|Year : 2019 | Volume
| Issue : 1 | Page : 28-33
Toilet training and parental help-seeking behavior toward elimination disorders: Our experience in a semi-urban setting
Taslim O Lawal1, Godpower Chinedu Michael2, Ibrahim Aliyu3
1 Department of Paediatrics, Federal Medical Centre, Birnin Kebbi, Nigeria
2 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria
|Date of Submission||07-Mar-2018|
|Date of Acceptance||27-Jul-2018|
|Date of Web Publication||18-Jan-2019|
Department of Paediatrics, Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Introduction: Elimination disorders consist of enuresis and encopresis. When a child fails to successfully achieve toilet training by the age of five and has repeated voiding of urine on the bed or clothing at least twice per week for at least 3 consecutive months it is called enuresis; while bowel continence if not achieved by age 4 years, is encopresis. This study seeks to determine parental/caregiver concerns and help-seeking behaviors toward elimination disorders. Materials and Methods: This study was cross-sectional and was conducted over a 3-month period from January 2017 to March 2017. Convenience sampling method was adopted, and pretested researchers-administered questionnaires were used. Results: Two hundred individuals were recruited consisting of 104 (52%) males and 96 (48%) females with a male-to-female ratio of 1.1:1. About 194 (97%) of the respondents were aware of elimination disorders, 62 (31.0%) of them reported elimination disorder occurred in their wards, only 24.2% of the caregivers had sought for medical treatment for elimination disorder. Majority of the caregivers did not know the cause of elimination disorder, but 2% of them believed evil spirits were responsible for elimination disorders. Enuresis was the most commonly reported elimination disorder and most occurred at night (80.6%), and none had isolated encopresis. Ethnicity and educational qualification of respondents had no relationship with their help-seeking behavior toward elimination disorder ([Fishers' exact test = 11.337, P = 0.023] and [Fishers' exact test = 8.074, P = 0.089]). Conclusion: Elimination disorders were prevalent; however, few caregivers seek for medical help/treatment, and their help-seeking behavior was not influenced by their ethnicity or educational qualification.
Keywords: Caregivers, educational qualification, elimination disorders, ethnicity, help-seeking behavior
|How to cite this article:|
Lawal TO, Michael GC, Aliyu I. Toilet training and parental help-seeking behavior toward elimination disorders: Our experience in a semi-urban setting. Med J DY Patil Vidyapeeth 2019;12:28-33
|How to cite this URL:|
Lawal TO, Michael GC, Aliyu I. Toilet training and parental help-seeking behavior toward elimination disorders: Our experience in a semi-urban setting. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Jun 16];12:28-33. Available from: http://www.mjdrdypv.org/text.asp?2019/12/1/28/250441
| Introduction|| |
During toddler age, a child usually becomes interested in mastering elimination. Most children have achieved bowel and bladder continence by age 4 years. Acquiring continence usually proceeds in the following order: nighttime bowel, daytime bowel, daytime bladder, and nighttime bladder. About 33% of children in the United States of America are completely toilet trained by age 24 months. Females achieve continence earlier than males. Toilet training is a complex process which requires anatomic/physiologic maturity, emotional readiness of both the child and the parents, and a child should have acquired gross motor skill such as the ability to sit, stand, and walk; sphincter control and behavioral readiness for toilet training.
Toilet training in children from developed countries have evolved socially and culturally, resulting in varied methods of toilet training and timing for commencing toilet training; this has resulted in several theories to substantiate their recommendations,, ranging from the “concept of permissive indulgence,” in which the child is allowed to physiologically and psychological mature to achieve the required milestone unhindered, to the extreme rigidity of scheduling time for bowel and bladder activity-which is also practiced in most developing countries, though their perception differ.
In the early 1930s, mothers started toilet training as early as possible and most concluding toilet training by the age of 6–8 months; their methods were usually regimental, coercive without regards for the emotional readiness or cooperation of the child; however, other methods such as “the child-centered approach” advocated by Brazelton was developed in 1962 based on the reviews of psychoanalytical and developmental milestone studies which evaluated the physical and emotional readiness of the child; while Fraiberg in his report also stated that the active participation of the child, developed sphincter control, with the child being able to indicate the urge to empty the bowel is required for successful training; other methods had evolved over time such as “the parent-oriented approach” advocated by Foxx and Azrin and operant conditioning; however, most academic bodies such as the American Academy of Pediatrics and the Canadian Paediatric Society recommend starting toilet training between 18 and 24 months and the child-oriented approach is most favored. Never the less, cultural attitude significantly influences infant behavior as exemplified by the bowel training method adopted by the Indigo tribe of East Africa.
The elimination disorders consist of enuresis and encopresis. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnostic criteria for enuresis defines enuresis as repeated voiding of urine into bed or clothing at least twice per week for at least 3 consecutive months after the age of 5 years; and the absence of bowel continence by age 4 years is encopresis.
This study, therefore, sought to determine parental/caregiver concerns about elimination disorders and their help-seeking behaviors.
| Materials and Methods|| |
This study was cross-sectional involving caregivers attending the Paediatric Outpatient Clinic of Federal Medical Centre, Birnin Kebbi. It was conducted over a 3-month period from January 2017 to March 2017. The sample size was calculated using the statistical formula for prevalence studies; (Z2 × pq/d2).
Where Z = standard normal deviation, set at 1.96 which corresponds to 95% confidence level.
p = the proportion of population estimated to have elimination disorder (enuresis) was previous reports as P = 23.2% (0.232) based on a previous report by Paul et al.
q = 1.0– p; and d = degree of accuracy desired was set at 0.05
N = (1.96)2 (0.232) (0.768)/(0.05)2
For population <10,000, the sample size was nf = N/1 + N/n
where n = Estimated population of caregivers attending the pediatric outpatient clinic during the study period was 500.
Therefore, nf = 274/1 + (274/500)
The minimum sample size was 171; however, 200 respondents were recruited. Convenience sampling method was adopted.
All caregivers seen at the pediatric outpatient department during the study.
Those that declined consent were excluded from the study.
Caregiver whose child was less that the required age for the definition of enuresis and/or encopresis
Pretested researchers-administered questionnaire was used. The questionnaire was developed in English, and it contained 25 questions consisting of both open- and close-ended questions. This questionnaire was pretested on 20 volunteers, and an internal consistency was determined having a Cronbach's alpha value of 0.80; and information, such as age, sex, educational status of the caregiver, ethnicity, caregivers understanding of elimination disorders, caregivers attitude toward elimination disorders, caregivers perception of causes of elimination disorders, and treatment sort for elimination disorders, was obtained.
Ethical approval was obtained from the Ethical Committee of Federal Medical Centre, Birnin Kebbi. Consent was obtained from the respondents.
Obtained data were entered into Statistical Package for Social Sciences (SPSS) version 16 (SPSS Inc. Chicago, IL, USA). Quantitative variables, such as age, were summarized as means and standard deviations; while qualitative variables, such as sex and educational qualification, were presented as frequencies and percentages. The association between categorical variables was tested using the Chi-square or Fishers' exact test with P < 0.05 being set as statistically significant.
| Results|| |
Two hundred respondents were recruited for this study, consisting of 104 (52%) males and 96 (48%) females with a male-to-female ratio of 1.1:1. There were 32 (51.6%) males and 30 (48.4%) females among children with reported elimination disorders.
Majority of the caregivers had attained tertiary educational qualification, and most were of the Hausa ethnic group (51.0%) [Table 1]. Furthermore, 189 (94.5%) of the respondents were married while 11 (5.5%) were divorced. Nearly 184 (92.0%) of the children were toilet trained, while only 16 (8.0%) of the children were not trained. However, most (158; 79%) were toilet trained within 1 year of life while only 26 (13%) were toilet trained after 1 year of life. Among the respondents, 194 (97%) were aware of elimination disorders; however, 6 (3.0%) were not aware; but only 62 (31.0%) of the respondents reported elimination disorder in their wards, while 138 (69.0%) were not reported.
seventy-one percent of the respondents reported that their wards achieved dryness/fecal continence between the ages of 1 and 4 years; however, majority of the caregivers did not know the cause of elimination disorder but 2% believed evil spirits were responsible for elimination disorders [Table 2]. Enuresis was the most commonly reported elimination disorder and most occurred at night (80.7%), none had isolated encopresis. However, only 24.2% of the caregivers had sought for medical treatment for elimination disorder.
Furthermore, 39 (19.5%) of the caregivers also reported having elimination disorder as a child while 161 (80.5%) did not; however, enuresis was the only reported elimination disorder among caregivers who had it as a child.
The bowl habit of the respondents ward was at least once within 3 days in 196 (98%); while 4 (2%) defecate at least once after every 3 days; however, 29 (14.5%) pass hard stools while 171 (85.5%) pass normal stools.
Majority of the respondents from all the ethnic groups' toilet-trained their wards, and they were aware of elimination disorders though these observations were not statistically significant (Fishers exact test = 5.736, P = 0.166, and Fishers' exact test = 1.684, P = 0.794, respectively); most of the reported cases of elimination disorder were among the Hausa ethnic group, but this was not statistically significant (χ2 = 3.914, df = 4, P = 0.420). However, most of the respondents from all the ethnic groups did not sort for medical care for elimination disorder, and this observation was statistically significant (Fisher's exact test = 11.337, P = 0.023) [Table 3].
|Table 3: Comparing ethnicity of caregivers with their attitude towards elimination disorders|
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Most respondents from all the ethnic groups did not know the cause of elimination disorders; however, this was not statistically significant (Fisher's exact test = 17.673, P = 0.609), furthermore, their educational qualification did not show any relationship with their perception of the causes of elimination disorders though this observation was not statistically significant (Fisher's exact test = 29.745, P = 0.069) [Table 4].
|Table 4: Comparing ethnicity and educational status of the caregivers with perception of causes of elimination disorders|
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Majority of the respondents from all the educational groups' toilet trained their wards, and they were aware of elimination disorders; though these observations were not statistically significant (Fisher's exact test = 3.970, P = 0.410; Fisher's exact test = 1.954, P = 0.744, respectively); however, most of the respondents from all the educational groups except the religious group did not seek for medical care for elimination disorder, however, this observation was not statistically significant (Fishers exact test = 8.074, P = 0.089) [Table 5].
|Table 5: Comparing educational status of caregivers with their attitude towards elimination disorders|
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| Discussion|| |
Our study showed that the majority of the parents commenced toilet training within the 1st year of life; this observation was at variance with recommendation from major medical societies such as the American Academy of Pediatrics and the Canadian Society which prescribed the age of commencement of toilet training as 18–24 months. However, our finding was similar to that reported by deVries and deVries, who reported early commencement of toilet training among the East African Digo children with successful outcome. Therefore, sociocultural influence may have significant impact on toilet training. There are varied reports of the influence of age at toilet training, while some report did not find any association between age at toilet training with poor urologic outcomes; Joinson et al., reported that training after 24 months was associated with higher risk of daytime enuresis. Age at the commencement of toilet training and its outcome has been an issue of debate. Some researchers had associated the increasing incidence of urinary incontinence and urinary tract infection with delayed toilet training, while others had reported delayed attainment of bladder/bowel control with early age of toilet training but without any untoward behavioral effect; however, these were not observed among the Digo children.
Enuresis was the most common form of elimination disorder in our study; this was reported by 31% of the respondents, this result was similar to that reported by Imoudu et al. in Kaduna, but differed from those reported from studies in America, Europe, and Asia where 4.8%, 3.7%, and 8% were documented, respectively,,, this disparity may highlight differences in toilet-training methods while most developed countries adopt outlined guidelines such as the “child-oriented approach” or the “parent-oriented approach” most African cultures still practice regimentally rigid approach. Furthermore, other reports from other regions in Nigeria documented a relatively lower prevalence of enuresis: Esezobor et al. in Southwest Nigeria reported 28.3%, while Iduoriyekemwen et al. in Edo, Nigeria, reported a prevalence of 21.3%. Similar prevalence of 23.2% and 22.2% were reported by Paul et al. in Port-Harcourt and Mbibu et al. in Zaria, respectively. These results did not show a clear regional variation but the northern part of Nigeria relatively had higher figures.
Only a single case (0.5%) of encopresis was documented in this study, this further highlights the rarity of this disorder, however, our report was at variance with that of Chinawa et al., who reported 10%, Although they attributed their differences to possible influence of a small sample size.
The prevalence of enuresis had no relationship with encopresis in our study; this finding was similar to that reported by Chinawa et al. Although genetic predisposition is a risk factor for enuresis, chromosomes 12q, 13q, and 22 have been implicated; however, its specific role in enuresis is still unknown but only 19.5% of parents reported ever having enuresis as a child in this study, which was similar to the 16.1% reported by Chinawa et al.
About 24.2% of caregivers had sort medical help for elimination disorder; our finding was higher than the 2.1% reported by Etuk et al. and that reported in Turkey (17.2%); but lower than that reported in Pakistan (54%). This study also showed that ethnicity, and educational qualification of the respondents did not influence their help-seeking behavior toward elimination disorders. Urinary and fecal incontinence are poorly discussed health topics and few patients often sought medical assistance from physicians. Schreiber et al. reported that only 25.3% of Danish and 31.4% of German women sought for medical help for urinary incontinence. Common predictors of positive help-seeking behavior identified in their study were severity and duration of urinary incontinence and those who actively seek for information on urinary incontinence. Furthermore, patients willingness to volunteer information on urinary incontinence may be hindered by other factors; such as the believe that bed-wetting may be normal; patronizing traditional healers either due to lack of funds to pay for hospital bills, or out of ignorance, which is common in most developing countries; similarly, the feeling of embarrassment and low self-esteem among affected patients may influence their self-reporting of this disorder. These factors may also be prevalent among our respondents.
| Conclusion|| |
Enuresis is a common elimination disorder among children of the respondents in this study; and nocturnal enuresis was the most common. However, the help-seeking behavior was dismally poor among the respondents, and this observation was not influenced by their ethnicity or educational qualification.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Adekanmbi AF, Ogunlesi TA, Fetuga MB, Oluwole FA, Alabi AD, Kehinde OA. Prevalence and risk factors for enuresis in children. Nigerian Hospital Practice 2011;7:3-4.
Mbibu NH, Ameh EA, Shehu AU, Wammanda RD. The prevalence of enuresis among primary school children in Zaria, Nigeria. Nigerian J Surg Res 2005;7:187-90.
Paul NI, Alikor EAD, Anochie IC. Prevalence of enuresis among primary school children in Port Harcourt. Niger J Paediatr 2012;39:18-21.
Vermandel A, Weyler J, De Wachter S, Wyndaele JJ. Toilet training of healthy young toddlers: A randomized trial between a daytime wetting alarm and timed potty training. J Dev Behav Pediatr 2008;29:191-6.
Kaerts N, Van Hal G, Vermandel A, Wyndaele JJ. Readiness signs used to define the proper moment to start toilet training: A review of the literature. Neurourol Urodyn 2012;31:437-40.
Law E, Yang JH, Coit MH, Chan E. Toilet school for children with failure to toilet train: Comparing a group therapy model with individual treatment. J Dev Behav Pediatr 2016;37:223-30.
deVries MW, deVries MR. Cultural relativity of toilet training readiness: A perspective from east Africa. Pediatrics 1977;60:170-7.
Barone JG, Jasutkar N, Schneider D. Later toilet training is associated with urge incontinence in children. J Pediatr Urol 2009;5:458-61.
Russell K. Among healthy children, what toilet-training strategy is most effective and prevents fewer adverse events (stool withholding and dysfunctional voiding)? Part A: Evidence-based answer and summary. Paediatr Child Health 2008;13:201-2.
Fraiberg SH. The Magic Years. New York: Charles Scribner's; 1959. p. 91-100.
Kaerts N, Vermandel A, Lierman F, Van Gestel A, Wyndaele JJ. Observing signs of toilet readiness: Results of two prospective studies. Scand J Urol Nephrol 2012;46:424-30.
Vermandel A, Van Kampen M, Van Gorp C, Wyndaele JJ. How to toilet train healthy children? A review of the literature. Neurourol Urodyn 2008;27:162-6.
Rugolotto S, Sun M, Boucke L, Calò DG, Tatò L. Toilet training started during the first year of life: A report on elimination signals, stool toileting refusal and completion age. Minerva Pediatr 2008;60:27-35.
Choby BA, George S. Toilet training. Am Fam Physician 2008;78:1059-64.
Etuk IS, Ikpeme O, Essiet GA. Nocturnal enuresis and its treatment among primary school children in Calabar Nigeria. Niger J Paediatr 2011;38:34-7.
Pourhoseinholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench 2013;6:14-7.
Hodges SJ, Richards KA, Gorbachinsky I, Krane LS. The association of age of toilet training and dysfunctional voiding. Res Rep Urol 2014;6:127-30.
Joinson C, Heron J, Von Gontard A, Butler U, Emond A, Golding J, et al.
A prospective study of age at initiation of toilet training and subsequent daytime bladder control in school-age children. J Dev Behav Pediatr 2009;30:385-93.
Alpaslan AH, Koçak U, Avci K, Güzel HI. Association between elimination disorders and abusive maternal attitudes. J Forensic Leg Med 2016;40:22-7.
Brown ML, Pope AW, Brown EJ. Treatment of primary nocturnal enuresis in children: A review. Child Care Health Dev 2011;37:153-60.
Mota DM, Barros AJ. Toilet training: Methods, parental expectations and associated dysfunctions. J Pediatr (Rio J) 2008;84:9-17.
Imoudu IA, Bugaje MA, Aikhionbare HA. Childhood enuresis: A study of Dogarawa community of north western Nigeria. J Dent Med Sci 2014;13:6-10.
Dolgun G, Savaser S, Balci S, Yazici S. Prevalence of nocturnal enuresis and related factors in children aged 5-13 in Istanbul. Iran J Pediatr 2012;22:205-12.
De Sousa A, Kapoor H, Jagtap J, Sen M. Prevalence and factors affecting enuresis amongst primary school children. Indian J Urol 2007;23:354-7.
] [Full text]
Bakhtiar K, Pournia Y, Ebrahimzadeh F, Farhadi A, Shafi zadeh F, Hosseinabadi R. Prevalence of nocturnal enuresis and Its associated factors in primary school and preschool children of Khorramabad in 2013. Int J Pediatr 2014. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4211300/
. [Last accessed on December, 31, 2017].
Esezobor CI, Balogun MR, Ladapo TA. Prevalence and predictors of childhood enuresis in southwest Nigeria: Findings from a cross-sectional population study. J Pediatr Urol 2015;11:338.e1-6.
Iduoriyekemwen NJ, Ibadin MO, Abiodun PO. Survey of childhood enuresis in the ehor community, the EDO state, Nigeria. Saudi J Kidney Dis Transpl 2006;17:177-82.
] [Full text]
Chinawa JM, Obu HA, Manyike P, Isreal OO, Tamunosiki CA. Prevalence of encopresis in children aged 5-12 years attending government primary schools in South East Nigeria. Afri J Med Health Sci 2015;14:13-7.
Nevéus T. Pathogenesis of enuresis: Towards a new understanding. Int J Urol 2017;24:174-82.
Ozden C, Ozdal OL, Altinova S, Oguzulgen I, Urgancioglu G, Memis A. Prevalence and associated factors of enuresis in Turkish children. Int Braz J Urol 2007;33:216-22. Available from: http://www.scielo.br/scielo
. [Last cited on 2017 Dec 07].
Schreiber Pedersen L, Lose G, Høybye MT, Jürgensen M, Waldmann A, Rudnicki M, et al.
Predictors and reasons for help-seeking behavior among women with urinary incontinence. Int Urogynecol J 2018;29:521-30.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]