Twenty women participated in five focus groups held during December 2017 to February 2018 in two health care locations in Edmonton. Groups ranged in size from two to six women.

Characteristics of the participants are presented in Table1. The majority of women were aged in their 50s, had attended higher education, worked full time and were married or living with a partner. The women were in menopause transition or post-menopausal. The group reported a wide range of physical activity, from high to low (including 2 self-proclaimed couch potatoes).

All participants suffered from severe, often multiple, symptoms of menopause that had significantly impacted their QOL over an extended period of time. Insomnia, night sweats/hot flashes and fatigue were the most prevalent symptoms discussed. In addition, lack of sex drive and vaginal dryness, memory loss, depression, and lack of motivation were described as troubling symptoms. Participants stated that the severity of the symptoms and their impact on the QOL were undermined by their primary care physicians. Most participants also reported feeling socially isolated, without connection to women with similar menopause problems.

In this context, participants discussed the features of a walking program that would be suitable for women in menopause. Four distinct characteristics emerged: (A) sensitivity to health related realities of women in menopause; (B) inclusivity of various expectations and levels of readiness (fitness) among participating women; (C) attentiveness to the need for social support, and (D) flexibility in planning locations and scheduling of the program.

The current health status and ability to be physically active varied among participating women. Participants who reported being able to exercise, described a positive impact on their wellbeing, such as improved sleep and better mental stability. Others, who were more active in the past, but developed co-morbidities or injuries, felt regret that they had to reduce the intensity and/or type of exercise. Participants who reported currently being less active, highlighted symptoms of fatigue and lack of energy as the de-motivating factor to exercise, stating Tired women will not walk (P2, FG5) and Youre too tired to do it (P1, FG5).

Walking was perceived by the participants across all five focus groups as a type of exercise that could be easy, accessible, relaxing, less risky for the body, and open to any level (P1, FG5). Still, many worried that the incapacitating nature of their menopause symptoms described by one participant as struggling to get out of bed in the morning (P4, FG2) as well as other health issues would be a potential barrier to joining a walking program. Therefore, the participants suggested that the walking program should be sensitive to different health realities among menopausal women, such as fatigue, the worry about injury (P1, FG3) (especially during the winter), and possible overheating/hot flushes while walking.

I get so hot and then I get really irritated when you get that hot and you're irritated and when you can only take off so much clothes, right (P2, FG1).

Several suggestions were put forward to overcome these challenges such as indoor walking as a safer winter solution, cooling aids to manage overheating and hot flashes and basic coaching to prevent injury.

but Im thinking for people who have not been active, the worry about injury and just having somebody who can maybe coach them through that a little bit and what to expect or how to stretch out or what to watch for because even though we talk about walking and it seems like a simple thing, I wonder if its possible to have walking injuries (P1, FG3).

In addition, as some of the participants stated, the program should incorporate a right kind of encouragement to keep women motivated, included, and overcoming their concerns.

In the context of these health realities, the focus groups further discussed the programs goals and expectations. While there was a range of opinions how specific the goals of the walking program should be, the participants believed that the sense of clear expectations and purpose should be transparent, [] something that keeps us in check as to what the purpose of the walk is (P6, FG2).

Some participants stressed the need for disciplined commitment to the programs schedule, emphasizing the importance of predetermined health outcomes, something to achieve, you know, to look forward to (P2, FG2) to ensure that the program will make a difference (P3, FG1).

I also think being out and getting out giving you a sense of accomplishment that you know that I'm you know I'm doing this for me and I'm committed to it and I'm actually getting it done. I want some real rewards (P4, FG2).

A more flexible approach was suggested by others. Some participants believed that establishing high-achieving goals may be attractive to some women, but these could also deter less active and less competitive women. The program therefore should respect womens different initial fitness, offering different levels of walking intensity and leave room for individual goals.

As somebody who like I said is just starting to be a functioning human being again [] the expectations [should not be] too great []so that they can start out small but grow as it can like expand as they feel like they can take on more (P4, FG2).

I like to be able to keep track of my steps, thats my own personal goal so I think if people had individual goals thats great too (P1, FG3).

While developing specific goals would be important for some participants, others would be comfortable with a more general purpose of wellness, envisioning a less competitive program that will improve health (P2, FG4) or contribute to feeling better (P1, FG5). Openness to and inclusion of women with various expectations and levels of fitness surfaced as consequential characteristics of the walking program.

In discussion about the appropriate nature of the program, the importance of the social support to women, described by one participant as connecting with someone who is walking the same steps as I am (P2, FG5), was emphasized across all focus groups.

The participants envisioned an organized, regularly scheduled walking group that would be fun, with an optional coffee time at the end. Such a program would simultaneously provide an opportunity for physical activity and mutual emotional and social support to women who often do not have a place to share their menopause experience. This was discussed for example in FG3:

[] and its not necessarily about the walk [] its about the socialization. (P3) Yeah thats a big part (P4). Because that helps, its not the exercise that helps, its the socialization and realizing that they're not alone (P3). [] I think if the main focus is socialization, just all in the same boat, but were going to walk down the block and talk about our menopausal symptoms, [] the walking is the secondary piece (P2).

The concept of a buddy system was also broadly discussed across the focus groups in the context of the lack of motivation to be physically active that women often experience. One exchange, which occurred in FG1, suggested that peer encouragement and mutually developed accountability to one another would be an incentive to continued participation:

I would need a buddy because I wouldn't want to do it on my own (P3). Walking partners are great (P1). Thats true too (P2). I would need a buddy. I think definitely the, you know like, group or buddy I think it would, like for me that would be great. []and yeah to be accountable to go, yeah theres an accountability piece, theres a social piece, there is just that Yeah theres a lot of features to the buddy thing (P3).

An additional suggestion, made in two focus groups described a virtual community that would use a Facebook and/or a mobile application accessible to all its members. This was described as multipurpose tools that could increase motivation, keep the social network engaged, and keep track of individual achievements.

And if you set it up something like you know on one of the social aspects on Facebook whenever you set a group up and say ok this is the plan for the day, this is where everybody is going, love to see you there, you know and kind of just whoever shows, shows. You know its not a hardcore that you have to be there, its you know feel free when you feel up to it or when you're having a day or when you just need to talk (P3, FG3).

While most participants anticipated a face-to-face walking program that provides social group activity, some participants mentioned the possibility for a combination of group and individual activities. In FG4, this was suggested as an additional opportunity to clock our own walking (P2, FG4). In FG2, two participants (one who lives out of town, and one self-described loner), proposed a virtual community where participants would exercise on their own, but could connect periodically in person with the rest of the walkers:

they should make a menopause walking app or something so you check in or something like that (P3, referring to MyFitnessPal). if we did something like that and there was an app that could be adapted to be used then you're doing it alone but you're not alone (P2). I would want to see how everyone else is doing you know like P1 did 10,000 steps or she walked 10 miles this week. [] so if theres an app [] and if were all willing to provide that information [] to motivate us (P6).

By developing in- person and virtual community, as well as individual and group activities, the walking program would demonstrate adaptability and flexibility to suit different lifestyles, while simultaneously creating a space for social interaction.

The weather and seasonal changes were emphasized as a key aspect of developing a walking program. The severity of winters with low temperatures and icy sidewalks on one hand, and hot summer days on the other, call for flexibility in identifying appropriate locations and venues for walking. All focus groups discussed summertime walking along the many city walking trails, except when the temperature is too high and walking would be more comfortable in air-conditioned spaces.

During the winter, walking inside was preferred as a safer option by the majority of participants, for example walking in recreation centers or shopping malls; though some participants felt inside walking was a less attractive option.

Discussions about geographical locations for the walking program provided less consistent suggestions. While some of the participants were willing to drive and meet the group wherever it is located, the majority would prefer the program being closer to home, to save time and avoid unnecessary driving. The following exchange in FG4 exemplifies this point:

Well I guess it depends on where the women are all located right? You want to make it feasible, like you want to make it, you know, easily accessible; if somebody has to travel a half an hour plus to get there, its best to sort of have it in three to four different areas in the city (P2). I totally agree with that [] because if there was a walking group that just met downtown I wouldnt join it because I live [in the part of the city] thats a half an hour drive to get there (P1). I agree, I wouldn't drive far to go for a walk because I would just go for a walk out of my house (P5). Im a driver so that wouldn't bother me; that would be fine for me (P2). Its just the time I think for myself anyways you know its just, its making the time (P4).

Possible solutions included providing the program simultaneously in different neighborhoods or parts of the city, or be mobile and move around the city on a weekly basis, with the various time schedule options, such as evening walking (during the week) and mid-days or afternoons (on weekends).

As participants discussed a number of factors related to the logistics of the planning (weather, location, time), the need for accommodation and flexibility has emerged across all focus groups, to ensure the access and commitment to and feasibility and sustainability of the program. Most important for all women was the commonality of menopause for the walking group; as one woman sums it up: There is always the one constant, its the menopause group, so that constant there (P1, FG1).

Link:
Walking together: women with the severe symptoms of menopause propose a platform for a walking program; outcome from focus groups - BMC Blogs Network

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