GWU MPH Program Advance Communications Presentation for a pilot potty training text messaging program.

1. By: Lindsey Goggin and
Kathleen MacDonald

2. 2 CENTRAL THEORIES FOR POTTY TRAINING
CHILDREN USED IN THE US
Gradual Child-Oriented Training (BRAZELTON METHOD)
• Child-oriented gradual training was designed in 1962 based on the recommendations of T.
Berry Brazelton, who conducted the largest toilet training survey in the United States.
Promotes readiness on the part of the child as well as the parents. Parents must respond to
signs of a child‟s readiness to train which include: physiologic attainment of bladder and
bowel control and sufficient neurologic maturity for the child to voluntarily accept the
responsibility to participate in toilet training. Parent‟s must also be willing to participate in
the training and be aware of obstacles to the training process such as daycare. 1,2
Structure, Endpoint-Oriented Training (AZRIN and FOX METHOD)
• Approach that emerged in the 1960s and 70s. The Azrin-Foxx method comes from from an
applied behavior analysis of toilet training in which they identified a number of component
skills that could be taught to a toddler. The child would be toilet trained once all of the
components were learned. This methodology allows for small deviations and failures as the
child is learning.1 Azrin and Fox Method is considered to be the more successful of the two2
1. Brazelton et. al., “Instruction, Timeliness, and Medical Influences Affecting Toilet
Training,” Journal of the American Academy of Pediatrics, 103 (1999); 1353-1358
2. Kalsson, et. al. “The Effectiveness of Different Methods of Toilet Training for Bowel
and Bladder Control.” Agency for Healthcare Research and Quality. 147 (2006):
Accessed September 25, 2011. http://www.ahrq.gov/clinic/tp/toilettrtp.htm

3. CURRENT EXISTING SOLUTIONS (BASED ON BRAZELTON AND
AZRIN-FOX’S METHOD)
1. The Readiness Approach: A method of toilet training based on
Brazelton‟s theory. The method is a relaxed, positive method that respects
the child's ability to learn, while watching for signs that the child is
physically, intellectually, and psychologically "ready" to be potty trained. A
child will show interest in potty training might include: talking about going to
the potty, being interested in other‟s going to the toilet. The age that a child
begins to potty train is based on the emergence of these signs rather then
the actual age of a child.1
2. Dr. Phil’s One-Day Method: Children are taught toilet training by
using a doll that wets. The child learns to use the potty themselves by
„teaching‟ the doll to go to the potty. „Big kid underwear‟ is put on the doll.
The doll is taken to the potty after it drinks something and uses the potty.
When the doll has success, it is thrown a “potty party” to celebrate. The child
is told that they will also have a party when they learn to use the bathroom.
The entire potty training process learned via demonstration with the doll.2
This method is based on the Azrin-Fox method.
1. “The Readiness Method.” Nick Jr.com. Date of access September 25, 2011. http://www.nickjr.com/preschool/potty-
training/advice/potty_training_readiness_ap.html
2. “Potty Train Your Child in Less Then One Day.” Dr. Phil.com. Accessed September 26, 2011.
http://drphil.com/articles/article/264/

4. CURRENT EXISTING SOLUTIONS CONTINUED
3. Practicing Safety Module for Toilet Training: Toilet training is a
period with a high incidence of abuse. This method aims to teach toilet
training to children while eliminating stress on the child and frustration on the
part of the parent-therefore making abuse less likely using various strategies.
Examples of these strategies include: noticing signs that a child is ready to
toilet train and not pushing them to do so unless they are ready and not trying
to train a child to toilet change during other dramatic family changes that will
cause stress on both the child and the parent (i.e. moving).1
1. “Practicing Safety Module in Toilet Training.” The American Academy of Pediatrics. Accessed September
26, 2011. http://www.aap.org/sections/scan/practicingsafety/Modules/ToiletTraining/ToiletTraining.pdf

5. CURRENT EXISTING SOLUTIONS THAT DEVIATE FROM
BRAZELTON AND AZRIN-FOX
4. Montessori Approach: Based on the idea that toilet training begins at
birth. Cloth diapers are used so children understand the discomfort from wetting
themselves and begin to associate their urinary function with the feeling of
wetness. Children are also shown the dirty diapers when it is changed as well the
clean ones and can assist in getting the new nappies so they feel a part of the
process and are aware of it. Scolding and over-congratulating are avoided.1
5. Elimination Communication: Mothers or caregivers learn through
observation (baby goes when he/she wakes up, after) to understand cues and
body language of a baby. Babies do not wear diapers. When they have to go to
the bathroom they bring the baby to a pot or wrap a cloth over them. As children
get older they begin to go to the pot themselves.
1. “A Montessori Approach to Toileting.” The Montessori Method. Accessed September 22, 2011.
http://www.michaelolaf.net/08%20toileting1.htm
2.Elimination Communication Simplified. Accessed September 22, 2011. http://ecsimplified.com/

6. TARGET AUDIENCE
Moms of children 24 to 36 months currently engaging or beginning to start
potty training their children
- Program will target both boy and girl toddlers with targeted messages
for each gender

7. HEALTH GOAL
By the completion of the Tots on Pots program, participants will decrease
their risk of emotional scaring (i.e. stress) as a result of poor toilet
training by 10%

8. COMMUNICATION OBJECTIVES
• By October 18th and the completion of the program, participants will increase
their knowledge of healthy, evidence based potty training tips by 20% such
as mentoring, modeling, reinforcements, and appropriate goal setting
(Behavior Capability)
• By October 18th , and the completion of the program, participants will be able
to identify 3 barriers for success such as poor goal setting, inconsistent
charting and reinforcements, and a negative training environment
(Expectancies and Environment)
• By October 18th, and the completion of the program, participants will be able
to identify successful reinforcement factors for aiding their toddler towards
successful toilet training such as providing treats, play time, or a special
treat (Expectatancies and Reinforcement).
• By October 18th, and the completion of the program, participants will have an
increase confidence in their ability to successfully potty train their tot than at
the start of the program (Self Efficacy).
• By October 18th, and the completion of the program, parents will have a
decreased sense of isolation and increased feelings of support as a result of
the interactive “DIAPER” support component. (Emotional Coping Response)

9. BEHAVIOR OBJECTIVES
• By October 11th, participants will increase their use of the toilet
by 30 %
• By October 11th, parents of toddler participants will increase
their ability to achieve potty training success by 30%
• By October 11th, participants will have a decrease in the number
of non-toilet voids by 15%
• By October 11th, participants will have an increase in accident
free nights by 10%

10. SOCIAL COGNITIVE THEORY
Albert Bandura’s Social Cognitive Theory will be the basis for the
development of our messaging program:
Environment: Factors physically external to the person; Provides
opportunities and social support
 Our program will encourage parents to create a safe/healthy
environment for their children to embrace potty training. Messages
focused on identify safe spaces, feeling comfortable in their
surroundings, and providing a pressure free environment will be
developed
Situation: Perception of the environment; correct misperceptions and
promote healthful forms
 Messages focused on creating a stress-free, comfortable
environment will encourage parents to help toddlers feel safe during
unknown situations

11. SOCIAL COGNITIVE THEORY CONTINUED
Behavioral Capability: Knowledge and skill to perform a given
behavior; promote mastery learning through skills training
 Messages will focus on skills to motivate their child to begin
potty training, as well as tips and suggestions for moving their
progress forward will be sent
Expectations: Anticipatory outcomes of a behavior; Model
positive outcomes of healthful behavior
 Messages on creating and establish attainable and achievable
goals an expectations will be set early on in the program

12. SOCIAL COGNITIVE THEORY CONTINUED
Expectancies: The values that the person places on a given
outcome, incentives; Present outcomes of change that have
functional meaning
 Parents will be encouraged to establish desirable incentives for good
behavior, such as time with a specific toy, candy, or stickers on a
reward chart
Self-Control: Personal regulation of goal-directed behavior or
performance; Provide opportunities for self-monitoring, goal
setting, problem solving, and self-reward
 Parents will be encouraged to establish a visible progress chart
within the home that both the child and parent can look upon daily.
Messages will be sent to remind parents to track their child's
progress on this chart

13. SOCIAL COGNITIVE THEORY CONTINUED
Observational learning: Behavioral acquisition that occurs by
watching the actions and outcomes of others‟ behavior;
Include credible role models of the targeted behavior
 In certain circumstances, some children may respond more by
mimicking their parents behavior, if so, messages on how best
to incorporate this into their training will be distributed

14. SOCIAL COGNITIVE CONTINUED
Reinforcements: Responses to a
person‟s behavior that increase or
decrease the likelihood of
reoccurrence; Promote self-initiated
rewards and incentives
 Messages reminding parents to
reward their child or to deliver
negative reinforcements will be sent
throughout the day. In addition, when
parents respond using the “Pee” “Poo”
and “Diaper” interaction
messages, Congratulatory or
“Encouragement” messages will be
sent.

15. SOCIAL COGNITIVE THEORY
Self-efficacy: The person‟s confidence in performing a particular behavior;
Approach behavioral change in small steps to ensure success
 Tips and suggestions for sustaining and increasing their confidence will be
sent sporadically, more frequently if some parents are struggling to make
progress.
Emotional coping responses: Strategies or tactics that are used by a person to
deal with emotional stimuli; provide training in problem solving and stress
management
 For parents with toddlers struggling emotionally with potty training, messages
focused on these responses will be sent along with tips and suggestions on
how best to overcome these obstacles.
Reciprocal determinism: The dynamic interaction of the person, the
behavior, and the environment in which the behavior is performed; consider
multiple avenues to behavioral change, including environmental, skill, and
personal change.
 At the beginning of the program, parents will be encouraged to create and
sustain a comfortable training environment to encourage behavior change in
their environment and social interactions, such as purchasing a potty chair
and introducing the child to the chair slowly in a pressure free environment.

16. INITIAL CONCEPT…
• Establish pre-test evaluation criteria to assess where each participant
stands in their training (not yet ready, contemplating, ready to
act, already training, struggling with training)
• Once assessed, participants will begin to receive targeted messages
based upon their pre-test responses
• For those not yet ready to act, messages about how to prepare their toddler
will be sent
• For those who are ready to act, messages focused on tips for introducing the
toilet to their toddler will be sent
• For those struggling with training, messages focused on how to remain calm
and suggestions for softly encouraging their child will be sent
• As a way to personalize the message, we will incorporate messages
based on their status as well as the gender of their baby. Potty training
boys is different than potty training girls, therefore the messages will be
targeted for these audiences.

17. INITIAL CONCEPT…
• In addition to messages sent to parents, we will foster interaction with two
way messaging. When a child successfully uses the toilet, parents will text
“Pee” or “Poo” to our number. This number will be tracked and the daily total
will be sent at the end of the day.
• At the end of each day, Participants who submitted successful attempts will
receive a text message containing the number of “potties” they earned for
the day with an option to submit a “Potty goal” for the next day
• If the parents are struggling, they can text “Diaper” to our number to receive
encouraging messages and suggestions on how to alter their behavior
• Parents will continue to receive encouraging and informative messages
throughout the entire week to build confidence and capabilities
• Parents can submit pictures of their child’s reward chart for additional
support messaging to show to their toddlers
• At the completion of the program, participants will be evaluated on their
progress and the effectiveness of the timing and content of the messages
sent

18. By: Lindsey Goggin and
Kathleen MacDonald

19. SUMMARY OF CONCEPT
• Established pre-test evaluation criteria to assess where each participant
stands in their training (not yet ready, contemplating, ready to
act, already training, struggling with training)
• Once assessed, participants received targeted messages based upon
their pre-test responses
• For those not yet ready to act, messages about how to prepare their toddler
were sent
• For those who are ready to act, messages focused on tips for introducing the
toilet to their toddler were sent
• For those struggling with training, messages focused on how to remain calm
and suggestions for softly encouraging their child were sent
• As a way to personalize the message, we incorporated messages based
on their status as well as the gender of their baby. Potty training boys is
different than potty training girls, therefore the messages were targeted
for these audiences.

20. SUMMARY OF CONCEPT…
• In addition to messages sent to parents, we fostered interaction with
two way messaging. When a child successfully uses the toilet, parents
texted “POTTY” to our number. This number was tracked and the daily
total was sent at the end of the day.
• At the end of each day, Participants who submitted successful attempts
were sent a text message containing the number of “potties” they
earned for the day with an option to submit a “Potty goal” for the next
day
• If the parents were struggling, they texted “Diaper” to our number and
received encouraging messages and suggestions on how to alter their
behavior
• Parents continued to receive encouraging and informative messages
throughout the entire week to build confidence and capabilities
• Parents could submit pictures of their child’s reward chart for additional
support messaging to show to their toddlers
• At the completion of the program, participants were evaluated on their
progress and the effectiveness of the timing and content of the
messages sent

21. TARGET AUDIENCE
Moms of children 24 to 36 months currently engaging or beginning to start
potty training their children
- Program will target both boy and girl toddlers with targeted messages
for each gender

22. HEALTH GOAL
By the completion of the Tots on Pots program, participants will decrease
their risk of emotional scaring (i.e. stress) as a result of poor toilet
training by 10%

23. COMMUNICATION OBJECTIVES
• By October 18th and the completion of the program, participants will increase
their knowledge of healthy, evidence based potty training tips by 20% such
as mentoring, modeling, reinforcements, and appropriate goal setting
(Behavior Capability)
• By October 18th , and the completion of the program, participants will be able
to identify 3 barriers for success such as poor goal setting, inconsistent
charting and reinforcements, and a negative training environment
(Expectancies and Environment)
• By October 18th, and the completion of the program, participants will be able
to identify successful reinforcement factors for aiding their toddler towards
successful toilet training such as providing treats, play time, or a special
treat (Expectancies and Reinforcement).
• By October 18th, and the completion of the program, participants will have an
increase confidence in their ability to successfully potty train their tot than at
the start of the program (Self Efficacy).
• By October 18th, and the completion of the program, parents will have a
decreased sense of isolation and increased feelings of support as a result of
the interactive “DIAPER” support component. (Emotional Coping Response)

25. OUR PROGRAM’S READING LEVEL SCORE
READING LEVEL: 8TH GRADE
Content Learning Simulation Motivation
a) Purpose is evident: 2 a) Interaction used: 2
b) Content about behaviors: 2 b) Behaviors are modeled and specific:
2
c) Scope is limited: 2
c) Motivation- self efficacy: 2
d) Summary or review included: 2
Cultural Appropriateness
Literary Demand
a) Match in logic, language, and
a) Reading grade level: 1
experience: 2
b) Writing style, active voice: 1
b) Cultural image and examples: 2
c) Vocab uses common words: 2
d) Context is given first: 2
TOTAL SAM SCORE: 26
e) Learning aids via “road” signs”: 2
TOTAL POSSIBLE SCORE: 28
Percent Score: 93%

27. THE FOLLOW-UP EVALUATION DELIVERED
MIXED REVIEWS…
• 100% of respondents changed their • 50% of respondents said their child
environment as a result of the program was more able to potty train
• 100% of respondent were able to identify 3 • 50% of respondents said their child’s
barriers to success (communication attitude toward potty training changed
objective met) positively, other 50% did not see this
change
• 50% of respondents were able to recall 3
tips they learned from the program, 1 • 100% of respondents strongly agreed
respondent could only mention 1 that the program helped them identify
(communication objective met) appropriate incentives
(communication objective met)
• 100% of respondents felt supported to
incredibly supported throughout the • 50% of respondents felt the program
program (communication objective met) helped encourage their kids toward
potty training, other 50% did not
• 50% of respondents felt more confident
after the program (communication • 100% of respondents loved the
objective met) supportive nature of the program as
well as the consistent reminders
(communication objective met)

28. SAMPLE EVALUATION RESPONSES
What was your favorite part about the program?
“Regular reminders throughout the day to help me remember to encourage her to
use the potty. Also, the positive/encouraging tone was helpful since potty
training is not my favorite :)”
What was your least favorite part about the program?
“It would have been helpful to select the times of day that worked best for me to
receive the messages. My daughter goes to bed super early & naps at a
weird time so I sometimes got the texts at times that were less useful than
other times could have been. That's a very minor thing though! “

30. PROGRAM STATISTICS
• Days of messaging: 7
• Number of participants: 7
• Number of messages per day: 3-5*
• Number of text messages sent: 30-35*
• Number of “Potty” interactions: 12
• Number of “Diaper” interactions: 2
*Depended on level of
interactivity for the user

31. THE PROGRAM EVALUATION YIELDED POSITIVE
RESULTS
• On a scale of 1 to
10, respondents gave our
program a 9
• Respondents marked our
information as Moderately
Relevant
• Respondents read all of the
messages
• Respondents said the
frequency was adequate
• Respondents appreciated
the interactive component
of the program
• All of the respondents
would recommend the
program to their friends

32. SAMPLE RECOMMENDATIONS:
What did you like most about the program?
“The most helpful aspect was just a reminder to be intentional about reminding &
encouraging my daughter. “
What did you not like about the program?
“It seems helpful to have a way to differentiate between peeing and pooping on
the potty for the "potty" texts that the user sends in since some children are so
much more comfortable with doing one than the other. “

34. CHANGES TO PROGRAM FROM INITIAL
CONCEPT
Improved Language of Texts
• Messages fun and readable
• Simple Language
• Shorter Messages
Changed the use of “PEE” and “POO” to “POTTY” to make it simpler
Gave people the option to track the total POTTY number at the end of each day or as
they went along
Incorporated explanations to remind them of program features along the way such as
reminding them to text their goal for the next day.

35. LESSONS LEARNED
Provide a good explanation of the program before it begins (i.e. what to
expect, examples of what they will be receiving, limitations of the
program)
Improve Interactive features of program
• Remind people of the interactive features throughout the program
• Make people feel like there is a person on the end of the texts rather
than it being an automated message
How to make language fit into a text message format
• Short and simple language
• Fun, readable messages

36. FUTURE RECOMMENDATIONS
Add in a function for working moms. This would include a different message track that takes into
account that the mom will only have mornings, evenings and weekends to reinforce these messages.
Program features that would allow moms to sign-up for program with other caregivers such as
dads, nanny's, grandmas or anyone else that spends a significant amount of time with the child.
Allow the person receiving the messages to select the quantity of text messages to receive and the
time of day that they would get it.
For moms that sign up for an additional week, a library of messages that would be geared towards
people in week two of training.
Stick with initial concept of separating “potties” into “pee” and “poop”, some children are more
comfortable with one over the other
Create the bank of support messages to be given when DIAPER is texted from a group of moms. Tell
the participants that the support messages were created by mom’s like them
Pair with a website and a hotline where people can call with specific questions and be directed to
more resources