Abstract
BACKGROUND:
Carrying a properly weighted schoolbag is an important factor in preventing the occurrence of muscular skeletal disorder in early school age children.
OBJECTIVE:
The purpose of this cross- sectional observational study was to examine the schoolbag weight and to determine the percentage of children were carrying overloaded schoolbag.
METHODS:
The study group included pupils from five primary public schools in Wrocław, Poland. Anthropometrical measurements such body weight (BW) and height were conducted on 650 children (51.1% of boys). Children’s age, gender, Cole’s Index was juxtaposed with schoolbag weight. The mean age of the examined students was 8.7±0.8 years (range 7 to 10 years).
RESULTS:
The mean schoolbags weight was 3.7±0.92 kg, which represented 13.0±3.8% of pupils’ BW. The percentage of pupils carry the schoolbags weighing more than 10% of their BW was 77.9%. More than a quarter of Polish children carry school backpack above 15% of their BW. The majority (96.8%) had schoolbags which may be carried on both shoulders. A significant negative correlation was observed between relative schoolbag weight and Cole’s Index (rho = –0.44, p < 0.05).
CONCLUSIONS:
The problem of overloaded schoolbags among elementary school children was frequent. Pupils ought to be educated in the proper packing of their school backpacks. Additionally, parents and teachers should pay attention regarding the contents carried by children in their respective schoolbags.
Introduction
A schoolbag is an essential items that accompany children in daily travel to their school. Pupils carry necessary textbooks, notebooks, school supplies and lunch in their schoolbags. Often schoolbags are filled with unnecessary items such as toys, electronic devices (smart phones, tablets), notebooks, and textbooks which are redundant during learning time spent in school [1–5]. All these additional accessories increase the weight of a schoolbag. An improper packing and carrying of schoolbag on one or both shoulder with too much load can cause musculoskeletal discomfort/disorder [6–11], changes in the sagittal plane of the spine [12], development of spine or reduced lung capacity [13]. The overloaded school backpacks may increase the risk of physical fatigue and decrease students’ participation in activities and assignments of school [14]. In recent years, there have been increasing interests in establishing a correlation ratio between the weight of the school bag to a child’s body weight [1, 15]. Polish Chief Sanitary Inspectorate and the American Physical Therapy Association (APTA) recommends 10–15% bodyweight as the upper limit for children’s schoolbags [16, 17]. In the United States, the American Occupational Therapy Association (AOTA) approved an upper load for school backpack reaching 10% of children’s body weight (BW) [18].
The observations presented in this study were based on the data obtained from two projects: ‘Lightweight Schoolbag’ and ‘Let’s Get the Kids Moving’. ‘Lightweight Schoolbag’ is a nationwide informational and educational campaign targeted for primary school students and their parents since 2011. It focuses on the problem of overloaded backpacks among pupils and the associated occurrence of high risk of postural defects. ‘Let’s Get the Kids Moving’ is a pro-health project created by researchers of the ‘Medical University’ and the ‘Run for Health Foundation’ and it addressed to both parents and teachers. It aims to promote a healthy lifestyle through participation in physical activity and to introduce the ideas of healthy diet. The common purpose of referring those projects in this study was to evaluate the weight of the schoolbag and to analyze whether the load depends on pupils’ age, gender, and bodyweight.
Method
Participants
In this study one probability sampling techniques, stratified random sampling focusing on public primary schools in Wrocław (urban areas in south-west Poland) was used. Among 53 public schools, 5 were randomly selected. Parents of all children from five primary schools in Wrocław, that declared participation in ‘Lightweight Schoolbag’ and ‘Let’s Get the Kids Moving’ projects received written information regarding this study. Participation of pupils for this study was voluntary and free. The inclusion criteria for the study were: written and informed parental consent, age of children between 7 and 10 years, and primary school attendance. The exclusion criteria of the study were: reported malaise by a child on the day of the study, the presence of serious musculoskeletal disability, or any other chronic illness. The study group consisted of 650 children. The study excluded 38 children (5.52%).
Procedure
Data collection was carried out between March and June 2018 during school days (Monday to Friday). Each student was tested once as in early childhood education they use one textbook and same notebooks every day. In addition, in all schools participating in the project, students have school lockers, where their clothes and shoes for sports activities and materials for art classes are kept.
Pupils’ weight and height and their respective schoolbags weights’ were measured using an identical medical weight scale with a stadiometer in all the five schools. Anthropometric measurements of bodyweight in kg and height in cm were carried out by physiotherapists in the designated place of the school protected by its management. The anthropometric measurements was individually taken for each child. Each child was dressed in light clothing with socks and without shoes. The same weighing scale, was used to measure the total weight of each backpack (school backpack with equipment weight). The relative schoolbag weight (%) was calculated by dividing schoolbag weight with the child’s BW (both expressed in kg). In the final part of the study, the type of backpack (backpack carried on both shoulders and backpack with wheels) were incorporated on the child’s examination form. Measurements were taken in the morning between 8:00 AM and 1:30 PM. The body mass weight of a child and schoolbag weight were measured with an electronic medical scale (Charder MS 6110, Taiwan) with an accuracy of±0.1 kg. The scales have a CE certificate and meet the directives MDD 93/42 EEC in the field of medical devices. Children’s height were measured using a Wall-Mounted Stadiometer (model HM-202P, Taiwan) with an accuracy of 0.1 cm.
Based on the measured body weight and height of a child, the nutritional status index i.e. Cole’s Index –CI was calculated according to McLaren’s classification. The actual body weight and height were compared with the body weight and height read from centile grids corresponding to 50th percentile for the age and sex of the child. The CI interpretation was <90% CI representing underweight, 90 –109% CI representing normal BW, 110 –120% CI representing overweight,>120% CI representing obesity [19, 20].
After anthropometric measurements, information posters about how to properly carry schoolbags were sent to each school participating in this projects. The researchers for the ‘’Lightweight Schoolbag” project carried out educational lessons for pupils and their teachers in each class related to the proper packaging of school backpacks and the possible consequences of carrying too heavy schoolbags. It was important as the students’ backpacks did not have any belts at chest or lumbar levels to lock the schoolbag tight to the body. Moreover, schoolbags with wheels had maximum height level for the handle which wasn’t correct for every pupils. Additionally, there is no elevator in the schools that participated in this study so the children with wheeled schoolbags had to carrying the respective schoolbags in their hand while going up and down the stairs.
Ethical approval for the study was obtained from the Wrocław Medical University Bioethics Committee, Poland (approval no. KB-738/2018). The study was conducted as per the Declaration of Helsinki and Good Clinical Practice guidelines. The recommendation of Strengthening Reporting of Observational Studies in Epidemiology (STROBE) was also followed in this study [21].
Data analysis
Statistical analysis was performed using Dell Statistica 13.1 (TIBCO Software Inc., USA). The descriptive statistical data was presented as mean, standard deviation (SD), median, ranges of variation (extreme values), inter quartile range (Q1, lower quartile - the 25th percentile and Q3, upper quartile - 75th percentile). The categorical variables were calculated as frequencies (percentages). The normal distribution was determined using the Kolmogorov-Smirnov test. The Levene’s test was used to test the homogeneity of variance. The Student’s t-test for assessing the significance of the difference between the mean values of two independent groups and Pearson’s chi-squared test for assessing the relation between the two nominal variables was used. To compare three groups or more in terms of the mean level of the quantitative variable ANOVA (analysis of variance) was used. Tukey’s post hoc test was used wherever significant differences were observed. The dependence between the selected variables was determined by the Spearman rank correlation test. The statistical significance level was set at p < 0.05 for all comparisons.
Results
Characteristic of the examined group
A total of 650 children from the 1st to 3rd grade o five primary schools in Wrocław, Poland were included in the study. The mean age of the examined pupils was 8.7±0.8 years. The study groups comprised 51.1% boys and 48.9% girls. The characteristics and anthropometric data of participants were presented in Tables 1 and 2.
Characteristic of the participants (n = 650)
Characteristic of the participants (n = 650)
Anthropometric data of study participants (n = 650)
Abbreviations: SD, standard deviation; Min, minimum value; Max, maximum value; Q1, lower quartile; Q3, upper quartile.
The schoolbag weight ranged between 1.0 to 7.2 kg (mean 3.7±0.9 kg) among the examined primary school pupils. There was no significant difference in schoolbags load between boys and girls (p = 0.2420).
Taking into account the school grade attended by the children, there are statistical significant differences in schoolbags weight presented in Fig. 1. (F = 7.93; p = 0.0149). The 1st-grade pupils had a schoolbag weight ranged between 1.2 to 5.8 kg (mean 3.6±0.8 kg). The 2nd-grade pupils had a mean schoolbag weight ranged between 1.8 to 7 kg (mean 3.7±0.9 kg). The mean absolute schoolbag load in 3rd-grade students was 3.8±0.9 and ranged between 1 to 7.2 kg. Children attending to 1st-grade carried a lighter school backpack than pupils from 3rd-grade (p = 0.0171).

Comparison of schoolbags weight in respective school grades.
Table 3 showed that schoolbag weight was associated with the children’s bodyweight category (p = 0.0024). There was a significant difference in mean schoolbags weight between children underweight and overweight (p = 0.0223). Underweight pupils had a lighter schoolbag than overweight children (3.6±0.8 kg vs. 4.0±1.0 kg). The Statistical significant differences in mean schoolbag load were also observed between students with underweight and obesity (p = 0.0116).
The one-way analysis of variance (ANOVA): Comparison absolute schoolbags weight (kg) in respective Cole’s Index category
Abbreviations: SD, standard deviation; Min, minimum value; Max, maximum value; Q1, lower quartile; Q3, upper quartile.
A tendency to carry a heavier backpack in correlation to % of BW was negatively correlated with children’s school grades (rho = –0.20; p < 0.05). There was no statistical difference between boys and girls in relative schoolbag weight (p = 0.1624). The statistical significant differences between pupils’ grade in school and relative schoolbags weight (p < 0.001) is shown in Fig. 2. The 1st-grade pupils had schoolbag weight ranging between 3.2 to 25.3% BW (mean 14.0±3.9% BW). The 2nd-grade pupils had a mean schoolbags weight % of BW ranging between 6.2 to 20.5% BW (mean 13.2±3.3% BW). The mean relative schoolbag weight in 3rd-grade students was 12.3±3.7% BW (ranging between 3.2 to 27.4% BW). Children from third grade had a lighter schoolbag in respect to % BW than pupils from second grade (p = 0.023) and first grade (<0.001), respectively. A statistically significant difference between Cole’s Index category and different schoolbag weight levels was presented in Table 4. Relative schoolbags weight more than 20% BW was observed in twenty-five (3.85%) underweight and normal body weight children. Pupils with obesity and overweight did not carry a backpack that exceeds 20% of their BW. In the examined group of children, schoolbags weight below 10% BW had 8.52% of underweight pupils, 20.06% of normal body weight, 33.78% of overweight, and 56.06% of obese pupils. The decrease in relative schoolbag weight was significantly associated with an increased in Cole’s Index (rho = –0.44; p < 0.01).

Comparison of schoolbags weight as a percentage of pupils’ body weight in respective school grades.
Pearson’s Chi squared test: Comparison of schoolbags weight levels in respective Cole’s Index category
We found a statistically significant difference between grade and schoolbag weight level (p < 0.001) (Table 5). The obtained results suggested that the first grade pupils were more often exposed to carry an overloaded backpack (more than 20% of their BW) than pupils in second and third grade (p < 0.01).
Pearson’s Chi squared test: Comparison of schoolbags weight levels in respective grade levels
96.77% of children were carrying schoolbags on both shoulder and 3.23% of students had school bags with wheels (p < 0.001). In the examined groups of pupils, fifteen (2.3%) girls and six (0.9%) boys had wheeled schoolbag.
A statistically significant difference between schoolbag weight and different types of school bags (p < 0.0001) was observed in Table 6. A higher mean weight of schoolbags was found in students who had a schoolbag with wheels (mean 4.4±1.0 kg) compared to those who had a schoolbag carried on both shoulders (3.7±0.9 kg) (p < 0.001). A statistically significant difference in relative schoolbag weight between different types of schoolbag in girls (p < 0.001) was seen in Table 7. The mean relative schoolbag weight was lower in female pupils who were carrying their backpacks on both shoulders (mean % BW: 13.0±3.7 %) than girls who had a schoolbag with wheels (mean % BW: 17.3±4.3 %).
T-student test: Comparison of absolute schoolbags weight (kg) in respective type of schoolbag
T-student test: Comparison of absolute schoolbags weight (kg) in respective type of schoolbag
Abbreviations: SD, standard deviation; Min, minimum value; Max, maximum value; Q1, lower quartile; Q3, upper quartile.
T-student test: Comparison of schoolbags weight as percentage of children body weight (%) in respective type of schoolbags and pupils gender
Abbreviations: SD, standard deviation; Min, minimum value; Max, maximum value.
This study was designed to assess whether the weight of schoolbags is associated with primary school children’s gender, grade, bodyweight category, and carrying the type of schoolbags. The main aim of the study was to verify what percentage of children from primary schools in Wrocław, Poland were carrying overloaded schoolbags and to determine the factors that contributed the health problem. The results obtained in our study revealed that 77.9% of pupils had schoolbag whose weight exceeded 10% of children’s BW. The results of different studies revealed high prevalence of overloaded schoolbags among school-age children. Spiteri et al. [22] in a cross- sectional study conducted on 3852 Maltese children aged 8–13 years observed that 71% of pupils had a backpack weighing more than 10% of their BW. A study carried out on 813 primary school children in Nigeria showed that 79.1% of students had school bags weighing at least 10% of their BW [23]. Dockell el at. [15] studied 462 primary school children and revealed that 31% of pupils had a schoolbag weighing less or equal to 10% of their BW. In a study with 155 pupils between 7 and 9 years old in Poland, it was observed that 79% of boys and 64% of girls had a schoolbag weighted more than the recommended limit [24]. Mohammadi et al. [11] presented that 28.3% of elementary school students in Teheran were carrying a backpack that weighed less than 10% of BW. The findings from a study performed in India showed that 40.9% of pupils between 8–10 years old were carrying schoolbags over 25% BW [3]. These results suggested that heavy schoolbags in school age children are an international problem.
Kasović et al. [25] in a study among 127 first grade primary school pupils from the Czech Republic observed that the mean schoolbag weight was 4.2 kg. Pupils in the first-grade in Croatia carried a schoolbag with a mean load of 4.5 kg [26]. In our study, the average weight of the backpack of first-grade students was 3.6 kg. It indicated that Polish pupils of the first- grade tended to carry lighter schoolbags than their counterparts in other countries. In another study among 462 Ireland children aged 9–11-year-olds the average schoolbags load was 4.7 kg [15]. The mean backpack weight in elementary school pupils from South West of Iran was 3.5 kg [10]. In our study, the average weight of the backpack of primary school pupils was 3.7 kg. Compared to our results, Spiteri et al. [22] and Brzęk et al. [24] showed that pupils in older grades had a heavier school backpack than pupils in younger grades. In this study, individual schoolbag weight was varied (between 1 to 7.2 kg), mean schoolbag weight was 3.74 kg and SD 0.92. This could be related to the different weight of the empty backpack (its frame), the amount of lunch carried, the way it was packed, the amount of drinks, the school supplies of pencil case and the other toys or electronic devices brought by children to school.
A study conducted in Czech Republic revealed that 96.6% of first grade pupils carried a backpack weighing more than 10% BW [25]. Overloaded school backpacks, especially in children from the youngest school grades, who are in the phase of developing bone, muscle joint and neural tissues, may negatively affect the development of their musculoskeletal system. Another study among 108 pupils in Poland showed that 78.3% of 1st grades students, 43.3% of 2nd grades children and 40.0% of 3rd grades pupils carry schoolbags weighted more than 10% of BW [4]. In our study, 84.5% of children in first grades, 83.2% of children in second grades, 73.1% of third grades children carried school backpacks that were over 10% of their BW. Our results indicated that pupils in the youngest grades were more likely to be affected by overloaded schoolbags (>10% of BW) than pupils in older grades in primary schools. Contrary to our study Spiteri et al. [22] stated that relative schoolbag weight was higher in children of higher grades.
Numerous studies from different countries indicated that schoolbags load above 10% of students BW was resulted in biomechanical abnormalities and musculoskeletal discomfort [6–8, 27]. Overloaded school bags might impact changes in body posture, gait, and muscle activity [26, 27]. Other studies emphasized that school bags’ type, its duration of carrying also influenced the occurrence of musculoskeletal abnormalities [8, 28]. Recent biomechanical studies presented that pupils might experience musculoskeletal discomfort and changes in body posture due to carrying the overloaded schoolbags. [25, 29–32] Chen et al. [29] revealed that schoolbags weighing 15% of BW changed a spine position in the sagittal plane. Drzał-Grabiec et al. [32] observed that asymmetrical carrying of schoolbags has an impact on evaluating body posture parameters in the sagittal plane. Vieira et al. [33] studied 37 primary school students in Portugal and showed that carrying backpack type (on both shoulders or over one shoulder) with load 15% of the students BW had a key influence on expiratory muscle strength. In contrast, Gelalis et al. [28] observed a lack of differences in kinematic parameters during walking with symmetrical or asymmetrical school backpacks between children causes mild idiopathic scoliosis compared to the control group. Pau et al. [31] stated that overweighed school backpacks increased the risk of foot discomfort in elementary school children. Overloaded school bags in children caused a shift in the center of pressure towards the forefoot [34]. Ornates-Gonzales et al. [30] showed that 53 assessed pupils had kinematic gait parameters without a backpack with wheels compared to those pulling a schoolbag with wheels having school bags 10%, 15%, and 20% of their BW. The obtained results showed that the asymmetrical load of school bags with wheels caused changes in the thorax position in the transverse plane. However, the above-mentioned adaptations in body posture were minimal so the authors [30] suggested that school backpacks on wheels can be used by pupils.
Observations of gender differences in the weight of the schoolbags are inconsistent. Some studies showed that boys were carrying heavier schoolbag than girls [24, 35]. In contrast, Barbosa et al. [36], Kellis et al. [37] and Al Salem et al. [38] revealed that girls used to carry heavier schoolbags than boys. Lasota et al. [4] and Bryant et al. [39] observed no differences in schoolbag weight between girls and boys.
In previous studies girls more frequently reported severe muscle pain and fatigue symptoms related to carrying overloaded schoolbags [37, 41]. Aprile et al. [40] suggested that anatomical, physiological and environmental factors might influence pain perception in children. Data obtained in a systematic review with meta-analysis did not confirm the association between overloaded schoolbags (>10% of BW) and lower back pain in children [42]. Similar results were obtained by Yamato et al. [43] in a systematic review of five prospective longitudinal studies. The researchers claimed that the schoolbag weight and method of its carrying did not have an impact on developing back pain in pupils [43].
Limitations of the study include schoolbags weight measurements on one day only, lack of specified duration of carrying a school bag, lack of data on musculoskeletal symptoms among examined pupils. A further limitation was the limited school grades of pupils taking part in the study. In our study, we analyzed the weight of the schoolbag of children in the 1st, 2nd, and 3rd grades in elementary schools (7–10 years old students). Further studies on this matter should include children from all grades in primary and secondary schools. The next study should also take into account the re-examination after conducting educational classes with children and teachers regarding the correct way of school bags’ packing and carrying. Further studies are needed to assess the levels of the schoolbags lower or higher than the lumbar level to see how it effects height levels of schoolbags on musculoskeletal pain. To the best of our knowledge, this is one of the biggest studies on schoolbag weight in the primary school pupils in Poland.
Conclusions
The results of this study indicate that children’s BW category is significantly associated with relative schoolbag weight. In the future recommendations for schoolbag weight limits for primary school, pupils should consider incorporating children’s bodyweight category. We highlight the importance of monitoring the weight of the schoolbag, especially in the youngest grade of pupils. Daily checking of the schoolbag content should prevent from taking unnecessary items to school by children. It is advisable to conduct prospective studies assessing the long-term asymmetrical use of backpacks with wheels exceeding the recommended 10% of BW on children’s body posture.
Footnotes
Acknowledgments
The program promoting a healthy lifestyle entitled ‘Let’s Get the Kids Moving’ has been supported by the Department of Education of the Municipal Office of Wrocław. The authors thank the school heads, teachers, and parents for agreeing and taking part in the project.
Conflict of interest
None declared.
