The aim of the situational analysis was to provide a baseline assessment of the environment in low-income primary schools relating to nutrition, physical activity and smoking behaviour. This would assist in designing an effective school-based intervention programme to prevent NCDs.
From the observational data, the general physical environment of the schools appeared to be in good condition, although concerns existed around the hygiene of toilet and bathroom facilities. This could have implications for hand hygiene, since the three primary measures associated with reduced incidence of infections include availability of a clean water supply, adequate disposal of waste (particularly for faeces), and hand hygiene
Another aspect of the general environment which needs addressing is the large number of signage boards on school premises sponsored by a soft-drink company. Displaying these boards would imply that the school supports and promotes the use of these particular soft drinks. Clearly this is not a health promotion message that should be encouraged, a view which is supported by findings from a qualitative study conducted in Australia with primary school learners
. This study found that children appeared to believe that school, and anything permitted at school, is inherently healthy. Further support came from parents, who postulated that the inconsistent messages about unhealthy energy-dense foods, including attractive marketing and advertising strategies, confused children
The data gathered from a large percentage of the principals provided insight into the surrounding communities. Principals expressed their concerns regarding the existence of poverty, unemployment, crime, violence and especially child abuse in these communities. Principals from the urban district identified their learners were facing these problems to a greater extent than the principals from rural schools. Clear differences were observed in the perceptions of urban and rural district principals that were not linked to the poverty grade (quintile). These findings are interesting because poverty is, as elsewhere in South Africa, a rural phenomenon, with the rural poverty rate in the Western Cape estimated at 26.1% compared to 20.1% in urban areas
. The reasons for this difference in perceptions about poverty and employment could possibly be explained by the fact that poverty and unemployment were referred to in the same question, and schools in the urban district are mostly located in the Cape Town municipality, which has the fourth highest unemployment rate in the Western Cape, despite having the lowest poverty rate
. The learners in these schools were, therefore, not only from communities facing high unemployment, but also from the poorest households in the urban district. On the other hand, learners in the rural district were often from agricultural households that face lower unemployment levels, although they have a higher poverty rate than their non-agricultural counterparts. The reason for the different perceptions about child abuse and neglect is less clear as it appears that living in deep poverty increases the vulnerability of children for abuse and neglect
Perceptions about higher crime and violence in the urban district are supported by findings that the homicide victimisation rates for men aged 15–29 years in the Cape Town townships, where many urban schools are located, are more than twice the average for the country
. Furthermore, crime and violence are closely related to alcohol and substance abuse. A review of studies on substance abuse trends found that the Western Cape had the second highest (7.1%) 12-month prevalence of substance use disorders and the highest (18.5%) lifetime prevalence of substance use disorders compared to other provinces
[27, 28]. In South Africa, the Western Cape had the highest alcohol consumption among males and females. Therefore, it is not surprising that principals reported substance abuse to be one of the top three health priorities for parents.
Regarding health and health-related priorities and programmes, it is clear from the results that school principals considered lifestyle-related health issues to be priorities for learners, educators and parents. They also indicated a need for programmes to address these health priorities. However, various barriers to implement these were identified, with lack of time and financial resources being the most important ones. Lack of time has been raised elsewhere as being a major barrier to health promotion programmes
[29, 30]. A study of Intermediate Phase (grades 4–6) educators also raised time limitation as a major problem for the implementation and presentation of Life Orientation, a compulsory learning area for primary school children. This learning area was introduced as part of the outcomes-based education system implemented in 1997 to eradicate the inequalities of the apartheid education system
. Life Orientation comprised four learning outcomes for the Intermediate Phase, i.e. health promotion, social development, personal development, and physical development and movement
, which made this the ideal vehicle for health promotion programmes. Changes have been made to the National Curriculum since the implementation of the HealthKick intervention. Life Orientation is now called Life Skills and is divided into three study areas: Personal and Social Well-being, Physical Education and Creative Arts
. At this stage, there is no clarity how external health promotion programmes, such as HealthKick, may be integrated into this subject. The WHO Health Promoting Schools (HPS) initiative however provides an existing framework for school health programmes
. Strengthening this initiative is furthermore listed as a strategy to address inequity and social determinants of health by the South African National Department of Health
Overall, parental and community involvement appeared to be poor. Only a third of the schools had parents who were involved in the school health and safety committee. This was also reflected by a lack of involvement of the parents in the SGB and the small number of schools where parent or SGB involvement in the school tuck shop was reported. A study conducted in 2004 on parental participation in SGBs, showed that lack of participation could be attributed to the low education level of parents in disadvantaged communities, language barriers and difficulty in attending meetings
The school food environment has been identified as one of the most important components in effective school-based interventions to promote healthy eating
[1, 36]. Apart from the finding that most of the schools participated in the NSNP, a large number had tuck shops and vendors selling food items. The findings clearly point to a need for intervention, since sweets (candy), chocolates, cold drinks and crisps were the main items sold by these providers.
Observations of learner spending during the survey showed that they spent little money at the tuck shop or food vendors. The small profit made is either used by the school to provide extra services to learners, or for vendors to make a living. This finding is supported by an evaluation report of the NSNP, which found that learners brought less than $0.3 to school to spend on food of “very poor nutritional value”
. The fear of losing the income (although small) generated by the sale of these items may however provide a barrier to the willingness of the school and the food vendors to sell healthier food items. An aspect that warrants further investigation, specifically in context of a developing country, has been recommended by Von Holy and Makhoane
. They suggest that baseline research is required to determine the safety and socio-economic importance of foods sold by vendors.
The feasibility of intervening in the nutrition-related environment of schools in disadvantaged settings where children’s buying power is limited, has received very little attention in the literature. A review on the impact of improving nutrition standards on school revenue concluded that in the North American situation very little evidence exists that revenues drop when healthier policies are adopted; however, this may not be the case in disadvantaged African settings
Very few schools in this study had clear policies guiding the food, nutrition and physical activity environment. This could possibly be ascribed to such policies not being required by the DOE. The WHO
, in their global strategy on the prevention of NCDs, urges government to draft policies that stimulate schools to promote healthy eating and encourage physical activity. Intervening in schools at the policy level has been successful in many studies
. In this regard South African schools are slow to follow.
Although principals from all the schools indicated that structured physical activity lessons were scheduled in the weekly timetable, this did not always translate to learners actually participating in physical activity outside the classroom. Possible explanations for this finding comes from a study in a similar sample by Van Deventer
, where educators indicated that the reasons for not presenting the Physical Development and Movement outcome had to do with a lack of time in the curriculum, educators who were not qualified to teach physical education and a lack of facilities and equipment. The latter is also relevant for extramural sport. Generally, the results showed that extramural sport was being offered at schools but that facilities, although available, were often not sufficient and/or in good condition. These findings reflect the legacy of apartheid when sport development and participation was a privilege set aside for only a small segment of the population
. Inadequate facilities were found to be the most important factor for non-participation in sport by black secondary school learners
Although children seem to be active and educators allocated for supervision during break times, no organised activities were observed. Leviton
 referred to studies which showed that learners were most active when equipment and facilities, such as basketball hoops and better playgrounds, were available along with organised active games under supervision.
Lastly, tobacco use is an important preventable factor in the war against NCDs
. The finding that 13% of school principals reported their learners were frequently smoking on school grounds is of great concern considering their age. Findings from the 2008 South African Youth Risk behaviour survey support our results
. In this survey, 21% of the youth aged 13 to 18 years indicated smoking daily. Clearly schools and parents need to take additional means of preventing such behaviour. However, schools also need to address the smoking practices of educators as a substantial number of schools (n = 29) reported having smoking rooms for their staff. Although the tobacco control act
 allowed this at the time, the negative modelling effect
 this practice could have on learner behaviour should be considered.