Abstract
Introduction: Constipation is a common complaint in the general population. Squatting (using a toilet stool) is associated with faster and more complete bowel emptying, and could therefore help prevent or treat constipation. We analyzed the reviews of online buyers of a toilet stool to assess perceived effectiveness, overall satisfaction and potential side effects.
Methods: In this exploratory mixed-method study, we collected all plain text reviews left between November 2013 and March 2020 by buyers of a toilet stool on Amazon. We adapted the Framework method to perform a seven-step process to analyze user reviews. We assigned numerical values from −5 (minimum) to +5 (maximum) to perceived effectiveness and overall satisfaction.
Results: We included comments left by 10,027 customers who purchased 19 different types of toilet stools (79.1% seven-inch stools, 16.1% folding stools, 4.8% other stools). Perceived effectiveness and overall satisfaction were high (median = 5 and interquartile range = 0 for both variables). Eighty-one individuals reported adverse events related to toilet stool use, mainly musculoskeletal pain (N = 26), numbness in the lower limbs (N = 16), falls (n = 11), constipation (N = 9), anorectal symptom (N = 8), and cramps (N = 6).
Conclusion: Perceived effectiveness and overall satisfaction were rated high by those who purchased a toilet stool online. In addition, their use seems to be safe (<1% reported adverse effects). Our results suggest a good risk-benefit ratio. The device may offer an inexpensive option to treat or prevent constipation, and may reduce the frequency of medical visits and the risks associated with long-term use of laxatives.
- Commerce
- Constipation
- Gastroenterology
- Laxatives
- Personal Satisfaction
- Primary Health Care
- Risk Assessment
Introduction
Constipation is a common complaint in the general population. It accounted for approximately 3 million visits in the United States in 2016.1 Nonpharmacological remedies provide a cost-effective alternative for affected individuals. In a recent survey, general practitioners reported that squatting during defecation (using a toilet stool) was an effective nonpharmacologic remedy for constipation.2
Squatting is associated with faster and more complete bowel emptying.3,4 A study on 52 individuals showed that toilet stools positively influenced bowel movement duration, straining patterns and bowel evacuation.5 The device could therefore help prevent or treat constipation.
When individuals purchase toilet stools online, they can provide feedback on their purchase. Analysis of these comments represents a simple and indirect way to explore the perception and experiences of toilet stool users.6
Our objective was to analyze the reviews of online buyers of a toilet stool to assess perceived effectiveness, overall satisfaction and potential side effects.
Methods
In this exploratory mixed method study, we collected all verified plain text reviews left between November/2013 and March/2020 by buyers of a toilet stool on Amazon. As described in Table 1, we adapted the Framework method7 to perform a 7-step process to analyze perceived effectiveness, overall satisfaction and potential side effects. We grouped the devices into 3 categories: 7-inch, folding and other toilet stools.
Methodology Used to Collect and Analyze the Reviews
Results
We included comments left by 10,027 customers (114 in 2013 to 2014, 364 in 2015 to 2016, 5,274 in 2017 to 2018 and 4,257 in 2019 to 2020; unknown date = 18). Customers purchased 19 different types of devices (10,023 available data: 7-inch stools = 79.1%, folding stools = 16.1%, other stools = 4.8%).
Perceived effectiveness (median = 5, IQR = 0) and overall satisfaction (median = 5, IQR = 0) are shown in Figure 1, both overall and for the 3 types of devices. The distribution curves were bimodal with 2 distinct peaks. The differences in distribution were not significant for perceived effectiveness (P = 0.08). By contrast, the distribution curves were statistically different for overall satisfaction (P < .001) because, despite identical medians, the distribution curve for 7-inch stools was slightly more spread out (IQR = 1, vs zero for the other 2 devices). Interrater agreement for step 5 of the Framework was high (weighted kappa = 0.72 for effectiveness, 0.86 for satisfaction).
Perceived effectiveness and overall satisfaction of using a toilet stool to prevent or treat constipation (n = 10,022; missing values = 5) (data presented overall, and by type of toilet stool).
Eighty-one individuals reported adverse events related to the use of a toilet stool, mainly musculoskeletal pain (n = 26), numbness in the lower limbs (n = 16), falls (n = 11), constipation (n = 9), anorectal symptom (n = 8) and cramps (n = 6).
Discussion
Analyzing the comments left on an online sales platform by buyers of a toilet stool, we found that perceived effectiveness and overall satisfaction were high. Yet the distribution of the curves was bimodal. One in 9 individuals reported that the toilet stool was not useful (effectiveness ≤ 0). Similarly, although the majority were satisfied with the device, 1 in 9 were of the opposite opinion (satisfaction ≤ 0). Their use seems to be safe (<1% adverse effects). However, users, especially the elderly, should be aware of the risk of falling.
This study did not allow us to determine whether people truly purchased a toilet stool with the objective to prevent or treat constipation. In addition, selection bias is inevitable: individuals are probably more likely to leave a comment when they are either (very) satisfied or (very) dissatisfied. There is also a risk that some negative reviews were removed from the platform.
Further studies are therefore needed to assess the overall effectiveness of the toilet stool and to determine subgroups of people for whom the device would be particularly recommended. Yet, our results are consistent with previous trends2,5 and suggest a good risk-benefit ratio. The device may offer an inexpensive option to prevent or treat constipation. It may reduce the frequency of medical visits and the risks associated with long-term use of laxatives.
Acknowledgments
We warmly thank Dr Emmanuel Viry, Martine Quinio, Clara Cuzin for their assistance in steps 2, 3 and 4 of our study, and Mathias Viry and Mohamed Amir Moussa for their help in steps 1 and 6.
Notes
This article was externally peer reviewed.
Funding: None.
Conflicts of interests: None.
Data availability: The data underlying this article are available from the corresponding author on request.
To see this article online, please go to: http://jabfm.org/content/35/4/836.full.
- Received for publication November 28, 2021.
- Revision received January 30, 2022.
- Accepted for publication February 3, 2022.
