Disparities Research for Pelvic Floor Disorders: systematic review and critique of literature

Objectives: To (1) characterize the landscape of PFD disparities literature using the three phases of disparities research agenda, (2) describe the characteristics of PFD disparities studies, and (3) identify critical knowledge gaps.

Methods: We performed a systematic review of peer-reviewed publications addressing disparities in PFDs (LUTS, POP, and AI). Using the triphasic framework for advancing health disparities research by Kilbourne et al., we categorized the included studies into the detecting phase (identifies and measures disparities in historically marginalized populations), understanding phase (establishes determinants of disparities), or reducing phase (conducts interventions to alleviate inequities). Within each phase, we identified the level of health determinants (patient, clinical encounter, provider, or healthcare system) measured in each study. For studies focused on patient level factors, we then used the surgical care access disparities conceptual model to categorize disparity outcomes into indication/detection of PFD, progression to treatment, receipt of optimal care, or provider access. We also identified the population of interest for each study and determined whether the authors attributed health disparities solely to individual characteristics versus structural factors such as all forms of racism, provider bias, institutional and societal policies, and inequitable allocation of resources. All screening, coding, and quality reviews were independently performed by two reviewers, with conflicts resolved by the senior author. We used descriptive analysis and chi-square for comparisons.

Results: We identified 123 studies between 1997 and 2022 (Figure 1) with 52.0% on LUTS, 25.2% on POP, 20.3% on multiple PFDs, and 2.4% on AI. Of the included studies, 98(79.7%), 22(17.9%), and 3(2.4%) were detecting, understanding, and reducing phase research, respectively. The most common disparity category investigated was race/ethnicity (104 studies), and only 32.9% attributed drivers of racial/ethnic differences to structural influences such as racism. The most measured detecting phase studies were on the indication/detection of PFD(64.3%) and followed by receipt of optimal care(15.3%), progression to treatment(14.3%), and provider access(6.1%). Of the 53 comparative studies on the indication/detection of PFD, 35.8% found historically marginalized populations having more prevalent or bothersome PFDs, 35.8% less prevalent/bothersome PFDs, and 28.3% with mixed results or no difference when compared to White individuals regardless of PFD types (P=.580). However, studies on progression to treatment, receipt of optimal care, provider access consistently demonstrated increased barriers and complications among historically marginalized populations (78.6%, 93.3% and 100%, respectively). Finally, although the volume of PFD disparities research is increasing, the trend showed detecting phase studies outpacing the growth of understanding and reducing phase research (Figure 2).

Conclusions: Most PFD disparities research focused on identifying historically marginalized populations with inadequate progression to understanding and reducing phases. Of the detecting phase studies, PFD detection was the most measured, yielding mixed results; however, the rest of the care continuum (progression to treatment, receipt of optimal care, provider access) demonstrated high percentages of barriers to marginalized populations. We recommend progressing PFD disparities research beyond the detecting phase to advance health equity in PFD.