The Journal of School Nursing2025, Vol. 41(3) 309–315© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221142031journals.sagepub.com/home/jsn
Abstract
Bathroom access and use in conjunction with biological urge to void is an important part of optimal bladder health. School settings are uniquely positioned to influence the development of bladder habits. The aim of this study was to identify barriers and facilitators to high school bathroom use for adolescent women. A qualitative study design was used to conduct semi-structured interviews focused on experiences with bathroom use while at school. Thirty adolescent women were interviewed, and transcripts were analyzed using thematic analysis methods. Barriers included unpleasant bathroom environments, lack of privacy, and school/teacher policies. Facilitators included clean, private bathrooms and menstruation. Improving bathroom cleanliness, privacy, and eliminating policies aimed at controlling bathroom access may reduce barriers to bathroom use. School nurses have a unique role in educating teachers, administrators, and students about the importance of clean bathrooms and policies that support bathroom use in conjunction with biological urge.
Keywords
adolescent bladder health, school bathroom, lower urinary tract symptoms, school toilet, school policy, high school, adolescents, menstruation, school nurses
Bathroom use is an important component of bladder health in adolescent and adult women, as delayed voiding has been associated with lower urinary tract symptoms including overactive bladder, urinary incontinence (UI), and recurrent urinary tract infections (UTI) (Shoham et al., 2021; Zhou et al., 2020; Zhu et al., 2019). There is limited information related to the incidence of UI in adolescent women available, but Sjögren et al. (2017) found that when compared with people who void in conjunction with biological urges, those who hold urine, or engage in delayed voiding, have been shown to have weaker bladder muscles and increased rates of UI. Additionally, an increased prevalence of childhood UI has been linked to UI in adulthood, indicating that UI symptoms do not necessarily resolve with age (Costantini et al., 2018). The negative effects of UI are well documented, with women experiencing higher rates of depression, reduced quality of life, and a high burden of cost for personal supplies (Cheng et al., 2020; Coyne et al., 2008, 2009).
Promoting bladder health in adolescent and adult women requires understanding and reducing the barriers that inhibit bathroom use so that delayed voiding is less likely to occur. Although important at every stage in the life course, adolescent women have additional factors that may increase their risk for bathroom avoidance. A desire for privacy and fears of negative peer interactions are important considerations that have been shown to decrease adolescents’ bathroom use in school settings (Ching et al., 2015; Norling et al., 2016; Shoham et al., 2021). Voiding, stooling, and caring for menstrual needs are actions that require increased privacy in school settings, due to fear of stigma from peers (Johnston-Robledo & Chrisler, 2013; Lee, 2008).
The effect of delayed voiding depends in part on how long adolescent women spend in the school environment and engage in delayed voiding. High school students in the United States spend an average of 6 hours a day in school and are required to follow school and teacher policies with regard to bathroom access and use (National Center for Education Statistics, n.d.). Teachers’ unofficial policies often aim to reduce bathroom use by restricting when and how frequently students access them, which may not align with general bladder health recommendations (Cooper et al., 2003; Ko et al., 2016; Secor-Turner et al., 2022).
While existing studies provide important information related to barriers to bathroom use that adolescents in other countries and adult women experience, information related to younger women the United States is limited (Norling et al., 2016). Knowledge related to specific bathroom barriers that adolescent women face would allow for the creation of interventions aimed at aligning policies for bathroom use in conjunction with biological urge and needs. The purpose of this qualitative study was to explore the experiences of adolescent women regarding bathroom use in the high school setting to understand the barriers and facilitators in place that may contribute to the development of healthy bladder habits.
A qualitative approach was used to explore facilitators and barriers to bathroom use in the high school setting, with particular emphasis on experiences related to access. The approach included semi-structured one-on-one interviews with thematic analysis informed by Braun and Clarke (2006). Purposive sampling was used to recruit adolescent women aged 14–18 years who attended high school in the Midwestern United States. Inclusion criteria included adolescent women currently in high school to allow for a shared social context and understanding of the physical spaces, the experiences of the adolescent women who use them, and provided the potential for increased depth in discussion. Exclusion criteria included anyone who did not identify as female, was not between the ages of 14–18 years, did not speak English, did not physically attend high school, did not provide consent or assent, or were unable to participate in the interview.
Participant recruitment involved placing flyers in areas that adolescent women frequent. These areas included social gathering places in urban settings designed as adolescent hangouts and adolescent health clinics. Flyers were also placed throughout several buildings in a large Midwestern research institution, and outreach efforts were made to engage faculty, staff, and students who have contacts with adolescent women from the University School of Nursing where the authors worked. In addition, each participant who attended an interview was asked to provide study contact information to friends who may have interest in participating. The interview and survey took an average of 45 minutes to complete, and participants were given a $30 Mastercard gift card as compensation for their time. In an effort to improve participant recollection, data collection occurred from January through June.
An interview guide informed by the Optimal Bladder Health Model was used to guide initial questions during the semi-structured interviews (Miller & Low, 2015). There are four dimensions of this model, including environmental, psychosocial and behavioral, biological, and life stage. Thus, questions in the interview guide included access to toilets and bathroom environments, societal attitudes, peer considerations, bathroom use during menstruation, and bathroom habits. Participants also filled out a demographic questionnaire to aid in sample description, with questions focused on age, race, year in high school, and socioeconomic status.
The first author, who had training in qualitative interviewing, conducted all the interviews. The interview guide was used in each interview, but additional questions were added as needed to further probe about emerging topics. Participants chose the location and time for the interviews. Audio recordings of the interviews were transcribed either by the first author or a professional transcription company. Transcripts provided by the company were verified by the first author for accuracy. Coding was conducted by the primary investigator and then reviewed by the second author for accuracy and congruency in identifying themes.
Thematic analysis was used to analyze the data gathered from transcripts and memos (Braun & Clarke, 2006). The first step in the analysis process was initial coding, in which the transcripts were coded line by line with descriptors of what the quotes best represent or how they were defined. As codes were generated, they were applied in a systematic fashion across all data. The next step involved grouping the codes into categories. These broader categories were then compared and analyzed for patterns and grouped into themes. Decisions were written in the form of memos to identify the researchers’ thought processes during analysis. AtlasTI was used in the analysis process. Demographic data were analyzed using SPSS Version 24.
This study was approved by the University of Michigan Health Sciences Institutional Review Board. Consent for participation was obtained for all participants, either for themselves if aged 18 years or by a parent if 17 years or younger, as well as assent for all participants 17 years or younger. Confidentiality of the participants was maintained by de-identifying all participant information, including transcripts from the interviews. Participant information was coded using a three-digit number that was not linked to identifying information. All analysis was conducted using the de-identified transcripts.
A total of 30 participants between the ages of 14–18 years were interviewed. Participants were 64% white, with 50% considering themselves rather or very well off in terms of socioeconomic status (Table 1). There was an almost even distribution of participants from each grade (9th–12th), and average age of participants was 16.1 years.
Participants attended 14 different high schools from 11 different school districts that varied in racial and socioeconomic demographic makeup. Twenty-nine of the students attended public high schools and one participant attended a private high school. Three participants attended public charter schools.
Thematic analysis identified several barriers and facilitators to high school bathroom use (Table 2), which was consistent in adolescent women from all types of high schools.
Bathroom environments affect students’ willingness to use them during the school day. Participants reported perceived cleanliness as a determinant in whether or not they would use the bathrooms at school. Issues of cleanliness generally included dirty floors and sinks; toilets with urine, blood, or stool in them; sinks with debris, paper towel, or items in them; and writing on the walls. One 9th grade participant explained, “All the other [bathrooms] they have trash on the floor and it’s kind of nasty and it’s like, ‘Oh okay, that’s kinda gross.’ So I don’t like to use those ones.”
Desire for privacy had an effect on participant’s desire to use or avoid school bathrooms. Feelings of privacy depended on bathroom size and personal preferences. School bathrooms were described as large with multiple stalls, and generally did not provide much privacy. Walls and doors that did not touch the ceiling or floor were common features. Large bathrooms with multiple stalls decreased feelings of privacy, as students were infrequently alone when using the bathroom, and had the increased potential of peers see then or potentially watching them when they entered or exited the ballroom stall. A tenth grade participant explained, “There’s like probably six or seven girls in there…when there’s people in there, I always wash my hands. Everybody watches you. There’s always this one girl who’s in there every single time, same time I am. She always makes sure that I wash my hands. She watches me, and it’s weird.”
The need for privacy for toileting increased during menstruation or when participants experienced the need to stool. Participants described the stigma associated with these activities, which created an increased desire for privacy. In the participants’ high schools, it was difficult to find the desired privacy in the large, multi-stall bathrooms. A12th grade participant explained, “I think that people are often really uncomfortable using the bathroom away from their house. I know that’s totally a stigma, that I can’t use the bathroom, especially for number two. I don’t think I’m super picky, but I do like my privacy. I’m definitely more comfortable going at home.”
School and teacher policies present at the high schools served as significant barriers to bathroom use. Participants described facing restrictive policies that limited the timing of bathroom use. These policies included not being able to go during at the beginning of class and at the end of class, due to the assumption that adolescent women should be able to wait to use the bathroom during passing time, or time between classes. An 11th grade participant explained, “Some teachers will say, ‘Oh, you should have gone during passing.’ Or, ‘You should’ve gone during lunch.’ It’s just the whole process of it is really annoying to me. I get that we’re in high school, and we’re still young and stuff, but to go from having to ask to go pee, and then just being thrown out in the world, I feel like it’s just really annoying as a high schooler. One year, you’re asking to go to the bathroom, and the next year you’re living on your own.”
The use of bathroom passes were outlined in policies that served to limit adolescent women’s abilities to use the bathroom freely during the school day. Participants described this process of receiving a bathroom pass as cumbersome and a deterrent to bathroom use, as it hindered autonomy and served as a notice to peers that the participant was going to the bathroom. A 9th grade participant explained, “I’ve had teachers before say you have to…sign a book, write the time, and then when you came back, write the time. I just don’t want anyone to see how long I was in the bathroom… It’s embarrassing…and it was almost like an invasion of privacy…knowing that either someone else in the class was waiting for you to get back so they could go.” Additionally, large, physical bathroom passes served as an undesired signal for bathroom use. A 9th grade participant explained, “It was this…huge trophy that you had to carry. I don’t even imagine what you’d do with it. There’s no room in the stall for it. And my friends are like, ‘Oh, you’re in that class.’ Sometimes I see people walking around with a huge trophy going to the bathroom…That made me not want to use the bathroom because I did not want to carry a huge trophy with me.”
Some students were allowed to use bathroom passes at their discretion. However, if all passes had been used during a specified time period, students were denied any more trips to the bathroom. An 11th grade participant explained, “If we have an emergency in class and a teacher won’t let you go, that is my worst nightmare…if you’re bleeding through your tampon…if you’ve used all of your bathroom passes, for example, you can’t ask the teacher to go. You sit there with so much anxiety because you know you can’t go to the bathroom. And sometimes, I won’t be able to go all day, which is so unhealthy.” Participants felt this policy resulted in bathroom avoidance, as they were reluctant to use a pass due to concern they might have a more urgent need for bathroom use at a later date. A 9th grade participant explained, “Some of my other teachers are, like, ‘You only get three bathroom passes the whole tri(mester).’ So usually, people want to save them, so we never go.” However, if at the end of the term a student had passes remaining, the teacher would give the student bonus points or another reward. This policy was effective at reducing participants’ willingness to use the bathroom, particularly if the class was a difficult one. A 10th grade participant explained, “Yeah, it’s three extra credit points, but I know, like, [chemistry]’s a really hard class, so most people want it…It’s not bad if you [use a pass], it won’t hurt you, but it will help you if you don’t.”
Clean, private bathrooms as facilitators. Participants reported that a few schools had bathrooms described as nicely decorated, clean, and well-functioning. However, these bathrooms were frequently located in areas that were not easily accessible to students, such as near an auditorium or stadium. A 10th grade participant explained, “There’s definitely nicer [bathrooms]. There’s one by the pool doors, which is not near any classes at all. That’s where the gym and the pool is. No one really uses it, and it’s more for the spectators in the gym [who are] watching games. It’s really nice, but it’s usually locked during the day.”
Single-stall bathrooms were generally preferred to the large bathrooms with multiple stalls, as they provided more privacy. These single-stall bathrooms were described as having walls that extended floor to ceiling, and doors that were lockable. A 9th grade participant explained, “I always feel much safer in a private [single-stall] bathroom, and I feel like I can like take my time and like very private, and … going to the bathroom is a private thing…”
Menstruation provided the opportunity for increased bladder emptying. Menstruation was not described as making the process of using the bathroom easier or more desirable, but it did increase the number of times bathrooms were used during school hours to change feminine hygiene products. A 12th grade participant explained, “I’m not like the kind of person who just makes a point of going to the bathroom super regularly, but yeah if I’m on my period then I go usually after every hour or after every other hour.”
The findings from this study suggest that there are many barriers to high school bathroom use, thus reducing the ability and or willingness of adolescent women to void in conjunction with biological urge. School nurses are in a unique position to influence policies related to bathroom use through educating administrators, teachers, and students of the importance of voiding in conjunction with biological urge.
These findings highlight the importance of a clean, well-stocked school bathroom environment. Adolescent women reported preferring to delay voiding for hours rather than use a dirty bathroom. This is consistent with student preferences regarding bathroom use in the United States and other countries (Camenga et al., 2019; Shoham et al., 2021). Bathroom environments have an important role in healthy bladder behavior development, as improving bathroom environments may facilitate adolescent women’s voiding in conjunction with urge. It is imperative that school administrators consider the influence of dirty bathrooms and the potential to negatively affect adolescent women’s bladder health habits through delayed voiding.
Lack of privacy must be considered when designing bathrooms in new school buildings and remodels. Bathroom stalls should include lockable doors without large gaps between doors and frames. Regular maintenance of high school bathrooms should include repairing missing doors, locks, or other impediments to student privacy. Another privacy consideration related to designing high school bathrooms is including single-stall bathrooms for student use. Student preferences for gender neutral, single-stall bathrooms have been reported in studies of transgender students, for privacy and reducing stigmatization (Porta et al., 2017). The results of this study reinforces that cisgender students also prefer private, single-stall bathrooms. Single-stall bathrooms that are centrally located and available to all students decrease stigma associated with menstruation, stooling, or other private acts.
Administrators play a key role in setting the “tone” for a school. Administrators who support healthy bladder behaviors for teachers, staff, and students are critically important to changing the policies that impede school bathroom use. Students who frequently request bathroom use warrant a referral to a school nurse for further assessment. Additionally, school nurses may educate teachers regarding the importance of reducing barriers to bathroom use. Teacher policies aimed at reducing bathroom use can contribute to poor bladder health, including increased incontinence and urinary tract infections (von Gontard et al., 2017). Bathroom policies should be reviewed to eliminate barriers, particularly those aimed at increasing student embarrassment and stigma related to bathroom use, such as requiring students to carry large, obtrusive bathroom passes that are hard to manage in the bathroom stall setting and raise questions about cleanliness of the item itself. Strategies to reduce embarrassment and stigma include removing names and times of bathroom use on passes. Additionally, risk for infectious disease transmission via shared objects carried to and from a bathroom setting should be considered, and regular sterilization of physical bathroom passes should be encouraged (Flores et al., 2011).
Bullying was not identified as a major theme that served to increase bathroom avoidance in this sample, as participants in this study generally felt safe using the bathrooms at school. This finding is in contrast with other research that identified bullying to be a major factor related to bathroom avoidance (Ching et al., 2015; Norling et al., 2016). The small, homogenous female sample of participants may have affected these results. Additional research is necessary to parse out the effect that bullying may have on bathroom use in adolescent women.
Few facilitators to bathroom use were found in this study. This is consistent with current literature, in which there is a paucity of interventions aimed at increasing bathroom access and use in conjunction with biological urge. The few facilitators that were reported by participants included clean, updated, and well-stocked bathrooms. These updated facilities were not always available for use, as administrators frequently placed restrictions on their use. Overall, the lack of reliable facilitators meant there was little respite to the difficulty adolescent women had with using bathrooms while at school.
One interesting finding from this study was the role of menstruation, which served to increase bathroom use for some adolescent women. Similar to findings in other studies, adolescent women used the bathroom more frequently to change feminine hygiene products (Secor-Turner et al., 2022). However, findings in this study identified that increased use of school bathrooms was accompanied by an increased fear of menstrual stigma from peers. Thus, menstruation did not necessarily serve as a facilitator that made the process of bathroom use easier.
The difficulties adolescent women experienced regarding bathroom use highlights the need to reduce barriers to bathroom use to aid in forming healthy bladder habits. The experiences shared identified the intersection of biological need and barriers to responding to those needs that students face while in school. The described barriers moved beyond location and size of school bathroom environments and included the policy implications that delay voiding or avoid school bathrooms altogether. Any consideration given to policies related to bathrooms in high schools must support a variety of biological needs, as well as recognize the potential for stigma associated with typical bathroom behaviors, such as caring for menstrual needs. If these intersections are not considered, any policies placed related to bathroom use in high schools may well add additional burden to the difficulties already present and further reduce bathroom use.
Limitations for this study include a lack of heterogeneity in participants. Homogeneity in participants allowed for reaching depth in experiences due to shared social context or experiences, which aided in illuminating critical issues that are shared by the participants in that group but limited generalizability. Further research is needed focused on students from a variety of backgrounds and varied school demographics to fully elicit the challenges that are faced regarding performing optimal bladder health practices while in school.
Improving bathroom experiences and decreasing bathroom avoidance for adolescent women requires changes in school bathroom environments and school and teacher policies. Specific strategies to reduce bathroom avoidance behaviors may include:
Increasing resources towards ensuring bathrooms remain clean throughout the day, with particular attention paid to maintaining clean sinks, floors, and toilet seats.
Increasing privacy in bathrooms stalls with floor to ceiling doors and walls and reducing gaps between doors and the sides of the stalls.
Providing access to single-stall bathrooms to increase feelings of privacy.
Placing an emphasis on student autonomy to choose when to use the bathroom by reducing policies aimed at discouraging students from using the bathroom, including the use of incentives for bathroom avoidance.
Investigate bathroom limiting practices used by teachers on campus and explore teachers concerns about bathroom access.
Educate teachers that bathroom use and alignment of bathroom use with biological urge can be a healthy practice and may not be a sign of class avoidance.
Frequent need for bathroom use could a symptom of physical or emotional concerns. Student frequent bathroom use should be referred to the school nurse for assessment and/or monitoring.
Assessments of students include questions related to bathroom use, both in effort to identify potential issues related to student health and to identify barriers related to bathroom use present at individual schools. This data may be used to further support changes in policies and infrastructure for schools and school systems.
Reducing the feelings of being “on display” caused by visible bathroom passes. These include using large, bulky passes and writing down student names and times of bathroom use that are available to other students.
The voices of adolescent women in this study contribute to an increased understanding and an in-depth view of the challenges adolescent women face when using high school bathrooms. The study reveals insights into the adolescent experience, particularly regarding the bathroom environments and school policies that serve to keep adolescent women in the classroom versus responding to their biological urge to void or stool. Future studies should address the implementation and evaluation of the proposed interventions to reduce barriers and increase bathroom use in adolescent women in high school, as well as consider the short- and long-term effects of delayed voiding on bladder health.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Elissa S. Allen https://orcid.org/0000-0001-5208-083X
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Elissa S. Allen, PhD, RN, CNE is an assistant professor in the Bronson School of Nursing at Western Michigan University, Kalamazoo.
Lisa Kane Low, PhD, RN, CNM, FACNM, FAAN is a professor and the associate dean for Professional Graduate Studies in the School of Nursing at University of Michigan, Ann Arbor.
1 Bronson School of Nursing, Western Michigan University, Kalamazoo, MI, USA
2 School of Nursing, University of Michigan, Ann Arbor, MI, USA
Corresponding Author:Elissa S. Allen, PhD, RN, CNE, Bronson School of Nursing, Western Michigan University, 1903 W Michigan Ave, Kalamazoo, MI 49008-5331, USA.Email: elissa.allen@wmich.edu
