Barriers to Urogynecologic Care

By Chiara Ghetti, MD

Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO

SYNOPSIS: There is a paucity of literature on barriers to urogynecologic care in racial/ethnic minorities. Continued evaluation is needed to better understand the unique barriers to urogynecologic care in these populations.

SOURCE: Ackenbom MF, Carter-Brooks CM, Soyemi SA, et al. Barriers to urogynecologic care for racial and ethnic minority women: A qualitative systematic review. Urogynecology (Phila) 2023;29:89-103.

The main objective of this study was to identify current knowledge of barriers and facilitators to urogynecologic care for racial and ethnic minorities. This was a qualitative systematic review. Eligible studies included those that explored barriers to care for persons with uroygnecologic conditions, had study cohorts of individuals with urogynecologic conditions and included underserved and/or underrepresented racial/ethnic minority individuals, used only qualitative methods, and were published in or after 2000 in English. Studies with subjects 18 years of age or younger, biologic male, or non-U.S. populations, as well as those without original data or without available full text, were excluded from this analysis.

Of the 360 studies identified by the original search strategy, 12 met inclusion and exclusion criteria and were reported in this review. Of these 12 studies of community dwelling populations, six studies had subjects with a diagnosis of urinary incontinence, three had subjects with prolapse, two had subjects with symptoms of both urinary incontinence and prolapse, and one had subjects with accidental bowel leakage. In nine studies, participants were actively seeking urogynecologic care. Six studies included Black/African American women, and 10 studies included Latina/Hispanic women.

The majority of studies reported provider-associated and patient-associated themes, whereas only half reported system(s)-associated themes. The main
provider-associated themes identified were communication and limited evaluation/management. Within these themes, the named barriers included minimizing/downplaying symptoms, normalizing symptoms, lack of meaningful interviews by the physician/provider, not engaging the patient, and lack of confidence in interpreters or failure of interpreters to improve the encounter.

Black women felt they were not given sufficient information, while Latina women felt overwhelmed by the amount of information. Approximately half of the studies reported themes identified as patient-associated barriers to care; the most frequent were self-reflection, fear/distrust, knowledge, and cultural. Within the theme of self-reflection, barriers of shame, embarrassment, stigma, secrecy, and avoidance were identified. Some of these barriers appeared to be associated with the patient’s response to provider encounters that resulted in fear/distrust. Half of the studies also reported system(s)-associated barriers. These included access, information, cost, and resources.

COMMENTARY

This qualitative systematic review identified several barriers to urogynecologic care in racial/ethnic minority women in the United States. Pelvic floor disorders are highly prevalent and have a dramatic effect on women’s quality of life.¹ Prior studies have identified lack of knowledge and reluctance to seek care as general barriers for urogynecologic care. However, prior studies did not specifically address the knowledge gap regarding specific barriers experienced by racial/ethnic minority populations.² Identifying these unique barriers to care is essential in improving access to care and achieving health equity for patients with pelvic floor disorders.

Ackenbom et al found only 12 studies that met criteria for inclusion. The majority of the barriers identified by this study included barriers related to physician/healthcare provider or patient-associated themes that related to communication and limited evaluation/management. A few system(s)-associated barriers also were identified. This study highlighted the scarce literature investigating barriers to care for racial and ethnic minorities seeking care for pelvic floor disorders.

This particular study examined barriers to care for pelvic floor disorders as a whole. Pelvic floor disorders frequently coexist, but they include a variety of conditions, such as urinary incontinence, pelvic organ prolapse, fecal incontinence, interstitial cystitis and bladder pain syndrome, as well as other lower urinary or bowel-related symptoms. Studies examining the relationship of race and pelvic floor disorders have many discrepancies.³ It is important to consider that the majority of studies rely on self-reported symptoms and primarily include women seeking care for urogynecologic symptoms.

These methodologic characteristics inherently limit the conclusions that can be drawn about racial differences in the prevalence of pelvic floor disorders, risk factors, and care-seeking and treatment behaviors. In addition, many studies are limited by a lack of diversity in the population studied. Furthermore, some studies examine prevalence using surgery as a proxy; however, this approach introduces further limitations, since numerous socioeconomic factors influence access to care and, therefore, access to surgery.

Healthy People 2030 defines a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”⁴

Urogynecologic care is focused on improving patients’ quality of life through a shared decision-making model. Health equity has a natural place within this arena. Health equity, defined by Healthy People 2030, is “the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.”

To provide the highest level of urogynecologic care, there is an urgent need to understand the health disparities related to pelvic floor disorders and to develop strategies to address disparities using culturally sensitive modalities focused on education, prevention, diagnosis, and treatment.

REFERENCES

1. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311-1316.
2. Gonzalez DC, Khorsandi S, Mathew M, et al. A systematic review of racial/ethnic disparities in female pelvic floor disorders. Urology 2022;163:8-15.
3. Whitcomb EL, Rortveit G, Brown JS, et al. Racial differences in pelvic organ prolapse. Obstet Gynecol 2009;114:1271-1277.
4. Healthy People 2030. Health Equity in Health People 2030. https://health.gov/healthypeople/priority-areas/health-equity-healthy-people-2030