Ethnic and Racial Social Identity, Socioeconomic Position, and Women’s Bladder Health

Abstract

To inform policies and programs designed to prevent lower urinary tract symptoms (LUTS) and promote bladder health among different social groups, this research utilized RISE FOR HEALTH data to examine potential health inequities in LUTS and bladder health by different indices of socioeconomic position, as well as ethnic and racial social identity. Data were collected in 2022–2023 from 3,322 adult women from nine regions of the United States. Higher socioeconomic position—regardless of whether it was measured as education, percent federal poverty level, or health insurance coverage and type—was associated with fewer, less frequent LUTS and better bladder health independent of ethnic and racial identity. These findings are consistent with the broader literature on LUTS, while also extending this literature to encompass different facets of bladder health, including perceived impact of bladder health status on social and occupational activities, physical activity, travel, and emotions. Poorer bladder health among women of Hispanic ethnic identity relative to Non-Hispanic White women appeared to be largely driven by socioeconomic disadvantage. Independent of socioeconomic position, women who identified as Non-Hispanic Black or Non-Hispanic Asian reported better bladder health relative to Non-Hispanic White women. Future qualitative research may be useful in identifying health promoting attitudes, behavioral habits, and intergenerational messages about caring for the bladder that can be incorporated into health promotion programs tailored to women’s ethnic and racial identity, as well as universal programs. Consistent with the World Health Organization’s Conceptual Framework for Action on Social Determinants of Health (Solar & Irwin, 2010), findings highlight the importance of policies that ensure equitable access to health promoting resources, including education, poverty-alleviating assistance, and high-quality health care.

Lower urinary tract symptoms (LUTS) include frequent and/or urgent urination, urgency urinary incontinence (UUI; strong urge “to go” with urine loss before reaching a toilet), stress urinary incontinence (SUI; urine loss with physical activity or increases in abdominal pressure such as a cough or sneeze), nocturnal enuresis (urine loss while asleep), difficulty urinating, dribbling after urination, and bladder or urethral pain before, during, or after urination (Cardozo et al., 2023a). LUTS are common among women. For example, the prevalence of overactive bladder (OAB), characterized by urgent and often frequent urination, with or without incontinence (Cardozo et al., 2023a), ranges between 15% and 33% in samples of adult women in the United States (U.S.) and Europe (Reynolds et al., 2016).

The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium was established in 2015 by the U.S. National Institutes of Health to expand research beyond the detection and treatment of LUTS to the prevention of LUTS and promotion of bladder health among girls and women (Harlow et al., 2018). Consistent with the WHO definition of health (World Health Organization, 2020), the PLUS Research Consortium defines bladder health as “a complete state of physical, mental, and social wellbeing related to bladder function, and not merely the absence of LUTS,” with function that “permits daily activities, adapts to short term physical or environmental stressors, and allows optimal well-being (e.g., travel, exercise, social, occupational, or other activities)” (Lukacz et al., 2018).

Potential Social Determinants of Bladder Health

As with any facet of health, bladder health may be influenced by the social ecology in which individuals are embedded. Social determinants of health (SDoH) have been defined as the conditions in which people are born, grow, learn, work, play, live, and age, as well as the wider set of structural factors shaping conditions of daily life (NIH-Wide Social Determinants of Health Research Coordinating Committee, n.d.). The World Health Organization (WHO) established a Commission on SDoH to summarize evidence for how the structure of societies—through governance, policies, culture, and values—determines the health of populations (Solar & Irwin, 2010). The WHO Framework for Action on SDoH asserts that societies stratify their populations according to gender, ethnicity, race, education, occupation, income, and other social factors (Solar & Irwin, 2010). These stratifications are often rooted in sexism, racism, classism, and other discriminatory systems. Resulting social hierarchies are embedded within different societal structures (e.g., schools, workplaces, health systems). Social hierarchy position in turn shapes exposure to health promoting and health constraining SDoH. A key implication of the WHO Framework is that governments are responsible for the social production of health and disease, and therefore responsible for remedying health inequities through policy and programs (Solar & Irwin, 2010).

Potential LUTS and Bladder Health Inequities by Ethnic or Racial Identity and Socioeconomic Position

The WHO Framework for Action on SDoH suggests that social identity (e.g., ethnic and racial identity) and socioeconomic position (SEP) (e.g., education) can be viewed as proxies for the degree to which a society confers opportunities for or constraints against health for specific groups of people. Studies have documented disparities in cancer, cardiovascular disease, kidney disease, diabetes, and obesity on the basis of socially-defined demographic variables (i.e., ethnic or racial social identity) and SEP (Cleveland et al., 2023; Havranek et al., 2015; Norton et al., 2016; Zavala et al., 2021). There are a limited number of studies that have centered the examination of ethnicity, race, or SEP in relation to LUTS or bladder health among community-dwelling women. In the U.S., LUTS appear to be less prevalent among Asian women in comparison to women of other ethnic and racial identities (Patel et al., 2022; Thom et al., 2006; Waetjen et al., 2007). Results are mixed with respect to differences in LUTS between women who identify as Black, Hispanic, or White (Coyne et al., 2012; Patel et al., 2022; Thom et al., 2006). Higher SEP is consistently associated with less frequent LUTS (Lin et al., 2021; Manso et al., 2023; Sebesta et al., 2022; Tellechea et al., 2021; Zwaschka et al., 2022) and better bladder health (Brady et al., 2024b; Markland et al., 2021).

Inconsistent associations of ethnic and racial identity with LUTS across studies may be due to different, unadjusted for SEP compositions among ethnic and racial groups or to unaccounted for interactions between ethnic/racial identity and SEP. Intersectionality is used as an analytic framework for understanding how aspects of a person’s social identities combine to position the person for different experiences of discrimination and privilege (Runyan, 2018). Associations between SEP and health may be different depending on social identity. For example, a more favorable SEP may benefit health to a lesser degree or fail to confer benefits if one’s social identity (e.g., ethnicity or race) is less valued by prevailing society (Chen et al., 2022; Lewis et al., 2015).

The Present Study

The present study utilizes data from adult women in the U.S. to address the following research questions: (1) Are ethnic and racial identity associated with LUTS and bladder health? (2) Are different indices of SEP associated with LUTS and bladder health? (3) Does ethnic and racial identity modify associations of different indices of SEP with LUTS and bladder health?

Materials and Methods

Procedure

RISE FOR HEALTH.

RISE methods have been previously described (Smith et al., 2023). The University of Minnesota Institutional Review Board (IRB) served as the single IRB of record. Eligible individuals were 18 years or older, born or currently identified as female, and from the civilian, noninstitutionalized population residing in 50 U.S. counties including or surrounding nine PLUS recruitment sites. Potential participants were identified through a marketing database and selected through a combination of simple and stratified random sampling to match population-based estimates of specific race, ethnicity, and age groups across the counties. Participants were recruited using personalized mailings in both English and Spanish. At baseline, participants completed self-administered surveys sent by mail or email. Baseline data were collected between May 2022 and December 2023. The response rate was 7.9% among invitations sent to valid addresses.

Measures

Ethnicity and Race.

Participants were asked, “Are you of Hispanic, Latina/x or Spanish origin?” followed by the question, “How would you describe your race/ethnicity?” Response options for the latter question were as follows: American Indian or Alaska Native; Asian; Black or African American; Middle Eastern or North African; Native Hawaiian or Other Pacific Islander; White or Caucasian; and Other Race, Ethnicity, or Origin. Through close-ended and open-ended questions, participants had the option of further describing their Hispanic, Latina/x or Spanish; tribal; and other racial or ethnic origins. Mutually exclusive categories for a combined ethnicity and race composite variable are shown in Table 1. Responses to questions were used to appropriately categorize participants. Sample size limited the number of groups with distinct social identities that could be formed.

Table 1.

Distributions of participant characteristics and study variables within the total analytic sample.

Participant Characteristic	Total Analytic Sample (n=3,126)
Social Identity and Demographic Variables Ethnic and Racial Social Identity, n (%)
Hispanic, Any Race	468 (15.4)
Non-Hispanic Asian	183 (6.0)
Non-Hispanic Black	376 (12.4)
Non-Hispanic White	1918 (63.0)
Non-Hispanic Other Racial Identity	30 (1.0)
Non-Hispanic Multiple Racial Identities   Missing n=83	68 (2.2)
Age, M (SD)   Missing n=4	51.1 (18.3)
Gender Identity, n (%)
Woman	3092 (99.2)
Transgender Woman	0 (0.0)
Other	24 (0.8)
Missing n=10
Female Sex Assigned at Birth, n (%)   Missing n=0	3126 (100.0)
Cisgender Female, n (%)   Missing n=10	3092 (99.2)
Language(s) Spoken at Home, n (%)
English	3042 (98.2)
Spanish	298 (9.6)
Another Language   Missing n=27	133 (4.3)
Socioeconomic Position Variables Education, n (%)
High school/GED or less	413 (13.3)
Some college or vocational training	512 (16.5)
Vocational or associate degree	396 (12.8)
Bachelor’s degree	1003 (32.4)
Graduate degree after college   Missing n=30	772 (24.9)
Income Relative to Household Size b Percent FPL, M (SD)   Missing n=657	452.2 (322.7)
Percent FPL, Categorical, n (%)
At or below 100%	251 (10.2)
At or below 200%, above 100%	357 (14.5)
At or below 300%, above 200%	361 (14.6)
At or below 400%, above 300%	254 (10.3)
At or below 500%, above 400%	346 (14.0)
At or below 600%, above 500%	157 (6.4)
At or below 700%, above 600%	272 (11.0)
At or below 800%, above 700%	116 (4.7)
Above 800%	355 (14.4)
Missing n=657
Insurance Coverage & Type, n (%)
No health insurance	124 (4.0)
Medicaid only	202 (6.5)
Medicare without supplemental health insurance	250 (8.0)
Medicare with supplemental health insurance besides Medicaid	395 (12.7)
Medicare and Medicaid	81 (2.6)
Tricare, other military health care, VA health care, or IHS (with or without supplemental health insurance)	26 (0.8)
Private health insurance	1892 (60.8)
Other   Missing n=15	141 (4.5)
Usual Source of Health Care, Illness, n (%)   Missing n=15 Usual Source of Health Care, Prevention, n (%)   Missing n=17	2960 (95.1) 2992 (96.2)
Parity
Overall Parity, M (SD)   Missing n=66	1.2 (1.5)
Vaginal Parity, M (SD)   Missing n=65	1.0 (1.4)
Comorbid Conditions BMI of 30 or above, n (%)   Missing n=195	994 (33.9)
Hypertension, n (%)   Missing n=12	1046 (33.6)
Diabetes, n (%)   Missing n=30	349 (11.3)
Kidney Failure, n (%)   Missing n=97	37 (1.2)
Neurologic Disease, n (%) c   Missing n=84	377 (12.4)
Outcome Variables, M (SD) LURN SI-10 Score   Missing n=22	5.5 (5.1)
PLUS Global Bladder Health Scale   Missing n=9	67.9 (20.1)
Impact of Bladder Health Status
Social and Occupational Impact   Missing n=15	90.2 (15.7)
Physical Activity Impact   Missing n=24	83.6 (24.5)
Travel Impact   Missing n=13	81.2 (19.7)
Emotional Impact   Missing n=10	82.7 (21.6)

^aOther gender identities included “man,” “non-binary,” “transgender man,” “queer,” “gender non-binary/gender nonconforming,” “agender,” “bigender,” and “other.”

^bHousehold size among the total sample ranged between 1 and 10, with a median household size of 2.

^cNeurologic disease includes the following conditions: history of neurogenic bladder; stroke or cerebrovascular accident; TIA (Transient Ischemic Attack), mini-stroke, or warning stroke; multiple sclerosis; Parkinson’s disease; brain or spinal cord injury, including traumatic brain injury; spina bifida; spinal stenosis, spinal disc disease, spinal nerve damage, or sciatica; or mild cognitive impairment or memory loss.

Socioeconomic Position.

Education, health insurance coverage and type, household income as a percentage of the federal poverty level (FPL), and having a usual source of health care were examined as proxies for SEP. Categories for education and health insurance coverage and type are shown in Table 1. Percent of Federal Poverty Level (FPL) is based on two self-reported variables—income, an ordinal variable with 13 categories, and number of people in the household. Percent of FPL was found by taking the midpoint of the selected income category, dividing this value by the 2023 FPL threshold corresponding to the participant’s stated household size, and multiplying this result by 100 (U.S. Centers for Medicare & Medicaid Services, n.d.) (see Supplemental Appendix A for further details). Resulting percent of FPL values were examined as a continuous variable in analyses. Two questions assessed usual source of health care: “Is there a place that you usually go when you are sick or you need advice about your health?” and “Is there a place that you usually go when you need routine or preventive care, such as a physical examination or check up?”. Dichotomous variables were created for each question (illness, prevention): having at least one place versus no place.

LUTS.

The 10-item Symptoms of Lower Urinary Tract Dysfunction Research Network-Symptom Index (LURN SI-10) was administered to assess urinary frequency, nocturia, urgency, incontinence, bladder pain, voiding, and post-micturition symptoms (possible score range, 0–38) (Cella et al., 2020).

Bladder Health.

Five PLUS Research Consortium bladder health scales were examined (Constantine et al., 2022), including global bladder health (6 items; e.g., How would you rate the function of your bladder?) and perceived impact of bladder health on social-occupational activities (6 items; e.g., spending time with friends, meeting day-to-day obligations), physical activity (3 items; e.g., lifting or carrying things, exercising), travel (3 items; e.g., getting around town, long distance traveling), and emotions (5 items; e.g., enjoying life less, lacking confidence). All scales are based on women’s perceived bladder health and are scored on a continuum, with 0 indicating the worst health and 100 indicating the best health.

Analytic Approach

The analytic sample was composed of participants with no missing data for a given analysis. RISE encouraged participation by all women, including gender identity minorities (Smith et al., 2023). Table 1 shows that 99% of the analytic sample may be categorized as cisgender female. Participants were excluded from the analytic sample if they did not report being assigned female at birth or identifying as a woman or transgender woman (n=15) or reported receiving a surgery relevant to bladder function (removal of bladder, childhood surgery to correct bladder problems) (n=2 and n=31, respectively), a history of radiation treatment in the abdominal, pelvic, or lower back area (n=23), a history of catheter use (not including the first few days after childbirth or a surgery) (n=71), or restrictions to mobility (required assistance to use a toilet) (n=172). A total of 296 participants were removed from the analytic sample as a result, leaving 3,126.

Preliminary analyses examined characteristics of the analytic sample and distributions of SEP and outcome variables, both within the total sample and by ethnic/racial identity categories. Next, scores for the LURN-10 symptom index and each of the 5 bladder health scales were separately regressed on ethnicity/race and each SEP variable. In analyses examining ethnic and racial identity, Non-Hispanic White women were selected as a comparison group. Relative to women of other ethnic and racial social identities in the U.S., Non-Hispanic White women often have more favorable health outcomes (Odlum et al., 2020). To test for potential interactions (i.e., intersectionality), an additional set of models included an interaction between ethnicity/race and a single SEP variable. Robust variance estimation was used to calculate confidence intervals and p-values. The Holm procedure was used to adjust for multiple comparisons (Holm, 1979). Due to their primary focus, results for main effects are reported before and after adjustment for multiple comparisons; due to their secondary focus, results for interaction effects are reported after adjustment for multiple comparisons. All analyses were conducted using R version 4.2.0 (R Core Team, 2022).

Covariates.

Regression analyses adjusted for age and vaginal parity, known LUTS risk factors (Cardozo et al., 2023b). Age was examined as a continuous variable. If women reported ever giving birth, they were asked to provide the number of cesarean and vaginal deliveries. Vaginal parity was examined as a 4-level ordinal variable (0, 1, 2, 3 or more). A limited approach to covariate adjustment was adopted because some factors could conceivably lie on a causal pathway between social identity or SEP and LUTS or bladder health. In a sensitivity test, regression analyses were adjusted for the following comorbid conditions: BMI of 30 or above and self-reported hypertension, diabetes, kidney failure, and neurologic disease.

Imputation.

In an additional sensitivity analysis, missing income and percent FPL values were imputed using an ensemble machine learning algorithm on participant demographic data and American Community Survey (United States Census Bureau, n.d.) financial data for participants’ zip code. All results for associations involving percent FPL remained unchanged when using imputed missing values.

Results

Table 1 contain the percentages of participants categorized into different ethnic/racial groups. Supplemental Appendix B contains specific identities of participants categorized into the Hispanic, Any Race; Non-Hispanic Other Racial Identity; and Non-Hispanic Multiple Racial Identities groups due to small sample sizes. The mean age of the total analytic sample was 51.5 years (SD=18.3) (Table 1). Over half of the sample reported no vaginal births (55.9%); 10.8%, 17.5%, and 13.5% reported 1, 2, and 3 or more vaginal births, respectively (not shown in table). Rates of BMI≥30 and reported hypertension were both over 30% and rates of reported diabetes and neurologic disease were both over 10%.

Supplemental Tables 1 and 2 show participant characteristics and study variables by ethnic and racial social identity. Lower percentages of Hispanic and Non-Hispanic Black participants were in the bachelor’s degree or graduate degree groups compared to Non-Hispanic Asian and Non-Hispanic White participants. In addition, a higher percentage of Non-Hispanic Asian participants were in the graduate degree group compared to Non-Hispanic White participants. Similarly, mean percent FPL (i.e., income relative to household size) was markedly lower for Hispanic participants (343%) and Non-Hispanic Black participants (323%), compared to other groups; Non-Hispanic Asian participants had the highest mean percent FPL (557%). The percentage of participants with private health insurance was lowest among Hispanic and Non-Hispanic Black participants and highest among Non-Hispanic Asian participants. The percentages of participants with no health insurance or Medicaid only were highest among Hispanic participants. The percentages of participants with Medicare, without supplemental insurance, or Medicare and Medicaid, combined, were highest among Non-Hispanic Black participants. Ethnic/racial differences in LUTS and bladder health were not as marked as differences in SEP (Supplemental Table 2).

Table 2 contains results from planned regressions of the LURN SI-10 LUTS score (possible range of 0–38) and different bladder health scores (possible range of 0–100) on ethnic/racial identity and SEP variables, adjusted for age and vaginal parity. Values in the table represent mean differences in scores between groups. In comparison to Non-Hispanic White participants, Hispanic participants of any race had a higher LURN SI-10 score; they also had lower scores for perceived positive impact of bladder health on social-occupational activities, physical activities, and emotions. Compared to Non-Hispanic White participants, Non-Hispanic Asian participants had a lower LURN SI-10 score; they also had a higher score for perceived global bladder health. Compared to Non-Hispanic White participants, Non-Hispanic Black participants had a similar LURN SI-10 score, higher scores for perceived global bladder health and positive impact on physical activity, and a lower score for positive impact on social-occupational activities.

Table 2.

Regressions of LUTS symptom index and bladder health scale scores on ethnic/racial identity and socioeconomic position variables, adjusting for age and vaginal parity. ^a

	Mean Difference in Symptom Index or Bladder Health Scale Score
Ethnic and Racial Identity or Socioeconomic Position Variable	LURN SI-10 Score	Global Scale	Social-Occupational Scale	Physical Activity Scale	Travel Scale	Emotional Scale
	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)
Ethnic and Racial Identity
(reference group, Non-Hispanic White) b
Hispanic, Any Race	0.7 (0.1, 1.3)	−0.1 (−2.2, 2.0)	−3.8 (−5.6, −2.0) c	−4.1 (−6.8, −1.4)	−1.6 (−3.7, 0.6)	−3.3 (−5.6, −0.9)
Non‐Hispanic Asian	−1.5 (−2.1, −0.9) c	4.2 (1.5, 7.0)	−1.6 (−4.0, 0.8)	1.0 (−2.2, 4.2)	−0.9 (−3.9, 2.2)	−0.6 (−3.8, 2.5)
Non‐Hispanic Black	0.2 (−0.4, 0.9)	2.5 (0.3, 4.8)	−2.6 (−4.5, −0.7)	3.0 (0.4, 5.6)	−1.0 (−3.4, 1.4)	0.7 (−1.7, 3.0)
Non‐Hispanic Other Racial Identity	1.2 (−1.0, 3.4)	−6.3 (−13.9, 1.4)	−5.6 (−12.4, 1.2)	−4.6 (−13.8, 4.7)	−4.9 (−14.2, 4.4)	−3.1 (−10.3, 4.2)
Non‐Hispanic Multiple Racial Identities	0.8 (−0.6, 2.2)	−1.7 (−6.5, 3.0)	−3.5 (−8.5, 1.4)	2.3 (−2.2, 6.9)	−1.7 (−7.3, 3.8)	−3.6 (−9.4, 2.3)
Education
(reference group, graduate degree after college)
High school/GED or less	1.6 (0.9, 2.3) c	−0.7 (−3.1, 1.8)	−4.2 (−6.3, −2.2) c	−7.7 (−10.8, −4.6) c	−0.6 (−3.1, 1.8)	−5.2 (−8.0, −2.5) c
Some college or vocational training	1.7 (1.1, 2.3) c	−3.6 (−5.9, −1.2)	−3.4 (−5.3, −1.6) c	−7.7 (−10.5, −4.9) c	−1.0 (−3.3, 1.2)	−5.3 (−7.8, −2.8) c
Vocational degree or associate degree	1.1 (0.5, 1.8) c	−1.0 (−3.5, 1.4)	−2.9 (−4.8, −0.9)	−5.9 (−9.0, −2.9) c	−1.2 (−3.7, 1.3)	−2.8 (−5.5, −0.2)
Bachelor’s degree	−0.0 (−0.5, 0.4)	0.6 (−1.3, 2.5)	0.8 (−0.5, 2.1)	−0.7 (−2.7, 1.3)	0.5 (−1.3, 2.3)	0.6 (−1.3, 2.5)
% FPL by 100 (continuous variable)	−0.3 (−0.3, −0.2) c	0.5 (0.3, 0.8) c	0.9 (0.7, 1.1) c	0.9 (0.6, 1.1) c	0.6 (0.3, 0.8) c	1.0 (0.7, 1.2) c
Health Insurance Coverage and Type
(reference group, private insurance)
No health insurance	1.8 (0.5, 3.0)	0.7 (−2.7, 4.2)	−4.9 (−8.4, −1.4)	−3.9 (−8.1, 0.4)	−5.3 (−9.6, −0.9)	−3.6 (−7.6, 0.5)
Medicaid only	2.6 (1.6, 3.6) c	−4.9 (−8.2, −1.7)	−9.4 (−12.4, −6.4) c	−7.6 (−11.4, −3.8) c	−3.8 (−7.0, −0.5)	−10.6 (−14.3, −6.9) c
Medicare without supplemental health insurance	0.7 (−0.0, 1.5)	−3.6 (−6.7, −0.5)	−3.9 (−6.3, −1.4)	−3.7 (−7.6, 0.3)	−3.3 (−6.1, −0.4)	−2.8 (−6.0, 0.4)
Medicare with supplemental health insurance besides Medicaid	0.3 (−0.2, 0.9)	−3.1 (−5.6, −0.6)	−1.7 (−3.6, 0.3)	2.9 (−0.2, 5.9)	−4.0 (−6.4, −1.5)	−0.6 (−3.3, 2.0)
Medicare and Medicaid	1.7 (0.1, 3.3)	−1.2 (−6.2, 3.7)	−6.9 (−12.0, −1.9)	−4.4 (−10.2, 1.4)	−5.4 (−11.0, 0.1)	−6.4 (−11.9, −0.9)
Tricare, other military health care, VA health care, IHS, or other insurance	0.6 (−0.3, 1.5)	−0.6 (−3.8, 2.6)	−3.3 (−6.0, −0.5)	−1.8 (−5.8, 2.2)	−2.0 (−5.3, 1.4)	−2.5 (−6.0, 1.0)
Usual Source of Health Care, Illness (yes versus no)	−0.3 (−1.2, 0.7)	1.8 (−1.5, 5.2)	3.1 (0.1, 6.1)	4.2 (0.2, 8.3)	1.6 (−1.9, 5.1)	5.3 (1.3, 9.3)
Usual Source of Health Care, Prevention (yes versus no)	−0.2 (−1.3, 0.9)	2.6 (−1.3, 6.6)	1.7 (−1.7, 5.1)	0.9 (−3.7, 5.5)	−0.6 (−4.5, 3.4)	3.5 (−1.0, 8.0)

^aScores were separately regressed on ethnicity/race and each SEP variable. Higher scores on all bladder health scales indicate better health.

^bThe reference group is Non-Hispanic White (no other endorsed race). Participants coded into the Non-Hispanic Asian, Non-Hispanic Black, and non-Hispanic White categories endorsed no other race.

^cThis association was significant after adjustment for multiple comparisons.

In comparison to participants who reported having a graduate degree, participants who reported that their highest level of education was high school or a GED, some college or vocational training, or a vocational or associate degree had higher LURN SI-10 scores and lower scores for perceived positive impact of bladder health on social-occupational activities, physical activities, and emotions. For each 100 percent higher FPL score, participants had a lower LURN SI-10 score and higher scores for perceived global bladder health and perceived positive impact of bladder health on social-occupational activities, physical activities, travel activities, and emotions. In comparison to participants with private insurance, participants with no health insurance, Medicaid only, and both Medicare and Medicaid had higher LURN SI-10 scores. Additionally, participants with Medicaid only had lower scores for perceived global bladder health and positive impact of bladder health on all domains. Participants with Medicare, without supplemental insurance or with supplemental insurance besides Medicaid, had lower scores for perceived global bladder health and positive impact of bladder health on travel activities. Participants with a usual source of care for illness had higher scores for perceived positive impact of bladder health on social-occupational activities, physical activities, and emotions.

Due to the marked differences in SEP that were observed by ethnic/racial identity (Supplemental Table 2), additional regression analyses were conducted in which ethnic/racial identity and SEP were mutually adjusted (Table 3). Associations between Hispanic ethnicity and the LURN SI-10 and bladder health physical activity and emotional impact scales became non-significant after adjustment for SEP variables; Hispanic ethnicity remained associated with less positive impact on social-occupational activities. Non-Hispanic Black social identity was no longer associated with perceived positive impact of bladder health on social-occupational activities, remained associated with perceived global bladder health and positive impact on physical activities, and was now associated with positive impact on emotions. SEP variables (education, percent FPL, health insurance coverage and type, and usual source of care for illness) were associated with the LURN SI-10 and bladder health scales in largely the same way before and after adjustment for ethnic and racial identity, with some attenuation of the magnitude of associations (see Table 2 and Table 3, respectively).

Table 3.

Regressions of LUTS symptom index and bladder health scale scores on ethnic/racial identity, adjusting for socioeconomic position variables, age, and vaginal parity, and on socioeconomic position variables, adjusting for ethnic/racial identity, age, vaginal parity.

	Mean Difference in Symptom Index or Bladder Health Scale Scorea
Ethnic and Racial Identity or Socioeconomic Position Variable	LURN SI-10 Score	Global Scale	Social-Occupational Scale	Physical Activity Scale	Travel Scale	Emotional Scale
	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)	b (95% CI)
Ethnic and Racial Identity
(reference group, Non-Hispanic White) b
Hispanic, Any Race	−0.0 (−0.7, 0.7)	0.8 (−1.6, 3.2)	−2.3 (−4.3, −0.3)	−2.1 (−5.2, 1.0)	−0.8 (−3.3, 1.6)	−0.8 (−3.5, 1.8)
Non‐Hispanic Asian	−1.3 (−1.9, −0.7) c	4.2 (1.1, 7.2)	−1.8 (−4.5, 0.9)	0.9 (−2.8, 4.5)	−0.1 (−3.5, 3.2)	−0.9 (−4.4, 2.7)
Non‐Hispanic Black	−0.6 (−1.3, 0.1)	4.1 (1.6, 6.7)	0.4 (−1.7, 2.4)	6.8 (3.8, 9.8) c	0.7 (−2.0, 3.3)	4.1 (1.6, 6.7)
Non‐Hispanic Other Racial Identity	−0.4 (−2.4, 1.7)	0.2 (−9.5, 10.0)	0.8 (−4.9, 6.5)	−1.8 (−14.1, 10.6)	−2.4 (−14.4, 9.6)	−0.4 (−11.2, 10.4)
Non‐Hispanic Multiple Racial Identities	0.6 (−0.8, 2.0)	−1.9 (−7.1, 3.3)	−3.0 (−7.9, 1.9)	2.1 (−2.7, 6.9)	−1.1 (−6.7, 4.5)	−2.8 (−8.8, 3.2)
Education
(reference group, graduate degree after college)
High school/GED or less	1.5 (0.8, 2.2) c	−1.0 (−3.5, 1.6)	−4.0 (−6.1, −1.9) c	−7.8 (−11.1, −4.6) c	−0.7 (−3.2, 1.8)	−5.5 (−8.3, −2.7) c
Some college or vocational training	1.6 (1.0, 2.3) c	−3.5 (−6.0, −1.1)	−3.1 (−5.0, −1.2)	−7.5 (−10.4, −4.6) c	−0.9 (−3.2, 1.5)	−5.2 (−7.8, −2.7) c
Vocational degree or associate degree	1.0 (0.4, 1.6)	−0.9 (−3.4, 1.6)	−2.6 (−4.6, −0.6)	−6.3 (−9.4, −3.2) c	−1.1 (−3.6, 1.5)	−3.0 (−5.6, −0.3)
Bachelor’s degree	−0.1 (−0.5, 0.3)	0.7 (−1.2, 2.6)	0.8 (−0.5, 2.2)	−0.6 (−2.6, 1.5)	0.6 (−1.2, 2.4)	0.6 (−1.3, 2.5)
% FPL by 100 (continuous variable)	−0.2 (−0.3, −0.2) c	0.6 (0.3, 0.8) c	0.8 (0.7, 1.0) c	0.9 (0.6, 1.2) c	0.6 (0.3, 0.8) c	1.0 (0.8, 1.3) c
Health Insurance Coverage and Type
(reference group, private insurance)
No health insurance	1.8 (0.5, 3.1)	0.2 (−3.4, 3.8)	−4.4 (−7.9, −0.8)	−4.2 (−8.8, 0.3)	−5.8 (−10.3, −1.3)	−3.7 (−8.0, 0.6)
Medicaid only	2.7 (1.7, 3.8) c	−5.6 (−8.9, −2.3)	−9.0 (−12.0, −5.9) c	−8.0 (−11.8, −4.1) c	−3.7 (−7.0, −0.3)	−10.9 (−14.8, −7.1) c
Medicare without supplemental health insurance	0.6 (−0.1, 1.4)	−3.6 (−6.7, −0.5)	−3.3 (−5.7, −0.9)	−3.2 (−7.2, 0.7)	−3.1 (−6.1, −0.2)	−2.5 (−5.7, 0.8)
Medicare with supplemental health insurance besides Medicaid	0.3 (−0.3, 0.9)	−3.0 (−5.6, −0.5)	−1.9 (−3.8, 0.1)	3.0 (−0.1, 6.1)	−4.2 (−6.7, −1.7)	−0.7 (−3.4, 1.9)
Medicare and Medicaid	1.9 (0.3, 3.6)	−1.4 (−6.5, 3.6)	−6.5 (−11.7, −1.2)	−5.4 (−11.5, 0.6)	−5.1 (−10.8, 0.6)	−6.6 (−12.3, −1.0)
Tricare, other military health care, VA health care, IHS, or other insurance	0.5 (−0.4, 1.5)	−0.7 (−3.9, 2.6)	−2.7 (−5.3, 0.0)	−2.0 (−6.2, 2.2)	−1.8 (−5.2, 1.6)	−3.2 (−6.9, 0.5)
Usual Source of Health Care, Illness (yes versus no)	−0.4 (−1.4, 0.5)	2.4 (−1.0, 5.9)	3.0 (0.0, 5.9)	4.3 (0.1, 8.5)	1.4 (−2.1, 4.9)	5.5 (1.5, 9.6)
Usual Source of Health Care, Prevention (yes versus no)	−0.3 (−1.5, 0.8)	3.2 (−0.9, 7.3)	1.6 (−1.9, 5.1)	0.9 (−3.8, 5.6)	−0.8 (−4.8, 3.3)	3.9 (−0.7, 8.6)

^aHigher scores on all bladder health scales indicate better health.

^bThe reference group is Non-Hispanic White (no other endorsed race). Participants coded into the Non-Hispanic Asian, Non-Hispanic Black, and non-Hispanic White categories endorsed no other race.

^cThis association was significant after adjustment for multiple comparisons.

Supplemental Tables 3 and 4 contain the results of a sensitivity test in which regression analyses of were further adjusted for comorbid conditions. Of 49 significant associations from Table 2 (LUTS and bladder health regressed on ethnic/racial identity and SEP, separately), 15 were no longer significant and one newly significant association emerged (Supplemental Table 3). Of 44 significant associations from Table 3 (LUTS and bladder health regressed on ethnic/racial identity and SEP, mutually adjusted), 11 were no longer significant and one newly significant association emerged (Supplemental Table 4). Interaction tests between ethnic/racial identity and SEP variables were not statistically significant when taking into account multiple comparisons.

Discussion

Associations of Ethnic and Racial Identity with Women’s LUTS and Bladder Health.

Associations differed depending on whether education, percent federal poverty level (FPL), health insurance coverage and type, and usual source of care were adjusted for in analyses. Prior to adjustment, women of any race who identified as Hispanic had higher LUTS scores and lower scores on perceived positive impact of bladder health status on social-occupational activities, physical activities, and emotions. All associations except that for social-occupational activities were reduced to non-significance after adjustment for SEP variables, suggesting that lower SEP of Hispanic women largely explained poorer bladder health relative to Non-Hispanic White women. One implication is that educational, financial, and medical care coverage, quality, and access barriers should be ameliorated to prevent LUTS and promote bladder health among Hispanic women living in the U.S. Other factors associated with Hispanic social identity (e.g., exposure to discrimination) may possibly explain less perceived positive impact of bladder health status on social-occupational activities.

After adjustment for SEP variables, Non-Hispanic Black women had higher scores on perceived global bladder health and positive impact of bladder health on physical activity and emotions. Associations may have reflected positive attitudes and feelings towards one’s bladder and its impact on the ability to engage in physical activity and feel good about oneself and one’s life, relative to the attitudes and feelings of Non-Hispanic White women. This finding is notable given that Non-Hispanic Black and White women had similar LUTS scores. In a previous study of LUTS among U.S. women, Black women perceived OAB to be less of a problem in comparison to White and Hispanic women, despite having a similar rate of OAB (Coyne et al., 2012). Such views may make it less likely that Black women seek treatment for mild to moderate LUTS. However, positive attitudes and feelings towards one’s body and health status may also be an asset in framing prevention and health promotion efforts, including seeking treatment for LUTS in order to preserve and potentially improve one’s current health status.

Lastly, in the present study, associations of Non-Hispanic Asian identity with LUTS and bladder health were the same regardless of adjustment for SEP. Compared to Non-Hispanic White women, Non-Hispanic Asian women had lower LUTS scores and higher scores on perceived global bladder health. This finding is consistent with previous literature among women from the U.S. showing lower prevalence of LUTS among Asian women in comparison to White women (Thom et al., 2006; Waetjen et al., 2007) and women of different ethnic and racial identities (Patel et al., 2022). Qualitative research among Non-Hispanic Asian women may yield information about bladder health habits that can be used to design tailored and universal health promotion programs. It may also be that Non-Hispanic Asian women have fewer risk factors for LUTS in comparison to women of other ethnic and racial identities (e.g., lower versus higher body mass index; Coyne et al., 2012; Thom et al., 2006).

In previous literature, results have been mixed with respect to differences in LUTS between U.S. women who identify as Black, Hispanic, or White. In population-based studies, White women have been found to have higher rates of urinary incontinence (UI) in the past 12 months in comparison to Black and Hispanic women (Patel et al., 2022; Waetjen et al., 2007), or to have similar rates of OAB in the past month (Coyne et al., 2012). In a random sample of women who were members of the Kaiser Permanente Medical Care Program in Northern California, prevalence of weekly UI was estimated to be greatest among women who identified as Hispanic, followed by women who identified as White, Black, and then Asian (Thom et al., 2006). Thom et al. (2006) did not compare rates of LUTS among women of differing ethnic and racial identities after adjusting for SEP; Patel et al. (2022), Waetjen et al. (2007), and Coyne et al. (2012) adjusted for education, but not other SEP. Because SEP may covary with ethnic and racial social identity, future research should measure and assess independent associations of both variables with LUTS and bladder health. Future research should also consider how ethnic and racial social identity may be associated with trajectories of LUTS and bladder health. In the U.S. Study of Women’s Health Across the Nation, African American women were more likely and Chinese, Japanese, and Hispanic women were less likely to develop incident monthly UUI over a 5-year period in comparison to White women (Waetjen et al., 2007).

Further, additional research on LUTS and bladder health is needed to understand the lived experiences for which ethnic and racial social identity may be a proxy, such as marginalization and discrimination (Brady et al., 2024a; Nseyo et al., 2021; Williams et al., In Press). The present study suggests that SEP is important to consider, in addition to other facets of lived experiences that may reflect interpersonal, institutional, and structural racism. Cultural norms and assets among different ethnic and racial communities are also important to consider (Williams et al., In Press).

Associations between Socioeconomic Position and Women’s LUTS and Bladder Health.

SEP variables were associated with LUTS and bladder health scores in largely the same way before and after adjustment for ethnic and racial identity. Higher SEP—regardless of whether it was measured as education, percent FPL, or health insurance coverage and type—was associated with fewer and less frequent LUTS and better bladder health independent of ethnic and racial identity. In addition, having a usual source of care for illness was associated with better perceived impact of bladder health on physical activities and emotions. These findings are consistent with the broader literature on associations of SEP, financial strain, and unmet social needs with LUTS. Previous literature has shown that lower levels of education (Lin et al., 2021; Manso et al., 2023) and income (Lin et al., 2021; Manso et al., 2023) and lack of home ownership (Lin et al., 2021) are associated with UI among women. Studies have also found that financial strain and unmet social needs, including financial insecurity, food insecurity, housing insecurity, unreliable transportation, and difficulty finding and keeping employment, are associated with OAB (Sebesta et al., 2022; Tellechea et al., 2021; Zwaschka et al., 2022), SUI (Zwaschka et al., 2022), UUI (Lee et al., 2020; Zwaschka et al., 2022), and other LUTS (Zwaschka et al., 2022) in samples of women or women and men, combined. Little research has examined SEP in relation to the more holistic concept of bladder health. In one study of women from four regions of the U.S., women with more education had better bladder health, defined as no LUTS or only mild LUTS with no negative impact on well-being. (Markland et al., 2021). In the same sample, financial strain over a 25-year period was associated with worse bladder health (Brady et al., 2024b).

The present study extends the literature with respect to the manner in which SEP was examined, as well as the inclusion of different bladder health outcomes. Women with a graduate degree or bachelor’s degree were no different from one another in their report of impact of bladder health status on different facets of life. In contrast, women with lower degrees of education (vocational or associate degree, some college or vocational training, high school or graduate equivalent degree) reported progressively worse impact of bladder health status on social-occupational activities, physical activities, and emotions relative to the report of women with a graduate degree (i.e., graded associations). Greater percent FPL was associated with lower levels of LUTS and greater levels of bladder well-being across all assessed domains. Because percent FPL is used to determine eligibility for federal- and state-level social safety net programs in the U.S. (U.S. Department of Health and Human Services, n.d.), associations involving percent FPL may be of particular interest to policymakers seeking to promote different facets of health, including bladder health. Findings involving health insurance coverage and type are also likely to be of interest to policymakers. Less than four percent of the sample reported having no health insurance. Not surprisingly, women with no health insurance reported higher levels of LUTS and worse impact of bladder health status on different life activities, relative to women with private health insurance. It is also notable that women insured through Medicaid or both Medicaid and Medicare reported higher levels of LUTS and worse perceived impact of bladder health status on different life activities. Women with Medicare, with no supplemental insurance or supplemental insurance besides Medicaid, also perceived worse bladder health. Beneficiaries of Medicaid and Medicare—government administered health insurance in the U.S.—may be in need of bladder health promotion programs and policies that ensure equitable access to high quality LUTS prevention interventions and treatments.

Intersecting Identities as a Potential Determinant of Bladder Health.

Interaction tests between ethnic/racial identity and SEP variables were not statistically significant when taking into account multiple comparisons. Further research with larger samples of participants with Hispanic ethnic identity and non-White racial identities, as well as a more uniform distribution of socioeconomic position, is warranted. Notably, the present research did not examine intersections between gender identity and either ethnic/racial identity or SEP in relation to LUTS or bladder health. A recent qualitative research study conducted by the PLUS Research Consortium suggests that Black women view their bladder health through the lens of both gender and race (Williams et al., In Press). For example, Black women in this study described internalizing expectations that they will engage in caretaking for their family to the point of neglecting their own health needs. Additional research on intersectionality is warranted with respect to understanding how different social identities may combine to influence bladder health.

Comorbid Conditions and Other Potential Mechanisms.

Sensitivity analyses showed that some observed associations of ethnic/racial social identity and SEP with LUTS and bladder health became statistically non-significant after adjustment for comorbid conditions. Social identity and SEP may confer differential exposure to health promoting and health constraining SDoH (Solar & Irwin, 2010), which may lead to comorbid conditions that increase LUTS risk. In addition to constraints on health behaviors and resulting comorbid conditions (Brady et al., 2024b; Cohen et al., 2016), psychological stress (Lee et al., 2020; Sebesta et al., 2022; Tellechea et al., 2021; Zwaschka et al., 2022), physiological stress (e.g., allostatic load, intestinal microbiome dysbiosis) (Bishehsari et al., 2023; Cohen et al., 2016; O’Connor et al., 2021), low social support (Brady et al., 2023), and less access to and ability to utilize healthcare (e.g., self-management of early LUTS versus seeking treatment) (Brady et al., 2024b) are potential mechanisms by which social identity and SEP may influence LUTS and bladder health over time.

Study Limitations and Strengths.

Causality cannot be inferred from this cross-sectional, observational study. It is possible that LUTS may influence facets of SEP (e.g., withdrawal from workforce, reduced work hours), which may influence percent FPL and health insurance coverage and type. Percent FPL numbers were rough estimates, and percent FPL at higher levels were truncated with respect to income. Additionally, 21% of the sample was missing percent FPL data. All results for associations involving percent FPL remained unchanged when imputing missing income values, mitigating this concern. Unassessed variables, including language barriers and other barriers to healthcare, may have influenced LUTS and bladder health.

The RISE sample may not be generalizable to populations outside of the U.S. or to regions in the U.S. beyond PLUS recruitment sites, including rural areas. The number of ethnic and racial identities examined was limited. The breadth of ethnic identities among women who reported Hispanic ethnicity and the relatively small numbers of women grouped into Non-Hispanic Other Racial Identity and Multiple Racial Identities prevented subgroup analysis. The sampling and recruitment approach, which relied on addresses in a marketing database, prevented inclusion of some groups of women with low SEP, including those experiencing incarceration or homelessness. While education varied among participants, over half of the sample had a Bachelor’s degree or graduate degree. Similarly, over half of the sample had private health insurance. An additional limitation is that analyses did not examine other social identities besides ethnicity and race, such as nativity, gender identity, and sexual orientation.

Some effects observed in the present study were modest in size. From a population perspective, however, modest effects can have sizable impacts on health (Rose et al., 2008). Multiple comparisons were made in the present study. Mitigating this concern are statistical adjustments that were made for multiple comparisons and an expectation that findings would not be independent from one another. Related indices of SEP were examined (education, percent FPL, health insurance coverage and type), as well as related indices of bladder health.

Strengths of the present study include its relatively large sample of adult women recruited from several regions of the U.S. and the inclusion of both LUTS and bladder health as study outcomes.

Conclusions

In the present study of women from the U.S., poorer bladder health among women of Hispanic ethnic identity relative to Non-Hispanic White women largely appeared to be driven by socioeconomic disadvantage. Independent of SEP, women who identified as Non-Hispanic Black or Non-Hispanic Asian reported better bladder health relative to Non-Hispanic White women. Non-Hispanic Asian women reported fewer and less frequent LUTS in comparison to Non-Hispanic White women, whereas reported LUTS were similar between Non-Hispanic Black and White women. Qualitative research may be useful in identifying health promoting attitudes, behavioral habits, and intergenerational messages about caring for the bladder that can be incorporated into universal health promotion programs and programs tailored to women’s ethnic and racial identity. The present study’s findings also suggest that programs and policies designed to promote health must address educational, financial, and medical care coverage, quality, and access barriers to bladder health among all women. Future research is needed to confirm study findings, particularly those involving ethnic and racial identity.

Highlights:

• U.S. Hispanic women reported poorer bladder health than Non-Hispanic White women

• This difference appeared to be largely driven by socioeconomic disadvantage

• Independent of socioeconomics, Black and Asian women reported better bladder health

• Higher socioeconomic position was associated with better bladder health

• This was true independent of racial and ethnic social identity