Factors Associated with Anxiety During Menopause in District Housing Samalanga

In 2020 in Indonesia, 14 million menopausal women will reach 7.4% of the total population. Anxiety is a common psychological symptom of menopause. The research aims to determine the factors associated with anxiety during menopause in the Lima Village, Samalanga District. This research is analytical with a cross-sectional approach. The population in the study of women aged 45-59 years in Lima Village was 504. The research sample was 83 people. Data was collected from 01 – 15 June 2023, using a questionnaire through interviews. Data analysis used the Chi-Square test. The research results showed that 76% of respondents experienced low anxiety, 54.2% had secondary education, 51.8% of respondents had less knowledge, 25.3% of respondents' attitudes were negative, 37.3% of respondents stated there was no family support, income did not match the UMP 79.5% and negative self-acceptance 31.3%. The research conclusion is that there is a relationship between knowledge, attitudes, family support, income and self-acceptance, and maternal anxiety during menopause


INTRODUCTION
Menopause is a condition in which a gradual decline in ovarian function eventually causes the permanent cessation of menstruation (Augoulea et al., 2019).The world's population of menopausal women continues to grow, in 2021, women aged 50 years and over accounted for 26% of all women and girls globally.This figure is up from 22% 10 years earlier (WHO, 2022a).
Nationally, in 2025, it is estimated that there will be 60 million menopausal women in Indonesia (Wigati & Kulsum, 2017).In 2020 in Indonesia, only 14 million women will reach menopause or 7.4% of the total population (Millati et al., 2022).
The most common symptoms that bother women during menopause are hot flashes, night sweats, cognitive disorders (memory loss, lack of concentration, inability to learn), and psychological problems (mood swings, anxiety, and depression) (Graziottin et al., 2019 ).These psychological symptoms hurt women's personalities, friends, family relationships, and work performance.WHO reports that depression is a major cause of morbidity, mortality, and suicide (WHO, 2022b).
Menopausal symptoms occur due to estrogen (the main endogenous ovarian hormone that decreases its secretion in a woman's body during menopause) (Joffe et al., 2020).The hormone estrogen is a powerful antioxidant, which prevents lipid peroxidation, and estrogen deficiency during menopause (Cakir et al., 2016).
Depression often occurs in postmenopausal women and it hurts everything, such as feeling tired quickly, sleeping problems, disinterest in any activity, and loss of motivation to work (Natari et al., 2018).Anxiety can be defined as an unpleasant emotional state of nervousness or agitation without a clear or realistic cause (Augoulea et al., 2019).
Based on the results of the initial survey conducted by researchers in 9 villages in one settlement, namely Lima settlement with a total of 45 respondents or 5 people in each town, 18 (40%) respondents had low anxiety, 26 (57.8) moderate anxiety and 1 ( 2.2%) high anxiety.Based on the above background, researchers are interested in researching the anxiety of women entering menopause, and to find out why women facing menopause experience anxiety.

LITERATURE REVIEW Menopause Anxiety
According to Burger (2005), menopause is defined as the cessation of the menstrual cycle forever for women who previously experienced menstruation as a result of the loss of follicle activity (Ulfah, 2019).Menopause is the time that marks the end of the menstrual cycle.A person is diagnosed after 12 months without a menstrual period.Menopause can occur in your 40s or 50s, but the average age in the United States is 51 years (NIH, 2021).
Meanwhile, perimenopause is a period that indicates approaching menopause.This period is characterized by instability of reproductive hormones.each woman will most likely experience it at a different age.Most women around the age of 40 feel the symptoms of this transition, but only a few women experience it in their 30s.Perimenopause symptoms last until reaching menopause (Proverawati & Sulistyawati, 2010).
Anxiety disorders are characterized by excessive fear and worry and associated behavioral disturbances.Symptoms are severe enough to cause significant distress or significant functional impairment.There are several types of anxiety disorders, such as generalized anxiety disorder (characterized by excessive worry), panic disorder (characterized by panic attacks), social anxiety disorder (characterized by excessive fear and worry in social situations), separation anxiety disorder (characterized by with excessive fear or anxiety about separation from people to whom the person has deep emotional ties), etc. (WHO, 2023b).
Anxiety in women approaching menopause will be seen using a questionnaire distributed to research subjects.The higher the score on the anxiety scale, the higher the subject's anxiety, and conversely, the lower the score on the anxiety scale, the lower the subject's anxiety (Baroroh, 2019) Research Hypothesis 1. Ha: There is a relationship between education and anxiety in mothers during menopause in Lima Village, Samalanga District 2. Ha: There is a relationship between knowledge and anxiety in mothers during menopause in Lima Village, Samalanga District 3. Ha: There is a relationship between attitudes and anxiety in mothers during menopause in Lima Village, Samalanga District 4. Ha: There is a relationship between family support and anxiety in mothers during menopause in Lima Village, Lima Village, Samalanga District 5. Ha: There is a relationship between income and anxiety in mothers during menopause in Lima Village, Samalanga District 6. Ha: There is a relationship between self-acceptance and anxiety in mothers during menopause in Lima Village, Samalanga District

METHODOLOGY
Analytical research with a cross-sectional approach.The population in this study was 504 women aged 45-59 years in Lima Village.The sample calculation was determined using the OpenEpi software application (OpenEpi, 2013), obtaining a sample of 83 people.Sampling was carried out using simple random sampling.Data were collected using a questionnaire adopted from previous research, namely a depression questionnaire using an anxiety scale according to Nevid, Rathus, and Greene (2005) in Baroroh (2019).Data analysis using the Chi-Square statistical test was carried out using SPSS.

RESEARCH RESULT
The number of respondents in this study was 83 women aged 45-59.The results of the univariate analysis of this research can be seen in Table 1, below  1 shows that in percentage terms (24.7%) of respondents experienced moderate anxiety, 36.1% of respondents had basic education, 51.8% of respondents had insufficient knowledge, 25.3% had negative attitudes, 37.3% did not have family support, 79.5% of respondents had family incomes below the provincial minimum wage (UMP) and 31.3% of respondents had negative self-acceptance.The statistical test results can be seen in Table 2  Table 2 shows that the proportion of respondents experiencing moderate anxiety is increasingly found in secondary and higher education (26.4%), respondents with less knowledge (37.2%), respondents with negative attitudes (52.4%) experiencing moderate anxiety, family support is not supported (38.7%), as many as (58.2%) respondents have income according to the UMP and negative self-acceptance (50.0%)

The Relationship between Education and Anxiety during Menopause
Education is a conscious and planned effort to create a learning atmosphere and learning process so that students actively develop their potential to have religious spiritual strength, self-control, personality, intelligence, noble morals, and the skills needed by themselves, society, nation, and state.(Estiani & Dhuhana, 2015).
The research results showed that the majority of respondents had secondary education.The results of statistical tests showed that there was no relationship between education and anxiety during menopause in the Lima area.There is no link or relationship between education and anxiety because respondents with high/middle and low education both tend to have low anxiety.
In line with research conducted by Juliana, Anggraini, and Amalia (2021), there is no relationship between education and complaints during menopause.Yuliastuti and Widiarta (2022) in their research found that there was no relationship between education and readiness for facing menopause.Other research also found that there was no relationship between education level and anxiety (Anggraeni, 2022).Research is inversely proportional to Yazia and Hamdayani (2020) that there is a relationship between education and anxiety.
Based on this, according to the researcher's analysis of this research, it is proven that the level of maternal education is one of the factors that will influence the level of maternal anxiety regarding menopause.Armed with sufficient knowledge, a mother will obtain more of the information needed, so they can choose and determine the best alternative for the problems they face.However, in this study education was not related because low anxiety was equally more common among respondents with tertiary, secondary, and primary education.

The Relationship between Knowledge and Anxiety during Menopause
The research results showed that the majority of respondents had little knowledge.The cross-tabulation results showed that respondents with less knowledge experienced moderate anxiety, 37.2% higher than 10% for respondents with good knowledge.The results of statistical tests showed that there was a relationship between knowledge and anxiety during menopause in Lima Village, Samalanga District.These results show that good knowledge can reduce anxiety levels.
The results of this research are in accordance with research by Wibowo and Nadhilah (2020) which shows that there is a relationship between knowledge about menopause and anxiety in women approaching menopause.This research also provides empirical evidence that the level of knowledge of premenopausal mothers acts as a positive control in controlling the level of anxiety in facing the period.menopause.
Other research shows that there is a link between knowledge about menopause and anxiety levels in premenopausal women in hospitals (Wahyuni & Ruswanti, 2018).Other research also states that there is a relationship between knowledge and anxiety in perimenopausal women (Iliwandi, 2022).In contrast to research by Wibowo and Nadhilah (2020) which states that there is no significant relationship between knowledge about menopause and anxiety in premenopausal women.
According to Bong (2019) quoted from Meilaningtyas, premenopausal women's anxiety in facing menopause is not only influenced by the level of knowledge, but many other factors, the anxiety that occurs in a person is not the same in several situations.The anxiety that occurs is influenced by one factor, namely the threat to self-integrity which includes physiological incompetence or interference with basic needs such as physical illness and assessing anxiety as a subjective experience which may be based on perceptions of the situation that occurs.
Apart from knowledge, there are other factors that influence premenopausal women's anxiety levels in facing menopause, namely coping efforts in facing menopause, attitude, family support, husband's support, economic conditions, lifestyle and self-image (Septiani & Mus seeni, 2019), According to researchers' assumptions, fear can occur due to lack of knowledge and information.Therefore, the participation of executives and health professionals is needed to provide information with counseling to have more mothers understand the signs of menopause and be able to face them without being overwhelmed by excessive fear.

Relationship between attitude and anxiety during menopause
The research results obtained that respondents generally had a positive attitude.The cross tabulation results show that respondents experiencing moderate anxiety were 52.4% higher in respondents with negative attitudes compared to 14.5% of respondents with positive attitudes.The results of statistical tests showed that there was a relationship between attitudes and anxiety during menopause in Lima Village, Samalanga District.
This research supports previous research conducted by Yuliastri et al (2022) that maternal attitudes are related to anxiety about facing menopause.This research is in accordance with Lastur Sinurat's research which shows that there is a relationship between maternal knowledge and attitudes and anxiety about facing menopause (Sinurat, 2018).These results show that forming a positive attitude in respondents can reduce anxiety in perimenopausal women (Iliwandi, 2022).In contrast to Zasri's (2012) research, there was no relationship between attitudes and anxiety facing menopause in mothers aged 45-50 years.
While a positive attitude helps women navigate menopause well while a negative attitude makes their menopausal transition difficult, a positive attitude towards menopause is also closely linked to a better quality of life for menopausal women.(Thapa & Yang, 2022).
The researcher's assumption is that there is a relationship between the mother's attitude towards menopause and her readiness to face menopause due to her level of education and employment, thus influencing the respondent's attitude towards changes during menopause.A positive attitude from mothers who are about to face menopause can also divert unpleasant feelings towards positive things and by doing useful activities such as attending religious studies and other social activities.

Relationship between family support and anxiety during menopause
The results of research in Lima Village, Samalanga District, showed that more than half of the respondents had supportive family support.The cross tabulation results showed that 38.7% of respondents experienced moderate anxiety, which was greater than that of respondents who had less family support, which was greater than 15.7% of respondents who had supportive family support.The results of statistical tests showed that there was a relationship between family support and anxiety during menopause in Lima Village, Samalanga District.These results show that having family support can reduce anxiety levels.
Supports previous research which shows that there is an influence between family support and anxiety before menopause (Septiani & Mus seeni, 2019).In line with Rahmawati's (2020) research, there is a significant relationship between family support and anxiety in menopausal women.Setiyani and Ayu (2019) in their research also found that there was a relationship between family support and anxiety in menopausal women.In contrast to the findings of Yuliastuti and Widiarta (2022), there is no relationship between family/husband support and readiness to face menopause.
Family support makes a woman facing menopause very valuable and adds peace to life.(Setiyani & Ayu, 2019).Family factors are also a cause of anxiety.The family is an environment that influences and determines the psychological stress of people affected by menopause, and a reduction in the number of family members can also be a cause of menopausal symptoms.(Proverawati & Sulistyawati, 2010).
From the description above, the researcher believes that respondents who have family support before menopause, whether psychological or other support, will not experience anxiety disorders in facing the period leading up to menopause.

Relationship between Income and Anxiety during Menopause
The research results obtained in Lima Village, Samalanga District, revealed that more than half of the respondents had low income.The cross tabulation results show that 58.8% of respondents experienced moderate anxiety in respondents with income according to the UMP, greater than 15.2% of respondents with income below the UMP.The results of statistical tests showed that there was a relationship between income and anxiety during menopause in Lima Village, Samalanga District.These results show that the higher the income, the higher the level of anxiety.
This research supports Yazia and Hamdayani (2020) where there is a significant relationship between socio-economic level and the level of anxiety in mothers when facing menopause.The results of this study also support the results of previous research by Rostina (2009) showing that there is a socioeconomic relationship with premenopausal mothers' anxiety in facing menopause.Other research states that socio-economic factors will influence the anxiety level of premenopausal mothers in facing menopause (Saimin et al., 2016).This is different from Anggraeni (2022) who stated that there is no socioeconomic relationship with anxiety in menopausal mothers.
Socioeconomics will influence the level of anxiety of premenopausal mothers in facing menopause.There are different opinions that socio-economic conditions influence physical factors, health and education.Women who come from lower economic groups tend to be resigned and able to adapt well when experiencing menopause (Bromberger et al., 2013).
Based on this, according to the researcher's analysis of this study, it is proven that socio-economics will influence the anxiety of premenopausal mothers, where with good socio-economic conditions of the mother, the mother's health problems can be treated early compared to mothers with a lower socio-economic level so that the mother's anxiety level will increase.lower.To reduce the anxiety level of premenopausal mothers regarding menopause, positive activities are needed for mothers that can generate income so that socio-economic conditions can be further improved.

Relationship between self-acceptance and anxiety during menopause
The research results obtained that respondents generally had positive self-acceptance.The cross tabulation results show that respondents experiencing moderate anxiety in negative self-acceptance respondents were 50% higher compared to positive self-acceptance respondents at 12.3%.The results of statistical tests showed that there was a relationship between selfacceptance and anxiety during menopause in Lima Village, Samalanga District.These results show that positive self-acceptance in respondents can reduce anxiety levels.It has been proven in research that self-acceptance will influence the mother's anxiety level.If the mother has a negative self-concept during menopause then the mother will think negatively so there will be a tendency for the mother to experience anxiety.
In line with Pusparatri's (2020) research, there is a relationship between self-acceptance and anxiety in facing menopause in premenopausal women.Other research also shows that there is a relationship between self-acceptance and anxiety about facing menopause in premenopausal women (Jannah, 2020).Other research also states that there is a relationship between self-acceptance and women's anxiety about facing menopause (Kaheksi et al., 2013).Other research reveals that there is a very significant negative relationship between self-acceptance and anxiety (Adhawiyah, 2018).
Women who have good self-acceptance will have a realistic assessment of the various physical and psychological changes that occur to them when they enter the menopause phase (Mardiani & Rohaeni, 2018).Women who experience menopause at a young age will have higher anxiety than women who enter menopause at an older age.Likewise, women with relatively low levels of self-acceptance will have higher anxiety than women who have high self-acceptance (Chaerani & Rahayu, 2019).
According to researchers, the concept of self-acceptance will influence the anxiety level of premenopausal mothers, where if the mother has a negative concept of self-acceptance then the mother will think negatively so there will be a tendency for the mother to experience anxiety.On the other hand, if the mother has a positive concept of self-acceptance, the mother will think positively and be able to accept her condition so that the mother considers that it is part of their life path and must be lived through so that the mother's anxiety level is reduced.

CONCLUSIONS AND RECOMMENDATIONS
Based on the results of the research that has been carried out, it can be concluded that from the five variables studied there are four related variables, namely knowledge, attitude, family support, income and self-acceptance.It is recommended that the Samalanga Community Health Center increase mothers' knowledge about menopause and change mothers' attitudes about menopause.It is hoped that there will be coordination between the community health center and posbindu/posyandu for the elderly by conducting outreach and implementing health literacy and health education about menopause more intensely and continuously, using literature and language that is easier to understand.

ADVANCED RESEARCH
This research has limitations in the interview process because this research uses a standard questionnaire so that some respondents find it difficult to understand.

Table 1 . Frequency Distribution of Anxiety, Education, Knowledge, Attitudes, Income and Self-Acceptance
Table