Objective
We sought to evaluate the prevalence of pelvic organ prolapse (POP) among a diverse group of women and to determine if race/ethnicity and/or socioeconomic status (SES) are factors in treatment-seeking behavior.
Study Design
All data were collected from the National Institutes of Health–supported Boston Area Community Health Survey. SES was calculated by a 2-factor index that combined household income with years of education. Inferential statistics comprised 1-way analysis of variance, with a post hoc Scheffé test performed to evaluate whether there were differences between individual groups. A χ 2 test was used to evaluate whether distributions were equal among the various questions by race/ethnicity and SES category.
Results
A total of 3205 women were included in the analysis. Hispanic ethnicity and younger age were associated with POP ( P < .002 and P < .001, respectively) as well as with seeking treatment for prolapse ( P = .007 and P < .001, respectively). These factors were also associated with subsequent surgical repair ( P = .027 and P = .019, respectively). A regression model showed that women were 4.9% more likely to seek treatment for every year younger they were, across the range of age. Although women of a higher SES were more likely to have POP, SES was neither associated with a higher likelihood of seeking treatment nor with the surgical management of prolapse.
Conclusion
Hispanic ethnicity and younger age were associated with seeking treatment for POP. Hispanics were more likely than whites or blacks to proceed with surgical management. There was no correlation of SES with any of the above factors.
Pelvic organ prolapse (POP) is a common condition that results in substantial psychosocial and economic burden. Many studies regarding the prevalence of POP involve women who are already integrated into a health care system. Published population-based studies regarding POP prevalence in diverse populations are limited by their disproportionate numbers of black and Hispanic women. Conclusions drawn from these studies are based largely on findings from white women and may not be generalizable to racial and ethnic minorities or socioeconomic status (SES). Information is needed on the prevalence of POP and treatment-seeking behavior among non-white women and women of varying SES because it is not known if either factor is a barrier to seeking treatment.
This study evaluated the prevalence of POP among a group of racially/ethnically diverse women and sought to determine whether or not race/ethnicity and/or SES are factors in treatment-seeking behavior for POP.
Materials and Methods
Study design and data collection
The National Institutes of Health–supported Boston Area Community Health (BACH) Survey is a community-based epidemiologic survey of a variety of urologic symptoms. Conducted among the residents of Boston, MA, the BACH Survey includes 3205 women and 2301 men across a broad age range (30–79 years). The methods of this survey are published in detail elsewhere. Briefly, the BACH Survey obtained cross-sectional data using a 2-stage cluster design. Its design led to a demographic composition in which there was an equal sample balance across gender and 3 racial/ethnic groups (black, Hispanic, and white). The BACH sample was recruited from April 2002 through June 2005, inclusive, during which time baseline interviews were conducted. Interviews were completed for 63.3% of eligible individuals. Information about urologic symptoms, medical and obstetrical history, lifestyle, anthropometrics, health care utilization, and sociodemographic data (education, income, marital status) were collected. A validated Short Form Health Survey (SF-12) was implemented to determine health status of all participants.
The SF-12 comprises 2 summary scales: physical and mental. Scores were tallied and reported according to each scale. Analyses for the present study were performed on data from the 3205 female subjects. All protocols and informed consent procedures were approved by the New England Research Institutes Institutional Review Board. This analysis of BACH data met criteria for exemption of human subjects research review by Hartford Hospital.
Pelvic organ prolapse
Data on POP were collected via a bilingual interviewer-administered self-reported questionnaire. Women with prolapse were identified by their response of “yes” to 1 of 2 questions: “Have you ever been told by a health care provider that you have or had a prolapsed uterus?” or “Have you ever been told by a health care provider that you have or had a prolapsed bladder (cystocele) or rectum (rectocele)?” Subjects who responded “yes” were asked to report their age at initial diagnosis.
Subjects with prolapse were asked, “Have you ever or are you currently receiving treatment for that condition?” Patients who answered in the affirmative were then asked if they had received surgical management for their prolapse. Those who answered “yes” were recorded separately.
Calculation of SES
SES was calculated by a 2-factor index that combined household income with years of education. Income was categorized as low, moderate, or high. Low income was based on a reported annual income <$10,000; moderate, $10,000-69,999; and high, ≥$70,000. Education was based on the number of years of schooling received and was categorized by low, moderate, and high, representing the lowest quartile (0-10 years of education), the second and third quartiles (11-15 years of education), and the upper quartile (≥16 years of education). SES combined income level and education level in quartiles, such that in a similar fashion, low SES was the lowest quartile of combined income and education, moderate SES was the second and third quartiles, and high SES was the highest quartile.
Other variables
Medical comorbidities including diabetes mellitus, hypertension, hypercholesterolemia, and asthma were considered present only if women reported that they “are currently receiving treatment.” Chronic lung disease and stroke were considered present if the patient reported having “ever been told by a health care provider that you have or had” the condition.
Data use and interpretation
All data were used in analyses. Missing values were interpreted as those cases for which a value should have been given but was blank, and values specifically coded as “missing.”
All continuous data (eg, age, body mass index [BMI]) were evaluated for normality. Descriptive statistics were composed of means and SD. Inferential statistics comprised 1-way analysis of variance, with a post hoc Scheffé test performed to evaluate whether there were differences between individual groups. For categorical data, frequencies were presented for distributions and expressed as percentages. A χ 2 test was used to evaluate whether distributions were equal among the various questions by race/ethnicity and SES category.
Findings from the study were based on a finite sample size of existing data, so no a priori power analysis was performed. A significance level was established at alpha = 0.05 such that all results yielding P < .05 were deemed statistically significant. Software (SPSS, version 19.0; IBM Corp, Armonk, NY) was used for all analyses.
Results
Medical and social characteristics for the 3205 women are listed by race/ethnicity in Tables 1 and 2 , respectively. There was an equal distribution of races/ethnicities (33.4% black, 34.7% Hispanic, 32% white). Mean age and BMI (±SD) were significantly different by race/ethnicity (analysis of variance, P < .001), with individual differences seen among all 3 groups (Scheffé, P < .001). Hispanics were the youngest (48.2 ± 11.9 years) whereas whites had the lowest BMI (28.9 ± 7.8 kg/m 2 ). There were also statistically significant differences in gravidity, marital status, health care insurance, and history of hysterectomy across all groups ( P < .001). Moreover, there were differences by race/ethnicity in the prevalence of medical comorbidities, with the exception of stroke ( P = .073). More than 90% of women reported receiving regular medical care, defined as having last seen a health care provider within the past year. The SF-12 measure of general health revealed significant differences between both the physical and mental component summary scale scores among the groups ( P = .001 and P = .045, respectively) ( Table 1 ). An analysis of SES among the races/ethnicities reveals a significant disparity in education and income: the majority of Hispanics fall into the lowest tertile, the majority of blacks are in the middle tertile, and greater than two thirds of whites fall into the highest tertile ( P < .001).
| Variable | Black | Hispanic | White |
|---|---|---|---|
| Sample size a | 1070 | 1111 | 1024 |
| Age (y), mean ± SD | 50.8 ± 12.8 | 48.2 ± 11.9 | 53.2 ± 12.8 |
| Body mass index, mean ± SD | 32.3 ± 7.8 | 30.7 ± 6.7 | 30.7 ± 7.6 |
| Medical comorbidities, n (%) | |||
| Diabetes mellitus | 162 (15.1) | 142 (12.8) | 93 (9.1) |
| Asthma | 159 (14.9) | 129 (11.6) | 118 (11.5) |
| Hypertension | 387 (36.2) | 272 (24.5) | 247 (24.1) |
| Chronic lung disease | 84 (7.9) | 112 (10.1) | 112 (11) |
| Stroke | 20 (1.9) | 16 (1.4) | 12 (1.2) |
| Hyperlipidemia | 200 (18.7) | 156 (14) | 223 (21.8) |
| Gravidity, b n (%) | |||
| ≤3 | 539 (50.6) | 543 (49.1) | 773 (75.7) |
| 4-9 | 481 (45.1) | 512 (46.3) | 237 (23.2) |
| ≥10 | 46 (4.3) | 52 (4.7) | 11 (1.1) |
| Last visit to any health care provider, n (%) | |||
| ≤1 y | 1016 (95.2) | 1044 (94.1) | 980 (95.7) |
| >1 but <5 y | 41 (3.8) | 64 (5.8) | 33 (3.2) |
| ≥5 y | 10 (0.9) | 2 (0.2) | 11 (1.1) |
| Menarche, mean age in y ± SD | 12.8 ± 2.1 | 12.9 ± 1.9 | 12.9 ± 1.7 |
| Menopause, n (%) | 545 (51) | 497 (44.8) | 581 (56.9) |
| Prior hysterectomy, n (%) | 234 (21.9) | 190 (17.1) | 163 (15.9) |
| SF-12, mean scores ± SD | |||
| Physical component summary score | 48.3 ± 11.8 | 47.8 ± 11.5 | 49.8 ± 11.8 |
| Mental component summary score | 34.6 ± 8.2 | 35.4 ± 8.3 | 34.9 ± 8.1 |
a Maximum number of respondents, not all women answered all applicable questions
b Percentages for these variables do not add to 100% because of rounding error.
| Variable | Black | Hispanic | White |
|---|---|---|---|
| Sample size a | 1070 | 1111 | 1024 |
| Smoking status, n (%) | |||
| Current or former | 533 (49.9) | 341 (30.7) | 624 (61.1) |
| Never | 535 (50.1) | 769 (69.3) | 398 (38.9) |
| Marital status, b n (%) | |||
| Married/living with partner | 290 (27.1) | 467 (42.1) | 461 (45.1) |
| Divorced/separated | 270 (25.3) | 337 (30.4) | 187 (18.3) |
| Widowed | 148 (13.9) | 80 (7.2) | 117 (11.4) |
| Single | 347 (32.5) | 219 (19.7) | 252 (24.7) |
| Other | 13 (1.2) | 6 (0.5) | 5 (0.5) |
| Insurance, n (%) | |||
| Private | 375 (35.1) | 202 (18.2) | 540 (52.8) |
| Government | 639 (59.8) | 688 (61.9) | 394 (38.5) |
| Self-pay | 24 (2.2) | 14 (1.3) | 80 (7.8) |
| Other | 31 (2.9) | 207 (18.6) | 9 (0.9) |
| Socioeconomic status, n (%) | |||
| <25% | 150 (23.6) | 416 (65.4) | 70 (11) |
| 25-75% | 729 (43.2) | 502 (29.7) | 457 (27.1) |
| >75% | 141 (21.1) | 63 (9.4) | 465 (69.5) |
a Maximum number of respondents, not all women answered all applicable questions
b Percentages for these variables do not add to 100% because of rounding error.
The overall prevalence of POP among this cohort was 4.2% and the mean age at diagnosis was 57.2 ± 12.4 years. A detailed comparison between races/ethnicities reveals a significant difference in mean age at diagnosis with blacks diagnosed at a younger age than whites (54.7 ± 11.8 vs 61.7 ± 13.7 years, P = .041); however, there was no difference in age at diagnosis between Hispanics and blacks ( P = .931) or Hispanics and whites ( P = .061).
The prevalence of uterine prolapse ranged from 2.4% in Hispanics to 2.9% in blacks and 3.5% in whites; however, this difference was not statistically significant ( P = .281). Among those diagnosed with uterine prolapse, 58.3% of whites sought treatment for their diagnosis in contrast to >70% of blacks and Hispanics, yet these differences also failed to achieve statistical significance ( P = .271) ( Table 3 ).
