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Determinants of delay in care seeking for pelvic floor disorders among Latina women in Los Angeles
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Determinants of delay in care seeking for pelvic floor disorders among Latina women in Los Angeles
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Content
Determinants of delay in care seeking for Pelvic Floor Disorders
among Latina women in Los Angeles
by
Nanjun Chen
A Thesis Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(MOLECULAR EPIDEMIOLOGY)
December 2021
Copyright 2021 Nanjun Chen
ii
Acknowledgements
Throughout the writing of the thesis, I have received a great deal of support and assistance.
I would first like to thank my supervisor, Dr. Mariana Carla Stern, whose expertise was invaluable.
Her guidance and advice carried me through all the stages of writing my project. And her insightful
feedback pushed me to sharpen my thinking and brought my work to a higher level. Muchas gracias!
I would also like to acknowledge my committee members, Dr. Lourdes Baezconde-Garbanati and
Dr. Jennifer Unger. They took their time to review this thesis and gave thoughtful comments and
suggestions, which provided more good points to complete this project. Muchas gracias!
In addition, a thank you to Dr. Larissa Rodriguez, another principal investigator for this project,
who led the surveys in the clinic sample and provided most points in the medical field. I also thank Dr.
Temitope Rude and Dr. Unwanaobong Nseyo for accomplishing fantastic previous work on determinants
of self-identified PFDs, contributing a lot to this thesis.
And my most enormous thank to my parents for their wise counsel and sympathetic ear. You are
always there for me. All your support offered me a good life and determination to pursue my academic
goals. Without you, I cannot study abroad, live following my heart, and working on what interests me.
Thanks to all my professors, teachers, and families for the support you gave in the last two years,
especially in such an unusual condition with the covid pandemic. All of you are amazing!
iii
Table of Contents
Acknowledgements ....................................................................................................................................... ii
List of Tables and Figures ............................................................................................................................ iv
Abstract ......................................................................................................................................................... v
Introduction ................................................................................................................................................... 1
Materials and Methods .................................................................................................................................. 3
Study population .............................................................................................................................. 3
Surveys ............................................................................................................................................. 4
Outcome Variables........................................................................................................................... 5
Statistical Analysis ........................................................................................................................... 7
Results ......................................................................................................................................................... 10
Community sample ........................................................................................................................ 10
Clinic sample ................................................................................................................................. 21
Discussion ................................................................................................................................................... 36
Community women ........................................................................................................................ 36
Clinic women ................................................................................................................................. 38
Strengths and limitations................................................................................................................ 39
Summary ........................................................................................................................................ 40
References ................................................................................................................................................... 42
iv
List of Tables and Figures
Figure 1. Questions and Variables ................................................................................................................ 9
Table 1. Community women characteristics ............................................................................................... 13
Table 2. Univariate analysis to evaluate the association of determinants and discussion of symptoms ..... 16
Table 3. Univariate analysis for determinates of seeking care .................................................................... 18
Table 4. Multivariate analysis for determinates of discussing symptoms and seeking care ....................... 20
Table 5. Clinic women characteristics ........................................................................................................ 25
Table 6. Univariate analysis for determinates of discussing symptoms ..................................................... 27
Table 7. Univariate analysis for determinates of seeking care .................................................................... 29
Table 8. Multinomial univariate analysis for determinants of delays in seeking care ................................ 31
Table 9. Multivariate analysis for determinates of discussing symptoms and seeking care ....................... 34
Table 10. Multivariate analysis for determinates of time to seeking care ................................................... 35
v
Abstract
Purpose
Latina women suffer a higher burden of pelvic floor disorders compared to other racial/ethnic groups. In
spite of this, they tend to delay seeking care. This study examined care-seeking behaviors among Latina
women in the community, and Latina women presenting to Urology clinics in Los Angeles, with the goal
of assessing whether cultural, psychosocial, and clinical factors could determine the willingness to discuss
pelvic floor disorders (PFDs) symptoms and seek care.
Methods/Materials
We did a cross-sectional study of Latina women in Los Angeles using standardized surveys, including
measures of acculturation; Latin-American values (familism, respect, religion and gender roles) and US
cultural values (independence, material success and competition); knowledge, attitude, behaviors and
beliefs about PFDs; pelvic floor disorders symptoms; and measures of stress and discrimination. We
included community Latina women (N = 197), and Latina women presenting to USC Urology clinics (N =
156). Both groups were evaluated separately. Descriptive statistics, univariate and multivariate logistic
regression, and multinomial logistic regression were performed to identify variables associated with
disclosing symptoms to friends or family, seeking care, and time to seek care (for clinic women only). In
this study we included all women who responded ‘yes’ or ‘unsure’ to the question of “Do you have
symptoms of a pelvic floor disorder?”, this included 57 community women and 110 clinic women.
Results
Among community women (N = 57), 44% confided symptoms in a healthcare provider, and 38% sought
care for symptoms right away. Higher score for independence value was associated with being more likely
to disclose symptoms to friends or relatives (OR = 4.96, 95%CI = 1.27-19.31). Higher score for material
success was associated with being more likely to seek care right away (OR = 3.85, 95%CI = 1.51-9.80).
vi
Lower US cultural value (OR= 0.23, 95%CI= 0.06-0.91) and Latin American Value scores (OR= 0.37,
95%CI= 0.14-1.01) were independently associated with being less likely to seek care due to not making it
a priority.
Among women recruited in the clinics (N = 110), the median number of months of delay in discussing
symptoms with doctors or friends/family were 6.95 and 3, respectively. We did not have information about
time to seek care for women residing in the community. Among women from the clinics, higher respect
value scores were associated with women being more likely to seek care right away (OR = 3.27, 95%CI =
1.44-7.42), and being less likely to not seek care due to lack of priority (OR = 0.31, 95%CI= 0.13-0.75).
Women who delayed longer to seek care from doctors were more likely to have higher Latin American
Orientation Score (LAOS) (OR=3.29, 95%CI=1.21-8.95) and lower respect value (OR=0.16, 95%CI=0.04-
0.63).
Conclusions
The care-seeking behaviors of Latina women were influenced by their values including US values and
Latin-American values. Interventions that take into account these Latin American values are needed to raise
awareness about pelvic floor disorders and to encourage women to recognize symptoms and discuss them
with their health care providers.
Key words: Pelvic floor disorder, Latina women, Care-seeking, Knowledge, Beliefs
1
Introduction
Pelvic floor disorders (PFDs), including pelvic organ prolapse, urinary, and fecal incontinence,
affect a substantial proportion of women, and increase with age
1
. It was reported that about one-fourth of
adult US women will have at least one PFD in their lifetime, and 12% will undergo surgery for a PFD by
age 80
2,3
. Given the increasing prevalence of PFDs, these disorders put a significant and increasing
emotional and financial burden on women
4
,and affect their quality of life
5
.
Latina women have been reported to have a significant burden of PFDs, with significant increasing
outpatient visits for PFDs from 3% to 10% in 1995-2006
6
. Compared to other race/ethnicities, Latina
women have the highest prevalence of incontinence symptoms
7,8
and prolapse symptoms
9
. However, it was
reported that compared to other women, Latina women seek care for their PFDs symptoms much later
6
, and
are less likely to initiate or complete pelvic floor physical therapy
10
. These disparities are understudied and
not fully understood. The existing research suggests that they might be explained by low health literacy,
communication barriers, provider specific barriers, sociocultural perspectives, personal barriers, and
financial factors, which may affect Latina women likelihood of reporting and seeking care for their PFDs
11–
14
. In addition, embarrassment and modesty may further contribute to many Latina women delaying seeking
care.
Identifying PFD symptoms is the most critical step for women to discuss the symptoms with others
and seek care. Using the validated Pelvic Floor Distress Index (PFDI-20)
15
, which can assess the symptoms
of pelvic organ prolapse, colorectal anal, and urinary distress, we previously observed that 63% of
community women in Los Angeles who self-identified having PFDs or were unsure reported at least one
symptom on the PFDI-20, whereas 60% of community women who self-identified not having PFDs
reported at least one symptom. On the PFDI-20. Reporting symptoms but not self-identifying a PFD was
associated with lower scores of values of independence, higher scores of value of religiosity, and higher
stress scores
16
.
2
In this study, we focused on Latina women who self-identified as having symptoms of PFDs, in
order to understand which are the key determinants of them seeking care for their symptoms. We focused
on two different groups of women along, which allowed us to identify determinants of intention to seek
care among women in the community who had not received care for their PFDs yet, as well as determinants
of delays in seeking care among women in the clinic who already received treatment for their PFDs. Based
on previous studies, and preliminary findings from focus groups we conducted among Latina women in
Los Angeles, we considered medical, cultural, and social factors and we hypothesized that women with
higher acculturation (higher Anglo orientation), higher scores for US cultural values, less perceived
discrimination, and less symptom severity would be more likely to seek care, both among women in the
community as well as those recruited in the clinics. We further explored determinants for them seeking care
right away, or delaying care due to two main reasons: financial concerns and lack of prioritizing their health
over other concerns.
3
Materials and Methods
Study population
We conducted a cross-sectional study of Latina women in the city of Los Angeles, which included
both women enrolled from the community, as well as women enrolled in Urology and Gynecology clinics
at the University of Southern California. All women were administered the same surveys. IRB approval
was obtained at the University of Southern California (USC) Institutional Review Board. All women who
participated were literate and asked to sign an informed consent.
Community Participants
A community health worker who works in Spanish-speaking communities (‘promotora de salud’)
identified women at health fairs, schools, parks, and community centers throughout the city of Los Angeles
between June 2019-October 2019, and administered surveys, in English or Spanish, on site. All participants
were women age 18 and above, self-identified as Latina, and were able to understand the survey in either
Spanish or English. Surveys were administered by the promotora de salud . Of the 205 women who
participated, 3 had extensive missing data, and 5 did not respond to the PFD self-identification question,
leaving a total of 197 participants in our sample. For these analyses, we only included women who identified
or were unsure about having PFD symptoms, which included 57 participants.
Clinic participants
Women were enrolled at three different clinics that are part of the University of Southern California
(USC) medical system, in three different settings: The Female Pelvic Medicine and Reconstructive Surgery
(FPMRS) clinic at the Los Angeles County (LAC)+USC Medical Center, a safety-net hospital in Los
Angeles, and two FPMRS clinics that are associated with the Keck Medical Center of USC, one in urban
Los Angeles, and one in Bakersfield, a rural setting in southern California. If a potential participant
happened to be in clinic for a visit they were recruited in person, otherwise they were recruited by phone.
Women were eligible for our study if they were 18 years or older, identified as Hispanic or Latina, and had
4
a diagnosis associated with a PFD, including POP, SUI and/or UUI. All women that were recruited were
established patients with a PFD diagnosis of POP, SUI, and/or UUI and had received prior treatment for
their PFD. Women with major cognitive deficits (intellectual disability and/or inability to concentrate or
remember things) or psychiatric impairments that would prevent appropriate communication and
participation in a focus group were excluded. Women were offered to answer questions in either English or
Spanish. Of the 170 women who participated, 3 had extensive missing data, 1 did not respond to the
essential urinary Distress Inventory questions, 10 were not clinic patients, leaving a total of 156 participants
in our clinic sample. For the analyses presented here, we only focused on the women who identified or were
unsure about having PFD symptoms, which included 110 women.
Surveys
The term PFD was defined to participants to include “a bulge in the vagina from the bladder, uterus
or rectum falling out, or involuntary leakage of stool or urine”. Surveys included seven sections:
demographics (patient age, marital status, employment status, income, and level of education);
acculturation; Latino values; knowledge, attitude, behaviors, and beliefs (KABB) about PFDs; PFD
symptoms survey; sexual function; perceived stress scale; and everyday discrimination. To measure
acculturation, the degree of assimilation to US culture, we used the validated revised Acculturation Rating
Scale for Latin-Americans-II which has been validated for Latinos/as individuals in the US
17
, based on
Berry’s model
18
(integration, separation, assimilation, and marginalization). The 30 questions in this scale
yield an Anglo Orientation Subscale (AOS), and a Latin-American Orientation Subscale (LAOS), which
range from 0-4, and allow to determine Latinos/as and American acculturation, independently.
The Values section included the Latina American Cultural Values Scale for Adolescents and
Adults
19
, and includes 50 questions that assess values of competition, familism, independence, material
success, religion, respect, and traditional gender roles, with sub-scores each ranging from 0-4. These sub-
scores are then grouped into US cultural values and Latin-American values summary scores, also with a
range of 0-4.
5
To assess PFD symptoms we used the Pelvic Floor Distress Index (PFDI-20) which has been
validated in a short form of 20 questions
15
. This questionnaire was validated for use in a symptomatic
population; however, since then it has increasingly been used to assess overall prevalence of PFD in US
women
20,21
, and it has been reported that survey scores correlate with self-identification of having PFD
among women
22
. The total PFDI-20 scores (0-300), as well as pelvic organ prolapse (POPDI-6), fecal
incontinence (CRADI-8), and urinary incontinence (UDI-6) (0-100) were used as continuous variables. We
also derived the following summary variables to capture different dimensions of PFD symptoms: 1)
Number of symptoms defined as the number of questions with at least one response with a score of 2-4; 2)
Number of bothersome symptoms defined as number of questions with a score 3-4; 3) Severity level
deriving from number of symptoms, defined as “not bothersome” (no questions’ score more than 1), “a
little bothersome” (at least one question=2 but <3), “bothersome” (at least one question >=3). For all these
symptoms-based variables, we considered a score of 0 or 1 as no symptom present and used this as the
reference category.
Stress was assessed using the Perceived Stress Scale (PSS)
23
which has been validated among
Latinos/as, and has scores 0-40
24
. We also assessed perceived discrimination using the Everyday
Discrimination Scale (EDS), was reported to perform well among Latinos/as
25
, and has scores 0-5
23,26
.
We also assessed demographic characteristics by including questions that captured age, education
level (completed primary school, secondary school or higher, employment status (unemployed/homemaker,
employed), religion (Catholic, Protestant, other), marital status (married, single/unknown), and nativity (US
born or foreign born).
Outcome Variables
Outcomes were assessed using the KABB section of our survey. This section includes 21 questions
developed for this study. We included one question that asked, “Do you think you have symptoms of pelvic
floor disorders?”; women who answered ‘yes’ or ‘unsure’, were asked to complete 6 additional questions
about patterns and determinants of seeking care (Figure 1). We considered the following outcomes:
6
Discussion of symptoms. Three variables were considered that captured discussion of symptoms as
categorical variables (yes/no): 1) Discussion of symptoms with females or friends (“Have you talked about
this with a female friend or relative”), 2) Confiding of symptoms with healthcare provider (“Did you report
these problems to your healthcare provider? For example, did you mention this to the person that did your
pap smear?”), 3)Intention to confide symptoms with a healthcare provider (“If you have not reported these
problems to your healthcare provider, do you intend to do so?”).
Reasons for delaying discussion of symptoms. We considered a dichotomous variable that captured
whether a woman discussed PFD symptoms with a healthcare provider right away or not, regardless of the
reason (yes/no). In addition, we considered two outcome variables that captured two main reasons why
women delayed discussing symptoms with healthcare providers: 1) delaying care due to financial concerns
(answers 9 and 10 in question 5, Figure 1; “I didn’t have health insurance” or “I was afraid of the cost”)
versus all other women, 2) delaying care due to not making it a priority (answers 1-8, 14, or 15 in question
5, Figure 1) versus all other women.
Time to seeking care (for women recruited from clinics only). Months to delay in discussing PFD
symptoms with a female friend or relative from doctor were derived from the KABB survey question “Have
you talked about this with a friend or relative, if so, when did you talk to someone about it” (question 3,
Figure 1). Months to delay in care-seeking from healthcare provider derived from the KABB question “Did
you report these problems to your healthcare provider? if so, when did you talk to them about it” (question
4, Figure 1). We calculate the delay in care-seeking (in months) by using these two dates and subtracting
the onset dates from the KABB survey question “When did you first start noticing symptoms of a pelvic
floor disorder (such as feeling of a bulge in your vagina, problems with urination and/or defecation, and
incontinence)” (question 2, Figure 1). We generated tertiles of these two derived variables based on the
distribution.
7
Statistical Analysis
Most variables in this study were skewed by Skewness and Kurtosis test for normality and were
described by medians and IQRs. To identify determinants of discussing symptoms with ether family or
friends, or with healthcare providers, we used univariate and multivariate logistic regression models. The
outcome variables were either “did you discuss symptoms with females or friends” (yes/no), or “did you
confide symptoms in healthcare provider” (yes/no) and “do you intend to confide symptoms with a
healthcare provider” (yes/no).
To identify determinants of time to seeking care, we used univariate and multivariate multinominal
logistic regression models. The outcome variables were tertiles of “Months to delay in care-seeking from
doctors” (1
st
tertile: no delay, 2
nd
tertle: delay longer, 3 tertile: delay longest) or “Months to delay in sharing
symptoms with friends or relatives” (1
st
tertile: no delay, 2
nd
tertle: delay longer, 3 tertile: delay longest).
Analyses were done to identify determinants of discussing symptoms, determinants of reasons for
delay seeking care, and determinants of time to seeking care (for the clinic sample only). We considered as
possible determinants the PFD severity level, age, education level, employment status, religion, marital
status , nativity , LAOS, AOS, Values scores (familism, respect, religion, gender roles, material success,
independence, competition, Lain-American Values and US cultural Values), EDS score, and PSS score.
Logistic and multinominal logistic regression models were used to estimate odds ratios (OR) and 95%
confidence intervals from separate models for each outcome. We considered as possible determinants any
variables that associated with our outcomes with a significance level of p <0.1 on univariate analysis. These
variables where then evaluated in multivariate models. The correlations between variables were used to
assess collinearity, and if the R
2
between two variables were more than 0.7, then those variables were not
included together in one model due to highly correlation. For example, R
2
between “familism” and “respect”
for the clinic sample was 0.75; thus, they were not included in the multivariate model together, but in
separate multivariate models with other determinants.
8
All the p-value in the models were from Wald’s test in the logistic models and multinominal logistic
models. Analyses were performed using STATA (version 15.1) and p <0.05 was considered statistically
significant for multivariate analysis.
9
Figure 1. Questions and Variables
10
Results
Community sample
The median age of participants was 51.60 (IQR 43.60-60.90) years old. Most participants were
foreign-born, unemployed or homemakers and had gone to secondary school or higher. For Acculturation
and Values, the median AOS was 1.38 (IQR 0.92-2.36) out of 4, and the median LAOS was 3.41 (IQR
2.88-3.71) out of 4. The median of Latin-American Values was 2.97 (IQR 2.65-3.24), and the median of
US cultural Values was 2.37 (IQR 1.90-2.67) out of 4. We also evaluated the individual values that are part
of the overall values scores, as summarized in Table 1. For the psychosocial assessment, the median of the
everyday discrimination scale was 0.78 (IQR 0.00-2.00) out of 4, and the median perceived stress scale was
18.00 (IQR 15.00-20.00) out of 40. For PFD symptom assessment, the median of pelvic floor distress index
was 75.00 out of 300; specifically, the median of pelvic organ prolapse distress index was 25.00 out of 100,
the colorectal distress index was 15.62 out of 100, and the median of urinary distress index was 33.33 out
of 100. Other demographic characteristics and scores for the independent variables are summarized in Table
1.
When considering what women do when they recognize symptoms of PFDs, 33% of women shared
discussing their symptoms with friends or relatives, with 44% of all women having confided symptoms to
a healthcare provider (Table 1). Among women who had not confided symptoms with a doctor, 61%
expressed intention to confide symptoms in healthcare (Table 1).
Only 38% of women had sought care right away. Among the reasons, 13% of women expressed
that it was due to financial concerns, while 66% of women did not seek care due to lack of making this a
priority (Table 1). We considered three questions about discussion of PFD symptoms, and conducted
separate univariate analyses for each (Table 2). We observed that women who discussed their symptoms
with friends and relatives, compared to those who did not, were more likely to be single (OR = 3.36; 95%CI
= 0.98-11.56, p-value = 0.06), less likely to be employed (OR = 0.29; 95%CI = 0.08-1.04, p-value = 0.06),
were more likely to have higher scores for the material success value (OR = 1.94; 95%CI = 1.05-3.58),
11
value of independence (OR = 2.51, 95%CI = 0.99-6.39, p-value = 0.05), and competition (OR = 2.04;
95%CI = 0.90-4.60, p-value = 0.09), and overall were more likely to have higher US cultural Values (OR
= 4.28; 95% CI = 1.35-13.58, p-value = 0.01) (Table 2).
Next, we evaluated the independent effects of these determinants and hypothesized that severity of
the symptoms may also influence these outcomes, so we included them in multivariate models (Table 4).
We observed statistically significant positive associations between higher scores for material success and
independence after adjusting for POPD, UD severity, and employment status (Table. 4).
When considering whether women confided their symptoms with a healthcare provider, we
observed that women who did were more likely to have higher scores for gender roles value (OR = 1.75;
95%CI = 1.03-2.97, p-value = 0.04), material success (OR = 1.98; 95%CI = 1.04-3.76, p-value = 0.04), and
US cultural values (OR = 2.69; 95% CI = 0.99-7.34, p-value = 0.05) (Table 2). There was no evidence of
correlation between the value of material success and the gender role value (R
2
= 0.59); therefore, we
evaluated the independent effects of these putative determinants using a multivariate model including the
material success and the gender role values, adjusted by the severity of the symptoms (Table 4). In this
analysis, we observed that women who confided in a healthcare provider were more likely to have
bothersome urinary symptoms (OR = 18.62; 95%CI = 1.35-256.65, p-value = 0.03) (Table. 4).
When considering intention to seek care from a healthcare provider, we did not observe any
statistically significant associations, albeit there were many positive and inverse associations, but
confidence intervals were wide, likely due to low sample size and reduced statistical power (Table 2).
Next, we considered determinants for seeking care right away, for not seeking care due to financial
concerns, and for not seeking care due to lack of priority (Table 3). Women who sought care right away
were less likely to be employed (OR = 0.31; 95%CI = 0.09-1.06, p-value = 0.06), and more likely to have
higher scores for gender roles value (OR = 1.92; 95%CI = 1.10-3.35, p-value = 0.02), higher score for
material success value (OR = 4.37; 95%CI = 1.81-10.56, p-value < 0.01), and competition value (OR =
3.85; 95%CI = 1.39-10.67, p-value = 0.01) (Table 3). In the multivariate analysis, after mutual adjustment
12
estimates for material success and competition were similar as univariate analyses, but were less precise,
with wider confidence intervals. (Table 4).
When considering determinants for not seeking care due to financial reasons neither of the variables
considered showed statistically significant associations (Table 3). Next, we observed that women who
delayed seeking care due to lack of prioritizing the symptoms, had lower scores for gender role value (OR
= 0.61, 95%CI: 0.36-1.05, p-value = 0.08), competition value (OR = 0.46, 95%CI: 0.20-1.06, p-value =
0.07), Latin-American values (OR = 0.23; 95%CI = 0.06-0.91), and US cultural values (OR = 0.37; 95%CI
= 0.14-1.01). In addition, women who delayed care were more likely to have more severe symptoms of
fecal incontinence as captured by CRADI-8 (OR = 11.08; 95% CI = 1.25-98.55) (Table 3). In the
multivariate analysis, all these estimates were similar as univariate analyses, but were less precise with
wider confidence intervals. And we still observed an association between women who delayed care and
having bothersome symptoms for CRAD (OR = 8.84; 95% CI = 0.95-81.87), albeit precision was reduced
due to small numbers
13
Table 1. Community women characteristics
N 57
Demographics
Age 51.60 (43.60, 60.90)
Marital Status (n,%)
Married 28 (50%)
Single/ unknown 28 (50%)
Education Level (n,%)
Primary School 21 (37%)
Secondary School or higher 36 (63%)
Nativity (n,%)
Foreign born 46 (81%)
US born 11 (19%)
Employment (n,%)
Unemployed/ Homemaker 34 (60%)
Employed 23 (40%)
Acculturation
Anglo Orientation Score 1.38 (0.92, 2.36)
Latin American Orientation Score 3.41 (2.88, 3.71)
Values
Familism 3.19 (2.88, 3.62)
Respect 3.00 (2.75, 3.50)
Religion 3.71 (3.14, 4.00)
Gender Roles 2.20 (1.20, 2.80)
Material Success 1.20 (0.60, 1.80)
Independence 2.80 (2.40, 3.20)
Competition 3.00 (2.50, 3.25)
Latin-American Values 2.97 (2.65, 3.24)
US cultural Values 2.37 (1.90, 2.67)
Psychosocial Assessment
Everyday Discrimination Scale 0.78 (0.00, 2.00)
Perceived Stress Scale 18.00 (15.00, 20.00)
Symptom Assessment
Pelvic Floor Distress Index (PFDI) 75.00 (25.00, 114.58)
Pelvic Organ Prolapse Distress Index
(POPDI)
25.00 (0.00, 33.33)
Colorectal Distress Scale (CRADI) 15.62 (0.00, 28.12)
Urinary Distress Index (UDI) 33.33 (8.33, 50.00)
Number of bother symptoms
Number of bother PFD symptoms 1.00 (0.00, 4.00)
14
Number of bother POPD symptoms 0.00 (0.00, 1.00)
Number of bother CRAD symptoms 0.00 (0.00, 0.00)
Number of bother UD symptoms 0.00 (0.00, 2.00)
Number of symptoms
Number of PFD symptoms 5.00 (0.00, 10.00)
Number of POPD symptoms 1.00 (0.00, 3.00)
Number of CRAD symptoms 1.00 (0.00, 2.00)
Number of UD symptoms 3.00 (0.00, 5.00)
PFD Severity Level
no bothersome 16 (28%)
a little bothersome 10 (18%)
bothersome 31 (54%)
POPD Severity Level
no bothersome 26 (46%)
a little bothersome 10 (18%)
bothersome 21 (37%)
CRAD Severity Level
no bothersome 28 (49%)
a little bothersome 16 (28%)
bothersome 13 (23%)
UD Severity Level
no bothersome 19 (33%)
a little bothersome 14 (25%)
bothersome 24 (42%)
Outcome variables
discuss symptoms with friend or relatives
No 36 (67%)
Yes 18 (33%)
confide symptoms in healthcare provider
No 28 (56%)
Yes 22 (44%)
intend to confide symptoms in healthcare
No 7 (39%)
Yes 11 (61%)
seeking care for symptoms right away
No 33 (62%)
Yes 20 (38%)
not seeking care due to financial concerns
No 46 (87%)
Yes 7 (13%)
15
not seeking care due to lack of priority
No 18 (34%)
Yes 35 (66%)
*Median and IQR are calculated for continuous variables; N and percentage are calculated
for categorical variables.
16
Table 2. Univariate analysis to evaluate the association of determinants and discussion of symptoms
Discuss symptoms with female
friends
Confide symptoms in
healthcare provider
Intend to confide symptoms in
healthcare
Demographics ORs (95%CI) P-value OR (95% CI) P-value OR (95% CI) P-value
N
Age 1.03 (0.99, 1.07) 0.19 1.02 (0.98, 1.06) 0.27 0.96 (0.90, 1.03) 0.28
Marital Status (n,%)
Married (ref)
(ref)
(ref)
Single/ unknown 3.36 (0.98, 11.56) 0.06* 1.78 (0.57, 5.58) 0.32 1.11 (0.16, 7.51) 0.91
Education Level (n,%)
Primary School (ref)
(ref)
(ref)
Secondary School or higher 2.50 (0.69, 9.12) 0.17 1.73 (0.52, 5.77) 0.38 3.38 (0.40, 28.75) 0.27
Nativity (n,%)
Foreign born (ref)
(ref)
(ref)
US born 0.70 (0.16, 3.04) 0.63 0.39 (0.09, 1.71) 0.22 5.00 (0.44, 56.62) 0.19
Employment (n,%)
Unemployed/ Homemaker (ref)
(ref)
(ref)
Employed 0.29 (0.08, 1.04) 0.06* 0.40 (0.13, 1.30) 0.13 2.08 (0.28, 15.77) 0.71
Acculturation
Anglo Orientation Score 0.80 (0.46, 1.40) 0.44 0.92 (0.54, 1.57) 0.77 1.75 (0.66, 4.66) 0.26
Latin American Orientation Score 1.20 (0.59, 2.44) 0.62 0.77 (0.40, 1.48) 0.44 3.67 (0.60, 22.23) 0.16
Values
Familism 1.68 (0.65, 4.35) 0.29 0.79 (0.36, 0.73) 0.55 0.53 (0.04, 6.23) 0.61
Respect 1.82 (0.69, 4.77) 0.22 0.96 (0.45, 2.07) 0.93 0.96 (0.09, 10.17) 0.97
Religion 0.93 (0.45, 1.91) 0.84 0.57 (0.25, 1.30) 0.18 0.66 (0.15, 2.99) 0.61
Gender Roles 1.11 (0.67, 1.82) 0.70 1.75 (1.03, 2.97) 0.04* 1.53 (0.50, 4.65) 0.45
Material Success 1.94 (1.05, 3.58) 0.04* 1.98 (1.04, 3.76) 0.04* 0.78 (0.28, 2.19) 0.63
Independence 2.51 (0.99, 6.39) 0.05* 1.66 (0.75, 3.65) 0.21 0.97 (0.28, 3.37) 0.97
17
Competition 2.04 (0.90, 4.60) 0.09* 1.24 (0.65, 2.39) 0.51 0.84 (0.23, 3.03) 0.79
Latin-American Values 1.23 (0.48, 3.15) 0.67 1.33 (0.53, 3.30) 0.54 1.18 (0.11, 12.31) 0.89
US cultural Values 4.28 (1.35, 13.58) 0.01 2.69 (0.99, 7.34) 0.05* 0.59 (0.12, 2.89) 0.51
Psychosocial Assessment
Everyday Discrimination Scale 1.31 (0.83, 2.06) 0.24 1.13 (0.72, 1.77) 0.61 0.78 (0.34, 1.78) 0.55
Perceived Stress Scale 1.02 (0.92, 1.14) 0.69 1.05 (0.94, 1.17) 0.42 0.95 (0.80, 1.13) 0.58
PFD Severity Level
no bothersome (ref)
(ref)
(ref)
a little bothersome 1.73 (0.22, 13.67) 0.60 0.22 (0.02, 2.37) 0.21 6.00 (0.35, 101.57) 0.21
bothersome 3.13 (0.74, 13.26) 0.12 1.43 (0.40, 5.16) 0.59 6.00 (0.58, 61.84) 0.13
POPD Severity Level
no bothersome (ref)
(ref)
(ref)
a little bothersome 0.71 (0.12, 4.32) 0.71 0.65 (0.13, 3.40) 0.61 2.00 (0.13, 31.98) 0.62
bothersome 1.31 (0.39, 4.42) 0.67 0.79 (0.23, 2.70) 0.71 2.50 (0.29, 21.40) 0.40
CRAD Severity Level
no bothersome (ref)
(ref)
(ref)
a little bothersome 1.81 (0.47, 6.97) 0.39 1.05 (0.28, 3.99) 0.94 3.00 (0.23, 39.61) 0.40
bothersome 1.70 (0.41, 6.98) 0.46 1.40 (0.35, 5.63) 0.64 3.00 (0.23, 39.61) 0.40
UD Severity Level
no bothersome (ref)
(ref)
(ref)
a little bothersome 0.62 (0.10, 3.92) 0.61 0.32 (0.05, 1.94) 0.21 6.67 (0.49, 91.33) 0.16
bothersome 2.37 (0.65, 8.68) 0.19 2.06 (0.57, 7.47) 0.27 2.00 (0.19, 20.61) 0.56
(ref) indicates reference group.
*Statistically significant at 0.1
Odds Ratios are from the logistic regression models for each dichotomous outcome.
18
Table 3. Univariate analysis for determinates of seeking care
seeking care for symptoms right away
not seeking care due to financial
concerns
not seeking care due to lack of
priority
Demographics OR (95% CI) P-value OR (95% CI) P-value OR (95% CI) P-value
N
Age 1.03 (0.99, 1.07) 0.10 1.02 (0.97, 1.08) 0.40 0.97 (0.94, 1.01) 0.19
Marital Status (n,%)
Married (ref)
(ref)
(ref)
Single/ unknown 2.06 (0.65, 6.54) 0.22 1.28 (0.26, 6.36) 0.77 0.66 (0.20, 2.13) 0.49
Education Level (n,%)
Primary School (ref)
(ref)
(ref)
Secondary School or higher 0.93 (0.29, 2.99) 0.90 0.65 (0.13, 3.26) 0.60 2.00 (0.61, 6.54) 0.25
Nativity (n,%)
Foreign born (ref)
(ref)
(ref)
US born 0.30 (0.06, 1.54) 0.15 3.56 (0.66, 19.11) 0.14 2.77 (0.53, 14.48) 0.23
Employment (n,%)
Unemployed/ Homemaker (ref)
(ref)
(ref)
Employed 0.31 (0.09, 1.06) 0.06* 1.07 (0.21, 5.32) 0.94 1.68 (0.52, 5.50) 0.39
Acculturation
Anglo Orientation Score 1.00 (0.58, 1.70) 0.99 0.77 (0.35, 1.73) 0.53 1.09 (0.63, 1.89) 0.76
Latin American Orientation
Score
0.71 (0.34, 1.46) 0.35 0.75 (0.30, 1.87) 0.54 1.10 (0.53, 2.28) 0.79
Values
Familism 1.82 (0.71, 4.66) 0.22 1.04 (0.33, 3.27) 0.95 0.54 (0.20, 1.43) 0.21
Respect 1.98 (0.76, 5.16) 0.16 0.81 (0.29, 2.26) 0.68 0.70 (0.29, 1.69) 0.43
Religion 0.77 (0.38, 1.56) 0.46 0.93 (0.35, 2.49) 0.89 0.64 (0.25, 1.62) 0.34
Gender Roles 1.92 (1.10, 3.35) 0.02* 1.68 (0.77, 3.69) 0.20 0.61 (0.36, 1.05) 0.08*
Material Success 4.37 (1.81, 10.56) <0.01* 1.17 (0.53, 2.54) 0.70 0.67 (0.37, 1.20) 0.18
Independence 1.79 (0.79, 4.05) 0.16 1.07 (0.38, 3.04) 0.90 0.59 (0.26, 1.35) 0.21
19
Competition 3.85 (1.39, 10.67) 0.01* 0.80 (0.34, 1.92) 0.62 0.46 (0.20, 1.06) 0.07*
Latin-American Values 2.47 (0.82, 7.47) 0.11 1.28 (0.32, 5.12) 0.73 0.23 (0.06, 0.91) 0.04*
US cultural Values 14.51 (2.67, 78.92) 0.00 0.91 (0.26, 3.20) 0.89 0.37 (0.14, 1.01) 0.05*
Psychosocial Assessment
Everyday Discrimination
Scale
1.16 (0.75, 1.81) 0.51 0.57 (0.23, 1.40) 0.22 1.22 (0.75, 1.99) 0.42
Perceived Stress Scale 1.02 (0.92, 1.13) 0.72 0.93 (0.79, 1.09) 0.40 1.02 (0.92, 1.13) 0.74
PFD Severity Level
no bothersome (ref)
(ref)
(ref)
a little bothersome 1.10 (0.15, 8.13) 0.93 1.60 (0.20, 12.69) 0.66 2.19 (0.32, 15.04) 0.43
bothersome 2.26 (0.59, 8.70) 0.23 0.28 (0.04, 1.87) 0.19 2.14 (0.60, 7.67) 0.24
POPD Severity Level
no bothersome (ref)
(ref)
(ref)
a little bothersome 0.56 (0.09, 3.36) 0.52 0.71 (0.07, 7.52) 0.78 2.14 (0.36, 12.89) 0.41
bothersome 1.25 (0.38, 4.13) 0.72 0.53 (0.09, 3.22) 0.49 1.79 (0.51, 6.14) 0.36
CRAD Severity Level
no bothersome (ref)
(ref)
(ref)
a little bothersome 1.00 (0.27, 3.69) 1.00 0.81 (0.13, 5.05) 0.82 1.85 (0.49, 6.98) 0.37
bothersome 0.67 (0.16, 2.77) 0.58 0.44 (0.04, 4.38) 0.48 11.08 (1.25, 98.55) 0.03*
UD Severity Level
no bothersome (ref)
(ref)
(ref)
a little bothersome 0.75 (0.14, 3.90) 0.73 2.86 (0.50, 16.36) 0.24 2.13 (0.42, 10.78) 0.36
bothersome 1.69 (0.48, 6.01) 0.42 1
a
1.94 (0.54, 6.99) 0.31
(ref) indicates reference group.
*Statistically significant at 0.1
Odds Ratios are from the logistic regression models for each dichotomous outcome.
a
indicates empty odds ratio due to small number,
20
Table 4. Multivariate analysis for determinates of discussing symptoms and seeking care
Outcome Determinates Odd Ratio p-value ll ul
discuss symptoms with friends Material Success 2.08 0.06 0.96 4.47
Independence 4.96 0.02* 1.27 19.31
Unemployed/ Homemaker (ref)
Employed 0.15 0.02* 0.03 0.76
POPD_severity (ref)
a little bothersome 0.20 0.24 0.01 2.96
bothersome 0.31 0.27 0.04 2.48
UD_severity (ref)
a little bothersome 1.21 0.87 0.13 11.36
bothersome 15.09 0.02* 1.41 161.74
confide symptoms in healthcare
provider Material Success 1.86 0.18 0.75 4.59
Gender Roles 2.00 0.10 0.87 4.62
POPD_severity (ref)
a little bothersome 0.23 0.26 0.02 3.08
bothersome 0.10 0.07 0.01 1.18
UD_severity (ref)
a little bothersome 0.74 0.79 0.08 6.83
bothersome 18.62 0.03* 1.35 256.65
seeking care for symptoms right
away Material Success 3.85 <0.01* 1.51 9.80
Competition 2.82 0.09 0.85 9.35
not seeking care due to lack of
priority Gender Roles 0.73 0.33 0.38 1.37
Competition 0.67 0.40 0.26 1.71
CRAD_severity (ref)
a little bothersome 1.45 0.61 0.35 5.96
bothersome 8.84 0.06 0.95 81.87
(ref) indicates reference group.
*Statistically significant at 0.05
21
Clinic sample
The median age of clinic participants was 55.60 (IQR 47.00-66.50) years old. Most participants
were Catholic, foreign-born, had gone to secondary school or higher (Table 5). Among women who
provided employment information, 66% women were unemployed or homemakers in the current data. For
Acculturation and Values, the median AOS was 1.31 (IQR 0.77-2.54) out of 4, and the median LAOS was
3.35 (IQR 2.94-3.76) out of 4. The median of Latin-American Values was 3.01 (IQR 2.61-3.29), and the
median of US cultural Values was 2.10 (IQR 1.73-2.58) out of 4. For The psychosocial assessment, the
median of the everyday discrimination scale was 0.67 (IQR 0.00-1.33) out of 4, and the median perceived
stress scale was 20.00 (IQR 14.00-23.00) out of 40. For PFD symptom assessment, the median of pelvic
floor distress index was 143.75 out of 300; specifically, the median of pelvic organ prolapse distress index
was 45.83 out of 100, the colorectal distress index was 25.00 out of 100, and the median of urinary distress
index was 66.67 out of 100. Other demographic characteristics and scores for the independent variables are
summarized in Table 5.
When considering what women do when they recognize symptoms of PFDs, 63.3% of women
shared discussing their symptoms with friends or relatives, with 88.1% of all women having confided
symptoms with a doctor.
When considering whether women sought care right away, only 37% had done so. When we
considered the reasons why they did not seek care right away, 15.7% of women expressed that it was due
to financial concerns, while 70.4% of women did not seek care due to lack of making the symptoms a
priority (Table 5).
When considering the time to delay in care-seeking from doctors, the median was 6.95 months
(IQR 0-36.53). When considering the time to delay in sharing with friends or relatives, the median was 3
months (IQR 0-42.67) (Table 5).
We considered determinants of whether women discussed their symptoms with friends or relatives
(Table 6). We observed that women who did, compared to those who did not, were more likely to attend
22
secondary school or higher (OR = 2.32; 95%CI = 1.02-5.28, p-value = 0.05), and were less likely to be
employed (OR = 0.32; 95%CI = 0.09-1.12, p-value = 0.07) (Table 6).
Next, we evaluated the joint effect of these determinants and hypothesized that perceived stress
may also influence these outcomes, so we included them in multivariate models (Table 9). All these
estimates were attenuated, but associations remain in the same direction as seen in univariate analyses.
Next, we considered determinants for seeking care right away, for not seeking care due to financial
concerns, and for not seeking care due to lack of prioritizing the symptoms (Table 7). Compared to women
who did not seek care right away, women who did had higher score for respect value (OR = 2.36; 95%CI
= 1.13-4.93, p-value = 0.02) and had lower score for material success value (OR = 0.64; 95%CI = 0.39-
1.05, p-value = 0.08). (Table 7). In the multivariate analysis, we observed that values of respect and material
success had independent statistically significant associations, similar to univariate analyses (Table 9).
Next, we observed that women who delayed seeking care due to financial reasons, compared to all
other women, were more likely to have higher score for respect value (OR = 2.64; 95%CI = 0.90-7.76, p-
value = 0.08), have higher score for competition value (OR = 1.74; 95%CI = 0.92-3.30, p-value = 0.09),
and less likely to have gone to secondary school or higher (OR = 0.38; 95%CI = 0.13-1.08, p-value = 0.07),
have more symptoms of pelvic organ prolapse (OR = 1.37; 95%CI = 0.99-1.91, p-value = 0.06), and more
bothersome symptoms of pelvic organ prolapse (OR = 1.25; 95%CI = 0.96-1.63, p-value = 0.09) (Table 7).
In the multivariate analysis, after adjusting the number of POPD symptoms, estimates for respect and
competition were attenuated and neither were statistically significant (Table 9).
When considering determinants for not seeking care due to lack of prioritizing symptoms, we
observed that women who fell in this category, compared to all other women, were more likely to have
higher age (OR = 1.03; 95%CI = 1.00-1.07, p-value = 0.07), less likely to have higher score for familism
value (OR = 0.50, 95%CI = 0.24-1.05, p-value = 0.07), higher score for respect value (OR = 0.34, 95%CI
= 0.15-0.80, p-value = 0.01), and higher Latin-American Values (OR = 0.39, 95%CI = 0.17-0.92, p-value
= 0.03) (Table 7). The correlation between familism and respect scores was R
2
=0.75. Hence, we evaluated
the joint effects of these putative determinants with a multivariate model including respect value and age,
23
or familism and age. In the analysis, we observed statistically significant negative associations between
higher score for respect, familism or Latin-American Values after adjusting for age (Table 9). We also fitted
a multivariate model including the Latin-American Values score instead of including either respect or
familism score, since Latin-American Value is an average of respect, familism religion and gender roles.
We observed a statistically significant inverse association (OR = 0.29, 95%CI = 0.11-0.74, p-value = 0.01)
(Table 9).
We considered two questions about time to care-seeking and time to discussing symptoms with
friends or relatives, and conducted separate univariate analysis for each (Table 8).
When considering the months to delay in care-seeking from doctors we observed that women who
delayed longer to seek care from a doctor were less likely to have higher score for respect value (OR 2
nd
vs.
1
st
= 0.25, 95%CI = 0.08-0.82; OR 3
rd
vs. 1
st
=0.23, 95%CI = 0.07-0.73; p-value = 0.04), have higher score
for gender roles value (OR 2
nd
vs. 1
st
= 0.76, 95%CI = 0.41-1.41; OR 3
rd
vs. 1
st
=0.48, 95%CI = 0.25-0.93;
p-value = 0.09), and overall have higher score for Latin-American value (OR 2
nd
vs. 1
st
= 0.33, 95%CI =
0.10-1.05; OR 3
rd
vs. 1
st
=0.22, 95%CI = 0.07-0.70; p-value = 0.04). Additionally, higher scores for Latin
American Orientation Score (OR 2
nd
vs. 1
st
= 2.32, 95%CI = 0.92-5.83) and lower scores for competition
(OR 2
nd
vs. 1
st
= 0.57, 95%CI = 0.30-1.10) were significantly associated with women who delayed longer
to seek care from a doctor, however, among women who delayed the longest, there was no association
(Table 8).
Next, we evaluated the joint effect of these determinants, and we observed the values of respect
and Latin American Orientation Score had independent statistically significant associations, similar to
univariate analyses (Table 10).
When considering the months to delayed in sharing symptoms with friends or relatives we observed
that women who delayed longer to share symptoms with friends or relatives were less likely to be single or
unknown (OR 2nd tertile vs. 1st tertile = 0.19, 95%CI = 0.04-0.79; OR 3rd tertile vs. 1st tertile = 0.47, 95%CI = 0.13-1.64,
p-value = 0.07), have higher score for perceived stress scale (OR 2
nd
vs. 1
st
= 0.89, 95%CI = 0.80-0.99; OR
3
rd
vs. 1
st
= 0.98, 95%CI = 0.90-1.08; p-value = 0.07), and higher score for everyday discrimination scale
24
(OR 2
nd
vs. 1
st
= 0.26, 95%CI = 0.08-0.84). However, among women who delayed the longest, there was
no association with perceived everyday discrimination. Additionally, women who delayed the longest were
more likely to have higher scores for religion (OR 3
rd
vs. 1
st
= 3.28, 95%CI = 0.89-12.06), but no association
among women who delayed longer. (Table 8). In the multivariate analysis, we evaluated the joint effect of
these determinants and observed associations remain in the same direction as seen in univariate analysis
(Table 10).
25
Table 5. Clinic women characteristics
Table 1: Participants Characteristics clinic
N 110
Demographics
Age 55.60 (47.00, 66.50)
Marital Status (n,%)
Married 54 (49.1%)
Single / unknown 56 (50.9%)
Religion (n, %)
Catholic 76 (69.1%)
Protestant 16 (14.5%)
Other 18 (16.4%)
Education Level (n,%)
Primary School 37 (33.6%)
Secondary School / higher 73 (66.4%)
Nativity (n,%)
Foreign born 90 (81.8%)
US born 20 (18.2%)
Employment (n,%)
Unemployed/ homemaker 33 (66%)
Employed 17 (34%)
Missing 60
Acculturation
Anglo Orientation Score 1.31 (0.77, 2.54)
Latin American Orientation Score 3.35 (2.94, 3.76)
Values
Familism 3.44 (2.94, 3.75)
Respect 3.38 (2.88, 3.62)
Religion 3.71 (3.14, 4.00)
Gender Roles 1.60 (1.20, 2.40)
Material Success 1.00 (0.40, 1.60)
Independence 2.80 (2.40, 3.20)
Competition 2.50 (2.00, 3.25)
Latin-American Values 3.01 (2.61, 3.29)
US cultural Values 2.10 (1.73, 2.58)
Psychosocial Assessment
Everyday Discrimination Scale 0.67 (0.00, 1.33)
Perceived Stress Scale 20.00 (14.00, 23.00)
Symptom Assessment
Pelvic Floor Distress Index (PFDI) 143.75 (83.33, 186.46)
Pelvic Organ Prolapse Distress Index (POPDI) 45.83 (25.00, 66.67)
Colorectal Distress index (CRADI) 25.00 (6.25, 43.75)
Urinary Distress Index (UDI) 66.67 (45.83, 83.33)
Number of bother symptoms
26
Number of bother PFD symptoms 7.00 (4.00, 11.00)
Number of bother POPD symptoms 2.00 (0.00, 4.00)
Number of bother CRAD symptoms 1.00 (0.00, 3.00)
Number of bother UD symptoms 3.00 (2.00, 5.00)
Number of symptoms
Number of PFD symptoms 11.00 (7.00, 14.00)
Number of POPD symptoms 3.00 (2.00, 5.00)
Number of CRAD symptoms 3.00 (1.00, 4.00)
Number of UD symptoms 5.00 (3.00, 6.00)
Outcome variables
discuss symptoms with friends or relatives
No 40 (36.7%)
Yes 69 (63.3%)
seeking care for symptoms right away
No 68 (63.0%)
Yes 40 (37.0%)
not seeking care due to financial concerns
No 91 (84.3%)
Yes 17 (15.7%)
not seeking care due to lack of priority
No 32 (29.6%)
Yes 76 (70.4%)
months to delay in care-seeking from doctor median (Q1, Q3)
All 6.95 (0,36.53)
1st tertile (N=24) 0 (0, 0)
2nd tertile (N=24) 6.95 (3.07, 12.17)
3rd tertile (N=24) 66.68 (36.53, 121.75)
months to delay in sharing with friend or relatives median (Q1, Q3)
All 3 (0, 42.67)
1st tertile (N=25) 0 (0, 0)
2nd tertile (N=14) 7.07 (3, 12.2)
3rd tertile (N=18) 98.42 (47.7, 158.27)
*Median and IQR are calculated for continuous variables; N and percentage are calculated for categorical variables.
27
Table 6. Univariate analysis for determinates of discussing symptoms
discuss symptoms with female friend
Demographics OR (95%CI) P-value
N
Age 1.00 (0.97, 1.03) 0.98
Marital Status (n,%)
Married (ref)
Single/ unknown 1.21 (0.55, 2.63) 0.64
Religion (n, %)
Catholic (ref)
Protestant 0.83 (0.27, 2.57) 0.74
Other 0.87 (0.30, 2.47) 0.79
Education Level (n,%)
Primary School (ref)
Secondary School or higher 2.32 (1.02, 5.28) 0.05*
Nativity (n,%)
Foreign born (ref)
all others 1.09 (0.40, 3.02) 0.86
Employment (n,%)
Unemployed/ Homemaker (ref)
Employed 0.32 (0.09, 1.12) 0.07*
Acculturation
Anglo Orientation Score 1.20 (0.82, 1.76) 0.36
Latin American Orientation Score 0.91 (0.51, 1.61) 0.75
Values
Familism 0.97 (0.54, 1.74) 0.92
Respect 0.98 (0.53, 1.80) 0.94
Religion 1.12 (0.65, 1.94) 0.69
Gender Roles 0.96 (0.63, 1.45) 0.84
Material Success 0.78 (0.50, 1.24) 0.29
Independence 1.14 (0.63, 2.08) 0.66
Competition 0.87 (0.57, 1.34) 0.53
Latin-American Values 1.00 (0.51, 1.96) 1.00
US cultural Values 0.83 (0.46, 1.51) 0.54
Psychosocial Assessment
Everyday Discrimination Scale 1.11 (0.68, 1.81) 0.67
Perceived Stress Scale 1.01 (0.95, 1.06) 0.79
Symptom Assessment
Number of bother PFD symptoms 1.01 (0.94, 1.10) 0.73
28
Number of bother POPD symptoms 1.07 (0.88, 1.30) 0.51
Number of bother CRAD symptoms 1.03 (0.83, 1.26) 0.81
Number of bother UD symptoms 1.00 (0.82, 1.21) 0.97
Number of symptoms
Number of PFD symptoms 1.00 (0.92, 1.08) 0.93
Number of POPD symptoms 1.04 (0.84, 1.29) 0.73
Number of CRAD symptoms 0.98 (0.83, 1.16) 0.83
Number of UD symptoms 0.96 (0.77, 1.21) 0.75
(ref) indicates reference group.
*Statistically significant at 0.1
Odds Ratios are from the logistic regression models for each dichotomous outcome.
29
Table 7. Univariate analysis for determinates of seeking care
seeking care for symptoms right away
not seeking care due to financial
concerns
not seeking care due to lack of
priority
Demographics OR (95%CI) P-value OR (95%CI) P-value OR (95%CI) P-value
Age 1.00 (0.97, 1.03) 0.91 1.00 (0.95, 1.04) 0.85 1.03 (1.00, 1.07) 0.07*
Marital Status (n,%)
Married (ref) (ref) (ref)
Single/ unknown 1.00 (0.46, 2.18) 1.00 1.15 (0.41, 3.24) 0.79 1.00 (0.44, 2.28) 1.00
Religion (n, %)
Catholic (ref) (ref) (ref)
Protestant 1.19 (0.38, 3.69) 0.77 0.67 (0.14, 3.31) 0.62 1.14 (0.33, 3.97) 0.84
Other 1.13 (0.39, 3.26) 0.82 0.26 (0.03, 2.09) 0.20 0.83 (0.28, 2.49) 0.74
Education Level (n,%)
Primary School (ref) (ref) (ref)
Secondary School or higher 1.27 (0.55, 2.95) 0.57 0.38 (0.13, 1.08) 0.07* 0.57 (0.23, 1.44) 0.24
Nativity (n,%)
Foreign born (ref) (ref) (ref)
all others 2.19 (0.80, 5.95) 0.13 1.00 (0.00, 0.00) 0.89 (0.31, 2.61) 0.84
Employment (n,%)
Unemployed/ Homemaker (ref) (ref) (ref)
Employed 1.57 (0.44, 5.64) 0.49 1.28 (0.31, 5.37) 0.73 2.95 (0.70, 12.46) 0.14
Acculturation
Anglo Orientation Score 1.16 (0.79, 1.69) 0.45 0.81 (0.48, 1.36) 0.43 0.73 (0.49, 1.09) 0.13
Latin American Orientation Score 0.84 (0.47, 1.48) 0.54 1.17 (0.52, 2.63) 0.70 1.14 (0.63, 2.07) 0.67
Values
Familism 1.35 (0.73, 2.49) 0.33 2.28 (0.83, 6.30) 0.11 0.50 (0.24, 1.05) 0.07*
Respect 2.36 (1.13, 4.93) 0.02* 2.64 (0.90, 7.76) 0.08* 0.34 (0.15, 0.80) 0.01*
30
Religion 1.25 (0.69, 2.27) 0.46 1.38 (0.58, 3.30) 0.47 0.62 (0.31, 1.26) 0.19
Gender Roles 1.00 (0.66, 1.52) 1.00 1.23 (0.71, 2.14) 0.47 0.73 (0.46, 1.14) 0.16
Material Success 0.64 (0.39, 1.05) 0.08* 1.11 (0.61, 2.02) 0.72 0.95 (0.59, 1.54) 0.84
Independence 0.65 (0.35, 1.18) 0.16 1.12 (0.50, 2.49) 0.79 1.19 (0.64, 2.24) 0.58
Competition 1.01 (0.66, 1.55) 0.97 1.74 (0.92, 3.30) 0.09* 0.68 (0.42, 1.10) 0.12
Latin-American Values 1.52 (0.75, 3.08) 0.25 2.21 (0.77, 6.38) 0.14 0.39 (0.17, 0.92) 0.03*
US cultural Values 0.68 (0.37, 1.26) 0.22 1.54 (0.69, 3.42) 0.30 0.81 (0.43, 1.54) 0.52
Psychosocial Assessment
Everyday Discrimination Scale 0.66 (0.39, 1.12) 0.12 1.57 (0.87, 2.83) 0.13 1.38 (0.79, 2.40) 0.25
Perceived Stress Scale 1.01 (0.96, 1.07) 0.65 1.00 (0.93, 1.07) 0.89 0.99 (0.94, 1.05) 0.84
Symptom Assessment
Number of bother PFD symptoms 1.00 (0.92, 1.08) 0.99 1.01 (0.91, 1.13) 0.79 0.98 (0.90, 1.06) 0.56
Number of bother POPD symptoms 1.08 (0.89, 1.32) 0.43 1.25 (0.96, 1.63) 0.09* 0.93 (0.76, 1.15) 0.51
Number of bother CRAD symptoms 1.03 (0.84, 1.26) 0.79 0.82 (0.59, 1.14) 0.24 0.88 (0.71, 1.08) 0.22
Number of bother UD symptoms 0.90 (0.74, 1.10) 0.29 1.01 (0.78, 1.31) 0.93 1.05 (0.85, 1.29) 0.67
Number of symptoms
Number of PFD symptoms 0.99 (0.91, 1.08) 0.83 1.04 (0.93, 1.17) 0.48 0.99 (0.91, 1.08) 0.87
Number of POPD symptoms 1.07 (0.86, 1.33) 0.57 1.37 (0.99, 1.91) 0.06* 0.99 (0.78, 1.24) 0.92
Number of CRAD symptoms 0.99 (0.83, 1.17) 0.89 0.92 (0.73, 1.17) 0.52 0.92 (0.76, 1.10) 0.34
Number of UD symptoms 0.89 (0.71, 1.12) 0.32 1.14 (0.82, 1.60) 0.43 1.12 (0.88, 1.41) 0.36
(ref) indicates reference group.
*Statistically significant at 0.1
Odds Ratios are from the logistic regression models for each dichotomous outcome.
a
indicates empty odds ratio due to small number,
31
Table 8. Multinomial univariate analysis for determinants of delays in seeking care
Determinants Months to delay in care-seeking from doctors Months to delay in sharing symptoms with friends or relatives
1st tertile 2nd tertile 3rd tertile 1st tertile 2nd tertile 3rd tertile
N n=24 n=24 n=24 n=25 n=14 n=18
Range (0, 0.933) (1.03, 20.267) (24.33, 447.43) (0, 0) (1, 24.37) (34.5, 383.47)
OR OR (95%CI) OR (95%CI) heterogeneity p-value OR OR (95%CI) OR (95%CI) heterogeneity p-value
Demographics
Age 1(ref) 0.98 (0.93, 1.03) 0.99 (0.94, 1.04) 0.65 1(ref) 1.01 (0.95, 1.07) 1.01 (0.96, 1.07) 0.86
Marital Status
(n,%)
0.49
0.07*
Married 1(ref) 1(ref) 1(ref) 1(ref) 1(ref) 1(ref)
Single/
unknown
1(ref) 0.84 (0.27, 2.64) 0.51 (0.16, 1.61) 1(ref) 0.19
+
(0.04, 0.79) 0.47 (0.13, 1.64)
Religion (n, %)
0.68
0.62
Catholic 1(ref) 1(ref) 1(ref) 1(ref) 1(ref) 1(ref)
Protestant 1(ref) 0.50 (0.04, 5.99) 1.33 (0.26, 6.78) 1(ref) 5.45 (0.50, 58.91) 0.00 (0.00, .)
Other 1(ref) 2.38 (0.38, 14.70) 1.58 (0.31, 8.15) 1(ref) 5.45 (0.50, 58.91) 1.82 (0.38, 8.73)
Education
Level (n,%)
0.11
1.00
Primary School 1(ref) 1(ref) 1(ref) 1(ref) 1(ref) 1(ref)
Secondary
School or
higher
1(ref) 0.59 (0.18, 1.90) 2.50 (0.64, 9.82) 1(ref) 0.97 (0.23, 4.15) 1.01 (0.26, 3.91)
Nativity (n,%)
0.33
0.44
Foreign born 1(ref) 1(ref) 1(ref) 1(ref) 1(ref) 1(ref)
US born 1(ref) 0.35 (0.06, 1.99) 1.27 (0.33, 4.89) 1(ref) 2.00 (0.35, 11.58) 2.82 (0.58, 13.79)
Employment
(n,%)
0.73
Unemployed/
Homemaker
1(ref) 1(ref) 1(ref) 1(ref) 1(ref) 1(ref) 0.55
Employed 1(ref) 1.07 (0.19, 5.91) 0.50 (0.07, 3.85) 1(ref) 0.00
a
(0.00, .) 2.33 (0.29, 18.97)
Acculturation
32
Anglo
Orientation
Score
1(ref) 0.67 (0.36, 1.25) 1.48 (0.84, 2.61) 0.04* 1(ref) 1.22 (0.66, 2.25) 1.24 (0.70, 2.19) 0.71
Latin American
Orientation
Score
1(ref) 2.32
+
(0.92, 5.83) 1.20 (0.58, 2.46) 0.20 1(ref) 0.74 (0.29, 1.86) 0.70 (0.30, 1.65) 0.69
Values
Familism 1(ref) 0.47 (0.17, 1.27) 0.39
+
(0.15, 1.05) 0.17 1(ref) 1.52 (0.57, 4.07) 0.99 (0.47, 2.12) 0.67
Respect 1(ref) 0.25
+
(0.08, 0.82) 0.23
+
(0.07, 0.73) 0.04* 1(ref) 2.47 (0.66, 9.28) 0.94 (0.41, 2.20) 0.36
Religion 1(ref) 0.44 (0.16, 1.21) 0.34 (0.12, 0.93) 0.11 1(ref) 1.86 (0.62, 5.58) 3.28
+
(0.89, 12.06) 0.16
Gender Roles 1(ref) 0.76 (0.41, 1.41) 0.48
+
(0.25, 0.93) 0.09* 1(ref) 0.87 (0.46, 1.66) 0.74 (0.41, 1.35) 0.62
Material
Success
1(ref) 1.09 (0.55, 2.13) 1.09 (0.55, 2.13) 0.96 1(ref) 0.87 (0.41, 1.84) 1.21 (0.62, 2.34) 0.70
Independence 1(ref) 1.13 (0.42, 3.03) 1.08 (0.40, 2.88) 0.97 1(ref) 0.78 (0.30, 2.06) 0.99 (0.40, 2.43) 0.87
Competition 1(ref) 0.57
+
(0.30, 1.10) 0.63 (0.33, 1.21) 0.22 1(ref) 0.82 (0.43, 1.57) 0.85 (0.47, 1.54) 0.80
Latin-American
Values
1(ref) 0.33
+
(0.10, 1.05) 0.22
+
(0.07, 0.70) 0.04* 1(ref) 1.52 (0.50, 4.57) 1.03 (0.41, 2.60) 0.74
US cultural
Values
1(ref) 0.73 (0.29, 1.84) 0.78 (0.31, 1.96) 0.78 1(ref) 0.77 (0.31, 1.89) 0.99 (0.43, 2.29) 0.83
Psychosocial
Assessment
Everyday
Discrimination
Scale
1(ref) 1.06 (0.46, 2.45) 1.89 (0.85, 4.21) 0.21 1(ref) 0.26
+
(0.08, 0.84) 1.07 (0.50, 2.33) 0.06*
Perceived
Stress Scale
1(ref) 0.94 (0.87, 1.02) 0.99 (0.91, 1.08) 0.30 1(ref) 0.89
+
(0.80, 0.99) 0.98 (0.90, 1.08) 0.07*
Symptom
Assessment
Number of
bother PFD
symptoms
1(ref) 0.95 (0.84, 1.08) 0.94 (0.83, 1.07) 0.62 1(ref) 1.06 (0.93, 1.22) 0.97 (0.86, 1.10) 0.49
Number of
bother POPD
symptoms
1(ref) 1.02 (0.76, 1.38) 0.85 (0.63, 1.15) 0.43 1(ref) 1.35 (0.93, 1.97) 0.94 (0.68, 1.30) 0.18
Number of
bother CRAD
symptoms
1(ref) 0.86 (0.64, 1.16) 0.86 (0.64, 1.16) 0.53 1(ref) 1.04 (0.74, 1.46) 0.91 (0.66, 1.27) 0.78
Number of
bother UD
symptoms
1(ref) 0.86 (0.64, 1.16) 0.97 (0.72, 1.30) 0.60 1(ref) 1.08 (0.78, 1.51) 0.98 (0.72, 1.32) 0.83
33
Number of
symptoms
Number of PFD
symptoms
1(ref) 1.01 (0.89, 1.14) 1.02 (0.90, 1.16) 0.94 1(ref) 1.06 (0.92, 1.23) 1.03 (0.90, 1.17) 0.72
Number of
POPD
symptoms
1(ref) 1.13 (0.82, 1.58) 1.06 (0.76, 1.46) 0.76 1(ref) 1.20 (0.80, 0.80) 1.08 (0.76, 1.54) 0.67
Number of
CRAD
symptoms
1(ref) 0.93 (0.72, 1.20) 0.96 (0.74, 1.24) 0.84 1(ref) 1.09 (0.82, 1.46) 0.99 (0.75, 1.31) 0.79
Number of UD
symptoms
1(ref) 1.06 (0.76, 1.47) 1.21 (0.85, 0.85) 0.57 1(ref) 1.10 (0.75, 1.63) 1.14 (0.79, 1.64) 0.76
(ref) indicates reference group.
+
Statistically significant at 0.1 for the Odds ratios by Wald’s test.
*Statistically significant at 0.1, and Odds Ratios are heterogeneity p-value to test the difference between OR for 2
nd
tertile and 3
rd
tertile.
a
indicates empty odds ratio due to small number.
34
Table 9. Multivariate analysis for determinates of discussing symptoms and seeking care
Outcome Determinates Odd Ratio p-value ll ul
Discuss symptoms with friend or
relatives
Perceived Stress Scale 1.03 0.61 0.93 1.14
Primary School (ref)
Secondary School or higher 1.48 0.58 0.36 6.09
Unemployed/ Homemaker (ref)
Employed 0.34 0.10 0.09 1.24
Seeking care for symptoms right
away
Respect 3.27 <0.01* 1.44 7.42
Material Success 0.49 0.01* 0.28 0.85
Not seeking care due to financial
concerns
Respect 1.84 0.31 0.57 5.95
Competition 1.46 0.31 0.71 3.01
The number of POPD symptoms 1.38 0.08 0.97 1.96
Not seeking care due to lack of
priority
Familism 0.41 0.03* 0.19 0.92
Age 1.05 0.03* 1.01 1.09
Not seeking care due to lack of
priority
Respect 0.31 0.01* 0.13 0.75
Age 1.04 0.04* 1.00 1.08
Not seeking care due to lack of
priority
Latin-American Values 0.29 0.01* 0.11 0.74
Age 1.05 0.02* 1.01 1.09
(ref) indicates reference group.
*Statistically significant at 0.05
35
Table 10. Multivariate analysis for determinates of time to seeking care
Outcome 1st tertile 2nd tertile 3rd tertile
heterogeneity
p-value
OR (95%CI) OR (95%CI)
Months to delay in care-
seeking from doctor
Latin American Orientation
Score
1(ref) 3.29
++
(1.21, 8.95) 1.75 (0.76, 4.05) 0.07
Respect 1(ref) 0.16
++
(0.04, 0.63) 0.15
++
(0.04, 0.59) 0.02*
Months to delay in sharing
symptoms with friends or
relatives
Everyday Discrimination Scale 1(ref) 0.34
+
(0.10, 1.16) 1.31 (0.56, 3.05) 0.11
Married 1(ref) 1(ref) 1(ref)
Single/ unknown 1(ref) 0.21
++
(0.05, 0.99) 0.38 (0.09, 1.56) 0.12
Religion 1(ref) 1.79 (0.50, 6.43) 3.62
+
(0.92, 14.34) 0.17
(ref) indicates reference group.
+
Statistically significance at 0.1 for the Odds ratios generated by multinominal logistic regression.
++
Statistically significance at 0.05 for the Odds ratios generated by multinominal logistic regression.
*Statistically significant at 0.05, and Odds Ratios are heterogeneity p-value to test the difference between OR for 2
nd
tertile and 3
rd
tertile.
36
Discussion
This study focused on understanding determinants of seeking care for PFDs among Latina women
in Los Angeles. We evaluated two different samples, one of community-resident Latina women, most of
whom had not sought out care yet for their PFDs, and a sample of Latina women already diagnosed with
PFDs, seeking care at urological clinics. This allowed us to identify determinants across the spectrum from
symptom recognition to seeking and receiving care from healthcare providers. The sample of community-
resident Latina women allowed us to identify determinants of intention to seek care, whereas the sample of
women in the clinic allowed us to identify determinants of having sought dare, and time to seeking care.
We observed that among both samples of women, employed women were less likely to discuss their PFD
symptoms with friends or relatives. Additionally, we observed that the lower scores for Latin-American
Values were key determinants for being more likely to not seek care due to lack of making symptoms a
priority. However, these two samples have many differences too. The community-resident Latina women
are a random sample of the population, whereas the women presenting to a clinic are a sample of the
population diagnosed with pelvic floor disorders. Therefore, we evaluated key determinants separately for
each sample, as we summarize below
Community women
In this study of the community Latina women, we evaluated possible determinants for discussing
their PFD symptoms with friends, relatives, or doctors, and for not seeking care due to financial reasons or
lack of making it a priority. We observed that higher scores for material success value, independence value,
and competition value were key determinants for being more likely to discuss symptoms with friends or
relatives. The higher the gender roles value, the material success value, and overall US cultural value were
the key determinants of more likely to discuss symptoms with doctors. Moreover, being unemployed, higher
scores for gender roles value, material success value and competition value were key determinants of being
more likely to seek care right away. A lower score for gender roles value, competition value, and overall
37
Latin-American values and US cultural values were key determinants of not seeking care due to not making
it a priority.
In a study done with a large Kaiser cohort, 57% of the total sample with PFDs reported seeking
care
27
, which is in contrast with our study where 44% Latina women had confided symptoms with a
healthcare provider, and only 38% sought care right away. Specifically for Latina women, 61% with pelvic
organ prolapse (POP), 52% with urinary incontinence (UI), 27% with anal incontinence (AI) reported
seeking care
27
. Additionally, in two other studies, younger age was a crucial determinant for seeking care
for PFDs
27,28;
however, in our study we did not observe age to have a significant role. This discrepancy
could be due to the modest size of our sample and differences in age distributions between studies, as well
as the fact that our study included women with a spectrum of health insurance, where one of these previous
studies included women with access to one specific healthcare provider.
It has been reported that a major barrier to seeking care of PFDs among African American (AA)
and Latina women is placing family demands before their own health needs
13
. In our study, we observed
that women with a high score in the US cultural values are more likely to discuss their symptoms with
friends, relatives, and doctors. The US cultural values included material success, independence, and
competition values, emphasizing the importance of achievement, self-reliance, and self-sufficiency. With a
high score in US cultural values, women are more likely to pay more attention to their own health needs
and seek care from others.
When considering the reasons for not seeking care, some qualitative studies reported that crucial
barriers included financial reasons
13
, lack of health information about PFDs
11–13
, and misunderstanding of
healthcare providers
12,29
. None of the determinants we considered showed significant associations with not
seeking care due to financial reasons . However, we observed that lower scores of gender roles, competition,
and overall US cultural values and Latin American Values were key determinants for not seeking care due
to not making it a priority. It suggests Latina women who have a low sense of female expectations (child-
rearing, protection of girls), competition with others to separate themselves, and low self-reliance and self-
sufficiency are more likely to not prioritize seeking care for PFD symptoms. The score for gender roles
38
may potentially associate with the attention to women-specific health needs, indicating that with high score,
women are more likely to focus on the importance of women health and seek care right away. To our
knowledge, there have been no other studies that examined the role of these specific Latino values using
the same scale we used here in relationship with seeking care of PFDs, so we cannot compare out findings
directly.
Clinic women
In the study of women recruited in the clinic, we evaluated possible determinants for discussing
their PFD symptoms with friends or relatives; whether not seeking care due to financial reasons or lack of
priority; as well as time to delaying in sharing symptoms with friends or discussing with doctors. We
observed that higher education level and unemployed status were key determinants of being more likely to
discuss symptoms with friends or relatives. The higher score for respect value and lower score for material
success were key determinants for being more likely to seek care right away. A lower education level,
higher scores for respect and competition values were key determinants for being more likely not to seek
care due to financial concerns. Additionally, the higher age, the lower scores for values of familism, respect,
and overall Latin-American Values were key determinants for not seeking care due to making it a priority.
When considering time to seeking care from doctors, higher Latin American Orientation score and lower
respect score were the crucial determinants. When considering time to delay in sharing symptoms with
friends, higher religion score and lower everyday discrimination score were crucial determinants.
One qualitative study examined Latina women’ knowledge and perceptions of POP, and reported
that key themes were feelings of shame, difficulty in talking with others for both English and Spanish
speaking women, and communication concerns specific for Spanish-only speaking women
30
. In this study,
69% of the Spanish speaking group reported a high school education or less
30
, which is comparable to the
observed 72% in our study. A cross-sectional study of English-speaking women in multiple clinics reported
that lower educational attainment was strongly associated with lack of knowledge proficiency for UI, POP
39
or both
31
. Similar to our study, lower education level was a key determinant for being less likely to discuss
symptoms with friends or relatives, as well as being more likely to not seek care due to financial reasons.
We observed that another key determinant seeking care right away was the value of religion. With
higher scores for religion value, women were more likely to seek care right away. With lower religion score,
women were more likely to not seek care due to lack of priority or delayed longer to seek care from doctors.
Moreover, when considering determinants of not seeking care due to making it a priority, in addition to the
value of respect, lower score for value of familism and overall Latin-American Values were key
determinants. This finding demonstrates that women who do not seek care due to making it a priority were
more likely to consider family or relatives’ demands first and ignore their own needs. Similar to our findings,
a previous qualitative study identified that a major barrier to seeking care among African American and
Latina women as placing family demands before their own health needs
13
. Overall, these findings suggest
that it is imperative to develop interventions that not only raise awareness about the importance of seeking
care for PFDs symptoms, but that also empower Latina women to prioritize making time to seek such care.
Efforts should be put to combine PFD screening/evaluation in conjunction with annual well women visits,
and to encourage health care providers to routinely ask a few questions about possible PFD symptoms
during regular check-ups.
Strengths and limitations
The strengths of this study include its focus on both community women and women presenting to
a clinic for PFD treatment, thus including a range of women at different stages in their journey dealing with
PFDs symptoms. To our knowledge, this is the first study to specifically investigate factors associated with
seeking care for PFDs symptoms among Latina women, including measures across various domains such
as demographics, Latinos/as cultural values, acculturation, stress, and clinical indicators of PFDs, using
instruments validated for use among Latinos/as. This work is also strengthened by the availability of
surveys in both Spanish and English, and the use of a promotora de salud to conduct the surveys among
40
women in the community. Another strength is that we only included women who self-identified as having
PFDs or were unsure about them, as women who did not identify them would not seek care.
Our study also includes several limitations. First, the sample size for both the community and clinic
sample was modest, leading to unprecise estimates with wide confidence intervals, and low statistical power
to detect associations of small magnitude. Second, we were unable to consider income data, as it was
deemed unreliable, with many women not knowing their household income. Incorporation of these data
would have helped with interpretation of our findings, especially when considering determinants for
delaying seeking care due to financial reasons. Third, this study describes the population in the east Los
Angeles area, where Latin American and Central American women comprise most of the Latino population,
and it is not a representative sample of all Latina women in Los Angeles or the US. Given the heterogeneity
of the Latinos/as population, with its racial, and geographic diversity, it remains to be evaluated if these
findings are generalizable to other populations of Latina women across the US.
Summary
In summary, our findings suggest that US cultural values including material success, independence,
and competition might be relevant in determining whether a Latina woman would like to discuss their
symptoms with friends or doctors in the community. In addition, the gender role value may determine if a
Latina woman seeks care right away or may not seek care due to making it a priority. The Latin-American
Values, such as values of respect, familism and religion may be relevant in determining whether a Latina
woman delay confiding her symptoms with friends, relatives, or doctors. Community outreach interventions
may benefit from taking these values into account, through storytelling or using personal vignettes through
videos that may incorporate themes and storylines that reflect these values, so that women can identify
themselves with the characters in the stories and feel empower to seek care. Such interventions should be
targeted to teach women about PFD symptoms, their treatability, and to empower them to listen to their
bodies and discuss their symptoms with their doctors at their annual check-ups. Moreover, interventions at
the provider level are needed, to raise awareness about cultural factors that may influence Latina women to
41
disclose and seek care for PFD symptoms, and to encourage providers to include a few questions about
possible PFD symptoms, to screen women who may benefit from further consultation with specialist .
Together, these interventions could lead to a decrease in disparities in receipt of care for PFDs. These
findings underscore the importance of considering an individual’s social and cultural context in trying to
understand their disease burden, their awareness of disease, and attitudes towards disease symptoms, as
they impact their ability to seek care and the impact of disease on their health-related quality of life.
42
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Abstract (if available)
Abstract
Purpose: Latina women suffer a higher burden of pelvic floor disorders compared to other racial/ethnic groups. In spite of this, they tend to delay seeking care. This study examined care-seeking behaviors among Latina women in the community, and Latina women presenting to Urology clinics in Los Angeles, with the goal of assessing whether cultural, psychosocial, and clinical factors could determine the willingness to discuss pelvic floor disorders (PFDs) symptoms and seek care. ❧ Methods/Materials: We did a cross-sectional study of Latina women in Los Angeles using standardized surveys, including measures of acculturation; Latin-American values (familism, respect, religion and gender roles) and US cultural values (independence, material success and competition); knowledge, attitude, behaviors and beliefs about PFDs; pelvic floor disorders symptoms; and measures of stress and discrimination. We included community Latina women (N = 197), and Latina women presenting to USC Urology clinics (N = 156). Both groups were evaluated separately. Descriptive statistics, univariate and multivariate logistic regression, and multinomial logistic regression were performed to identify variables associated with disclosing symptoms to friends or family, seeking care, and time to seek care (for clinic women only). In this study we included all women who responded ‘yes’ or ‘unsure’ to the question of “Do you have symptoms of a pelvic floor disorder?”, this included 57 community women and 110 clinic women. ❧ Results: Among community women (N = 57), 44% confided symptoms in a healthcare provider, and 38% sought care for symptoms right away. Higher score for independence value was associated with being more likely to disclose symptoms to friends or relatives (OR = 4.96, 95%CI = 1.27–19.31). Higher score for material success was associated with being more likely to seek care right away (OR = 3.85, 95%CI = 1.51–9.80). Lower US cultural value (OR = 0.23, 95%CI = 0.06–0.91) and Latin American Value scores (OR = 0.37, 95%CI = 0.14–1.01) were independently associated with being less likely to seek care due to not making it a priority. ❧ Among women recruited in the clinics (N = 110), the median number of months of delay in discussing symptoms with doctors or friends/family were 6.95 and 3, respectively. We did not have information about time to seek care for women residing in the community. Among women from the clinics, higher respect value scores were associated with women being more likely to seek care right away (OR = 3.27, 95%CI = 1.44–7.42), and being less likely to not seek care due to lack of priority (OR = 0.31, 95%CI = 0.13–0.75). Women who delayed longer to seek care from doctors were more likely to have higher Latin American Orientation Score (LAOS) (OR = 3.29, 95%CI = 1.21–8.95) and lower respect value (OR = 0.16, 95%CI = 0.04–0.63). ❧ Conclusions: The care-seeking behaviors of Latina women were influenced by their values including US values and Latin-American values. Interventions that take into account these Latin American values are needed to raise awareness about pelvic floor disorders and to encourage women to recognize symptoms and discuss them with their health care providers.
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Asset Metadata
Creator
Chen, Nanjun
(author)
Core Title
Determinants of delay in care seeking for pelvic floor disorders among Latina women in Los Angeles
School
Keck School of Medicine
Degree
Master of Science
Degree Program
Molecular Epidemiology
Degree Conferral Date
2021-12
Publication Date
10/01/2021
Defense Date
08/08/2021
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beliefs,care-seeking,Knowledge,Latina women,OAI-PMH Harvest,pelvic floor disorder
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Stern, Mariana Carla (
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), Garbanati, Lourdes Baezconde (
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nanjunch@usc.edu
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https://doi.org/10.25549/usctheses-oUC16021813
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Tags
beliefs
care-seeking
Latina women
pelvic floor disorder