), 1240–1243. https://doi.org/10.1136/BMJ.322.7296.1240 Chan, C., Yiu, K., Yuen, P., Sahota, D., & Chung, T. (2009). Menstrual problems and health -
seeking behaviour in Hong Kong Chinese girls. Hong Kong Med J, 15(1), 18-23
64 https://www.researchgate.net/publication/23983448_Menstrual_Problems_and_health_- seeking_behavior_in_Hong_Kong_Chinese_girls
Chen, C. X., Shieh, C., Draucker, C. B., & Carpenter, J. S. (2018). Reasons women do not seek healthcare for dysmenorrhea. Journal of Clinical Nursing, 27(1–2), e301.
https://doi.org/10.1111/JOCN.13946
Chen, C. X., Kwekkeboom, K. L., & Ward, S. E. (2016). Beliefs about dysmenorrhea and their relationship to self‐management. Research in nursing & health, 39(4), 263-276.
Creswell, J. (2013). Qualitative inquiry & research design. SAGE publications. http://www.ceil conicet.gov.ar/wp-content/uploads/2018/04/CRESWELLQualitative-Inquary and- Research-Design-Creswell.pdf
Cypress, B. S. (2017). Rigor or reliability and validity in qualitative research: Perspectives, strategies, reconceptualization, and recommendations. Dimensions of Critical Care Nursing: DCCN, 36(4), 253–263. https://doi.org/10.1097/DCC.0000000000000253
Fernández-Martínez, E., Onieva-Zafra, M. D., & Parra-Fernández, M. L. (2019). The impact of dysmenorrhea on quality of life among spanish female university students. International Journal of Environmental Research and Public Health, 16(5).
https://doi.org/10.3390/IJERPH16050713
Ministry of Health NZ. (2020). Health and disability services at alert level 2.
https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-
novelcoronavirus/covid-19-health-advice-public/health-and-disability-servicesdifferent- alert-levels/health-and-disability-services-alert-level-2
Hewison, A., & van den Akker, O. B. (1996). Dysmenorrhoea, menstrual attitude and GP consultation. British Journal of Nursing (Mark Allen Publishing), 5(8), 480–484.
https://doi.org/10.12968/BJON.1996.5.8.480
65 Iacovides, S., Avidon, I., & Baker, F. C. (2015). What we know about primary dysmenorrhea today: A critical review. Human Reproduction Update, 21(6), 762–778.
https://doi.org/10.1093/humupd/dmv039
Iacovides, S., Avidon, I., Bentley, A., & Baker, F. C. (2014). Reduced quality of life when experiencing menstrual pain in women with primary dysmenorrhea. Acta Obstetricia et Gynecologica Scandinavica, 93(2), 213–217. https://doi.org/10.1111/AOGS.12287
Lambert, V. A., & Lambert, C. E. (2012). Qualitative descriptive research: An acceptable design. Pacific Rim International Journal of Nursing Research, 16(4), 255-256.
Leach, M. J., Sundberg, T., Fryer, G., Austin, P., Thomson, O. P., & Adams, J. (2019). An investigation of Australian osteopaths’ attitudes, skills and utilisation of evidence-based practice: A national cross-sectional survey. BMC Health Services Research, 19(1), 1–12.
https://doi.org/10.1186/S12913-019-4329-1/TABLES/5
Li, A. D., Bellis, E. K., Girling, J. E., Jayasinghe, Y. L., Grover, S. R., Marino, J. L., & Peate, M. (2020). Unmet needs and experiences of adolescent girls with heavy menstrual bleeding and dysmenorrhea: A qualitative study. Journal of Paediatric and Adolescent Gynaecology, 33(3), 278–284. https://doi.org/10.1016/J.JPAG.2019.11.007
Lincoln, Y., & Guba, E. (1994). Competing Paradigms in Qualitative Research.
https://miguelangelmartinez.net/IMG/pdf/1994_Guba_Lincoln_Paradigms_Quali_Resear ch_chapter.pdf
Manero, M. G., Royo, P., Olartecoechea, B., & Alczar, J. L. (2009). Endometriosis in a postmenopausal woman without previous hormonal therapy: A case report. Journal of Medical Case Reports, 3, 135. https://doi.org/10.1186/1752-1947-3-135
Osayande, A., & Mehulic, S. (2014). Diagnosis and initial management of dysmenorrhea.
American Family Physician, 89(5), 341–346.
66 O’Brien B.C., Harris, I.B., Beckman, T.J., Reed, D.A., & Cook, D.A. (2014). Standards for reporting qualitative research: A synthesis of recommendations. Academic Medicine, 89(9), 1245-1251.
Parker, M., Sneddon, A., & Arbon, P. (2010). The menstrual disorder of teenagers (MDOT) study: Determining typical menstrual patterns and menstrual disturbance in a large population-based study of Australian teenagers. BJOG: An International Journal of Obstetrics & Gynaecology, 117(2), 185–192. https://doi.org/10.1111/J.1471- 0528.2009.02407.X
Pirritano, R. (2004). Osteopathic treatment to patients with primary dysmenorrhea (Doctoral dissertation, Victoria University).
Proctor, M., & Farquhar, C. (2006). Diagnosis and management of dysmenorrhoea. BMJ: British Medical Journal, 332(7550), 1134. https://doi.org/10.1136/BMJ.332.7550.1134
Pullon, S. R. H., Reinken, J. A., & Sparrow, M. J. (1987). The prevalence of premenstrual symptoms in Wellington women. New Zealand Medical Journal, 100(831), 562–564.
Schwerla, F., Wirthwein, P., Rütz, M., & Resch, K. L. (2014). Osteopathic treatment in patients with primary dysmenorrhoea: A randomised controlled trial. International Journal of Osteopathic Medicine, 17(4), 222–231. https://doi.org/10.1016/j.ijosm.2014.04.003
Thomas, E., & Magilvy, J. K. (2011). Qualitative Rigor or Research Validity in Qualitative Research. Journal for Specialists in Paediatric Nursing, 16(2), 151–155.
https://doi.org/10.1111/J.1744-6155.2011.00283.X
Thorne, S. (2009). Interpretive Description. Medical Anthropology Quarterly, 23(4), 506–507.
https://doi.org/10.1111/j.1548-1387.2009.01076.x
67 Unsal, A., Ayranci, U., Tozun, M., Arslan, G., & Calik, E. (2010). Prevalence of dysmenorrhea and its effect on quality of life among a group of female university students. Upsala Journal of Medical Sciences, 115(2), 138–145. https://doi.org/10.3109/03009730903457218
Waugh, M. D. (2019). Women’s experiences of osteopathic care whilst living with endometriosis (Master’s thesis). https://www.researchbank.ac.nz/handle/10652/4880
Whittemore, R., Chase, S. K., & Mandle, C. L. (2001). Validity in qualitative research.
Qualitative Health Research, 11(4), 522–537.
https://doi.org/10.1177/104973201129119299
68
APPENDICES
69
APPENDIX A: JOURNAL OF ADVANCED NURSING AUTHOR
GUIDELINES
70
71
72
73
APPENDIX B: RECRUITMENT POSTER
74
APPENDIX C: PARTICIPANT INFORMATION FORM
Information for participants
Research Project Title
Osteopathic Management of Dysmenorrhea: A Snapshot of New Zealand Women's Experiences Synopsis of project
To investigate the experiences of New Zealand women who have incorporated osteopathic care into managing their dysmenorrhea. Women aged 18-50 years old will be interviewed for 45-60 minutes on their experiences of osteopathic care for their condition.
What we are doing
We will be interviewing you about your experience of osteopathic treatment for your painful periods. The researcher will ask you a series of questions to answer to the best of your ability. If there are any questions you do not want to answer, you do not have to. The interview will be audio- recorded by a tape-recorder and/or a mobile phone and there may also be a research assistant present if needed for extra safety.
Once you have given your consent to join the research project, you will be contacted via email/telephone by the researcher (Anna) to arrange the most convenient date/time for you to attend an interview. Prior to the interview, the intention, purpose and ethical considerations of the research will be discussed. The interviews will be conducted between January and March at Unitec Institute of Technology, Mt Albert Campus, Building 60 in a quiet and private room. Zoom meetings are also available if you wish. If you will decide to come to the Unitec Institute of Technology, the researcher will compensate for the travel cost by providing petrol vouchers. The length of each interview will be 45-60 minutes. A tape-recorder and/or a mobile phone will be used to record all conversations for the analysis purpose. You will be asked questions about your experience of osteopathic treatment for your dysmenorrhea. Once the interview has finished, in appreciation of your contribution, you will be given a Koha. The recording will be transcribed and analysed. The analysis is when your interview transcripts and any notes are written down during the interview are collected, organised, and examined by the researcher and her supervisors to identify common themes. This means that firstly the transcription will be read many times by the researcher and supervisors to explore general codes such as relevant phrases or sentences related to the topic that you told us while answering specific questions. Your main ideas on each question will be then identified, using the codes. This gives the researcher information to