Women’s perceptions of public restrooms and the relationships with toileting behaviors and bladder symptoms: a cross-sectional study

Abstract

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 (ICIQ-FLUTS), and toileting behavior (TB-WEB). We compared women who reported limiting the 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 non-sitting positions when away from home and holding urine to avoid public restrooms, higher ICIQ-FLUTS scores, and more frequent overactive bladder and <7 voids a day.

Conclusions:

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

Introduction.

Public restrooms have existed since the dawn of urbanization and were hailed as the epitome of public works by the late 19^th century.¹ However, recent trends have been toward decreased access to and availability of public restrooms.² Women typically face more barriers to restroom use, such as fewer facilities, longer lines, care-giver duties, and additional biological needs (e.g. menstruation).^3,4 Lack of cleanliness is a common perception⁵ and women often adapt many toileting behaviors to cope, including self-restricting toilet use in public⁶ and hovering or crouching over the seat.⁷

Notwithstanding these common experiences, there is little scientific literature that examines public restrooms and the associations with toileting behaviors and bladder health. Therefore we sought to identify women’s attitudes and perceptions towards using public restrooms, to examine toileting behaviors and coping strategies women may adopt when confronted with public restrooms, and to explore the associations between LUTS and the use or avoidance of public restrooms. We previously conducted a cross-sectional, electronic survey of a convenience sample of non-institutionalized U.S. adults to collect information on self-reported LUTS, toileting behaviors, and perceptions of access to public toilets.^8,9 This study is a planned, secondary analysis focusing on public restroom use.

Methods

Eligibility and Recruitment

This was an IRB-approved (#171455), cross-sectional, survey-based study of a convenience sample of women identified through two recruitment referral databases available at our institution.^10–12 Between October and December 2017, approximately 106,000 potential subjects from Researchmatch and the Research Notifications Distribution list received a single email advertisement that incentivized women to complete an anonymous, English-only, electronic REDCap survey with the chance to win two randomly drawn Apple iPads. Of those, 7,892 at least started the survey, for a response rate of 7.4%. No data were available for non-responders.

We excluded non-cisgender women who were younger than 18 years, did not complete the questionnaires, were currently pregnant, or had medical comorbidities thought to affect their bladder function and potential use of the restroom (see Figure 1 for specific exclusion reasons). The final analytic sample included 6,004 women or 76% of the sample that responded to the invitation to participate.

Figure 1.

Participant disposition and creation of analytic data set

Data Collection

Participants reported whether they limited public restroom use by answering “Do you purposefully limit your use of the restroom out in public?” (Not at all, Occasionally, Sometimes, Most of the time, All of the time). Those responding at least occasionally were also asked to select reasons why (“Quality of the restroom is poor”, “Limited availability of a bathroom”, “Long line to use the bathroom”, and “Other reason”). We also asked: “based on when you used a public restroom, please rate how satisfied you are with the following” with questions specific to restroom accessibility, cleanliness, availability of toiletries, safety, and privacy. Responses were scored individually on a 10-point visual analog scale (1 extremely dissatisfied, 5 neutral, 10 extremely satisfied) for each domain.

Women completed the TB-WEB scale, which collects behavior responses across domains of place preference, premature voiding, delayed voiding, straining to void, and position preference.¹³ Subscale scores were created by summing responses for each domain and individual toileting behaviors were defined by whether or not a woman performs the behavior at least often (i.e. often or always vs. never, occasionally, or sometimes), representing habitual behavior.¹⁴

Bladder health outcomes were assessed with the ICIQ-FLUTS with a 4-week recall.¹⁵ We calculated a total LUTS score and defined LUT conditions based on frequency of voids (<7 voids a day) and whether the participant selected at least “sometimes” for urgency, UUI, and SUI. We defined OAB as urgency and/or UUI at least sometimes.¹⁶ Monthly UI was defined as any frequency of urine leakage in the past month and any amount of urine leaked more than “none”.¹⁷ Subjects reported whether they had 3 or more UTIs in the past year (i.e. recurrent UTI).

In addition, we collected self-reported information on: age; race/ethnicity; highest education; relationship status; general health; physical health; ability to carry out physical activities; use of cane, walker, or wheelchair; and parity. We also categorized participants by age group (18–24, 25–44, 45–64, >=65 years).¹⁸ Participants reported frequency of bowel movements (categorized as > 2 times a day; twice a day, once a day, or every other day; or every 3 or more days); whether or not they had any anal incontinence to solid stool, loose stool, or mucus,¹⁹ and; whether or not they had ever been diagnosed with IBS.

Statistical Analysis

The primary exposure for analyses was whether women avoided using public restrooms, defined as either “most of the time” or “always”, as we considered this to potentially reflect habitual behavior, in a manner analogous to dichotomous definitions reported for toileting behaviors.¹⁴ Women selecting “not at all”, “occasionally”, or “sometimes” were considered to not limit restroom use. For descriptive analyses, we summarized data as counts and percentages or medians with interquartile range, using Chi square or Wilcoxon rank sum tests. We used simple logistic and linear regression to estimate the strength of associations between toileting behaviors and restroom use.

To test our hypothesis that women who avoid public restrooms are more likely to report LUT conditions, we created multivariable logistic regression models to calculate ORs for each LUT condition as the dependent variable and whether women limited restroom use as the primary exposure variable. We similarly created a multivariable linear regression model with the total ICIQ-FLUTS score as the dependent variable. A beta coefficient greater than 0 or OR greater than 1 suggests a positive association between limited restroom use and LUTS or condition. Covariates in the model were selected a priori and included age, race, education, general health, pregnancies, and bowel movement frequency. All analyses used STATA 15.1 (StataCorp, College Station, TX).

Results.

Of the 6,004 women included in our sample, 1,249 (21%) did not limit their use of restrooms out in public, while 1,661 (28%) limited use occasionally, 1,500 (25%) sometimes, 1,147 (19%) most of the time, and 447 (7%) all of the time. Based on our exposure definition as limiting restroom use either “most of the time” or “all of the time”, we classified 1,594 (26%) women as limiting public restroom use and 4,410 (74%) as not.(Table 1) Demographically, women who limited restroom use were slightly younger, non-Hispanic Black, Multiracial, or Hispanic, less well-educated, and had greater parity. They also reported their general health, physical health, and confidence in carrying out physical activities lower than those who did not limit. They were also more likely to report limited mobility requiring a cane, walker, or chair, although this was uncommon overall.

Table 1.

Demographic information for the sample, according to whether they limit public restroom use most or all of the time or not. Data represent N (%) or Median (interquartile range, IQR)

	Do not limit	Limit restroom
N (%)	4,410 (74)	1,594 (26)
Age, Median (IQR)	37 (28 – 54)	37 (28 – 51)	.04
Age categories
18 – 24	587 (13)	209 (13)	<.001
25 – 44	2,110 (48)	820 (51)
45 – 64	1,327 (30)	477 (30)
>= 65	386 (9)	88 (6)
Race/Ethnicity
NonHispanic White	3,665 (83)	1,104 (69)	<.001
NonHispanic Black	236 (5)	226 (14)
Asian	186 (4)	66 (4)
Other/Multiracial	152 (4)	101 (6)
Hispanic	171 (4)	97 (6)
Education
Less than college	1,106 (25)	569 (36)	<.001
College or higher	3,304 (75)	1,025 (64)
Relationship status
Single	1,813 (41)	648 (41)	0.9
Married	1,954 (44)	717 (45)
Divorced/separated/widowed	643 (15)	229 (14)
General Health
Excellent	798 (18)	218 (14)	<.001
Very good	2,002 (45)	648 (41)
Good	1,223 (28)	479 (30)
Fair	337 (8)	201 (13)
Poor	50 (1)	48 (3)
Physical Health
Excellent	698 (16)	169 (11)	<.001
Very good	1,759 (40)	542 (34)
Good	1,368 (31)	549 (34)
Fair	500 (11)	272 (17)
Poor	85 (2)	62 (4)
Able to perform physical activities
Completely	3,536 (80)	1,142 (72)	<.001
Mostly	574 (13)	238 (15)
Moderately	202 (5)	134 (8)
A little	91 (2)	66 (4)
Not at all	7 (<1)	14 (1)
Uses a cane, walker, or wheelchair	91 (2)	60 (4)	<.001
Parity
0	2,253 (51)	694 (43)	<.001
1	579 (13)	236 (15)
2	720 (16)	267 (17)
3+	858 (20)	397 (25)

Perceptions and Use of Public Restrooms

Of the 79% women who reported as least occasionally limiting public restroom use, poor quality of the restroom was the most common reason why (84%), followed by long line (42%), accessibility (19%), and other reasons (14%).(Figure 2) Those who limited public restroom use most or all of the time consistently rated satisfaction with accessibility, cleanliness, availability of toiletries, safety, and privacy lower (Figure 3). Cleanliness received the lowest mean scores for both groups (5.0 [95% CI, 4.8 – 5.1] vs. 6.6 [95% CI, 6.5 – 6.6], respectively), followed by availability of toiletries (6.1 [95% CI, 6.0 – 6.2] vs. 7.3 [95% CI, 7.2 – 7.4]) and privacy (6.1 [95% CI, 5.9 – 6.2] vs. 7.3 [95% CI, 7.3 – 7.4]).

Figure 2.

Proportion of women who avoid public restrooms and reasons why.

Figure 3.

Mean visual analog scale scores for public restroom attributes, according to whether or not they avoid public restrooms.

Toilet Behavioral Habits

Women who limited restroom use reported more toileting behaviors considered to be unhealthy than those who did not limit (Table 2). Significant differences were particularly seen for place preference for voiding, with the majority of women who limit public restroom use worried about cleanliness of public toilets (OR 9.3) or try to hold urine until they get home (OR 15.6). Behaviors involving delayed voiding and straining to void were also significantly more common in women who avoided public restrooms.

Table 2.

Individual toileting behaviors and toileting behavior questionnaire subscale scores reported by women, according to whether they limit using the public restroom. Data presented as number (%) for individual behaviors or mean (95% CI) for subscale scores.

	Do not limit	Limit restroom	OR or Beta coefficient* (95 % CI)
Place preference for voiding
Worry about cleanliness of public toilets	2,156 (49)	1,433 (90)	9.3 (7.8, 11.1)
Avoid public toilets	721 (16)	1,287 (81)	21.4 (18.5, 24.9)
Empty bladder before leaving home	3,417 (77)	1,449 (91)	2.9 (2.4, 3.5)
Try to hold until get home	472 (11)	1,038 (65)	15.6 (13.5, 17.9)
Mean subscale score	12.5 (12.4, 12.6)	17.1 (17.0, 17.2)	4.6 (4.4, 4.7)
Premature voiding (voiding without feeling the need to)
At home	275 (6)	225 (14)	2.5 (2.1, 3.0)
When away from home	193 (4)	85 (5)	1.2 (0.9, 1.6)
At someone else’s house	129 (3)	86 (5)	1.9 (1.4, 2.5)
In public places	111 (3)	31 (2)	0.8 (0.5, 1.1)
Empty “just in case”	536 (12)	262 (16)	1.4 (1.2, 1.7)
Mean subscale score	8.9 (8.8, 9.0)	9.1 (8.9, 9.3)	0.2 (0, 0.4)
Delay voiding
Delay when busy	1,924 (44)	1,062 (67)	2.6 (2.3, 2.9)
Wait until cannot hold any longer	618 (14)	533 (33)	3.1 (2.7, 3.5)
Wait too long (until strong urge or leak)	665 (15)	506 (32)	2.6 (2.3, 3.0)
Mean subscale score	8.0 (7.9, 8.1)	9.6 (9.4, 9.7)	1.6 (1.4, 1.7)
Straining to void
To start urinating	270 (6)	168 (11)	1.8 (1.5, 2.2)
To keep urine flowing	312 (7)	199 (12)	1.9 (1.6, 2.3)
To empty bladder completely	466 (11)	262 (16)	1.7 (1.4, 2.0)
To empty bladder faster	430 (10)	304 (19)	2.2 (1.9, 2.6)
Mean subscale score	7.5 (7.4, 7.6)	8.3 (8.1, 8.5)	0.8 (0.6, 1.0)
Position preference, home
Sit on the toilet seat	4,361 (99)	1,562 (98)	0.5 (0.3, 0.9)
Crouch (hover) over the seat	100 (2)	79 (5)	2.2 (1.7, 3.0)
Squat on the seat	22 (1)	10 (1)	1.3 (0.6, 2.7)
Stand	0	4 (<1)	--
Mean subscale score	4.4 (4.4, 4.4)	4.6 (4.5, 4.7)	0.2 (0.1, 0.3)
Position preference, away from home
Sit on the toilet seat	2,992 (68)	624 (39)	0.3 (0.3, 0.3)
Crouch (hover) over the seat	947 (21)	750 (47)	3.2 (2.9, 3.7)
Squat on the seat	113 (3)	128 (8)	3.3 (2.6, 4.3)
Stand	29 (1)	38 (2)	3.7 (2.3, 6.0)
Mean subscale score	7.1 (7.0, 7.2)	8.9 (8.7, 9.0)	1.8 (1.6, 1.9)

^*Simple logistic or regression models of behavior or subscale against group

Almost all women reported sitting on the toilet seat when at home regardless of whether they limit public restrooms (98%); however, when away from home, those who limit public restroom use were much less likely to sit on the seat (OR 0.3) and more likely to hover (OR 3.2), squat on the seat (OR 3.3), or stand over the toilet (OR 3.7) compared to those who did not limit public restrooms.

Bowel and Bladder Health Outcomes

Even though most women reported having bowel movements as frequently as twice a day to once every 2 days (81%), women who limited public restroom use more commonly reported having a bowel movement fewer than once every 3 or more days (13.3% [95% CI, 11.7 – 15.1] vs. 7.8% [95% CI, 7.0 – 8.6]). Overall, 37% (95% CI, 35.9 – 38.3) of women reported anal incontinence to formed stool, liquid stool, or mucus, although this did not differ between groups. A history of self-reported IBS was more common among women who limit public restrooms (15.8% [95% CI, 14.1 – 17.7] vs. 12.7% [95% CI, 11.8 – 13.7]).

In terms of bladder health, women who limited public restrooms consistently reported higher LUTS scores and more frequent LUT conditions than those who did not limit restrooms (Table 3). After adjustment for covariables, total ICIQ-FLUTS score were slightly higher for those who limit restrooms (beta coefficient 0.42 [95% CI 0.14 – 0.71]). The proportions of women reporting urgency, urgency incontinence, OAB, stress urinary incontinence, recurrent UTIs, and <7 voids a day were also higher for those who limit restroom use; however, when adjusted for co-variates, only OAB (OR 1.17), SUI (OR 1.39), and <7 voids a day (OR 1.14) remained significant.

Table 3.

Lower urinary tract conditions reported by women, according to whether they do or do not limit public restroom use, including results of multivariable regression models.^*

	Do not limit restroom	Limit restroom	Regression model (95% CI)
ICIQ-FLUTS total score, mean (95% CI)	7.0 (6.8, 7.2)	8.0 (7.7, 8.3)	Beta 0.42 (0.14, 0.71)
Urgency, n (%)	819 (19)	376 (24)	OR 1.11 (0.96, 1.29)
Urgency incontinence, n (%)	696 (16)	321 (20)	OR 1.17 (1.00, 1.37)
Overactive Bladder (urgency +/− urgency incontinence), n (%)	1,093 (25)	504 (32)	OR 1.17 (1.02, 1.34)
Stress incontinence, n (%)	868 (20)	428 (27)	OR 1.39 (1.20, 1.60)
Urinary incontinence, monthly, n (%)	2,247 (51)	874 (55)	OR 1.08 (0.95, 1.22)
Recurrent UTI (3 or more in past year), n (%)	207 (4.7)	114 (7.2)	OR 1.28 (1.00, 1.64)
Void < 7 times per day, n (%)	2,462 (56)	1,024 (64)	OR 1.41 (1.24, 1.59)

^*Linear or logistic regression models, adjusted for age, race, education, general health, pregnancies, bowel movement frequency

Discussion.

Our study shows that most women have concerns and reservations about using public restrooms. Those who limit public restroom use most or all of the time had greater concerns particularly regarding cleanliness, toiletries, and privacy of public restrooms. Furthermore, these women also more commonly reported toileting behaviors that are generally considerd to be unhealthy, such as delayed voiding and non-sitting positioning, as well as unhealthy bowel and bladder symptoms, such as infrequent bowel movements and greater LUTS. While it is generally recognized that many women have an aversion to using public restrooms at times, this is one of first studies that has quantified this, as well as to examine toileting behaviors and LUTS as they relate to public restroom use.

Two recent studies from focus groups of women identified concerns about cleanliness as a major theme that underlies women’s experiences with using the restroom in public, including the behavior of self-restricting toilet use (i.e. deciding not to use toilet despite biologic need to urinate).^5,6 Concerns about cleanliness are thought to imply a fear of biological and bodily contamination (i.e. “catching something”) that underlies avoidance of public restrooms for many individuals.²⁰ However, there is little scientific basis for this fear; in fact, public restroom fixtures, including the toilet seat, often harbor fewer bacteria and biochemical markers for contamination than many commonly handled, everyday items.²¹ Nevertheless, this preconception is pervasive.

Women in this study who limited public restroom use more frequently reported toileting behaviors that are considered unhealthy, especially when performed habitually. Whether to sit on or hover over the toilet seat in a public restroom is a common consideration for many women. In this study, we found that women who limited public restroom use were significantly less likely to sit on the seat and more likely to hover, crouch on top of the seat (i.e. squat), or even stand over the toilet when away from home. Similar findings have been reported for women who limited restroom use while at work⁹ and among employed women in general.^17,22

Hovering or crouching over the toilet seat is generally considered an unhealthy behavior, as some evidence suggests this results in inefficient voiding and incomplete emptying.^7,23 Others have found few differences in uroflow parameters between seated and crouching positions.^24,25 Squatting, as is done using squat-toilets, is a more frequent toileting behavior for those living in many non-Western cultures and has been proposed as a more efficient toileting posture.²⁶ However, for the women in the present study, less than 1% overall reported squatting at home, suggesting this is not a common behavior in this sample.

While we detected significant differences in perceptions of public restrooms and toileting behaviors, we found only small or no differences in LUTS and LUT conditions. Total LUTS scores were higher in those who limit public restrooms, while SUI, OAB, and <7 voids a day were also more common, but the strengths of these associations were modest. It may be that women with frequency and/or urgency (with or without UUI) are generally not able to avoid using the restroom even though they may want to or may limit their activities so that they are not faced with public restrooms. On the other hand, awareness of public restroom availability and modifying behavior or activity to accommodate restroom availability (or lack thereof) are common quality of life factors for individuals with OAB.²⁷ The association with SUI is less clear. In this study SUI may be a marker for another behavior related to avoiding restrooms, for instance urine holding (i.e. a woman with a fuller bladder from avoiding a public restroom use may be more likely to have SUI).

A number of limitations to this study should be considered in interpreting the results. As a volunteer-based survey, the study is subject to an inherent selection bias. Incentivizing participation and the large number of study subjects help to mitigate this bias. While the response rate was low, it is consistent with unsolicited email advertisement studies using Researchmatch.^10,12 As a convenience sample of adult women participating in these recruitment resources, our study cohort does not necessarily reflect racial/ethnic and socio-economic diversity of the general population. Therefore, the findings may not generalize or be applicable to the population at large. Since this was a cross-sectional study, we cannot assess causality or temporal relationships. Also, there may be many, unrecognized factors that could contribute to the differences seen in this study between the two groups that were not assessed. As per the nature of a questionnaire-based study, we relied on self-report of LUTS and conditions, albeit with validated patient-reported outcome measures, when available. While developing this project, we found no examples of validated measures for assessing use or perceptions of public restrooms, and therefore we explored these constructs with non-validated items.

Despite these limitations, this study is significant because it examines not only women’s attitudes towards public restrooms but also the relationships between public restroom use, toileting behaviors, and LUTS. As one of the few such studies in the medical literature, the results have important implications for bladder health and public health advocacy and may help inform public policy towards public restroom availability and quality.

Conclusion.

In this study, most women limited their use of public restrooms at least occasionally and had concerns over cleanliness, availabilities of amenities, and privacy. Women who habitually limit public restroom use more frequently reported unhealthy toilet behaviors and some LUT conditions, namely SUI, OAB, and voiding <7 voids a day. As restroom accessibility and availability are generally underappreciated from a public health perspective, these results will help not only guide future research, but inform public policy and bladder health awareness.