Effects of a school-based health intervention and cross-sectional associations of schoolchildren’s academic performance, selective attention and health-related quality of life in Port Elizabeth, South Africa

Background Globally, only one in five children achieve the recommended 60 minutes of moderate-to-vigorous intensity physical activity per day. This number is even lower in low- and middle-income countries such as South Africa, where only half of all children and adolescents achieve the global physical activity recommendation. Regular physical activity is associated with children’s mental health and wellbeing, academic performance and the ability to pay attention at school. However, many South African primary schools located in disadvantaged areas, do not offer regular Physical Education classes due to a lack of facilities and equipment, insufficiently trained teachers and the school subject’s low status. Furthermore, access to adequate sanitation facilities and clean water are often lacking in disadvantaged primary schools. This in turn increases the risk of soil-transmitted helminths infections. Being infected with parasitic worms such as Ascaris lumbricoides and Trichuris trichiura, may lead to symptoms such as abdominal pain, (bloody) diarrhoea and anaemia. Moreover, soil-transmitted helminth infections may lead to growth retardation, school absenteeism, impaired cognitive abilities and reduced physical fitness. Therefore, children from low resourced communities are at an increased risk of ill health which may hamper their development, wellbeing, and academic success. Aim This PhD project aims to investigate health indicators and the effect of a 20-week multicomponent school-based physical activity intervention. Our study sample included approximately 1000 fourth grade schoolchildren from disadvantaged primary schools in Port Elizabeth, South Africa. The specific objectives were i) to explore cross-sectional associations and possible determinants of selective attention and academic performance; ii) to investigate the associations between health-related quality of life, self-reported physical activity and cardiorespiratory fitness; iii) to evaluate the effect of a 20-week school-based physical activity intervention program on academic performance, selective attention and health-related quality of life. Methods The disease activity and schoolchildren’s health study is a cluster-randomized controlled trial with a twice 10 week multicomponent intervention program. Eight quintile three schools were selected based on their classification (quintile 1 represents the poorest schools, while quintile 5 reflects the least poor schools), geographic location, population demographics and the number of students in the grade four classes (at least 100 children). The schools are located in and around Port Elizabeth in south-eastern South Africa. Four schools are in the areas of Kwazakhele, Motherwell, New Brighton and Zwide, which are referred to as townships (mainly inhabited by black Africans who mostly speak Xhosa). The additional four schools are in the areas of Schauderville, Helenvale, Hillcrest and Booysenspark, which are colloquially referred to as the Northern areas (mainly inhabited by coloured people whose native language is Afrikaans). Physical fitness was assessed via the 20-m shuttle run test (VO2max) and upper body strength was determined with the grip strength test. Self-reported physical activity was measured with the health-behaviour of school-aged children survey and health-related quality of life was assessed with the KIDSCREEN-27 questionnaire, representing wellbeing. Selective attention was assessed with the pencil and paper version of the d2-test of attention measuring concentration performance and error percentage. The averaged end-of-year school results (Maths, Life Skills, Home Language, and Additional Language) were used as an indicator of academic performance. Demographic data and socio-economic status were captured with a questionnaire. Stool samples were analysed with the Kato-Katz thick smear technique to diagnose soil-transmitted helminth infections. When soil-transmitted helminth infections were detected, children were treated with Albendazole (single dose, 400mg) after each assessment. Haemoglobin levels and anthropometric indicators were measured with standard tools. The multidimensional physical activity intervention was implemented in four schools, whereas four schools served as control. The intervention lasted for 2x10 weeks and consisted of five parts: i) two Physical Education lessons per week, ii) weekly moving-to-music classes, iii) daily in-class physical activity breaks and iv) physical activity homework as well as v) the creation of a low-cost physical activity-friendly school environment. Results At baseline, the study population consisted of 1009 primary schoolchildren aged 9-12 years (501 girls, 508 boys) from 26 school classes. Cross-sectional baseline data revealed that higher academic achievement and selective attention were associated with higher shuttle run performance (p<0.05; p<0.001). Furthermore, lower selective attention and lower school grades were observed in children with soil-transmitted helminth infection (p<0.05; p<0.001). Higher self-reported physical activity was associated with health-related quality of life (p<0.001). The five dimensions of health-related quality of life are: physical wellbeing, psychological wellbeing, parent relations and autonomy, social support and peers and school. We found small but significant group differences across all five dimensions of health-related quality of life when comparing children with low and high self-reported physical activity (p<0.001). No associations were observed between cardiorespiratory fitness and health-related quality of life. The physical activity intervention had a positive effect on academic performance (p=0.032) by contributing to the maintenance of school grades, meaning they remained stable. Whereas in the control group a decrease was observed. No effect was found on selective attention (concentration performance; p=0.469; error percentage; p=0.237) or health-related quality of life, except for the dimension social support and peers reporting a decline after the intervention. However, the concentration performance and health-related quality of life of physically active children was higher compared to their less active peers, independent of control or intervention condition. Also, physically fit children had better concentration performance and reported better physical wellbeing. Conclusion The physical activity intervention was positively associated with children’s academic performance. Our findings suggest that a physical activity intervention of this nature has the potential to counteract decreases in academic performance in children living in low-resourced communities. Additionally, we found that higher physical activity and positive change in physical activity were prospectively associated with better health-related quality of life. Hence, the regular implementation of Physical Education lesson, and therefore the promotion of physical activity, might have beneficial effects on children’s academic performance and wellbeing. Furthermore, low physical fitness and soil-transmitted helminth infections are negatively associated with selective attention. Based on our findings, there is an urgent need to increase children’s overall physical activity, to implement regular deworming, and to strengthen hygiene awareness. South African policy makers should support schools and Physical Education teachers in their effort to implement quality Physical Education lessons. Furthermore, the investment in school infrastructure such as the provision of physical activity friendly environments and sport facilities that promote physical activity and play are worthwhile. And the renovation of water and sanitation facilities are paramount for the health and wellbeing of children

Shrinking risk profiles after deworming of children in Port Elizabeth, South Africa, with special reference to Ascaris lumbricoides and Trichuris trichiura

Risk maps facilitate discussion among different stakeholders and provide a tool for spatial targeting of health interventions. We present maps documenting shrinking risk profiles after deworming with respect to soil-transmitted helminthiasis among schoolchildren from disadvantaged neighbourhoods in Port Elizabeth, South Africa. Children were examined for soil-transmitted helminth infections using duplicate Kato-Katz thick smears in March 2015, October 2015 and May 2016, and subsequently treated with albendazole after each survey. The mean infection intensities for Ascaris lumbricoides were 9,554 eggs per gram of stool (EPG) in March 2015, 4,317 EPG in October 2015 and 1,684 EPG in March 2016. The corresponding figures for Trichuris trichiura were 664 EPG, 331 EPG and 87 EPG. Repeated deworming shrank the risk of soil-transmitted helminthiasis, but should be complemented by other public health measures

Disease, activity and schoolchildren's health (DASH) in Port Elizabeth, South Africa: a study protocol

BACKGROUND: An in-depth epidemiological investigation on intestinal parasite infections in an impoverished area of Port Elizabeth, South Africa provides a unique opportunity for research on its impact on children's physical fitness, cognitive performance and psychosocial health. Additionally, we will screen risk factors for the development of diabetes and hypertension in adulthood. METHODS/DESIGN: A 2-year longitudinal cohort study will be conducted, consisting of three cross-sectional surveys (baseline and two follow-ups), in eight historically black and coloured (mixed race) primary schools located in different townships in Port Elizabeth, South Africa. Approximately 1000 Grade 4 primary schoolchildren, aged 8 to 12 years, will be enrolled and followed. At each survey, disease status, anthropometry and levels of physical fitness, cognitive performance and psychosocial health will be assessed. After each survey, individuals diagnosed with parasitic worm infections will be treated with anthelminthic drugs, while children with other infections will be referred to local clinics. Based on baseline results, interventions will be tailored to the local settings, embedded within the study and implemented in half of the schools, while the remaining schools will serve as controls. Implementation of the interventions will take place over two 8-week periods. The effect of interventions will be determined with predefined health parameters. DISCUSSION: This study will shed new light on the health burden incurred by children in deprived urban settings of South Africa and provide guidance for specific health interventions. Challenges foreseen in the conduct of this study include: (i) difficulty in obtaining written informed consent from parents/guardians; (ii) administration of questionnaires in schools where three languages are spoken (Afrikaans, Xhosa and English); (iii) challenges in grasping concepts of psychosocial health among schoolchildren using a questionnaire; and (iv) loss to follow-up due to the study setting where illiteracy, mobility and violence are common. Finally, designing the health interventions together with local principals and teachers will allow all concerned with the research to bolster a sense of community ownership and sustained use of the interventions after the study has ceased

Changes in Self-Reported Physical Activity Predict Health-Related Quality of Life Among South African Schoolchildren: Findings From the DASH Intervention Trial

Introduction: Regular physical activity is associated with multiple health benefits for children. Evidence from cross-sectional studies suggests that physical activity is positively associated with health-related quality of life (HRQoL). The promotion of physical activity, and hence HRQoL, through a school-based intervention is therefore an important endeavor, particularly in disadvantaged areas of low- and middle-income countries, including South Africa. Methods: We designed a multicomponent physical activity intervention that was implemented over a 20-week period in 2015 in eight disadvantaged primary schools of Port Elizabeth, South Africa. Overall, 758 children aged 8-13 years participated. HRQoL was measured with the 27-item KIDSCREEN questionnaire. Self-reported physical activity was assessed with a single item of the Health-Behavior of School-Aged Children test, and cardiorespiratory fitness with the 20-m shuttle run test. Post-intervention scores were predicted with mixed linear regression models, taking into consideration the clustered nature of the data. Results: Higher baseline levels as well as increasing levels of self-reported physical activity predicted all dimensions of children's HRQoL. Baseline levels and increases in cardiorespiratory fitness predicted children's self-perceived physical well-being (one of the HRQoL subscales). Participation in the multicomponent physical activity intervention did not affect children's HRQoL. Conclusion: Higher and increasing self-reported physical activity predict all assessed HRQoL dimensions, which underlines that the promotion of regular physical activity among children living in disadvantaged settings is an important public health measure. Policy makers should encourage schools to create physical activity friendly environments, while schools should implement regular physical education as proposed by the school curriculum

Physical fitness and nutritional anthropometric status of children from disadvantaged communities in the Nelson Mandela Bay region

Background: Information about the relationships between physical fitness, body composition and nutrition has increased in recent years; however, little is known about physical fitness and the coexistence of under-/overnutrition among children living in disadvantaged areas. Objectives: To determine the physical fitness status and its association with body composition, growth and selected socio- demographics in primary schoolchildren from disadvantaged communities in the Nelson Mandela Bay region. Methods: Nine hundred and sixty-five children (49% girls, M=9.5 years) participated in this cross-sectional study. Height and weight were measured to establish body mass index, and height-for-age z-scores. Physical fitness was assessed using tests from the Eurofit Physical Fitness test battery (flexibility, upper/lower body muscular strength and cardiorespiratory fitness). Between- group differences and cross-sectional associations were examined with univariate (Chi2-tests, analyses of variance) and multivariate methods (mixed linear/logistic regression). Results: Most children had normal weight (76.7%), while 4.5% were underweight and 18.7% were overweight/obese. Underweight children and children with stunted growth (11.5%) had lower average upper body strength (p&lt;0.001). Overweight/obese children had lower scores in weight-bearing activities (p&lt;0.001). Children with higher socio-economic status were more likely to be overweight and obese (p&lt;0.001). In the multivariate analyses, sex, age, body mass index, and stunting were associated with children’s physical fitness. Conclusion: Fitness assessments seem to be a relevant measure of the current health status of children in disadvantaged settings. Compared to international norms, the children in this study had relatively low scores for both upper- and lower body muscular strength. Therefore, effective school-based intervention programmes should be developed to improve children’s physical fitness in disadvantaged schools

Associations between selective attention and soil-transmitted helminth infections, socioeconomic status, and physical fitness in disadvantaged children in Port Elizabeth, South Africa: an observational study

BACKGROUND: Socioeconomically deprived children are at increased risk of ill-health associated with sedentary behavior, malnutrition, and helminth infection. The resulting reduced physical fitness, growth retardation, and impaired cognitive abilities may impede children's capacity to pay attention. The present study examines how socioeconomic status (SES), parasitic worm infections, stunting, food insecurity, and physical fitness are associated with selective attention and academic achievement in school-aged children. METHODOLOGY: The study cohort included 835 children, aged 8-12 years, from eight primary schools in socioeconomically disadvantaged neighborhoods of Port Elizabeth, South Africa. The d2-test was utilized to assess selective attention. This is a paper and pencil letter-cancellation test consisting of randomly mixed letters d and p with one to four single and/or double quotation marks either over and/or under each letter. Children were invited to mark only the letters d that have double quotation marks. Cardiorespiratory fitness was assessed via the 20 m shuttle run test and muscle strength using the grip strength test. The Kato-Katz thick smear technique was employed to detect helminth eggs in stool samples. SES and food insecurity were determined with a pre-tested questionnaire, while end of year school results were used as an indicator of academic achievement. PRINCIPAL FINDINGS: Children infected with soil-transmitted helminths had lower selective attention, lower school grades (academic achievement scores), and lower grip strength (all p<0.05). In a multiple regression model, low selective attention was associated with soil-transmitted helminth infection (p<0.05) and low shuttle run performance (p<0.001), whereas higher academic achievement was observed in children without soil-transmitted helminth infection (p<0.001) and with higher shuttle run performance (p<0.05). CONCLUSIONS/SIGNIFICANCE: Soil-transmitted helminth infections and low physical fitness appear to hamper children's capacity to pay attention and thereby impede their academic performance. Poor academic achievement will make it difficult for children to realize their full potential, perpetuating a vicious cycle of poverty and poor health. TRIAL REGISTRATION: ClinicalTrials.gov ISRCTN68411960

Prevention of overweight and hypertension through cardiorespiratory fitness and extracurricular sport participation among South African schoolchildren

Hypertension and overweight are growing public health concerns in school-aged children. We examined whether cardiorespiratory fitness and sport participation contribute to the prevention of hypertension and overweight. We conducted a cluster-randomized controlled trial with 853 children aged 8-13 years in eight primary schools in Port Elizabeth, South Africa. Cardiorespiratory fitness, sport participation, body mass index, and blood pressure were assessed at baseline and after a physical activity intervention, which took place at two time-points (July-September 2015 and February-April 2016) for 10 weeks each. Mixed logistic regressions were employed to analyze the data. At baseline, 18.8% of the children were classified as overweight/obese and 13.5% as hypertensive. High cardiorespiratory fitness and high sport participation were negatively associated with overweight/obesity, while high sport participation was associated with lower risk for hypertension. Longitudinally, normal weight children who initially had higher cardiorespiratory fitness showed less decrease in this variable, while those who participated in the physical activity intervention were less likely to become overweight/obese. High cardiorespiratory fitness and sport participation are linked with children's weight status. Children who are fit and participate regularly in sport outside school hours are less likely to be hypertensive. Our findings highlight the importance of regular extracurricular physical activity and maintaining cardiorespiratory fitness levels

Effect of a 20-week physical activity intervention on selective attention and academic performance in children living in disadvantaged neighborhoods : a cluster randomized control trial

OBJECTIVES: To evaluate the effect of a 20-week school-based physical activity intervention program on academic performance and selective attention among disadvantaged South African primary school children. DESIGN: Cluster randomized control trial. METHODS: The study cohort included 663 children from eight primary schools, aged 8-13 years. Data assessment took place between February 2015 and May 2016 following the implementation of a 20-week school-based physical activity program. The d2 test was employed to assess selective attention, while the averaged end-of-year school results (math, life skills, home language, and additional language) were used as an indicator of academic performance. Physical fitness was assessed using the 20-m shuttle run test (VO2 max) and grip strength tests. We controlled for cluster effects, baseline scores in selective attention or academic performance, and potential confounders, such as children's age, gender, socioeconomic status, self-reported physical activity (as determined by a pre-tested questionnaire), body mass index, hemoglobin (as a proxy for anemia, as measured by blood sampling), and soil-transmitted helminth infections (as assessed by the Kato-Katz technique). RESULTS: Our multivariate analysis suggested that the physical activity intervention had a positive effect on academic performance (p = 0.032), while no effect was found on selective attention (concentration performance; p = 0.469; error percentage; p = 0.237). After controlling for potential confounders, the physical activity condition contributed to the maintenance of academic performance, whereas a decrease was observed in learners in the control condition. Furthermore, physically active and fit children tend to have better concentration performance (CP) than their less fit peers (self-reported activity; p0.021). CONCLUSION: A 20-week physical activity intervention contributes to the maintenance of academic performance among socioeconomically deprived school children in South Africa. School administrators should ensure that their school staff implements physical activity lessons, which are a compulsory component of the school by the curriculum