U.S. Adolescent and Adult Women's Experiences Accessing and Using Toilets in Schools, Workplaces, and Public Spaces: A Multi-Site Focus Group Study to Inform Future Research in Bladder Health

Bladder Health Knowledge, Attitudes, and Beliefs among US Adolescent Women

STUDY OBJECTIVE

Lower urinary tract symptoms (LUTS) can have a pronounced impact on adolescent women's overall health and quality of life, both during adolescence and across the life course. Little research has examined adolescent women's knowledge, attitudes, and beliefs about bladder health and preventing LUTS.

METHODS

This study combines data from two large multi-site focus group studies of individuals born female who identified as women conducted by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. The first study included data from 8 focus groups conducted in 2018 with 44 adolescents aged 11 through 17 years. The second consisted of data from 20 focus groups conducted in 2020 with 123 adolescents aged 13 through 17 years. We used directed content analysis, including deductive and inductive approaches, to explore textual data and identify emergent insights. We present themes that emerged from analyzing coded data related to knowledge, attitudes, and beliefs.

RESULTS

Themes included: (1) lack of information about bladder function, leading to limited knowledge, (2) hydration as a healthy behavior, (3) distinguishing healthy versus unhealthy voiding, (4) social and environmental barriers to voiding, and (5) shame and stigma of bladder related behaviors.

CONCLUSION

Our data suggests that adolescent women are aware of healthy and unhealthy behaviors related to bladder health, despite little exposure to formal education about the bladder. Social and environmental factors, including stigma, appear to be primary drivers of adolescents' behaviors around bladder health, suggesting that multi-level socio-ecological prevention interventions are needed to prevent LUTS in this population.

Creating a community advisory board for pediatric bladder health

Introduction

Pediatric lower urinary tract symptoms (LUTS) are highly prevalent in neurologically healthy school-aged children. However, no evidence-based programs exist to prevent or treat LUTS in the community setting. To address this, we established the first community advisory board (CAB) that aims to identify individual and societal structures impacting pediatric bladder health in Northern California's Bay Area and co-design culturally relevant bladder health interventions.

Methods

Probability and non-probability sampling methods were used to recruit community stakeholders to the CAB. Our final CAB comprised of two parents, two community health workers, one educator, one pediatric urology registered nurse, and one pediatrician. The CAB met quarterly during the 1-year study period.

Results

Bi-directional feedback identified community-level barriers to bladder health, particularly in the school environment, and the need for tailored resources to teach children and families about healthy bladder behaviors.

Discussion

The CAB co-designed school-based bladder health interventions, including bladder health posters, and provided feedback on three school-based research study proposals. The CAB will continue to guide and inform future community-engaged research efforts.

Public toilets and their potential impact on an individual's health

In modern society, people engage in social interactions and activities outside their own home. When in public settings people may need to eliminate bodily waste, so public toilets are required. Accessibility, availability and adaptability are essential principles for safe, private, and purposeful visits to public toilets. A diverse range of individuals use public toilets: various age profiles, all gender groups, vulnerable individuals and people with additional needs. Public toilets essentially need to be a place of privacy, safety and cleanliness to facilitate elimination of urine, evacuation of faeces, management of menstruation, and changing/disposing of continence wear products in a secure environment.

Parental Knowledge, Beliefs, Practices, and Barriers Related to Children's Bladder Health in the School Environment

BACKGROUND

Pediatric lower urinary tract symptoms (LUTS) are a set of common childhood problems. Community-level interventions that target behavioral change among children with LUTS can improve symptoms outside of the clinic environment. Parents, navigating the home and school environments, are key in supporting healthy bladder behaviors. Thus, we asked parents about their perceptions and barriers related to pediatric bladder health.

METHODS

English-speaking parents (n = 30) of children ages 5-10 years with and without LUTS were interviewed. Transcripts were coded iteratively by two independent coders using deductive and inductive approaches that emphasized consensus coding and peer debriefing.

RESULTS

Ninety-three percent of participants were women, 50% were 30-39 years old, and 60% held a graduate degree. Parents identified school-, classroom-, and child-based barriers to bladder health. These included the bathroom environment, restrictive policies for bathroom use, and anxiety on how and when to use the bathroom.

CONCLUSIONS

Addressing school-, classroom-, and child-based barriers is necessary to promote healthy bladder habits among children in the school environment and beyond. Recommended school-based interventions include bathroom use and sanitation policies that support students' voiding needs, teachers' professional development, and school readiness initiatives. Limitations include participation of English-speaking parents only.

Black women's perspectives on bladder health: Social-ecological and life course contexts

AIMS

This paper explores Black women's perspectives on bladder health using a social-ecological conceptual framework and life course perspective.

METHODS

We conducted a directed content analysis of data from the Study of Habits, Attitudes, Realities, and Experiences (SHARE), a focus group study by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. Analysis was conducted on data from five focus groups and a member-checking session where all participants self-identified as Black or African American.

RESULTS

Forty-two participants aged 11-14 or 45+ years reported life course experiences with their bladder. The intersection of race and gender was the lens through which participants viewed bladder health. Participants' accounts of their perspectives on bladder health explicitly and implicitly revealed structural racism as an explanatory overarching theme. Participants described (a) historically-rooted and still pervasive practices of discrimination and segregation, engendering inequitable access to quality medical care and public facilities, (b) institutional barriers to toileting autonomy in educational and occupational settings, promoting unhealthy voiding habits, (c) internalized expectations of Black women's stereotyped role as family caregiver, compromising caregiver health, (d) lack of reliable information on bladder health, leading to unhealthy bladder behaviors, and (e) potentially stress-related comorbid chronic conditions and associated medication use, causing or exacerbating bladder problems.

CONCLUSIONS

Bladder health promotion interventions should address social-ecological and life course factors shaping Black women's bladder health, including social and structural barriers to accessing equitable health information and medical care.

Effect of household toilet accessibility on physical health of ethnic minority adolescents: a longitudinal study from the China Education Panel Survey 2013 and 2014

BACKGROUND

Accessing household toilets is vital for adolescent health during crucial stages of growth and development; however, some ethnic minority families in China lack toilets. The relationship between household toilet accessibility and the physical health of adolescents in China's ethnic minority areas has been underexamined.

METHODS

Using two waves of data from the China Education Panel Survey (2013 and 2014), this study explored the effect of household toilet accessibility on Chinese ethnic minority adolescents' physical health. The sample consisted of 576 ethnic minority adolescents with an average age of approximately 13 years. To test the health effect of household toilet accessibility on ethnic minority adolescents, a fixed effects ordinary least squares model and difference-in-differences combined with propensity score matching method were used.

RESULTS

The results of the fixed effects model and difference-in-differences combined with propensity score matching showed a significant and positive effect of household toilet accessibility on adolescents' physical health. The heterogeneity analysis indicated that among the toilet types of soil cesspits, cement cesspits, squat toilets, and flush toilets, the flush toilets were proven to be the most efficient in improving adolescents' physical health. Moreover, the family living arrangement was proven to play a moderating role in the effect of household toilet accessibility on the physical health of ethnic minority adolescents. The average marginal effects of household toilet accessibility on the physical health of ethnic minority adolescents who lived without parents were more evident and significant than those who lived with their parents.

CONCLUSION

Promoting household toilet accessibility in China's ethnic minority areas is essential for improving adolescents' health. Moreover, having a household toilet is not sufficient, the quality and dignity of household toilets are also important.

Need for Public Health Messaging Related to Bladder Health from Adolescence to Advanced Age

Objective: The purpose of this analysis was to explore adolescent and adult women's interest in public health messaging around bladder health and perceptions of its usefulness. Materials and Methods: Directed content analysis of focus group data from the Study of Habits, Attitudes, Realities, and Experiences, which explored adolescent and adult women's experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health across the life course. This article reports an analysis of the "Public Health Messaging" code, which included participants' desire or need for information about bladder health and recommendations for appropriate priority audiences. Results: Forty-four focus groups were conducted with 360 participants organized into six age groups (11-93 years). There was consensus across age groups that more information about the bladder is wanted and needed throughout the life course, as there is currently a lack of reliable educational resources. Information on bladder health was seen as useful and important because it enables people to anticipate negative changes in bladder health and act to prevent these. Several priority audiences were identified based on their risk of developing symptoms, but participants also saw value in educating the general public regardless of risk status. They also recommended education for parents and teachers who are in positions to control bathroom access. Conclusions: Results indicate a uniform desire for information on women's bladder health and a need for more research to develop individual prevention strategies and public health messaging for women of all ages, as well as guidance for organizations with a role in supporting bladder health.

Negative experiences with public bathrooms and chronic illness-related shame

INTRODUCTION

The use of public bathrooms is a challenge for everyone, but especially for those who are affected by a bathroom-dependent condition. Being dependent on bathrooms is linked with different negative emotions. One of them is a clinically relevant emotion: shame associated with the chronic condition.

MATERIALS AND METHODS

In a cross-sectional survey study (n = 193) of people who suffer a bathroom-dependent condition we asked about health conditions, well-being, and shame related to chronic condition outcomes.

RESULTS

We show a link between negative public bathroom experiences, and diminished well-being and feelings of shame related to chronic illness. We found that this relationship between negative experiences with public bathrooms and shame is not specific to the different conditions.

CONCLUSION

We conclude that the negative experiences which people with different gastrointestinal illnesses face is an environmental stressor associated with more embarrassment as a result of the condition suffered.

Humans peeing: Justice-involved women's access to toilets in public spaces

Justice-involved women face myriad challenges as they negotiate the terms of community supervision and manage the long-term implications and stigma of living with a criminal record. Major tasks that women juggle include securing safe, affordable housing, finding and retaining employment, accessing physical and mental health care (including substance use treatment), and handling relationships with family, friends, children, and intimate partners. In addition to these responsibilities, women must meet their basic physiological needs to eat, sleep, and use the toilet. Women's ability to safely meet their personal care needs may impact their capacity to manage their criminal-legal challenges. This study uses qualitative methods to understand justice-involved women's lived experiences related to urination. Specifically, the study reports on a thematic analysis of 8 focus groups conducted with justice-involved women (n = 58) and the results of a toilet audit conducted in the downtown areas of the small city in the United States where the focus group participants were living. Findings suggest that women had limited access to restrooms and reported urinating outside. Lack of restroom access impacted their engagement with social services support and employment and their ability to travel through public spaces. Women perceived their public toilet options as unsafe, increasing their sense of vulnerability and reinforcing the idea that they did not have full access to citizenship in the community because of their criminal-legal involvement. The exclusion and denial of women's humanity that is perpetuated by a lack of public toilet access impacts women's psychosocial outcomes. City governments, social service agencies, and employers are encouraged to consider how lack of toilet access may impact their public safety and criminal-legal objectives and expand opportunities for people to access safe restroom facilities.

Adolescent Women's Perspectives on Barriers and Facilitators to High School Bathroom Use

Bathroom access and use in conjunction with biological urge to void is an important part of optimal bladder health. School settings are uniquely positioned to influence the development of bladder habits. The aim of this study was to identify barriers and facilitators to high school bathroom use for adolescent women. A qualitative study design was used to conduct semi-structured interviews focused on experiences with bathroom use while at school. Thirty adolescent women were interviewed, and transcripts were analyzed using thematic analysis methods. Barriers included unpleasant bathroom environments, lack of privacy, and school/teacher policies. Facilitators included clean, private bathrooms and menstruation. Improving bathroom cleanliness, privacy, and eliminating policies aimed at controlling bathroom access may reduce barriers to bathroom use. School nurses have a unique role in educating teachers, administrators, and students about the importance of clean bathrooms and policies that support bathroom use in conjunction with biological urge.

Noncancerous Genitourinary Conditions as a Public Health Priority: Conceptualizing the Hidden Burden

OBJECTIVE

To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood.

METHODS

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden.

RESULTS

The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects).

CONCLUSION

NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.

Public toilets from the perspective of users: a case study in a public place, Brazil

Public toilets are essential infrastructure to guarantee the right to sanitation in public spaces and, in more general terms, the right to inclusive and sustainable cities. Moreover, since the equipment has a direct user interface, it is important to understand their demands and needs. Given this, the present research aims to understand the perspective of public toilet users on the Pampulha Lake Shore (PLS), a public touristic place in Belo Horizonte, Brazil. For that, observations and semi-structured interviews were carried out with different public toilet users. In addition, comments posted on the Google Local Guides tool of Google Maps were used as a secondary database for understanding users' experience of PLS toilets. The analysis made it possible to identify aspects related to availability, quality (health and hygiene), security, and accessibility. Collected data showed how the conflicting choice of whether or not to use the toilet was directly related to the health and conservation of the urban equipment and interfered with social and leisure prospects. On the whole, the importance of the user's perspective was highlighted in this study with emphasis on elaborating adequate urban planning with regard to health, sanitation, and accessibility issues.

Real-time daily assessment of work interference on healthcare professionals' restroom use: A pilot study

AIMS

Certain occupations may predispose individuals to develop lower urinary tract symptoms presumably through the adoption of unhealthy toileting behaviors. This study aimed to pilot the feasibility of recording healthcare workers' perceptions of daily, work-related interference with toilet use using a cellular, text-based survey tool.

METHODS

A cohort study of adult healthcare professionals completed a baseline questionnaire, a daily survey for fourteen consecutive days regarding their restroom use for the current workday, and a posttest survey providing feedback on study design and participation. Contributors to daily toilet use were analyzed in a linear mixed effects model that allowed for modeling effects within a given day. A backward stepwise regression was performed to assess for the presence of the effect of toilet use among control variables.

RESULTS

Increased work burden (i.e., increased inconvenience for using the restroom at work) was provisionally found to be associated with fewer voids per day. The number of voids at work was also associated with the number of breaks, urinary urgency, and limiting fluids. Subjects reported that participation in the study was easy, did not interfere with work, and that they would be willing to participate again in a similar study.

CONCLUSION

The utilization of a daily text message survey is a feasible way to study healthcare workers and their toileting behaviors at work. A larger similarly designed study could potentially confirm that limitations to restroom use may result in toileting behaviors that could predispose healthcare workers to develop bothersome urinary symptoms. Further investigation is warranted.

School Toileting Environment, Bullying, and Lower Urinary Tract Symptoms in a Population of Adolescent and Young Adult Girls: Preventing Lower Urinary Tract Symptoms Consortium Analysis of Avon Longitudinal Study of Parents and Children

OBJECTIVES

To examine whether the school toilet environment at age 13, including bullying at toilets, is associated with female lower urinary tract symptoms (LUTS) at ages 13 and 19, as little is known about the association among school toilet environment, voiding behaviors, and LUTS in adolescent girls.

METHODS

The sample comprised 3962 female participants from the Avon Longitudinal Study of Parents and Children. At age 13, participants reported on 7 school toilet environment characteristics and a range of LUTS items. At age 19, participants completed the Bristol Female Lower Urinary Tract Symptoms questionnaire.

RESULTS

All toilet environmental factors were associated with at least 1 LUTS outcome at age 13. Holding behavior was associated with all school toilet environmental factors, with odds ratios ranging from 1.36 (95% confidence interval [CI]: 1.05, 1.76) for dirty toilets to 2.38 (95% CI: 1.60, 3.52) for feeling bullied at toilets. Bullying was associated with all daytime LUTS symptoms and nocturia; odds ratios ranged from 1.60 (95% CI: 1.04, 2.07) for nocturia to 2.90 (95% CI: 1.77, 4.75) for urgency. Associations between age 13 school toilets and age 19 LUTS were in the same direction as age 13 LUTS.

CONCLUSION

This is the first examination of associations between school toilets and LUTS. Toileting environments were cross-sectionally associated with LUTS in adolescent girls. While further work is needed to determine whether these associations are causal, school toilet environments are modifiable and thus a promising target for LUTS prevention.

Social Processes Informing Toileting Behavior Among Adolescent and Adult Women: Social Cognitive Theory as an Interpretative Lens

Little is known about social processes shaping adolescent and adult women's toileting behaviors. The "Study of Habits, Attitudes, Realities, and Experiences" (SHARE) examines adolescent and adult women's experiences related to bladder health across the life course. Forty-four focus groups with 360 participants organized by six age groups were conducted across seven sites. A transdisciplinary team used social cognitive theory as an interpretive lens across a five-stage analysis. The act of observing was identified as the overarching social process informing women's toileting behaviors in three ways: (a) observing others' toileting behavior, (b) being aware that one's own toileting behaviors are monitored by others, and (c) observing oneself relative to others. We found that underlying processes of toileting behaviors, seemingly private are, in fact, highly social. We suggest, given this social embeddedness that health promotion efforts should leverage interpersonal networks for "social norming" interventions and policies to promote healthy toileting behaviors.

The impact of COVID-19 on surgical training: a systematic review

Background

Coronavirus disease (COVID-19) has caused global disruption to health care. Non-urgent elective surgical cases have been cancelled, outpatient clinics have reduced and there has been a reduction in the number of patients presenting as an emergency. These factors will drastically affect the training opportunities of surgical trainees. The aim of this systematic review is to describe the impact of COVID-19 on surgical training globally.

Methods

The review was performed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered with the Open Science Framework (OSF). Medline, EMBASE, PubMed and the Cochrane Central Register of Controlled Trials were searched.

Results

The searches identified 499 articles, 29 of which were included in the review. This contained data from more than 20 countries with 5260 trainees and 339 programme directors. Redeployment to non-surgical roles varied across studies from 6% to 35.1%. According to all of the studies, operative experience has been reduced. Knowledge learning had been switched to online platforms across 17 of the studies and 7 reported trainees had increased time to devote to educational/academic activities. All of the studies reporting on mental health report negative associations with increased stress, ranging from 54.9% to 91.6% of trainees.

Conclusions

The impact of COVID-19 on surgical trainees has been experienced globally and across all specialities. Negative effects are not limited to operative and clinical experience, but also the mental health and wellbeing of trainees. Delivery of surgical training will need to move away from traditional models of learning to ensure trainees are competent and well supported.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-020-02404-5.

Women's Perceptions of Public Restrooms and the Relationships with Toileting Behaviors and Bladder Symptoms: A Cross-Sectional Study

PURPOSE

Because current knowledge about public restroom use and bladder health is limited, we sought to identify why women avoid public restrooms and the associations of lower urinary tract symptoms and toileting behaviors.

MATERIALS AND METHODS

Between October and December 2017 we recruited a convenience sample of U.S. women to complete a cross-sectional, anonymous questionnaire about public restroom use, lower urinary tract symptoms (International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms [ICIQ-FLUTS]) and toileting behavior (Web-Based Toileting Behavior [TB-WEB]). We compared women who reported limiting public restroom use all or most of the time to those who did not limit or did so occasionally or sometimes.

RESULTS

Of the 6,004 women in the study 26% limited public restroom use most or all of the time and were more concerned with cleanliness than those who did not limit public restroom use. They also reported more often using nonsitting positions when away from home and holding urine to avoid public restrooms, higher ICIQ-FLUTS scores, more frequent overactive bladder and fewer than 7 voids a day.

CONCLUSIONS

A large number of women reported avoiding public restrooms, often over concerns of cleanliness, availability of amenities and privacy. Women who habitually limit public restroom use more frequently reported unhealthy toilet behaviors and lower urinary tract conditions. These findings will help guide future research and inform public policy and bladder health awareness.

Is the juice worth the squeeze? Transdisciplinary team science in bladder health

AIMS

Prior research on lower urinary tract symptoms (LUTS) has focused on the treatment and management of these conditions with scant attention to prevention. The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium was formed to address the complexities of preventing LUTS and promoting bladder health.

METHODS

Herein, we describe challenges faced and strategies used to develop the PLUS Research Consortium into an engaged and productive transdisciplinary scientific team. We apply four previously defined team science phases (development, conceptualization, implementation, and translation) to frame our progress.

RESULTS

Strategies to progress through the development phase included the generation of a shared mission, and valuing of other disciplinary perspectives. The conceptualization phase included generating a shared language and developing a team transdisciplinary orientation. During the implementation phase, the group developed roles and procedures and focused on conflict management. The translation phase includes continued refinement of the mission and goals, implementation of research protocols, and robust dissemination of the scientific work products related to bladder health.

CONCLUSION

A diverse group has matured into a productive transdisciplinary team science consortium. Achieving this outcome required dedicated effort for each member to engage in activities that often required more time than single discipline research activities. Provision of the necessary time and tools has fostered a transdisciplinary team science culture and rich research agenda that reflects the complexity of the health issue to be addressed. Our experience may be useful for others embarking on team science projects.

Why Do Women Not Use the Bathroom? Women's Attitudes and Beliefs on Using Public Restrooms

There are a variety of factors and influences, both internal and external, that may impact an individual’s public toileting experience and may ultimately have repercussions for bladder health. This study sought to identify predominant constructs underlying a women’s attitude towards using restrooms at work, at school, and in public in order to develop a conceptual model incorporating these themes. We performed a secondary analysis of a cross-sectional, survey-based study that included open-ended questions about limitations to restroom use using a mixed-methods approach. Qualitative data coding and analysis was performed on 12,583 quotes and, using an iterative inductive-deductive approach, was used to construct the conceptual framework. Our conceptual framework reveals a complicated interplay of personal contexts, situational influences, and behavioral strategies used by women to manage their bladder and bowel habits away from home. These findings can inform future research and public policy related to bladder health awareness related to toilet access in the workplace and in public.

Laying the Foundation for Bladder Health Promotion in Women and Girls

Prevention strategies have been effective in many areas of human health, yet have not been utilized for lower urinary tract symptoms (LUTS) or bladder health (BH). This commentary outlines LUTS prevention research initiatives underway within the NIH-sponsored Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS). Prevention science involves the systematic study of factors associated with health and health problems, termed protective and risk factors, respectively. PLUS is enhancing traditional prevention science approaches through use of: (1) a transdisciplinary team science approach, (2) both qualitative and quantitative research methodology (mixed methodology), and (3) community engagement. Important foundational work of PLUS includes development of clear definitions of both BH and disease, as well as a BH measurement instrument that will be validated for use in the general population, adolescents, and Latinx and Spanish-speaking women.¹ The BH measurement instrument will be used in an upcoming nationally-representative cohort study that will measure BH and investigate risk and protective factors. PLUS investigators also developed a conceptual framework to guide their research agenda; this framework organizes a broad array of candidate risk and protective factors that can be studied across the life course of girls and women.¹ As PLUS begins to fill existing knowledge gaps with new information, its efforts will undoubtedly be complemented by outside investigators to further advance the science of LUTS prevention and BH across additional populations. Once the BH community has broadened its understanding of modifiable risk and protective factors, intervention studies will be necessary to test LUTS prevention strategies and support public health efforts. LUTS providers may be able to translate this evolving evidence for individual patients under their care and act as BH advocates in their local communities.