Reducing Disparities in Urinary Control Symptoms for Minority Women

Several recent large, population-based studies report that the prevalence of bothersome urinary incontinence (UI) and lower urinary tract symptoms (LUTS) ranges from 55-73%, and a woman's lifetime risk of surgery for pelvic floor disorders is 20%. In other words, one in every five women can expect to undergo surgery for UI or prolapse by age 80, underscoring the public health impact of these conditions. For perspective, a woman's lifetime risk of breast and lung cancer are 15% and 6%, respectively. Although the lifetime risk of UI/LUTS is significantly higher than that of breast cancer or lung cancer, UI/LUTS have not received the same level of attention by the public or the healthcare community, despite the severe consequences on quality of life. Women are often embarrassed to seek treatment and lack knowledge about how to manage these bothersome conditions. These barriers lead to reduced healthcare-seeking for these disorders, which further exacerbates the detrimental consequences for quality of life. Similarly, the study team recently found in a geographically diverse, population-based study that housing insecurity, unreliable transportation, housing insecurity, not having enough money to make ends meet, and percent federal poverty levels of 300% or less were associated with more LUTS and lower perceived bladder health.

Additionally, there are disparities in access to treatment for PFDs and inclusion in PFD research for racially minoritized women. One important disparity is the lack of access to evidence-based non-surgical options (e.g., diet and weight loss counseling, behavioral modification, physical therapy (PT), and cognitive behavioral therapy (CBT)) that should be recommended to most women because these treatments can treat multiple PFDs and restore quality of life without the need for more invasive approaches. These conservative interventions are often not offered to racially minoritized women due to poor access and coverage. Improving non-surgical treatment of bladder symptoms is crucial because treatments are complex and multidimensional; treating one symptom surgically can sometimes exacerbate other symptoms. Up to 6% of women who have surgery for stress urinary incontinence (SUI) will undergo a second surgery within 9 years. Women are also at increased risk for de novo urinary symptoms (urinary incontinence and urinary tract infection) after surgical interventions. Likewise, bladder symptoms lead to emotional distress (i.e., anxiety and depression), and in turn, emotional distress can exacerbate UI/LUTS. In order to prevent this cycle of cumulative symptoms and distress, environmental barriers to LUTS must be reduced, and publicly-insured women of low socio-economic status should be able to have the same access to non-surgical interventions as privately insured women.

Pelvic floor physical therapy (PFPT) is a well-established first-line treatment for UI/LUTS. A 2014 Cochrane Review, which included 21 trials with 1281 incontinent women, compared pelvic floor muscle exercises to sham or control treatments. Patients who performed pelvic floor muscle exercises were 17 times more likely to be cured or improved. Standard pelvic floor physical therapy, which combines behavioral retraining and manual muscle therapy, takes 8-12 sessions and requires insurance coverage, copays, travel, a significant time commitment, and effective communication with the therapist. Although some hospitals employ pelvic floor physical therapists, most operate within private practices and do not work with Medicaid or Medicare payers. Likely as a result of these disparities, prior studies have found that racially minoritized women are more likely to assume that surgery is the only treatment option for PFDs.

This study is designed to address the disparity in available conservative/behavioral treatments for UI/LUTS. The investigators created a patient-centered, culturally adapted, self-directed, 8-week, home-based module for women with LUTS/UI. The SUPPORT program combines multiple evidence-based conservative treatments for LUTS/UI, including cognitive behavioral therapy, behavioral modifications, and home physical therapy exercises. The program was developed by experts from urogynecology, psychology, and physical therapy, and then modified based on focus group feedback from racially minoritized women. The inclusion of women from all races and ethnicities in the study will allow for comparisons across groups, providing the fullest understanding of how to deliver effective self-management for pelvic floor disorders. Progression through the home-based program is supported by research staff. The aim of this prospective interventional study is to assess the feasibility and acceptability of the SUPPORT program and its impact on patient-centered treatment outcomes.

The SUPPORT workbook follows a template for how pelvic floor physical therapy is delivered in the typical in-person setting with a combination of education, bladder re-training exercises, pelvic floor stretching, and core strengthening. The educational topics were chosen by consensus among the clinical experts as the most common and important clinical contributors to UI/LUTS symptoms and common areas of patient misinformation.

To aid in the demonstration of physical therapy exercises, the workbook includes QR-coded links to videos of a physical therapist performing the exercises in an ideal form. The videos include audio instruction to ensure that patients can learn the concepts in either visual, auditory, or written form.

Recognizing the limited time that patients have to engage with this intervention and mimicking the time commitment of standard pelvic floor PT, the investigators aimed to have the program take no more than 2 hours per week. This time commitment is split between time dedicated to reading the chapter, time spent completing the physical therapy or cognitive behavioral therapy exercises on a daily basis, and the time spent engaging in physical activity of the patient's choosing. Patients are counseled that exercise is important to the program as it improves core strength, pelvic floor mobility, bowel motility, and behavioral activation while reducing anxiety.

The cognitive behavioral therapy (CBT) portion of the workbook is adapted from the standardized CBT protocol and includes short introductions and exercises pertaining to cognitive flexibility, behavioral activation, and social support.

Recent advances in artificial intelligence, particularly in the development of large language models (LLMs), have opened new possibilities in healthcare. The investigators also aim to explore the use of a customized LLM-based health coach to assist women participating in the SUPPORT program. By providing real-time support and guidance, the AI health coach could help overcome barriers to care and keep patients engaged in the treatment. This approach has the potential to enhance the effectiveness of self-management programs for pelvic floor disorders, making care more accessible and helping more women achieve better health outcomes.

Major goals of the study include:

Aim 1. To use a human-centered, iterative approach with qualitative interviews to create and adapt a self-managed CBT (SM-CBT) intervention along with a self-directed behavioral modification/PT (Home PT) program for women with UI/LUTS from all races and ethnicities, including those who are minority, low-income, and publicly insured.

Aim 2. To determine the efficacy of the SUPPORT intervention on UI/LUTS outcomes as well as patient acceptability and adherence.

Aim 3. To evaluate a large language model-based digital coach's ability to be integrated into a self-managed pelvic floor program.