Muhammad Irfan

Background: Menopause affects more than one billion individuals worldwide, yet outcome measurement in research remains narrow, inconsistent, and largely focused on vasomotor and genitourinary symptoms. Existing frameworks do not adequately capture the broader functional and psychosocial impacts reported by patients. We aimed to develop and validate a global Core Patient-Reported Outcome Set for Menopause (cPRO-MARiE) using prospective mixed-methods data from thirteen countries. Methods: We analysed quantitative data from 5,228 participants and qualitative interviews from 302 individuals across thirteen countries spanning diverse socio-cultural and health-system contexts. Validated instruments assessed symptom severity, psychological wellbeing, cognitive function, sleep disturbance, pain and somatic symptoms, and functional outcomes. Qualitative data underwent reflexive thematic analysis guided by the Delanerolle–Phiri framework. A COMET-aligned process integrating quantitative severity patterns, qualitative thematic convergence, cross-country reproducibility, psychometric validation and equity considerations was applied to derive the core outcome set. Findings: Seven domains were consistently identified across all settings: sleep disturbance; psychological wellbeing; cognitive function; pain and somatic symptoms; vasomotor symptoms; genitourinary and sexual health; and social, relational and occupational functioning. These domains demonstrated conceptual stability, cross-country reproducibility and psychometric coherence and were strongly linked to functional impact. The resulting cPRO-MARiE specifies mandatory Tier 1 patient-reported outcomes within each domain, with Tier 2 outcomes retained for context-specific and equity-focused research. Interpretation: cPRO-MARiE is the first empirically derived, globally validated core outcome set for menopause. By capturing symptom domains and functional impacts prioritised by patients across diverse settings, it provides a robust and clinically meaningful framework for outcome measurement in research, routine care, and health-system evaluation.

Background: Menopause is a universal life-course transition that coincides with midlife employment for a growing proportion of the global female workforce. Despite increasing recognition, robust cross-country evidence linking menopausal symptoms to burnout and workforce wellbeing remains limited, particularly outside high-income settings. Methods: This mixed-methods analysis draws on MARIE WP2a, a multi-country cross-sectional cohort of 5,133 participants aged 40–65 years across 13 countries (Brazil, Ghana, India, Sri Lanka, Malaysia, Nigeria, Nepal, Oman, Pakistan, Rwanda, Singapore, Tanzania, and the UK). Quantitative data assessed burnout using the Burnout Assessment Tool (BAT-12) and its subscales (exhaustion, mental distance, cognitive impairment, emotional impairment). Linear mixed-effects models examined associations with employment characteristics, health factors, and menopausal treatments. Qualitative interviews were synthesised with a topics guide using cross-country thematic analysis to contextualise workforce impacts. Results: Overall burnout burden was moderate (mean BAT-12 2.41, SD 0.84), with exhaustion and cognitive impairment most pronounced. Participants early in their current specialty (1–5 years) consistently demonstrated higher burnout and subscale scores than those with ≥21 years’ experience. Disability and long-term conditions were associated with significantly higher burnout across domains. Marked cross-country heterogeneity was observed, reflecting differences in labour structures and social protection. Qualitative findings revealed convergent mechanisms across countries: symptom-driven capacity loss, amplification by inflexible work structures, stigma and non-disclosure, reliance on informal support, policy absence, and financial precarity. Conclusions: Menopause substantially shapes workforce wellbeing across diverse economic and cultural contexts. Symptoms interact with job demands, stigma, and inequitable access to care to drive presenteeism, reduced productivity, and constrained occupational choice. Menopause-informed workplace policies, manager training, low-cost job adjustments, and equitable access to evidence-based care are urgently required to protect women’s health, workforce participation, and productivity in ageing economies.

Objective: Traditional behavioral finance—which examines how cognitive biases, emotions, and context shape economic decision-making— often assumes cognitive stability, rationality, and consistent risk evaluation, based largely on male-dominated samples. Emerging evidence from the Menopause and Ageing Research in International Environments (MARIE) WP2a program, encompassing over 6,300 women across thirteen countries, suggests that the menopause transition brings about significant neurocognitive, emotional, and sociostructural changes that may influence financial decision-making processes. These influences remain under-theorized within current behavioral economics models. This study proposes a new conceptual framework—the Behavioral Finance–Menopausal Cognition (BF-MC) Model—that integrates menopause-related cognitive, psychological, and sociostructural dynamics with behavioral finance theory. Methods: A theory-building synthesis was conducted using quantitative and qualitative findings from the MARIE WP2a cohort. Menopausal symptom domains were mapped onto established behavioral finance constructs, such as risk aversion, present bias, and liquidity preference. The synthesis also explored sociostructural moderators across diverse contexts that shape these pathways. No empirical financial behavior data were analyzed in this framework. Results: The BF-MC Model identifies four interrelated domains: (1) neurocognitive regulation, (2) affective-behavioral regulation, (3) sociostructural mediation, and (4) economic adaptation and resilience. Menopausal symptom domains interact with sociocultural factors, such as employment conditions, caregiving responsibilities, and financial system design, to influence decision-making pathways. The model reframes midlife women’s financial behavior as a dynamic biopsychosocial process rather than a deficit, highlighting adaptive responses to fluctuating cognitive and emotional resources. Conclusion: The BF-MC Model provides a conceptual framework to understand how menopausal cognitive and psychosocial changes may shape financial decision-making. It highlights potential pathways and moderators that warrant empirical testing, offering a foundation for future research on gender-responsive financial behavior and policy. While the model identifies plausible mechanisms, its pathways remain theoretical and require validation with longitudinal financial data.

Objectives: Accreditation systems play a crucial role in shaping medical education programs globally; however, there are concerns about the equitable application of standards across diverse contexts. This study explored expert perspectives on the conceptualisation of equity in basic medical education accreditation standards. Methodology: This study employed a qualitative theory-informed analysis design, conducted over the period from January 2024 to April 2025. Semi-structured one-to-one interviews were conducted with 14 experts from various geographical locations, all of whom were involved in accreditation as researchers, surveyors, or members of national or international accrediting bodies. The data were analysed using thematic analysis guided by Aristotle's theory of equity. Results: Experts emphasised the need for context-responsive standards that maintain quality while allowing flexibility in implementation. Five key themes emerged: 1) Equity or equality; what should be preferred 2) Quality over quantity and contextualisation 3) Equity is not lowering the standards 4) Equity is flexibility in achieving the standards 5) Striking balance between equity and equality; the way forward. Conclusions: By incorporating equity principles, accreditors can foster inclusive excellence across diverse medical education landscapes by embracing flexibility (equity to achieve equality), contextualisation, systematic surveyor training, and collaborative improvement without compromising the quality of medical education.

Introduction: Menopause is a universal life transition with lived experiences shaped by biological, psychological, socio-cultural, and systemic factors. In Singapore, where diverse cultural norms intersect with a high-pressure professional environment, little is known about how these influences converge to shape symptom recognition, coping, and care.Methods: This qualitative study formed part of the multi-country MARIE project on menopause and midlife health. Eighteen participants with different menopausal stages were purposively sampled ensuring variation in age, ethnicity, socio-economic and health status. Semi-structured interviews explored symptom profiles, psychosocial wellbeing, family and workplace dynamics, and healthcare experiences. Data were analysed using the Delanerolle and Phiri Framework, integrating biological, psychological, socio-cultural, and health system domains.Results: Participants described heterogeneous symptom trajectories, with vasomotor, genitourinary, and cognitive most prominent. Multimorbidity and surgical menopause intensified symptom burden and narrowed treatment options. Anxiety, low mood, and brain fog impaired work, particularly without workplace support. Socio-cultural silences and misinformation reinforced self-management and delayed care-seeking. Resilience rooted in peer and family support, and culturally familiar coping strategies buffered distress for some. Health system gaps included inconsistent GP knowledge, reluctance to prescribe hormone therapy, and private care costs. Study participation itself triggered symptom recognition and help-seeking in some, underscoring menopause invisibility in routine care.Conclusion: Findings highlight that menopause in Singapore is navigated through intersecting clinical, cultural, and structural determinants. Addressing inequities requires embedding women’s voices into clinical pathways, training clinicians in culturally competent care, and implementing workplace and public health policies legitimising menopause as a health and occupational issue.

Introduction: Menopause, a biological transition, which marks the permanent cessation of menstruation and is commonly experienced between 45–55 years. In Pakistan, the mean age of menopause is reported as 47 years. While menopause has been extensively studied in Western contexts, psychological well-being, coping strategies, and awareness remain underexplored in Pakistan. Cultural taboos, limited utilisation of healthcare services, and absence of workplace policies compound the challenges women encounter during this transition. This study explores the lived experiences of Pakistani women to inform culturally appropriate interventions and evidence-based policy development. Methods: A qualitative study was conducted as part of the MARIE WP2A project from March to May 2024 in urban and peri-urban Peshawar. Twenty peri-menopausal, surgical menopausal, and post-menopausal women aged 45–68 years participated in semi-structured, in-depth interviews. A pre-designed topic guide explored physical and psychological symptoms, coping strategies, healthcare engagement, social support, and workplace policies. Interviews were conducted in Pashto or Urdu, transcribed, translated into English, and analysed using Braun and Clarke’s six-step thematic analysis framework. Results: Six key themes emerged. Physical symptoms were widespread, with musculoskeletal pain (65%), hot flushes (60%), and urinary complaints (55%) most reported. Psychological symptoms included emotional lability (60%), lack of concentration (60%), and anger issues (35%). Coping strategies were largely informal, including family support (25%) and pacing daily activities (20%). Most participants reported limited social support, with menopause often experienced in isolation. Only 35% sought healthcare, with hesitancy towards hormone replacement therapy due to fear of side effects. Awareness of workplace policies was absent, though participants highlighted the urgent need for structured support. Conclusions: Menopause in Pakistan is shaped by cultural silence, limited healthcare engagement, and systemic neglect. Addressing these gaps through community awareness, culturally appropriate healthcare guidelines, and workplace policies is essential to improve psychological well-being and quality of life for midlife women.

Background Menopause is a critical life stage for women’s health, yet it remains under-recognised in Malaysia despite an ageing female population and documented ethnic and regional diversity. Previous studies have reported symptom prevalence and mean age at menopause but lacked an integrated, population-level approach to understanding biological, sociocultural, and health system determinants. Methods We conducted a cross-sectional analysis of baseline data from 632 women enrolled in the Malaysian arm of the Menopause and Ageing Research in International Environments (MARIE) study. Menopause type was classified as natural, medical, or surgical using direct self-reports supplemented by rule-based derivation from hysterectomy, premature ovarian insufficiency (POI), and gonadotrophin-releasing hormone (GnRH) analogue use. Descriptive statistics, Wilson confidence intervals, and multivariable logistic regression with cluster-robust standard errors were used to examine associations with age, ethnicity, education, employment, and urban versus non-urban residence. A burden index was developed to assess cumulative disadvantage across clinical, treatment, and sociocultural domains. Results The mean age at menopause was 50.1 years (SD 4.5). Natural menopause predominated (72.7%), with 16.0% experiencing surgical and 11.3% medical menopause. Surgical menopause was markedly higher among Bumiputera Sarawak women (35.5%) compared to Chinese (12.5%) and Malay (13.9%) groups. Urban residence was associated with higher odds of both surgical (OR 2.47, 95% CI 1.25–4.86) and medical menopause (OR 1.87, 1.07–3.26). Women with surgical menopause had the highest cumulative burden scores. Conclusion These findings highlight substantial ethnic and contextual disparities in menopause pathways and treatment access. Addressing inequities through improved access to conservative care, culturally sensitive services, and integrated women’s health policies is urgently needed.

Background: Low educational literacy is associated with high rates of mental health problems. In Pakistan, only 60% of the population is literate. Traditional CBT requires literacy skills. Interventions to address the literacy barriers need to be developed. Aims: To evaluate the feasibility, acceptability, and preliminary efficacy of a culturally adapted CBT-based animated ‘Shorts’ series for depression and anxiety in individuals with no or low educational literacy. Method: This randomized, rater-blind randomized controlled trial (RCT) compared an animated Shorts series and treatment as usual (TAU) with TAU alone in Pakistan. The primary outcomes were feasibility (recruitment, retention, adherence to treatment and trial processes) and acceptability (drop-outs and participants’ feedback). The secondary outcomes included the Hospital Anxiety and Depression Scale (HADS) and the WHO Disability Assessment Schedule 2 (WHODAS 2). Thirty consenting participants were randomly allocated to one of the groups in a 1:1 ratio and were assessed at baseline and the end of the intervention at 12 weeks. Results: The intervention was feasible and acceptable and was successful in reducing the symptoms of depression and anxiety. However, these findings need to be further confirmed in a larger RCT. Conclusions: These preliminary findings are encouraging, and if future studies confirm that this approach can work, we should be able to overcome the literacy barrier in low- and middle-income countries.