The knowledge–symptom paradox in urinary incontinence: a health literacy and equity challenge in urban Southeast Asia

Background: Urinary incontinence (UI) affects nearly one in three women in Southeast Asia, yet remains underrepresented in public health agendas. Conventional models assume that symptom severity drives health knowledge and care-seeking. This study examined whether such assumptions hold true in Thai women and explored demographic predictors of UI knowledge. Gaps in health literacy for UI undermine progress toward Universal Health Coverage and gender-equitable health systems in low and middle-income countries (LMICs). Methods: We conducted a cross-sectional study of 700 overweight and obese Thai women (≥ 20 years) attending gynecological services at a major urban tertiary hospital in Bangkok (May–October 2024). Symptoms were assessed using the Thai-validated International Consultation on Incontinence Questionnaire–Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), and knowledge using the Thai-validated Prolapse and Incontinence Knowledge Questionnaire, UI subscale (PIKQ-UI). High symptom burden was defined as ICIQ-FLUTS ≥ 5, and adequate knowledge as ≥ 70% correct responses. Multivariable logistic regression identified predictors of adequate knowledge. Results: Mean age was 49.0 years (SD 14.1); all participants had BMI ≥ 25 kg/m². High symptom burden was observed in 404 women (57.7%). Only 50 women (7.1%) achieved adequate knowledge. Among women with high symptoms, 12 (3.0%) had adequate knowledge compared with 38 (12.8%) of those with low symptoms (χ²=25.1, p < 0.001). In multivariable analysis, high symptom burden was associated with significantly lower adjusted odds ratio (aOR) of adequate knowledge (aOR 0.25, 95% CI 0.09–0.71, p = 0.01). Higher education (aOR 1.72, 95% CI 1.04–2.97) and healthcare worker status (aOR 27.99, 95% CI 7.93–98.86) were the strongest predictors of knowledge. Conclusions: Thai women demonstrated critically low levels of UI knowledge regardless of symptom severity, with those most affected being least informed. This knowledge–symptom paradox highlights systemic inequities in women’s health literacy. Addressing this paradox is essential to reduce health inequities, improve women’s health literacy, and strengthen UHC implementation in Southeast Asia.