Decision-making about bladder-related behaviors occurs multiple times each day with potential significant impact over a lifetime. Beliefs and assumptions about bladder health and function may influence daily toileting behaviors and early management of lower urinary tract symptoms (LUTS) in women. Yet, little is known about how these are shaped by multilevel factors such as societal norms, media messages, health literacy, and interpersonal relationships. The aim of this study was to characterize adult women’s lay beliefs and assumptions about bladder health and function to inform future prevention intervention strategies.

The Study of Habits, Attitudes, Realities, and Experiences (SHARE) is a qualitative study of the Prevention of Lower Urinary Tract Symptom (PLUS) Research Consortium. It explored adolescents’ and adult women’s experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health and function across the life course (1, 2). The SHARE study recruited participants for 44 focus groups from urban and rural areas across seven U.S. research centers. Applying a life course perspective, participants were recruited and organized into six age categories: 11-14; 15-17; 18-25; 26-44; 45-64; and 65+. The current analysis focused on data from the 36 focus groups conduced with women 18 years of age or older (N=316). To ensure having a full conceptualization of women’s experiences of “healthy bladder,” the study included participants without respect to LUTS status. Following focus group sessions, participants completed self-administered measures to characterize the sample in terms of demographics, physical/health conditions, and LUTS status (3). Focus groups were audio-recorded and transcribed. Following transcript and fieldnote coding for documenting nonverbal communication, multi-level qualitative content analysis was used to classify emergent themes. A transdisciplinary lens and inductive approach guided data interpretation of the “bladder beliefs and assumptions code.” A team of investigators articulated interpretive insights, which were validated by a community engagement panel.

Table 1 summarizes demographic information on the four age groups. The sample was diverse with respect to race, ethnicity, education, socioeconomic status, physical/health conditions, LUTS status, geography (urban/rural), and language, including focus groups conducted in Spanish. 82.9% of participants reported experiencing at least one LUTS. It is not known if participants sought treatment. Table 2 summarizes reported LUTS on the LUTS Tool questionnaire (3) among adult participants. X % reported experiencing at least one LUTS.    It is not known if participants sought treatment.

Women exhibited limited understanding of bladder health and function, with assumptions and beliefs shaped by personal experience and hearsay from friends, family, television commercials, etc. Except for the rare occasion when women had input from a medical professional, notions about bladder health and function were characterized by uncertainty, tentativeness, and unconfirmed impressions. Women speculated on (a) the function of the urinary tract system in cleansing or flushing the bodily system of impurities and toxins, (b) the functional relationships between and among the kidneys, bladder, urethra, vagina, and pelvic floor and (c) the impact on bladder function of medications for chronic conditions. Women’s assumptions and beliefs about bladder health were framed within a “cause and effect” perspective, covering a wide array of habits/behaviors (e.g. eating and hydration habits, “holding urination”, exercise), while conjecturing about the physiological mechanisms through which such practices promote or deter bladder health. Finally, there was agreement on the importance of bladder friendly habits and the inadvisability of potentially harmful practices. This was accompanied by an assumption that bladder problems could be prevented by developing community-based programs for educating women about bladder health and function, encouraging women to practice healthy bladder habits, eliminating taboos about discussing bladder health, and empowering women to speak out about their bladder-related experiences and concerns.

This is the first study to apply a socioecological, life course perspective to characterize adult women's lay beliefs and assumptions about bladder health and function. Results show a discordance between lay women’s beliefs and assumptions about bladder health and function and the body of scientific knowledge used by primary care providers to screen for LUTS, as well as by clinical specialists to treat women with LUTS. Women’s beliefs and assumptions about where and when to void are framed within the context of toileting socialization processes in the home and schools, which often include cautionary tales based on lay experiences. Assumptions and beliefs about delayed voiding, for example, may reflect adaptations to practical concerns such as limited toileting autonomy in the workplace and reduced toilet access in public places.

Across the life course, lay women’s understanding of bladder health and function could benefit from input from health care professionals, particularly in preventive care settings where women could be encouraged to engage in healthy bladder habits. Additionally, community-engaged public health messaging can inform women’s assumptions and beliefs about bladder health/function, educating women about the promotion of bladder health and the prevention of LUTS.

Low LK, Williams BR, Camenga DR, Hebert-Beirne J, Brady SS, Newman DK, James AS, Hardacker CT, Nodora J, Linke SE, Burgio KL Prevention of Lower Urinary Tract Symptoms Research Consortium Focus Group Study of Habits, Attitudes, Realities, and Experiences of Bladder Health. J Adv Nurs. 2019 Jul 9. doi: 10.1111/jan.14148. [Epub ahead of print] PMID:31287183
Williams BR, Nodora J, Newman DK Low LK, James A, Camenga DR, Hebert-Bernie J, Brady SS, Hardacker CT, Smith AL, Cunningham SD, Burgio KL; Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. (2020) “I never knew anyone who peed on themselves on purpose:” Exploring adolescent and adult women’s lay language and discourse about bladder health and function. Neurourol Urodyn. Jan;39(1):225-236. doi: 10.1002/nau.24174. Epub 2019 Oct 2.PMID:31578778
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