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Although motor skills, physical fitness and self-efficacy are considered important agents in promoting health and well-being, there is limited research on how exercise can be used to enhance these factors in children within the South African context, particularly among those living in low socio-economic environments. Accumulating evidence worldwide and in South Africa has shown decreased levels of physical activity (PA) among the youth. It is now known that the greatest decline in PA occurs in adolescent girls as compared to boys. Given that insufficient PA and the lack of opportunities to engage in PA is linked to poor motor skills, obesity and harmful health outcomes, it is important to identify effective methods to address PA among high school girls with motor problems and among those who are overweight and obese. International and local data suggest that adolescent girls are “a high-risk” population who have greater risks for obesity and chronic diseases compared to children and adolescent boys. Research has found that adolescent girls are more likely to exhibit poor motor skills and become overweight or obese. Within the South African context, it is believed that adolescent girls in low-income settings are even more prone to becoming physically inactive and obese because they have fewer opportunities to participate in regular PA. Compared to boys, girls have a higher prevalence of overweight and obesity, and perform poorly on motor performance tests. However, the healthcare community has been challenged to provide effective health promotion solutions to these physical health problems encountered in this demographic group due to the lack of empirical evidence on the efficacy of motor interventions. In recognition of this gap, this study was designed to develop and evaluate the efficacy of exercise programmes among high school girls. The study had four aims. The first aim was to examine the relationship between body mass index (BMI), motor competence, physical fitness and self-efficacy in adolescent girls attending high school in a low-income community of Cape Town, South Africa. The second aim was to determine the effects of different motor interventions in a subsample of girls with low motor abilities. The third aim was to compare intervention effects of two different exercises in a separate sample of girls who are overweight and obese. The fourth aim was to determine if participation in a task-oriented functional training would elicit different changes in fitness performance between girls with varying weight status. To achieve these aims, six separate but interrelated studies were conducted in two phases. In phase 1, eligible participants completed various tests aimed to assess their levels of motor competence, physical fitness, self-efficacy and body composition. Phase 2 involved four other intervention studies which examined the effectiveness of two movement programmes in specified populations. In each of these studies, participants were exposed to either a novel Wii Fit protocol (specifically developed for this research) or task-oriented functional training. Both interventions were scheduled 45 minutes per week for 14 weeks. Pre- and posttesting were performed using selected measures of motor coordination, physical fitness and self-efficacy. In this thesis, aim 1 was assessed by Studies 1 and 2, and aim 2 was evaluated by Studies 3 and 4. Similarly, aims 3 and 4 were assessed by Studies 5 and 6. Inclusively, six papers presented in this thesis provided answers to all the aims formulated. With regards to aim 1, the findings indicated that BMI was negatively and independently associated with cardiorespiratory fitness, musculoskeletal fitness, motor competence and self-efficacy. Adolescent girls with increased BMI had decreased cardiorespiratory levels, low musculoskeletal fitness, poor motor competence and reduced self-efficacy compared to peers with a healthy weight. The results highlight the need to develop interventions to target these health markers to optimise health and well-being. To address aim 2, preliminary data were collected to quantify the effects of the newly developed Wii Fit intervention, called the graded Wii Fit protocol among a sample of adolescent girls with low motor ability (probable developmental coordination disorder). Results demonstrated that graded Wii Fit training may be capable of increasing aerobic and anaerobic fitness without decreasing participants’ perception of enjoyment. Following this pilot study, the Wii Fit intervention was compared to task-oriented functional training in a relatively large sample of adolescent girls (who were not included in the preliminary study) with developmental coordination disorder. Significant improvements in motor coordination, aspects of physical fitness and overall self-efficacy emerged for both groups. However, no between group differences were observed on any of the outcomes. These findings indicate that activity-based interventions may elicit positive physical and psychological health benefits in girls with movement difficulties. Either of these interventions could be prescribed to treat motor impairments in female adolescents. The choice of interventions may be influenced by available resources (such as equipment, instructors, electricity etc.) or individual preferences. In relation to aim 3, seeking to compare intervention effects of the two programmes in female adolescents who are overweight and obese, girls who received either the Wii Fit protocol or task-oriented functional training demonstrated improved motor competence and physical fitness without any significant changes in self-efficacy for the two groups. However, no significant differences were observed between the groups on any of the outcomes. This finding indicates that activity-based motor interventions may be useful tools for addressing obesity-related impairments. People working with high school girls who have excess weight could adapt these strategies to promote health, particularly in resource-limited environments. With regards to aim 4, looking at the changes in fitness performance between female adolescents with low and high BMI following the intervention, the results showed significant gains in fitness performance for all participants regardless of weight status. In contrast to girls with high BMI, participants with low BMI demonstrated greater changes in performance on balance and agility tasks. This finding suggests that individuals with excess weight may need adapted programmes to improve their balance and agility performance. In conclusion, the findings of this thesis provide first-hand empirical data explaining the relationship between BMI, motor competence and physical fitness among high school girls in low-income settings. More importantly, results have demonstrated that activity-based motor interventions are capable of improving motor performance in girls with motor difficulties as well as those with excess weight. Further, this thesis makes a significant contribution to the paediatric exercise science literature by showing how ecological theories can be used to develop cost-efficient exercise interventions for the adolescent girls in low-income settings. It is envisaged that people working in low-income schools would apply these ideas to promote optimal physical health. Moreover, the findings may serve as an important resource to inform policy frameworks aimed at promoting physical and psychological health among high school girls within the South African lowincome contexts or other populations with similar characteristics. It is hoped that future studies will evaluate these interventions in heterogeneous samples (e.g. boys and girls) and diverse contexts. Lastly, the sustainability of the changes associated with these interventions needs to be further investigated.

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Background Physical fitness is an important indicator of health in childhood and a strong predictor of wellbeing in later life. Adiposity, decreased aerobic fitness and low levels of physical activity (PA) are associated with cardiovascular disease risk in children (Andersen et al., 2004). Estimates of PA and fitness in young children at the population level is still lacking for many African countries such as Ghana. One major challenge to conducting research on PA and fitness in children in these settings is the lack of accurate and reliable measures of these constructs. Several valid and reliable field-based physical fitness tests require test kits that are too expensive for people working in low socio-economic settings and lack norms for this population (Smits-Engelsman et al., 2020a). The Alpha-fit is one of the most used tests in Europe (Cvejić et al., 2013; Kolimechkov et al., 2019; Ruiz et al., 2011) and is considered to be a valid, reliable, feasible and safe health-related fitness test battery (Assessing Levels of Physical Activity (ALPHA), 2009; Ruiz et al., 2011). However, the Alpha-fit does not assess movement skills (e.g. throwing and catching, hopping, and balance), and has no norms for children living in Sub Saharan Africa. In recognition of these challenges, the Performance and Fitness (PERF-FIT) test battery was developed to provide a set of valid, reliable fieldbased motor performance items for the assessment of health-related physical fitness in low resource communities (Smits-Engelsman, 2018). However, the validity of the PERF-FIT has not been examined in children within the Ghanaian context. The aims of this study were to determine: (1) the physical fitness levels of school children aged 6 to 12 years in a lowincome urban area in Ghana using the Alpha-fit and (2) the construct validity of the PERFFIT among school children aged 6 to 12 years in a low-income urban area in Ghana by comparing it to tests of the Alpha-fit which measure similar constructs. Method A cross-sectional study design was adopted. Three public elementary schools located in La, a suburb of the La Dade Kotopon Municipal Assembly (LADMA), Accra, Ghana which met the criteria of low socio-economic status, (on the basis of geographical location) was selected using convenience sampling. The total number of pupils aged 6 - 12 years in all three schools were 376. A total of 186 children (aged 6-12 years) took part in the study. Children who provided assent after their parents had consented to participate in the study were recruited. Prior to testing, demographic information, health status and PA levels of children provided by a researcher-developed parent questionnaire were documented. Children with physical or medical conditions [determined with the Children‟s Physical Activity Readiness Questionnaire] that would have made testing unsafe were excluded. The two-item Physical Activity Questionnaire (Prochaska et al., 2001) was used to measure participants‟ PA and to identify those meeting the World Health Organization (WHO) PA guidelines for children. Testing was done on a playground/designated classroom at the participants‟ school during Physical Education periods. Weight and height measurements were taken using an electronic weighing scale and a wall-mounted tape measure. Cardiorespiratory endurance, power, agility and motor skills performance were assessed using the PERF-FIT and Alpha-fit assessment batteries. Only the 20-meter shuttle run test (20mSRT), long jump, Body Mass Index (BMI), waist circumference and 4 x10 meter shuttle run (4 x10m SR) which are items 1, 3, 4, 5 and 7 respectively of Alpha-fit were assessed. The tests were carried out in accordance with the instruction manuals. In describing the fitness levels of the participants, the Alpha-fit norms were used (Kolimechkov et al., 2019), and scores for each component were categorized into very poor (below 3rd percentile), below mean (between 3rd and 25th percentile), normal range (between 25th to 75th percentile), above mean (between 75th and 97th percentile) and very good (above 97th percentile). For the PERF-FIT, scores were collated as raw scores. Descriptive statistics: mean, median, standard deviation, percentages, and frequencies were used to summarize descriptive data. To compare differences of scores on the PERF-FIT and Alpha-fit between those who meet the WHO recommended guidelines and those who did not, the Mann-Whitney U test was used. To test the construct validity, hypotheses were formulated and tested for the expected magnitude of the relation between scores on the PERF-FIT and Alpha-fit intended to measure partly comparable constructs. The level of significance used was 0.05 Results One hundred and eighty-six children (96 boys and 90 girls) from low-income homes participated in this study. The median age of participants was 10.00 years. Only 12% of fathers and 3% of mothers had tertiary education whereas 40% of fathers were Artisans and self-employed, 68% of mothers were traders. Participants who were found to have met the WHO recommendation for moderate-tovigorous physical activity (MVPA) were 65.6% (n = 120),only 15.6% (n = 29) participate in sports outside school. Majority of them, 86.6% (n= 161) walk to school and 28.5% (n = 53) were underweight. Categorizing the Alpha-fit items scores, for item 1(20mSRT), 72 % (n = 134) were below the mean, 1.3 % (n = 3) performed very poorly, 25.3 % (n = 47) had normal scores, only 0.5 % (n=1) scored above mean. For item 3 (long jump), 2.2 % (n = 4) scored very good, 23.7% (n = 44) were above the mean, 59.7% (n = 111) scored normal, 12.9% (n = 24) scored below the mean and 1.1% (n = 2) performed very poorly. For item 7 (4 x10m SR), 22.6% (n = 42) scored very good, 33.2% (n = 50), scored above the mean, 30.1 % (n = 56) scored normal range, 11.8% (n = 22) scored below the mean while 2.7% (n = 5) scored very poor. No significant difference on the PERF-FIT ladder run, ladder step, side jump, long jump and overhand throw (p = 0.26,0.16,0.54,0.90 and 0.99 respectively) and Alpha-fit longjump,4 x 10m SR, and 20mSR level (p = 0.99,0.77 and 0.10 respectively) between the group that met the WHO recommendation for PA and those who did not were found. However, there was a statistically significant difference between the two groups on BMI (p =0.05, with those not meeting the recommendation having a higher BMI). Significant correlations were observed between the PERF-FIT (power and agility) items and the Alpha-fit 4 x10m SR and Long jump. The Alpha-fit 4 x10m SR showed low to moderate correlation with the PERF-FIT ladder run, ladder step and long jump (rs= 0.26, 0.20, and 0.35 respectively) while the Alpha- fit long jump showed moderate to high correlations with the PERF-FIT side jump, long jump and overhand throw (rs= 0.36, 0.84 and 0.62 respectively). Conclusion Participants in the study demonstrated good muscular strength and agility measured by the long jump and 4 x10m SR as a result of habitual PA. However, the low participation in organized sports observed by this study could have accounted for the poor aerobic fitness demonstrated by low scores on the 20mSRT. The majority of the children were physically active and met global (WHO) recommendations for PA as reported by their parents. They mostly employed active transportation to get in and out of school (walking). Nevertheless, the BMI of the group of children not meeting the WHO recommendations was significantly higher than the group that met the recommendations. Scores on both Alpha-fit and PERF-FIT were however not significantly different between the two groups. The relation between PERF-FIT and Alpha-fit was mainly (80%) of the hypothesised magnitude. Majority the PERF-FIT (power and agility) items showed moderate to high correlation with the Alpha-fit 4 x10m SR and long jump which shows that the PERF-FIT measures a partly comparable construct to these tests. Identifying deficits in physical fitness in children living in low socioeconomic settings is recommended as a critical step toward the development of a large-scale effective prevention and/or intervention for children with low levels of physical fitness. Participants understood all the PERF-FIT instructions and carried out tests accordingly, testing was time-efficient since participants could be tested in small groups. Assessors found it easy to score participants. Our study findings show that the PERF-FIT performed well in this setting and may be used to assess fitness levels of children in this context.