Article
Parents’ views on toilet training (TT): A quantitative study to identify the beliefs and attitudes of parents concerning TT
Journal of Child Health Care 2015, Vol. 19(2) 265–274 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493513508232 chc.sagepub.com
Karolien van Nunen and Nore Kaerts University of Antwerp, Belgium
Jean-Jacques Wyndaele and Alexandra Vermandel University of Antwerp, Belgium; University Hospital Antwerp, Belgium
Guido Van Hal University of Antwerp, Belgium
Abstract Background: In recent years, the age at which parents start and finish toilet training (TT) their children has increased. To cope with the problems caused by this later completion, it is essential to identify the beliefs and attitudes of the parents. Methods: Two thousand questionnaires were distributed to parents of children aged 30 to 36 months, attending 50 randomly selected schools in Antwerp, Belgium. Results: Too many children are toilet trained after the minimum school age of 30 months. Most parents are not aware of the possible negative consequences this can entail. Mothers with a paid occupation think more often that children should be toilet trained before the age of 30 months, and the higher the mother’s educational level, the more likely she will send her child to school toilet trained. More of single parents think that children who are not yet toilet trained should be allowed to go to school and more often send their not fully toilet-trained children to school. Conclusion: Parents should be better informed about the possible negative consequences of a later completion of TT. Single parents, more than other parents, should be assisted in the TT process and offered more support. Keywords Bowel and bladder control, nursery school, parents, potty training, toilet training Corresponding author: Karolien van Nunen, Department of Epidemiology and Social Sciences, Faculty of Medicine and Health Sciences, Research Group Medical Sociology and Health Policy, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium. Email: [email protected]
Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on June 13, 2015
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Journal of Child Health Care 19(2)
Introduction Toilet training (TT) is one of the most challenging developmental stages of early childhood and one that all children must complete successfully to comply with the norms of our society and to gain autonomy and self-esteem. In recent years, the age at which parents start and finish TT their children has increased (Bakker and Wyndaele, 2000; Bakker et al., 2002; Barone et al., 2009; Schum et al., 2001). During the 40s, parents started TT before their child reached the age of 18 months, whereas nowadays this age has increased to 21 to 36 months (Schum et al., 2002). At the end of the 90s, children were toilet trained 12 to 15 months later than the children who were toilet trained in the 50s (Schum et al., 2001). Blum et al. (2003, 2004) argue that the characteristics of children have undergone very few changes in the past 30 to 50 years. Therefore, they assume this current trend for a later completion of TT finds its cause in the environment of the child or in the experiences children have during their TT. Other authors (e.g. Bakker and Wyndaele, 2000; Schum et al., 2001) share this opinion of a cause external to the child. A cause that is mentioned by many authors is the use of disposable absorbent diapers (Bakker and Wyndaele, 2000; Berk and Friman, 1990; Schum et al., 2001). Also, today many parents work outside (Bakker and Wyndaele, 2000), resulting in less time that can be spent on the TT of their children (Schum et al., 2001). In addition, parents nowadays tend to be less consistent and authoritarian, and they often apply a more liberal approach of education (Horstmanshoff et al., 2003; Schum et al., 2001). The postponed age of TT entails negative consequences for the child, parents, health, environment and society (Bakker et al., 2004; Barone et al., 2009; Hellstrom, 2000; Mota et al., 2008). As shown in day-care centres and nursery schools, more infectious diseases occur due to the increased presence of non-toilet-trained children (Hadler and McFarland, 1986; Pickering et al., 1986). Moreover, parents and child encounter problems of hygiene, a high dependence of the child on the parents and possible social discomfort until TT is completed (Foxx and Azrin, 1973). A later age for TT can also cause stress, frustration and tension between the parents and the child (Luxem and Christophersen, 1994; Taubman, 1997). In addition, if TT is not yet completed, children will not be allowed to attend some schools (Bakker et al., 2001; Luxem and Christophersen, 1994). A later completion of TT also causes problems in the schools themselves. Because of the increased presence of non-toilet-trained children, the educational activities are impeded, and the nursery teachers experience additional workload due to problems associated with TT (Vermandel et al., 2011). Another consequence is the impact on the environment. On average, a baby utilizes about 5000 disposable diapers before being toilet trained. Presuming this number is correct, disposable diapers comprise 8.5% of all Belgian waste (Luxem and Christophersen, 1994; Province of Antwerp, 2010). To cope with the problems caused by later completion of TT, it is essential to identify the beliefs and attitudes of the most significant actors in this process: the parents. This is necessary so as to inform and sensitize them about this issue in an appropriate way. Our research studies these beliefs and attitudes in the parents. Until now, as far as we are aware, such data were not available for Flanders.
Methods To examine the views and attitudes of parents regarding TT, a cross-sectional quantitative research method using a self-administered questionnaire was chosen. The target population includes parents
Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on June 13, 2015
van Nunen et al.
267
of children aged two and a half to three years. To identify these parents, they were contacted through the nursery schools. During the school year 2009–2010, schools in the province of Antwerp, Belgium, were approached about the study. In this school year, the 70 municipalities of the province of Antwerp had 684 nursery schools enrolling 69,461 children. Of these, 50 nursery schools were chosen at random. First, informed consent to cooperate was requested from the principals of the schools. This was followed by the distribution of 2000 questionnaires to the parents via the nursery teachers. The parents received an envelope with the questionnaire and an information form. We did not apply for approval from an ethics committee, but the information form explained that completion of the questionnaire is voluntary, as well as the goal of the study and the protection of their privacy (all questionnaires were filled out anonymously). Most of the questions were pre-coded. If applicable, it was indicated that multiple answers could be given. After completion, the parents returned the questionnaires in a sealed envelope to the nursery teachers. After an agreed period of time, the completed surveys were collected from the schools. For the selection of the questions, we looked at the literature concerned for the important topics and also at two defended PhDs on TT in Flanders, also using questionnaires in Dutch. The questionnaire gathered information on socio-demographic data, the age parents find appropriate for the child to be toilet trained, the methods they use to toilet train, when they start this training and their opinions about TT in nursery school. Also examined is whether the parents are aware of a later attainment of bladder control and whether they do or do not perceive this as a problem. All data were entered, cleaned and analysed in Statistical Package for Social Sciences version, SPSS 15.0. Simple frequencies and bivariate analyses were performed when relevant and appropriate. The bivariate analyses used 2 tests. Statistical significance was tested at 5% probability level. A clear definition of the concept ‘being toilet trained’ was given to the respondents. They were asked to complete the questionnaire with the following definition in mind: The child is toilet trained when he/she wears underpants during the day. The child goes to the potty or toilet by himself/herself or indicates the need to go. This must happen without the parent or teacher reminding the child to urinate or have bowel movements (independent reaction to their urge). The child has a maximum of one accident a day.
Results Of the 2000 distributed surveys, 1158 were returned completed. The total response rate was thus 57.9%. The 1158 respondents have a combined total of 2409 children. Of these 2409 children, 49.2% are girls (n ¼ 1186) and 46.5% are boys (n ¼ 1121). The gender of 102 children was not reported. The child that goes to the nursery school and to whose parents the questionnaire was distributed is referred to as the index child. We did not include all the 1158 completed questionnaires in all the analyses. Not only did the missing values sometimes cause a lower response rate, some parts of the questionnaire were also not applicable for some parents (e.g. when the parents had not yet started to toilet train their child).
Characteristics of the respondents Most of the respondents were married or cohabiting (92.5%; n ¼ 1062 of 1148); the others were single parents. Of the mothers, 59.2% (n ¼ 679 of 1146) were highly educated, 29.6% (n ¼ 339 of
Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on June 13, 2015
268
Journal of Child Health Care 19(2)
Table 1. Desired age of dryness in the opinion of the parents and actual age of dryness. Desired
Actual a
N ¼ 1888b
N ¼ 1145
Before 30 months (
Parents’ views on toilet training (TT): A quantitative study to identify the beliefs and attitudes of parents concerning TT
Journal of Child Health Care 2015, Vol. 19(2) 265–274 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493513508232 chc.sagepub.com
Karolien van Nunen and Nore Kaerts University of Antwerp, Belgium
Jean-Jacques Wyndaele and Alexandra Vermandel University of Antwerp, Belgium; University Hospital Antwerp, Belgium
Guido Van Hal University of Antwerp, Belgium
Abstract Background: In recent years, the age at which parents start and finish toilet training (TT) their children has increased. To cope with the problems caused by this later completion, it is essential to identify the beliefs and attitudes of the parents. Methods: Two thousand questionnaires were distributed to parents of children aged 30 to 36 months, attending 50 randomly selected schools in Antwerp, Belgium. Results: Too many children are toilet trained after the minimum school age of 30 months. Most parents are not aware of the possible negative consequences this can entail. Mothers with a paid occupation think more often that children should be toilet trained before the age of 30 months, and the higher the mother’s educational level, the more likely she will send her child to school toilet trained. More of single parents think that children who are not yet toilet trained should be allowed to go to school and more often send their not fully toilet-trained children to school. Conclusion: Parents should be better informed about the possible negative consequences of a later completion of TT. Single parents, more than other parents, should be assisted in the TT process and offered more support. Keywords Bowel and bladder control, nursery school, parents, potty training, toilet training Corresponding author: Karolien van Nunen, Department of Epidemiology and Social Sciences, Faculty of Medicine and Health Sciences, Research Group Medical Sociology and Health Policy, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium. Email: [email protected]
Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on June 13, 2015
266
Journal of Child Health Care 19(2)
Introduction Toilet training (TT) is one of the most challenging developmental stages of early childhood and one that all children must complete successfully to comply with the norms of our society and to gain autonomy and self-esteem. In recent years, the age at which parents start and finish TT their children has increased (Bakker and Wyndaele, 2000; Bakker et al., 2002; Barone et al., 2009; Schum et al., 2001). During the 40s, parents started TT before their child reached the age of 18 months, whereas nowadays this age has increased to 21 to 36 months (Schum et al., 2002). At the end of the 90s, children were toilet trained 12 to 15 months later than the children who were toilet trained in the 50s (Schum et al., 2001). Blum et al. (2003, 2004) argue that the characteristics of children have undergone very few changes in the past 30 to 50 years. Therefore, they assume this current trend for a later completion of TT finds its cause in the environment of the child or in the experiences children have during their TT. Other authors (e.g. Bakker and Wyndaele, 2000; Schum et al., 2001) share this opinion of a cause external to the child. A cause that is mentioned by many authors is the use of disposable absorbent diapers (Bakker and Wyndaele, 2000; Berk and Friman, 1990; Schum et al., 2001). Also, today many parents work outside (Bakker and Wyndaele, 2000), resulting in less time that can be spent on the TT of their children (Schum et al., 2001). In addition, parents nowadays tend to be less consistent and authoritarian, and they often apply a more liberal approach of education (Horstmanshoff et al., 2003; Schum et al., 2001). The postponed age of TT entails negative consequences for the child, parents, health, environment and society (Bakker et al., 2004; Barone et al., 2009; Hellstrom, 2000; Mota et al., 2008). As shown in day-care centres and nursery schools, more infectious diseases occur due to the increased presence of non-toilet-trained children (Hadler and McFarland, 1986; Pickering et al., 1986). Moreover, parents and child encounter problems of hygiene, a high dependence of the child on the parents and possible social discomfort until TT is completed (Foxx and Azrin, 1973). A later age for TT can also cause stress, frustration and tension between the parents and the child (Luxem and Christophersen, 1994; Taubman, 1997). In addition, if TT is not yet completed, children will not be allowed to attend some schools (Bakker et al., 2001; Luxem and Christophersen, 1994). A later completion of TT also causes problems in the schools themselves. Because of the increased presence of non-toilet-trained children, the educational activities are impeded, and the nursery teachers experience additional workload due to problems associated with TT (Vermandel et al., 2011). Another consequence is the impact on the environment. On average, a baby utilizes about 5000 disposable diapers before being toilet trained. Presuming this number is correct, disposable diapers comprise 8.5% of all Belgian waste (Luxem and Christophersen, 1994; Province of Antwerp, 2010). To cope with the problems caused by later completion of TT, it is essential to identify the beliefs and attitudes of the most significant actors in this process: the parents. This is necessary so as to inform and sensitize them about this issue in an appropriate way. Our research studies these beliefs and attitudes in the parents. Until now, as far as we are aware, such data were not available for Flanders.
Methods To examine the views and attitudes of parents regarding TT, a cross-sectional quantitative research method using a self-administered questionnaire was chosen. The target population includes parents
Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on June 13, 2015
van Nunen et al.
267
of children aged two and a half to three years. To identify these parents, they were contacted through the nursery schools. During the school year 2009–2010, schools in the province of Antwerp, Belgium, were approached about the study. In this school year, the 70 municipalities of the province of Antwerp had 684 nursery schools enrolling 69,461 children. Of these, 50 nursery schools were chosen at random. First, informed consent to cooperate was requested from the principals of the schools. This was followed by the distribution of 2000 questionnaires to the parents via the nursery teachers. The parents received an envelope with the questionnaire and an information form. We did not apply for approval from an ethics committee, but the information form explained that completion of the questionnaire is voluntary, as well as the goal of the study and the protection of their privacy (all questionnaires were filled out anonymously). Most of the questions were pre-coded. If applicable, it was indicated that multiple answers could be given. After completion, the parents returned the questionnaires in a sealed envelope to the nursery teachers. After an agreed period of time, the completed surveys were collected from the schools. For the selection of the questions, we looked at the literature concerned for the important topics and also at two defended PhDs on TT in Flanders, also using questionnaires in Dutch. The questionnaire gathered information on socio-demographic data, the age parents find appropriate for the child to be toilet trained, the methods they use to toilet train, when they start this training and their opinions about TT in nursery school. Also examined is whether the parents are aware of a later attainment of bladder control and whether they do or do not perceive this as a problem. All data were entered, cleaned and analysed in Statistical Package for Social Sciences version, SPSS 15.0. Simple frequencies and bivariate analyses were performed when relevant and appropriate. The bivariate analyses used 2 tests. Statistical significance was tested at 5% probability level. A clear definition of the concept ‘being toilet trained’ was given to the respondents. They were asked to complete the questionnaire with the following definition in mind: The child is toilet trained when he/she wears underpants during the day. The child goes to the potty or toilet by himself/herself or indicates the need to go. This must happen without the parent or teacher reminding the child to urinate or have bowel movements (independent reaction to their urge). The child has a maximum of one accident a day.
Results Of the 2000 distributed surveys, 1158 were returned completed. The total response rate was thus 57.9%. The 1158 respondents have a combined total of 2409 children. Of these 2409 children, 49.2% are girls (n ¼ 1186) and 46.5% are boys (n ¼ 1121). The gender of 102 children was not reported. The child that goes to the nursery school and to whose parents the questionnaire was distributed is referred to as the index child. We did not include all the 1158 completed questionnaires in all the analyses. Not only did the missing values sometimes cause a lower response rate, some parts of the questionnaire were also not applicable for some parents (e.g. when the parents had not yet started to toilet train their child).
Characteristics of the respondents Most of the respondents were married or cohabiting (92.5%; n ¼ 1062 of 1148); the others were single parents. Of the mothers, 59.2% (n ¼ 679 of 1146) were highly educated, 29.6% (n ¼ 339 of
Downloaded from chc.sagepub.com at UNIVERSITE DE MONTREAL on June 13, 2015
268
Journal of Child Health Care 19(2)
Table 1. Desired age of dryness in the opinion of the parents and actual age of dryness. Desired
Actual a
N ¼ 1888b
N ¼ 1145
Before 30 months (
