VOL: 96, ISSUE: 40, PAGE NO: 2
Linda Haines, MSc, BSc, is principal research officer, Royal College of Paediatrics and Child Health, London
June Rogers, BA, RN, RSCN, DPSN, is paediatric nurse adviser (continence promotion/special needs), St Helens and Knowsley Community Health NHS Trust;Penny Dobson, MSc, RGN, CQSW, is director, Enuresis Resource and Information Centre, BristolContinence problems in children, including daytime wetting and constipation, usually respond to structured training programmes that include a regular fluid intake and easy access to toilets (Hellstrom et al, 1987; Rogers, 1996). But anecdotal reports from school nurses managing such programmes suggest that many children have difficulty getting extra drinks or access to the toilet while at school.
Continence problems in children, including daytime wetting and constipation, usually respond to structured training programmes that include a regular fluid intake and easy access to toilets (Hellstrom et al, 1987; Rogers, 1996). But anecdotal reports from school nurses managing such programmes suggest that many children have difficulty getting extra drinks or access to the toilet while at school.
In some schools there also appears to be a lack of awareness among staff about the importance of a regular fluid intake in maintaining good health. These concerns led to the two school surveys reported here.
The first survey was carried out in 1995 by the research unit of the Royal College of Paediatrics and Child Health on behalf of the Enuresis Resource and Information Centre. All 242 primary, junior and secondary schools in a Welsh local education authority (LEA 1) took part in it.
The second survey was carried out independently by one of the authors in an LEA in the north-west of England (LEA 2) in 1998.
The 242 schools in LEA 1 were sent a questionnaire on the drinking facilities they offered to pupils. Completed questionnaires were received from 201 schools (83%). The second survey used the same questionnaire as the first survey. It was sent to 72 primary schools in LEA 2, of which 42 (58%) responded.
Provision of drinking water
Schools were asked about their policy on the provision of water for children at lunchtimes. The questionnaires revealed that:
- 76% of the schools that responded in LEA 1 and 67% in LEA 2 provided water for all children;
- 18% in LEA 1 and 14% in LEA 2 provided water only for children having school dinners;
- 5% in LEA 1 and 19% in LEA 2 provided water only on request;
- Two schools did not make any special provision in regard to water.
Overall in LEA 1, 76% of infant schools, 80% of primary schools, 65% of junior schools and 70% of secondary schools provided water for all children at lunchtimes.
Access during lessons
Schools were asked whether children were generally allowed out of lessons to use the toilet. The results showed that in LEA 1, 92% of the schools that responded did so, 6% did not and 2% did so only for children up to a certain age. In LEA 2 only 70% of schools allowed children access to the toilet during lessons.
Allowing children out of lessons to get a drink was less common. Overall, 47% of the schools in LEA 1 and 51 % in LEA 2 permitted this, with 7% in LEA 1 and 12% in LEA 2 doing so only for children up to a certain age (Fig 1).
Schools with older pupils were less likely to allow children out of class to get a drink. Only 19% of secondary schools permitted this compared with 61% of infant schools.
The results showed a wide variation in the provision of drinking facilities for pupils. Overall, 10% (20) of the schools that responded in LEA 1 appeared to have no drinking facilities and only purchased drinks were available at a further 3% (six).
The 174 schools with at least one drinking facility were most likely to have a drinking-water tap. The next most common facility was a water fountain. The types of drinking facilities available are shown in Fig 2.
The following percentages do not total 100 because some schools had facilities in more than one location.
At schools in LEA 1, freshwater taps were located in toilet areas (53%), classrooms (36%), cloakrooms (16%) or outside (14%).
Of the 76 schools with fountains, 61 were in a toilet area, 24% in a cloakroom, 13% outside, 6% in a corridor and 3% in a classroom. Just over half (55%) of the schools with drinking-water taps provided cups, but these were more likely to be communal (81%) than disposable (19%).
In LEA 2,19 schools provided taps for drinking water but only six of them provided cups, most of which were also communal.
The survey of LEA 2 also asked whether a tuck shop was available. Although 18 schools had a tuck shop, only 43% of them sold drinks. When questioned about this, concern about spillages was given as a reason for their reluctance to sell drinks.
To assess the level of provision in relation to the size of the school, the number of pupils per drinking facility was calculated for the 164 schools in LEA 1 with at least one free drinking outlet.
The number of pupils per outlet ranged from 11 to 700, with a mean of 80.1. Overall, 42% of schools had at least one facility for 40 or fewer children, 30% had one facility for 41-80 children, and 28% had one facility for 80 or more children.
The number of facilities provided was not associated with the age of the school building but was related to its size: larger schools had proportionately fewer facilities. Schools with at least one facility for 40 or fewer pupils had a mean number of 210 pupils compared with a mean of 514.2 pupils in schools with only one facility for 80 or more pupils.
Although the number of pupils per facility is a measure of provision, in practice the amount children drink in school will depend on when they are allowed access to these facilities, their location and how well maintained they are.
Although most schools provided water at lunchtimes, allowing children to leave lessons for a drink was less common and less than half of the schools surveyed permitted this.
Although this is understandable in terms of minimising class disruption, it makes it even more important that drinking facilities are sited within easy reach of pupils during breaks or between lessons.
The most common drinking facilities in the schools surveyed were taps, followed by water fountains, and both were most likely to be found in a toilet area. Although there are obvious practical reasons for this, the result may be that children are less likely to drink water, especially if the facilities are some distance from the recreational areas.
Another concern is that bullying and boisterous behaviour often take place in toilet areas, which may discourage some children from using the facilities.
There are also health implications when drinking facilities are placed in toilet areas, particularly as few schools provided disposable cups.
A study of 12-14 year olds in Northumbria (Rugg-Gunn et al, 1987) showed that their intake of water was significantly higher at weekends than on weekdays. This may have been related to drinking facilities in schools. It has also been reported that some children do not drink at all for the six hours of the school day (Almond, 1993).
An adequate fluid intake is essential to maintain optimal health, particularly in children because their active lifestyle and large body-surface area relative to their weight can result in a proportionally high fluid loss. For children of school age, who spend much of their day in a structured environment, the availability of drinks at school is an important factor in ensuring optimal fluid intake.
Low fluid intake has been associated with a variety of health problems in children, particularly excretory disorders such as constipation and kidney stones.
One study found that a low fluid intake was an independent risk factor for acute appendicitis in children (Nelson et a1, 1986).
There is also a suggested link between low fluid intake and poor bladder control (Morgan, 1988).
Anecdotal evidence suggests that children with bowel or bladder problems show significant improvement if they are allowed free access to drinks and toilets and that encouraging those with enuresis to drink more at school has a positive effect on bladder control. At least six to eight drinks a day are considered adequate (Clayden and Agnaarsson, 1991).
The provision of clean, well-positioned drinking facilities in schools could have potential health benefits for children, but they also need to be encouraged to drink water rather than sweet or fizzy drinks.
A recent study of children's drinking habits found that those in infant schools were already accustomed to sweet drinks and rarely drank water (fetter et al, 1995).
Ideally, improvements in school drinking facilities should be accompanied by an educational programme for parents and pupils on the health benefits of drinking water. It is also important that vending machines are not seen as an alternative to drinking water outlets.
Drinking facilities in many schools could be improved with relatively few resource implications. The first step is recognising that the provision of adequate facilities is an important health issue, and this is an area in which school nurses could play a vital role.
Drinking facilities for pupils should also be given a higher priority when schools are being planned. Current Department for Education and Employment regulations on school premises make no reference to drinking facilities in schools other than to state that 'a school shall have a wholesome supply of water for domestic purposes including a supply of drinking water' (Department of Education and Employment, 1999).
The government's identification of schools as a key setting for action to improve health (Department of Health, 1998) and the recent establishment of the healthy schools initiative provide an ideal opportunity to initiate improvements in school drinking facilities.
The timing appears to be right for school health professionals to play a vital role in helping to initiate improvements by drawing attention to poor facilities and highlighting how improving them could benefit children's health.