Menopause symptoms, sexual dysfunctions and pelvic floor disorders in refugee and asylum seeker women: a scoping review

Abstract

Refugee and asylum seeker women face a variety of health challenges. However, little is known globally about health problems in these women at midlife and beyond, including menopausal symptoms, sexual dysfunctions and pelvic floor disorders. This scoping review aimed to understand these neglected health issues with respect to prevalence and risk factors. Eight databases were searched in August 2022 without the limit of publication year. Data were analyzed narratively. A total of 10 reports from seven studies were included with 945 women living in Australia, Canada, the USA and Pakistan. Three reports were addressing menopause, seven addressed sexual dysfunctions and one addressed pelvic floor disorders. There were no data regarding menopause symptoms; however, perceptions of menopause varied widely across studies. Few studies reported a high prevalence of sexual dysfunctions and pelvic organ prolapses, but none of them used a validated questionnaire. Taboos and cultural factors, lack of knowledge and education, lack of family support, language insufficiency and financial problems were common barriers to not seeking care for these health issues. This review demonstrates lack of evidence of these neglected health issues in refugee and asylum seeker women at midlife, and further studies with validated questionnaires and larger samples are warranted.

摘要

难民和寻求庇护的女性面临着各种健康挑战。然而, 全球对这些女性中年及以后的健康问题知之甚少, 包括更年期症状、性功能障碍和盆底疾病。这项范围综述旨在了解这些被忽视的健康问题的患病率和风险因素。2022年8月检索了8个数据库, 不受发表年份的限制。对数据进行叙述性分析。共有来自7项研究的10份报告, 涉及居住在澳大利亚、加拿大、美国和巴基斯坦的945名女性。3份报告涉及更年期, 7份涉及性功能障碍, 一份涉及盆底疾病。没有关于更年期症状的数据；然而, 在不同的研究中, 对更年期的看法差异很大。很少有研究报告性功能障碍和盆腔器官脱垂的高发, 但没有一项研究采用了有效的问卷调查。禁忌和文化因素、缺乏知识和教育、缺乏家庭支持、语言不足和经济问题是不寻求治疗这些健康问题的常见障碍。这篇综述表明, 在难民和寻求庇护的中年女性中, 缺乏这些被忽视的健康问题的证据, 有必要通过有效的问卷和更大的样本进行进一步的研究。

Keywords:

• Menopause
• sexual dysfunctions
• pelvic floor disorders
• refugees
• asylum seekers

Background

According to the United Nations High Commissioner for Refugees (UNHCR), refugees and asylum seekers account for the second and third-largest groups among forcibly displaced people with an estimated population of 27.1 million and 4.6 million in 2021, respectively [1,2]. More than two-thirds of all refugees originated from the five countries of Syria, Venezuela, Afghanistan, South Sudan and Myanmar in 2021 [3]. The USA, Canada and Australia have been the largest resettlement countries between 2003 and 2022 [4].

The UNHCR estimates that approximately 25% of refugee women are aged between 18 and 59 years [1]. The majority of refugee and asylum seeker women are likely to have compromised health in their homeland due to exposure to war, conflict, economic crisis or natural disaster [5]. Furthermore, they may face challenges in accessing social and health services in host countries due to having insufficient information about the available services, legal restrictions, financial problems, limited access to transport and lack of culturally insensitive care and interpreters [6].

Recent reviews have focused on the mental and perinatal health of refugee and asylum seeker women [7–10]. However, women in midlife and beyond experience different health issues including menopause symptoms, sexual dysfunctions and pelvic floor disorders (PFDs). For example, approximately 75% of Australian postmenopausal women experience vasomotor symptoms [11], which are associated with lower psychological and general well-being [12] and higher depression [13]. Sexual dysfunctions affect approximately 20% of Australian premenopausal women [14], while at least 28% of Australian women at midlife experience sexual dysfunction [15]. A systematic review of symptomatic PFDs among women in low and middle-income countries showed a prevalence of 25% [16]. As these gender-specific health issues have sociocultural and economic determinants [16–18], the prevalence of these conditions in refugee and asylum seeker women may differ from other women. The aim of this scoping review was to identify studies that assessed menopause symptoms, sexual dysfunction and PFDs in refugee and asylum seeker women. The findings of this review will inform future research regarding the health and well-being of refugee and asylum seeker women.

Methods

This review was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [19], and was registered in PROSPERO (CRD42022351518).

Eligibility criteria

We included quantitative and mixed-methods studies that investigated the prevalence of menopause symptoms, sexual dysfunction and PFDs and their associated factors in refugee and asylum seeker women. Qualitative studies were also included if they explored the attitude, experience and knowledge of refugee and asylum seeker women regarding menopause, sexual dysfunction and PFDs. Only English language studies were included. Studies that included men or children, or did not clearly differentiate between refugees or asylum seekers and migrants were excluded.

Information sources and search strategy

We searched multiple databases including Ovid Medline, Embase, Emcare, CINAHL, PsycInfo, Global Health, ProQuest and Web of Science. Moreover, the reference lists of articles were searched manually. The last search was done on 4 August 2022. The search strategy includes a combination of medical subject headings (MeSH) and keywords searches in all databases. These terms were combined with ‘OR’ and ‘AND’ operators. The MeSH terms included refugees, menopause, premature menopause, perimenopause, postmenopause, hot flashes, climacteric, urinary incontinence, pelvic floor disorder/s, pelvic organ prolapse/s, sexual dysfunction/s, dyspareunia, vaginismus, libido and orgasm. The final search strategy in Ovid Medline is shown in Supplementary Table 1.

Study selection and data extraction

Title, abstracts and full-text screening were independently done by M.J. and R.M.I. Disagreements were resolved through discussion with the third reviewer (E.F.). The first author, publication year, country, study objectives, study design and sampling, country of origin, data collection and study setting, sample size and age range, analysis method and key findings were extracted from the included studies (Table 1).

Table 1. Characteristics of the included studies.

Author, year, country	Study design and sampling	Country of origin	Data collection and study setting	Sample size, age range	Analysis method	Key findings
Menopause and menopausal symptoms
Stanzel, 2021, Australia	Qualitative and convenience sampling with flyers	Eritrea, Ethiopia, South Sudan, Sudan	Semi-structured interview in community health services, community learning centers and community groups	N = 11 45–60 years	Thematic analysis	Women with positive perceptions described menopause as being relieved of reproductive roles and menstrual inconvenience Limited educational opportunity in their home countries, lack of information provided by general practitioners, English illiteracy, regarding menopause as a secret linked to lack of knowledge about menopause
Stanzel, 2022, Australia	Qualitative and convenience sampling with flyers	Vietnam	Semi-structured interview in food markets, community groups, and community and learning centers in areas with a high proportion of residents who were migrants from Vietnam	N = 12 45–60 years	Thematic analysis	Women with a neutral perception considered menopause as just another life stage and a natural transition, embraced its symptoms and reflected this view in their experiences and management of menopause by approaches such as exercise, dietary changes and traditional herbs rather than prescribed medicines Lack of information provided by general practitioners and English illiteracy linked to lack of knowledge about menopause Shyness, preference for female healthcare provider and giving menopause a low health priority in their communities linked to limited access to menopause-related health care
Ussher, 2019, Australia and Canada	Qualitative and convenience sampling with flyers	Afghanistan, India (Punjab), Iraq, Somalia, South Sudan, Sri Lanka (Tamil), Sudan and various South American (Latina: Mexico, Columbia, Puerto Rico, El Salvador, Peru, Cuba and Chile)	Individual interview and focus groups in sexual and reproductive health clinic, pre-existing community migrant support groups and members of their community	N = 169 18–70 years	Thematic analysis	Women with positive perceptions described menopause as being relieved of menstrual inconvenience, no longer being worried about pregnancy and contraception, and a time when life starts Women with negative perceptions of menopause viewed menopause as causing negative mood, adverse physical changes and poor health and stigma, a taboo subject, the end of fertility and indicative of aging
Sexual dysfunctions
Balsara, 2010, Pakistan^a	Mixed-method with convenience sampling	Afghanistan	Individual interview and survey with structured questionnaire in basic health units	N = 634 12–70 years	Thematic analysis and χ^2 test	Dyspareunia, 69.7% More than 70% did not seek treatment Reason for not seeking treatment: shame, 27.3% cost, 33.8% lack of familial support, 18.5% unaware that treatment was available, 7.9%
Connor, 2016, USA	Mixed-method with convenience sampling	Somali	Semi-structured interview and survey with structured questionnaire	N = 30 18–40 years	Thematic analysis and χ^2 test	The majority (82%) indicated they experienced sexual desire. FGC: Sexual pain in all types of FGC, 40% Positive relationship between more severe forms of FGC (type II = III) and sexual pain in comparison with less severe forms (type I = IV) (64% vs. 13%; χ2 = 5, p = 0.03) Approximately half indicated that FGC negatively affected their sexual relationship
Hawkey, 2019, Canada and Australia	Qualitative with convenience sampling	Afghanistan, Iraq, Somalia and Sudan in both Australia and Canada/Sri Lankan (Tamil) and South Sudanese in Australia/South American (Latina) in Canada	Individual interview and focus groups in sexual and reproductive health clinic, pre-existing community migrant support groups and members of their community	N = 160 18–70 years	Thematic analysis	Positioning marital sex as a duty associated with absence of women’s sexual enjoyment Not being freely able to verbalize their sexual desire within the marital relationship Positioning coital sex as a means to ‘bear children’ Few being unable and a majority being able to communicate their pain to their husbands Experiencing sexual pain, particularly due to lack of vaginal lubrication Not seeking medical attention or not knowing of solutions to overcome sexual pain Positioning women’s sexual desire as secondary to men’s Challenging traditional views on women’s sexual agency by migration Using religion to reinforce women’s right to experience sexual pleasure Believing women’s pleasure is an integral part of sex Arranged marriage as a contributing factor to the negative experience of sex after marriage and ongoing sexually unfulfilling relationships
Howard, 2016, USA	Mixed-method Sampling not reported	Swahili, Somali	Pre-intervention and post-intervention surveys with a qualitative approach (NR)	N = 47 Age NR (abstract study)	NR (abstract study)	Somali women: difficulty feeling satisfied (33%), possibly as a result of FGC Swahili-speaking women: sexual pain (73%), low desire (67%)
Metusela, 2017, Australia and Canada	Qualitative with convenience sampling	Afghanistan, Iraq, Somalia and Sudan in both Australia and Canada/Sri-Lankan (Tamil), Indian (Punjabi) and South Sudanese in Australia/South America (Latina) in Canada	Individual interview and focus groups in sexual and reproductive health clinic, pre-existing community migrant support groups and members of their community	N = 169 18–70 years	Thematic analysis	Talking or thinking about sex is taboo Feeling unable to refuse marital sex or to address sexual pain Cervical screening inappropriate for unmarried women Inability to refuse marital sex Low prioritization of sexual health care Traumatic first sex experiences and ongoing sexual pain Reluctance to be examined by male health professional Little knowledge and use of lubricants to ease vaginal discomfort
Ussher, 2012, Australia	Qualitative with convenience sampling	Iraq (Assyrian community) and Myanmar (Karen community)	Focus group in community groups	N = 42 18–78 years	Thematic analysis	Premarital chastity as a barrier to enjoying sex after marriage Premarital chastity results in lack of knowledge Premarital chastity prohibits cervical screening for unmarried women Considering sexual pain as a normal experience in marital relationship The majority not seeking care for sexual pain
Ussher, 2017, Australia and Canada	Qualitative with convenience sampling	Afghanistan, Iraq, Somalia and Sudan; Sri Lankan (Tamil), Indian (Punjab) and South Sudanese women were also included in the Australian sample and women from various South American (Latina) backgrounds in the Canadian sample	Individual interview and focus groups in sexual and reproductive health clinic, pre-existing community migrant support groups and members of their community	N = 169 18–70 years	Thematic analysis	Traumatic first experience as a result of no sexual knowledge Relating sexual pain to vaginal tightening due to low sexual frequency Feeling unable to communicate their pain to their husbands Having no concept of their own sexual pleasure due to lack of sexual communication and knowledge Considering women’s sexuality as something to give pleasure to men Using religious imperatives for their rights to enjoy sex Positive impact of migration on understanding their rights and openness about sexual health Risk of being stigmatized in case of initiating or expressing their sexual desires
Pelvic floor disorders
Balsara, 2010, Pakistan	Mixed-method with convenience sampling	Afghanistan	Individual interview and survey with structured questionnaire in basic health units	N = 634 12–70 years	Thematic analysis and χ^2 test	POPs using questionnaire, 60.4% POPs during examination, 53.9% – including uterine prolapse (31.1%), cystocele (42.4%) and rectocele (25.2%) Reason for not seeking care: shame, 13.1%, cost, 34.5% lack of cooperation from their husbands and/or mothers-in-law, 29.8%

^aStudy reports both sexual dysfunctions and pelvic floor disorders.

FGC, female genital circumcision; NR, not reported; POP, pelvic organ prolapse.

Data synthesis

The quantitative data were reported as a frequency or percentage, and the qualitative data were aggregated and categorized according to relevant recurring themes, and reported narratively highlighting menopause, sexual function and PFDs.

Results

Study characteristics

A PRISMA flowchart of study selection is presented in Figure 1. The initial search resulted in 1512 reports/publications, of which 627 were duplicates. A further 835 reports were excluded after title and abstract screening, leaving 50 reports for full-text review, of which five full texts could not be retrieved. At this stage, 35 further reports were excluded due to ineligibility (Supplementary Table 2), leaving 10 reports from seven studies for this review. These reports were published between 2010 and 2022 with a total sample of 945 refugee and asylum seeker women. Four reports were from one study of the same participants and included both migrant and refugee populations from more than 10 different countries. As more than 80% of the participants were refugees and asylum seekers, these papers were included [20–23].

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram.

Of the 10 reports, seven used a qualitative study design [20–26] while three used mixed-methods study design [27–29]. One study, resulting in four publications, was conducted in both Australia and Canada (combined recruitment) [20–23], three were undertaken in Australia [24–26], two in the USA [27,28] and one in Pakistan [29].

Convenience sampling was used in all studies [20–29]. Data were collected via individual interviews with focus group discussions [20–23], semi-structured interviews [24,25], focus group discussions only [26], survey with semi-structured interviews [28,29], and pre-intervention and post-intervention surveys combined with a qualitative approach (the qualitative method was not described) (n = 1) [27]. Three publications were addressing menopause, seven addressed sexual dysfunctions and one addressed PFDs. The publication by Balsara et al. reported both sexual dysfunctions and PFDs [29].

Menopause and its symptoms

No study reported menopausal symptoms in refugee and asylum seeker women. Three qualitative reports explored women’s perceptions of menopause with mixed results of positive, neutral and negative attitudes [21,24,25]. Ussher et al. reported findings for premenopausal and postmenopausal refugees (n = 143) and migrants (n = 26), aged 18–70 years, with different backgrounds who had arrived in Australia or Canada on average 6.3 years ago. Participants reported both negative and positive attitudes toward menopause [21]. Two Australian studies were of postmenopausal women aged 45–60 years with refugee backgrounds who had reached Australia more than 10 years ago; the women from Vietnam had mainly neutral attitudes toward menopause, whereas the women from the Horn of Africa mainly expressed positive attitudes toward menopause [24,25]. Women with a neutral perception considered menopause as just another life stage and a natural transition [25]. Women with positive perceptions toward menopause described being relieved of reproductive roles and menstrual inconvenience, no longer being worried about pregnancy and contraception, and viewing menopause as a time when life starts [21,24]. The women with negative perceptions of menopause viewed menopause as causing negative mood, adverse physical changes and poor health and as stigma, a taboo subject, the end of fertility and indicative of aging [21].

All three of these publications reported that women lacked knowledge about menopause and did not seek care but dealt with their symptoms by approaches such as exercise, dietary changes and traditional herbs rather than prescribed medicines [21,24,25]. They reported taboos and cultural factors as the most common barriers to seeking menopause-related care and knowledge, including shyness, preference for a female healthcare provider, menopause having a low health priority in their communities [25] and regarding menopause as a secret and taboo [21,24]. Additional barriers identified in the Australian studies included lack of educational opportunities in their home countries, lack of information provided by general practitioners and English illiteracy [24,25].

Sexual dysfunction

None of the seven publications reporting on sexual dysfunction used validated questionnaires [20,22,23,26–29]. Identified sexual problems included sexual pain, low sexual satisfaction and low sexual desire [20,22,23,26–29].

Six publications provided data on sexual pain [20,22,23,26,28,29]. The sexual pain prevalence in three separate studies was 40% in Somali women [28], 70% in Afghan women [29] and 73% in Swahili women [27]. The studies of Somali and Swahili women included fewer than 50 participants [27,28] while the study of Afghan women included 624 participants [29].

Four publications further reported on sexual pain, three from the one study in Australia and Canada [20,22,23,28]. In the Australian–Canadian study, refugees and migrants from different backgrounds attributed their pain to a traumatic first experience as a result of no sexual knowledge, vaginal dryness and tightening due to low sexual frequency and lack of knowledge about using lubricants [20,22,23], while Somali women believed female genital circumcision was the main reason for their pain with sex [28]. Few women sought medical care to their sexual pain [23,26,29].

Four publications reported findings pertaining to sexual relationship, sexual desire and pleasure in six publications [20,22,23,26–28]. A US study of 47 Somali and Swahili women reported a prevalence of low sexual satisfaction of 33% for Somali women and low sexual desire of 67% for Swahili women [27]. Three publications found that being Muslim and migration positively influenced sexual relationships [22,23,28]. The Muslim religion encourages men to sexually satisfy their wives and has given women the right to ask their husbands for sex [22,23,28], and migration has positively impacted on couples’ understanding of women’s rights [22,23]. Cultural factors were also common barriers to a positive sexual relationship across two studies (four publications) [20,22,23,26], including the cultural construction of sex as a marital duty to bear children and satisfy their husbands [20,22,23,26], taboos around expressing sex desire and initiating sex in marriage such as being stigmatized by their husbands [22,23], taboos around sexual knowledge [22], premarital chastity [26] and arranged marriage [23].

In terms of sexual health-seeking behavior, two publications found cultural prohibitions as barriers to some types of sexual health care, such as a pap smear for virgins [20,26] and being examined by male health professionals [20]. Non-seeking healthcare behavior was also linked to shame, financial problems, lack of family support and lack of information [29]. One publication reported that migration was perceived as a beneficial factor in openness toward sexual health care by women [22].

Pelvic floor disorders

One publication regarding Afghan refugee women with an average age of 29.6 years reported the prevalence of PFDs [29]. Of the 634 participants, 60.4% answered ‘yes’ to the question: ‘Do you feel heaviness below – as if something is falling out from under you’. During pelvic examination, 53.9% of the participants were diagnosed with pelvic organ prolapses (POPs) including uterine prolapse (31.1%), cystocele (42.4%) and rectocele (25.2%). Forty-four percent of those who self-reported prolapse in the questionnaire did not seek care due to shame, lack of financial means or lack of cooperation from their husbands and/or mothers-in-law [29].

Discussion

This systematic review demonstrates wide variation in the perception of menopause amongst refugee and asylum seeker women, along with a stark lack of prevalence data for menopausal symptoms amongst such women. While there was a concerning, high prevalence of sexual difficulties and POPs among these populations, few women appeared to seek medical attention for these conditions. Moreover, there were no data pertaining to the risk factors for these conditions. Unfortunately, none of the included studies used validated questionnaires or demonstrated representativeness of their samples, which limits the interpretation of the findings.

This review reveals that refugee and asylum seeker women have tended to not seek care for their menopausal, sexual and pelvic floor health issues. This was consistently attributed to taboos and cultural factors, lack of knowledge and education, lack of family support, language insufficiency and financial problems. A systematic review by Siddiq et al. [30] found that refugee women from Muslim-majority countries underutilize preventive services, specifically mammography, pap smears and colonoscopy screening. Sociocultural factors such as religious beliefs about cancer, stigma, modesty and gender roles within the family context were considered as the barriers. However, Islam et al. found that in Bangladesh, a predominantly Muslim country, the primary barrier to breast and cervical cancer screening was lack of understanding of why a woman would have a test for a condition when she had no symptoms [31]. This highlights the importance of health literacy in preventative care.

A study reporting menopause symptoms and risk factors in refugee and asylum seeker populations was not identified. There is a controversy regarding how menopause symptoms can be affected by sociocultural factors, different ethnicities and countries of origin [18,32–34]. A systematic review of menopausal experiences among immigrant women, published in 2018, reported that these women have more vasomotor and other related symptoms, as well as poorer mental health, than non-immigrant women [34]. Another systematic review of the prevalence of perimenopausal and postmenopausal symptoms in Asian countries found similar prevalence of vasomotor symptoms in Asian women and women in western countries [32].

It is important that the experience of refugees and asylum seeker women may differ from women in their countries of origin as their circumstances have been complicated by traumatic events before, during and after displacement that may accelerate aging and may increase the likelihood of early menopause [35,36]. More research into these populations is urgently needed to determine the effects of forced displacement rather than migration on reproductive aging.

The differing attitudes toward menopause reported in different studies may reflect study designs, participants backgrounds, age and length of stay in host countries. Similar to our review, low educational level, host language insufficiency and lack of information from healthcare professionals have been associated with limited menopause-associated knowledge [37]. Additionally, lack of information provided by health professionals has been attributed to insufficient consultation time and healthcare providers lacking confidence in culturally competent care [37]. This highlights the importance of cultural competence education for health professionals in host countries. More comprehensive studies examining a variety of associated factors affecting menopause perceptions in refugee and asylum seeker women are required to identify what are the risk factors and how they can be mitigated.

Low sexual desire is considered the most common sexual problem in western countries [15,38,39]. The included studies showed sexual pain as the most reported sexual dysfunction among refugee and asylum seeker women, with its prevalence higher than that reported in general populations [40,41]. This contradiction may reflect the impact of cultural factors [42,43], while female genital circumcision also contributes to the high prevalence of sexual pain [44]. However, no study in our review used validated questionnaires and representative samples, emphasizing that these are speculations.

The negative impact of cultural factors and taboos extended to women not seeking sexual health care. Prior studies have identified lack of sexual health services and insufficient service delivery in countries with a large influx of refugees and asylum seekers such as Australia and Canada [45–47]. Refugee and migrant women in these studies emphasized gaps in the healthcare system in terms of providing sexual knowledge, including sexual pain and pleasure, libido, sexual rights and healthy intimate relationships [45–47]. The paucity of data regarding the sexual health of these populations can be a challenge for developing culturally appropriate healthcare programs.

There was only one study that reported a high prevalence of POPs in refugee women (53.9%) [29], which is considerably higher than that in community-dwelling women in low-income countries such as Bangladesh (at least one PFD, 35.3%) [48]. Risk factors for PFDs include at least three births, low socioeconomic status, having diabetes [48] and a long postmenopausal life span [49]. No data are available regarding risk factors of PFDs in refugee and asylum seeker populations. While lack of knowledge about symptoms and treatment of PFDs was previously identified as a barrier to seeking care in the general population [50], refugee women in this study regarded financial and cultural issues as the main barriers, pointing out the significance of culture in healthcare-seeking behaviors and financial issues that refugees are facing in host countries. However, little attention has been paid to this area of reproductive health, and no study has investigated other PFDs such as problems with bladder and bowel function in these populations.

The strength of this review is the comprehensive search of multiple databases without applying the publication year limit. We limited the search to the English language and therefore may have missed data published in other languages. We were also limited to providing a narrative review of predominantly qualitative data which was dictated by the paucity and nature of publications addressing refugee and asylum seeker women’s health.

Conclusion

This scoping review of menopause symptoms, sexual dysfunction and PFDs in refugee and asylum seeker women demonstrates the paucity of data regarding these important aspects of women’s health. Given that 80% of the world’s refugees are women and children, many of whom have been subject to violence and sexual abuse [51], these neglected gender-specific health issues need to be better understood with respect to prevalence and risk factors. This will enable the most pressing needs to be identified and appropriately addressed.

Potential conflict of interest

S.R.D. has been paid for developing and delivering educational presentations for Besins Healthcare, Abbott, Mayne Pharma, BioFemme and Lawley Pharmaceuticals; has been on Advisory Boards for Theramex, Abott Laboratories, Mayne Pharma, Gedon Richter and Roche Diagnostics; is a consultant to Lawley Pharmaceuticals, Southern Star Research and Que Oncology; and has received institutional grant funding for Que Oncology and Ovova Bio research. E.F. and R.M.I. have received support from Lawley Pharmaceuticals for conference attendance. M.J. has no potential conflicts of interest to declare.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.