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. Author manuscript; available in PMC: 2026 Jan 1.
Published in final edited form as: Ethn Health. 2024 Oct 7;30(1):85–97. doi: 10.1080/13557858.2024.2413358

Health Risks Associated with Urinary Incontinence among Older Korean Americans Living in Subsidized Senior Housing

Yuri Jang 1,2, Juyoung Park 1, Jung In Park 3, Hi-Woo Lee 4, Soondool Chung 2, Sunmin Lee 5
PMCID: PMC11666396  NIHMSID: NIHMS2032574  PMID: 39373267

Abstract

Objectives:

We examined the association of urinary incontinence (UI) with physical, mental, and social health among older Korean Americans living in subsidized senior housing.

Design:

Data were obtained from surveys conducted in 2023 with older Korean Americans residing in subsidized senior housing in the Los Angeles area (n = 313). UI was measured using a question about the frequency of involuntary urine loss. Physical, mental, and social health risks were assessed with a single item for self-rated health (fair/poor rating), the Patient Health Questionnaire–9 (probable depression), and the Lubben Social Network Scale–6 (isolation from family and friends).

Results:

Over half of the sample reported UI, with 46.3% experiencing it infrequently (i.e., seldom) and 10.3% frequently (i.e., sometimes or often). UI was significantly associated with physical and mental health indicators; the odds of reporting fair or poor health and having probable depression were 1.94 to 7.32 times higher among those with either infrequent or frequent UI compared to those without UI. While family isolation was not associated with UI, the odds of being isolated from friends were 2.85 times greater among those with frequent UI compared to those without UI.

Conclusion:

Our findings confirm the adverse impact of UI on physical and mental health and highlight its unique role in social health. UI-associated social isolation was significant only in relationships with friends, providing new insights into the distinction between isolation from family and friends. These findings enhance our understanding of the health risks associated with UI and inform strategies for health management and promotion within the senior housing context.

Keywords: urinary incontinence, social isolation, health risk, senior housing, older immigrants

SDG Keyword: Good health and well-being

Introduction

Urinary incontinence (UI), defined as the involuntary loss of urine,1 is a significant health issue among older adults.2,3 Due to variations in definitions, measures, and sampling methods, the reported prevalence of UI in population-based studies ranges widely, from 5% to 70%.4 Research consistently shows that UI is more common in females than in males and its severity increases with age.4,5 More than 40% of women over the age of 70 and nearly three-quarters of individuals in nursing homes report experiencing UI.4,5 Additionally, UI is often underreported and undertreated due to the misconception that it is a normal part of aging and the associated social stigma.6,7 As populations age, the health and social implications of UI warrant further attention.

UI as a Life Stressor and Its Impact on Physical and Mental Health

In the fields of gerontology and health psychology, the development of chronic medical conditions (e.g., cancer, stroke, heart disease) or functional disabilities is well-recognized as a major life stressor.8,9 Beyond these well-defined and well-studied health events, attention needs to be paid to UI, a common geriatric condition that does not necessarily form a discrete disease category1 but nonetheless can have a substantial impact on individuals’ daily life and sense of well-being.2,3 Research has shown that UI is closely associated with poor health outcomes, increased disease susceptibility, reduced self-esteem, and heightened symptoms of depression, anxiety, and psychological distress.10,11 Furthermore, when UI interferes with daily life, the risk of depression is substantially increased,11 highlighting the interconnectedness of physical and mental health vulnerabilities associated with UI in later life.

Social Health: Another Health Domain under the Impact of UI

Social health may also be impacted by UI, yet this domain has received relatively little attention. UI is often associated with feelings of shame and embarrassment, which can limit older individuals’ participation in social activities and affect their interpersonal relationships.12,13 A qualitative study by Esparza and colleagues14 found that social isolation was a major concern for individuals living with UI. Many reported that they had stopped engaging in activities they once enjoyed (e.g., dancing, playing sports, traveling) and reduced social interactions due to fears of urine leakage and potential odor. Our conceptualization of UI as a risk factor for social isolation acknowledges the critical health hazard posed by isolation15 and highlights the need to identify various contributing factors throughout the life course.15,16

Given the different roles and functions of family and friends as sources of support,17 it is essential to consider how UI impacts social isolation from these groups differently. Family members are typically prioritized for personal care needs, while friends are often preferred for social and leisure companionship.18 Therefore, UI may have a more significant impact on relationships with friends than with family. Additionally, the distinct roles of family and friends should be considered in the context of cultural variations in social relationship norms and expectations.17,18

Target Group: Older Korean Americans Living in Subsidized Senior Housing

UI and associated health risks are particularly relevant for older immigrants and members of ethnic minorities in the United States. This study focuses on Korean Americans, who are the fifth-largest Asian American subgroup.19 Many older Korean Americans are foreign-born immigrants who face cultural and linguistic challenges.19,20 Research has shown that older Korean Americans have notably high rates of limited English proficiency and low levels of acculturation, leading to disparities in accessing and utilizing health and social services.21,22 Additionally, older Korean Americans are identified as being at high risk for physical, mental, and social health issues.23,24 Cultural and immigration-related factors, such as collectivistic orientations, familism, and barriers related to language and cultural differences, significantly influence their health and use of services.21–24

Further narrowing the focus, the present study examined older Korean Americans living in subsidized senior housing in the Los Angeles area. Approximately one-third of all Korean immigrants in the U.S. reside in California, with over two-thirds of the Korean population in California concentrated in the greater Los Angeles area.20 This region offers Korean-oriented resources and services, including senior housing facilities with Korean-speaking service providers. Subsidized senior housing is available to older adults with an annual income below 80% of the area’s median income.25 These facilities serve as homes for many older Korean Americans who are socioeconomically disadvantaged and linguistically isolated, helping them maintain independent living within their communities. Generally, senior housing residents experience poorer health and well-being compared to other community-dwelling older adults,26,27 and this disparity is also seen among Korean-American tenants.28 Despite growing attention to the health and well-being of senior housing residents, UI has received limited focus. Our study’s emphasis on UI in the senior housing context is driven by its impact on residents’ independent living and aging in place,29,30 as well as the close-knit nature of ethnic minority communities and the communal setting of senior housing.26–28

The Present Study

In the present study, we examined how UI is associated with physical, mental, and social health among Korean American residents in senior housing, using self-rated health, depressive symptoms, and social isolation as measures. Self-rated health is a well-established indicator that is often as predictive, or even more so, than objective physical health measures such as disease diagnosis and laboratory parameters.31,32 Depressive symptoms were chosen as a mental health indicator due to their common prevalence.33 Recognizing the multidimensional nature of health31,32 and the impact of UI on social life,12–14 we also included social isolation as a health outcome, distinguishing between isolation from family and friends.

Covariates were selected based on related literature3,8–13,21–24 and include sociodemographic characteristics (age, sex, marital status, education), immigration-related factors (length of stay in the U.S. and acculturation), and basic health and function (chronic medical conditions and functional disability). The inclusion of chronic medical conditions and functional disability was based on the idea that UI’s impact on physical, mental, and social health extends beyond these basic health aspects.2,3,10,11 Understanding the risks associated with UI across various health domains can aid in developing interventions to improve the quality of life for this vulnerable and underserved group of older adults.

Methods

Data

Using purposive sampling, we surveyed Korean-American residents in subsidized senior housing within the greater Los Angeles area. We first identified target facilities from a resource database that we had previously established. This database lists available resources and services relevant to various Asian communities in the region. Based on input from social service providers in these communities, we created a shortlist of target facilities located within a 20-mile radius of our main research center. Our goal was to obtain a minimum sample size of 300 to ensure sufficient power for multivariate analyses of key contextual characteristics. We ultimately surveyed 351 residents across six facilities from April to June 2023.

At each participating facility, housing staff distributed invitation flyers. Eligibility criteria included (a) self-identification as Korean American, (b) being 65 years of age or older, (c) residing in the participating facility, and (d) the ability to read, understand, and sign a consent form. Our research team visited the facilities on scheduled dates to conduct the surveys. Following the IRB-approved protocol, all participants were informed of the study’s goals and procedures, and they signed a consent form.

The self-administered survey consisted of a 10-page structured questionnaire, completed with paper and pencil. Questionnaires were available in both English and Korean, but all participants used the Korean version. At each site, bilingual and bicultural survey assistants were available to help participants who needed assistance. The surveys were administered and completed in common areas of the facilities, such as meeting rooms and cafeterias.

After participants completed the self-administered survey, trained research personnel assessed their cognitive function in Korean using the Mini Mental State Examination (MMSE).34 Thirty-four individuals with severe cognitive impairment (MMSE ≤ 10) were excluded from the study. Additionally, eight participants with more than 10% missing data for the variables used in this investigation and two with missing responses on UI were excluded, resulting in a final sample of 313.

Measures

UI.

Participants were asked about the frequency of involuntary urine leakage or loss of bladder control over the past 12 months. This question was adapted from the Korean Longitudinal Study of Aging.35 Instead of using a yes-or-no response format, we employed a 4-point scale (0 = never, 1 = seldom, 2 = sometimes, 3 = often). This modification aimed to address the stigma associated with UI and to mitigate concerns about under-reporting.

Physical health.

Self-rated health was assessed with a single question: “How would you rate your overall health?” The original response, which had a 5-point response scale, was dichotomized (0 = excellent/very good/good, 1 = fair/poor).

Mental health.

Depressive symptoms were measured using the Patient Health Questionnaire–9 (PHQ–9).36 Participants were asked to report how often they were bothered by problems such as ‘little interest or pleasure in doing things,’ ‘feeling down, depressed, or hopeless,’ and ‘poor appetite or overeating’ over the past 2 weeks. Each item was rated on a 4-point scale, ranging from 0 (not at all) to 3 (nearly every day). Total scores could range from 0 to 27, with higher scores indicating greater levels of depressive symptoms. The scale has been translated into Korean, and the psychometric properties of the translated version have been validated.37 In this sample, the scale demonstrated high internal consistency (α = .86). Using the recommended cut-off score of PHQ–9 ≥ 10, 36 participants were categorized into two groups: 0 (no depression) and 1 (probable depression).

Social health.

The Lubben Social Network Scale–6 (LSNS–6)38 was employed to identify social isolation from family and friends. The LSNS–6 includes six items addressing relational ties, three on ties with family and another three on ties with friends. The scale assesses the number of family/friends that the respondent (a) sees or hears from at least once a month; (b) feels at ease with, to the point of being able to discuss private matters; and (c) feels close to, to the point that the participants could call on them for help. Each item response was scored on a 6-point scale (0 = none to 5 = nine or more). The total scores for the subscale of family or friends range from 0 to 15. The Korean version of the LSNS–6 was validated in previous studies with older Korean Americans,39 and high internal consistency was observed in the current sample for both the family (α = .90) and friends (α = .89) subscales. Using the established cut-off scores for each subscale, 38 cases of isolation from family (LSNS–6 family subscale score < 6) and isolation from friends (LSNS–6 friend subscale score < 6) were identified, with 0 indicating no isolation and 1 indicating isolation.

Covariates.

The sociodemographic characteristics selected were age (in years), sex (0 = male, 1 = female), marital status (0 = not married, 1 = married), and educational attainment (0 = ≤ high school graduation, 1 = > high school graduation). The length of stay in the U.S. (in years) and acculturation represented immigration-related variables. Acculturation was assessed using a 12-item inventory, which included English proficiency, media consumption, and familiarity with the culture of the host country.40 Each response was scored on a scale of 0 (not at all) to 3 (very well), with total scores from 0 to 36, indicating higher acculturation. Cronbach’s alpha was 0.87.

Chronic medical conditions and functional disability were considered as general indicators of health and function. The total count for the checklist of 10 chronic diseases and conditions common in older populations (e.g., diabetes, cancer, arthritis, heart disease, high blood pressure) was used as a continuous value. In addition, functional disability was assessed using a composite measure, including activities of daily living and instrumental activities of daily living.41 The scale included 16 activities (e.g., walking, bathing, dressing, managing medication), and participants were asked to indicate how they performed each activity. The responses were coded as 0 (able to do without help), 1 (able to do with help), or 2 (unable to do). The total scores ranged from 0 (no functional disability) to 32 (severe functional disability). The internal consistency of the scale in this sample was high (α = .89).

Analytic Strategy

Descriptive statistics were used to identify the overall characteristics of the sample. After reviewing the UI frequency distribution, the sample was divided into three groups: no UI, infrequent UI, and frequent UI. Group comparisons of the study variables were conducted using F or χ2 tests. Effect sizes were reported using η2 or Cramér’s V.

Four separate logistic regression models were established for health outcomes: fair/poor ratings of health, probable depression, family isolation, and friend isolation. For each model, we examined the odds of health risks associated with UI group membership, adjusting for covariates such as age, sex, marital status, education, years in the U.S., acculturation, chronic medical conditions, and functional disability. We also tested interactions between UI and background variables to explore potential moderating effects.

Given the nature of a non-probability sample, our goal was to explore the dynamics among key variables within the sample rather than to estimate population parameters. Additionally, since odds ratios alone do not provide information about absolute differences, we provided predicted probabilities to offer a clearer estimate of the likelihood of outcomes for different levels of UI. All analyses were performed using Stata Version 16 (StataCorp LLC, College Station, TX).

Results

Descriptive Characteristics

Table 1 presents the characteristics of the sample. The mean age of the participants was 79.4 years (SD = 6.63). Approximately 72% were female, over 39% were married, and 36% had more than 12 years of education. All participants were foreign-born, with their length of stay in the U.S. ranging from 3 to 63 years, with an average of 32.5 years (SD = 11.1). The mean acculturation score was 9.29 (SD = 5.38). The average number of chronic medical conditions and functional disabilities was 1.78 (SD = 1.18) and 3.75 (SD = 4.60), respectively. More than half of the sample (56.5%) experienced UI, with 46.3% reporting it as “seldom,” 9.3% as “sometimes,” and 1% as “often.” Due to the skewed distribution, the latter two response categories were combined. The groups were categorized as follows: no UI (never), infrequent UI (seldom), and frequent UI (sometimes or often). In the multivariate model, the no UI group served as the reference. About 48% of the sample rated their health as fair or poor. The mean score for depressive symptoms was 7.01 (SD = 3.49), with over 18% of the sample exhibiting probable depression. The network scores for family and friends averaged 8.14 (SD = 3.47) and 7.01 (SD = 3.49), respectively. The rate of social isolation was over 20% in the family domain and about 28% in the friend domain.

Table 1.

Descriptive Characteristics of the Sample

Total Sample (N = 313) No UI (n = 136) Infrequent UI (n = 145) Frequent UI (n = 32) F (χ2) η2 (Cramér’s V)
Urinary incontinence (UI),1 %
 Never 43.5 – – – –
 Seldom 46.3 – – – –
 Sometimes 9.3 – – – –
 Often 1.0 – – – –
Health risks
 Self-rated health (fair/poor), % 47.9 33.1 54.5 81.3 (28.7***) (.30)
 Probable depression, % 18.4 7.4 22.4 46.9 (29.7***) (.31)
 Family isolation, % 20.3 20.7 19.3 22.6 (.20) (.03)
 Friend isolation, % 27.7 25.9 24.1 53.1 (11.4**) (.19)
Covariates
 Age, M±SD 79.4±6.63 78.6±6.37 79.5±6.92 82.3±5.58 4.25* .03
 Female, % 71.6 75.0 67.6 75.0 (2.10) (.08)
 Married, % 39.6 41.2 41.4 25.0 (3.18) (.10)
 > high school graduation, % 36.6 40.9 34.5 28.1 (2.33) (.09)
 Year in the U.S., M±SD 32.5±11.1 32.4±10.8 33.5±11.3 27.6±10.4 3.59* .02
 Acculturation, M±SD 9.29±5.38 9.79±5.16 9.50±5.64 6.25±4.15 5.98** .04
 Chronic medical conditions, M±SD 1.78±1.18 1.54±1.03 1.89±1.15 2.34±1.62 7.45*** .05
 Functional disability, M±SD 3.75±4.60 2.48±4.24 4.38±4.40 6.25±5.40 11.9*** .07
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1

The responses were classified into no UI (never), infrequent UI (seldom), and frequent UI (sometimes or often).

*

p < .05.

**

p < .01.

***

p < .001.

Table 1 also shows comparisons across the three UI groups. The frequent UI group had notably higher risks for three out of four health outcomes: over 81% rated their health as fair or poor, about 47% exhibited probable depression, and over 53% were isolated from friends. This group was older and had fewer years of residence in the U.S., lower levels of acculturation, more chronic medical conditions, and greater functional disability compared to the other groups.

Logistic Regression Models of Health Risks

Table 2 presents logistic regression models for the four health outcomes. In the models for physical and mental health, a significant role for UI was found, along with a dose-response effect. Relative to the group with no UI, those with infrequent UI had 1.94 times higher odds, and those with frequent UI had 4.69 times higher odds of reporting fair or poor health. Similarly, the odds of probable depression were 3.10 times higher in the infrequent UI group and 7.32 times higher in the frequent UI group compared to the reference group. UI did not have a significant impact on family isolation. However, individuals with frequent UI showed 2.85 times higher odds of being isolated from friends compared to the reference group. No interaction term of UI with covariates was statistically significant. Our model predicted that the probability of reporting fair or poor health ranged from 39% to 68%, depending on UI severity. The corresponding ranges for probable depression, family isolation, and friend isolation were 9% to 35%, 20% to 23%, and 23% to 50%, respectively.

Table 2.

Logistic Regression Models for Health Risks

Odds Ratio (95% Confidence Interval)
Self-rated Health (fair/poor) Probable Depression Family Isolation Friend Isolation
Urinary incontinence (UI)
 No UI [reference] [reference] [reference] [reference]
 Infrequent UI 1.94* (1.09, 3.45) 3.10** (1.32, 7.27) .97 (.51, 1.84) .77 (.42, 1.40)
 Frequent UI 4.69** (1.60, 13.7) 7.32*** (2.47, 19.9) 1.14 (.40, 3.23) 2.85* (1.18, 6.85)
Covariate
 Age .99 (.95, 1.03) 1.00 (.94, 1.05) .98 (.93, 1.03) 1.02 (.97, 1.06)
 Female 1.05 (.56, 1.99) .44 (.19, 1.02) .50 (.25, 1.01) .33*** (.17, .61)
 Married .97 (.54, 1.74) .76 (.35, 1.63) .18*** (.08, .40) .59 (.32, 1.07)
 > high school graduation .60 (.33, 1.09) .47 (.21, 1.06) .77 (.39, 1.52) .63 (.34, 1.19)
 Years in the U.S. .99 (.97, 1.02) .97 (.94, 1.00) 1.01 (.98, 1.04) 1.01 (.98, 1.03)
 Acculturation .91** (.86. .97) 1.05 (.97, 1.13) .98 (.92, 1.04) .98 (.93, 1.04)
 Chronic medical conditions 1.55*** (1.19, 2.03) 1.21 (.89, 1.63) .76 (.59, 1.01) .96 (.76, 1.23)
 Functional disability 1.14*** (1.05, 1.22) 1.19*** (1.10, 1.28) 1.03 (.95, 1.11) 1.03 (.96, 1.09)
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*

p < .05.

**

p < .01.

***

p < .001.

Discussion

Focusing on older Korean-American residents in subsidized senior housing, we examined the prevalence of UI in this group and its association with physical, mental, and social health. UI was not uncommon among the sample. While it was experienced infrequently (i.e., seldom) by 46.3% of the sample, over 10% reported frequent episodes of UI (i.e., sometimes or often). Although these rates are at the upper end of the prevalence range reported for UI across diverse groups of older adults,4,5 the possibility of underreporting should not be ruled out.

In line with studies reporting health challenges among residents of senior housing,26,27 this sample exhibited adverse conditions across all health measures. For instance, more than 18% of the sample fell into the category of probable depression, which is three times higher than the rate observed in the older population of the U.S. in general.33 While the small sample size necessitates caution in interpreting these results, comparisons among the three UI groups reveal heightened vulnerability among those with frequent UI. Except for family isolation, the frequent UI group demonstrated significantly worse health conditions compared to the other groups, with over 81% reporting fair or poor health, about 47% having probable depression, and over 53% being isolated from friends. These findings suggest that the frequency of UI may be an indicator of broader health concerns, warranting further attention in health promotion efforts within senior housing settings.

Multivariate regression models indicated that UI posed a significant risk to physical and mental health. The odds of reporting fair or poor health and having probable depression were 1.94 to 7.32 times greater among those with UI compared to those without. This finding also demonstrated a dose-response effect, with the odds associated with frequent UI being substantially higher than those associated with infrequent UI. Frequent UI increases the risk of urinary tract infections, skin irritation, falls, and other comorbid conditions,10–13 all of which could contribute to a negative self-assessment of physical health and depressive symptoms. These findings corroborate the literature,10–13 confirming the physical and mental health adversities associated with UI.

Uniquely, this investigation examined social isolation as a social health outcome, distinguishing between family and friends as sources of isolation. We found that the risk of social isolation associated with UI was relevant only in relationships with friends. This finding may be interpreted in terms of the distinct social roles assumed by family and friends.17,18 The notable impact of UI on social ties with friends warrants particular attention in senior housing, where peer relationships are crucial and residential settings are proximal.26–28 The experience of UI could lead older adults to withdraw from social interactions or cause their peers to avoid or even bully them, resulting in voluntary or involuntary isolation. Additionally, the lack of association between UI and family isolation suggests that ties with family members may not be affected by UI and may continue to provide social contact and support for personal care. It is also possible that family members who do not reside with the older adult may not fully recognize the situation with UI. These findings highlight the need for active engagement of older adults, family members, friends, and co-resident peers in senior housing to promote awareness, prevention, and management of UI.

Certain limitations of our investigation should be noted. First, we adopted a cross-sectional design and used nonprobability sampling, which restricts the ability to draw causal inferences or generalize findings to a broader population. Additionally, the geographic focus on an ethnically concentrated area further limits generalizability. While the study aimed to explore the dynamics among UI and various health measures within the sample, rather than to infer population-level estimates, the inherent limitations of a non-probability sample should be considered when interpreting the findings. Second, although we conceptualized UI as a predictor of health outcomes, reversed causation is also possible. For example, physiological changes or certain medications could cause UI. Moreover, despite the recruitment efforts of the research team, potential participants with mobility and cognitive challenges, or those disconnected from their communities, might have been excluded. Additionally, the use of self-reported data could have led to an underestimation of UI prevalence due to recall and social desirability biases. Future studies should consider examining the health impacts of UI using longitudinal data and objective diagnostic measures of health. Furthermore, potential mechanisms underlying the linkage between UI and health outcomes need to be explored by identifying psychosocial and cultural factors (e.g., self-efficacy, perceived support, familism, collectivism). It is also recommended to address the interconnectedness among health measures, as they share common variance and could influence one another.

Despite these limitations, our findings highlight UI as a critical health concern in senior housing settings. Its impact on a wide range of health domains underscores the need for targeted programs and services for residents. Effective prevention, detection, and management of UI should involve both pharmacological and non-pharmacological approaches. Additionally, efforts should focus on collaboration with older residents, their families, friends, healthcare providers, and senior housing administrators. Given the misconceptions and stigmatization surrounding UI, educational programs to enhance knowledge and awareness could foster healthier and more respectful senior housing environments where medical concerns are properly addressed. For those affected by UI, intervention programs should include mental health counseling, education in hygiene management, and case management for health and social care. The cost of incontinence treatment and supplies is a concern for low-income older adults, and targeted approaches are necessary, especially for those with severe physical and cognitive impairments.

Funding:

Data collection was supported by a grant from the National Institute of Dental and Craniofacial Research (R21DE029579, PI: Yuri Jang, PhD).

Footnotes

Conflict of Interest: There are no potential conflicts of interest for all authors. No financial disclosures were reported by the authors of this paper.

Human Participants: The study was approved by the University of Southern California Institutional Review Board (UP-23–00115).

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