Prevalence of childhood obesity in a representative sample of elementary school children in Puerto Rico by socio-demographic characteristics, 2008.
Objective: Childhood obesity is a worldwide epidemic; its
prevalence has quadrupled in the US among children from 6-11 y/o. In the
US, Hispanic children have a higher prevalence of obesity compared to
non-Hispanic whites. No representative data was available for Puerto
Rican children from first to sixth grades in Puerto Rico or the US. The
aim of this study was to measure the prevalence of childhood obesity
among Puerto Rican children from first to sixth grade by different
socio-demographic characteristics in a sub-urban municipality in Puerto
Methods: A two-stage stratified cluster sampling design was used (n=250). Weights and heights were measured twice to the nearest 0.1 kg and 0.1 cm, respectively. Weight status of children was determined based on the CDC criteria. Chi-square and Fisher tests were used to compare proportions. Simple logistic regressions were used to assess associations with socio-demographic variables.
Results: Nearly half of the students (51.0%) were boys; mean age was 9.5 + 1.9 years. Almost 40% of the children had family monthly incomes under $1,000. Overall childhood obesity prevalence (BMI > 95th percentile) was 26.8%. Prevalence of having some type of overweight (BMI for age > 85%) was statistically similar by gender and school grade. Low family-income children had 76% higher odds of having some type of overweight compared with those with higher income.
Conclusion: This study documents a high prevalence of Puerto Rican childhood obesity among first to sixth grade regardless of grade level and gender, which is higher than the prevalence among Hispanics in the US. A higher probability of overweight was seen among the poorer children. This is the first study conducted among first to sixth graders. Thus, it calls for attention towards Puerto Rican children in the island and the US. [P R Health Sci J 2010;4:357-363]
Key words: Prevalence of Childhood Obesity, Puerto Rico, Low Income Families
Objetivo: La obesidad en ninos es una epidemia mundial; su prevalencia se ha cuadriplicado en los ninos de 6-11 anos. En EU, los ninos Hispanos tienen una prevalencia mas alta que los ninos blancos no Hispanos. No existen datos sobre la prevalencia de obesidad para los ninos de primero a sexto grado en Puerto Rico o en los Estados Unidos. El objetivo de este estudio fue medir la prevalencia de obesidad en ninos de escuelas elementales (primero a sexto grado) de una municipalidad semi-urbana en Puerto Rico por distintas caracteristicas socio-demograficas.
Metodos: Se selecciono una muestra representativa por medio de un diseno de muestreo por conglomerados estratificada en dos etapas (n=250). El peso y estatura de los ninos se midio dos veces, redondeando las cifras al 0.1 kg y 0.1 cm mas cercanos, respectivamente. Se utilizo el criterio establecido por CDC para la clasificacion de peso por talla y sexo. Se usaron las pruebas de Ji-cuadrada y Fisher para comparar proporciones. Se evaluaron asociaciones con caracteristicas socio-demograficas por medio de Regresiones Logisticas Simples. Resultados: Cerca de 51% eran varones y la edad promedio fue de 9.5 + 1.9 anos. Casi el 40% de los ninos eran de familias de ingresos <$1,000. En general, la prevalencia de obesidad (IMC > percentila 95) fue de 26.8%. La prevalencia de tener algun sobrepeso (IMC > percentila 85) fue estadisticamente similar por sexo y grado escolar. Los ninos de familias con ingresos <$1,000 tuvieron 76 veces mayor probabilidad de estar en sobrepeso que los ninos de familias de ingresos mas altos. Conclusion: Este estudio documenta la alta prevalencia de obesidad en ninos de escuelas elementales en Puerto Rico independientemente del grado o sexo; esta prevalencia es mayor que la reportada para ninos Hispanos en Estados Unidos. Dicha prevalencia fue mucho mayor entre los ninos de familias mas pobres. Este es el primer estudio realizado con ninos de primero a sexto grado en la isla. El mismo representa un llamado a una mayor atencion a los ninos puertorriquenos en la isla y los Estados Unidos.
Rivera-Soto, Winna T.
|Publication:||Name: Puerto Rico Health Sciences Journal Publisher: Universidad de Puerto Rico, Recinto de Ciencias Medicas Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Universidad de Puerto Rico, Recinto de Ciencias Medicas ISSN: 0738-0658|
|Issue:||Date: Dec, 2010 Source Volume: 29 Source Issue: 4|
Childhood overweight is a worldwide epidemic (1). Over the past 30
years, the prevalence of obesity in the United States (US) has nearly
tripled for children 2 to 5 years of age and youth 12 to 19 years,
whereas it has quadrupled for children 6-11 years old (2-3). Although
this epidemic surpasses socio-economic boundaries, a higher prevalence
is seen among lower socio-economic populations and ethnic minorities.
Hispanic children in the US have a higher prevalence of obesity when
compared to Non-Hispanic Whites (4). The most recent National Health and
Nutrition Examination Survey (NHANES) data (2007-2008) showed that all
Hispanic children 6-11y/o, of both sexes (including Mexican Americans)
have a higher prevalence of obesity (25.1%) compared to
Mexican-Americans exclusively (24.7%), non-Hispanic Blacks (19.4%), or
non-Hispanic White children (19.0%). However, these national estimates
fail to distinguish the heterogeneity among Hispanics in the US,
particularly Puerto Ricans who represent the second largest Hispanic
subgroup in the states.
Among Hispanics, Puerto Ricans continue to be one of the most disadvantaged and vulnerable subgroups. More than half (58.5%) of Puerto Rican children living in the island, and almost one-third (29.4%) of Puerto Rican children in the US, live in poverty compared to only 8.7% of White children (6). Adult Puerto Ricans have a higher prevalence of overweight and obesity (64.5%) compared to non-Hispanic Whites (61.7%) and the burden of the metabolic syndrome is substantial (7-8). However, there is very limited information on the prevalence of childhood obesity in Puerto Rico, particularly among elementary school children (6-11 years old) living in the island, the group of age with the highest increase in childhood obesity prevalence in the states. A study conducted by the Puerto Rico Department of Health showed a high prevalence of overweight (26%) and overweight (16%) however the study only included children from second grades. Another study, conducted by Otero and Garcia in a small convenience sample (n=154) of children ages 2-12 receiving primary care in a local Hospital in San Juan, Puerto Rico, also found a high prevalence (56%) of obesity (9); however, no stratification by age groups or sex were reported. Children weight status, and consequently their association to health conditions, is determined not only by their age group, but also by their sex characteristics.
The increased prevalence in childhood overweight worldwide represents an "unprecedented burden" on children's health. Obesity is associated with significant health problems in the pediatric age group and is an important early risk factor for much of adult morbidity and mortality (10). The disproportionate burden of overweight and its related co-morbidities in Hispanics, especially type 2 diabetes, is evident early in life (11). For example, the risk of developing diabetes is higher among Hispanics, with a lifetime risk approximately 50% higher for children born in the year 2000. Some very obese youths suffer from immediate health problems, such as respiratory disorders, orthopedic conditions, and hyper insulinemia (1218). Overweight in young people is also related to elevated blood cholesterol levels, high blood pressure, asthma, sleep apnea, and social discrimination which can lead to low self-esteem and depression.
A myriad of studies document the persistence of childhood overweight into adulthood thus representing a risk factor for severe obesity over the life course (19-23). Obesity decreases longevity, quality of life, and economic productivity (24). Obese adults are at higher risk for serious diet-related non-communicable diseases, including diabetes mellitus, cardiovascular disease, strokes, and cancer, among other chronic conditions that reduce the overall quality of life and contribute to premature death. These non-communicable diseases are by far the leading causes of death in the world (25).
In view of these tendencies, it is important to identify, early in life, children who are overweight or obese in order to reduce morbidity and mortality risks associated to it. Therefore in 2008, a nutritional study was conducted in Cayey, a suburban municipality of Puerto Rico with the goal of measuring dietary, socioeconomic, and environmental factors associated with the prevalence of childhood overweight among elementary school children from public and private schools. As previously stated, children from these age groups have had the greatest increase in childhood overweight over the last decades compared to other age-groups in the US. Our study represents the first one examining the prevalence of childhood obesity among a representative sample of children from elementary schools (first to sixth grades) living in the island.
This article focuses on describing the prevalence of childhood overweight in a representative sample of Puerto Rican children participating in this study. In addition, it describes the association between parental socio-economic status and children weight status, since there is a need to examine how obesity and its consequences are patterned socially.
This study was conducted in two stages. The first stage of the study consisted of a series of focus group sessions conducted with both parents and students, separately, that were selected from the same geographic areas as the survey sample. This qualitative phase allowed investigators to become familiar with the target audience's characteristics and lifestyles associated to childhood overweight or obesity. Six focus group sessions were conducted with groups of 7-10 children from each grade with similar characteristics to the students to be included in the study. Four focus group discussions were conducted with parents from schools not included in the sample. The information obtained from the focus groups allowed the development of parental and child questionnaires used for the second phase of the study. The questionnaires were pilot-tested on 20 students selected from all grades in a school not included in the sample.
The second stage of the study was a cross-sectional survey. The parents' validated and self-administered questionnaire, along with a consent form for participation, were sent to parents through homeroom teachers. This questionnaire included questions on socio-demographic characteristics, dietary practices, weight, and height, as well as physical activities of both students and parents. Family socio-economic status (SES) was measured by means of two variables: family monthly income and health insurance coverage. This last criterion was used as a proxy of socioeconomic status since eligibility for participation in the public health insurance, called "La Reforma de Salud" (Health Reform), is based on poverty level. Based on the Puerto Rican Health Reform Law, health insurance coverage is provided free of charge to individuals of family groups with family income (including wages, properties, or other economic assets) below 200% of poverty threshold (26). Parents returned the questions to the teachers in a sealed envelope provided by the researchers.
A trained interviewer administered the children's questionnaire at the school using food models and measuring tools for estimating quantity of food consumed. This questionnaire included questions regarding dietary practices, physical activities, and leisure activities of children, as well as their perception of their weight status. Weights and heights were measured to the nearest 0.1 kg and 0.1 cm, respectively, by survey personnel using a portable and standardized scale/ stadiometer (Detecto). Shoes were removed for the height and weight measurements. Waist circumference was measured using a flexible tape measure. All measurements were taken twice by the same research staff member. A nutritionist and a nutrition graduate student administered a 24 hour food recall for the dietary assessment.
A representative sample of students from first to sixth grades, as well as their parents, from public and private elementary schools in the municipality of Cayey, Puerto Rico, was selected using a two-stage stratified cluster sampling design. Cayey is a suburban municipality located in the mountain region of Puerto Rico with a population of 47,370 inhabitants (2000 Census), and a tremendous economic and demographic growth over the last decades. Approximately 47.4% of the population is below poverty level similar to the rest of the island (45.0%).
The sampling frame, a list of all elementary schools, included the number of enrolled students stratified by grade. The study population consisted of approximately 5,441 children. The first stage of sample selection was the selection of the schools within each strata (private or public schools) using probability proportional to size of the student population. Each school selected was further stratified by grade. After selection of schools, a field supervisor visited all the schools and prepared a list of all available sections before the selection of the groups for the sample. The second stage of sample selection was the selection of the specific groups within the schools using a modified Kish table (27). All students and their parents within the selected groups (clusters) were included in the final sample. Using the STATCALC module of Epi-Info, version 6.04d, software, a sample size of 398 students and their respective parents of caregivers was determined using an expected prevalence of 24%, a desired precision of [+ or -] 4%, and a 5% significance level (28). This study was approved by the Human Research Subjects Protection Office at the Medical Sciences Campus of the University of Puerto Rico (protocol A1470107). Children provided written assent and parents gave written consent prior to participation in the study.
Weight status of children was determined based on the 2000 sex-specific body mass index (BMI) for age growth charts from the Centers for Disease Control and Prevention (CDC) (29). Obesity was defined as at or above the 95th percentile of the sex-specific BMI-for-age growth chart. Overweight was defined as at or above the 85 th percentile, but less than the 95th percentile of the sex-specific BMI for age, as defined by the growth chart. Normal weight was defined as a BMI for age between the 5th and the 85th percentiles, and underweight as a BMI for age below the 5th percentile.
The data was analyzed using SPSS (Statistical Package for the Social Sciences) for Windows (version 15.0) and SAS (SAS Institute Inc.) for Windows (version 9.1). Bivariate analyses were performed in order to compare the proportion of children with some type of overweight and children not overweight. These proportions were compared across socio-economic status and demographic characteristics. Chi-square and Fisher tests were used to compare proportions. Simple logistic regression models were used to assess the strength of the association between demographic and socioeconomic characteristics and overweight. This sample is representative of all students between first and sixth grade in Cayey. Results were weighted using the inverse of the probability of sample selection. All analyses were performed on weighted data.
A total of 250 student participants and their parents were included in the final sample. This represented a response rate of 63.0% among children and 44.0% among parents. Sociodemographic characteristics of students are summarized in Table 1. Nearly half of the students (51.0%) were boys, and the mean age was 9.5 +1.9 years. Students from public schools accounted for 78.1 % of the sample; 52.7% were located in a rural area. Among those students who had health coverage, 52.2% had government-provided health insurance ("La Reforma de Salud"). Only 2.6% of parents reported not having any health insurance coverage. Among parents of students, a higher proportion (37.3%) reported monthly incomes of less than $1,000. Only one fifth (18.6%) of parents reported monthly family incomes of $3,000 or higher.
Overall, the prevalence of obesity among students was 26.8% with 11.3% overweight. The weight status of children participating in this study is summarized in Table 2. A slightly higher proportion of girls (29.8%) were classified as obese compared to boys (24.0%), and a higher proportion of boys (12.4%) were classified as overweight compared to girls (9.9%). However, these differences were not statistically significant (p=0.081).
Table 3 summarizes the prevalence of some type of overweight (BMI>85 percentile) within groups of children for selected socio-demographic characteristics. The sub-groups with the highest prevalence of some type of overweight were: girls in lower grades (40%), except males in fifth or sixth grade (56.1%), girls in private school (52.0%), and girls with a <$1,000 monthly family income (50.0%).
Students in fifth or sixth grade had a higher prevalence of some type of overweight (46.8%) than students in third or fourth grade (38.5%) or in first or second grade (28.4%). This difference was marginally significant (p=0.07). However, prevalence of overweight was similar by school type, private (40.0%) or public (37.4%). Females in all grades, except those in fifth or sixth grade, had a higher prevalence of overweight than boys. Over half (56.1%) of male fifth or sixth graders had some type of overweight compared to only 36.8% of females in the same grades. There was also a higher prevalence of overweight among girls from private schools (52.0%) compared to the prevalence seen among girls from public schools (37.4%).
A higher prevalence of some type of overweight (BMI >85th percentile) was seen among children from rural areas (41.7%) compared to children from urban areas (33.6%), for both girls and boys. Prevalence among children with government health coverage or no insurance (38.5%) was similar to the prevalence seen among children with private health coverage (35.6 %). The highest prevalence of overweight was seen among children whose family's monthly income was less than $1,000 (45.7%), with the highest prevalence among girls in that income level (50.0%).
Table 4 presents the estimated association of having any type of overweight (BMI >85th percentile) with selected socioeconomic characteristics and the odds associated to these characteristics. In general, the odds of being obese increased with school grade. Children in higher grades (5th or 6th) had over twice the odds of being overweight (POR 2.23; C: 1.12, 4.44) than children in 1st or 2nd grade. Also, students in schools located in rural areas had 41% higher odds of being overweight compared with those in schools in urban areas, although this association was not statistically significant (p=0.200). Children with a low family income (<$1,000 per month) had 76% higher odds of being overweight compared with those with a high income ([greater than or equal to] $1,000). This association was marginally significant (p=0.051). Moreover, there seems to be a dose-response relationship between income and overweight; the lower the income the higher the prevalence (data not shown).
This research is the first study in Puerto Rico that measures the extent of childhood overweight in a representative sample of first to sixth grade children, most of which are aged 6-11 years old, the age group with the highest increase in childhood overweight in the US. This study provides prevalence estimates of childhood overweight in a representative sample of children from this age group in the municipality of Cayey, and explores socio-demographic correlates of overweight.
Our study documents a high prevalence of obesity among Puerto Rican children from Cayey (26.8%), which is higher than the prevalence of childhood obesity prevalence reported in the US among non- Hispanic Whites (19.0%), non-Hispanic Blacks (19.4%), and even among all Hispanic children (25.1 %), a group that includes Mexican Americans and Hispanic from other different backgrounds, and compared to Mexican Americans exclusively (24.7.%). In addition, this study confirms results from other studies indicating a higher prevalence in poorer populations. These results posit the plausibility that children from this municipality could be at a higher risk for overweight-associated chronic conditions, compared to US children.
This high prevalence is consistent across gender, age groups, socio-economic levels, type of school (private or public), and geographic location of school (rural or urban). However, our study also shows a higher probability of being overweight among the poorer children, compared to children with higher family incomes. This result confirms other studies associating overweight with poverty thus the health disparity that prevails among lower income populations (30).
Our study calls attention to the need for the development of nationwide strategies as to the measurement and monitoring of the prevalence of childhood overweight in the entire island. There is a need to examine how obesity and its consequences are patterned socially. A health disparities perspective, which systematically examines how health is distributed across racial/ ethnic and socioeconomic groups, can contribute to obesity research (31). Moreover, results from this study document the need for the design of a culturally-based prevention program targeted to both Puerto Rican children and their families, particularly from the lower socio-economic levels that tend to have a higher prevalence of childhood overweight.
One of the strengths of this study is that it is a representative sample of all students between first and sixth grade in a suburban municipality in Puerto Rico. This represented a population of approximately 5,500 students. In addition, the study included the parents of students in the study, which contributed to obtaining information not familiar to children. Parents were able to provide information regarding family's socio-economic status and lifestyles more accurately.
However, our results should be interpreted in light of several limitations, particularly pertaining to the extrapolation of the findings. Given the fact that the study was conducted in a particular suburban municipality, our results provide preliminary data only for the Cayey population. More research is needed in order to better estimate the prevalence of childhood overweight for the entire Puerto Rican population. Another limitation pertains to the self-administered methodology used with the parents. Sending the questionnaire with the student may have limited the response rate of parents and the completion of some areas of the questionnaires, such as parental health status and income level. These factors may have limited some of the data analyses. Also, 37% of students did not participate, which may lead to selection bias and an under-reporting of the prevalence of overweight, particularly among students in private schools. Approximately 29% of the students did not participate because their parents did not give authorization. This non participation was disproportionally high among children in private schools; over half of the non participating parents had children in private schools. Underreporting of overweight among private school students, and thus among those with higher family income, might have occurred. This is a concern since family income was the only socio-demographic characteristic marginally associated with overweight. It is possible that this characteristic could have been found not to be associated with obesity, had some of the non participating private school children participated in the study.
Nonetheless, our study fulfills a gap in the literature as to the measurement of the overweight prevalence in a representative sample of Puerto Rican children from different socio-economic levels. Our study evidences the need for the inclusion of Puerto Rican children living in the island in future epidemiological as well as intervention studies, in order to better understand the factors associated to childhood overweight and to identify best practices for its prevention.
Funding provided by: Agency for Healthcare Research and Quality (AHRQ), the U.S. Department of Health & Human Services, and the Puerto Rico Health Services Research Institute (PRHSRI), UPR Graduate School of Public Health, Grant #5 R24 HS014060-06.
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Winna T. Rivera-Soto, PhD, MPH, LND*; Linnette Rodriguez-Figueroa, MSc, PhD ([dagger]); Glena Calderon, MS *
* Department of Human Development, [dagger] Department of Biostatistics and Epidemiology, ([double dagger]) Department of Health Services Administration, University of Puerto Rico, Graduate School of Public Health, San Juan, Puerto Rico
The authors have no conflict of interest to disclose.
Address correspondence to: Winna T. Rivera-Soto, PhD, Nutrition Graduate Program, School of Public Health, P.O. Box 365067, San Juan, Puerto Rico 00936-5067. Tel: (787) 758-2525 Ext. 1478 * Fax: (787) 759-6719 * E-mail: firstname.lastname@example.org
Table 1. Description of Socio-Demographic Characteristics among Elementary School Students, Cayey, Puerto Rico, 2008 Socio-demographic Unweighted Unweighted Weighted Weighted characteristics frequency percentage frequency percentage Gender Female 121 48.4 1,883 49.0 Male 129 51.6 1,960 51.0 School grade First or Second 59 23.6 1,026 26.7 Third or Fourth 101 40.4 1,469 38.2 Fifth or Sixth 90 36.0 1,348 35.1 School type Public 205 82.0 3,001 78.1 Private 45 18.0 842 21.9 School geographic location Rural 130 52.0 2,024 52.7 Urban 120 48.0 1,819 47.3 Type of medical insurance Private 101 45.5 1,607 46.6 Government 115 51.8 1,755 50.9 None 6 2.7 88 2.6 Family monthly income <$1,000 84 39.3 1,244 37.3 $1,000-1,999 59 27.6 922 27.7 $2,000-2,999 36 16.8 549 16.5 [greater than or equal to] $3,000 35 16.4 618 18.6 Total 250 100.0 3,843 100.0 Table 2. Weighted Prevalence Estimates of Weight Status by Gender among Elementary School Students, Cayey, Puerto Rico, 2008 Gender * Total Weight status Female Male % 95% CI % 95% CI % 95% CI Obese 29.8 21.6-37.9 24.0 16.4-31.6 26.8 21.3-32.4 Overweight 9.9 4.6-15.2 12.4 6.5-18.3 11.3 7.2-15.1 Normal weight 51.2 42.3-60.1 61.2 52.5-69.8 56.2 49.9-62.4 Underweight 9.1 4.0-14.2 2.5 0-5.2 5.7 2.8-8.7 * p=0.081 Table 3. Prevalence Estimates of Overweight (BMI for age >85th percentile) within Selected Groups by Socio-Demographic Characteristics of Elementary School Students, Cayey, Puerto Rico, 2008 Gender Socio-Demographic Female Male characteristics Prevalence 95% CI Prevalence 95% CI (%) (%) School grade First or Second 41.9 24.6-59.3 14.3 2.7-25.9 Third or Fourth 41.2 27.7-54.7 35.6 21.6-49.5 Fifth or Sixth 36.8 21.5-52.2 56.1 40.9-71.3 School type Public 37.1 27.5-46.7 38.5 28.5-48.5 Private 52.0 32.4-71.6 30.0 13.6-46.4 School geographic location Rural 40.9 29.0-52.8 42.4 30.5-54.3 Urban 38.9 25.9-51.9 29.1 17.1-41.1 Type of medical insurance Private 38.8 25.1-52.4 31.4 18.6-44.1 Government or none 40.3 28.1-52.5 36.4 23.7-49.1 Family monthly income <$1,000 50.0 34.1-65.9 41.9 27.1-56.6 $1,000-1,999 34.4 17.9-50.8 26.9 9.9-44.0 $2,000-2,999 30.0 9.9-50.1 33.3 6.7-60.0 [greater than or 37.5 13.8-61.2 33.3 14.5-52.2 equal to]$3,000 Total 40.0 31.2-48.8 36.4 27.8-44.9 Socio-Demographic Total characteristics Prevalence 95% CI (%) School grade First or Second 28.4 17.6-39.2 Third or Fourth 38.5 28.8-48.3 Fifth or Sixth 46.8 35.8-57.8 School type Public 37.4 30.5-44.4 Private 40.0 27.1-52.9 School geographic location Rural 41.7 33.3-50.1 Urban 33.6 24.8-42.5 Type of medical insurance Private 35.6 26.3-45.0 Government or none 38.5 29.6-47.3 Family monthly income <$1,000 45.7 34.8-56.5 $1,000-1,999 31.0 19.1-42.9 $2,000-2,999 29.0 13.1-45.0 [greater than or 35.0 20.2-49.8 equal to]$3,000 Total 100.0 Table 4. Weighted Prevalence Estimates of Weight Status among Elementary School Students and Prevalence Odds Ratios by Socio-Demographic Characteristics, Cayey, Puerto Rico, 2008 Weight status Socio-demographic Overweight/ At Normal weight/ characteristics risk of overweight Underweight (%) (%) Gender Female 40.0 60.0 Male 36.4 63.6 School grade First or Second 28.4 71.6 Third or Fourth 38.5 61.5 Fifth or Sixth 46.8 53.2 School type Public 37.4 62.6 Private 40.0 60.0 School geographic location Rural 41.7 58.3 Urban 33.6 66.4 Type of medical insurance * Private 35.6 64.4 Government or none 38.5 61.5 Family monthly income <$1,000 45.7 54.3 [greater than or 32.3 67.7 equal to]$1,000 Socio-demographic Prevalence characteristics p value Odds Ratio 95% CI (POR) Gender Female 0.561 1.17 0.69-1.96 Male Reference School grade First or Second 0.073 Reference Third or Fourth 1.58 0.81-3.10 Fifth or Sixth 2.23 1.12-4.44 School type Public 0.730 0.90 0.49-1.66 Private Reference School geographic location Rural 0.200 1.41 0.83-2.38 Urban Reference Type of medical insurance * Private 0.668 Reference Government or none 1.13 0.65-1.96 Family monthly income <$1,000 0.051 1.76 1.00-3.12 [greater than or Reference equal to]$1,000 * Medical insurance dichotomized (private vs. public or none) for analysis
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