The Cumulative Effect of Unmet Social Needs on Noncancerous Genitourinary Conditions and Severity of Lower Urinary Tract Symptoms

Abstract

Purpose:

There is growing awareness on how social determinants of health may significantly influence health outcomes. The purpose of this study was to investigate the relationship between unmet social needs and the incidence and severity of multiple noncancerous genitourinary conditions.

Materials and Methods:

A community-based sample of United States adults was recruited electronically to complete questionnaires on clinical and demographic information, urinary symptoms, and social needs. Logistic regression was used to assess the effect between the number of unmet social needs and various noncancerous genitourinary conditions and severity of lower urinary tract symptoms. Model was adjusted for age, gender, race, insurance, and type of living community.

Results:

4,224 participants were included for final analysis. Incidence of all genitourinary conditions assessed was associated with an increasing number of unmet social needs. Additionally, having 3 or more unmet social needs, as compared to no needs, was associated with an increased risk of all conditions and worse symptoms – including a 23.7% increased risk of interstitial cystitis (95% CI 18.8–28.7%, p<0.001), 21.9% risk of urge urinary incontinence (95% CI 16.8–27.0%, p<0.001), and 20.6% risk of overactive bladder (95% CI 15.6–25.7, p<0.001).

Conclusions:

Unmet social needs are associated with an increased incidence of noncancerous genitourinary conditions as well as worse symptom severity, with multiple unmet social needs displaying a cumulative effect. These findings suggest that there is utility in screening patients for unmet social needs and that the health care system should develop a more integrated approach for patients with urinary conditions.

Introduction

Social determinants of health (SDOH) are non-medical factors that describe the environments in which people live, work, and learn.¹ They encompass multiple domains, including economic stability, health care access, social and community context, education access, and neighborhood environment, and describe a person’s overall social ecology. Social determinants of health are important factors that influence health outcomes and explain disparities in healthcare access. Prior studies have demonstrated the effect of individual social needs (like food insecurity) on the progression of chronic conditions² and the cumulative negative impacts of multiple unmet needs on chronic conditions.³ Increasing awareness and improving management of health-related social needs can lead to increased medication adherence and clinic attendance, which may then result in improved clinical outcomes.⁴

Non-cancerous urinary conditions, such as urinary incontinence (UI), overactive bladder (OAB) interstitial cystitis/bladder pain syndrome (IC/BPS), and recurrent urinary tract infections (rUTIs), are highly prevalent, have significant impact on quality of life, and represent substantial burdens to an person’s health and society.^5,6 These conditions share many aspects with non-urinary chronic conditions that have been associated with unmet social needs. Yet the associations between SDOH and urinary conditions have only been investigated in a few instances, with recent studies demonstrating the effect of socioeconomic status on degree of urgency UI (UUI)⁷ and the effects of multiple individual social needs on OAB severity in women.⁸ Therefore it remains largely unknown whether unmet social needs are associated with additional noncancerous urinary conditions and in men and women.

To address this important knowledge gap, we sought to examine more broadly the impacts of unmet social needs on multiple, noncancerous urinary conditions in both men and women. Thus, the objectives of this study were to determine whether unmet social needs are associated with common urinary conditions, including UI, OAB, IC/BPS and rUTIs, and severity of lower urinary tract symptoms (LUTS) in general, in a large, community-based sample of adult men and women in the United States.

Methods

Participant recruitment:

With Institutional Review Board approval (#211445), a community-based sample of adult participants was recruited electronically via ResearchMatch, a recruitment referral database available at our institution.⁹ From September 2021 to January 2022, approximately 140,000 potential participants from ResearchMatch were contacted via a single email advertisement incentivizing anyone 18 years or older to complete an anonymous, electronic survey in Research Electronic Data Capture (REDCap)^10,11 with the purpose of investigating the relationship between bladder symptoms and lifestyle (including housing situation, work environment, and community). Participants were incentivized with the chance to be one of ten people randomly selected to win $100. Of those contacted, 5,233 (about 3.7%) started the survey.

Participants were excluded if younger than 18 years old, did not complete the entire electronic questionnaire, were currently pregnant, or had a history of a cystectomy. The final sample included 4,224 participants, which is 80.7% of people who responded to the invitation to participate and started the survey.

Data collection:

Social needs

Unmet social needs were assessed with a 10-question SDOH screener, which was developed for a study examining chronic medical conditions and SDOH in a primary care setting based on the Health Leads’ screening toolkit¹² (Table 1).³ Social needs encompassed several different domains including housing instability and quality, food insecurity, utilities, transportation, healthcare cost, child care, legal issues, and interpersonal relationships and violence. Responses obtained were dichotomous. For analysis, participants were categorized into groups reporting none, 1, 2, or 3 or more unmet social needs, as in previous studies.³

Table 1:

Screening questions regarding unmet social needs, and proportion of participants with a positive response to each unmet need.

SDOH screening questions	Variable name	“Yes” (%)
Are you worried that in the next 2 months, you may not have a safe or stable place to live? (eviction, being kicked out, homelessness)	Housing instability	224 (5.3)
Are you worried that the place you are living now is making you sick? (has mold, bugs/rodents, water leaks, not enough heat)	Housing quality	366 (8.7)
In the last 12 months, did you worry that your food could run out before you got money to buy more?	Food insecurity	423 (10.0)
In the last 3 months, has the electric, gas, oil, or water company threatened to shut off services to your home?	Utilities	188 (4.5)
In the last 3 months, has lack of transportation kept you from medical appointments or getting your medications?	Transportation	246 (5.8)
In the last 3 months, did you have to skip buying medications or going to doctor's appointments to save money?	Healthcare cost	458 (10.8)
Do you need help getting child care or care for an elderly or sick adult?	Child or elder care	174 (4.1)
Do you need legal help? (child/family services, immigration, housing discrimination, domestic issues, etc.)	Legal	208 (4.9)
Are you finding it so hard to get along with a partner, spouse, or family members that it is causing you stress?	Interpersonal relationships	756 (17.9)
Does anyone in your life hurt you, threaten you, frighten you, or make you feel unsafe?	Interpersonal violence	189 (4.5)

Urinary symptoms and conditions

To assess urinary symptoms and conditions, participants completed several validated questionnaires and questions on past urinary diagnoses. The Lower Urinary tract dysfunction Research Network 10-item symptom index (LURN SI-10)¹³ is a 10-question measure assessing urinary symptoms including urgency, frequency, incontinence, nocturia, bladder pain, voiding, and post-micturition syndromes over a 7-day recall. To avoid redundant measures, question 1 was omitted, and questions 2 and 3 were combined. The score total score was calculated according scoring recommendations scored from 0 (least severe) to 38 (most severe).¹⁴ A moderate or severe score was defined as 7 or greater, which was previously correlated with an American Urologic Association Symptom Index (AUA SI) score of 9, indicating at least moderate urinary symptoms, in a validation study.¹³ Stress urinary incontinence (SUI) was defined as an answer of more often than “Never” to the question “In the past 7 days, how often did you leak urine or wet a pad while laughing, sneezing, coughing, or doing physical activities?” Urge urinary incontinence was defined as an answer of more often than “Never” to the question “In the past 7 days, how often did you leak urine or wet a pad after feeling a sudden need to urinate?”

The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF),¹⁵ is a 4-item questionnaire to assess urinary incontinence over 4 weeks in terms of frequency, severity, and impact. Urinary incontinence (UI) was defined as an answer more often than “Never” to the question “How often do you leak urine?”

The Patient Perception of Bladder Condition (PPBC)¹⁶ is a single-item global assessment of the patient’s own perception of their bladder condition scored on a 6-point Likert scale from “no problems” to “severe” problems. A severe PPBC was defined as a score of 5 or more, indicating “severe” or “many severe” problems related to the bladder.

The RAND Interstitial Cystitis Epidemiology (RICE) criteria for IC/BPS were assessed in 3 questions about pain and/or pressure in the pelvis over the past 3 months (“Yes”/”No”), presence of urinary urgency over the past 3 months (“Yes”/”No”, and reason for urgency (pain versus fear of wetting, neither, or both).¹⁷ Interstitial cystitis/bladder pain syndrome was defined as an positive answer to pain/pressure in the pelvis and urinary urgency, with urgency due to pain and not fear of wetting alone.

Overactive bladder was defined as UUI and/or urinary urgency (from the RICE criteria) with urinary frequency more than 8 times daily (from the LURN SI-10).

Participants were also asked about a past diagnosis of other urinary conditions. Recurrent UTIs were defined as self-reported history of 3 or more UTIs requiring treatment in a 12-month period. Neurogenic lower urinary tract dysfunction (NLUTD) was defined as a self-reported history of problems with bladder emptying due to the nerves in the bladder not working well.

Other demographics and clinical history

Participants also reported age, gender, race/ethnicity, highest education level, employment status, type of insurance, living community, total household income, number of members living in the household, and other general health conditions. In order to calculate the poverty rate, the total household income according to the number of persons living in the household was compared to the 2021 Poverty Guidelines.¹⁸

Statistical analysis:

Overall, descriptive statistics were performed summarizing data as counts and percentages or as means and standard deviations. Independent variables included individual social needs, and the overall number of needs, categorized as none, 1, 2, 3 or more. Multivariable logistic regression was used to assess the effect between the number of unmet social needs and various noncancerous genitourinary conditions and symptom severity using odds ratios. Additionally, the increase in risk associated with an increase from no unmet needs to 3 or more needs was calculated as a risk difference percentage. Models were adjusted for age, gender, race/ethnicity, type of insurance, and living community. All analysis was performed in Stata 17.0 (StataCorp, College Station, TX) with a p-value <0.05 considered significant.

Results

The number and percentage of participants who answered “yes” to each question on the SDOH questionnaire are shown in Table 1. Table 2 displays baseline characteristics of the study population. A total of 4,224 participants were included, with mean age of 49.1 ± 17.4 years. The majority of participants identified as female (76.4%) and non-Hispanic white (84.2%). A little over one-third reported living in a suburban community (37.6%), while one-quarter reported living in a small town or city (26.0%) or an urban/large city community (24.2%). Over half of participants reported using private insurance only (54.1%), with smaller proportions using Medicare (12.4%) or Medicaid/Medicare plus a private insurance (10.1%). Overall, 231 participants (5.5%) qualified as living below the 2021 United States poverty level. Among all participants, the majority did not report any unmet social needs (65.0%), however nearly one-fifth reported at least 1 unmet social need (18.1%), with smaller proportions reporting 2 (7.0%) or 3 or more (9.9%) unmet needs.

Table 2:

Sociodemographic information for all study participants

	N (%)
Total	4,224
Mean age (yrs [SD])	49.1 (17.4)
Mean BMI (kg/m2 [SD])	27.7 (6.7)
Gender (%)
Male	893 (21.1)
Female	3,226 (76.4)
Transgender/non-binary	97 (2.3)
Unspecified	8 (0.2)
Race/ethnicity (%)
White, non-Hispanic	3,549 (84.0)
Black, non-Hispanic	213 (5.0)
All Hispanic	150 (3.6)
Asian	136 (3.2)
Multiracial	96 (2.3)
Other	53 (1.3)
Unspecified	27 (0.6)
Living community (%)
Rural area	518 (12.3)
Small town/city	1,097 (26.0)
Suburban	1,587 (37.6)
Urban/large city	1,022 (24.2)
Health insurance (%)
Uninsured	276 (6.5)
Medicaid	292 (6.9)
Medicare	522 (12.4)
Private	2,287 (54.1)
Medicaid/Medicare + Private	427 (10.1)
Military	67 (1.6)
Other	353 (8.4)
Household income below 2021 U.S. poverty guideline (%)	231 (5.5)
Number of unmet social needs (%)
None	2,744 (65.0)
1	764 (18.1)
2	296 (7.0)
3+	420 (9.9)

Over half of participants reported any UI (57.1%), with 32.8% having UUI and 33.6% having SUI (see Table 3). After UI, OAB was the next most common urologic condition reported, which was present in 42.2% of participants. rUTIs, IC/BPS, and NLUTD occurred less commonly, reported by 8.7%, 23.3%, and 7.2% of participants, respectively. Finally, when considering participants with more severe urinary symptoms, 39.0% were categorized as having a moderate to severe urinary symptoms according to LURN SI-10 score and 3.3% reported a severe score on PPBC.

Table 3:

Adjusted odds ratios of urologic outcomes by number of unmet social needs (no needs used as reference) and risk difference between those with no unmet social needs and 3 or more needs

Urologic outcome	N (%)	1 Need OR (95% CI)	p-value	2 Needs OR (95% CI)	p-value	3+ Needs OR (95% CI)	p-value	Risk difference from 0 to 3+ needs (%) (95% CI)	p-value
UI	2,412 (57.1)	1.28 (1.08–1.53)	0.005	1.51 (1.16–1.97)	0.002	2.50 (1.94–3.22)	<0.001	13.40 (8.58–18.21)	<0.001
UUI	1,386 (32.8)	1.47 (1.21–1.77)	<0.001	1.86 (1.41–2.46)	<0.001	3.74 (2.91–4.81)	<0.001	21.87 (16.80–26.95)	<0.001
SUI	1,418 (33.6)	1.43 (1.20–1.72)	<0.001	1.36 (1.04–1.79)	0.03	2.63 (2.06–3.36)	<0.001	17.79 (12.71–22.87)	<0.001
OAB	1,784 (42.2)	1.30 (1.09–1.54)	0.003	1.56 (1.21–2.03)	0.001	3.08 (2.42–3.92)	<0.001	20.64 (15.61–25.67)	<0.001
rUTIs	368 (8.7)	1.62 (1.21–2.16)	0.001	1.46 (0.95–2.24)	0.09	3.65 (2.65–5.03)	<0.001	15.12 (11.10–19.15)	<0.001
IC/BPS	984 (23.3)	1.29 (1.06–1.57)	0.01	2.00 (1.53–2.61)	<0.001	2.58 (2.04–3.27)	<0.001	23.74 (18.79–28.69)	<0.001
NLUTD	302 (7.2)	1.37 (0.99–1.90)	0.06	2.36 (1.55–3.58)	<0.001	2.99 (2.08–4.30)	<0.001	8.64 (5.18–12.09)	<0.001
Severe PPBC	140 (3.3)	1.66 (1.02–2.71)	0.04	1.75 (0.85–3.63)	0.13	6.99 (4.37–11.16)	<0.001	8.73 (5.69–11.77)	<0.001
Mod/severe LURN SI-10 Score	1,647 (39.0)	1.63 (1.37–1.94)	<0.001	1.75 (1.35–2.27)	<0.001	4.41 (3.45–5.63)	<0.001	30.36 (25.44–35.27)	<0.001

UI, urinary incontinence; UUI, urge urinary incontinence; SUI, stress urinary incontinence; OAB, overactive bladder; rUTIs, recurrent UTIs; IC/BPS, interstitial cystitis/bladder pain syndrome; NLUTD, neurogenic lower urinary tract dysfunction; PPBC, Patient Perception of Bladder Condition; LURN SI-10, Lower Urinary tract dysfunction Research Network Symptom Index 10

The associations (reported as odds ratios) between number of unmet social needs and all urinary conditions, adjusted for covariates, are shown in Table 3 and Figure 1. Positive associations were found for most conditions, with varying strengths of measures. Overall, increased number of unmet social needs was associated with an increased OR for a given conditions. Compared to no unmet social needs, participants reporting 3 or more had a 23.7% increased risk of IC/BPS (95% CI 18.8–28.7%, p<0.001), 21.9% increased risk of UUI (95% CI 16.8–27.0%, p<0.001), and 20.6% higher risk of OAB (95% CI 15.6–25.7%, p<0.001).

Figure 1:

Adjusted odds ratio of outcomes by number of unmet social needs. No needs used as reference

For those with 1 unmet social need, the strongest association was with NLUTD (OR 1.66, 95% CI 1.02–2.71, p=0.04), rUTIs (OR 1.62, 95% CI 1.21–2.16, p=0.001), and a moderate/severe LURN SI-10 score (OR 1.63, 95% CI 1.37–1.94, p<0.001). For 2 unmet needs, strongest associations were again with NLUTD (OR 2.36, 95% CI 1.55–3.58, p<0.001) and with IC/BPS (OR 2.00, 95% CI 1.53–2.61, p<0.001), and 3+ unmet needs was most strongly associated with a severe PPBC (OR 6.99, 95% CI 4.37–11.16, p<0.001), although the confidence interval is quite large, and a moderate/severe LURN SI-10 score (OR 4.41, 95% CI 3.45–5.63, p<0.001).

Figure 2 demonstrates which individual unmet social need was most strongly associated with each urinary outcome. After controlling for age, gender, race, insurance type, and living community, severe PPBC was most strongly associated with food insecurity (OR 5.26, 95% CI 3.31–8.17, p<0.001), having moderate/severe LURN SI-10 scores was most strongly associated with utility service issues (OR 3.73, 95% CI 2.66–5.22, p<0.001), and UUI was most strongly associated with housing instability (OR 3.40, 95% CI 2.49–4.64, p<0.001). Interestingly, the social need which represented the strongest associated need to multiple urologic outcome assessed was utilities. This was strongest social needs association with UI (OR 2.44, 95% CI 1.71–3.49, p<0.001), SUI (OR 2.47, 95% CI 1.77–3.44, p<0.001), OAB (OR 2.92, 95% CI 2.10–4.06, p<0.001), rUTIs (OR 3.13, 95% CI 2.12–4.62, p<0.0001), and moderate/severe LURN SI-10 score.

Figure 2:

The specific unmet social need with the strongest adjusted association with each urologic outcome assessed, measured as odds ratios with 95% confidence interval bars.

Discussion

This study has several important findings associating unmet social needs and urinary conditions in a large, community-based sample of United States adults. Not only were individual unmet social needs associated with an increased risk of urinary conditions, but the cumulative number of unmet needs was also significantly associated with many conditions. Participants with 3 or more unmet social needs, in particular, as compared to no needs, were at high risk of all conditions a including UI (both UUI and SUI), OAB, rUTIs, NLUTD, and IC/BPS, and worse symptoms LURN SI-10 and perception of bladder condition on PPBC. Several specific social needs were more strongly associated with specific urologic outcomes, and in our study the social need that was most often strongly associated was a worry about losing utilities in the past 3 months. To our knowledge, this is the first study to evaluate the effects of unmet social needs broadly across multiple, common noncancerous genitourinary conditions and LUTS severity, while additionally demonstrating this cumulative relationship between the number of unmet social needs and urologic outcomes.

It has been previously reported that specific unmet social needs are associated with increased OAB symptom severity.⁸ A recent multi-center, cross-sectional study on a diverse population of 256 adult female patients presenting to a Female Pelvic Medicine and Reconstructive Surgery clinic in an urban setting showed that participants with increasing OAB severity had more issues with food insecurity, transportation, employment, and prescription drug use. Our findings are consistent with these results, although our study included a broader range of urinary conditions, and demonstrated the additive effect of having multiple unmet social needs. Additionally, the individual social needs with the strongest association to urologic outcomes was different in the present study. While lack of transportation to medical appointments continues to be a strong association in our study, we also observed that lack of utilities was strongly associated to multiple urologic outcomes. It is interesting to consider how a lack of utilities, including water which affects home plumbing, may affect urinary conditions specifically, and provides hypotheses for future study.

Additionally, while not described in relation to urinary conditions previously, the cumulative effect of an increasing number of unmet social needs having a stronger association to health conditions has been demonstrated in the primary care literature.³ A recent large, multicenter, prospective study on a diverse population of 33,550 adult patients presenting to primary care clinics demonstrated a similar cumulative effect of increasing social needs to chronic conditions including hypertension, diabetes, asthma, depression, anxiety, and smoking. The individual social needs that had the strongest associations with multiple chronic conditions assessed included healthcare transportation, which is similar to findings in our study, and interpersonal relationships.

Finally, just as unmet social needs are associated with both physiologic and psychologic stress, it has been documented in the literature that psychiatric disorders are associated with LUTS. Rezaeimehr et al describes an association between obsessive compulsive disorder (OCD) with LUTS, finding that the interplay between urge symptoms, voiding dysfunction, and perceived cleanliness all point to a psychosomatic contribution to LUTS, including urge and stress incontinence.¹⁹ Similarly, Lai et al found that this effect may be bidirectional; OAB patients reported higher anxiety symptom scores compared to age-matched controls, as well as more problems with sleep, fatigue, and depression. This study noted that it is still not clear whether anxiety is a causal factor for OAB or if it results from having these bladder symptoms; regardless, the strength of association between the two was significant.²⁰

There are several limitations of the present study. Our sample was recruited by email solicitation through ResearchMatch and was majority white, non-Hispanic, and female population with internet access, which may exclude populations that do not use email as frequently, such as the elderly or those without broadband internet access. No information is available on non-responders, so selection bias is an important consideration and the results are not likely generalizable to the greater United States population. Future studies would benefit from databases that purposefully oversample minority groups (like the National Center for Health Statistics) to specifically investigate barriers these at-risk groups face when receiving health care. However, even in our relatively homogeneous study population, it is quite revealing that a meaningful proportion of participants reported unmet social needs. Additionally, participants with urinary symptoms were possibly more likely to complete our survey, as it was advertised as investigating bladder symptoms. This likely accounts for the high proportion of participants in the survey that suffer from various urinary conditions including OAB and IC/BPS, which is greater than the general population. The percentage of participants with OAB in this study was 42.2%, while nationally it ranges from 9 to 43%.^21,22 Furthermore, the proportion of those with IC/BPS symptoms in our study was 23.3%, while nationally, it ranges from 0.8% to 2.7% in women and 0.2% to 1.2% in men.²³ Choosing to dichotomize variables of PPBC and LURN SI-10 score with specific cut-points can also introduce bias as opposed to using a continuous variable, however, we felt this was a practical way to interpret the data. Lastly, our study was cross-sectional by design, so causality cannot be determined between unmet social needs and urinary conditions from a single time point of assessment. Additionally, the relationships between unmet social needs, different sociodemographic factors, and health conditions, such as the urinary conditions and symptoms assessed in this study are complex, and bidirectional or circular in nature, as in many conditions.²⁴ The study therefore inherently introduces confounding bias. While we addressed this limitation as best we could by controlling for various covariates, it is impossible to completely remove all confounding variables, and the relationships presented in this study should be interpreted with this in mind.

Despite these limitations, this study is the first to examine, in a large, community-based sample of United States adults, the association between unmet social needs and a number of common, noncancerous urinary conditions and urinary symptom severity. The growing body of literature suggests that unmet social needs impact urinary conditions just as with other common chronic conditions. These studies have important implications for the future of urinary care and hopefully will guide a more integrated approach for patients with LUTS. While it is becoming more widely acknowledged that SDOH influence health outcomes, the role of screening for SDOH, especially in sub-specialized clinics such as urology, is poorly defined and there are no current guidelines for doing so, even for single dimension issues.^24,25 The first step in rectifying healthcare disparities is identifying them and drawing awareness, which is the primary goal of the present study. We identified unmet social needs that impact patients and determined that their cumulative effects impact LUTS and urinary conditions; hopefully, this will lead to more proactive screening by clinicians and increased resources directed towards alleviating these factors. Additional work is needed in various clinical settings, including specialty clinics, to address these needs and help mitigate the inherent disparities of unmet social needs.

Conclusion

Unmet social needs, such as housing instability, food insecurity, utilities, and lack of transportation were associated with an increased risk of noncancerous urinary conditions. Additionally, multiple unmet social needs produced a cumulative effect; having 3 or more unmet social needs was associated with both increased risk of all conditions and worse symptom scores. Future studies will help determine the role of screening in a specialty clinic setting and continue the development of an integrated, multi-disciplinary approach to improve care of people with urinary conditions.

Data availability

The full data that support the findings of this study are available from the corresponding author (EMS), upon reasonable request. The authors confirm that summarized data supporting the findings of this study are available within the article and tables.