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

Abstract

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-staged analysis. The act of observing was identified as the overarching social process informing women’s toileting behaviors in three ways: (1) observing others’ toileting behavior; (2) being aware that one’s own toileting behaviors are monitored by others; and (3) 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.

Introduction

Prevention efforts traditionally target conditions with substantial population health impact, such as cardiovascular and mental health conditions. Unlike other health conditions with significant burden and impact, the promotion of bladder health and prevention of lower urinary tract symptoms (LUTS) among adolescent and adult women has rarely been addressed for prevention. Bladder health is defined as a complete state of physical, mental, and social well-being related to bladder function and not merely the absence of LUTS (Lukacz, 2018). Lower Urinary Tract Symptoms encompass a range of conditions including stress and urgency urinary incontinence, urinary urgency, frequency, nocturnal enuresis, difficulty urinating, and bladder or urethral pain (Lowder, 2019; Haylen, 2010). LUTS are highly prevalent conditions, with at least one LUTS affecting an estimated 47% of the female world population in 2008 (Irwin et al., 2011). In a study of women in the United States, United Kingdom and Sweden, the prevalence of at least one LUTS at least ‘sometimes’ was 76.3% for women; with 52.5% of female participants with LUTS reporting the experience of symptoms “often” or “more” (Coyne, 2009). LUTS have a significant impact on quality of life, as women with LUTS report higher rates of anxiety, depression, and social isolation (Coyne, 2009; Coyne, 2013; Grzeda, 2017). Despite the proportion of the population of adolescent and adult women affected by LUTS, the factors that promote bladder health, remain largely underexplored at the individual and population level across the life course.

Women’s discourse about the importance of maintaining bladder health and function across the life course occurs primarily in family and friendship groups (Williams et al., 2020). Recent efforts to promote bladder health and prevent LUTS reveal a role for qualitative research to identify the underlying social processes shaping lay women’s assumptions and practices related to bladder health and function (Low et al., 2019). In particular, the identification of the social processes underlying toileting behaviors, such as norms regulating bathroom use (Camenga et al., 2019), can inform our understanding of risk or protective factors for bladder health. Social processes underlying toileting behaviors, and social norms including frequency of visiting the bathroom to void (empty one’s bladder), voiding position, and duration in the bathroom, may in fact be risk or protective factors for bladder health. Exploration of these social processes are needed.

Social cognitive theory (SCT) (Bandura, 1986) provides a framework for investigating the psychosocial and socioecological underpinnings of the processes of toileting behaviors. SCT operates primarily at the interpersonal level of social ecology, explaining human behavior in terms of the reciprocal interaction of cognitive, behavioral, and social-environmental factors. This framework maintains that individuals are self-regulating and self-reflective agents who acquire knowledge by observing and interacting with others and being exposed to social messaging. Individuals process what they have learned to determine its relevance for their own behavior. SCT encompasses a variety of constructs that influence behavior, including observational learning, knowledge, normative beliefs, outcome expectations, intentions and goal setting, behavioral skills, self-efficacy, collective efficacy, social support, reinforcement and punishment, and barriers and opportunities (Kelder, Hoelscher, & Perry, 2015).

SCT has been used in research on adolescent and adult health behaviors as an explanatory framework and as a tool to guide intervention programs promoting health behavior change among women. Application of SCT has aided planning interventions for health behavior changes in women ranging from HPV vaccination initiation among adolescents (Teitelman et al., 2011; Willis & Knobloch-Westerwick, 2014), breastfeeding among new mothers (Edwards et al., 2018; Schindler-Ruwisch et al., 2019), to osteoporosis prevention in older ages (Schmiege et al., 2007).

One area in women’s health that is notably absent from this social cognitive conversation is toileting behaviors. The purpose of this paper is to gain insight into the underlying social processes shaping toileting behaviors and habits. Toileting behaviors and habits include activities associated with voiding or urination, such as use of the bathroom and toilet (public or private), the way women void, what they hear or see related to voiding practices, and social norms informing voiding habits. The construct of toileting behaviors, as addressed in this manuscript, excludes direct activities involved in toileting others (e.g., children, older adults) but may involve observation of others who are involved in toileting other individuals.

Methods

This study was conducted by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium, a transdisciplinary network of seven geographically diverse research centers and a Scientific and Data Coordinating Center designed to expand research related to promotion of bladder health in adolescent and adult women (Harlow et al., 2018). The PLUS Consortium launched its research with a multi-site exploratory qualitative study to ground its efforts in adolescent and adult women’s lived experiences, the Study of Habits, Attitudes, Realities, and Experiences (SHARE). The present study analyzes specific codes from the SHARE focus group transcripts.

The SHARE study used focus group methodology and a community-engaged research approach to explore adolescent and adult women’s experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health and function across the life course. Focus group methodology was well-suited for gaining insight through discourse and discussion from a small group of individuals who share a social context (Kamberelis et al., 2014). A multidisciplinary team, with expertise in nursing, adolescent health, behavioral and social sciences, and public health, led the analysis and interpretation of findings. The full protocol has been published elsewhere (Low et al., 2019).

Participants

Participants were adolescent and adult women, across a broad age range (11–65+), recruited at seven geographically diverse research centers. We used an intentional recruitment approach based on community relationships to reach a socially diverse population of adolescent and adult women across the life course. The recruitment approach included the identification of age-appropriate methods and key socio-contextual characteristics of females within each subgroup. As focus group sessions were completed, we examined and monitored the composition of the sample cumulatively, within and across age groups. Recruitment was coordinated across centers to strategically determine the composition of each focus group and ensure overall study participant diversity. We aimed to recruit a sample that was diverse with respect to race, ethnicity, education, socioeconomic status, geography (urban/rural), and language. To this end, a subset of focus groups were conducted in Spanish.

Applying a life course perspective, participants were recruited and organized into six age categories from early adolescents to older women. See Table 1 below.

Table 1:

Age Distribution of Women across 44 Focus Groups

	Overall	Ages 11–14	Ages 15–17	Ages 18–25	Ages 26–44	Ages 45–64	Ages 65+
N	360	18	26	51	72	104	89
Number of focus groups	44	4	4	6	9	11	10
Age yrs, mean (SD)	45.8 (21.6)	12.4 (1.1)	16 (0.8)	21.8 (2.1)	34.9 (5.8)	54.9 (5.9)	73.2 (6.9)
Age yrs, range	11–93	11–14	15–17	18–25	26–44	45–64	65–93

Eligibility for participation included being 11 years of age or older, being assigned female at birth, speaking English or Spanish, being able to read and provide written informed consent (or assent and parental permission for those 11–17 years of age), and self-reporting the absence of any physical or mental condition that would impede participation. Current pregnancy was an exclusion criterion due to the known effects of pregnancy on toileting behaviors. Participants were included without regard to LUTS status, which was assessed only following focus group participation.

The study was approved by the University of Pennsylvania Institutional Review Board (IRB), which served as the central review board for six of the seven centers, and a local university IRB at the remaining site.

Procedures

Between July 2017 and April 2018, 44 focus groups were conducted within the previously described six age categories to encourage comfort and open communication among participants. Focus groups were led by female moderators who received standardized training in the qualitative research principles adopted by the PLUS Consortium for best practices for focus group research and the SHARE study protocol (Hebert-Beirne et al., 2019). Sessions were held in familiar community settings, such as churches, libraries, universities, community centers and clinics (e.g., federally qualified health centers), and lasted about 90 minutes. Each session followed a semi-structured focus group guide informed by the PLUS conceptual framework (Brady et al., 2018), including five domains and 16 core questions aligned with relevant socioecological level influences. See Supplemental Figure 1. The domains of the focus group guide were healthy bladder, knowledge acquisition, LUTS and care-seeking, terminology, and public health messaging.

The focus group sessions were audio-recorded and transcribed verbatim. Focus group sessions conducted in Spanish were transcribed in Spanish and then translated into English for analysis. In addition, trained investigators observed the sessions and made written notations using a field note guide for documenting nonverbal communication, characterizing the focus group dynamic, and reflecting about emerging insights. Field note observations also were used to address moderator fidelity to the focus group guide. After each focus group session, participants completed self-administered measures to characterize the sample in terms of demographics, LUTS status and toileting behaviors (Coyne et al., 2012; Wang & Palmer, 2011).

Data Analysis and Interpretation

Verbatim focus group transcripts and field notes were coded in Dedoose (Dedoose, 2016). A five-stage analysis approach included the following steps: (1) The coders and investigator team created a codebook, including a priori codes aligned with the PLUS conceptual framework and inductive codes that emerged in a memoing process of the transcripts. Coders then coded all 44 transcripts and field notes. (2) The interpretation team, comprised of multiple disciplinary expertise (community health, health promotion, nursing, behavioral health, social science, and pediatric and adolescent medicine), identified emerging themes, including observing toileting behavior as a social process. (3) To member check the credibility of the emerging focus areas, community trustworthiness checks were conducted by three of the research centers. (4) The interpretation team examined a set of codes related to the social processes of observing toileting behavior. The interpretation team identified three domains of social processes, described in the Results. (5) The writing team then identified SCT as an appropriate analytic lens, further operationalized the three domains, and identified the best evidence in the data to support identified subthemes within domains.

Results

A racially/ethnically and socio-economically diverse group of 360 adolescent and adult women participated in the 44 focus groups across the seven sites. The age of participants spanned from 11 to 93 years. Just over half of participants were aged 45 years or older with a mean age of 45.8 (standard deviation (SD)=21.6). The focus groups were conducted with six different age groups. Four focus groups were held among the 11–14-year-old group with 18 young women participating (Mean age =12.4; SD=1.1). Four focus groups were held among the 15–17-year-old group with 26 women participating (Mean age=16; SD=0.8). Six focus groups were held among the 18–25-year-old group with 51 women participating (Mean age=21.8; SD=2.1). Nine focus groups were held among the 26–44-year-old group with 72 participating (Mean age= 34.9; SD=5.8). Eleven focus groups were held among the 45–64-year-old group with 104 women participating (Mean age=54.9; SD=5.9). The final age group comprised 89 women ages 65 and older (Mean age=73.2; SD=6.9) who participated in one of 10 focus groups. Six of the focus groups were conducted in Spanish.

Forty percent of participants identified as White; 32% as African American; and 33% as Hispanic/Latina. Nearly 70% resided in urban areas, with 17% living in suburban and 13% in rural areas, as defined by U.S. Census (U.S. Census Bureau, 2020). Participants shared a geographic social context, but they were diverse by other social identity characteristics. Seventy-four percent of participants reported an income under $75,000; and 14%, over $75,000.

Age group, geography (urban/suburban/rural), and general income level of the groups are provided to characterize the shared social context of the focus group from which each excerpt was selected. We used self-reported income levels and self-report of financial strain (i.e., at the end of the month, having not enough money to make ends meet, just enough, some money left over, or more than enough left over) to categorize groups into high, middle, low, or mixed income level. In the focus groups categorized as high income, the majority of participants reported income over $75,000 and indicated they had more than enough money left over at the end of the month. For those categorized as middle income, the majority of participants reported income between $50,000 and $75,000 and revealed they generally needed more money than they had at the end of the month. In the focus groups categorized as low income, the majority of participants reported income less than $50,000 and specified they did not have enough to make ends meet, or they had just enough money left over at the end of the month. In the mixed income focus groups, the participants had a range of reported income and levels of financial strain.

Observing as a social-cognitive process shaping bladder behaviors among adolescent and adult women emerged as a central theme across the domains explored in the focus group sessions. The social process of observing, broadly defined, is the act of attending to the words and actions of oneself or others. This includes noticing or perceiving self or others and focusing on what one sees as affectively, cognitively, and/or behaviorally relevant across individual, interpersonal, social, institutional, and cultural domains. For the purpose of this analysis, the social process of observing was conceptualized on a spectrum ranging from random observations or exposures that occur without method or conscious decision, to purposeful surveillance or tracking over time that is conducted in an organized way. The scope of this definition does not include clinical observation or monitoring (e.g., by a health care provider or self-monitoring of urine output) but rather observations by or of family members, friends, teachers, co-workers, and even unknown individuals in public restrooms. In the observation codes, we included focus group text describing the following activities: noticing, witnessing, or watching what others say or do (i.e., less directed forms of observing), and keeping an eye on, noticing, scrutinizing, monitoring, or keeping track of what others say or do (i.e., more directed forms of observing). We found that the process of observing toileting behavior includes three distinct domains of observation: (1) observing others’ toileting behavior to determine norms and expectations; (2) being aware that one’s own toileting behavior is being monitored by others who may guide or gate-keep; and (3) observing oneself to align one’s behavior with others and to assess its conformity to subjective norms.

Observing Others’ Toileting Behavior

Participants’ discussion of others’ toileting behavior encompassed two subthemes: (1) seeing voiding positions and toileting behaviors, and (2) attending to social context and social interaction.

(1). Voiding Positions and Toileting Behaviors

For community-dwelling adolescents and adult women, real-life direct observation of another’s voiding positions and toileting behavior is not the norm. As one young woman points out,

Nobody really knows how anyone else uses the bathroom. You know, I mean we do but we don’t, you know. There’d be no way of knowing unless somebody like told.

(18 to 25 years, suburban, mixed income)

However, within familial and other close relationships, the norms of privacy can be relaxed, permitting individuals to view others’ toileting habits or issues and learn from these observations. Participants observed others using toilet paper to line the toilet seat before sitting, struggling to reach the bathroom in time, and caring for older adults with incontinence.

My mom also struggled with stress incontinence, and even though I have no children of my own, I struggle with it a lot because I know there’s a genetic factor to it and they weren’t so good to me. But I used to laugh at my mom because she would trip over stuff and pee and I’m like, you can’t hold it, and now I totally understand.

(26 to 44 years, urban, low income)

Individuals also are privy to the toileting behavior of intimate others, regularly observing toileting frequency in relation to fluid intake, noting patterns and cataloging degrees of perceived normality.

Among family, friends and classmates, young people monitored others’ bladder behavior, such as frequency of visiting the bathroom, and compared this with their own behavior. Monitoring was a way of determining the range of normality and acceptability with respect to bladder behavior.

I think that they learned about it because, umm, during, like doing any activities like going to work and stuff, ahh, how many times they usually use the bathroom and how many times we usually use the bathroom. Sometimes you have to compare it and see like how many times I use the bathroom and how many times my mom uses the bathroom and then it depends on whether you go, like the same, whether you go at the same time the next day and then whether my mom goes the same time the next day.

(11 to 14 years, urban, mixed income)

I feel like with our age group, too, like it’s common to compare to your friends like what’s normal for them to try and like figure out where you lie on that spectrum of normal or not.

(18 to 25 years, rural, middle income)

Noticing others’ bladder-related behavior, frequency of urination, and duration of time in the bathroom can inform girls and women about a range of bladder problems and sensitize them to the burden of LUTS. Participants described others engaging in a range of behaviors including voiding frequently to avoid incontinence, rushing to the toilet, sitting suddenly outside a bathroom to reduce the sense of urgency and avoid urine loss, regular use of containment products, such as absorbent pads to manage urine loss, the use of plastic mattress pads and frequent changing of sheets and clothes, as symptoms become more severe. Participant discourse included:

But I think sometimes, um, you see people go and they got to go a lot and you don’t, you, you don’t say anything. A lot of times because you don’t want to embarrass anybody and, and, and it’s like supposedly it’s a known thing that the older you get, your bladder is not going to work and you’re going to have to go a lot so everybody don’t, so we just accept it.

(65+ years, urban, low income)

I think about the same thing, especially with my mom, she can’t hold it and it’ll like come on all of a sudden, and then she’ll like have to go immediately and sometimes she won’t even make it to the restroom and that’s very different from my ability to hold it or my younger sister’s ability to hold it.

I agree. I watch my mother struggle with the same thing.

My grandma is using diapers now. She cannot hold. Just during the night. During the day, she can, but she wakes up during the night and she cannot make it to the bathroom, so she’s using diapers.

(26 to 44 years, urban, low income)

Participants also described being exposed to and observing others’ LUTS and adaptive behaviors based on contextual and environmental conditions. Adaptations included restricting fluid intake, stocking up on incontinence products, avoiding leaving the house, and toilet mapping when in public or at a social event. Toilet mapping involves anticipating the need to use a bathroom and therefore identifying the locations of bathrooms, or times of the day one can use the bathroom, (e.g., “fourth period” in the school day), to relieve urgency and avoid urine leakage when away from home. One participant described that she “lost her mom” because her mom “doesn’t dare leave the house” (45 to 64 years, suburban, mixed income). Another noted:

One of the things I noticed with my mom She’s not able to leave the house, so she’s ordering everything online and there’s constantly boxes coming in for all these different kinds of pads and she’s trying out different kinds of diapers and she has like four different products that she’s uses for different times of day and I think she’s even putting pads in the diapers because she’s having a hard time. And she really tries to like not drink very much.

(45 to 64 years, suburban, mixed income)

(2). Attending to Social Context and Social Interaction

Observing also occurred to gauge the toileting climate in less intimate social settings and to appraise the dispositional mindset of gatekeepers who controlled bathroom access. For example, the younger participants described monitoring their peer groups for implicit or explicit permission to void due to norms of going to the bathroom in dyads or small groups. Women shared experiences of having to monitor others’ attitudes and practices relating to bathroom access to know if leaving social situations to use the bathroom was acceptable behavior, or whether it was more acceptable to justify one’s own toileting needs and elicit permission to use the restroom. There was evidence of complex social processes involved in acquiring implicit or explicit permission to void as needed. The rules and dynamics of this process often go unstated.

I didn’t know that in college classes, you’re really not supposed to get up and leave to go to the bathroom. I went to a really lax high school, so I thought it was kind of normal to just like get up and leave and then come back.

(18 to 25 years, suburban, mixed income)

Peer observations may occur during the teenage years when the impulse to conform can provoke close attention to others’ behaviors with long-term recollection of specific information.

Yeah, there’s this girl in my class, in my math class, who I used to sit next to, and she’s, she’s like my friend and, umm, she was just, she always used to go in emergency. And she, ‘cause she used all of her passes, my teacher would always let her go, she would go like four times a day.

(11 to 14 years, suburban/high or urban/mixed)

Adolescents’ focus group narratives included rich accounts of the purpose of bathroom visits such as staging (i.e., using private space to prepare oneself to reenter public space), socializing in groups of girls, texting, and using a trip to the bathroom to avoid other activities.

Observing others’ experiences with seeking and gaining permission to use the restroom can serve as a means of ascertaining the bladder climate or bladder culture of the classroom.

Watching people. Like not like creepily, but like you notice when the teacher like says okay, you can go to the bathroom, so and so, like if you have class, then like you like just subconsciously understand when they go to the bathroom or not.

(11 to 14 years, urban, mixed income)

Young people describe the social context of sports teams and the normal experience of leaking urine at the end of a race.

So basically, by the end of the race, sometimes you’re so tired that you can’t hold your urine anymore, so you just pee your pants. So, a lot of my teammates peed their pants all the time. I think I did once, but it was just like normal and we all brought like extra pair of underwear and shorts.

(18 to 25 years, urban, low income)

Being socialized into the norms for public restroom use involved attending to the peer social etiquette of public restroom use.

You learn from your friends, your parents, your environment around you when your friends go. Like oh, me, too, especially for women. I don’t know when we learn this, but we learn that this is how it’s done. You don’t go to the bathroom by yourself. Always take a friend. Not necessarily for safety. It’s just this is just what we do. So I think there’s a, a social aspect to that because I don’t remember ever learning that in a class or like you should go X number of times a day or how many, at least every six hours or you know but it, it’s all been social, social event for me.

(26 to 44 years, urban, low income)

Women described monitoring the social norms and toileting practices of workspaces (i.e., how often and when the bathroom was used; what language is used around toileting behaviors) to determine, without asking, if and when they could access the bathroom. For example, during long meetings, women would postpone emptying their bladders despite having a strong urge to void if no one else was leaving the room to use the bathroom.

I find it rude to like, so like, for example, like here, like if you’re having a discussion as a presentation or a meeting like I feel like it’s rude to like stop and leave… even if I have to go to the restroom or not, and so that I would then probably stay until, um, I could, until I basically explode and have to like exit out, which is probably more embarrassing than just subtly, um, leaving the room. But I feel like that’s a norm that I feel from my coworkers and people I work with, um, to not leave to go to the restroom.

(26–44 years, suburban, high income)

Similarly, participants described enduring long car rides because their companion, often described as male (e.g., father, husband, boyfriend), had not yet expressed a need to void. One described needing to urinate but waiting for someone else to express a need before echoing a desire to urinate as well. Women also talked about feeling uncomfortable (e.g., guilty, embarrassed) about inconveniencing others for their own bladder needs.

Being Aware of One’s Toileting Behavior being Observed by Others

Focus group participants described being aware that one’s own toileting behavior is sometimes observed by others, including parents, partners, peers, friends, teachers, other school staff, and work supervisors. Participants’ descriptions of being observed seemed to reflect experiences in three areas: (1) observations made by family or others that were intended to teach, guide, or help; (2) observations made by teachers or supervisors that were intended to control toileting behaviors to serve the needs of school or work settings; and (3) the impact of being observed, including concerns around what others would think.

(1). Observations Made by Others to Teach, Guide, or Help

Focus group participants described helpful forms of observations by others throughout the life course. In childhood, being observed by mothers or other family members was often seen as a process of teaching and guiding children as they learned appropriate toileting behaviors. Women commented that lessons learned and guidance received in turn shaped their lifelong bladder habits. Some described being reminded to drink enough fluids to stay hydrated. Others were reminded to monitor their need to void or to void before the need arose (i.e., preemptive voiding).

[In reference to mother] It’s like a constant thing growing up. It’s like does everyone need to go to the bathroom? Does anyone need to go to the bathroom? It’s this constant like checking, so it’s like do I need to go to the bathroom? Should I be needing to go to the bathroom?

(26 to 44 years, urban, low income)

And also, by my nana, my abuelita, my grandma used to make me go pee before I would go to any place, and I still do it. I make myself, even if I don’t feel like I need to go, I go and pee before I go, always.

(26 to 44 years, urban, low income)

Many participants recalled being told they were told to “hold it” when in public. This advice was perceived to be rooted in concerns about cleanliness or safety of public or others’ toilets. Teens and young adults also received advice from their peer network about “holding” habits, which included ‘don’t break the seal.’ This advice encouraged the delay of voiding until completely necessary when out drinking alcohol and socializing, otherwise one’s need to void would increase after the first void.

We have this, in this friend group of mine, whenever we all go out drinking, you know, it’s like ‘don’t break the seal!’ Because as soon as you break the seal, you’re just going to have to keep going back and back and back and back and back to the bathroom.

(18 to 25 years, suburban, mixed income)

During adulthood, observers could be individuals who expressed caring or concern for participants – for example, a spouse, sister, other family member, or friend. The purpose of monitoring was usually to help identify, prevent, and solve health problems. The process of informal observation or being observed can generate bladder allies who alert each other to signs of abnormality. Such supportive social ties, that emerge from connecting with others, can provide instrumental and emotional resources and facilitate problem solving (Jackson, 2012).

…we just accept because that’s what I did for a while. I was going to the bathroom all the time and it wasn’t until someone that was running with me was like you are going to the bathroom way too much, and just called me out on it and was like you gotta go to the doctor, ‘cause I couldn’t run a race without having to stop to go to the bathroom in a porta-potty, you know? It’s like, umm, someone telling you that this isn’t right, you need to figure out what’s going on. Umm, I think that’s a lot of what we deal with. Our girlfriends are the ones that, or our family members, like what [fellow participant] was saying, are the ones that help us get to the point of solving a problem.

(45 to 64 years, urban/suburban, middle income)

(2). Observations Made by Others to Control Toileting Behavior in the Interest of Social Needs

In schools, monitoring and controlling of toileting behaviors by teachers seemed geared toward preserving the integrity of the classroom, as well as to prevent perceived inappropriate use of the bathroom (Camenga et al., 2019). Participants noted that school administrators, teachers, and staff express beliefs that youth access toilets in school settings for reasons other than the need to urinate (e.g., to get away from the classroom, to engage in negative behaviors such as e-cigarette or drug use). Participants described negative consequences of frequent need to access the bathrooms in the school setting as a result of administrators and teachers’ concerns about inappropriate behaviors potentially occurring in the bathrooms.

Yeah. And if you’re always in the hallway frequently. Let’s say you have a bladder problem and you go to the bathroom. If they catch you in the hallway like three times umm with the pass, sometimes you get in-school suspension, so.

(15 to 17 years, urban, mixed income)

Peer pressure and the threat of social condemnation was used to discourage bathroom use during class, such that “if you do need to go to the bathroom, the whole class has to suffer the consequences of that” (15 to 17 years, urban, mixed income).

In work settings, the focus was on monitoring toileting behaviors to ensure that workers were fulfilling their responsibilities and to preserve full functioning of the workforce. Adults described unique challenges related to workplaces with limited resources (e.g., not enough staff to “cover” for one another), highly visible restrooms (e.g., customers and coworkers observing one emerging from the bathroom), or less commonly, a presumption of malicious intent on the part of employees (e.g., not wanting to work steadily, taking too much time away from work).

It’s different because I guess of the whole grocery store, like the intercom is through the whole grocery store, so everybody can hear your name. In the bathroom like I’m in it, you can’t hear the intercom. You can’t hear it and so because it’s towards the like parking lot so you can’t even hear it, so you walk out of the bathroom and everybody’s looking at you like where were you, and it’s kind of embarrassing.

(18 to 25 years, urban/suburban, mixed income)

Participants described use of cameras near the bathrooms to monitor the movements of students, and intercoms to call employees back to work (i.e., institutional-level monitoring). In some cases, limits were placed on the number or duration of bathroom breaks.

I’ve encountered a lot of timed bathroom breaks in my life. Not now but when I worked in a call center, they would time us for how long it took for us to go to the bathroom and so we only had so long to go to the bathroom and it was really stressful because you, you know, sometimes things don’t always work out the way you wanted it to. Sometimes you’re on your period. Sometimes you know you’re not feeling too well, so that was added a sense of urgency, I guess.

(18 to 25 years, urban/suburban, mixed income)

Adult participants recalled being made to feel like a child when attempting to gain permission to void from gatekeepers or asserting one’s need to void at school or work. For example, a college student described how a professor humiliated student who attempted to leave the classroom, stopping them as they stood and making them answer questions.

I mean if I’m in like lecture hall at school and, like, you know, if we’re having, like, a long lecture about important topic - if my professor sees that you’re getting up, he’ll call you out. He’ll be like where are you going? And then you, in front of 300, 200 students and they look at you and they’re like -

And she said where are you going?

(18 to 25 years, urban, low income)

(3). Impact of being observed by Others – What will others think?

Having one’s toileting behaviors observed by others typically was unwelcome and engendered a sense of embarrassment. The experience of being monitored, even unintentionally, was characterized by concerns about what others would think and anticipation of being judged. Some youth expressed fear that peers would judge the sounds and smells they made while toileting. Others took great lengths to conceal their voiding behaviors and use of incontinence products (e.g. absorbent pads). Many expressed concern about the perceived frequency of urination. A young participant reported feeling anxious when anticipating needing to use the bathroom during a movie, fearing her peers would “be like ‘why is she going to the bathroom in the movie and whatever’” (11 to 14 years, urban, mixed income). Anxiety was also expressed by an older participant,

But if I, but if I’m in…public and I’m with like in a restaurant and there’s people around and I got to be going, I’ll, I’ll just like, like we’re done with this and we’re going because then I’m realizing that it becomes a problem that I’m not going too. I’m a people person that I know... “Ay no..que van a decir” (Spanish for “Oh no, what will they say”)… that I have a something and I have to keep going to the bathroom excusing myself. (65+ years, urban, low income)

Participants across the age groups described being aware that they could be seen through the cracks in stalls or that someone could be listening to the sounds they make in the process of voiding. A young participant described others within hearing range as “not supportive” and “annoying” recalling “like they’ll say something ‘oh who is stinking up the bathroom?’” (15 to 17 years, suburban, mixed income). During an older adult focus group, participants described being self-conscious and embarrassed by the prospect of others hearing and judging the noises associated with voiding and described strategies to conceal the sound of urination in public bathrooms.

Some participants described avoiding urinating altogether, especially if they would have to encounter people when they were heading for the bathroom, for fear that others would know what they were doing.

Participants described being concerned that their teacher, coach, or boss would think they were lazy, weak, or disruptive if they stepped away from their duties to void. Some women worried about inconveniencing others, choosing instead to endure what was described as pain, anxiety, and stress associated with delaying urinating to avoid disappointing or annoying particular people in their social networks.

Ongoing monitoring of the social context and interactions between people in one’s social context, along with being aware of being observed by others, led many individuals to identify a context in which they could exercise bladder and toileting autonomy. Participants described processes of avoiding asking permission in order to avoid social interactions around asking to urinate. Participants decided that they could instead postpone voiding until they could find a situation without a gatekeeper (typically, though not exclusively their home).

Observing Oneself to Assess Behavior Relative to Others

The final domain type involves observing oneself in relationship to others. This domain includes benchmarking one’s toileting behaviors against social norms or perceived social norms. It also includes seeking clarification about an experience compared to what might be a norm in the absence of knowing or having been taught the social norm.

Participants described how they compared their behaviors related to toileting position and what they perceived as the social norm. In public spaces, the social norm was perceived as not sitting on the toilet seat, whereas at home it was perceived as sitting on the toilet seat. Participants described situations and locations where their behaviors do not comply with social norms, such as sitting on the toilet in “boy’s bathrooms” and “airports,” or squatting at home.

I’ll squat at home. It’s embarrassing. … but I squat in my own house. (Group laughing.) I know, it’s just like I hear my mother, like “do not sit on that seat”.

(26 to 44 years, suburban, high income)

It was also noted by participants that the urge to urinate might be triggered by others announcing their need to void. Participants compared their ability to hold urine and the frequency of voiding to that of peers to support or establish benchmarks for themselves. Participants described monitoring their own and their peers’ ability to delay voiding in situations such as a car trip and expressed admiration for those who can “outlast” others (45–64 years, suburban, mixed income). Similarly, a younger participant described a social situation where the capacity for holding urine was a prized attribute: “When I drink with friends, we all kinda try to see how long we can go without peeing” (18 to 25 years, suburban, mixed).

The comparisons included experiencing night-time incontinence.

…my mother has incontinence and has had it for many years now. I already mentioned that I can’t go through the night without having to get up two, three, four times. - -And now last couple of two, three months, I’m not going to get up out of bed. I don’t quite make it to the bathroom. I hold myself. (Group saying mmm hmm.) So like oh, no. It’s happening. I’m turning to my mom. But yeah. I think it’s going to start. I think it’s going to start happening to me more frequently.

(45 to 64 years, suburban, mixed income)

Discussion

This study explored adolescent and adult women’s experiences to gain insight into the underlying social cognitive processes shaping toileting behaviors. We found the act of observing was an overarching social process informing women’s toileting behaviors in three ways: (1) observing others’ toileting behavior to determine norms and expectations; (2) being aware that one’s own toileting behavior is being monitored by others who gate-keep and guide; and (3) observing oneself to align one’s behavior with others and to assess its conformity to subjective norms.

While observing others is not unique as a social process, the phenomenon of observing has not been well described in the research literature on toileting, whose bladder health may be significantly impacted by toileting behaviors.

Observing others is a ubiquitous social cognitive process rooted in neurological underpinnings of primate behavior (Reber et al., 2013). Monitoring the performance of others involves “attending to, looking at, or watching” their behaviors to attain information (social cues) about group dynamics for the purpose of maximizing one’s position in the social hierarchy (Weinberg -Wolf & Chang, 2018). The present study’s findings suggest a role for social cognitive processes in the bladder health behaviors of adolescents and adult women. One of the key concepts of SCT is modeling, whereby individuals learn by observing others. Observing others’ behavior provides clues to their beliefs and intentions, providing information for aligning behavior to conform to perceived expectations (Isoda, 2016; Shestakova et al., 2013; Shamay-Tsoory et al., 2019). This includes observing the outcomes of others’ toileting behaviors, predicting the risks and benefits of adopting such behaviors, manifesting the intention to engage in a behavior, having the confidence to do so, and expecting a successful outcome. The concept of observing, we used, included both mindful observation to gain information and insight and passive awareness through “taking in” what others were doing and saying (Keng, 2011; Vago, 2016; Roeser, 2009). The social cognitive processes of observing self and others are key elements of behavior adaptation. Focusing attention on actions and their consequences provides individuals with social information needed to interact with others in complex social situations (e.g., school, work, leisure, familial settings) and to adjust behaviors to changing interpersonal and social contexts (Ninomiya et al., 2018; Ullsperger et al., 2014; Burke, 2009; Meyer, 2002).

The social cognitive process of observing others also encompasses assessing the behavior of similar others for adherence to rules and consequences of deviance. Peer monitoring in community settings can encompass efforts to promote the common good (Heffernan et al., 2016). Parental monitoring of adolescent behavior has been shown to have beneficial effects on factors related to school performance among racial/ethnic minority youth (Lowe & Dotterer, 2013). Among African American adolescents, monitoring peer eating behaviors and perceiving parental dietary expectations is associated with diet quality (Wrobleski et al., 2018). Among adults, the presence and the eating behavior of others provide social cues to the appropriateness of snacking (Schüz et al., 2018).

The social processes informing adolescent and adult women’s toileting behaviors may have implications and consequences at the cognitive and affective levels, in addition to the behavioral levels. At the cognitive level, the process of observing may inform beliefs of what is healthy or unhealthy with respect to bladder health and may contribute to perceived norms. At the affective level, there may be consequences of observing by life course stage. For example, during childhood and adolescence, awareness of being observed by others can engender a fear of being punished for toileting at school or being judged negatively by peers. During adulthood, women may be afraid of being judged by others, including patrons at a workplace. Behaviorally, observing may inform the development of toileting habits, coping strategies (e.g., avoiding toilets, turning on a faucet to cover the sound of urination) and adjustment of behavior because of awareness of being observed (e.g., not using public restrooms if others are present). Behavioral habits may be developed, in part, through cognitive and affective processes (e.g., perceived norms leading to never sitting on public toilets, fear of being judged leading to delaying voids until school or one’s work shift is over). This fear of being judged, embarrassment and shame previously was associated with incontinence symptoms (Siu, 2014) but not with voiding experiences.

Limitations

Participants in this study described their perceptions and experiences of the social process of observing toileting behaviors including interactions with gatekeepers, peers and family. Descriptions of interactions were one-sided, but other participants in the focus group echoed support or shared similar experiences. Participants were ethnically and racially and socio-economically diverse and ranged in ages although sampling was weighted towards the older ages and representation from rural communities was limited. The diversity of participants by socio-demographics, notably age, suggests there may be a wide range of toileting experiences and behavior. Analyzing these diverse experiences as a group may have omitted unique age-related aspects of the social process of toileting that are important to understand in bladder health promotion. Future studies should examine differences in experiences with observing toileting behaviors and habits that may be rooted in experiences made different due to race, ethnicity, religion, or social class. Our findings on observing toileting behaviors and habits reflect the experiences of adolescent and adult cisgender women. With data collection occurring across seven sites, fidelity was attended to by a strong moderator training that continued throughout the study and an administrative core that assured adherence to the research protocol. Using a transdisciplinary lens and theory-informed framework for the analysis allowed for the generation of robust data to answer the research questions.

Implications for Prevention

We suggest that underlying processes of toileting behaviors, seemingly private and largely stigmatized, may in fact be highly social, involving the observing of others, being aware of being observed by others, and observing self in relation to others. Given the social embeddedness of observing toileting behaviors, health promotion efforts could leverage social networks for ‘social norming’ interventions and engage systems’ representatives and policy makers to promote healthy toileting behaviors and endorse voiding autonomy.