Table 1 Measures to be assessed and techniques utilized in the i-SPAN study

Focus group discussions (FGDs)

a. Selected school governing body members

b. Selected learners in grades four and seven

Phase 1- Elicitation phase

An interview schedule has been developed by the research team and will be used as a guide during the FGDs to explore current practices at each school.

All FGDs will be audio-recorded and conducted in the language of choice by fieldworkers. The audio-recordings will be sent to an external transcriber who will transcribe verbatim.

Structured in-depth interviews (IDIs)

School principals

Phase 1- Elicitation phase

An interview schedule has been developed by the research team and will be used as a guide during the IDI regarding health promotion in schools.

Questionnaire

a. LO educator

b. Learners

c. Parents of learners

Phase 2- Intervention phase

The questionnaires will be designed and adapted from questionnaires used in previous school intervention studies [23,24,25].

a. Educators will complete a pre and post intervention questionnaire based on diet and physical activity.

b. Demographic data, diet and physical activity questionnaires for children and adolescents will be collected. Questionnaires will include pictures for food choices to enhance the learning activities.

c. Same as b. Questionnaires will be sent home with the participating learners and asked to be returned within the same school week

Reliability of the questionnaire will be ensured as follows: During the training of the fieldworkers’ changes/amendments to the questions will be made to ensure that there is clarity and no ambiguity in the questions being asked of all participants. The questionnaires will be translated into isiZulu by a person familiar with the content and back-translated into English by an independent translator. The questionnaire will be conducted in the language of choice (English or isiZulu) of the participant. The activities during the intervention will be conducted in English but as the children are young, the fieldworkers will be able to assist them in isiZulu whenever needed. Questions will further be refined during and after the pilot study to further detect any ambiguity or difficulty.

Anthropometry

Weight and height for all participating children and adolescents

Phase 2- Intervention phase

Weight and height will be measured using a digital weighing scale, and stadiometers. (Model no. 210/217/876; Seca, Hamburg, Germany). The weight of the participant will be taken to the nearest 0.1 kg for accuracy. The participants will be weighed with minimal clothing, and preferably with an empty bladder and before a meal [26]. Measurements using the stadiometer will be taken to the nearest 0.1 cm for accuracy. The participants will be measured without shoes. Participants are required to stand with their legs straight, heels and the height measure touching at the back, arms at the sides, relaxed shoulders, with chin level to ground and looking straight ahead [26]. Weight and height measurements will be taken in duplicate for accuracy and a correct average.

The body mass index (BMI) for age Z scores, according to the 2006 WHO Growth Standards for children, will be used to classify being at risk of overweight with a Z score of SD 1, overweight with a Z score SD > 1 and obese as a Z score SD > 2 [27].

Workshop

LO educators

Phase 2- Intervention phase

To facilitate study implementation, educators will be invited to attend a two-day training workshop at the university to assist educators in understanding and delivering the classroom lessons as part of the intervention. They will also be provided with the findings of the baseline data to assist them.

Health Promotion Toolkit

Schools randomized into intervention arm

Phase 2- Intervention phase

The toolkit consists of the learner pamphlet, the educator manual, and sports box.

a. The pamphlet includes all relevant information for learners and simplified regarding overweight and obesity.

b. Instead of being a stand-alone school subject, physical education became one of the four learning outcomes of the LO subject of the new curriculum, thus not receiving adequate attention as an important part of healthy living for the learner outcomes [28]. The educator manual has been developed and adapted from teaching manuals in previous nutrition and school-based intervention studies [29, 30]. The manual consists of collated materials that constitutes the learner outcomes of the Life Orientation curriculum. The LO learner outcomes, as per the South African National Curriculum, include health promotion, as well as social, personal and physical development and movement [28]. The manual explains the significance of the obesity epidemic in South Africa and in children, the purpose of the manual, the goals and objectives of the i-SPAN study, as well as the monitoring and evaluation processes. The intervention and lesson plans are designed so that educators have some level of flexibility as topics may overlap. Activities are also included after every lesson to assist educators and make the lessons more enjoyable for the learners. If lessons similar to those in the manual are being conducted, then the manual will serve as a reinforcing tool for the educators. However, if the nutrition and physical activity components are not part of a school LO classroom lesson plan, then the educators will be introduced to and assisted with understanding the importance of the healthy lifestyle components during the educator workshops that will take place prior to commencement of the study.

c. The Department of Sport and Recreation South Africa actively promotes the options of indigenous games as recreational or formal games. There are ten games have been identified as part of an indigenous games national project. These include: dibeke (a running ball game); diketo (a coordination game); kgati (a rope jumping game); ncuva (a board game); morabaraba (a board game); jukskei (a throwing and target game); kho-kho (a running game); Iintonga (a stick fighting game); arigogo (similar to rounders) and drie stokkies (running and jumping game). It is important to capitalize on such opportunities as they serve as inexpensive, culturally and context-specific tools that contribute to child health. Therefore, members from the Department of Sports and Recreation will assist the educators and fieldworkers during the physical activity times (this will be negotiated with LO teachers and principals for suitable times such as during breaks, after school and during the specific physical activity times as indicated by stakeholders within the four sub-districts). It will not be possible to include all games but the Department of Sports and Recreation has proposed teaching the learners at least a few of the indigenous games that they are familiar with, their parents know of or basically introducing it as a novel experience to them.