Little is known about adolescent and adult women’s experiences with toileting behaviors that may confer risk or protection for bladder health. The Study of Habits, Attitudes, Realities, and Experiences, the foundational qualitative study of the NIH/NIDDK’s Prevention of Lower Urinary Tract Symptoms Research Consortium, examines adolescent and adult women’s experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health and function across the life course.

The present study explores the social processes that inform women’s toileting behaviors. Forty-four focus groups with 360 female participants organized by six life course age groups from 11 to over 65 years of age were conducted across seven US research sites.  A transdisciplinary interpretive lens was used across five stages of analysis: first, a codebook was develop with a priori, conceptual framework-informed, codes and inductive codes identified in the memoing process; second, verbatim transcripts and field notes were coded through multi-staged directed content analysis; third, community sessions were conducted to insure data trustworthiness and enhance contextual understanding of the social processes informing toileting behavior; fourth, a small interpretation team examined the relevant codes to identify observation domain types; fifth, the larger writing team then identified Social Cognitive Theory as an appropriate analytic lens, further operationalized the domains, and identified the optimal evidence among the coded textual excerpts to support the subthemes within domains. Data analysis and reporting were conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

The act of observing was identified  as the overarching social process informing women’s toileting behaviors. The act of observing is conceptualized on a spectrum ranging from random observations or exposures that occur over time without method or conscious decision, to purposeful surveillance or tracking that is conducted in an organized and deliberate way. The scope of our definition does not include clinical observing or monitoring but rather lay observations. 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, scrutinizing, monitoring, or keeping track of what others say or do (i.e., more directed forms of observing).

We found that the single process of observing toileting behavior includes three distinct types 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 gate-keep and guide; and (3) observing oneself to assess one’s own behavior relative to subjective norms.

These qualitative findings suggest that underlying processes of toileting behaviors are highly social. Given the social embeddedness of observing toileting behaviors, health promotion efforts should leverage social networks for social norming interventions and engage systems’ representatives and policy makers to promote healthy toileting behaviors and to endorse voiding autonomy.