Stakeholder perspectives of barriers and facilitators to enhancing hydration in elementary schools within a socio-ecological framework

Introduction: Adequate hydration is vital for cognitive performance, fine motor skills, and visual attention, foundational for academic success. However, children spend a considerable portion of their waking hours at school, where they do not consume enough water. The Healthy, Hunger-Free Kids Act of 2010 requires school district wellness policies to implement provisions ensuring that free, clean, accessible, safe drinking water is available during the school day, including mealtimes. Despite ongoing policy efforts, numerous barriers to equitable drinking water access persist, particularly in lower-resourced school districts. This study explores stakeholders' perspectives on barriers and facilitators influencing the hydration landscape in an urban school district in central Virginia to inform the development of a school-based intervention. Methods: =15) conducted among wellness leaders, school personnel, and site coordinators. Trained coders applied a multi-step grounded theory approach to identify themes across multiple levels of the social-ecological model. A multi-sectorial community advisory board contributed to the design, interview guide questions, and interpretation of findings. Results: Stakeholders identified nine key themes: (1) perceived importance of hydration (e.g., health benefits, water as a necessity); (2) students' motivation to drink water (e.g., hydration station novelty, perceived water source cleanliness); (3) teachers' role in student hydration (e.g., role modeling, providing education on healthy hydration); (4) home environment influences (e.g., available hydration options, water quality); (5) classroom management strategies (e.g., hydration breaks); (6) access to resources (e.g., availability of reusable water bottles); (7) competing school priorities (e.g., teacher workload, standardized testing); (8) community influences (e.g., access to healthy hydration options); and (9) awareness of current hydration policies (e.g., communicating policy efforts). Discussion: Stakeholders identified barriers and facilitators influencing hydration in schools. Access to resources, community partnerships, and classroom hydration policies, emerged as key intervention targets for achieving water equity in elementary schools.