Bridging Knowledge and Practice in Toilet Training: A Parent-Focused Correlational Study to Develop an Instructional Module

INTRODUCTION

Toilet training (TT) is a significant developmental milestone for children, involving a complex process influenced by anatomical, physiological, and behavioural factors.^[1,2] Physiological readiness for bowel and bladder control usually develops by 18 months, but this does not always coincide with psychological readiness.^[3] Achieving control over these functions is a crucial developmental task for toddlers, involving complex neuromuscular integration.^[4] Mastering toileting skills in early childhood promotes independence and prevents bladder and bowel issues. Any delay in the mastery of toileting skills is linked to anxious and depressed symptoms, diminished self-esteem, reduced quality of life in the child, and significant parenting stress.^[5] It can be quite challenging for children, mothers, and healthcare professionals.

Mothers serve as the primary initiators and guides in children’s toilet training journey. A qualitative study found that caregivers seek accessible and trustworthy sources like healthcare providers, family, and day-care staff for clear, understandable guidance on when and how to train their child.^[6] Other research shows that social support, especially informational and practical (“instrumental”), helps boost mothers’ confidence and reduce stress, facilitating smoother toilet training.^[7]

Mothers set the tone through consistent modelling, encouragement, and responsiveness to cues. In community surveys, many mothers described behavioural strategies that diverged from official guidelines and often relied on the internet rather than seeking paediatrician advice.^[8] Indian mothers, for instance, commonly begin training earlier than Western norms; this tradition is still practiced among some immigrant families in Western countries, where children are typically diaper-free by 10-18 months.

A study from Belgium showed that many mothers delayed training until nursery school began rather than waiting for readiness cues, highlighting social timetable pressures rather than child development signs.^[9] In rural Odisha, India, limited sanitation access and heavy maternal workloads make toilet training a newer, sometimes stressful task, so community and family support play a vital role.^[7]

In the United States, beliefs about the optimal initiation age differ by race and socioeconomic status: Caucasian mothers tended to start later (25 months) than African American mothers (18 months), regardless of income or education.^[10]

In Indian knowledge, attitude, and practice (KAP) studies, maternal educational level and occupation correlated significantly with knowledge levels, influencing practice quality.^[11] Studies consistently find that better parental knowledge leads to more appropriate and timely practices. In Ludhiana, most mothers had average knowledge yet adequate practice (64% knowledge vs. 73% practice).^[12] In Saudi Arabia, a study showed gaps in mothers’ knowledge of childhood continence and its management, underlining the need for education to improve practice and outcomes.^[13]

Research also highlights that knowledge alone does not guarantee ideal behaviour. Some caregivers, despite information, used punitive or outdated approaches, and knowledge gaps remained regarding subtle triggers like distraction or forceful timing.^[14] Many mothers begin toilet training due to external milestones such as impending nursery school rather than observing developmental readiness signs. In a Flanders study, 50% started training due to school entry timelines, while only 27% responded to child readiness cues, and those who did begin with readiness signs completed training earlier and more efficiently.^[9]

Nearly 41% of mothers rely on the Internet rather than healthcare professionals for training methods. Fewer than half involve their paediatric provider in guidance, leading to widespread inconsistent or outdated strategies.^[8] Unrealistic expectations are also common. According to a literature review, mothers often expect earlier diaper withdrawal than developmentally appropriate, and current published training methods remain underutilized. Premature or stress-related training can prolong the process or contribute to health issues like constipation, enuresis, or voiding dysfunction.^[15]

Mothers want clear and accessible guidance. Qualitative interviews demonstrated that mothers prefer simple, clearly illustrated instructional materials from trusted sources such as paediatricians, nurseries, or reputable agencies to support timely and effective toilet training.^[6] Despite the availability of lay and clinical literature, accurate guidance from international paediatric bodies is less accessible to many mothers, especially in low-resource settings, resulting in gaps in evidence-based practice.^[15]

Delayed continence is another concern. A UK cohort study showed that initiating training after 24 months increases the odds of persistent daytime wetting, delayed control, or relapse in bladder function even after adjusting for temperament or maternal depression.^[4] In a Brazilian sample, delayed toilet training (mean completion at 31.6 months) was significantly associated with maternal employment outside the home and prematurity, even though no direct link to urinary tract symptoms was observed.^[1] Stressful or forced training without considering readiness or under parental pressure can extend the process and increase parental anxiety or child distress.^[15]

Several gaps in parental knowledge and practice have been identified in the context of toilet training. One of the most common misconceptions is that mothers often rely on the child’s age or external factors, such as school admission deadlines, rather than recognizing individual readiness signs. This can lead to inappropriate timing and ineffective training. Inconsistent practices are also common, with many mothers depending on internet advice or informal sources rather than paediatric guidance. Unrealistic expectations, such as premature initiation or comparisons with arbitrary benchmarks, can cause stress and hinder a child’s natural pace. A significant concern is the lack of tailored, accessible instructional tools, particularly for mothers from diverse linguistic, educational, or cultural backgrounds.^[16] Without standardized, easy-to-understand materials, mothers are often left misinformed. These gaps can result in delayed bladder control, poor hygiene habits, frequent accidents, and heightened stress for both mothers and children. The success of toilet training in toddlers between the ages of 18–36 months is greatly influenced by maternal support.^[17] The study aims to evaluate mothers’ knowledge and toilet training practices, and to examine the correlation between the two to guide the development of a practical instructional module.

MATERIAL AND METHODS

This study adopted a survey-based descriptive correlational design to assess the level of knowledge regarding toilet training and examine the practices followed by mothers of toddlers. In this study, “parents” were operationally defined as mothers of toddlers, and data were collected exclusively from mothers. Data were collected from mothers of toddlers attending the paediatric outpatient department (OPD) at a selected, 1,000-bed super-specialty tertiary care facility. The sample size was calculated based on the estimation of a single-proportion formula. With a level of significance (α) of 0.05 (Z = 1.96), an anticipated proportion (P) of 0.50 to ensure maximum variability, and a precision (d) of 0.069, the required sample size was determined to be 200. This sample size was selected to ensure a representative demographic distribution of mothers visiting the paediatric OPD and to give adequate statistical power for the correlation analysis. A total of 200 mothers of toddlers aged between 1 and 3 years were recruited using a simple random sampling technique. Inclusion criteria included mothers of toddlers within the specified age range who were visiting the paediatric OPD and were willing to participate in the study. Exclusion criteria included mothers of children diagnosed with anorectal anomalies, habitual constipation, or those with a colostomy. A list of all mothers who satisfied the inclusion criteria was created each morning during the data collection period. Every mother who met the requirements was given a special identifying number that matched her registration order for that day. These numbers were put in a container, and the participants for that day’s survey were chosen at random from a specified number of tokens. Data were collected in a face-to-face setting after obtaining informed written consent from the participants. The participants were informed about the objectives and purpose of the study through a participant information sheet. An average of 20–25 min was taken to complete the questionnaires. Confidentiality and anonymity were maintained, and participants were allowed to withdraw from the study at any time.

RESULTS

A total of 200 mothers participated in the study. The majority were aged 28–32 years (n = 72, 36%), followed by 23–27 years (n = 45, 22.5%) and 18–22 years (n = 6, 3%). In terms of socioeconomic status, 165 mothers (82.5%) reported an annual income of ₹1,00,001–₹5,00,000, while only one (0.5%) reported ₹10,00,001–₹15,00,000. Educationally, 94 (47%) had completed PUC, 52 (26%) held a degree, and one (0.5%) had no formal education. Regarding occupation, 132 (66%) were employed in the private sector, 24 (12%) in the government sector, and 44 (22%) were unemployed. Over half (n = 111, 55.5%) had not received prior information on toilet training. Constipation was reported in 35 children (17.5%): 17 (8.5%) for 1–6 months, 14 (7%) for 7–12 months, and 4 (2%) for 13–18 months. Most children (n = 193, 96.5%) were 1–2 years old. Male children comprised 125 (62.5%) and females 75 (37.5%).

DISCUSSION

This study explored the knowledge and practices of mothers regarding toilet training in toddlers. More than half of the mothers (54%) demonstrated adequate knowledge, while 46% showed inadequate knowledge. The mean practice score was 10.53 ± 3.22, reflecting a moderate level of appropriate toilet training practices.

CONCLUSION

This study reveals that mothers of toddlers generally possess moderate knowledge and demonstrate satisfactory toilet-training practices. A significant, moderate positive correlation was identified between parental knowledge and their actual practices, confirming that higher levels of awareness directly translate into more supportive, developmentally appropriate behaviours. Although mothers showed great proficiency in hygiene, identifying readiness, and providing positive reinforcement, there are still significant gaps in their ability to identify the dangers of improper timing and deal with training setbacks. These information gaps result in inconsistent toileting schedules and inadequate reinforcement, leading to negative effects like behavioural problems or chronic constipation. To bridge these gaps, there is a clear need for structured, culturally sensitive educational programs and practical instructional modules. Paediatric nurses and community health experts are crucial in providing proactive support to ensure potty training is a stress-free and successful milestone for both mothers and children.