Background: Dysmenorrhea is a common menstruation problem that affects young adult females. People suffering from this condition seldom seek medical advice but often self-manage with different strategies. The Internet offers a convenient source of health information for people with conditions that are socially embarrassing like dysmenorrhea. However, how and why young adult females search and use Internet information for this menstruation condition is not widely known.
Method: 10 female adults with dysmenorrhea were interviewed and the data were thematically analyzed.
Findings: Dysmenorrhea affects the informants physically, emotionally, socially and academically. Informants tended to rely on search engines to search for information to manage their menstruation symptoms. They usually visited personal blogs and forums instead of medical-oriented websites. Readability of websites affected their length of stay on these websites and their subsequent use of website information. Informants also reported the use of traditional Chinese medicine modalities for managing their painful menstruation.
Conclusion: Nurses should be aware of the phenomenon that young adults are actively using Internet websites for health information, which often lack quality monitoring and review. Nurses should also be equipped with adequate traditional Chinese medicine knowledge to provide competent health education for conditions like dysmenorrhea.
Dysmenorrhea, or primary dysmenorrhea, is a cramping pain in the lower abdomen that happens before or during menstruation without other organic causes or diseases (Coco, 1999). It is a common female gynecological condition and a majority of women experience this pain during their first menstruation (Harel, 2008). People with the conditions do not always seek medical advice but adopt various self-care strategies. Since the rise of the Internet over the last couple of decades, more and more people, particularly young adults, are turning to websites for information that can help them to manage their own health However, how and why young adult females search and use Internet information for this menstruation condition is not widely known. This study explored this behaviour and aimed to reveal the young female adults' habits in adopting the health information obtained from the Internet for their dysmenorrhea.
Young and active females are significantly being affected by dysmenorrhea. The pain often interferes the day to day aspects of life as well as hampering their quality of life considerably and directly (Chan et al, 2009; Chia et al, 2013; Harel, 2006; Unsal, Ayranci, Tozun, Arslan & Calik, 2010). Specific disturbances of dysmenorrhea in adolescent and young females adults include decreasing sports and social activities, absenteeism in school or workplace, low concentration in class, as well as sleep disturbance (Al-Kinda & Al-Bulushi, 2011; Charu, Amita, Sujoy & Thomas, 2012; Chia et al, 2013; Ortiz, 2010). A study done in an university in China reported that 56.4% of the students were affected by this condition (Zhou and Yang, 2010).Academic performance was also being affected (Oritz, 2010), together with low concentration in classes (Chiou & Wang, 2008; Wong & Khoo, 2010).
Although dysmenorrhea does affect people considerably, seeking medical advice is not a common management strategy for those having this condition (Chan et al, 2009). Instead, people with dysmenorrhea often seek a variety of self-care strategies (Al-Kindi & Al-Bulushi, 2011; Chia et al, 2013; Wong, 2011). The reported rates of seeking medical attention for dysmenorrhea by Asian females were exceptionally low, ranging from 12% of adolescents in Malaysia, 7% in Thailand and 3% in Oman (Al-Kindi & Al-Bulushi, 2011; Tangchai et al, 2004; Wong & Khoo, 2010). In Hong Kong, only 6% of university students sought medical advice for their dysmenorrhea (Chia et al, 2013). Some females viewed pain during their menstruation as part of a normal process, thus avoided seeking medical attention for the condition (O'Connell, Davis & Westhoff, 2009; Polat et al, 2009).
A local study focused on 240 university students suffering from primary dysmenorrhea reported 70% of the respondents choose self-care strategies for their gynecological problems (Chia et al, 2013). One of the most frequently used means for seeking self-care information for dysmenorrhea was the Internet. People get involved in their own health care decision through searching for information on the Internet, which is now considered to be an important source of health information (Rainie & Fox, 2007).
Traditional sources of health information include mass media, brochures, peers and health professionals (Koch-Weser, Bradshaw, Gualtieri & Gallagher, 2010). The rapid growth of the Internet as well as the publishing of uncountable number of websites hosting different kinds of health information have made it the most popular source of health information in the 21st century (Audulv, Asplund & Norbergh, 2012). The Internet is becoming more and more popular as the primary source for health information with each passing year (Sillence, Briggs, Harris & Fishwick, 2007). It is particularly welcomed by those who are younger and more educated (Koch-weser, Bradshaw, Gualtieri & Gallagher, 2010). This includes searching for support groups for specific medical conditions as well as alternative treatments for diseases (de Boer, Versteegen & van Wijhe, 2007). A study in the U.S.A. reported that 80% of American Internet users have searched for health information from Internet websites (Fox, 2006). Another study in Hong Kong also reported that 44% of the 443 people surveyed had looked for health information from the Internet (Yan, 2010).
Among those who searched for information from the Internet, those with an university level of education were more likely to participate in self-health decision-making (Horgan & Sweeney, 2009; Percheski & Hargittai, 2011; Smith et al, 2009). University students were more interested in searching for information about specific diseases or medical issues (Fox, 2006). On the other hand, young females were more likely to seek health information online than males (Percheski & Hargitta, 2011). The availability of huge amounts of health information on the Internet has made the online platform a popular new source of health information that attracts ever-increasing attention from university students (Vijayanand, 2012).
The Internet offers confidential and convenient access to people seeking health information, without the need of exposing personal identity. The Internet has become a place that offers a wealth of information for conditions or diseases that are relatively private and sensitive, including dysmenorrhea. The nature of this gynecological problem has led to an increase in people searching for information over the Internet instead of seeking medical attention. The Internet offers a lot of health information for managing pain conditions, including dysmenorrhea (Henderson, Rosser, Keogh & Eccleston, 2012).
Menstruation problems are often considered embarrassing topics among adolescents and young adult females (Ackard & Neumark-Sztainner, 2001; Wong, 2011). Self-care approaches to dysmenorrhea are the preferred approach for sufferers in view of the nature of this condition, which is relatively private and personal. Adolescents are particularly prone to use the Internet as their primary health information source (Gray et al, 2005). Seeking medical information from the Internet saves people from having to expose their own identity and their privacy is secured (Bergera, Wagner & Bakerb, 2005; Franck, Noble & McEvoy, 2008; Nwagwu, 2007).
How young adult females use the Internet for information on dysmenorrhea has been investigated quantitatively. The empirical picture of how these young adults use the Internet for their gynecological problem is, however, still a mystery. This study aimed to discover this phenomenon through interviews with those who really suffer dysmenorrhea to give a first-hand peek into their health-seeking behaviors.
This study used a cross-sectional qualitative design. Data was collected through personal interviews. Invitation advertisements were posted on a social media webpage of the University. People who I) have primary dysmenorrhea, ii) have experiences searching the Internet for information about self-care strategies for their dysmenorrhea problem; and iii) are able to communicate in Cantonese were invited to take part in our study. A female researcher contacted those who expressed interest in joining the study through private email. The details of the study were explained to these potential informants through phone conversations. Those who agreed to participate were invited by the female researcher to participate in an interview. A total of 10 informants were finally recruited and interviewed.
How does dysmenorrhea affect the informants' lives?
What are the informants' habits of searching for health information through the Internet?
What are the factors affecting the informants in using the information gathered from their search?
The interviews were held individually with a female interviewer after written consent was obtained. The interviews were audio-taped and lasted for about one hour each. The interviews were carried out in a solitary room at the university.
Thematic content analysis was used to analyze the data as this method suits the explorative nature of this study (Green & Thorogood, 2004). The taped audio interviews were transcribed verbatim for subsequent analysis. Then the whole transcripts were read repeatedly to gain an overall impression of the data. Then the repeated ideas were coded and their frequencies were counted. Major codes (those with high appearing frequencies) were allocated into categories. Categories were further condensed into major themes for reporting (Vaismoradi, Turunen & Bondas, 2013).
The mean age of the informants was 22.8 years old. All of participants are students from tertiary institutions but none of them are known to each other. Half of them have a relatively long history of dysmenorrhea (more than ten years).
Thematic content analysis was done and the themes evolved are categorized according to the foci of the investigative questions.
Dysmenorrhea was found to have impacted on the informants in various aspects of their lives. The informants' emotional, social and academic aspects of life are particularly affected.
All ten informants reported that their emotions were being disturbed by the pain from dysmenorrhea.
"I am very agitated during those days with menorrhea… the secretion of hormones are unstable! And my emotions are fluctuating… and I know my attitudes towards others are not well too…" – Informant 6.
"The fluctuations of (my) emotions are huge… and I lose my temper very easily during those days (with dysmenorrhea)." – Informant 1.
"I become so sensitive to others' comments on me and I often scold others often, even though it is just one or two sentences. Actually I am not too aware of it initially… until some of my friends told me this pattern… that was the most awkward and embarrassing moment!" – Informant 7.
The social aspect of life was also affected as reported by all ten informants.
"… (During dysmenorrhea) I can't walk too fast and my friends need to slow their pace for me, and they feel that I am troublesome" Informant 9.
"I have to decline nearly all of the social activities, including all the agreed and unplanned… and I only attended those which could not be declined… for example, a good friend's wedding ceremony. For all other common social activities, I have to decline and stay at home instead…"- Informant 1.
"Of course I will not throw tantrums to my friends. But during the social gathering, I became silent as the pain hits, and then my friends will ask me why I did not say a word in the gathering. They thought that I was angry or unhappy in the meeting. That's why I now choose not to attend too many social gatherings… and you know, actually, my social circle is being affected by this (dysmenorrhea) problem…"- Informant 4.
"…yes, there was an incident last year that (the abdomen) became very painful while I was travelling to class, and I was paralyzed in a street for a while; and I became late for school and couldn't attend class… finally I ended up in the Medical Treatment Room in the school and received treatments and then went back home… the day of school was totally missed!" – Informant 8.
"That was the time when I was sitting for DSE (the Diploma of Secondary School Education); it was the (English) listening test, and the dysmenorrhea came … it made me very tired and I couldn't concentrate on the listening… it turned out that the results were really not very up to expectation…" – Informant 7.
"The primary school teachers had a bad impression of me… I had dysmenorrhea since I was 10. I had repeated sick leave due to dysmenorrhea and the teachers thought that I was having sick leave with minor ailments. They just didn't believe me that the pain was so intolerable…" – Informant 2.
All but one of the ten informants said they just type the keyword "dysmenorrhea" into search engines on the Internet for finding information about how to manage it. Eight informants said they do not memorize the website addresses but just search for websites when needed. The majority of them said they only search for this information on managing dysmenorrhea when they are having painful menstruation. Only one informant said she would search for dysmenorrhea information when she was not having pain.
Some informants said they will not choose those websites showing "too" proper information.
"I prefer visiting blogs or Facebook instead of those proper websites. Those websites have information that is so decent and medical… I think they are written for medical students but I am not in the medical field, so I don't understand at all!" – Informant 7.
"Since I am not studying medical sciences, I will close the webpage if the information is just too complicated for me… just like those websites which have many technical words that I do not totally understand." – Informant 10.
Eight informants said they will visit blogs of people who have dysmenorrhea too. They will surf their blogs for self-management information.
"Blogger is more informative. Many bloggers have tried a lot of different strategies for their own (dysmenorrhea) problems and they have commented on which one works and which one doesn't. So it is more effective and trustworthy than other commercial websites." – Informant 3.
"I have the same feelings with the one who write the blog if I encounter the same issue of the method of treating my own problem (of dysmenorrhea). For example, the use of warm water bottle… it really works, although not to a very great effect. And other example is eating chocolate… there was one blogger who tried to eat 1 kg of chocolate each day during her menstruation period… you can guess the results…and I don't think that makes sense at all!" – Informant 4.
Informants also mentioned that they visit forums, especially those that are famous and commonly visited by girls for information on "female problems".
"I used to visit the forum on the health section on female issues in that website. There are many people who posted many comments or personal experiences on their own problems or issues. And I found that dysmenorrhea is one of the hot topics there." – Informant 5.
One of the advantages of visiting forum is that the informant can browse many comments related to the same issue by many people all at once.
"I visit forums more than blogs… as I want to save time and find the most (information) out of it… you know, you are in pain, and you just want to get to know what methods can ease your pain. And you can't concentrate long over the Internet when you are in pain." – Informant 2.
All informants reported that they search for information on traditional Chinese medicine (TCM) for managing their menstruation problems. The interviewer did not mention the term TCM during the interview but all the informants reported that they had searched the Internet for TCM information on the management of dysmenorrhea. There are mainly 2 areas of TCM that they searched: acupressure and traditional Chinese dietary advice.
Five informants mentioned they searched for information about the TCM modality of acupressure.
"I heard that pressure on the meridian points can sometimes instantly relieve pain, so I wanted to search for those information when I suffered pain in my abdomen. I do not want to take Panadol, as sometimes the doctors just told me to take Panadol whenever I have pain during menstruation in the future." – Informant 3.
"I have heard that TCM is good for dysmenorrhea. I mean those that need not taking any medicine but can use the meridian points for relief. I know acupuncture has been in TCM for a long time; and I found some websites teaching you how to do the meridian point stimulation without using needle and taking TCM drugs." – Informant 4.
Seven informants said that they would also pay attention to the TCM dietary remedial advice mentioned on the websites they searched, particularly on the forums and blogs.
"The blogger said she had tried the use of "Yick Mao Chao" (a kind of Chinese herb whose name in Chinese means 'for the benefits of mothers') and it works… so I also bought some from the market. And miraculously, it works for me too…" – Informant 8.
Another informant mentioned the use of "Hung Cho Sui" (red dates water) was mentioned in a forum.
"…actually I doubted the effects initially… but my mother has always got some red dates in our kitchen. So one day I tried that (preparing the red date drinks) out and it seems that it has some effects on me… I feel less pain indeed… but the effects seem to not last for long… maybe I am not preparing it right… I don't know… but that's really a cheap and good remedy during those (dysmenorrhea) times)"- Informant 5.
What are the factors affecting the informants in using the information searched?
The informants were also asked about how credible they viewed the information they searched for and how did they choose to adopt the information from websites.
One of the commonly mentioned criteria affecting the informants in choosing to use the information or not was the authoritativeness of the websites. Some informants said they will trust those websites or comments that were mentioned by professionals.
"…yes, I only trust those from those who have authoritativeness. For example, some websites told others to drink red dates drinks and eat chocolate… many of them are actually mothers at home only… so I prefer to visit those websites written by TCM practitioners… at least they have proper professional knowledge."- Informant 6.
Some informants said they consider and try those strategies that they think are "practical" and affordable.
"First of all, I will see whether the suggestions are easy to do or not. For example, one website I found suggested the people having painful menstruation do yoga. The exercises the website suggests are very difficult for a layman like me to perform. And you know, I prefer not to move so much when the pain comes, so it is strange that the website teach people to do yoga when they are having dysmenorrhea."- Informant 8.
"There is a website asking you to do exercises when you have dysmenorrhea in order to distract (you from) the pain. They have some pictures showing you how to do those exercises. But I tried a few reps of the exercises and I got sweating all over, and I don't want to continue… I have to take a shower then and it is quite troublesome. Actually I prefer to have a hot shower for a long time, and the relaxing effect is the same!" – Informants 10.
"We are students, and some websites asked us to buy some TCM herbs for making some dietary formulae to drink. You know, we don't have the money to buy those herbs … and it is a bit troublesome to visit the markets to buy those herbs… I have no concept at all on those TCM herbs." – Informant 9.
Besides the content, how the websites present their information to the surfers also affect their stay on a particular website.
"If the website presented the texts very complicatedly… that is… the texts are arranged chaotically, grouping all the things together in one place… I will not see and use the information in that website."- Informants 2.
"…and I prefer those with pictures to explain the information. For example, there is a website talking about the use of pressure over a meridian site… and if there is a picture indicating where the meridian point is, then I think it is easier for me to understand. And it is better if there is (video) clip teaching me how to do the action." – Informants 3.
"I only visit those websites with Traditional Chinese characters. (Interviewer: why?) Because, you know, there is a lot of fake stuff from (Mainland) China. So I cannot trust the information from those websites written in simplified Chinese characters."- Informant 4.
Dysmenorrhea affects the informants physically, emotionally, socially and academically. The impact of dysmenorrhea on informants' daily lives in this study echoed the findings reported by a recent local survey (Chia et al, 2013). The informants also seldom sought medical consultations for their menstrual problems, which was consistent with another local study's findings (Chan et al, 2009). This reflects that young adults having dysmenorrhea prefer to tackle the problem themselves instead of seeking professional medical advice.
Ever since the evolution of the Internet for public use, using the Internet to seek health information has become a common health action (Brooks, 2001). The Internet represents a wealth of health information sources (Ryhanen, Siekkien, Rnakinen, Korvenranta & Leino-Kilpo, 2010). Searching information online is evolving as a trend in many metropolitan areas, and young females are a rising sector of the population who are adopting these health behaviors (Yan, 2010). Nurses should always be aware of this new trend in getting health information and apply this when delivering health education (Kemppainen, Tossavainen & Turunen, 2012).
Although all informants in this study were students of tertiary institutions, they preferred seeking health information from blogs and forums over websites that are more medically oriented. This phenomenon might reflect that the informants are not viewing the dysmenorrhea as a formal disease per se, albeit the effects it had on their lives was profound. They live with their painful menstruation to a certain extent and non-professional sharing of experiences is more appealing to them. They preferred to try strategies from other's personal experiences on common self-care treatments on dysmenorrhea instead of believing in the commercial information from more medically-oriented websites. Although some informants mentioned that those websites from physicians or medical organization are usually more trustworthy, these kinds of websites often have discounted readability as many of them are usually information intensive with plenty of medical jargon (Henderson, Rosser, Keogh & Eccleston, 2012).
Nevertheless, website quality has been a concern for researchers, who noticed that the Internet is now a trend for health information seekers. Information from forums, for example, may be of questionable quality that might not be helpful (or even harmful) to the surfers at all (Eysenbach & Kohler, 2002). The lack of peer review on most of the webpages on the Internet might actually sometimes create more problems than solutions for the visitors. The blooming of blogs, forums and discussion boards provide a lot of information from real personal experiences. However, the persons who posted the comments are often from diverse background and sometimes biased towards some publicly accepted medical information (Henderson et al, 2012).
As reflected from the findings of this study, the informants preferred websites with traditional Chinese characters over those with simplified Chinese characters. Although Hong Kong is now a special administrative region of the People's Republic of China, the official Chinese characters still remain as the traditional set instead of the simplified set. So it is expected that the informants' literacy on the simplified Chinese characters will be very limited. On the other hand, the informants also liked to use information from those websites with clear organization of information and less irritating pictures. Navigational design was one of the concerns on the use of the Internet for information. The organization of information on websites, the use of language and characters types, as well as the ease for surfing are all factors affecting the surfer's stay and use of the information (Cline & Haynes, 2001).
Use of traditional Chinese medicinal modalities was mentioned by half of the informants. This reflected that the use of TCM has formed certain concepts into the young adults' minds. Actually the use of TCM in Hong Kong has been increasing ever since its formal introduction into the special administrative region (Chung et al, 2007). Many young people are now trying to adopt TCM for their own health maintenance. Nevertheless, how the informants adopt the TCM modalities for their menstrual problems was not intensively reported. The execution of the acupressure, for example, will surely affect the effectiveness of relieving the menstrual pain. Further studies are needed for exploring the TCM background knowledge and practices of the young adults in Hong Kong in managing their own health.
Finally, the informants searched dysmenorrhea information only when they were in pain. None of them said they memorize any website addresses to consult for their future dysmenorrhea attacks. The Internet offers a convenient source of information for the young females to search for health information regarding their embarrassing health issues. And the informants took the painful menstruation as an event that recurs upon their next menstruation.
Young adults are prone to dysmenorrhea and the Internet has become a convenient source of information for them to search for strategies in managing their painful menstruation. Young adults preferred the reporting of personal experiences in blogs and forum over medical-oriented experiences which raises the need for nurses to act as a knowledgeable advocate for public education on this gynecological condition. The need for nurses to develop adequate knowledge on Traditional Chinese Medicine is also evident in view of the ever-increasing acceptance of the TCM modalities in the management of people's own health states and conditions.
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Dave LAM is a lecturer in nursing in the Division of Nursing & Health Studies, The Open University of Hong Kong. He is a PhD candidate and his major research interests are management of public health, nursing informatics and end of life care. He has substantial experiences in conducting qualitative studies.
Caroline CHARM is a lecturer in nursing in the Division of Nursing & Health Studies, The Open University of Hong Kong. Her primary research interests are public health management and nursing education. She is a doctoral student in education and has substantial experiences in conducting qualitative studies.