Dr. Sebesta on household toilet and sanitation insecurity and bladder health

In this video, Elisabeth M. Sebesta, MD, describes the background and notable findings from the Urology study “Household Toilet and Sanitation Insecurity is Associated with Urinary Symptoms, Psychosocial Burden, and Compensatory Bladder Behaviors.” Sebesta is an assistant professor of urology at Vanderbilt University Medical Center in Nashville, Tennessee.

Transcription:

Please describe the background for this study.

About 2 years ago now, I conducted a study that was designed to look at unmet social needs and urinary symptoms in a community-based sample of men and women. We've published several things from this initial study. But when designing it and thinking about different social determinants of health and associations with urinary symptoms, I was specifically very interested in how access to toilets and plumbing and sanitation in the home might be an under investigated unmet social need in this space. So I included several questions in this initial study about toilets and plumbing and water access that really hasn't been something previously looked at in the urology literature. And so this is the first publication that's a more in-depth look at these associations. I think it's a really interesting thing to think about in the context of bladder health. Previously, people have looked at public restroom access or access to restrooms in the workplace. But toilet access in someone's home is really not something we often think about as a problem in the United States or other wealthy countries outside of the unhoused population. Usually, it's talked about more in a global health setting, and the only estimates we had before this looking at toilet and sanitation access in the United States have comes from US Census data. They estimate about 2 million Americans lack access to functional plumbing. But the issues with the definition that they use, translated into wealthier countries like the United States, is that it's a really limited view. So they basically just ask 1 or 2 questions on the type or availability of plumbing that you have in your home. "Do you have a toilet? Do you have running water?" It doesn't really dive into the experience of use, the accessibility, reliability, affordability, number of people that share a toilet in the home, all that kind of stuff. Again, most of this comes actually from unhoused people or those in very metropolitan areas. So I hypothesized that it was more complicated than that; it's more than just having a physical toilet. I wanted to understand a little bit more about these issues, and then how having toilet access could affect people who have urinary symptoms.

What were some of the notable findings? Were any of them surprising to you and your coauthors?

We used a couple of questions, like I said, to broaden the view of how we're defining people who might be at risk for sanitation and toilet insecurity in their home, which included things like, are you worried about a place to urinate in your home, do toilets or plumbing not work consistently in your home, kind of broaden the definition to include some of that experience, even if you do have a toilet. The sample included a little over 4000 men and women throughout the country. And 17% answered positively to 1 of our questions indicating they might be at risk for some sort of home toilet or sanitation insecurity, or at least they experienced some sort of worry or stress about having access consistently to a working toilet in their home. This is way higher than what the US Census data suggests, which is basically around 1% of the US population is what they say suffers from this. I did aim to be a lot more inclusive with my definition, so I expected this. I expected to be including a higher proportion of people, but 17% is pretty high. Particularly in this study sample, which I recruited from Research Match, which is like an online research registry, and it generally includes people who are overwhelmingly educated, employed, have internet access, that kind of stuff. So I think that we certainly under appreciate how many people living in our country might actually be affected by this issue. You don't know how many people are suffering from this unless you ask or talk to them about it. In terms of the overall notable findings, the main takeaway is that people who we deemed were at risk for toilet or sanitation insecurity were also more likely to report more severe urinary symptoms, even after adjusting for a whole bunch of different other confounding variables. This makes sense to me; you can imagine having overactive bladder, for example, if you don't have reliable, consistent access to a toilet, even at home, that affects how you perceive your symptoms. Likewise, if you have a lot of urgency, you may not feel like you have good access to a toilet if you have to wait a roommate, for example. The relationship here certainly is kind of intuitive to me, and it's certainly bi-directional and a little more complicated. But that was the main takeaway from this study.

This transcription was edited for clarity.