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Exploring the Use of Sport as a Platform for Health Promotion with Youth in Africa: A Scoping Review. Exploring the Use of Sport as a Platform for Health Promotion with Youth in Africa: A Scoping Review. Adam H. Hansell Follow this and additional works at: https://researchrepository.wvu.edu/etd Recommended Citation Hansell, Adam H., "Exploring the Use of Sport as a Platform for Health Promotion with Youth in Africa: A Scoping Review." (2018). Graduate Theses, Dissertations, and Problem Reports. 8209. https://researchrepository.wvu.edu/etd/8209 This Thesis is protected by copyright and/or related rights. It has been brought to you by the The Research Repository @ WVU with permission from the rights-holder(s). You are free to use this Thesis in any way that is permitted by the copyright and related rights legislation that applies to your use. For other uses you must obtain permission from the rights-holder(s) directly, unless additional rights are indicated by a Creative Commons license in the record and/ or on the work itself. This Thesis has been accepted for inclusion in WVU Graduate Theses, Dissertations, and Problem Reports collection by an authorized administrator of The Research Repository @ WVU. For more information, please contact researchrepository@mail.wvu.edu. Exploring the Use of Sport as a Platform for Health Promotion with Youth in Africa: A Scoping Review Adam H. Hansell Master’s Thesis submitted to the College of Physical Activity and Sport Sciences at West Virginia University in partial fulfillment of the requirements for the degree of Masters of Science in Sport and Exercise Psychology Peter Giacobbi Jr., Ph.D., Chair Dana K. Voelker, Ph.D. Ed Jacobs, Ph.D. Department of Sport and Exercise Psychology Morgantown, West Virginia 2018 Keywords: sport, health promotion, Africa, youth development, disease, community, intervention Copyright 2018 Adam H. Hansell ABSTRACT Exploring the Use of Sport as a Platform for Health Promotion with Youth in Africa: A Scoping Review Adam H. Hansell According to the World Health Organization, Africa has the highest rates of disease and child mortality in the world. Previous research suggests that sport may be an effective vehicle to enhance health knowledge and behaviors among at-risk youth. The primary purpose of this review was to analyze and synthesize published interventions exploring the use of sport or physical activity for health promotion with children and youth in Africa. A total of 916 articles were retrieved from ten electronic bibliographic databases with 28 meeting inclusion criteria. Targeted health outcomes in sport-based interventions included HIV-related knowledge and behaviors, essential health practices, physical and mental health, physical activity, and overall fitness levels. Statistically significant improvements in targeted health outcomes were observed in 23 of the 28 interventions included. However, the authors conducted risk of bias ratings for each study, and 23 articles were rated as having a “serious” or “critical” risk of bias. Our findings suggest that the use of sport- and physical activity as a health promotion intervention may be an effective with children and youth in Africa. However, future researchers must incorporate more rigorous methodological approaches, such as randomized controlled trials with wait-list control or crossover design. iii Table of Contents Page Introduction 1 Methods Overview 7 Study Identification and Data Sources 8 Identification and Selection of Relevant Studies 8 Data Charting and Synthesis 9 Risk of Bias 10 Consultation with Practitioners 11 Results Outcomes 12 Contextual Considerations 14 Funding 18 Risk of Bias 21 Practitioner Feedback 21 Discussion Characteristics of Interventions 32 Recommendations for Future Research 35 Recommendations Based on Practitioner Feedback 38 Limitations 39 References 43 Appendices Expanded Literature Review 52 Limitations 88 Definition of Terms 92 Coding Sheet 93 IRB Approval 94 SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 1 Exploring the Use of Sport as a Platform for Health Promotion: A Scoping Review Infectious diseases such as pneumonia, diarrhea, and malaria are the primary cause of child mortality in Africa (Black et al., 2010; Liu et al., 2015). It has been estimated that more than ten million children under the age of five die every year, and nearly all of these deaths occur in poor, developing countries (Black, Morris, & Bryce, 2003). In 2000, 36 of the 42 countries with the highest global rates of under-five child mortality were in Africa (Black et al., 2003). Since the 1990s, many countries in sub-Saharan Africa have experienced increases in child mortality rates, while others have experienced stalled or slowed progress in this domain (Fotso, Ezeh, Madise, & Ciera, 2007). Another recent report highlighted sub-Saharan Africa as having the world's highest child mortality rate with over three million deaths of children under the age of five, meaning that one child out of every 12 dies before their fifth birthday (United Nations, 2015). Since 2000, 64.3% of deaths in children under five were attributed to infectious diseases, reflecting nearly five million premature deaths (Liu et al., 2015). Infectious diseases were also a leading cause of death for older children and adolescents in Africa, with pneumonia (14.7%), diarrhea (9.9%), and malaria (7.4%) serving as the three biggest culprits (Liu et al., 2015). The World Health Organization reported that Africa has the highest incidence rates of infectious diseases in the world, which include HIV and AIDS, tuberculosis, and malaria (World Health Organization, 2016). Compared to other global regions, HIV incidence rates were over seven times higher in the African Region in 2014 with an average of 2.6 people out of 1000 being infected (World Health Organization, 2016). Globally, of a total of 438,000 deaths caused by malaria in 2015, roughly 90% of fatalities occurred in sub-Saharan Africa, and approximately 70% of deaths were children under the age of five. Africa also had the highest incidence rates of tuberculosis in 2014, with 281 cases per 100,000 people (World Health Organization, 2016). SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 2 Therefore, Africa has the highest incidence and mortality rates of three of the world’s most deadly infectious diseases, which highlights the urgent need for interventions and resources. The World Health Organization (2016) reported that Africa also had the highest number of deaths caused by exposure to unsafe drinking water and inadequate sanitation and hygiene practices. Nearly half of an estimated total of 871,000 global deaths caused by unsafe water exposure occurred in Africa in 2012. The vast majority of these deaths were caused by infectious diseases contracted from contaminated drinking water and inadequate or non-existent hygienic facilities (World Health Organization, 2016). Another study estimated that unsanitary water was responsible for approximately 1.5 million deaths in children in 2000 (Black et al., 2003). Clearly, exposure to, and the use of, contaminated water is a risk factor for early mortality. Due to the dangers posed by exposure to and use of contaminated water, tangible and educational resources should be allocated to communities that are exposed to unsafe water. Socioeconomic status is one of the primary risk factors for acquiring infectious diseases as individuals living in poverty are far more likely to contract these ailments (World Health Organization, 2016). In addition to being at higher risk of contracting infectious diseases, individuals living in poverty often have limited access to resources that can treat infectious diseases after they are contracted (World Health Organization, 2016). Given the disproportionate amount of people living in poverty in Africa compared to the rest of the world, interventions and resources aimed at improving these conditions should be allocated to at-risk communities. Although education and awareness initiatives may have the most long-term preventative impact, there are numerous tangible resources that could both prevent and treat different infectious diseases. These include condoms to prevent the spread of HIV and AIDS, bed nets to help SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 3 protect against malaria and other mosquito-borne illnesses, and water filtration systems to help reduce the instances of infectious diseases caused by contaminated water. It has been noted that 63% of child deaths caused by disease could have been prevented by implementing known and effective interventions, such as vaccines (Bryce et al., 2003). However, many poor and middle-income African countries have unacceptably low accessibility to these essential health resources (Bryce et al., 2003). Thus, it is imperative for researchers to develop feasible health promotion interventions that align with the health-system development of the countries they are aiming to help (Bryce et al., 2003). For example, initiatives could focus on collecting data at the community level to assist and inform public health planning in an attempt to promote widespread accessibility to known and effective interventions such as condoms, water filters, and vaccines (Bryce et al., 2003). Therefore, one plausible direction for future health initiatives would involve a shift in focus away from medical services in hospitals and clinics towards community-based approaches, particularly in countries where the overall access to public health services is poor or non-existent. One example of a preventative, educational approach to health promotion that also can provide tangible resources involves the use of sport. Sport for development initiatives, which use sport as a vehicle to promote positive social change, have become increasingly popular in recent years (Schulenkorf, Sherry, & Rowe, 2016). Specifically, sport for development programs use the popularity of sport to attract large groups of individuals, and use sport-related themes to discuss and initiate positive development (Jones et al., 2017; Schulenkorf et al., 2016). Previous researchers have used sport as a platform to achieve a broad range of positive outcomes for individuals and communities, including disease management and prevention, improved physical and mental health outcomes, life skills development, gender equity, and social cohesion (Jones et SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 4 al., 2017; Schulenkorf et al., 2016). Based on this approach, sport-based programs have potential to play a significant role in helping at-risk youth navigate their environments. Previous research suggests that participation in sport promotes the development of important life skills such as goal-setting, teamwork, discipline, decision-making, time management, and emotion regulation (Theokas et al., 2008). Life skills that are deliberately taught through sport can steer youth away from various risk-taking behaviors that may lead to lifelong consequences, such as substance abuse, sexual activity, and crime (Kulig, 2003). For instance, sport programs can help youth develop essential life skills such as self-efficacy, confidence to withstand peer pressure, and the ability to develop healthy coping strategies, all of which can significantly reduce the chances of contracting an infectious disease (Balfour et al., 2013; Whitley et al., 2016). A recent review of sport for positive youth development research found that sport involvement was most commonly linked to confidence and positive identity, which may contribute to the avoidance of risk-taking behaviors among at-risk youth (Jones et al., 2017). In addition to protecting against non-communicable diseases through life skills development, previous research also suggests that sport is an advantageous platform to educate youth about common infectious diseases and essential health practices as well (Fuller et al., 2010; Kaufman, Spencer, & Ross, 2013). Considering the inherent physical, mental, and social benefits that are associated with playing sport, sport for development initiatives have significant potential to help at-risk youth in Africa (Jones et al., 2017). Instead of physical activity, children and adolescents often engage in maladaptive and self-destructive behaviors such as substance abuse and petty crime, which are often accompanied by unemployment and poverty (Draper et al., 2010; Uys et al., 2016). Using sport as a health promotion platform could also encourage youth to engage in positive and SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 5 adaptive behaviors with their peers while also being physically active (Schulenkorf et al., 2016). For instance, individuals who are involved in a sport-based health promotion initiative may be more likely to play sport in their spare time instead of engaging in risky behaviors such as substance abuse or crime. It has also been well established that exercise and other forms of physical activity can reduce risk factors associated with obesity, diabetes, and cardiovascular disease (Booth, Gordon, Carlson, & Hamilton, 2000; Pedersen, 2006). Therefore, using a health promotion program that engages youth in physical activity can reduce the risks of developing non-communicable diseases through physical activity as well as promote the development of adaptive life skills. Given the worrying statistics regarding infectious diseases in Africa, researchers have also explored using sport for development initiatives to provide youth with resources to protect themselves against infectious diseases such as HIV and malaria (Fuller et al., 2010). The results of a recent systematic review found strong evidence that sport-based health promotion interventions can positively influence HIV-related knowledge, attitudes, stigma, self-efficacy, and communication skills with children and youth in Africa (Kaufman et al., 2013). Although it is unclear how long these improvements are sustained beyond the intervention, it is evident that sport-based initiatives can be effective in educating youth in Africa about infectious diseases and equipping them with protective skills and resources (Kaufman et al., 2013). Although improving national health systems should be the ultimate goal to reduce rates of child mortality, small-scale community-based interventions have been successful in improving overall and disease-specific health knowledge and awareness for children, adolescents, and adults (Balfour et al., 2013; Clark et al., 2006; Fuller et al., 2010; 2011; 2015; Maro, Roberts, & Sørensen, 2009). For instance, three studies used soccer as a platform to educate 5,128 youth SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 6 participants about various infectious diseases, the use of clean water, safe sex, basic sanitary health practices, getting vaccinated, taking prescribed medications, and nutrition (Fuller et al., 2010; 2011; 2015). Following the sport-based interventions, participants’ mean health knowledge scores were 14.3% higher in South Africa, 18.4% higher in Zimbabwe, and 17.8% higher in Mauritius, which highlights the effectiveness of these programs in improving the health awareness and knowledge among children in rural, low-income communities (Fuller et al., 2010; 2011). In the study conducted by Fuller et al. (2015), participants’ mean health knowledge scores following the sport-based intervention were 25.1% higher in Ghana, 10.3% higher in Malawi, 27.4% higher in Namibia, 15.1% higher in Tanzania, and 17.2% higher in Zambia. Furthermore, it has been noted that the use of sport at schools in South Africa can provide a safe place for students to learn and participate in organized activities (Struthers, 2011). The use of sport is an innovative and fun way to promote positive and sustainable health changes with potentially large numbers of youth in communities throughout Africa. Future research that targets the use of soccer and other types of sport as platforms to educate children about essential health practices warrants further exploration. As discussed, previous research suggests that the use of sport as a platform to educate children and adolescents can be a successful vehicle for improving health and disease-specific knowledge among children and youth in many African countries. Based on the observed improvements in health knowledge among youth participants following sport-based health promotion interventions, it is worth investigating the use of sport as a platform for health promotion in a more systematic manner. As this body of research continues to expand, it is important to analyze and synthesize effective components of previous interventions to inform future efforts. A close analysis of the long-term sustainability of these types of programs, SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 7 theoretical considerations, how these interventions were delivered and by whom, and other aspects of the interventions (e.g., gender) could inform future efforts that maximize impact with limited resources. Scoping reviews are ideally suited to address these issues because they provide researchers with a descriptive analysis about the breadth and the depth of a research field and provide justification for future systematic and quantitative reviews (Levac, Colquhoun, & O'Brien, 2010). Although there have been several attempts to promote necessary public health practices that could significantly reduce the high rates of child mortality in Africa, a structured synthesis of this literature could guide future interventions. This is particularly true for rural areas and communities where public health services are hard to access (Bryce et al., 2003). Considering the urgent need for effective interventions to improve rates of child mortality in Africa, a detailed review of the effectiveness of previous health promotion interventions using sport as a delivery mechanism would be helpful for directing future research endeavors in this domain. Specifically, the primary aim of this scoping review is to provide a detailed summary of the measured outcomes observed in previous studies that investigated the use of sport as a platform for health promotion with youth in Africa. Secondary purposes are to identify characteristics of interventions related to the length, nature, content, and methods employed in previous sport based interventions targeting children and youth in Africa. A third purpose was to conduct a risk of bias assessment to thoroughly analyze the methodologies employed in each intervention (Sterne et al., 2016). Finally, to increase the translational utility or practical impact of this study, the major findings will be presented to practitioners in the field for their feedback. Method Overview SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 8 In line with recommendations by Levac et al. (2010), the steps for the current scoping review included the following: (1) identification of the research question; (2) identification of relevant studies; (3) study selection; (4) charting of the data; (5) data synthesis; and (6) consultation with practitioners (e.g., coaches and staff members of sport-based non-profit organizations in Africa). Additionally, the first author independently coded each article included in our review for Risk of Bias using the ROBINS-I tool for assessing risk of bias in non randomized studies of interventions (Sterne et al., 2016). Study Identification and Data Sources Citations were retrieved from ten electronic bibliographic databases (Academic Search Complete, CINAHL, eHRAF, ERIC, Google Scholar, Physical Education Index, PsycInfo, PubMed, SportDiscus, and Web of Science). Keywords included sport, health promotion, Africa, youth, children, adolescents, youth development, disease, community, mortality, and intervention. A range of health terms and disease processes including HIV, AIDS, malaria, and clean water were included in this search, and relevant Medical Subject Headings (MeSH) terms were included. MeSH terms contain all relevant search terms identified by the United States National Library of Medicine’s thesaurus (USNLM, 1999). All searches were conducted in consultation with a West Virginia University Librarian in order to identify all appropriate databases and ensure the use of relevant MeSH terms. Studies were not bound by a specific date range in order to gain a comprehensive assessment of sport-based interventions targeting health promotion outcomes among youth in Africa. Identification and Selection of Relevant Studies For purpose one of the scoping review, the inclusion criteria included the following: (1) the use of sport as the intervention method; (2) the study being conducted in Africa; (3) youth SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 9 participants 24 years of age or younger, or families that included individuals that were 24 years old or younger; (4) pre/post measurements conducted before and following an intervention, and (5) publications in English. Studies were selected by the first author and were reviewed in consultation with the senior investigator. Data Charting and Synthesis To address the second purpose of this study we focused on articles that included sport based interventions. A codebook was developed by the first author which is shown in Appendix D. Variables included the following: (1) study author(s); (2) journal publication and year; (3) study design; (4) study outcomes; (5) country in Africa where study was conducted; (6) total sample size; (7) number of completers; (8) age range and mean age of participants; (9) participant gender; (10) setting of intervention; (11) duration of study; (12) theoretical foundation of interventions; and (13) source of funding. The first author independently coded, with input from the second author, all studies that met our review’s inclusion criteria. Study outcomes were charted and synthesized in three steps. First, the first author read each abstract and documented the outcomes being investigated from terms used in the study titles, abstracts, and key words. This process allowed the first author to observe thematic similarities in measured outcomes across studies which led to the development of a coding template. This template was used in a second round of coding by the first author to qualitatively describe the outcomes observed. A list of outcomes was developed by the first author in consultation with the senior investigator and each outcome was given a dummy code. The outcome frequencies were then calculated among all the included studies using the frequency command in IBM's Statistical Package for the Social Sciences (IBM SPSS). SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 10 Levac and colleagues (2010) suggest that scoping reviews are ideally suited to map the range, extent, and nature of previous research initiatives, and they may inform future research endeavors, including quantitative reviews. Importantly, scoping reviews differ from systematic reviews in the wider breadth of research questions that can be addressed as well as an emphasis on the narrative integration of extant research evidence (Levac et al., 2010). Given that the use of sport-based health promotion interventions with youth in Africa is a relatively new line of research with a clear scope of inquiry and a broad range of research questions, scoping reviews are ideally suited to review existing research regarding the use of sport-based interventions targeting health promotion outcomes for children and youth in Africa (Levac et al., 2010). Risk of Bias All articles were coded for risk of bias using the ROBINS-I tool for assessing risk of bias in non-randomized studies of interventions (Sterne et al., 2016). The ROBINS-I tool was developed over a three-year period by methodological experts and systematic review authors and editors (Sterne et al., 2016). The ROBINS-I tool allows for a comprehensive analysis of risk of bias in relation to a hypothetical randomized control trial, and the categories for risk of bias assessments are low risk, moderate risk, serious risk, and critical risk. If an article does not provide sufficient information to receive a risk of bias rating, it should be coded as no information (Sterne et al., 2016). In addition to addressing important confounding domains and co-interventions, the ROBINS-I tool asks a series of signaling questions across seven domains of bias; baseline confounding, selection of participants into the study, classification of interventions, deviations from the intended intervention, missing data, measurement of outcomes, and selection of the reported result (Sterne et al., 2016). Importantly, the judgments made for each of these seven domains of bias carry forward to an overall risk of bias for the SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 11 study. For example, if a study is deemed to have a moderate risk of bias in six domains and a high risk of bias in the seventh domain, then the article would be considered as high risk of bias. To receive a low risk rating, the risk of bias should be similar to that of a high quality randomized control trial (Sterne et al., 2016). Therefore, most non-randomized control trials are likely to earn a rating of at least a moderate risk of bias. Consultation with Practitioners The sixth and final step of scoping review methodologies is to incorporate consultation with relevant stakeholders to acquire additional insight beyond what is available in published literature (Levac et al., 2010). The first author contacted Grassroot Soccer, which is a non-profit organization that uses soccer to build resiliency in children and adolescents to help protect against the infection of HIV and other infectious diseases (Peacock-Villada, DeCelles, & Banda, 2007). The researchers created an anonymous survey on Qualtrics with a brief description of our preliminary findings and the following questions: (1) What is your role at Grassroot Soccer? (2) What is your gender?; (3) How many years of experience do you have working in Africa?; (4) Please share your general thoughts or observations about these research findings. What stands out to you?; (5) What steps could be taken to help sport-based health promotion?; and (6) What would you like to see in future sport-based health promotion interventions? An anonymous survey link was sent via email to staff members and coaches at Grassroot Soccer working in South Africa, Zambia, and Zimbabwe. Results from this survey were synthesized and exemplar quotations are presented to highlight the potential contributions of sport in future health promotion efforts. SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 12 Results A total of 916 articles were collected and screened for eligibility. The initial comprehensive database search yielded 322 duplicate publications, and a total of 594 articles remained after these were identified and removed. Following the removal of duplicate articles, the first author screened 540 titles and abstracts of the remaining search results to determine if they met the inclusion criteria for our review. Full texts of the remaining 54 articles were evaluated by the first author. Following this final review process, a total of 28 articles were deemed to meet the study’s eligibility criteria. If there was uncertainty about the eligibility of a specific article based on title and abstract alone, the first author obtained and evaluated a full text of the paper. A PRISMA flow diagram of this process is shown in Figure 1 that summarizes reasons for inclusion/exclusion throughout the review process. Outcomes Specific outcomes of each of the 28 articles that met inclusion criteria for this review are included in Table 1. Targeted outcome variables examined in these studies included HIV-related outcomes (n = 8); knowledge and awareness of nine essential health behaviors (physical activity, clean water use, proper sanitation practices, substance abuse, nutrition, malaria prevention, vaccinations, taking prescribed medications, HIV awareness, gender equality, and social support (n = 3); physical fitness (n = 9); physical activity levels (n = 6); social protective factors (n = 3); physical health (n = 4); mental health (n = 1); and injury prevention (n = 2). A total of 36 outcomes were examined in this review. The countries where each intervention was conducted are included in Table 1. Over half of the interventions included in this review were conducted in South Africa (n = 18). Other African countries Mauritius (n = 1), Namibia (n = 1), Nigeria (n = 1), Uganda (n = 1), SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 13 Identification Screening Eligibility Included Figure 1: PRISMA 2009 Flow Diagram Records identified through database searching (n=916) Records after duplicates removed (n=594) Assessment of titles and abstracts (n=594) Full-text articles assessed for eligibility (n=54) Studies included in qualitative synthesis (n=28) Articles excluded with reasons (n=540) Did not include sport (n=86) Did not include an intervention (n=360) Study was not conducted in Africa (n=21) Study did not include health promotion (n=12) Study did not include youth participants (n=61) Full-text articles excluded with reasons (n=26) Did not include sport (n=2) Did not include an intervention (n=11) Study was not conducted in Africa (n=2) Study did not include health promotion (n=4) Study did not include youth participants (n=7) SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 14 Zambia (n = 2), and multiple (n = 5). Eleven of 28 studies reported using specific theoretical frameworks to guide their efforts as shown in Table 1. These theories included Achievement Goal Theory (n = 3), Social Learning Theory (n = 3), the Social-Ecological Model (n = 2), Self Determination Theory (n = 1), the Theory of Planned Behavior (n = 1), and Psychosocial Theory (n = 1). The authors of the remaining 17 articles did not explicitly mention incorporating a theoretical foundation into their interventions. Contextual Considerations Additional contextual considerations for the studies included in our review are included in Table 2. Fifteen of the 28 interventions were conducted with youth in a school setting either as part of the existing school curriculum or immediately after school (See Table 2). Twelve interventions were conducted in community settings such as gyms, sporting venues, and health centers. One intervention included both in-school and community-based components (See Table 2). The majority of interventions were delivered by individuals from the community in which the research initiative took place who were trained in the intervention protocol. Specifically, trained peer coaches (n = 12), trained athletic coaches (n = 2), trained school staff members (n = 4), professional soccer players (n = 1), university students (n = 3), fitness trainers (n = 1), untrained teachers (n = 1), and principal investigators (n = 2) delivered the intervention to program participants (See Table 2). Two articles did not report who administered the intervention to participants. Based on the information provided in Table 2, the average sample size across all the interventions was 704 participants. There was an average of 199 dropouts across the interventions, leaving an average of 505 participants who completed the intervention. Of SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 15 Table 1. Results in selected studies Authors Outcomes Measured Country Theoretical Foundation Results Fuller et al. (2010) Fuller et al. (2011) Fuller et al. (2015) Clark et al. (2006) Maro et al. (2009) Maro & Roberts (2012) Hershow et al. (2015) Sørensen et al. (2016) Awotidebe et al. (2014) Bloemhoff (2006) Bloemhoff (2012) Nine essential health practices Nine essential health practices Nine essential health practices HIV/AIDS knowledge + stigma; awareness of local resources HIV prevention knowledge, attitudes, and awareness Effect of mastery motivational climate on HIV prevention, knowledge, and awareness HIV/AIDS knowledge, attitudes, communication skills, and HCT uptake Gender differences in HIV/AIDS prevention, knowledge, and awareness HIV knowledge and communication skills Resiliency and protective factors Resiliency and protective factors None None None Social Learning Theory Achievement Goal Theory Achievement Goal Theory Social Learning Theory Achievement Goal Theory Theory of Planned Behavior None None South Africa Mauritius and Zimbabwe Ghana, Malawi, Namibia, Tanzania, Zambia Zimbabwe Tanzania Tanzania South Africa Tanzania South Africa South Africa South Africa Significant improvements in knowledge of all measured outcomes Significant improvements in knowledge of all measured outcomes Significant improvements in knowledge of all measured outcomes Significant improvements in HIV/AIDS knowledge Significant improvement in HIV knowledge and awareness No significant improvement in measured outcomes due to mastery motivational climate Significant Improvements in all measured outcomes No significant differences in measured outcomes between boys and girls Significant improvements in HIV knowledge and negotiation skills Significant improvements in all measured outcomes Significant improvements in all measured outcomes SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 16 Table 1 Cont. Results in selected studies Authors Outcomes Measured Country Theoretical Foundation Results Kaufman et al. (2016) Voluntary Medical Male Circumcision (VMMC) uptake Chetty & Edwards (2007) Mental health promotion (self-esteem, depressive symptoms, behavioral problems) Ferguson et al. (2015) Motor skills, fitness Lennox & Pienaar (2013) Aerobic fitness; PA levels Monyeki et al. (2012) Naidoo et al. (2009) Body composition PA levels; sport participation; fitness tests; nutrition Naidoo & Coopoo (2012) PA levels; sport participation; fitness tests Owoeye et al. (2014) Parker et al. (2016) Richards et al. (2014) Injuries; injuries by type of exposure; injuries to lower extremities Pain severity; pain interference; self-efficacy; depression; quality of life Physical fitness; body composition; mental health Social Learning Theory Psychosocial Theory Social Ecological Model None None None None None None None Zimbabwe South Africa South Africa South Africa South Africa South Africa South Africa Nigeria South Africa Uganda Significant increase in VMMC uptake among participants Significant improvements in self esteem and physical self-perception; significant reduction behavioral problems Significant improvements in all measured outcomes No significant improvements in all measured outcomes No significant improvements in intervention condition Significant improvements in health behaviors and PA at school Significant improvements in all measured outcomes Significant reduction in all measured outcomes for participants’ in the intervention condition Significant reduction in pain for both conditions Significant improvements in cardiovascular fitness for both conditions; Significant decrease in positive mental health outcomes for boys SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 17 Table 1 Cont. Results in selected studies Authors Outcomes Measured Country Theoretical Foundation Results Starzak et al. (2016) Tian et al. (2017) Ley et al. (2014) Kemp & Pienaar (2009) Uys et al. (2016) Walter (2014) Peacock-Villada et al. (2007) Saliva tests for mucosal immunity and SNS activation; body composition; cardiovascular fitness PA levels Strength; cardiovascular fitness; weight; BMI Fitness outcomes; body composition PA levels; PA knowledge; fitness tests PA levels during school Resiliency; Decision making skills None Self Determination Theory None None Social Ecological Model None None South Africa South Africa South Africa South Africa South Africa South Africa South Africa; Zambia Significant improvements in measured salivary and fitness outcomes, significant reduction in BMI, body fat %, and waist circumference Significant improvements in MVPA Significant improvements in strength, no significant improvements in cardio fitness, BMI, weight Significant improvements in all measured outcomes Significant improvements in PA knowledge and fitness test outcomes, no significant improvement in PA levels Significant improvements in MVPA levels among participants Significant improvements in all measured outcomes SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 18 these 505 participants, an average of 280 participants were males and 225 were females. Additionally, the average age of participants across the included interventions was 14.08 years. Lastly, the average sport-based health promotion intervention included in our review lasted 21.23 weeks. Funding Of the 28 articles included in our review, 22 reported receiving funding for their intervention (Awotidebe et al., 2014; Chetty & Edwards, 2007; Clark et al., 2006; Ferguson et al., 2015; Fuller et al., 2010; 2011; 2015; Hershow et al., 2015; Kaufman et al., 2016; Kemp & Pienaar, 2009; Ley, Leach, Barrio, & Bassett, 2014; Maro et al., 2009; Maro & Roberts, 2012; Monyeki et al., 2012; Naidoo & Coopoo, 2012; Naidoo et al., 2009; Parker, Jelsma, & Stein, 2016; Richards Foster, Townsend, & Bauman, 2014; Sørensen et al., 2016; Starzak, Konkol, & McKune, 2016; Uys et al., 2016; Walter, 2014). Funding sources included FIFA (n = 3 articles), the International Development Research Center, Ottawa, Canada (n = 1 article), the Bill and Melinda Gates Foundation (n = 1 article), EMIMA Kicking AIDS Out Program (n = 3 articles), VLIR (n = 1 article), 3ie (n = 1 article), South African National Research Foundation (n = 1 article), University of Cape Town Research Committee (n = 1 article), Universidad Politécnica de Madrid (n = 1 article), the National Research Foundation (n = 2 articles), KwaZulu-Natal Department of Health and Education (n = 2 articles), the Dphil Scholarship: University of Oxford (n = 1 article), the Medical Research Council of South Africa (n = 1 article), the World Diabetes Foundation (n = 1 article), and the Nelson Mandela Metropolitan University (n = 1 article). One article mentioned receiving four sources of funding, including Imago Dei, the Elton SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 19 Table 2. Contextual Considerations Authors Setting Sport Personnel Sample Size Completed Age Gender Duration (Weeks) Fuller et al. (2010) School Soccer Trained peer coaches 492 370 13.3 M: 180 F: 190 11 Fuller et al. (2011) School + Community Soccer Trained peer coaches 822 784 12.3 M: 390 F: 394 11 Fuller et al. (2015) School Soccer Trained peer coaches 3,814 3,814 12.4 M:1873 F:1941 11 Clark et al. (2006) School Soccer Professional soccer players 304 304 12-14 M:151 F:153 2 Maro et al. (2009) Community Soccer Peer coaches 950 764 13.7 M:555 F:209 8 Maro & Roberts (2012) Community Soccer Peer coaches 950 764 13.7 M:555 F:209 8 Hershow et al. (2015) Community Soccer Peer coaches 4260 514 14.2 M:0 F:514 48 Sørensen et al. (2016) Community Soccer Peer coaches 950 764 13.7 M:555 F:209 8 Awotidebe et al. (2014) School Soccer Peer coaches 430 340 15.2 M:204 F:226 12 Bloemhoff (2006) Ropes Course Ropes Course Researcher 106 106 15.7 M:106 F:0 0 (4 hours) Bloemhoff (2012) Ropes Course Ropes Course Researcher 92 67 16.8 M:0 F:67 0 (4 hours) Kaufman et al. (2016) School Soccer Trained peer coaches 1226 878 16.2 M:1226 F:0 0 (1 hour) Chetty & Edwards (2007) Children’s Institutional Homes Soccer and Netball Unknown 33 33 10.7 M: 14 F: 19 12 Ferguson et al. (2015) School Playground games Undergraduate students 41 41 7.8 M: 18 F: 23 9 Lennox & Pienaar (2013) School Aerobic, strength, flexibility, sports (soccer and netball) Postgraduate students 318 279 14.5 M: 137 F: 181 26 SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 20 Table 2 Cont. Contextual Considerations Authors Setting Sport Personnel Sample Size Completed Age Gender Duration (Weeks) Monyeki et al. (2012) School Strength, speed, balance, stretching PE teacher 322 322 10.7 M: 322 F:0 43 Naidoo et al. (2009) School Active learning during school Trained teachers 256 185 Not reported M: 81 F: 104 26 Naidoo & Coopoo (2012) School Active learning during school Trained teachers 798 270 Not reported M: 147 F: 123 78 Owoeye et al. (2014) Sports’ field Warm-up activities Trained soccer coaches 416 385 17.7 M: 385 F:0 26 Parker et al. (2016) Community health center Aerobic and strength exercises Trained peer leaders 27 27 30.8 M: 0 F: 27 6 Richards et al. (2014) Community sports’ fields Soccer Trained peer coaches 1462 1447 12.9 M: 618 F:844 11 Starzak et al. (2016) Community sports’ fields Soccer Trained soccer coaches 50 34 12.2 M: 34 F:0 12 Tian et al. (2017) School Aerobic exercise (including soccer), strength training Trained PE teachers 110 Not reported Not reported M: 33 F: 77 12 Ley et al. (2014) Community gym Aerobic exercise, strength training, stretching Fitness trainers 50 23 30 M: 3 F:20 10 Kemp & Pienaar (2009) School Dancing, stretching Not reported 38 38 12.5 M:0 F: 38 10 Uys et al. (2016) School No prescribed activities Trained school staff 1088 997 9.9 M: 471 F: 526 156 Walter (2014) School Games, playground materials, sport equipment (soccer, rugby, netball) University students 120 79 10.3 M: 38 F:41 6 Peacock Villada et al. (2007) School Soccer Trained peer coaches 670 Not reported Not reported Not reported 6 SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 21 John AIDS Foundation, the MAC AIDS Fund, and the USAID-New Partners Initiative (Hershow et al., 2015). Lastly, one intervention stated that they used the 3rd author’s own research funding to finance their intervention (Starzak et al., 2016). Risk of Bias Ratings of risk of bias for each article were conducted by the first author. The final risk of bias ratings for each of the 28 interventions are reported in Table 3. Ten articles were deemed to be at critical risk of bias, thirteen articles were considered serious risk of bias, four articles were rated as moderate risk of bias, and one article was rated as no information (See Table 3). Most of the ratings of serious risk and critical risk resulted from the interventions missing a significant amount of participant data due to exclusion or attrition. Other reasons for ratings of serious or critical risk of bias were due to baseline confounding, lack of blinding of participants’ intervention status to researchers during the intervention, different start and follow-up times among participants, interventions not being classified appropriately, bias in the measurement of the outcome(s), and bias in terms of selecting the results that were reported. The article that received a rating of no information did not report sufficient information to make a risk of bias judgement. Practitioner Feedback Finally, in order to increase the translational utility and practical impact of the major findings presented above, five coaches and staff members employed by Grassroot Soccer responded to our survey and offered feedback on our findings. The five survey respondents included three females and two males with an average of 3.75 years of experience working with the organization. When asked to provide feedback on our results regarding the use of sport for health promotion with children and youth in Africa participants provided the following SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 22 responses: “I would confirm the outcomes are quite true, it’s something that’s on the ground. To me what stands out is ‘improving social protective factors such as resiliency and ability to cope with peer pressure.’” Another participant discussed how sport can be an effective teaching tool, stating “sport is a good tool for learning if you use it for demonstration of activities...What stands out is educating young people on matters that affect them using the power of soccer…Young people find it fun, exciting, and interactive.” Lastly, one Grassroot Soccer staff member highlighted the impact of sport-based interventions with regards to HIV and AIDS Table 3. Risk of bias Article ROB1 ROB2 ROB3 ROB4 ROB5 ROB6 ROB7 ROBoverall Awotidebe et al. (2014) Serious Mod Mod Serious Mod Mod Serious Serious Bloemhoff (2006) Serious Mod Mod NI Mod Serious Mod Serious Bloemhoff (2012) Mod Mod Mod NI Serious Serious Mod Serious Chetty & Edwards (2007) Mod Mod Mod NI Mod Mod Mod Mod Clark et al. (2006) Serious Mod Mod NI Mod Serious Mod Serious Ferguson et al. (2015) Mod Mod Mod NI Serious Mod Mod Serious Fuller et al. (2010) Serious Serious Mod NI Critical Mod NI Critical Fuller et al. (2011) Serious Serious Mod Mod Serious Mod Mod Serious Fuller et al. (2015) Serious Serious Mod Mod Serious Mod Mod Serious Hershow et al. (2015) Serious Serious Serious Mod NI Serious Mod Serious Kaufman et al. (2016) Mod Mod Mod NI Mod Mod Mod Mod Kemp & Pienaar (2009) Mod Mod Serious NI Low Serious Mod Serious Lennox & Pienaar (2013) Serious Mod Serious Critical Serious Serious Mod Critical Ley et al. (2014) Serious Mod Serious NI Mod Mod Serious Serious Maro et al. (2009) Low Mod Mod NI Critical Mod Serious Critical Maro & Roberts (2012) Low Mod Mod NI Critical Mod Critical Critical Monyeki et al. (2012) Serious Mod Mod NI NI Serious Mod Serious Naidoo & Coopoo (2012) Serious Mod Mod Serious Critical Serious Mod Critical Naidoo et al. (2009) Serious Mod Mod NI Critical Serious Mod Critical Owoeye et al. (2014) Mod Mod Mod NI Low Serious Mod Serious Parker et al. (2016) Low Low Low NI Low Mod Mod Mod Peacock-Villada et al. (2007) NI NI NI NI NI NI NI NI Richards et al. (2014) Low Low Mod NI Mod Mod Mod Mod Sorensen et al. (2016) Low Mod Mod NI Critical Mod Critical Critical Starzak et al. (2016) Serious Mod Critical NI Critical Serious Mod Critical Tian et al. (2017) Serious Mod Mod NI Low Critical Mod Critical Uys et al. (2016) Mod Serious Mod NI Mod Serious Mod Serious Walter (2014) Serious Mod Serious NI Critical Serious Mod Critical Note: ROB1) Bias due to confounding; ROB2) Bias in selection of participants; ROB3) Bias in classification of interventions; ROB4) Bias due to deviations from intended interventions; ROB5) Bias due to missing data; ROB6) Bias in measurement of outcomes; ROB7) Bias in selection of reported result SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 23 prevention with youth, stating “HIV-related outcomes…stand out because sport is playing a huge role in reducing new HIV infections and also changing attitudes and knowledge of beneficiaries. This [suggests] that sport-based education involves everyone even in the hard to reach areas.” When asked what steps could be taken to help sport-based health promotion, one participant reported: “increase its buy-in in all societies by engaging all communities. Engage key stakeholders and ministries. Make sport education an ongoing process not a once off event in societies.” A second participant discussed the potential role that sport can have in strengthening communities: “Support the role of sports in strengthening communities where young people come from—use sport as a vehicle to communicate about priority health matters.” Additionally, a participant stated that they wanted to “advocate for health services through sport-based health activities.” Lastly, participants provided the following responses when asked what they would like to see in future sport-based health promotion initiatives: “A more inclusive way of addressing harmful gender norms that have a large effect on the development of young aspiring female sports players and females in general.” Other participants stated that they would like to see “more stakeholders to come on board and support sport-based health” and “more free health services with sport-based health.” Lastly, one participant shared that they would like to see “increased participation in sport especially for females—increased social connections— increased healthy eating habits—reduce smoking and alcohol intake in young people.” Discussion The results of the present study suggest that sport can be an effective platform for health promotion with children and youth in Africa pending improvements in the methodology of future studies. Statistically significant improvements in health-related outcomes were observed in 23 of the 28 articles that met our study’s inclusion criteria. Targeted health outcomes included HIV SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 24 related knowledge and behaviors, essential health practices, physical activity, physical and mental health outcomes, and overall fitness levels. Considering the broad range of health outcomes in interventions included in this review, our results suggest that sport-based interventions may improve multiple physical and mental health outcomes with youth in Africa. We conducted risk of bias assessments for the included articles to enhance the quality of our review. The results of our risk of bias ratings for the 28 studies included in our review report that ten articles were deemed to be at critical risk of bias, 13 were at serious risk of bias, four were at moderate risk of bias, none of the articles were rated as low risk of bias, and one article was coded as no information. These findings are similar to those of a meta-analysis of sport based HIV prevention interventions, which found that only two of the 21 studies included in their analyses could be considered “good quality” (Kaufman et al., 2013). However, it is important to note that the ROBINS-I tool rating protocol involves comparing each intervention to a hypothetical randomized control trial (Sterne et al., 2016). Considering that many of these interventions were conducted with at-risk youth in low socio-economic communities, strictly adhering to a randomized control trial procedure would have been difficult. Furthermore, it could be argued that using a true control group in health promotion interventions with at-risk children is not ethical, as it requires researchers to not administer a potentially life-saving program to a group of youths. Ethical issues notwithstanding, future researchers should target conducting more scientifically rigorous studies to gain a more comprehensive understanding of how, why, and under what circumstances sport-based health promotion interventions are successful to maximize and sustain impact with limited resources. Bearing in mind the above methodological considerations in the reviewed studies, participants in this review demonstrated statistically significant improvements in HIV-related SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 25 outcomes (Awotidebe et al., 2014; Clark et al., 2006; Hershow et al., 2015; Kaufman et al., 2016; Maro & Roberts, 2012; Maro et al., 2009; Peacock-Villada et al., 2007; Sørensen et al., 2016). Specific HIV-related outcomes included knowledge and attitudes (Awotidebe et al., 2014; Clark et al., 2006; Hershow et al., 2015; Maro & Roberts, 2012; Maro et al., 2009; Sørensen et al., 2016), communication skills (Awotidebe et al., 2014; Hershow et al., 2015; Peacock-Villada et al., 2007), awareness of local preventative resources and treatment facilities (Clark et al., 2006; Hershow et al., 2015; Kaufman et al., 2016), and uptake of preventative treatments (Hershow et al., 2015; Kaufman et al., 2016). Therefore, our results support the findings of a recent meta analysis of 21 sport-based HIV-prevention initiatives that found strong evidence of positive effects with regards to HIV-related knowledge, stigma, self-efficacy, communication, and recent condom use (Kaufman et al., 2013). To our knowledge, our review is the first to suggest that sport-based health promotion interventions can significantly improve the uptake of HIV prevention and treatment procedures. Participants in two interventions included in our review demonstrated statistically significant improvements in the uptake of HIV-related services. Specifically, one soccer-based intervention led to a significant increase in HIV counseling and testing (HCT) services among adolescent girls in South Africa (Hershow et al., 2015). Another soccer-based intervention led to a statistically significant increase in voluntary medical male circumcision (VMMC) uptake among a group of adolescent males in Zimbabwe (Kaufman et al., 2016). Taken together, the results of these studies suggest that sport-based health promotion initiatives can be effective in promoting the uptake of HIV-related prevention services among children and youth in Africa. However, additional research is warranted to provide further evidence of this relationship. SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 26 One common theme among the sport-based interventions included in our review that targeted HIV-related outcomes and essential health knowledge is that they were conducted in collaboration with existing non-profit organizations (Awotidebe et al., 2014; Clark et al., 2006; Delva & Temmerman, 2006; Fuller et al., 2010; 2011; 2015; Hershow et al., 2015; Kaufman et al., 2016; Maro et al., 2009; Peacock-Villada et al., 2007). Specifically, eight studies included in our review were administered in collaboration with Grassroot Soccer, which uses a sport-based teaching model to build resilience in children and youth to help protect themselves against HIV (Peacock-Villada et al., 2007). Based on the promising results of each intervention, partnering with existing non-profit organizations is a promising avenue for future researchers, as the organizations’ knowledge and experience can enhance the development and implementation of effective sport-based health promotion interventions targeting children and youth in Africa. Furthermore, collaborating non-profit organizations can have experienced staff members conduct the intervention or provide comprehensive training sessions for the individuals who will administer the interventions to participants (Fuller et al., 2010; 2011; 2015). As part of these partnerships, Grassroot Soccer and other non-governmental organizations have increasingly utilized peer-led interventions with HIV-prevention initiatives in Africa, and the results have been promising (Maticka-Tyndale & Barnett, 2010). This approach is based on the assumption that adolescents rely on their peers to learn from and model their behavior after, and norms and behaviors are most likely to change when those of the group change (Campbell, 2004; Maticka-Tyndale & Barnett, 2010). In our review, trained peer-leaders or peer coaches were used to deliver a sport-based intervention in eleven of the articles. Participants in each study that utilized peer-coaches to deliver the intervention demonstrated statistically significant improvements in HIV-related outcomes (Awotidebe et al., 2014; Fuller et SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 27 al., 2010; 2011; 2015; Hershow et al., 2015; Kaufman et al., 2016; Maro & Roberts, 2012; Maro et al., 2009; Peacock-Villada et al., 2007; Sørensen et al., 2016), cardiovascular fitness outcomes (Richards et al., 2014), and reductions in pain (Parker et al., 2016). Therefore, our results support the use of trained peer coaches and peer leaders in sport-based interventions with children and youth. Our review also included three studies that used an 11-week soccer-based intervention to improve knowledge and awareness of essential health practices among children and youth from eight different African countries (Fuller et al., 2010; 2011; 2015). Participants in all eight countries demonstrated statistically significant improvements in health knowledge scores from baseline to post-intervention in outcomes related to physical activity, HIV prevention, malaria prevention, substance abuse, personal hygiene, clean water use, nutrition, vaccinations, and prescribed medication usage. These findings suggest that sport-based health promotion interventions that focus on a broad range of health behavior practices may be effective for children and youth in many different African countries. Although additional research is needed, these results speak to the potential generalizability and translational utility that sport-based interventions may have throughout Africa. One critique of previous sport-based health promotion interventions is that there has been an over-emphasis on HIV-related outcomes (Fuller et al., 2015). In our review, 39% of the included articles targeted HIV-related outcomes. Although HIV/AIDS is a public health epidemic, research suggests that rates of HIV/AIDS are much lower in children and adolescents in sub-Saharan Africa compared to adults (Delva & Temmerman, 2006). A recent systematic analysis suggested that HIV was responsible for approximately 8% of child deaths in sub Saharan Africa compared to 25% for neonatal disorders, 22% for malaria, 21% for pneumonia, SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 28 and 20% for diarrhea (Black et al., 2010). However, statistics relating to sub-Saharan Africa may be misleading, as health issues vary from country to country (Black et al., 2010). Therefore, one direction for future sport-based health promotion initiatives is to adapt program structures and protocols so they can address the specific needs of the countries and communities they are hoping to serve. Considering the significant amount of evidence supporting the use of sport based health promotion interventions targeting the prevention and treatment of HIV, additional research is warranted to understand the impact of sport-based health promotion interventions with other diseases and essential health behaviors as well. Sport- and physical activity-based interventions can be used to target other important health topics. For instance, it has been well documented that participation in physical activity and exercise is associated with improved fitness outcomes among youth (Armstrong, Tomkinson, & Ekelund, 2011). Our review included ten articles that investigated the impact of a sport- or physical-activity-based intervention on participants’ fitness levels. Specifically, seven studies resulted in statistically significant improvements, including improved muscular strength and endurance (Ferguson et al., 2015; Kemp & Pienaar, 2009; Ley et al., 2014; Naidoo & Coopoo, 2012; Naidoo et al., 2009), cardiovascular fitness (Ferguson et al., 2015; Kemp & Pienaar, 2009), anaerobic fitness (Ferguson et al., 2015), flexibility (Kemp & Pienaar, 2009; Naidoo & Coopoo, 2012), and lean body mass (Starzak et al., 2016). Two interventions resulted in statistically significant improvements in participants’ fitness levels in both the experimental and control conditions, but no statistically significant differences were found between the conditions at post-intervention (Richards et al., 2014; Uys et al., 2016). One study did not observe statistically significant improvements in participants’ fitness levels following a sport-based intervention, but the researchers hypothesized that this was due to low program compliance from SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 29 participants in their program (Lennox & Pienaar, 2013). Therefore, the results of our review suggest support for the notion that participation in sport and physical activity can enhance multiple fitness outcomes for youth. Additionally, participants in five studies demonstrated statistically significant improvements in physical activity levels (Lennox & Pienaar, 2013; Naidoo & Coopoo, 2012; Naidoo et al., 2009; Tian et al., 2017; Walter, 2014). Only one study found no significant improvements in participants’ physical activity levels, which the researchers hypothesized was due to the structure of the physical activity portion on their intervention (Uys et al., 2016). Physical activity is an inherent component of sport-based health promotion interventions, so it is not surprising that participants in these programs demonstrated higher levels of physical activity throughout the study. However, additional research is needed to determine whether participants’ increased levels of physical activity are sustained beyond the intervention. Aside from the physical benefits derived from physical activity, previous research also suggests that youth participation in sport and exercise may enhance mental health functioning (Kulig, 2003; Theokas et al., 2008). For example, it has been suggested that there is a strong positive relationship between physical activity and positive mental health outcomes with children and adolescents, including decreased symptoms of depression and anxiety and improved levels of self-esteem and cognitive functioning (Biddle & Asare, 2011). Our findings support the notion that sport- and physical activity-based interventions can improve mental health outcomes for children and youth in Africa. Six articles investigated the impact of sport- or physical-activity based interventions on mental health outcomes, and four studies resulted in statistically significant improvements in mental health outcomes among participants. Specifically, sport based interventions were found to be effective in reducing participants’ symptoms of depression SPORT FOR HEALTH PROMOTION WITH YOUTH IN AFRICA 30 and anxiety (Parker et al., 2016) and behavioral problems (Chetty & Edwards, 2007). Sport based interventions also resulted in higher levels of self-efficacy (Parker et al., 2016), self perception (Chetty & Edwards, 2007), and coping skills (Bloemhoff, 2006; 2012; Peacock Villada et al., 2007). Therefore, the results of our review suggest that physical activity and participation in sport can significantly improve several mental health outcomes with children and youth in Africa. In addition to the mental health benefits associated with physical activity, it has also been suggested that youth participation in sport promotes the development of important and adaptive life skills such as discipline, confidence to withstand peer pressure, goal-setting, and the ability to develop healthy coping strategies (Theokas et al., 2008). Engaging at-risk youth in sport can foster the development of essential life skills that may help them avoid risk-taking behaviors that can lead to lifelong consequences such as substance abuse, crime, and sexual activity (Kulig, 2003). Therefore, in addition to improving levels of health knowledge and awareness, there may b