Bladder health promotion can prevent and improve urinary incontinence (UI) in women but little is known about its uptake in the general population. We partnered with a U.S. state population health survey to disseminate evidence-based bladder health promotion materials and used mixed methods to understand uptake and engagement. Our aims were to identify factors that differentiate those who engage with bladder health promotion from those who do not, and to understand reasons for engagement or lack of engagement with bladder health promotion.

In 2018 a bladder health promotion packet was mailed to all 2016 adult female participants in a state population health survey, followed by a mail survey two weeks later asking about their engagement with materials in the packet. The bladder health promotion packet contained a brochure, a DVD containing a 20-minute video proven to prevent UI in older women, and a phone wallet containing a link to a website where women could view the same video, download an app proven to treat stress UI in women, and read additional information about bladder health and this research study. Descriptive analyses characterized non-respondents, respondents, and users of the brochure, video, website, and app. A subset of respondents, some of whom engaged with materials and some of whom did not, were invited to participate in qualitative telephone interviews about their use of bladder health materials. Interviews were audio-recorded, transcribed verbatim, and analyzed with conventional content analysis.

Survey response rate was 54% (214/399); 25% of respondents and 60% of the entire sample did not access any of the bladder health materials (Figure 1). The brochure was the most commonly accessed material (Figure 1), followed by the video, website, and app. Respondents, versus non-respondents, were more likely to be older, non-Hispanic white, college educated, >200% federal poverty level (FPL), and rural (Table 1). Respondents were more likely to have had a dental cleaning in the last year and to get healthcare from a consistent primary care provider; they were less likely to need help reading health materials. 

Women who accessed the brochure, versus those who did not, had similar characteristics to respondents, and additionally were significantly more likely to have incontinence. Women who accessed the video were significantly older than those who did not and were more likely to be >200% FPL; they also were more likely to live in rural areas and experience UI (p<.1 rather than <.05). Women who accessed the website were older than those who did not; the number of women who accessed the app was too small to allow meaningful characterization of them versus non-users of the app. 

Bladder symptoms, valuing overall health, and prevention motivated engagement; perceived importance of bladder health was the most significant predictor. Among respondents, those who were older, non-white, with higher BMI were more likely to prioritize bladder health. Common reasons for not engaging included lack of time or prioritization of bladder health. Women reported opening the packet because they trusted the population health survey and recommended electronic rather than mail for dissemination of digital resources.

Bladder health outreach via mail reaches educated women with high health literacy and resources. The most commonly accessed material was the brochure; almost no one downloaded an app. Common reasons for uptake of bladder health promotion include current bladder symptoms, specific interest in bladder health, and interest in general health and prevention. Women who do not engage with bladder health promotion cite lack of time, relevance, and prioritization of bladder health as barriers.

Fewer than half of women engage with bladder health promotion via mail from a trusted source; even fewer access digital resources. Women of color, who are younger, with less education, and with lower health literacy, are less likely to be reached through outreach by mail, though this strategy does reach rural women. Most of those reached already prioritize bladder health. Suggested strategies that may improve uptake of bladder health promotion efforts include: (1) Highlighting relevance of bladder health promotion for groups who are less likely to engage; (2) Matching dissemination formats to materials, such as mailing written materials and emailing electronic materials; and (3) Making outreach materials brief, colorful, and graphic, and tailoring for those with low health literacy. Further research should explore how to increase uptake of a bladder health app, given very low uptake in this study.