Children’s health and well-being are influenced by cultural, environmental, and socioeconomic factors as well as living conditions and social and community networks [1]. In low- and middle-income countries (LMICs), infectious diseases remain an important public health problem [2-4] with negative impacts on child development [5]. Over 200 million children are infected with parasitic worms (helminths) [6,7] leading to chronic infections causing abdominal pain, diarrhea, and anemia, and may impair cognitive and physical development [8], which in turn might result in reduced fitness and work productivity [9]. In addition, helminth infections can negatively impact children’s nutritional status [10].

Although helminth infections and other neglected tropical diseases (NTDs) do not feature prominently in the burden of disease statistics of South Africa, some NTDs are common in disadvantaged populations, especially among children of poor communities [11]. The nutritional status of school children from poor neighborhoods is adversely affected by food outlets in close proximity to the schools. Indeed, many school children routinely purchase unhealthy foods from local vendors and tuck shops that are generally low in nutritional value, often refined, processed, and of low fiber content [12]. In a 12-country study (Australia, Brazil, Canada, Colombia, Finland, India, Kenya, People’s Republic of China, Portugal, South Africa, United Kingdom, and United States of America) [13], South African children showed the highest intake of sugar-sweetened beverages [14]. Schools located in poor communities in South Africa are part of the National School Nutrition Program, where members of the community, usually unemployed parents, are employed as food preparers. They do not have any food- or nutrition-related qualification.

A deprived socioeconomic environment can put children at risk of malnutrition resulting in growth retardation [15]. Studies have shown that malnutrition is associated with stunting and poor cognitive development, resulting in a low intelligence quotient, cognitive delays, and negative impact on motor development [15]. This, in turn, negatively affects children’s ability to concentrate, process information, and focus on academic tasks [16]. Children from low socioeconomic status (SES) families are also less likely to have access to health care or health insurance [17]. Together, this leads to a greater risk of illness, school absence, and ultimately poor academic performance and life prospects [18]. These deficiencies, caused mainly by the socioeconomic environment, can prevent school-age children from realizing their full potential and perpetuate a vicious cycle of poverty and poor health.

In addition, noncommunicable diseases (NCDs) are a rapidly evolving public health problem worldwide, especially in LMICs, imposing a growing burden on population health [2,19] including that of children [20]. Urban African populations have moved toward a disease profile similar to western countries, with increasing proportions of deaths attributed to chronic, lifestyle-related diseases [20]. The coexistence of under- and overnutrition has resulted in a double burden of nutrition-related diseases in Africa [21]. Children may, already at a young age, develop risk factors predisposing them to NCDs in adulthood [22,23]. Hence, children are at risk of compromised health because of a dual burden of disease, which may hamper their development and well-being [2,24]. Potential drivers of this double burden may be related to the shift in dietary habits and reduced energy consumption. This dual burden constitutes a large and growing challenge for health systems in African countries.

With up to 80% of all chronic diseases, stroke, and diabetes being preventable through healthy nutrition and regular exercise, more emphasis should be placed on prevention and awareness campaigns [25]. Physical education (PE) plays a critical role in holistic health education of the child. A randomized controlled trial (RCT) with Swiss elementary school learners (first and fifth graders) has shown that a 1-year school-based intervention can markedly improve physical activity and fitness, while simultaneously reducing obesity [26]. Regular physical activity contributes to the development of physical competence and fitness, as well as to the cognitive, social, and emotional development of the child [27]. As a rule of thumb, children should undertake at least 60 min of moderate-to-vigorous physical activity (MVPA) daily [28].

The Healthy Active Kids South Africa Report Card (2018) has shown that many children, particularly from marginalized communities, do not achieve the minimal daily requirements of MVPA [14]. Schools play an important role in making a meaningful contribution to the goal of achieving the recommended daily physical activity guidelines by incorporating PE lessons, among others, into the school curriculum. One plausible strategy to promote children’s health is through school-based health promotion programs. An attempt by a Swiss-South African research team to increase health literacy in South African children at school was the Disease, Activity and Schoolchildren’s Health (DASH) project [4]. The study focused on grade 4 children and the creation of an enabling school environment. The intervention program consisted of 4 main components, including (1) a medical examination and anthelmintic treatment, (2) micronutrient supplementation in the form of a nutrient-dense paste enriched with protein, essential vitamins (vitamin A), minerals, energy, and essential fatty acids, (3) health education (eg, hygiene and healthy nutrition), and (4) physical activity (dancing and playful games).

Our experiences with the DASH project also revealed that many South African teachers are at risk of cardiovascular diseases [29,30]. This insight was confirmed in a representative sample of South African educators (n=21,307) in public schools. Educators reported high stress levels, and there were significant associations between stress, lack of job satisfaction, and stress-related illnesses [31]. In South Africa, NCDs among adults have steadily increased. Indeed, although 42.90% (256,645/598,240) of deaths in 2005 were attributable to NCDs, the proportion rose to 57.40% (262,096/456,612) in 2016 [32]. Furthermore, in 2017, more than 1.8 million cases of diabetes were recorded in South Africa, representing 5.41% (1,826,100/33,762,000) of the adult population [33]. The project Healthy Schools for Health Communities presented here addresses this dual burden of disease, both in school children and teachers in South Africa (Figure 1).

Having identified the potential for health status improvement among teachers and knowing the importance of teachers as role models in the education process of children, teachers will also participate in the proposed research project by involving themselves in a workplace health intervention. We will capitalize on the experiences from the aforementioned DASH project by scaling up the intervention program and monitoring and improving the efficacy and effectiveness of the intervention program. The goal of the KaziBantu project is to assess the impact of a school-based health intervention package on communicable diseases, risk factors for NCDs, health behaviors (beliefs and actions relating to health and well-being), and psychosocial health in primary school children in disadvantaged communities in Port Elizabeth, South Africa. In addition, we aim to test a workplace health intervention targeted at teachers.

Ethical approval for the study has been received from the following ethics committees in Port Elizabeth, South Africa: (1) The Nelson Mandela University Ethics Committee (reference #H18-HEA-HMS-001; obtained on 26 March 2018), (2) Eastern Cape Department of Education (obtained on 9 May 2018), and (3) Eastern Cape Department of Health (reference #EC_201804_007; obtained on 5 June 2018). The study is registered at the ethical review board of the Ethics Committee Northwest and Central Switzerland (EKNZ; reference #R-2018-00047; registered on 1 March 2018).

On the basis of a uniform study information sheet, the investigators will explain to each participant (children and teachers) the purpose of the study, procedures involved, expected duration, and potential risks and benefits. Participation is voluntary, and hence, participants can withdraw at any time without any further obligations. All participants will be provided with an information sheet and a consent form describing the study. Individual medical information obtained during this study will be treated confidentially. Subject confidentiality will be ensured by utilizing subject identification code numbers to correspond to treatment data in password-protected computer files. For data verification purposes, authorized representatives of the EKNZ and the Nelson Mandela University Human Ethics Committee may require direct access to parts of the clinical records relevant to the study, including participants’ medical history.

The study will be conducted in historically black and colored primary schools in Port Elizabeth townships (Motherwell, Zwide, Kwazakhele, and New Brighton) and northern areas (Schauderville, Bethelsdorp, Windvogel, and Booysens Park), which form part of the Nelson Mandela Bay Municipality (Figure 2). These schools and communities are characterized by poverty and high unemployment rates. They represent the typical institutional and teacher-related PE barriers faced by the schools [34], including (1) shortage of qualified, accountable, and engaged PE teachers; (2) PE is marginalized as priority–it lost its standalone subject status in 1997 and is placed within the life skills and life orientation learning area, as more importance is given to other (examinable) subjects; (3) teachers lack the ability to integrate PE with other study areas within the life skills and life orientation subject (personal and social well-being, creative arts, and PE); (4) large class sizes; (5) insufficient and inadequate infrastructure and equipment; and (6) safety and security challenges.

The intervention arm targeting school children is designed as a 36-week RCT, including an intervention group (4 schools) and a control group (4 schools). The 4 intervention schools, assigned through randomization, will be further allocated randomly to the following intervention conditions: all schools will receive the teaching materials (KaziKidz and KaziHealth), but the components workshop and coaching will be assigned as follows: (1) teaching materials only, (2) teaching materials plus workshops, (3) teaching materials plus coaching, and (4) teaching materials plus workshops plus coaching (Figure 3).

The 4 remaining schools will be assigned to the control group. In the control schools, there will be documentation of routine PE and sports in school.

The primary comparison will be made between the 4 intervention schools and the 4 control schools to assess the benefit of teaching materials. Secondary comparisons will be between teaching materials plus coaching and teaching materials without coaching or teaching materials plus workshop and teaching materials without workshop. In view of the factorial design of our study, each comparison group consists of 2 schools.

By focusing on change in quantitative outcomes from baseline to follow-up, preexisting differences between schools should play less of a role. Although the intervention covers grades 1 to 7, in each school, 1 class each from grades 4, 5, and 6 will be randomly selected for evaluation of the intervention. After completion of the baseline assessment, children of the intervention schools will take part in a school-based health promotion program (32 school weeks, 1 PE lesson of 40 min per week, 1 moving-to-music lesson of 40 min per week, 3 health education lessons, and 3 nutrition education lessons of 40 min per year across the whole study period). The follow-up will be after 36 weeks (Figure 4). Qualitative data on the feasibility and acceptability of the intervention measures will also be collected from teachers through focus group discussions (FGDs).

For teachers, the study is designed as a 20-week RCT (Figure 5). The baseline assessment will also be offered to the teachers in the control schools. Intervention schools will be randomly assigned to the 4 different combinations of the additional components. After completion of the baseline assessment, all teachers will be informed about their personal health profile, providing an overview of cardiovascular health markers and mental health parameters. For each parameter, established internationally accepted cut-off and normative values will be used to estimate teachers’ health risks.

The intervention program consists of the 3 main components discussed below.

Assuming that the prevalence of obesity varies across schools according to a log-normal distribution with a mean value of 3% and a SD of 2%, 125 children per school in each of the 8 schools would provide a prevalence estimate between 1.5% and 5% with a probability of 95%. Under this assumption, 95% of school-specific prevalence would range between 0.8% and 8.2%. Hence, our aim is to recruit 125 children per school.

The power calculation for the intervention study is based on the change in a quantitative outcome variable from baseline to follow-up. We denote the SD of its change across schools and children by sigma (σ). Assuming an intervention effect size of 0.5 x σ and an intraclass correlation of .04 for the clustering of individual changes within schools (corresponding to a random effect SD of 0.2 x σ), 400 children in the 4 intervention schools (ie, 100 children per school) participating in baseline and follow-up, and 400 children in the 4 control schools would provide over 85% power to observe a statistically significant difference in the mean change of the respective outcome variable between intervention and control schools at the 5% level.

Enrollment of schools will be done by the local research team. To prevent contamination of the intervention effects, schools rather than classes were randomized in January 2019. Before randomization, schools were divided into 2 geographic groups; namely, township areas and northern areas, each containing 4 schools. Township areas are predominantly inhabited by black Africans and northern areas by colored people (after an apartheid-era classification, which refers to people from a multiracial ethnic background and can include persons of Khoi and San origin).

The randomization into intervention and control schools was done separately in each of the 2 groups so that each group was assigned 2 intervention and 2 control schools. To keep the design as balanced as possible, the 4 intervention schemes (ie, teaching materials only, teaching materials plus teacher workshops, teaching materials plus teacher coaching, and teaching materials plus teacher workshops plus teacher coaching) will be assigned in such a way that the intervention schools of 1 group will get teaching materials plus either teacher workshops or teacher coaching. Randomization will allow to determine which of the 2 groups gets which of the 2 pairs of intervention schemes. Sequentially numbered, opaque, sealed envelopes will be used for the assignment of the intervention arms to the schools.

The effect of the KaziKidz teaching material will be evaluated in 1 randomly selected class in grades 4, 5, and 6 (=intermediate phase) in each of the 8 study schools (interventions are randomly assigned to any of the 4 northern area or 4 township schools) even though KaziKidz teaching material will be offered to all classes in grades 1 to 7 as part of the life skills and life orientation courses in the school curriculum.

For KaziHealth, all teachers from the 8 schools will be invited to participate in the program. All participating teachers will undergo the full health risk assessment, and teachers at the intervention schools will have the option to participate in the 20-week intervention. The teachers from the control schools will be offered the intervention program after the completion of the study.

South African public schools are classified into 5 groups, with quintile 5 representing the least poor and quintile 1 representing the poorest. The quintiles are determined through the national poverty table developed by the treasury [38]. Areas are being ranked on the basis of income levels, dependency ratios, and literacy rates in the area. The quintile ranking of a school determines the no-fee status of the school and the amount of money that a school receives from the government, with the poorest schools receiving the greatest per-child allocation. Approximately 200 principals and/or representatives from 349 quintile 3 primary schools (no-fee paying schools) of the Nelson Mandela Bay Municipality attended information-sharing sessions at the Eastern Cape Department of Education in October 2018. The intention was to be inclusive and invite as many interested principals as possible to inform them of the study. A total of 64 responses were received from interested schools; however, only 8 of the responses (representative of typical quintile 3 primary schools) matched the following criteria:

The school authorities will be informed about the project and asked for their interest and consent. Interested schools will be visited, and the investigators will consult with the school administrators to find out if the school environment is conducive for conducting the study. Principals and teachers from selected schools will be informed about the objectives, procedures, and potential risks and benefits of the study. Teachers, children, and parents or guardians will be informed and teachers and children invited to participate in the study. Before enrollment, a participant information sheet will be provided in English, IsiXhosa, or Afrikaans (local languages) to all potential participants and in case of the children, their parents or guardians. For the evaluation part of the study, oral assent of each participating child will be obtained, whereas written informed consent will be obtained from parents or guardians and teachers. Participation is voluntary; hence, children and teachers can withdraw anytime without any further obligations.

Potential participants will be enrolled in the project for evaluation purposes if they meet the following inclusion criteria: (1) are willing to participate in the study, (2) have a written informed consent (for children by a parent or guardian), (3) are not participating in other clinical trials during the study period, and (4) do not suffer from severe medical conditions, as determined by qualified medical personnel. Approximately 1000 grade 4 to 6 school children, aged 9 to 13 years, and approximately 60 teachers from 8 primary schools will be recruited during the KaziBantu baseline survey in early 2019.

Primary outcomes for the KaziKidz testing battery include (1) anthropometric and clinical examinations, (2) physical fitness and self-reported and objectively assessed activity, (3) cognitive and academic performance, and (4) questionnaire for assessment of psychosocial health. Primary outcomes for the KaziHealth testing battery include (1) anthropometric and body composition assessments, (2) clinical examinations, (3) self-reported and objectively assessed physical activity and physical fitness, and (4) questionnaire results from psychosocial health assessment. Further measures include diet and nutritional analysis with the 24-hour dietary recall. Secondary outcomes for both tests are gender, ethnicity, SES, age, weight, and height. Figure 7 summarizes the assessment methods to be utilized in this study. For baseline and follow-up surveys, the same scientifically recognized procedures will be selected and conducted by professional staff, adhering to standardized, quality-controlled protocols.

Utilizing the same protocol as for KaziKidz, each participant’s body weight and height will be measured to calculate the BMI. Utilizing the same protocol as for KaziKidz, waist and hip circumferences will be measured to determine waist-to-hip ratio, a risk indicator for heart disease [39]. Bone mineral density and body fat percentage will be measured with the Discovery Hologic Dual-Energy X-ray Absorptiometry (DXA) QDR 4500A (APEX System Software Version 4.0.2) by a qualified radiographer. Pregnant individuals, individuals who underwent investigations using radioisotopes in the previous 10 days, and individuals with internal metal artifacts will be excluded from the DXA scan. Calibration will be conducted before testing, using the quality check test. Participant’s height, weight, gender, birth date, and ethnicity will be entered before the participant is instructed to lay supine on an open X-ray table within specified position boundaries. The participant will be instructed to lay still and breathe normally while the scan is being conducted, a process that takes approximately 7.5 min.

The datasets generated and/or analyzed during the present study are not publicly available due to confidentiality but are available from the corresponding author on reasonable request.

The project was funded in April 2017 and enrollment of the participants was completed in January 2019. The baseline survey was conducted from January to March 2019. At the time the present paper is being written, the KaziKidz and KaziHealth intervention are underway. The follow-up survey is planned for September to October 2019. At the end of the study, the results will be communicated to the Department of Health and the Department of Education in Port Elizabeth, as well as the involved schools. All intervention materials will be made available to the control schools after completion of the study. Workshops will be offered to the control schools to prepare teachers to implement the KaziKidz teaching material. Furthermore, teachers of the control schools will have the possibility to take part in the workplace health promotion intervention program after the completion of the second health assessment. The key findings will be submitted for publication to the peer-reviewed literature and presented at national and international conferences.

Results from the DASH study revealed that the prevalence of soil-transmitted helminth infections among grade 4 children was above 60% (90/149) in several schools in Port Elizabeth [56]. Moreover, infected children had lower VO₂ max compared with their noninfected peers [56]; helminth infections and low physical fitness were significant predictors of low selective attention and poor academic achievement [16]; physical activity was associated with health-related quality of life [57]; almost one-third of all school children were classified as hypertensive [58]; and the physical activity intervention component contributed to the maintenance of academic performance [27] and resulted in a significantly delayed increase in children’s BMI [59]. Importantly, the DASH intervention package was well received in all schools.

The KaziBantu project is a logical continuation and expansion of the DASH project and aims at contributing to healthy schools and healthy communities. Teachers, as leaders in communities, have an important role to play in this regard. We conjecture that teachers as healthy role models will be able to promote better health behaviors and encourage a healthy, active, and inspiring environment for learners and peers at school. Various health professionals will empower teachers with specific knowledge related to infectious and NCD risk factors, physical activity and fitness, and psychosocial health and nutrition. Improved health and well-being increase teachers’ productivity, benefiting their own health and well-being and that of the children they teach and educate. We hypothesize that implementing KaziBantu will result in less absenteeism, a reduction in stress, and better coping with work demands.

Pursuing the present study protocol will provide specific answers to the following questions: Are KaziKidz teaching materials useful? What are the difficulties in using the teaching materials from the perspective of the teachers? What are the teachers' experiences with regard to the coaching by the teacher coaches? What experiences do the coaches have in their work with the teachers? What attitudes do teachers have with regard to the lessons proposed? What are the conditions for an effective and sustainable implementation of this teaching material? Does the acceptance of the KaziKidz teaching material by the teachers moderate its effectiveness?

With regard to the implementation of KaziKidz and KaziHealth, 3 languages are spoken by the communities in the study area, namely, Afrikaans, IsiXhosa, and English. To ensure comprehension, questionnaires translated into the local languages have been pretested by native speakers, with an emphasis on those that focus on mental health indicators to match the educational attainment of children and help them to understand and answer the questions. The study will be conducted in impoverished and harsh environments where illiteracy, neglect, and violence are common [60,61], which might have an impact on the granting of informed consent by parents and guardians. For illiterate parents or guardians, a literate witness will be invited to sign, whereas participants will be asked to provide a thumbprint. To ensure return of the signed consent forms, we might ask potential study participants several times. Specific safety measures are in place to implement the research. Although it is difficult to predict the extent of people’s mobility and movement, we anticipate a substantial loss to follow-up as people show considerable mobility in this setting. Multiple imputations will be used to deal with missing data, as appropriate.

Taken together, the KaziBantu project presented here builds upon the previous DASH study and aims to improve physical health and well-being, cognitive performance, and psychosocial and clinical health of children and teachers. The South African Department of Education seeks to create a lifelong learner who is confident, independent, literate, numerate, multiskilled, compassionate, and has respect for the environment and the ability to participate in society as an active citizen. The Department of Education also envisions healthy teachers who are qualified, competent, dedicated, and caring and who will be able to fulfill the various roles of an educator. Hence, the project aspires to assist the Department of Education by contributing to the development of the full potential of each learner and the transformation of education in South Africa. In addition, developed and validated KaziKidz workshop material may be translated into short learning programs for accreditation of Teachers’ Continued Professional Development. The KaziChat app will be made available to the Department of Education's directorate responsible for human resources for distribution to all teachers together with encouragement for implementation. This study builds on local evidence and offers the opportunity of providing new evidence on health intervention responses to NCD risk factors as a benchmark for future controlled studies that will enable comparisons among marginalized communities between South Africa and other African countries.