A small body of empirical research has found that different social determinants of health (SDOH), including food insecurity, housing insecurity, unreliable transportation, and difficulty paying for utilities, are associated with overactive bladder, stress urinary incontinence, urge urinary incontinence, and other lower urinary tract symptoms (LUTS) [1]. SDOH are thought to influence LUTS and their impact, at least in part, through less access to and utilization of healthcare [1,2]. Stress-related mechanisms may also link SDOH to LUTS. Accumulation of risk over time [3], a life course epidemiology concept, posits that cumulative damage to biological systems occurs as the number, duration, or severity of life course stressors and other risk exposures increase, and as body systems age and become less able to repair damage. Financial strain may be conceptualized as a SDOH that can cause cumulative damage to biological systems through stress responses. The present study utilizes Coronary Artery Risk Development in Young Adults (CARDIA) study data to examine whether underutilization of healthcare, assessed in 2005-06 and 2010-11, mediated potential associations between financial strain, assessed in 1995-96 and 2000-01, and LUTS and their impact, assessed in 2012-13.

CARDIA is a prospective cohort study of the development of cardiovascular disease (CVD) that recruited 5,115 Black and White women and men aged 18-30 years at baseline (1985-86) from the populations of four U.S. cities (Birmingham, Alabama; Minneapolis, Minnesota; Chicago, Illinois; Oakland, California). The analytic sample for this study was comprised of women with complete data for analyses involving mediation tests of data collected at 4 assessments (n=951). Separate dichotomous variables were created to indicate how hard it was for women and their families to pay for (1) the very basics like food and heating, and (2) medical care in 1995-96 and 2000-01. Responses of “not very hard” were coded as 0, and all other responses were coded as 1. In 2005-06 and 2010-11, women were asked whether there was any time during the past two years when they did not seek medical care because it was too expensive or health insurance did not cover it, excluding dental care. Responses of “yes” were coded as 1, and responses of “no” were coded as 0. In 2012-13, self-reported data on LUTS and their impact were collected for the first time. The outcome variable was previously developed through a cluster analysis of four constructs: UI severity, UI impact, other LUTS severity, and other LUTS impact. Women were classified into bladder health (44%) versus mild (31%), moderate (20%), or severe (5%) symptoms/impact clusters. “Greater LUTS/impact” was defined as membership in a more symptomatic LUTS category with greater burden. Two financial strain variables (difficulty paying for the very basics, difficulty paying for medical care) were created by summing across values for each of the two assessments (range of values, 0-2). Similarly, an underutilization of care variable was created by summing across values for each of the two assessments (range of values, 0-2). Structural equation modeling was conducted to simultaneously estimate direct and indirect effects of financial strain variables on LUTS/impact, with underutilization of healthcare as a potential mediator.

Table 1 shows the percentages of women reporting financial strain and underutilization of healthcare within the total sample and by LUTS/impact cluster. The percentage of women reporting financial strain (difficulty paying for basics or medical care) in 1995-96 and 2000-01 was greater among women who experienced LUTS/impact versus bladder health in 2012-13. The percentage of women reporting underutilization of healthcare in 2010-11 increased in a graded fashion across 2012-13 LUTS/impact cluster groups. Figure 1 shows results of structural equation modeling. When difficulty paying for basics and medical care were adjusted in the same model, only difficulty paying for medical care was directly associated with greater LUTS/impact (see bottom arrow; β=.08, p=.03). Difficulty paying for medical care was also indirectly associated with greater LUTS/impact through underutilization of healthcare (see bottom mediation pathway; β=.26 p<.01; β=.09 p<.01).

Underutilization of healthcare due to expense or lack of health insurance coverage partially mediated the association between difficulty paying for medical care and LUTS/impact. Additional research is needed to better understand other mechanisms that may link financial strain to LUTS/impact, such as psychological stress. A notable limitation of the present study is that LUTS and impact were not assessed during the first 25 years of the CARDIA cohort study, which was designed to study the etiology of cardiovascular disease. This prevented examination of incident LUTS or change in LUTS/impact over time. While the present findings are consistent with the idea that financial strain may lead to greater LUTS/impact, it is also conceivable that LUTS/impact may lead to financial strain. For example, women with greater LUTS/impact may reduce their time at work or leave work due to symptoms. It is also conceivable that financial strain may lead to progressively worse LUTS/impact among those who already have symptoms. Financially stressed women who experience LUTS early in their lives may be less likely to seek treatment due to financial strain, and then experience a worsening of LUTS/impact. In this scenario, financial strain would not be prospectively associated with LUTS incidence, but would be associated with the maintenance and worsening of LUTS/impact.

Financial strain may constrain other SDOH that are meant to be health promoting – namely, utilization of healthcare. In the present study, however, healthcare utilization only partially explained associations between financial strain and LUTS/impact. Research is needed to examine other mechanisms that may explain the association between financial strain and LUTS/impact, such as stress responses. Accumulated evidence on associations between SDOH and LUTS/impact from additional, more diverse cohorts could inform interventions to remove structural barriers related to financial strain, permit greater access to LUTS treatment, and ameliorate other unmet social needs.

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