Discrimination has been defined as the unequal treatment of members of groups who are considered to be inferior, both by individuals and societal institutions [1]. Perceived discrimination on the basis of race or ethnicity is associated with a wide range of negative health outcomes, including mental health symptoms (e.g., depression, anxiety), behavioral health indices (e.g., substance use), and pre-clinical or clinical markers of cardiovascular disease (e.g., inflammation, hypertension) [2]. With the exception of one published abstract, a literature review yielded no research studies that have examined perceived discrimination in relation to lower urinary tract symptoms (LUTS). Nseyo and colleagues [3] published an abstract from a cross-sectional study of Latina women recruited from community sites or clinics specializing in urology or urogynecology in Los Angeles, California, United States of America (U.S.). Experiences of everyday discrimination were associated with frequency of urination, urgency urinary incontinence (UUI), urinary incontinence (UI) with activity, and urinary pain among women recruited from the community, and with difficulty urinating among women recruited through clinics. The present study utilizes Coronary Artery Risk Development in Young Adults (CARDIA) cohort study data to examine whether discriminatory experiences on the basis of race reported from early adulthood through middle age are associated with LUTS and their impact among Black and White women. It was hypothesized that racial discrimination would be associated with more symptomatic and burdensome LUTS. Racial discrimination was examined in different ways (number of settings in which discrimination occurred, frequency of exposure, perceived stress of discrimination).

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). Perceived exposure to discrimination on the basis of race or color was assessed 3 times (1992-93, 2000-01, 2010-11). At each assessment, experiences of racial discrimination were separately assessed in 7 settings (e.g., when getting a job, medical care, or housing). The number of settings in which women reported racial discrimination was averaged across assessments (M=1.09 setting, SD=1.46). Frequency of discrimination was assessed in 2000-01 and 2010-11; values were averaged across settings, with individuals who did not report discrimination within a given setting being assigned a value of zero for that setting. Resulting frequency values were then averaged across assessments (M=0.25, SD=0.42, corresponding to a mean frequency between “never” and “rarely”). At the 2010-11 assessment, women who reported racial discrimination were asked how stressful experience(s) were using a 5-point Likert scale (M=2.79, SD=1.06). 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. Proportional odds logistic regression analyses were conducted among 972 women with complete data; analyses adjusted for age, education, and parity.

A greater percentage of Black women than White women reported racial discrimination across all settings and assessments (see Table 1). For example, between 1992-93 and 2010-11, 33.3-48.8% of Black women and 4.8-7.5% of White women reported racial discrimination at work. During the same time period, 12.0-14.5% of Black women and 0.2-0.5% of White women reported racial discrimination when getting medical care. At the 2010-11 assessment, perceived stress of racial discrimination on a 5-point scale did not statistically differ between Black women (M=2.81, SD=1.09) and White women (M=2.75, SD=1.00). In analyses stratified by race, White women reported greater LUTS/impact with racial discrimination in more settings (OR=1.27; 95% CI=1.10,1.46) and with more frequent discriminatory experiences across settings (OR=2.64, 95% CI=1.49,4.69) (see Table 2). For both White women (OR=1.16, 95% CI=1.02,1.32) and Black women (OR=1.29, 95% CI=1.02,1.65), greater perceived stress of racial discrimination was associated with greater LUTS/impact (see Table 2).

Associations between racial discrimination and LUTS/impact were observed for both Black women and White women in the present study. However, the pattern of associations differed by race. It is not clear why the bladder health of White women, but not Black women, was associated with the number of settings in which racial discrimination occurred, as well as the frequency of racial discrimination across settings. Because discrimination was less commonly reported among White women than Black women, it is possible that White women tended to have fewer strategies, less well developed strategies, or less effective strategies for coping with the stress of racial discrimination. However, greater perceived stress of racial discrimination was associated with greater LUTS/impact among both Black and White women. For both Black and White women, experiences of discrimination perceived as stressful may be particularly likely to initiate and maintain physiological stress responses that can impair bladder function over time. 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 CVD. This prevented the examination of incident LUTS or change in LUTS/impact over time. It is conceivable that experiences of racial discrimination may lead to progressively worse LUTS/impact among those who already have symptoms. For example, women who experience racial discrimination early in their lives may be less likely to seek treatment due to mistrust of medical institutions, and then experience a worsening of LUTS/impact. In this scenario, discrimination would not be prospectively associated with LUTS incidence, but would be associated with the maintenance and worsening of LUTS/impact.

Longitudinal research with baseline and repeated assessments of LUTS/impact is needed to better understand the mechanisms by which racial discrimination may be associated with the bladder health of women over time. Additional research on other cohort studies with more diverse samples is needed to understand whether racial differences observed in the present study are present in other samples and whether discrimination is associated with the bladder health of women from other racial and ethnic groups. Findings from accumulated evidence may inform prevention interventions designed to reduce structural and interpersonal forms of discrimination and promote health, including bladder health.

Williams, D. R. (1999). Race, socioeconomic status, and health: The added effects of racism and discrimination. Annals of the New York Academy of Sciences, 896(1), 173–188. https://doi.org/10.1111/j.1749-6632.1999.tb08114.x
Williams, D. R., Lawrence, J. A., Davis, B. A., & Vu, C. (2019). Understanding how discrimination can affect health. Health Services Research, 54(S2), 1374–1388. https://doi.org/10.1111/1475-6773.13222
Nseyo, U., Chen, N., Sevilla, C., Yosufi, N., Dancz, C., Ginsberg, D., Stern, M., & Rodriguez, L. (2021). PD66-12 Association between stress, discrimination and lower urinary tract symptoms among Latina women in Los Angeles. The Journal of Urology, 206(3S), e1163–e1164. https://doi.org/10.1097/JU.0000000000002110.12

Continence 7S1 (2023) 101013
DOI: 10.1016/j.cont.2023.101013