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Received: 12 March 2018 Revised: 29 June 2018 Accepted: 8 July 2018 DOI: 10.1111/and.13125
ORIGINAL ARTICLE
Association between the symptoms of benign prostatic hyperplasia and social disparities: Does social capital promote prostate health? Myung‐Bae Park1 4
Sung Won Kwon
| Dae Sung Hyun2,3 4
| Sae Chul Kim
| Jae Mann Song4
| Hyun Chul Chung5 1,6
| Chhabi Lal Ranabhat
7
| Tae Sic Lee
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Sang‐Baek Koh
1 Department of Gerontal Health and Welfare, Pai Chai University, Daejeon, Korea
Abstract
2
This cross‐sectional study investigated the relationships between socioeconomic fac‐
Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea 3
Department of Biostatistics and Computing, The Graduate School of Yonsei University, Seoul, Korea 4
Korea Prostate Health Council, Seoul, Korea 5
Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea 6
Manmohan Memorial Institute of Health Science, Solteemode, Kathmandu, Nepal
7
Department of Family Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
tors and social capital and benign prostatic hyperplasia symptoms. The participants were 100,000 adult men who participated in the Korea Community Health Survey. The surveyors used the International Prostate Symptom Score. As regards occupation, the prevalence of benign prostatic hyperplasia was higher in men with blue‐collar occupa‐ tions or those who were unemployed than in those with white‐collar jobs. In terms of marital status, the prevalence of benign prostatic hyperplasia was 1.319 times higher among divorced men than married men. As regards social capital, the prevalence of benign prostatic hyperplasia in men with positive attitudes towards one’s community scores that reflected good, poor and very poor community scores was 1.228, 1.246 and 1.447 times higher than that of men who had very good scores respectively. The groups with good, poor, and very poor community participation scores had 1.115, 1.202 and
Correspondence Sang‐Baek Koh, Department of Preventive Medicine, Yonsei University Wonju College of Medicine, 20 Ilsan‐Ro, Wonju‐City, Gangwon‐Do 26426, Korea. Email:
[email protected]
1.364 times higher prevalence of benign prostatic hyperplasia than the group with very
Funding information Medical Research Center Program of Korea government, Grant/Award Number: 2017R1A5A2015369
KEYWORDS
good scores. Social disparities and social capital of a community were associated with the prevalence of benign prostatic hyperplasia. Thus, the use of social capital in the community setting will be effective in the management of the condition.
benign prostatic hyperplasia, community health, social capital, social disparities, the International Prostate Symptom Score
1 | I NTRO D U C TI O N
in Asians is recently increasing (Ekman, 1989; Park et al., 2009). Although BPH does not directly affect mortality, it is associated
The prostate is an organ that embraces the urethra in the lower
with the symptoms of lower urinary tract infection, such as oligu‐
part of the bladder of men. Its weight is approximately 20 g. Benign
ria, urgency and nocturia, and it has negative effects on the quality
prostatic hyperplasia (BPH) is a disease that is characterised by
of life in terms of physical, mental and social aspects (Salinas‐
an increase in prostate weight and size due to ageing, lower uri‐
Sanchez et al., 2001). Pathologically, the cause of BPH remains un‐
nary tract occlusion, various paruria and other symptoms. It is one
clear; however, a change in age‐related sex hormone ratio, such as
of the most common andropathies, and its prevalence increases
oestrogen/androgen ratio, is a significant risk factor (Vignozzi et
with age. The prevalence of BPH in Asians is generally lower than
al., 2014). Furthermore, dihydrotestosterone (DHT) is associated
that in African Americans and Caucasians, although its prevalence
with the increased incidence of BPH (Parsons, 2010) and is made
Andrologia. 2018;e13125. https://doi.org/10.1111/and.13125
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from testosterone that is activated by 5‐alpha reductase (5‐ARI).
smoking, alcohol consumption, and diet; use of medical services; dis‐
Moreover, it has a better affinity for androgen receptors than tes‐
ease morbidity; vaccinations and physical examinations; accidents and
tosterone (Chatterjee, 2003; Nahata & Dixit, 2012). In this regard,
addiction; inactivity and quality of life; use of health institutions; socio‐
the use of drugs or surgical treatment is recommended to inhibit
physical environment; cardioplegy; education; and economic activities.
5‐ARI. Furthermore, herbal medicines that inhibit 5‐AR, which is
Raw data can be obtained from KCDC at the CHS website (https://chs.
expected to be relatively noninvasive and has lower side effects,
cdc.go.kr/). For this study, 2011 CHS data were used because the prev‐
is also effective in treating and improving BPH (Nahata & Dixit,
alence of prostate issues was investigated once in 2011; the subjects
2014; Steenkamp, Gouws, Gulumian, Elgorashi, & Van Staden,
were adult men aged 19 years and older.
2006). From a sociological and public health perspective, BPH is associated with various risk factors, and a variety of other risk fac‐ tors, including race, ethnicity, medical history, health behaviour
2.2 | Benign prostatic hyperplasia symptom
and chronic diseases, is also associated with BPH. From a perspec‐
The dependent variable of this study was BPH, which can be most
tive on health behaviour, BPH is significantly correlated to poor
accurately diagnosed with urine tests, blood testing for pros‐
dietary habits, such as high intake of fats, alcohol, milk and meat
tate‐specific antigen, ultrasound, International Prostate Symptom
(Thorpe & Neal, 2003), and it is also associated with body mass
Score (IPSS) and uroflowmetry test. However, it is difficult to
index (Araki, Watanabe, Mishina, & Nakao, 1983). Socioeconomic
conduct such clinical tests in a large‐scale population survey. The
factors may also influence BPH; generally, social disparities affect
IPSS has been widely used to assess BPH prevalence in large‐scale
health (Katz, 2001). However, the impacts of social disparities on
population studies, with a score of 8 or higher as the diagnosis
BPH have not yet been reported. Advanced studies on BPH have
criterion (KUA, KAFM, & KCS, 2015), and the IPSS was used for
mainly focused on racial and ethnic minorities in the United States
this study as well. It takes the form of a self‐report questionnaire
(Martinez, Maislos, & Rayford, 2008), but recent studies have em‐
and is effective for determining BPH (KUA, 2015; O’Leary, Wei,
phasised the effects of conventional social factors (such as race,
Roehrborn, & Miner, 2008); it has also been used to measure BPH
education and income) and social capital (an intangible factor) on
prevalence in community surveys (Barry et al., 2017; Choi, Lam, &
health. Social capital includes concepts, such as social exchange,
Chin, 2014; Goh, Kim, Nam, Choi, & Moon, 2015; Madersbacher
network, trust and civic participation, that affect all parts of so‐
et al., 2004).
ciety (Putnam, 2001). It is considered as a key factor for health and is correlated to mental health (Henderson & Whiteford, 2003) and physical health, including life expectancy, mortality, cancer, diabetes and infectious diseases (Kim, Subramanian, & Kawachi, 2008). Social capital and socioeconomic disparities have indepen‐ dent impacts on health, and social capital is sometimes correlated to health disparities as well (Uphoff, Pickett, Cabieses, Small, & Wright, 2013).
2.3 | Socioeconomic status (SES) Education and income are typical factors that affect health, and mar‐ ital status and history are also related to health outcomes (Robards, Evandrou, Falkingham, & Vlachantoni, 2012). For this study, house‐ hold income and type of health insurance were selected as the major SES variables.
From the perspective of public health, advanced research on BPH has focused on clinical studies. In terms of population group studies, most have focused on racial issues in specific countries. However, there are no studies on the effects of social capital on BPH. Therefore, this cross‐sectional study aimed to determine whether various socio‐ economic factors and social capital were correlated to BPH.
2.4 | Social capital Additionally for this study, social capital was divided into positive at‐ titude towards one’s physical community environment as well as par‐ ticipation in social activity; positive attitude was determined based on seven questions, and participation in social activity was evaluated using four items: religious, social, leisure and charity activities (Table 1). These
2 | M ATE R I A L S A N D M E TH O DS 2.1 | Data source The Korea Centers for Disease Control & Prevention (KCDC) has con‐
questions were developed by the “KCDC’s index committee” based on the theory of Putnam(Putnam, 2001) and Snelgrove (Snelgrove, Pikhart, & Stafford, 2009). All questions were yes/no, with one point for yes an‐ swers and zero points for no answers. The points were summed, and the total points were then divided into four quantiles and analysed.
ducted a Community Health Survey (CHS) since 2008 of 200,000 adults aged 19 years and older nationwide. The KCDC surveys house‐ holds extracted by stratified random sampling with computer‐assisted
2.5 | Statistical analysis
personal interviewing. The survey is divided into household and indi‐
To assess BPHs prevalence by characteristics, descriptive analysis
vidual surveys: The household survey includes family composition and
and cross‐tests were conducted. To identify factors related to BPHs,
family income, and the individual survey comprises 11 detailed items:
multiple logistic regression analysis was conducted. All analyses
basic information such as gender and age; health behaviour such as
were conducted using SAS for Windows 9.4.
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TA B L E 1 Social capital questionnaire Positive attitude towards community 1. My neighbours in town can trust each other. 2. In case of neighbours’ congratulations and condolences, we have a tradition of helping each other. 3. I am satisfied with the overall safety level in my town (natural disasters, traffic accidents, farm work accidents and crimes).
followed by 9.03% among the second (good) quantile, 13.31% among the third poor quantile and 18.68% among the men in the fourth (very poor) CPS quantile.
3.2 | Influences on BPHs To analyse factors that affected BPHs, multiple logistic regression
4. I am satisfied with the natural environment (air quality, water quality, etc.) in my town.
analysis was conducted, and the results are shown in Table 3. Model 1
5. I am satisfied with the life environment (electricity, water and sewage, garbage removal, sport facilities, etc.) in my town.
income, type of health insurance, and employment and marital status.
6. I am satisfied with public transportation (bus, taxi, subway, railway, etc.) in my town. 7. I am satisfied with the medical services (clinics, hospitals, traditional herbal medicine hospitals, pharmacies, etc.) in my town. Community participation • Do you participate in the following activities once a month or more regularly? 1. Religious activities 2. Social activities (alumni meetings, senior‐citizen centres, etc.) 3. Leisure activities 4. Charity
consisted of demographic characteristics: age, education level, monthly Model 2 included features of social capital, specifically the PAS and CPS. At last, Model 3 combined Models 1 and 2. In all models, smoking, alcohol consumption, and body mass index were adjusted for. In Model 1, the odds ratios (ORs) for BPHs among men in their 50s, 60s and 70s were 3.279, 6.030 and 8.378, respectively, reveal‐ ing a higher chance of having BPHs with increasing age. In the case of education level, the ORs for having BPHs were 1.627 and 1.469, respectively, for men with elementary school or less education and middle school education. By monthly household income, the ORs for having BPHs were, respectively, 1.328 and 1.231 for the men with monthly incomes of less than 1,000,000 KRW and of 1,000,000– 2,000,000 KRW. By health insurance type, the ORs for who were
3 | R E S U LT S
currently receiving or had received medical aid were 1.789 and
3.1 | Demographic characteristics and descriptive statistics
of having BPHs were, respectively, 1.240 and 2.148 for the men with
Participants’ demographic characteristics and BPHs prevalence
were 1.336 and 1.123 respectively.
1.450, respectively, and by employment status and type, the ratios blue‐collar jobs and the unemployed men. By marital status, the ORs for having BPHs among the currently widowed and divorced men
are summarised in Table 2. By age, prevalence was 4.23% among
In Model 2, the OR for having BPHs was 0.755 for men in the
the men aged 50 younger, 22.58% in men in their 50s, 41.29%
fourth (very poor) PAS quantile, and for the CPS, the ORs for the
in men in their 60 s and 56.90% in men in their 70 s and older;
second (good), third (poor) and fourth quantiles were 1.357, 1.916
that is, prevalence increased with age. By education level, BPHs
times and 2.682 respectively.
prevalence was 33.21% among men with elementary school edu‐
In Model 3, BPHs prevalence was significantly higher among men
cation or lower, 19.88% among middle school graduates and 6.78%
over age 50 and men with less education. By health insurance sub‐
among high school graduates; that is, BPHs prevalence decreased
scribers, the ORs in Model 3 for the men who were currently receiv‐
with higher education levels. By monthly household income, BPHs
ing medical aid and those who had in the past were 1.727 and 1.391
prevalence was 32.66% among men with monthly incomes of less
respectively. By job status, the ORs for BPHs in this model were,
than 1,000,000 KRW (one US dollar = about 1,230 KRW), 17.05%
respectively, 1.233 and 2.080 for the men with blue‐collar jobs and
among men with incomes of 1,000,000–2,000,000 KRW and 6.7%
those who were unemployed, and by marital status, divorced men
among those with incomes of more than 2,000,000 KRW; in short,
had an OR of 1.319. The ratios for the men who reported good, poor
the higher the monthly income, the lower the prevalence of BPHs.
and very poor PAS scores were 1.228, 1.246 and 1.447, respectively,
By health insurance type, BPHs prevalence was 31.57% among
and those for the men with good, poor and very poor CPS were
men who received medical aid, 24.35% among those who had pre‐
1.115, 1.202 and 1.364 also respectively.
viously received medical aid (ex‐medical aid) and 12.3% among those with national health insurance. By occupation, BPHs preva‐ lence was the highest, at 33.10%, among the unemployed men,
4 | D I S CU S S I O N
and by marital status, it was highest (39.31%) among divorced men. By the positive attitude towards the community scale score,
Benign prostatic hyperplasia is a natural phenomenon caused by
BPHs prevalence was the highest (16.35%) in the first (very good)
ageing, and because it has no direct relationship with mortality, men
PAS quantile, followed by 14.89% in the second (good) quantile,
neglect it until the symptoms worsen. However, BPH can deteriorate
14.60% in the third (poor) quantile and 11.88% in the fourth (very
the quality of life. It negatively affects urinary diseases, life expec‐
poor) quantile. By community participation score, BPHs preva‐
tancy and family health (Bhojani et al., 2014) as well as mental health
lence was lowest in the first (very good CPS) quantile at 7.20%,
because of symptoms, such as stress and depression (Rodrigues,
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IPSS
