Navigating the System: Adolescent Women and High School Bathrooms

Abstract

One in three women will experience urinary incontinence in their lifespan, and withholding urine has been shown to increase risk. Adolescents pose significant risk for withholding behaviors due to psychosocial developmental stage and fear of negative peer interaction. Little is known about adolescent women’s feelings and experiences with high school bathrooms that might influence use, such as fear of bullying, environmental considerations, and school policies. The purpose of this dissertation research is to explore adolescent women’s experiences with high school bathroom use to better understand early lifespan behaviors that may lead to future development of urinary incontinence. To guide this endeavor, the Optimal Bladder Health (OBH) Model was used, as well as variables of psychosocial developmental stage, school policies, privacy, bathroom cleanliness, and peer interaction. This dissertation 1) identified factors that influences school bathroom behaviors in adolescent women, 2) explored knowledge related to bladder health, including voiding frequency, beverage intake, societal attitudes, and experiences with incontinence, and explored strategies adolescent women use to avoid or delay bathroom use, and 3) used these findings to inform the Optimal Bladder Health Model. A constructivist grounded theory approach was used to conduct individual interviews with adolescent women between the ages of 14-18 years and who attend high schools in the Midwest United States. Interviews were audio recorded and verbatim transcripts were made. Grounded theory’s constant comparison method of analysis was used to identify emerging themes, and descriptive statistics were used to describe the sample. One-on-one interviews were conducted with 30 adolescent women from 14 high schools, 11 (79%) of which were public schools. Adolescent women described difficulty in navigating through the many barriers to bathroom use in the high school setting. Themes that emerged were amount of time to use the bathroom, bathroom environment, privacy, school policies, and school bathrooms as a safe space. Bullying was not a factor in bathroom avoidance, but rather bathrooms served as a safe space to receive support from peers. Adolescent women preferred teacher policies supporting autonomy to leave the classroom for bathroom use, as well as clean, private, and well-stocked environments. Knowledge of bladder health was limited due to lack of having received any education, and three types of strategies to avoid or delay bathroom use were employed: physical, mental, and behavioral. Factors added to the Optimal Bladder Health Model included access to toilets at school, safe environment, general bathroom environment, social support, and peer interaction, resulting in the Adapted Optimal Bladder Health Model for Adolescent Women (Adapted OBH Model). This model may be used to guide future research concerning adolescent women and bladder health. Opportunities to improve the school bathroom experience include providing clean, private, and well-supplied bathrooms. Nurses and other health care providers may aid in increasing school bathroom use through providing education about the importance of not withholding urine. In addition to this, restructuring school policies to better support autonomy to use the bathroom with biologic cues may potentially reduce school bathroom avoidance.