The thesis set out to document the process of developing and testing a non-pharmacological biopsychosocial intervention programme which included exercise and health education for women with musculoskeletal conditions attending a clinic in a poorly resourced area of the Free State Province in South Africa. To inform the development of an appropriate intervention, several sub-studies were undertaken. Systematic reviews on the use of exercise and health education in adults were undertaken, one on the impact of these interventions on adults with chronic diseases of lifestyle (diabetes mellitus type II, hypertension) and the risk factor obesity, and the other on the impact on adults with musculoskeletal conditions. The selected research tools, which were chosen based on the framework of the International Classification of Functioning, Disability and Health (ICF) were subjected to a rigorous translation process. A facility-based descriptive observational cross-sectional study was undertaken to determine the prevalence and nature of musculoskeletal conditions amongst women between the ages of 40 and 64 years attending a community clinic. The gathered information was then used to modify and adapt existing non-pharmacological programmes and develop an intervention programme tailor made for these patients. Finally, an experimental randomised controlled trial was undertaken to determine the effectiveness of usual care against a non-pharmacological intervention utilising a workbook for the women identified in the survey.

Background: Road traffic injuries are the leading cause of death in children and young adults. Children are at increased risk of fatalities and serious injury due to the differences in their body segment proportions affecting their body kinetics in a vehicle accident. Serious injury and death can be reduced by the appropriate use of car restraint systems (CRS). Children with special health care needs (CSHCN), particularly children with poor postural control, may need adaptive seating to improve postural support and sitting ability within the vehicle due to their additional physical needs. Standard CRS might be unsafe or inappropriate for children with physical disabilities. Research Aims: The thesis aimed to understand the current CRS usage as well as the parents' experiences and perspectives of transportation of CSHCN in the Western Cape, and to determine the postural support needs of CSHCN and the suitability of different CRS designs to meet these needs during transportation. This was achieved through a survey study, followed by a cross-sectional study. Assessing the use of car restraint systems in children with special health care needs; a Western Cape based survey study Objectives: To determine the modes of transport and the prevalence of the use of postural support systems by CSHCN. Along with describing the current use of seatbelts, standard or specialised CRS and exploring the challenges faced by parents of CSHCN during transportation. Methods: A descriptive quantitative survey was performed amongst a convenience sample of all parents of CSHCN between the age of 4 – 18 years enrolled at three special needs schools in the Western Cape, South Africa. Parents had to be able to read and understand English or Afrikaans to be eligible for enrolment in the study. Focus group discussions were conducted to validate the self-designed questionnaire. Results: Parents of 268 children were enrolled in the study (median (IQR) age 11.52 (14.63- 8.86) years; 58.96% male). The most common diagnosis was cerebral palsy (CP) (29.10%), and most children were transported to school with public transport, including school bus (73.13%). The mode of transport was linked to the distance travelled and affordability, and each had its own challenges. The main challenges of parents using private transport were transporting the wheelchair (10.82%) and the unavailability of demarcated disability parking bays (7.46%). When using public transport parents identified their child's poor sitting balance (6.34%) and lack of space within the vehicle (5.60%) as the greatest challenges. The majority of children (58.96%) came from low-to-middle income households (< R6500 per month), significantly impacting the use of a CRS, with more children from higher income families being transported in a CRS (X²= 48.14, p< 0.001). Difficulties with sitting balance was reported in 25.75% of the children and was significantly association to the parents understanding of their child's sitting balance (X²= 17.72, p< 0.001). Parents who felt that their child had difficulty with their sitting balance were more likely to use a CRS. Furthermore, a significant association between currently using a CRS and child's weight was observed (X²= 11.54, p=0.021), as children who weighed more were less likely to still be using a CRS. Most parents (54.48%, n=146) did not know South Africa's current legislation on CRS, which was significantly associated with a lower CRS usage (X²= 19.84, p< 0.001). Half of the parents (n= 139, 51.87%) were not willing to spend money on a CRS as they felt that a car seat was not necessary for their child. The amount parents were willing to spend on a CRS was significantly associated with having ever made use of a CRS (X2=43.38, p< 0.001). Conclusions: Parents of CSHCN reported many challenges in transporting their child depending on the mode of transportation. CRS usage was associated with parent perception on the child's sitting abilities, lower weight, knowledge of legislation and a higher household income. Despite these, CRS usage amongst CSHCN is lower than expected as (48.88% – 55.22%) children that are still within the age and weight range to use a CRS as required by law did not report CRS usage. This could link in with the affordability of the CRS and failure to know the legislation on CRS by parents. This study highlights the need for national campaigns to promote and educate citizens on road safety and CRS legislation. Due to the lack of financial resources in low to middle income countries, it is vital that an affordable CRS is made available or is subsidized by the government where families are unable to afford the cost themselves, particularly for use in public transport. Effectiveness of currently available car restraint systems to maintain correct seating position during transportation for children with special health care needs Objectives: To determine the characteristics of CSHCN who require specialised CRS for their postural support needs, through assessment of their sitting ability and whether these needs are met by different CRS. Methods: Participants in the earlier survey study were invited to take part in a crosssectional and pre-post design study. A screening tool for identifying sitting balance problems was developed and found to be reliable for inter- and intra-rater reliability (k>0.700, p0.879). This tool was used to identify CSHCN who had difficulty sitting independently on different types of seats. These participants underwent a standardised sitting balance assessment, using the Level of Sitting Scale (LSS), to identify eligible participants with postural support needs. Participants were excluded if they recently had surgery or had an unstable health condition which could alter their sitting balance. The ability of two standard CRS (Car Seat and Booster seat), two Specialised CRS (one locally and one internationally produced), and Seatbelt only to provide adequate postural support was investigated. Head and trunk postures were analysed and categorised, by deviation from the midline, by photographs taken from different viewpoints. Results: There were 78 CSHCN enrolled in the study (mean (SD) age 11.50 (3.70) years; 65.75% male), the most common diagnosis was CP (63.48%), the majority of participants did not require any support to maintain sitting balance and were categorised as levels 5-8 of the LSS (78.08%). According to the World Health Organisation anthropometric guidelines 54.79% (n=40) of the participants should still use a CRS, either a Booster Seat (42.47%, n=31) or a Car Seat (12.33%, n=9). The head or torso fully supported and between the side supports of the CRS was the most common posture in all the viewpoints of the different CRS except for the lateral head viewpoint of the CRS Car Seat (50.00%; n=4), the Booster Seat (60.00%; n=18), and the International Specialised CRS (60.61%; n=20), as well as the anterior torso viewpoint of the Seatbelt only (50.75%; n=34). The CRS that resulted in the largest proportion of unacceptable posture deviations from the standard position were the Seatbelt only (20.90%, n=56) and the Booster Seat (18.33%, n=22). Out of position (OOP) postures were observed in all the devices for the anterior and lateral head positions (3.03% - 20.00%). The Booster Seat, the Local Specialised CRS and the Seatbelt only devices had participants with OOP postures in all four viewpoints. A key observation in the current study is the lack of torso support for the majority of CSHCN in the anterior torso viewpoint of the Seatbelt Only CRS (55.22%, n=37), indicating that the use of a Seatbelt only does not provide adequate postural support for all CSHCN despite them meeting WHO anthropometric requirements. No significant association was found between the pre- and post-test postural analysis scores of the Seatbelt only (X2=2.14, p=0.144) which could be as a result of the large postural deviations pre-testing (41.79%, n=28) remained post-testing. However, there was a significant association between the preand post-test scores of the anterior head viewpoint of the Booster seat (X2= 7.94, p=0.005), indicating lateral head deviation. The post-test postural analysis score of the Booster Seat anterior head viewpoint was significantly associated with a deviated posture (X2= 7.94, p=0.005). Other OOP observations included postures that could not be categorised by head and trunk deviation from the midline including head or torso rotation, abnormal limb placement, body extension and slouching. Overall performance scores are a sum of the number of viewpoints where the CSHCN posture worsens post-test. an indication of the number of CSHCN whose posture worsened post-test in each of the viewpoints of the CRS. Although there was no correlation between the LSS score and the overall performance score of any CRS device which would indicate if the CSHCN balance influences CRS performance, the Booster Seat (80.00%, n=24) and the Seatbelt only (55.23%, n=37) devices had the greatest number of participants with a poor overall performance. The viewpoints which had the worst performance scores were the anterior and lateral head of the Booster Seat (46.67%, n=14 and 43.33%, n=13 respectively) and both viewpoints had majority of participants worsen their scores. All CRS performed adequately in the lateral torso viewpoint, indicating sufficient support of the torso in the sagittal plane. Conclusions: The postural support needs of CHSCN are unique and depend on the child's anthropometry and the severity of their disability. The currently available CRS designs may not provide the postural support needed for many CSHCN. Postural deviations of the head, torso and limbs were observed which could be dangerous in the event of an accident. This study was not able to determine specific characteristics of CSHCN that require specialised CRS, as there was no association between the LSS and the overall performance score for any of the CRS devices. However, devices that offer less head and torso lateral support, or do not offer additional harness support such as the Seatbelt Only and the Booster Seat showed the largest proportion of OOP postures in CSHCN. Thesis Conclusion: This thesis highlights the complex transportation needs of CSHCN in South Africa and how the different CRS can influence posture. Additional observational research is required to determine the CRS usage in the CSHCN population to compare to the prevalence of CRS usage found in this survey study. Future research could incorporate other specialised CRS designs, particularly ones that are suitable for CSHCN beyond standard CRS weight and height limits or those with severe physical limitations that could not be tested during this study's simulated course. Practitioners prescribing and advising parents on CRS devices for the safe transportation of CSHCN should integrate thorough patient assessment and knowledge of manufacturer CRS design specifications to promote CRS usage. Policies should consider and accommodate for the challenges faced by CSHCN and their families in accessing, affording and utilising transport services. Advocacy and education programs should be combined with legislation enforcement to support improved implementation of CRS usage amongst all children, regardless of their disability status. For effective implementation for CSHCN, CRS should be affordable, accessible, functional and accommodate growth and postural support needs.

Includes bibliographical references / Purpose: Cardio-respiratory physiotherapy for patients undergoing abdominal surgery has been found to be beneficial in improving lung function post-operatively and in the prevention and treatment of post-operative pulmonary complications (PPCs). The Blow Bottle, a Positive Expiratory Pressure (PEP) therapy device, is commonly used as an adjunct to physiotherapy. The Blow Bottle is low cost and can be easily made by the physiotherapist using readily available materials in the hospital setting. However, evidence to support the use of Blow Bottles in the post-operative management of abdominal surgery is minimal, with few studies reporting significant positive effects especially when compared to conventional cardio-respiratory physiotherapy techniques. Methodology: A randomized control was implemented in a public tertiary institution within the Western Cape. Patients admitted for open abdominal surgery via midline incision were eligible for the trial. Participants were randomly allocated to either the control group (CG) receiving conventional post-operative cardio-respiratory physiotherapy, or the intervention group (IG) who received the additional use of the Blow Bottle. Lung function and the development of post-operative pulmonary complications were the primary outcome s of this study. Lung Function was evaluated by means of spirometry testing and interpretation of Forced Expiratory Volume in 1 second (FEV 1) and Forced Vital Capacity (FVC). The development of post-operative pulmonary complications were diagnosed using the criteria by Mackay et al. (2005) where changes from pre-operative findings of auscultation; temperature, X-ray and sputum are evaluated post-operatively and recorded using the Adapted Abdominal Physiotherapy Outcomes Data Sheet (A-APODS). Results: A total of 19 participants were enrolled in the study, n=11 (CG) and n=8 (IG), predominantly female (n=14) and admitted for cancer related abdominal surgery (n=9). There was a statistically significant (p<0.05) marked reduction in post-operative lung function from baseline across groups, 62% in FEV 1 and 47% in FVC on the first post-operative day. The FEV 1 and FVC were similar across both the control and intervention groups for the first three post-operative days. On auscultation majority of participants had decreased breath sounds on the first post-operative day. However, no one participant developed a PPC across the duration of the study as diagnosed using the criteria by Mackay et al. (2005). Conclusion: Whether the additional use of the Blow Bottle is more beneficial than conventional post-operative cardio-physiotherapy alone is inconclusive due to the incremental drop out of participants from the study and small sample size. In this study there was however a significant reduction in lung function post-operatively. This mandates the need for further research investigating the abdominal surgical field and the use of devices to improve lung function, such as the Blow Bottle, as literature is scant and outdated, and sorely lacking in the resource constraint South African hospital settings.

Background: Osteoarthritis (OA) is one of the most common musculoskeletal conditions (MSCs) worldwide, most commonly affecting those over 60 years of age. OA is associated with pain and disability, and also has negative social and emotional effects on the individual. End stage management for OA of the knee, when the individual is no longer receiving adequate relief from conservative measures, is total knee arthroplasty (TKA). Long waiting lists are a challenge globally and in South Africa (SA) where patients often have to wait years to receive their surgery. Evidence suggests that the longer an individual is in pain, the more likely they are to stay in pain and thus long waiting lists may result in poor post-operative outcomes. It has been found that 10-34% of patients undergoing TKA do not gain adequate relief from surgery. Literature suggests that self-management interventions using exercise and education are effective in reducing pain and improving function in patients who are on a waiting list, in a South African context. The current literature on selfmanagement programmes does not include post-operative follow-up and thus the current study was warranted to determine the effects of a six-week pre-operative physiotherapist-led exercise and education intervention on post-operative recovery in patients with OA undergoing total knee replacement. Methods: A single-blind randomized controlled trial was conducted at Tygerberg Hospital (TBH) in the Western Cape, SA. Pain was the primary outcome measure, with disability (WOMAC), healthrelated quality of life (EQ-5D-5L), fear of movement (TSK) and function (ALF) as secondary outcomes. Participants were randomly placed into the experimental or control group. The experimental group took part in a six-week, group programme, which they attended at TBH. Classes were two hours long and consisted of education, exercise and relaxation training. The control group’s management remained unchanged and they received their usual care. Measurements were taken at recruitment, post-intervention, pre-operatively, post-operatively, and at six weeks and three-months postoperatively by a blinded research assistant. Analysis was by intention to treat. Due to the small sample size, non-parametric analysis was conducted and results are presented as median and range throughout. Effect sizes were calculated with a 95% confidence interval. Results: There were no significant changes between groups on the primary outcome measure of pain. The only outcome revealing any significant change between groups was the TSK, with a large effect size of 1.39 (0.41 – 2.26 95% CI), indicating that the experimental group performed better than the control group at three months post-operative follow-up. Conclusion: Participation in the intervention provided no significant benefit to the experimental group over the control group and did not change post-operative outcomes. There were challenges with regard to participation and completion of the measurement tools used, raising questions regarding issues of pain and fear, self-efficacy, social learning, social cohesion and behavior change. The suitability of this intervention for use in a pre-operative population for post-operative benefits, needs to be reviewed; it would appear that what is suitable for those on a waiting list, with no clarity on when surgery will occur, may not necessarily apply to those who are actually due to undergo surgery. Future research should consider modifying the intervention, including information appropriate to pre and post-operative needs of the population. The roles of self-efficacy, social cohesion and social learning in behavior change should be considered and, levels of self-efficacy and fear of movement beliefs assessed prior to randomization, in order to adequately establish the effect of the intervention on these factors.

Background Neuropathic pain affects 7 – 10% of people and responds poorly to pharmacotherapy. Numbers needed to treat for first line drugs range from 4 – 8. Therefore, there is an obvious need for improved understanding of the mechanisms of neuropathic pain to inform improved treatments. Mechanistic research on neuropathic pain frequently uses a human surrogate model of secondary hyperalgesia that is a common feature of neuropathic pain. The value of experimentally inducing secondary hyperalgesia is that one can then test the influence of different pharmacological and nonpharmacological interventions. This may shed some light on the physiological mechanisms within the spinal cord, which possibly also translates to the effects of the interventions on other pathways that are involved in processing signals that may be related to pain. Additionally, pain is known to be influenced by the threat value of the situation. Many South Africans live under constant threat: less than a third of South Africans feel safe walking alone at night. This constant threat may be perpetuating the pain problem in South Arica. However, the mechanism by which threat achieves this influence on pain is unclear. This project is focused on one possible mechanistic hypothesis: that threat influences pain by affecting central physiological changes within the dorsal horn of the spinal cord. These central changes often present clinically as secondary hyperalgesia. A thorough understanding of these mechanisms will inform improved treatment strategies. Methods Phase one: systematic review and meta-analysis The aim of this systematic review was to identify, describe, and compare methods that have been used to manipulate experimentally induced secondary hyperalgesia in healthy humans. A systematic search strategy (conducted on 01 October 2019) was supplemented by reference list checks and direct contact with identified laboratories to maximise the identification of data reporting the experimental manipulation of experimentally induced secondary hyperalgesia in humans. Studies were only included if they were published and in-press or accepted records for which the title, abstract, and full-text versions were available in English. Duplicate screening, risk of bias assessment, and data extraction procedures were used. Risk of bias was appraised for the following domains: selection, performance, detection, attrition, measurement, reporting, and other sources of bias. Data were extracted using a standardised data extraction form. This form was piloted and refined beforehand. Authors were asked to provide data were necessary. Data were pooled by method of v manipulation and outcome (intensity of secondary hyperalgesia, area of secondary hyperalgesia, or both). Phase two: experimental paradigm An experimental study was developed and conducted to investigate the effect of a stimulus threat on secondary hyperalgesia. The aim of this study was to investigate the effect of a manipulation of the threat value of a stimulus on experimentally induced secondary hyperalgesia in healthy human volunteers. All participants underwent a sham skin examination (the threat stimulus) at both the experimental and control sites. Through this sham skin examination, participants were informed that their skin integrity was fragile at the experimental site and robust at the control site. Secondary hyperalgesia was induced with high-frequency electrical stimulation at both the experimental and control site. Sensory testing was conducted at the experimental and control site, providing a withinsubject comparison of the intensity and area of secondary hyperalgesia at each site. It was hypothesised that greater threat will be associated with (hypothesis 1) greater intensity and (hypothesis 2) greater surface area of induced secondary hyperalgesia. Results Phase one: systematic review Twenty-one studies with non-pharmacological manipulations were included. Nine (out of 21) studies assessed intensity of secondary hyperalgesia after manipulation. Nicotine deprivation and negative expectations about the induction increased the intensity of secondary hyperalgesia. Three studies using attentional modulation and cognitive loading reported conflicting results with two studies having no effect and the other reporting a decrease in the intensity of secondary hyperalgesia. Emotional disclosure decreased the intensity of secondary hyperalgesia at four days and at one month after the manipulation. Hot/cold application, and verbal suggestion had no effect on the intensity of secondary hyperalgesia. Seventeen (out of 21) studies assessed area of secondary hyperalgesia after manipulation. Nicotine deprivation and sleep deprivation increased the area of secondary hyperalgesia. Hyperbaric oxygen therapy, cognitive behavioural therapy, emotional disclosure, spinal manipulation, transcranial direct current stimulation, and placebo analgesia decreased the area of secondary hyperalgesia. Interestingly, the effects of emotional disclosure and hyperbaric oxygen therapy were evident one month after manipulation. Acupuncture had no significant effect on the area of secondary hyperalgesia. Four studies assessed the effect of hot/cold application. Three studies reported no effect and one study reported an increase in the area of secondary hyperalgesia after cold application.

Includes abstract. / Includes bibliographical references (leaves 235-263). / Deficient truncal postural control is said to be the main factor in the development of motor disorders, however in cerebral palsy (CP) the role of the trunk especially in lower limb function is not clearly understood. This research project aimed to investigate the role of the abdominal muscles and determine its contribution to the motor dysfunction seen in stance and during gait in children with spastic-type CP (STCP).

Disability is a complex construct, and our understanding of it has evolved over the years from a purely medical description to encapsulating the experience of those with disability in the context in which they live. The International Classification of Functioning, Disability and Health (ICF) provides a framework to explore the concept in a biopsychosocial framework taking into account the interaction of a person with a health condition with their environment. The central purpose of this thesis was to explore disability within an under resourced context in order to provide data to service planners to improve the health and well-being of those affected. The exploration of disability involved a cross-sectional survey using instruments based on the ICF framework including the Washington Group Short Set of Questions on Disability, the WHODAS-2, the WHOQOL-BREF and the EQ-5D. The objectives were to establish the prevalence of disability and the description of the impairments, functional limitations and participation restrictions of those identified with disabilities. A total of 950 households were visited in Oudtshoorn (a semi-rural town) and Nyanga (a peri-urban area) and information was gathered on 7336 individuals with a mean age of 30.5 years. The majority of the participants were women. Both areas presented with estimates higher than those from the national census (5.0-6,7%). The urban area of Nyanga presented with a disability prevalence of 13.1% and the semi-rural area of Oudtshoorn with a prevalence of 6.8%. Overall the disability rate was 9.7%. The types of impairment and functional limitations were similar in the two areas, but more severe disability was reported in the semi-rural area, that also had significantly more elderly people. Non-communicable diseases were identified as the major cause of disability in both areas, followed by communicable diseases in Oudtshoorn and unintentional trauma in Nyanga. However, a person was twice as likely to be disabled due to non-communicable disease (Odds Ratio 2.2) when living in Oudtshoorn, and three times more likely to be disabled due to intentional trauma when living in Nyanga (Odds Ratio 0.3). Non-communicable diseases were responsible for the largest number of healthy life years lost. Those living in Nyanga had a higher burden of disability due to their lower quality of life scores as measured by the EQ-5D. Respondents in Nyanga consistently scored higher (worse) on all domains of the WHODAS-2 compared to respondents in Oudtshoorn. Living in Nyanga was associated with a 10% increase in domain scores. However, the pattern of scoring was similar and both areas reported worst functioning for the domains of Getting Around and Life Activities, which are associated with physical mobility. Respondents in Oudtshoorn reported better QoL and HRQoL than those in Nyanga. Functional level predicted the QoL scores, with Nyanga reporting worse functioning. Being employed and married was associated with a higher (better) EQ-5D VAS score, while mobility problems, pain or discomfort and anxiety or depression decreased the score. Transport was the most commonly identified barrier in both areas. Major barriers for those living in Oudtshoorn were Surroundings and Help in the home, whereas Help in the home and Prejudice and discrimination were viewed as the major barriers for respondents in Nyanga. The elderly were the ones most likely to not receive the rehabilitation services that they needed. The conclusions that can be drawn from this research are that context influences the experience of disability, and that disability prevalence alone is an insufficient basis for service planning. Those who experience greater deprivation also have a worse experience of disability. It is therefore essential for South Africa policy makers to view disability through a socio-political lens to ensure the equalisation of opportunities for people with disabilities. Improved quality of life for those living in under-resourced communities should be a priority. Service providers should have a broad range of skills to enable them to address not only the rehabilitation needs of people with disabilities, but also their social needs.

Includes bibliographical references. / This thesis investigated the effects on critically ill, mechanically ventilated paediatric patients of two related, frequently performed physiotherapy procedures: nonbronchoscopic bronchoalveolar lavage (NB-BAL) and endotracheal (ET) suctioning. General aims: To investigate un- or poody-documented complications of paediatric NBBAL and ET suctioning, and to test a method for each procedure of reducing the incidence and/or severity of these complications.

Background: Physiotherapists have been identified as key role players in health promotion (HP) as well as in the prevention and treatment of non-communicable diseases (NCDs). As key role players engaged in physical activity (PA) HP who society observe as role models, it is valuable to investigate the health behaviours of physiotherapists and physiotherapy students alike. There is a paucity of evidence on the levels of PA of physiotherapists and physiotherapy students, making it difficult to predict their effectiveness as role models and the effectiveness of HP strategies they use. Aim: The aim of this study is to describe the perceived benefits and barriers to exercise and their association with levels of PA in physiotherapy students (first to fourth year) attending university in the Western Cape province of South Africa. Method: This study follows a quantitative, cross-sectional, survey design. Two hundred and ninety-six participants (median age = 22 years) were recruited from the three universities in the Western Cape (University of Cape Town, University of the Western Cape and University of Stellenbosch). Participants completed a demographic questionnaire (DQ), 43 item exercise benefits and barriers scale (EBBS) and the international physical activity questionnaire short form (IPAQ-short). Results: Female students accounted for 83% of the sample. From the 296 participants, 58% lived off campus and 65% were involved in sporting activities six hours per week. The median score on the EBBS was 136 (54-167) for all years. Responses with the highest agreement for perceived benefits were: (1) Exercise increases my level of physical fitness, (2) Exercise improves functioning of my cardiovascular system and (3) exercise improves the way my body looks. Alternatively, the top three responses for perceived barriers were: (1) exercise tires me, (2) I am fatigued by exercise and (3) Exercise is hard work for me. The IPAQ scores revealed that the majority of students had low PA. Only 37.5% students engaged in high PA. Scores on the EBBS categorised by level of physical activity (low, moderate and high) showed that students with high PA had significantly higher scores on the EBBS than those with moderate and low PA. There were no significant differences between the EBBS scores of students with high, moderate and low PA leves in the first year of study [H (2, N=41) =3.01 p=0.22]. However, students in the second (n=61), third (n=111) and fourth years of study with high PA had significantly better scores on the EBBS than those with low and moderate PA. Conclusion: Undergraduate physiotherapy students in the WC across all three universities do not engage in adequate PA. In this group of students, benefits associated with high PA related to physical performance and barriers associated with low levels of PA related to physical exertion. Clinical relevance: Physiotherapists who do not practice what they preach are not effective role models and may not be effective in obtaining behavior change through PA HP. Global mortality by NCDs is on the rise and physiotherapists need to respond by taking a leadership role. Physiotherapy students should be encouraged to participate in PA as part of their undergraduate training. Methods of promoting PA in this population should take into account the perceived barriers and benefits of this group of students.

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.