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Nelson LE, Nyblade L, Torpey K, Logie CH, Qian HZ, Manu A, Gyamerah E, Boakye F, Appiah P, Turner D, Stockton M, Abubakari GM, Vlahov D. Multi-level intersectional stigma reduction intervention to increase HIV testing among men who have sex with men in Ghana: Protocol for a cluster randomized controlled trial. PLoS One 2021; 16:e0259324. [PMID: 34843529 PMCID: PMC8629287 DOI: 10.1371/journal.pone.0259324] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/12/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Men with have sex with men (MSM) in Africa face high levels of stigma due to elevated HIV exposure (actual or perceived), same-sex practices, and gender non-conformity. These stigmas are documented barriers to HIV prevention and treatment. Most stigma-reduction interventions have focused on single-level targets (e.g., health care facility level [HCF]) and addressed one type of stigma (e.g., HIV), without engaging the multiple intersecting stigmas that MSM encounter. Determining the feasibility and acceptability of multi-level intervention of reducing intersectional stigma and estimating its efficacy on increasing HIV testing are needed. METHODS We proposed a mixed method study among MSM in Ghana. First, we will develop the intervention protocol using the Convergence Framework, which combines three interventions that were previously implemented separately in Ghana for reducing stigma at the HCF-level, increasing HIV testing at the peer group-level, and increasing peer social support at the individual-level. Then, we will conduct a cluster randomized controlled trial with four pairs of HCFs matched on staff size. HCFs within each pair are randomized to the HCF-level stigma-reduction intervention or control arm. MSM (n = 216) will be randomized to receive the group-level and individual-level interventions or standard of care control arm. MSM will be assigned to receive HIV testing at one of the HCFs that match their study assignment (intervention or control facility). The frequency of HIV testing between MSM in the study arms at 3 and 6 months will be compared, and the predictors of HIV testing uptake at the HCF, peer group and individual-levels will be assessed using multi-level regression models. DISCUSSION These findings from this study will provide important evidence to inform a hybrid implementation-effectiveness trial of a public health intervention strategy for increasing HIV case detection among key populations in sub-Saharan African communities. Accurate information on HIV prevalence can facilitate epidemic control through more precise deployment of public health measures aimed at HIV treatment and viral load suppression, which eliminates risk of transmission. TRIAL REGISTRATION This study was prospectively registered on ClinicalTrials.gov, Identifier: NCT04108078, on September 27, 2019.
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Affiliation(s)
- LaRon E. Nelson
- School of Nursing, Yale University, New Haven, CT, United States of America
- Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, CT, United States of America
- Yale Institute for Global Health, School of Public Health, New Haven, CT, United States of America
| | - Laura Nyblade
- RTI International, Washington, DC, United States of America
| | - Kwasi Torpey
- Department of Population, Family & Reproductive Health, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - Carmen H. Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Han-Zhu Qian
- Department of Biostatistics, School of Public Health, Yale University, New Haven, CT, United States of America
| | - Adom Manu
- Department of Population, Family & Reproductive Health, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - Emma Gyamerah
- Educational Assessment & Research Center, Accra, Ghana
| | | | | | - DeAnne Turner
- College of Nursing, University of South Florida, Tampa, FL, United States of America
| | - Melissa Stockton
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, United States of America
| | - Gamji M. Abubakari
- Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, CT, United States of America
| | - David Vlahov
- School of Nursing, Yale University, New Haven, CT, United States of America
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Choi SKY, Holtgrave DR, Bacon J, Kennedy R, Lush J, McGee F, Tomlinson GA, Rourke SB. Economic Evaluation of Community-Based HIV Prevention Programs in Ontario: Evidence of Effectiveness in Reducing HIV Infections and Health Care Costs. AIDS Behav 2016; 20:1143-56. [PMID: 26152607 PMCID: PMC4867003 DOI: 10.1007/s10461-015-1109-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Investments in community-based HIV prevention programs in Ontario over the past two and a half decades are assumed to have had an impact on the HIV epidemic, but they have never been systematically evaluated. To help close this knowledge gap, we conducted a macro-level evaluation of investment in Ontario HIV prevention programs from the payer perspective. Our results showed that, from 1987 to 2011, province-wide community-based programs helped to avert a total of 16,672 HIV infections, saving Ontario's health care system approximately $6.5 billion Canadian dollars (range 4.8-7.5B). We also showed that these community-based HIV programs were cost-saving: from 2005 to 2011, every dollar invested in these programs saved about $5. This study is an important first step in understanding the impact of investing in community-based HIV prevention programs in Ontario and recognizing the impact that these programs have had in reducing HIV infections and health care costs.
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Affiliation(s)
- Stephanie K Y Choi
- The Ontario HIV Treatment Network, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David R Holtgrave
- Department of Health, Behaviour and Society, Bloomberg School of Public Health, John Hopkins University, Baltimore, MD, USA
| | - Jean Bacon
- The Ontario HIV Treatment Network, Toronto, Ontario, Canada
| | - Rick Kennedy
- The Ontario AIDS Network, Toronto, Ontario, Canada
| | - Joanne Lush
- AIDS Bureau, Ontario Ministry of Health and Long-term Care, Toronto, Ontario, Canada
| | - Frank McGee
- AIDS Bureau, Ontario Ministry of Health and Long-term Care, Toronto, Ontario, Canada
| | - George A Tomlinson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Sean B Rourke
- The Ontario HIV Treatment Network, Toronto, Ontario, Canada.
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St., Toronto, Ontario, M5B 1W8, Canada.
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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The Role of Syndemic in Explaining Health Disparities Among Bisexual Men: A Blueprint for a Theoretically Informed Perspective. SOCIAL DISPARITIES IN HEALTH AND HEALTH CARE 2016. [DOI: 10.1007/978-3-319-34004-3_4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Reback CJ, Larkins S. HIV risk behaviors among a sample of heterosexually identified men who occasionally have sex with another male and/or a transwoman. JOURNAL OF SEX RESEARCH 2011; 50:151-163. [PMID: 22206223 DOI: 10.1080/00224499.2011.632101] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Discordance between sexual identity and sexual behavior is not new; however, little is known about the HIV risk behaviors of heterosexually identified men who have occasional sex with a male and/or a male-to-female transgender woman. Open-ended qualitative interviews were conducted with 31 heterosexually identified men who reported at least one sexual encounter with a male and/or a transwoman in the previous 12 months. Sixty-one percent were African American/Black, the mean age was 38.9 years (SD = 8.4), 58.1% reported current substance use, and 58.1% were HIV infected. Among those who had a sexual encounter with a transwoman, the majority (81.3%) were the insertive partner during anal sex. In comparison, among those who had a sexual encounter with a male partner, almost one-half (42.9%) were the receptive partner during anal sex. HIV-infected participants were more likely to use a condom with a biological female partner than with a male or transwoman partner. HIV-uninfected participants reported limited condom use with any partner type, highlighting their potential role in the diffusion of HIV and other sexually transmitted infections. Participants' HIV status, partner type, substance use, and cultural factors influenced sexual decision-making and HIV risk behaviors.
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Affiliation(s)
- Cathy J Reback
- Friends Research Institute, Inc., Los Angeles, CA 90028, USA.
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Frye V, Koblin B, Chin J, Beard J, Blaney S, Halkitis P, Vlahov D, Galea S. Neighborhood-level correlates of consistent condom use among men who have sex with men: a multi-level analysis. AIDS Behav 2010; 14:974-85. [PMID: 18712593 DOI: 10.1007/s10461-008-9438-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Accepted: 07/16/2008] [Indexed: 11/30/2022]
Abstract
There is growing evidence that the neighborhood environment influences sexual behavior and related outcomes, but little work has focused specifically on men who have sex with men (MSM). Using interview data from a probability sample of 385 young MSM living in New York City, recruited at public venues in 1999 and 2000 as part of the Young Men's Survey-New York City, and data on neighborhood characteristics obtained from the U.S. Census 2000, we conducted multi-level analyses of the associations between neighborhood-level characteristics and consistent condom use during anal intercourse, while controlling for individual-level sociodemographic and other factors. After adjusting for individual-level factors, neighborhood-level gay presence remained significantly and positively associated with consistent condom use during anal intercourse. This finding suggests that neighborhoods with a significant gay presence may have norms that act to discourage high risk sexual activity.
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Affiliation(s)
- Victoria Frye
- Urban Public Health Program, Hunter College, City University of New York, New York, USA.
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Lert F, Sitta R, Bouhnik AD, Dray-Spira R, Spire B. HIV-positive men who have sex with men: biography, diversity in lifestyles, common experience of living with HIV. ANRS-EN12 VESPA Study, 2003. AIDS Care 2009; 22:71-80. [DOI: 10.1080/09540120903012544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- France Lert
- a INSERM , U687, 16 avenue Paul Vaillant-Couturier, Hôpital Paul Brousse Bat 15/16, 94807 , Villejuif , France
| | - Rémi Sitta
- a INSERM , U687, 16 avenue Paul Vaillant-Couturier, Hôpital Paul Brousse Bat 15/16, 94807 , Villejuif , France
| | | | - Rosemary Dray-Spira
- a INSERM , U687, 16 avenue Paul Vaillant-Couturier, Hôpital Paul Brousse Bat 15/16, 94807 , Villejuif , France
| | - Bruno Spire
- b INSERM , U912, 23 rue Stanislas Torrents, 13006 , Marseille , France
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Dodge B, Jeffries WL, Sandfort TGM. Beyond the Down Low: sexual risk, protection, and disclosure among at-risk Black men who have sex with both men and women (MSMW). ARCHIVES OF SEXUAL BEHAVIOR 2008; 37:683-96. [PMID: 18512140 PMCID: PMC2566750 DOI: 10.1007/s10508-008-9356-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Little information is available about sexual risk, protective, and disclosure practices among Black bisexually active men and how these may be amenable to intervention when necessary. In-depth interviews were conducted with 30 at-risk urban Black men who have sex with both men and women (MSMW). Participants reported protecting themselves and their partners through routine HIV testing, using condoms consistently, engaging in strategic positioning during sexual activity, and limiting the number of sexual partners. In addition, they described several reasons for not using protection, including not having condoms available, enjoying sexual activity more without condoms, and perceiving female partners to be "safer" than male partners. Disclosure of bisexuality was complex and reportedly difficult, in particular to female and gay-identified male partners. Future interventions must not only build protection and disclosure skills among MSMW, but also increase broader social awareness and acceptance of male bisexuality.
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Affiliation(s)
- Brian Dodge
- Center for Sexual Health Promotion, Department of Applied Health Science, Indiana University, HPER 116, 1025 E. Seventh St., Bloomington, IN 47405-7109, USA.
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Lauby JL, Millett GA, LaPollo AB, Bond L, Murrill CS, Marks G. Sexual risk behaviors of HIV-positive, HIV-negative, and serostatus-unknown Black men who have sex with men and women. ARCHIVES OF SEXUAL BEHAVIOR 2008; 37:708-19. [PMID: 18521734 DOI: 10.1007/s10508-008-9365-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Black men who have sex with men and women (MSMW) are at high risk for HIV infection and transmission. This study compared the sexual risk behaviors of Black MSMW who self-reported being HIV-positive with those who reported being HIV-negative and those who did not know their HIV status. Respondent-driven sampling (RDS) was used to recruit 1,154 Black MSM in Philadelphia and New York who completed an audio computer-assisted self-interview (ACASI). Of these men, 212 had engaged in anal sex with male partners and vaginal or anal sex with female partners in the past 3 months. A quarter (23.6%; n = 50) of MSMW self-reported testing positive for HIV at their last test, 59.4% (n = 126) reported testing negative for HIV at their last test, and 17.0% (n = 36) reported never having an HIV test. Multivariate logistic regression analysis revealed that HIV-positive MSMW were much less likely than HIV-negative men and never-tested men to have engaged in unprotected intercourse with main male and main female partners perceived to be HIV-negative or of unknown serostatus. However, HIV-positive men were equally as likely as HIV-negative men to have unprotected intercourse with non-main male and non-main female partners perceived as HIV-negative or of unknown serostatus. Our findings indicate that some HIV-positive MSMW engage in unprotected sex that places female and male partners at risk for HIV infection. However, MSMW who have never taken an HIV test, or who have not been recently tested, may be a greater source of HIV transmission to their female and male partners.
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Affiliation(s)
- Jennifer L Lauby
- Research and Evaluation, Philadelphia Health Management Corp., 260 S. Broad St., 18th Floor, Philadelphia, PA 19102, USA.
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Benefo KD. Determinants of Zambian men's extra-marital sex: a multi-level analysis. ARCHIVES OF SEXUAL BEHAVIOR 2008; 37:517-529. [PMID: 17999170 DOI: 10.1007/s10508-007-9243-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Revised: 09/13/2006] [Accepted: 05/22/2007] [Indexed: 05/25/2023]
Abstract
Research interest in extra-marital sex has increased as scholars have become aware of its role in sustaining epidemics of STDs in sub-Saharan Africa and elsewhere. While most research has used the socioeconomic and demographic features of individuals as determinants of extra-marital sexual behavior, this study examined the role played by community characteristics. Using data from the 2003 Zambian Sexual Behavior Survey for a sample of 1,118 men aged 15-59 and multilevel logistic regression techniques, the study analyzed the effects of community social and demographic characteristics on involvement in extra-marital sex while controlling for the men's individual-level characteristics. Men's involvement in extra-marital sex was found to vary with the characteristics of communities. The chances of men's involvement in extra-marital sex increased with community-level ethnic heterogeneity and urbanization, decreased in commercial centers, and in communities with a demographic surplus of males, health workers active in AIDS prevention, and access to the mass media. These results show that scholars trying to understand the motivations for extra-marital sex must pay attention to the characteristics of both individuals and communities.
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Affiliation(s)
- Kofi D Benefo
- Department of Sociology and Social Work, Lehman College, City University of New York, 250 Bedford Park Blvd. West, Bronx, NY 10468-1589, USA.
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Cartagena RG, Veugelers PJ, Kipp W, Magigav K, Laing LM. Effectiveness of an HIV prevention program for secondary school students in Mongolia. J Adolesc Health 2006; 39:925.e9-16. [PMID: 17116526 DOI: 10.1016/j.jadohealth.2006.07.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Revised: 06/14/2006] [Accepted: 07/18/2006] [Indexed: 11/18/2022]
Abstract
PURPOSE To evaluate the effectiveness of a 3-year human immunodeficiency virus (HIV) prevention program for adolescents attending secondary school in Mongolia. METHODS Comparisons of knowledge, attitudes, self-efficacy and safe sex practices of grade 10 students from schools with a peer education prevention program to grade 10 students from schools without the intervention. Peer education programs were launched in 2000 across Mongolia. In 2004, survey data was collected among 720 randomly selected students from eight schools with the peer education prevention program and compared with those of 647 students from eight schools without this intervention. Data was collected in Ulaanbaatar and three Mongolian provinces and analyzed using multilevel regression methods. RESULTS Students of schools with the program were statistically significantly more knowledgeable, had less traditional attitudes, and had greater awareness of their self-efficacy in regards to HIV and sexual health. Students from schools with the peer education program were more likely to practice safe sex, though the difference was not statistically significant. However, safe sex practice was found to be statistically significantly safer in a subset of schools that had small teams of peer educators. CONCLUSION Adolescents in Mongolia are sexually active and at risk for infection with HIV and other STIs. Peer education programs, particularly those that are managed by small teams, appear effective and should be implemented more broadly.
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Affiliation(s)
- Rosario G Cartagena
- Department of Public Health Sciences, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Smith AMA, Subramanian SV. Population contextual associations with heterosexual partner numbers: a multilevel analysis. Sex Transm Infect 2006; 82:250-4; discussion 254. [PMID: 16731679 PMCID: PMC2564749 DOI: 10.1136/sti.2005.018549] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The study examines whether an individual's sexual behaviour is associated with the demographic context within which they live. METHODS Data from a large behavioural survey were matched to the census and the number of opposite sex partners individuals reported having in the year before interview was modelled against a suite of individual characteristics and analogous characteristics for the population in which they lived. RESULTS The number of partners reported (none, one, two, three, or more) were variously associated with an individual's gender, age, marital status, sexual identity, and same sex activity in the previous year. Additionally, population age structure, sex ratio, and the proportion of the population reporting specific patterns of sexual activity were associated with the behaviour of individuals. CONCLUSIONS This study demonstrates that population context is associated with individual behaviour even after individual characteristics have been taken into account. This suggests that multilevel modelling of sexual behaviour data can provide new insights into the pattern of sexual behaviour.
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Affiliation(s)
- A M A Smith
- Australian Research Centre in Sex, Health and Society, La Trobe University, 215 Franklin Street, Melbourne 3000, Australia.
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Taylor SL, Leibowitz A, Simon PA, Grusky O. ZIP code correlates of HIV-testing: a multi-level analysis in Los Angeles. AIDS Behav 2006; 10:579-86. [PMID: 16552623 DOI: 10.1007/s10461-005-9064-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In this study we examine how individuals' residential areas relate to their HIV-testing, regardless of individuals' characteristics. Data from a 1999 random probability sample of Los Angeles (LA) County adults (n = 5475) was used to conduct a multi-level analysis of HIV-testing among respondents in (1) all 233 ZIP codes and (2) the subset of regions with higher rates of higher-risk sex. Results showed that HIV-testing rates varied across individuals' residential ZIP codes. Throughout LA and in higher-risk regions, residents of areas containing concentrations of African Americans were more likely to test for HIV than residents of White or Latino areas, regardless of individuals' own race/ethnicity or the number of AIDS cases or testing sites in ZIP codes. However, residents of Latino areas were no more likely to test than residents of White areas. This is a concern because of increasing rates of HIV-infection among Latinos. We conclude that opportunities exist to increase testing in Latino higher-risk areas.
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Veugelers PJ, Fitzgerald AL. Effectiveness of school programs in preventing childhood obesity: a multilevel comparison. Am J Public Health 2005; 95:432-5. [PMID: 15727972 PMCID: PMC1449197 DOI: 10.2105/ajph.2004.045898] [Citation(s) in RCA: 226] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES In light of the alarming increase in childhood obesity and lack of evidence for the effectiveness of school programs, we studied the effects of school programs in regard to preventing excess body weight. METHODS In 2003, we surveyed 5200 grade 5 students along with their parents and school principals. We measured height and weight, assessed dietary intake, and collected information on physical and sedentary activities. We compared excess body weight, diet, and physical activity across schools with and without nutrition programs using multilevel regression methods while adjusting for gender and socioeconomic characteristics of parents and residential neighborhoods. RESULTS Students from schools participating in a coordinated program that incorporated recommendations for school-based healthy eating programs exhibited significantly lower rates of overweight and obesity, had healthier diets, and reported more physical activities than students from schools without nutrition programs. CONCLUSIONS Our finding that school programs are effective in preventing childhood obesity supports the need for broader implementation of successful programs, which will reduce childhood obesity and, in the longer term, comorbid conditions and health care spending.
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Affiliation(s)
- Paul J Veugelers
- Department of Public Health Sciences, Faculty of Medicine and Dentistry, University of Alberta, Room 13-106D, Clinical Sciences Bldg, Edmonton, Alberta T6G 2G3, Canada.
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