Citation
Biocultural correlates of child nutrition and growth and development in Costa Rica

Material Information

Title:
Biocultural correlates of child nutrition and growth and development in Costa Rica
Creator:
Simpson, Sharleen Hirschi ( Dissertant )
Lieberman, Leslie S. ( Thesis advisor )
Bernard, H. Russell ( Reviewer )
Doughty, Paul L. ( Reviewer )
Dinning, James S. ( Reviewer )
Safa, Helen I. ( Reviewer )
Place of Publication:
Gainesville, Fla.
Publisher:
University of Florida
Publication Date:
Copyright Date:
1984
Language:
English
Physical Description:
vii, 182 leaves : ill., map ; 28 cm.

Subjects

Subjects / Keywords:
Child psychology ( jstor )
Children ( jstor )
Diseases ( jstor )
Families ( jstor )
Food ( jstor )
Infants ( jstor )
Malnutrition ( jstor )
Mothers ( jstor )
Nutrition ( jstor )
Nutritional status ( jstor )
Anthropology thesis Ph. D
Child development -- Costa Rica -- San Jose ( lcsh )
Children -- Growth -- Costa Rica -- San Jose ( lcsh )
Dissertations, Academic -- Anthropology -- UF
Nutrition -- Psychological aspects ( lcsh )
City of Gainesville ( local )
Genre:
bibliography ( marcgt )
non-fiction ( marcgt )
Spatial Coverage:
Costa Rica -- San José

Notes

Abstract:
Groups of low (n=19) and normal (n=25) weight for length children were selected from an initial random sample of 107 children from poor neighborhoods in San José, Costa Rica. These children were all born in 1980 and were between the ages of 1 and 2 years at initial measurement. They were than measured monthly for six additional months. Data were also collected about socioeconomic status, food habits, maternal reproductive history, medical history of the child, and food buying patterns. The Denver Developmental Screening Test (DDST) was administered and a clinical assessment of nutritional status was also made. In-home observations of child-rearing activities were made during which time nurturing or mothering behaviors were recorded. No significant differences between the two groups are reported with respect to total income, food costs, household size, environment, children under 6, birth order, or household food frequency. The matrifocal extended family was found to be an effective survival strategy for poor families. Low weight/length children were breast-fed slightly longer with later introduction of bottle feeding and solid foods and obtained slightly more abnormal or questionable scores on the DDST than normal weight/length children. Families of low weight/length children owned more material goods, spent more money on food, and tended to be less organized in their habits than were families of normal weight/ length children. By use of multivariate regression and discriminant function analyses a model was constructed to predict membership in the low or normal weight/length group. Birth weight, the number of children aged 6 years and under, and other variables representing maternal competence and economic managing abilities as well as material style of life were found to be significant predictors of low or normal weight for length status. Mothering or nurturing behaviors were found to be positively associated with height, weight, and growth in the low weight/ length group. The maternal factor, which includes adequate prenatal care and nutrition, as well as maternal competence, is suggested to be of great importance in determining whether low income families have normal or low weight/length children.
Thesis:
Thesis (Ph. D.)--University of Florida, 1984.
Bibliography:
Bibliography: leaves 134-145.
General Note:
Typescript.
General Note:
Vita.
General Note:
English and Spanish.
Statement of Responsibility:
by Sharleen Hirschi Simpson.

Record Information

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University of Florida
Holding Location:
University of Florida
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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Resource Identifier:
030514356 ( alephbibnum )
11750803 ( oclc )
ACP2485 ( notis )

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BIOCULTURAL CORRELATES OF CHILD NUTRITION AND GROWTH AND DEVELOPMENT
IN COSTA RICA












BY

SHARLEEN HIRSCHI SIMPSON


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF
THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY


UNIVERSITY OF FLORIDA















ACKNOWLEDGMENTS


The data for this dissertatation were gathered between September

1981 and December 1982 under the auspices of a grant (#BNS8104679) from

the National Science Foundation. I would like to thank all personnel

from the Costa Rican Ministry of Health who aided in the data gather-

ing. In particular, I wish to thank Dr. Carlos Diaz Amador, Dr. Enrique

Freer Miranda, Dona Evelyn Jaensthke Maglakin, and Doia Juanita

Alvarez Elizondo de Quiros. Dr. Jose Antonio Camacho was very helpful

in advising me about the urban situation. To Flory Desanti Jimenez and

Eulalia Obando Naranjo, who as former health auxiliary workers were of

invaluable assistance, I give deepest thanks. Appreciation is also

due Dr. Leslie S. Lieberman, chairman of my supervisory committee, for

her support and comments, and the other members of my committee,

Drs. H. Russell Bernard, Paul L. Doughty, James S. Dinning, and Helen I.

Safa. A special thanks goes to Ron Thomas for his patience in advis-

ing me in the statistical analysis. I wish also to thank my parents,

Donna and LaVell Hirschi, for giving me a great start in life and pro-

viding continuing emotional support. To Roderick and Randy Simpson I

give thanks for being extremely supportive and loving to a frazzled

mother trying to finish a dissertation, and for adapting so well in

Costa Rica. Most of all, I wish to thank those Costa Rican families

who with great kindness and patience allowed me to make innumerable

interviews and observe them in action. A final thanks goes to the chil-

dren; for them I have great love and respect.

ii















TABLE OF CONTENTS


Page

ACKNOWLEDGMENTS . . . . . . . . ... ...... .ii

ABSTRACT . . . . . . . . ... . . .... .vi

CHAPTER

I OVERVIEW OF NUTRITION PROBLEMS WORLD-WIDE WITH A FOCUS ON
THE SITUATION IN COSTA RICA . . . . . .... .. 1

Causal Factors Related to Malnutrition . . . . 4
Socioeconomic Factors . . . . . . . . 6
Changes in Child-Feeding Practices . . . . . 8
Changes in Family Structure and Women's Roles . . 9
Economic Development as a Contributing Factor .... 10
The Costa Rican Situation . . . . . .... .13

II STATEMENT OF THE PROBLEM . . . . . . .... .25

III METHODS . . . . . . . ... . . . .33

Phase I: Setup . . . . . . . .... . 33
Contacts . . . . . . . .... . .. .33
Archival Research . . . . . . . ... .33
Interviewers . . . . . . . .... . 34
Pretest . ............ 34
Phase II: Initial Survey Target Population and Samp-
ling Design . . . . . . . . .. . . 35
Anthropometry . . . . . . . .... . 38
Denver Development Screening Test ......... 39
Maternal Level of Living: Quality of Environment 40
Assessment of Clinical Signs of Malnutrition . . 41
Phase III: In-Depth Longitudinal Study . . ... 41
Long-Term Data Gathering . . . . . . . 43
Assessment of Socioeconomic Status . . . ... 44
Weekly Marketing Items and Food Budget ...... 44
Maternal Reproductive History . . . . .. 45
Dietary Data . . . . . . . . . 45
Q-Sort Techniques ..... ... . . . . . 46
Observation of the Index Child . . . . .. 47
Fees Paid to Subjects . . . . . . . . 49
Phase IV: Data Analysis . . . . . .... .50


~












IV SOCIOCULTURAL PARAMETERS AFFECTING THE NUTRITION, GROWTH,
AND DEVELOPMENT OF THE CHILD . . . . . .... 54

Family Networks. .... . . . . . . . 54
Family Structure . . . . . . . . ... .55
Food-Buying Patterns . . . . . . .... .60
Child Rearing . . . . . . . . ... . 62
Family Interaction and Child Development ...... 65
Child Health . . . . . . . .. .. . 68
Diet and Food Habits as They Relate to Children . .. 70

V RESULTS . . . . . . . . ... . . . .77

Anthropometric Data . . . . . . . . . 77
Growth Patterns . . . . . . . . . . 79
Maternal Reproductive History and Birth Weights . .. 84
Illness Classification . . . . . . . . 85
Psychomotor Development . . . . . . .... .87
Socioeconomic Factors . . . . . . .... .87
Dietary Data . . . . . . . . ... . 99
Food Frequency . . . . . . . . . 99
Breast-Feeding Patterns . . . . . . .. 102
Attitudes About Food .......... ... 102
In-Home Observation of the Index Child . . ... 107
Multivariate Analyses . . . . . . . . 114
Stepwise Multivariate Regression . . . ... 116
Stepwise Discriminant Analysis . . . . .. 116

VI DISCUSSION AND CONCLUSIONS. . . . . . .. 121

Socioeconomic Factors . . . . . . .... 122
Dietary Factors . . . . . . . . . . 125
Conceptual Model Describing Children at Nutritional
Risk in the Urban Area . . . . . . .... .126
Conclusions . . . . . . . .... .. .. 128

REFERENCES . . . . . . . . ... .... . . 134

APPENDIX

1 FAMILY REGISTRY . . . . . . . . ... . 147

2 MEDICAL HISTORY OF THE INDEX CHILD . . . . .. 149

3 HISTORY OF MATERNAL LACTATION . . . . . ... 152

4 CONDITION OF HOUSING AND ENVIRONMENT . . . ... 154

5 ANTHROPOMETRIC MEASUREMENT . . . . . . ... 158


CHAPTER


Page










APPENDIX Page

6 SYMPTOMS OF MALNUTRITION . . . . . . ... 160

7 SOCIOECONOMIC STATUS . . . . . . . . 162

8 FOOD BUDGET AND BUYING PATTERNS . . . . . . 165

9 REPRODUCTIVE HISTORY OF MOTHER . . . . .... 170

10 OBSERVATION OF INDEX CHILD'S BEHAVIOR . . . ... 171

11 SELECTED FOODS THOUGHT TO BE APPROPRIATE AND INAPPROPRIATE
FOR THE INDEX CHILD AMONG LOW INCOME FAMILIES IN SAN JOSE,
COSTA RICA . . . . . . . ... .. . . 175

BIOGRAPHICAL SKETCH . . . . . . . ... .. .. . 182















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of
the Requirements for the Degree of Dcotor of Philosophy

BIOCULTURAL CORRELATES OF CHILD NUTRITION AND GROWTH AND DEVELOPMENT
IN COSTA RICA

By

Sharleen Hirschi Simpson

August 1984

Chairperson: Leslie S. Lieberman
Major Department: Anthropology

Groups of low (n=19) and normal (n=25) weight for length children

were selected from an initial random sample of 107 children from poor

neighborhoods in San Jos6, Costa Rica. These children were all born

in 1980 and were between the ages of 1 and 2 years at initial measure-

ment. They were than measured monthly for six additional months.

Data were also collected about socioeconomic status, food habits,

maternal reproductive history, medical history of the child, and food

buying patterns. The Denver Developmental Screening Test (DDST) was

administered and a clinical assessment of nutritional status was also

made. In-home observations of child-rearing activities were made dur-

ing which time nurturing or mothering behaviors were recorded. No

significant differences between the two groups are reported with respect

to total income, food costs, household size, environment, children

under 6, birth order,or household food frequency. The matrifocal

extended family was found to be an effective survival strategy for










poor families. Low weight/length children were breast-fed slightly

longer with later introduction of bottle feeding and solid foods and

obtained slightly more abnormal or questionable scores on the DDST than

normal weight/length children. Families of low weight/length children

owned more material goods, spent more money on food, and tended to be

less organized in their habits than were families of normal weight/

length children. By use of multivariate regression and discriminant

function analyses a model was constructed to predict membership in the

low or normal weight/length group. Birth weight, the number of chil-

dren aged 6 years and under, and other variables representing maternal

competence and economic managing abilities as well as material style of

life were found to be significant predictors of low or normal weight

for length status. Mothering or nurturing behaviors were found to be

positively associated with height,weight, and growth in the low weight/

length group. The maternal factor, which includes adequate prenatal

care and nutrition, as well as maternal competence, is suggested to be

of great importance in determining whether low income families have

normal or low weight/length children.














CHAPTER I
OVERVIEW OF NUTRITION PROBLEMS WORLD-WIDE WITH
A FOCUS ON THE SITUATION IN COSTA RICA


The incidence of undernourished children in the developing world

is known to be high. The Commission on International Relations of the

National Research Council (1977:63) cites FAO estimates that as many

as 30% of preschool-aged children in low-income countries suffer from

second- or third-degree malnutrition, and an additional 40-50% have

first-degree malnutrition based on weight for age standards such as

those set by Gdmez (1956). Jelliffe (1968) notes that the children most

at risk nutritionally are between the ages of 6 months and 3 years.

This observation has also been verified in nutritional surveys con-

ducted in Africa (Khan and Gupta 1979; Omololu 1978), in Asia (Berg 1973;

Winikoff 1978) and in Latin America (Home et al., 1977; M6nckeberg

1976; Schrimshaw and B6har 1976). At this age breast-feeding no longer

meets the child's needs. Weaning usually takes place during this time;

the diet of adults is not adequate for the child; and the infant is more

vulnerable to infections (Jelliffe 1968). Malnutrition may occur during

or immediately after episodes of infectious disease, even though the

child may have been in a state of adequate nutrition before and growing

at a normal rate (Mata 1978b). Field studies in India and Guatemala have

identified the interaction between malnutrition and infectious disease

(Mata 1977; Wyon and Gordon 1971). Mortality in nearly all types of

infectious disease is greater in nations with prevalent malnutrition






2



because of a decreased ability among debilitated or malnourished chil-

dren to fight off illness (Schrimshaw et al. 1968).

More recently attention is turning to what has been called

"invisible malnutrition." According to international health experts,

the image of the starving baby is too often used to represent the

developing world. Visible and obvious malnutrition occurs relatively

rarely, mostly during times of famine and war. Invisible malnutrition,

on the other hand, affects about one-fourth of the developing world's

children, stealing their energy, lowering their resistance to disease,

and thus retarding growth (International Health News 1983:1). Noting

that the child's first reaction to the lack of energy intake is to re-

duce energy output, it is observed that by conserving health and

growth at the expense of activity, the child can maintain a normal ap-

pearance. Studies have shown that "even children who are regularly

eating only three-fourths as much food as they actually need can still

maintain weight and growth by cutting out discretionary activity"

(International Health News 1983:2). The report further notes that the

mutually reinforcing relationship between invisible malnutrition and

infection is responsible for the majority of the 40,000 deaths every

day among the developing world's infants and children.

Undernutrition of the preschool child has been found to have

substantial long-term effects on the subsequent ability of the child

to develop, to be educated, and otherwise to function as a useful mem-

ber of society. Marcondes et al. (1973) found that children with his-

tories of severe malnutrition have poor performances on the Gesell even

after being rehabilitated. The Gesell test, developed by Arnold Gesell









and Catherine Amatruda (Knoblock and Pasamanick 1974) is a timetable

characterizing infant development during the first years. It includes

the categories of physical, gross motor, fine motor, sensory, vocaliza-

tion, and socialization. Richardson et al. (1972) and Cravioto and

DeLicardie (1968, 1976) found that children who showed evidence of

undernutrition in earlier years were less able to adapt and perform in

school. Cravioto and Robles (1963) found the area of hearing and speech

to be most retarded in the long run. Yatkin and McLaren (1970), compar-

ing two groups of infants recovering from severe marasmus, found that

stimulated children showed greater improvement than did the unstimulated

group. Five mental functions comprising the development quotient given

with the Griffiths Mental Development Scale were evaluated. These in-

cluded the areas of locomotor, personal-social, hearing and speech, eye

and hand, and performance. Neither group, however, attained the normal

quotients by the end of the rehabilitation.

The volume edited by Greene (1977) documents the long-term dele-

terious effects of malnutrition on the learning capacities and conse-

quent socioeconomic development of whole societies, particular socio-

economic strata (i.e. peasants), and ethnic groups (i.e. Ladinos)

throughout the world. Thus, the problem is an important one, the ef-

fects of which are potentially very harmful to the well-being of a

nation, particularly a developing nation (Aranda-Pastor 1975; Ashworth

and Picou 1976; Berlin and Markell 1977; Burgess et al. 1972; Jelliffe

1966; Seth et al. 1979; Villarejos et al. 1971; Wray and Aguirre 1969).

Although the existence of undernourished and malnourished chil-

dren has been documented in developing countries the world over, and










many important sociocultural variables have been identified, until re-

cently there has been little work done at the household level on the

behavioral, attitudinal, and habitat correlates of malnutrition. Most

of the work which has been done has taken the form of cross-sectional

surveys rather than longitudinal in-home observations. Surveys, how-

ever, often do not uncover the causal chain of events leading to con-

sumption-related malnutrition.

Causal Factors Related to Malnutrition

Nutrition workers generally agree that malnutrition in developing

countries is the result of many interrelated factors including low in-

come and underemployment, ignorance, poor sanitation, lack of access to

medical facilities, family instability (Beghin et al. 1979), changing

women's roles in relation to urbanization and participation in the work

force (Popkin 1980a; Uyanga 1980), and family structure (size, birth-

spacing, one-parent families, etc.).

Taylor and Taylor (1976) constructed a model which, according to

them, shows the interrelationships of factors that cause most of the

malnutrition in the world. They group causal factors under three head-

ings: the production of food, its distribution, and its utilization.

Under production they include factors related to agricultural labor,

distribution of land and technology which affects the level of produc-

tivity, thus determining the supply of food available. Under distribu-

tion are included economic factors (prices and income); demographic

factors (population growth and urbanization); cultural factors (beliefs

about food, childcare and feeding, social status); and health and

nutrition services (feeding programs, integrated services). Under


00000










utilization are included physiological differences (vulnerable groups,

e.g. pregnant women and children; malabsorption, genetic adaptation),

level of activity, and infection and parasites. Taylor and Taylor

note, however, that while they regard these as being general causes

they must be adjusted to local situations. Similar patterns of mal-

nutrition may result from different combinations of causes. Thus,

they advocate nutrition surveys which go beyond standardized descriptive

data to include information which will permit the development of a local

causal profile.

Brown and Brown (1977), in their paper giving guidelines for

finding the causes of protein-calorie malnutrition in the community,

suggest that adequacy of household food supplies, availability of food

supplies (agriculture), food procurement (purchases),and food use and

feeding practices are useful categories for evaluating the local situa-

tion.

Fleuret and Fleuret (1980:250) suggest the following circumstances

leading to what they term "consumption-related malnutrition": (1) Food

production is inadequate due to lack of land, labor, capital, or any

one of these; (2) food production is adequate but some people cannot

afford enough food or the right kinds of food; (3) food production is

adequate but cultural factors (e.g. food preferences, intrahousehold

distribution) cause unhealthy consumption patterns; (4) both aggregate

food production and overall income levels are adequate; beliefs and

values are nutritionally neutral, but certain categories of the popula-

tion are constrained by other social and economic factors to make con-

sumption decisions that are inconsistent with good nutrition. Of these










approaches, the latter seems to be the most useful in terms of develop-

ing countries.

Reutlinger and Selowsky concur with this latter set of circum-

stances, noting that "at the global level malnutrition is the inequi-

table distribution of world income and not the result of an insuffi-

cient supply of food" (1979:21).

Socioeconomic Factors

Keeping in mind general guidelines and models, one can find a

number of specific studies which illustrate in detail some of the

causal factors included in the general framework already mentioned.

Rawson and Valverde (1976) in San Ram6n, Costa Rice, found that

access to land, fathers who worked as day laborers, working mothers,

physical condition of the house, and the number of children under 6

years of age negatively affected the nutritional status of children.

Wray and Aguirre (1969) in Candelaria, Colombia, found that the in-

come of the father, family size, birth spacing, and birth order were

related to malnutrition in children.

Increasing urbanization as a result of industrialization and the

migration of rural people to the cities in developing countries have

contributed to the development of malnutrition. Clark (1980) found

urban preschoolers to be smaller and less physically developed than

their rural counterparts. Villarejos et al. (1971) found the opposite

in Costa Rica where rural children exhibited more retarded growth than

did urban children. It seems that the change in environment caused by

the move to an urban area combined with existing culturally determined

food habits has created problems. In Costa Rica this is evidently










mitigated by the existence of extensive health and social welfare pro-

grams.

Specific customs of food consumption may interact with local con-

ditions to produce childhood undernutrition. For example, among the

Tongans Clark studied, the adult males began the meal,followed by adult

females and younger males, with children eating last. When meat was

consumed by the family, this was seldom reflected in the diet of the

child. Although this custom was prevalent in the rural situation, in

the city it created great problems because food items such as domestic

meats were less available. Clark also notes that in rural areas where

cash income levels were often lower, food purchases were supplemented

by family production of meats, fish, and vegetables. Urban families,

while enjoying higher cash incomes, lacked sufficient purchasing power

to replicate the food variety and quantity available to rural families.

Clark also notes that "bush foods" (wild foods which are hunted or col-

lected)were constantly present in the rural diet and almost totally

absent from urban diets. This decrease in variety of foods included

in the diet seems especially significant in view of the work of Dewalt

et al. (1980) in highland Mexico, which suggests that complex diets

contain more of the essential nutrients than do more restricted diets.

In addition to these socioeconomic factors a number of other

parameters having biological and social significance have indicated

that large families, short interpregnancy intervals, and a large num-

ber of preschool children at home are risk factors for malnutrition.

MacCorquodale and Rond6n de Nova (1977) found that in Santo Domingo










malnourished preschool children were from families averaging 4.7 chil-

dren, while well nourished children came from families with an average

of 4.0 children. In Costa Rica, Rawson (1975) found that a significant

risk factor for malnutrition was the presence of more than 2 preschool-

age children in a household. In Haiti, Ballweg (1972) reported a

greater likelihood of undernutrition associated with large families.

In addition to family size, the sex of the infant may be a corre-

late of malnutrition. Dorjahn (1976) reported that infant mortality

in Sierra Leone was higher for females in both the rural and urban

areas and suggested sex differential feeding as a causal factor. Other

researchers (Rawson 1975) have noted no sex differences in the fre-

quency of malnourished children.


Changes in Child-Feeding Practices

Another important causal factor in the development of malnutrition

is the changing pattern of infant feeding. In developing countries

this is particularly important because, as Berg (1973) notes, the move

away from traditional breast-feeding places a child in double jeopardy:

first because of the loss of a high quality food supply (formulas are

frequently mixed incorrectly) and secondly through the increased

potential for contact with infection as formulas are mixed with unclean

water and placed in dirty bottles. This gives rise to what E. F. P.

Jelliffe (1979) calls "comerciogenic" malnutrition.

Popkin et al. (1980) note that examination of worldwide data

based on large nationally representative samples suggests that, al-

though there has not been a widespread general decline in the prevalence










of breast-feeding (the percentage of women who ever breast-fed), there

has been a decline in the duration of breast-feeding, especially in

urban areas of Latin America and the Caribbean.


Changes in Family Structure and Women's Roles

Changes in family structure and women's roles have directly af-

fected child-care and thus child-feeding practices. One of the most sig-

nificant changes in family structure has been the rise of the one-

parent household, primarily with the migration of men or women to urban

areas and/or the inability of the man to obtain an adequate job. The

presence of only one parent has been found to have a negative effect

on a child's nutritional status, primarily because a woman who has a

child not supported by its father has little economic security. In

Jamaica, Desai et al. (1970) found that presence of both parents, small

family size, and birth intervals of at least 24 months were associated

with high rates of weight gain in children.

Of primary importance is the entry of women into the work force,

particularly in urban areas where work may be in factories and is not

generally compatible with child care (as selling goods in a village

market may be). Women's work hours and conditions have a great in-

fluence on child care. Uyanga (1980) notes that having a job which is

compatible with child care is positively associated with breast-feeding

behavioral changes. He also notes that in urban areas the presence of

other members of the family, e.g. daughters, other nonnuclear family

members (aunts, grandmothers, etc.), has a positive impact on child-

care time and thus a potentially positive effect on nutritional status.


M










Reutlinger and Selowsky (1976) have observed that infant mal-

nutrition as a result of absence from the home of lactating mothers

participating in the labor force is a case of income redistribution

within the family in the face of urbanization. Unless sufficient

food is purchased for the infant to compensate for the nutrients

lost by reduced breast-feeding, the child suffers a negative income

effect. Recent research from India according to Reutlinger and

Selowsky suggests that a woman would have to spend 76% of her earn-

ings to provide adequate quantities of formula or milk for a 4-month-

old infant. In Kenya this would require 58% of the wage, and in

Tanzania 51% (Latham 1979). Latham also points out that,since many

tropical countries have rather small dairy industries, most of the

manufactured milk formulas are imported, requiring the use of scarce

foreign exchange. This also contributes to the dependency of develop-

ing countries on foreign capitalist powers and multinational corpora-

tions like Nestl6.


Economic Development as a Contributing Factor

It is difficult to demonstrate a relationship between socio-

economic development and nutritional status because of the multi-

factoral etiology of malnutrition and because it is difficult to iso-

late the effect a specific program may have had. Commericalization

of agriculture, long a favorite goal of third world economic de-

velopment programs, is recognized as leading to a decline in

nutritional status (Fleuret and Fleuret 1980; Gross and Underwood

1971). Commercialization of agriculture usually implies introduction










of capital-intensive technology used for producing cash crops for

export, e.g. coffee, soy beans, African palm, bananas, horticultural

products. Along with this comes a decline in subsistence produc-

tion as small farmers become involved as wage laborers on large

plantations and agroindustrial plants or in producing cash crops on

contracts. Women may be left to bear the burden of the garden, or

subsistence farming, responsibilities for which they may be unprepared,

as they may lack education or experience with gardening or farming.

The result is a decline in both yields and in subsistence farming as

a whole. Staples must then be purchased with hard earned cash, which

tends to arrive in lump sums rather than being distributed throughout

the year. This has the effect of making peasant households less self-

sufficient and less able to withstand seasonal variations in the supply

of staple foods. The net result is an increased vulnerability to

malnutrition. This is especially true since private enterprise is

rarely able or willing to provide directly for the reproduction of

labor power which would entail paying wages sufficient to enable a

worker to support a family and obtain adequate housing and health ser-

vices (Roberts 1978). Certainly Gross and Underwood's (1971) study

of the introduction of sisal agriculture in northeastern Brazil is

an excellent example of this process. In this example the introduc-

tion of sisal, which employed men in the hard and exhausting labor of

harvesting and processing, resulted in such increased energy costs in

relation to the low wages that a systematic deprivation of adequate

calories to the wives and children of the sisal workers was the result.










In order to maintain physical strength, the male of the household had to

eat the lion's share of the available food. Thus in the population

studied, the children were exhibiting signs of malnutrition-retarded

growth and development. The working poor were essentially subsidizing

capitalist private enterprise.

The implication of the preceding discussion is that malnutrition,

especially infantile protein-energy malnutrition,has a complex etiology.

Solutions based on food and nutrients alone are completely inadequate

(Pellet 1977). Expecting malnutrition to disappear with economic

development and increased GNP seems unrealistic also, in view of the

past record and because evidence indicates that low-economic groups

benefit unequally in the process of capitalist-oriented economic develop-

ment (Cornelius and Trueblood 1975; Roberts 1978).

According to Reutlinger and Selowsky (1979:22), empirical evi-

dence suggests that the caloric intake will increase at approximately

half the rate at which per capital income rises. On the basis of these

assumptions it would take 30 years before the poorest 20% of the popula-

tion of these countries could reach an adequate level of caloric in-

take. In their view the high incidence of malnutrition among chil-

dren of developing countries is not likely to be reduced as part of the

development process. The only effective solution according to them

lies either in a more equitable income distribution or in supplying

food to the target population at low prices. This view is echoed by

Teller et al. (1979:21) who state that in general poor countries will

attain an adequate nutritional status only when they can provide most of

their people with a "minimum socioeconomic package" (permanent employ-

ment, adequate income, social security, housing, etc.).









The Costa Rican Situation

Costa Rica (see Figure 1) is unique in Central America because it

has long had a democratic form of government, a social conscience among

the upper classes, and a fairly large middle class. The Spanish settlers

of Costa Rica, throughout the colonial period, found themselves forced to

reside in the country where each family labored to produce its own food

(Munroe 1918:140).

As the population grew, the entire Meseta Central became divided

into small farms. There were a few wealthy and influential families who

had been given special privileges by Spain, but they never occupied the

dominant position which the aristocracy of Guatemala and Nicaragua had

been able to assume, and the land they held never amounted to more than

a small portion of the cultivated area of the colony. In 1848 through a

special decree the people were permitted to buy the land they had fenced

and were using, a measure which had the effect of greatly increasing the

number of landholders (Munro 1918:142-143).

Costa Rica achieved independence from Spain in 1821 when she joined

with seven other provinces of Central America to form the United Provinces

of Central America, which was later disbanded in 1838 because of internal

conflicts. Full national sovereignty was not established until 1848.

The period between 1938 and 1902 was largely one of dictatorships succeed-

ing one another through coups. Also, during this period Costa Rica had

to defend herself against a Nicaraguan invading force in 1836 and from

the troops of the North American adventurer William Walker in Nicaragua

in 1853-57 (Fanger 1968).

The radical transformation of Costa Rican geography since its inde-

pendence can be attributed to the development of two agricultural









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products, coffee and bananas (Hall 1976:14). Coffee reached Costa Rica

some time before the end of Spanish rule in 1821. A letter from

Governor Tomds de Acosta to the king in about 1808 mentions the plant,

and by 1829 it was the most important produce of the country. A rush

to plant coffee took place in 1841, and the country's economy and

thinking became oriented around coffee growing and coffee prices

(Lundberg 1976:114). During the 1940s large uncultivated tracts of

land owned by the government were sold at low prices or given away as

premiums to encourage the planting of coffee. During the last years of

the 19th century many persons acquired land this way, and gradually a

class of large landholders developed, although the Meseta Central was

still composed largely of small farmers (Munro 1918).

The banana has been cultivated since the end of the 19th century

in the coastal regions of Costa Rica on great plantations, a system

commonly associated with the cultivation of agricultural products for

export in many developing countries. These regions have only recently

been integrated into the Costa Rican economy and then with great diffi-

culty. Communication and transport were and are major problems. Costa

Ricans from the interior (Meseta Central) had little to do with the

development of the banana regions. In the Atlantic zone, the north

American fruit companies were responsible for developing plantations with

labor provided by Negroes from the West Indies (Hall 1976:14).

Although there is at present a small class of large landholders

resulting at first from the introduction of coffee and bananas,as noted,

and later extending to the Guanacaste area with the introduction of

cattle raising for export of beef (Edelman 1983), there has always









existed an egalitarian philosophy on the part of the government and the

upper classes. Beginning, particularly in 1948, with the progressive

reforms of Calder6n Guardia, a series of enlightened social welfare pro-

grams have been enacted concerning social security, health, housing, and

protection of children. At the present time, Costa Rica, with a popula-

tion of slightly over 2 million people, has one of the most effective

an aggressive health systems in Latin America, encompassing both cura-

tive and preventive medicine. An infant mortality rate in 1980 of 19.1

per 1000 population and a life expectancy at birth of 73.4 years (Mini-

sterio de Salud 1982) reflect the general health status of the popula-

tion. This is comparable to that of the United States in 1970 when the

infant mortality rate was 20 per 1000 population. Life expectancy at

birth in the United States in 1978 was 73 years. In 1978 the United

States had an infant mortality of 12/1000 for whites, 23.1/1000 for blacks,

and 21.1/1000 for blacks and other minorities. The infant mortality rate

overall was 13.8/1000 (U.S. Dept. of Commerce, Bureau of the Census 1981).

Other countries in Central and South America had the following infant

mortality rates: El Salvador and Guatemala in 1979, 53 per 1000 and 70.1

per 1000 respectively; Colombia, 39.5 per 1000 in 1977; and Argentina,

40.8 per 1000 in 1978 (Demographic Yearbook-1980,1982). Mata et al.

(1980a, 1981) notes that the diarrhoeal disease death rate was 11 per

100,000 with about 140 infant deaths per year due to diarrhea. No cases

of poliomyelitis or diptheria have been recorded in recent years and few

cases of measles and whooping cough, indicating a favorable national

health immunization system.

The health system, as it is currently organized, dates from the

early 1970s when the National Plan of Economic and Social Development










was implemented. This plan has as its goal the improvement of the

quantity and quality of basic services available to Costa Rican citi-

zens and was begun in rural areas in 1973 and in urban areas in 1974.

In relation to health care, these basic services involve the coopera-

tion of the Ministry of Health, the Costa Rican Social Security Adminis-

tration, the Costa Rican Institute of Aqueducts and Sewers, and the

National Insurance Institute. The goals of the program are as follows:

1. To extend basic health services to poor rural and urban com-

munities using health auxiliary workers.

2. To control and reduce infectious diseases through immunization

programs.

3. Referral of patients to either preventive or curative facili-

ties, depending on medical diagnosis.

4. Planned visits to homes and businesses to evaluate health

needs.

5. Emphasis on environmental health, health education, and com-

munity organization. (Freer Miranda 1980)

In 1966 a national nutrition survey was conducted in Costa Rica by

the Instituto de Nutricidn de Centro America y Panam--INCAP (1969).

Rawson (1975), Rawson and Valverde (1976), and Valverde et al. (1975)

investigated the nutritional status of preschool children in the com-

munity of Concepcidn de San Ram6n, Costa Rica. In general these studies

indicated nutritional deficiencies in preschool children which were

moderate but chronic. Deficiencies were more pronounced in low socio-

economic groups. According to the INCAP study (INCAP 1969), the

four types of malnutrition which most frequently occur in Costa Rica









are protein-energy malnutrition (PEM), nutritional anemias, vitamin A

deficiency, and goiter (iodine deficiency). Mata (1979), however, notes

that of these four the single most important deficiency is that of

protein-energy malnutrition, or PEM. It is the most common and has

the most complex etiology which makes its study and control more diffi-

cult.

Results of the San Ram6n study, in which the G6mez scale (Gdmez

et al. 1956) was used, revealed that 38.9% of 149 children aged 0-5 years

were of normal weight, whereas 46.3% exhibited first degree malnutrition,

13.4% second degree malnutrition, and 1.3% third degree malnutrition.

Therefore, more than half of the children (61%) were found to be below

the normal weight range. Fifteen percent were in the lowest two groups

(below 75% of normal weight). Contrary to findings already cited for

other areas, the effects of malnutrition in San Ram6n apparently become

worse as the children grow older. This pattern of chronic rather than

acute malnutrition in neonates and preschool-age children points to fac-

tors or interrelationships of causal factors different from those found

in other developing countries.

Rawson (1975) and Rawson and Valverde (1976) note a number of

socioeconomic and cultural variables associated with nutritional status.

Variables significantly (p 5 0.02) associated with childhood malnutrition

were access to less than 1.4 hectares of land, more than one sibling under

6 years of age, father works as a day laborer, mother works outside the

home, house in poor physical condition, poor stove quality, and little

access to fresh milk. Variables not significantly associated with child-

hood nutritional status included education level of the parents, type of










family unit (nuclear, extended, or single parent), sex of the child, age

at weaning, and salary income.

A more recent National Nutrition Survey (Ministerio de Salud 1978)

also noted relationships between house conditions and nutritional

status. Poor housing conditions were associated with poor nutritional

status among preschool children (Table 1). The condition of the house

was assessed on type of house construction, number of rooms, presence

and condition of bathrooms and toilets, water supply, presence and con-

dition of windows, quality of cooking facilities, etc.

Table 1 indicates that the highest prevalence of malnutrition

(G6mez's first, second, and third degree combined) in children aged 0-5

years occurs among children in poor housing in the urban areas-63.1% com-

pared to 51.3% in the dispersed rural areas and 55.5% in concentrated

rural areas. The overall national percentage of children and infants in

poor housing with first degree malnutrition is 45.1%. As housing condi-

tions improve, the proportion of children underweight for age decreases

markedly.

Some studies have suggested that malnutrition in Costa Rica is fre-

quently the result of factors other than lack of food, such as passive

child abuse manifested as neglect. Stunting and wasting were found to be

much higher among abused children (Mata et al. 1980b). Mata, in another

paper (1980), cites decreased maternal competence, failure of bonding,

and infections as factors which are just as important as available food

in the development of PEM.

Salazar and Cervantes (1979),in a preliminary report based on the

national survey, also note positive relationships between education of the










Table 1. National Distribution of Children 0-5 Years by Weight for Age
According to Condition of Housing and Degree of Urbanization


Weight for age

Condition Second and
of housing Overweight Normal First degree third degree


National

Good

Fair

Poor


Urban

Good

Fair

Poor


Concentrated
rural

Good

Fair

Poor


11.4 42.7

14.2 47.7

13.0 44.5

5.6 34.2


14.0

18.5

13.8

6.0



11.6

11.6

13.5

7.7


43.0

46.8

46.0

30.9



43.6

49.7

42.8

36.8


Dispersed rural 7.7 40.8

Good 8.4 44.5

Fair 11.5 46.2

Poor 3.8 34.4

Source: National Nutrition Survey
aG6mez (1956) classification.


37.3 8.6

31.6 6.5

36.2 6.3

45.1 15.1


37.0

30.8

36.9

49.1



36.0

29.5

36.3

43.5


39.5

40.0

34.9

43.7

(Ministerio


6.0

3.9

3.3

14.0



8.8

9.2

7.4

12.0


12.0

7.1

7.4

18.1

de Salud 1978).










head of the family and spouse and nutritional status of preschool chil-

dren. In households where the head of the household is illiterate,

57.9% of the children 0-5 years of age are malnourished based on the

G6mez scale. As the educational level increases, the proportion of mal-

nourished children decreases: secondary-level education-37% mal-

nourished; university-level education-20.2% malnourished.

The 1978 survey also revealed a downward trend in the incidence

of breast-feeding. Thirty-seven percent of infants in rural areas were

weaned in the first month of life, often at birth, and by 5-6 months

approximately 60% had been weaned to formula milks. Also, infants who

were breast-fed frequently received supplements; only 19% were exclus-

sively breast-fed at 4 months of age. In response to this problem

Dr. Leonardo Mata and his team of workers from the National Institute

for Health Research (INISA) have begun an innovative and very interest-

ing nutrition-related project. The primary site of this work is the

area of Puriscal, primarily involving dispersed and concentrated rural

settlements. The Puriscal study was begun in September 1980 in conjunc-

tion with an intervention aimed at increasing breast-feeding. All the

mothers in this area are included through the prenatal clinics. Eighty-

four percent of deliveries are in the San Juan de Dios Hospital, 13% in

maternities and clinics of San Jose,and 3 percent in the home. The

objective of the project is to increase breast-feeding by increasing

the opportunities for maternal/infant bonding in the hospital situation

after birth. Attempts were made to change hospital policy to foster

rooming-in to some degree. A milk bank was created to provide milk and

colostrum for high-risk neonates. The project includes in-home sur-

veillance as well as the hospital stimulation. The result has been a










dramatic increase in the incidence of breast-feeding in the study popula-

tion (Mata et al. 1981).

Another program of great interest is that of the canasta basica

alimentaria, or basic food basket program. This has been in the process

of development since the survey of 1966. A basic diet was elaborated

which as of 1981 included 12 basic food items considered necessary for

an adequate diet (see Table 2). This list is used to determine the im-

pact of cost-of-living increases and also to plan national food produc-

tion with the aim of ensuring adequate supplies of these items. Another

objective of the basic food basket concept is to control prices so that

these items remain within the reach of the poor (Murillo et al. 1981).

Until 1982 most of the items on this list were subject to controlled

prices. At that time, inflation forced prices to be raised. The con-

cept is still very useful, however, because it tends to focus national

attention on the basic requirements for maintaining good nutrition for

all population groups.

Costa Rica also has a nutrition rehabilitation center housed in

the facilities of the Costa Rican Institute of Investigation and Teach-

ing in Nutrition and Health (INCIENSA) located in Tres RTos. In addi-

tion to ongoing research projects, this institution is a referral center

for severely undernourished children (3rd degree by G6mez standards).

These children come from all over Costa Rica. Their numbers are rela-

tively small, however, because of the ongoing surveillance program con-

ducted by the community health workers.

As part of the national nutrition surveillance program,the System

of Nutrition Information (SIN) was set up to utilize the data which are










Table 2. Structure of the Basic Costa Rican Food Basket in Grams per
Person per Day (average for the country)


Quantity Percent of
Food (grams) Calories total calories

Milk (liquid) 445 289 9.95

Eggs 31 46 1.60

Meats 84 206 7.10

Beans 74 255 8.80

Vegetables 105 34 1.17

Fruits 44 17 0.60

Bananas and
plantains 49 56 1.95

Roots and tubers 69 78 2.70

Rice 187 682 23.50

Wheat bread 78 218 7.50

Tortilla 68 136 4.70

Sugar 102 377 13.00

Vegetable
shortening 51 447 15.40

Ground coffee 13 29 1.00

Soft drinks 96 30 1.05

Total 1496 2900 100.00


Source: Murillo and Mata (1980:101-104).









constantly being collected locally by health workers to define and de-

scribe target groups of households at risk for undernutrition on a

national level. The goal of SIN has been to develop a functional classi-

fication which involves describing categories of poor families and relat-

ing the prevalence of malnutrition with relevant specific social,

economic, and cultural factors. A functional group is defined as a set

of families sharing a similar pattern of living, that is, the same type

of production, the same type of social and economic constraints and

access to existing resources, and similar cultural practices (Valverde

et al. 1981).

Thus, while nutrition problems exist in Costa Rica, a number of

very effective and sophisticated programs exist for the purpose of evalu-

ation and surveillance of nutritional status. Nutrition problems in

Costa Rica, while not severe, are complex, requiring subtle and inno-

vative ways of measuring the extent of the problem and evaluating the

progress already made. Subsequent chapters will deal in more depth

with the statement of the problem and methods used in looking at the

status of child nutrition among the urban poor in San Jose.















CHAPTER II
STATEMENT OF THE PROBLEM

The major purpose of this research was to define biocultural

causal factors in undernutrition and retarded growth and development in

a sample of infants aged 12 to 24 months in the poor urban barrios of

San Jos6, Costa Rica. A holistic anthropological approach was used to

elucidate the diverse strategies employed at the household level which

lead to well or poorly nourished children.

Undernutrition is most prevalent among poor people; yet, among

the poor there are those who maintain good or excellent health and

nutritional status. The underlying hypothesis of this research is that

strategies of resource accrual and dispersion as well as absolute levels

of nonshelter-related real income within a household are significant

factors in the determination of nutritional status. It was anticipated

that below a certain level of income, the proportion of undernourished

children would increase dramatically with relatively small decreases in

real income. The object of the research was to do in-depth, cross-

household evaluation of resource utilization in poor households, compar-

ing those with well nourished children to those with undernourished chil-

dren.

Nutritionally related high-risk factors and strategies have been

identified for rural populations (Desai et al. 1970; Rawson and Valverde

1976). These factors tend to be related to ownership and access to farm

lands. In the urban context, however, little work has been done to


I










elucidate those factors which contribute to well or poorly nourished

children. The urban populations are of special concern because as

migration continues from rural to urban areas, the increased popula-

tion size puts pressure on the economic system to provide more jobs and

wage-related income for recent migrants. These migrants, usually young

and within the growth phase of family development, are suddenly con-

fronted with new economic and environmental stressors which require the

development of new resource-related strategies and the development of

new skills to enhance their wage-earning abilities. As a result, the

more resourceful have developed coping mechanisms which enable them to

survive on very little, primarily within the informal economy or small-

scale sector, e.g. lottery ticket sellers, street venders (Roberts 1978).

This "tertiarization" of the economy-the expansion of employment in the

commercial and service sectors rather than in manufacturing-has been

associated with urban poverty as an adaptive mechanism allowing migrants

to the city to eke out an existence. Peattie (1975) provides an excel-

lent description of how this phenomenon works in a Latin American city.

The resourcefulness of the poor is further emphasized by such works as

that of Lomnitz (1977) describing mutual reciprocity networks and Arizpe

(1980) who investigated relay migration (family members taking turns go-

ing to the city to live and work). Both of these works were carried

out in Mexico and illustrate very well that if anyone can squeeze better

nutrition out of a low income, these people can. One of the objectives

of this research was to become more familiar with these strategies as

they exist in Costa Rica and to glean knowledge which would be helpful

in understanding this complex problem.










In particular, the research focused on strategies of food acquisi-

tion and allocation within the household context and on the decision-

making associated with these strategies. As noted earlier, malnutrition

has a multifactorial etiology; nutritional and health surveys often do

not uncover the underlying and/or intervening variables which are the

essential links between access to food and the nutritional status of

the child. In addition, survey data tend to obscure intracultural di-

versity which accounts for the observation that among the poor some

children are well nourished while others are not. In short, we know

that malnutrition exists. We have many supposed causes. We do not

understand very well how these causes relate to specific cases at the

family and household level. In other words, we do not know much about

the target group, particularly in the urban areas where most of the

poor are now concentrating in developing countries. It may be that

below a certain level of income the only way to improve nutrition is to

increase income. Above this income level, however, there is a tremen-

dous gray area which still includes many families in which there are

undernourished children. This gray zone may be amenable to many kinds

of programs, such as education, food subsidies, etc. The problem occurs

when a program is aimed at those people below the crucial economic

level but uses methods which are meant for the people in the gray zone.

The program may then be evaluated as a failure when very few people in

the target group respond to it. Or it may be judged as a success by

the number of people participating but yet not reach those who are

critically in need of assistance. This research, therefore, was aimed

at investigating intracultural diversity at the household level by use of










a variety of research techniques to obtain a clearer picture of causal

factors involved in undernutrition of specific groups. This research

contributes methods for characterizing children at risk nutritionally

which allows more effective targeting of nutrition intervention pro-

grams.

Data indicating the importance of family structure to the sur-

vival of low income families came from an in-depth multidisciplinary

study done in the urban barrios of San Jos6 which focused on marijuana

use by adult males (Carter et al. 1976). This study contains some in-

formation on the nutritional status of adult males. More important

for the purposes of this research was the information on family dynam-

ics, kinship-based networks, and the general environment of lower-class

neighborhoods. As described by the adult male informants in the study,

a typical family of orientation has about five members, including both

parents, two or three children, and occasionally a bilateral relative

such as a sibling or an aging parent. The range in family size, how-

ever, is reported to be wide. A frequent pattern encountered was a

periodic doubling up on space within an extended family group to reduce

costs during periods of economic stress, which frequently occurs be-

cause many children and adults are seasonal laborers. In this study

20% of the marihuana users and 5% of the nonusers came from single

parent households headed by the mother. Often surrogate parents, e.g.

grandmothers, aunts, or uncles, were child caretakers. In contrast to

other areas in Latin America, fictive kinship, godparents, and com-

padrazgo are relatively unimportant (True 1976:69).

Although the households were found to be largely restricted to the

immediate nuclear family, both marihuana users and nonusers were almost










always in constant contact with extended kindred networks. These net-

works are potentially very important to the nutritional status of the

child since they tend to be the source of most surrogate parents and

kin may share food, material goods, and money.

Costan Rican anthropologist Eugenia Lopez de Piza (1979:4-5) has

described four family types which she had found to be common in Costa

Rica: the nuclear family, consisting of father or father substitute,

mother, and children; the extended family, consisting of related nuclear

families; the matrifocal family centered around the mother and her chil-

dren; and what she has termed the "Queen Bee" family, which is a vari-

ant of the matrifocal type and consists of the grandmother, her daugh-

ters, and their childern. In this latter family type, the daughters

work and the grandmother cares for the children and controls the money.

This extended matrifocal family is similar in structure and function to

the three-generation family with a female head described by R. T. Smith

(1956:106) for British Guiana. It is also similar to the "grandmother

families" described by M. G. Smith (1962) for the West Indies. Lopez

de Piza (1979:15) calls the matrifocal family in Costa Rica, particu-

larly the "Queen Bee" variant, the best adaptive mechanism enabling

poor women to obtain economic necessities and care for and educate chil-

dren.

Mothering ability or maternal competence is another factor which

has been implicated as a risk factor for malnutrition. Mata (1979) in

Costa Rica cites deficiencies in maternal technology and social path-

ology as becoming increasingly important causal factors in child mal-

nutrition in modern times. Alvarez et al. (1977) in Chile found that










maternal education levels were important in influencing the development

of healthful food habits among children.

Data from the study on marihauna consumption in San Jos6 indi-

cated that while most subjects reported that meals were prepared and

served at regular hours in their homes, because of employment hours

at least half of the males did not eat at the same time as the rest of

the family. The rest of the family (mother/wife, children, and other),

however, generally followed a regular schedule for meals (Rawson and

Phillips Arizmendi 1976:589-590).

Alcohol use by a parent was cited as a cause for going hungry and

other unhappy childhood experiences which could directly affect the

nutritional status of young children. Slightly less than half of mari-

huana users and nonusers had fathers who drank heavily (True et al.

1976; True 1976).

A model was developed based on prior work done in San Ram6n, a

small village, and the surrounding rural area by Rawson (1975). This

model was modified to make it more appropriate for testing in the urban

situation and to include most of the risk factors already mentioned.

Figure 2 illustrates this model. The model was to be tested through

the collection of extensive biocultural data and by use of a mixed

cross-sectional and longitudinal design. Both the methodologies and

the model were to be evaluated for applicability to other urban set-

tings.

Unlike Rawson's study (1975) in which the basic independent

variable was access to an adequate amount of agricultural land (i.e.

two manzanas, or 1.4 hectares), this study used a factor labeled "real
















































































































NOuilunN1IVV tiO ASIH MOT


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s:


NOIIiIinN'iVN HO: ASIaH HDIH










income." "Real income" is composed of wages, credit, savings, monetary

gifts, inheritance, etc., averaged weekly to allow for variations such

as seasonal ones. There were a number of intervening variables involv-

ing the allocation of resources, the adequacy of the physical environ-

ment, and the quality of child care. These variables were directly

observable and measurable and are described in Chapter III in the sec-

tion on methods.

One of the objectives of the study was to augment the community-

based nutritional research completed by the Ministry of Health, the

National Institute for Health Research (INISA), and the Costa Rican

Institute for Research and Training in Nutrition and Health (INCIENSA).

The project emphasized a longitudinal, in-depth behavioral approach

which was used to delineate the variables and diversity of coping

strategies leading to poor and well nourished children among the urban

poor. This information will be used to characterize that portion of

the population which is at greatest risk for malnutrition and to assist

in the development of intervention programs which are targeted specifi-

cally at the high risk group. This approach has as its goal the con-

servation of scarce resources by facilitating directed programs which

provide the greatest return on invested materials and manpower. The

identification of risk factors and strategies which lead to malnutri-

tion on the basis of household data can be extrapolated for use on the

community level.














CHAPTER III
METHODS


Phase I: Setup

Contacts

In my position as field director of the project,I traveled to

Costa Rica in August 1981. The appropriate contacts were made with the

project consultants,Dr. Carlos Diaz Amador, director of the Department

of Nutrition of the Ministry of Health, and Dr. Jos6 A. Camacho, profes-

sor of anthropology at the University of Costa Rica. Through these

individuals, contacts were made with the director of the Community Health

Program, Dr. Enrique Freer Miranda, and Dr. J. Manual Alvarado Obando,

director of Health Region 1, which has metropolitan San Jos6 in its juris-

diction. After obtaining the appropriate authorization, contacts were

made with the directors and personnel of all the health centers from

which the samples of children were to be drawn. This selection was made

with the aid of Dr. Diaz Amador and Dr. Camacho and by use of the criteria

of a large population of poor people and, where possible, areas which

had not been overstudied by various investigators in the past.

Spanish translations of the proposed project and the permission

form to be used for inclusion of each child in the study were presented

to the Ministry of Health and were approved.


Archival Research

Archival research was carried out in the libraries of the Univer-

sity of Costa Rica, the National Children's Hospital, the Costa Rican










Institute for Research and Teaching in Nutrition (INCIENSA) at Tres Rfos,

the National Museum, and the Ministry of Health. Documents were also ob-

tained from the National Office of Planning (OFIPLAN), the National

Nutrition Information System (SIN), the Ministry of Health, and the

National Institute for Research in Health (INISA).


Interviewers

Through the auspices of Dr. Enrique Freer Miranda, head of the

Community Health Program at the time of this study, two women who had

worked for four years as health auxiliary workers in the Hatillo Health

Center were hired. These two women, Flory Desanti Jimenez and Eulalia

Obando Naranjo, worked with me to develop the survey instruments,

assisting particularly with translation of the language to the idiomatic

Spanish of the urban lower class. They were also trained to conduct

structured interviews, do anthropometric measurements, and give the

Denver Developmental Screening Test (DDST).


Pretest

With the help of the two interviewers, 10 households were chosen

from various neighborhoods which had people similar to the sample popu-

lation but which were not to be included in the survey. In these house-

holds children were weighed and measured, interview schedules were filled

out, and the Denver Developmental Screening Test (DDST) was given.

Polaroid photos were taken and left with each family.

In addition to this pretest situation, prior to the beginning of

the formal study, about 70 children from a squatter settlement were

measured and weighed to provide additional training in measurement tech-

niques for the research assistants. These children are not included in






35

this study, however. The DDST was also given to 30 children with myself,

Flory, and Eulalia scoring each test simultaneously. By the time the

formal investigation was begun,everyone was comfortable with all instru-

ments and procedures. There was also very little variance in the manner

with which each procedure was carried out.


Phase II: Initial Survey Target Population
and Sampling Design

Greater San Jos--San Josd and surrounding urban areas--had a

population in 1973 of 837,000 which is projected to reach 1.8 million

people by the year 2000, increasing the present labor force from 260,000

to 500,000 persons. In 1976 there were more than 240 slums in the

metropolitan area in which there were one-room shacks occupied by

several families, according to a USAID report (1976). According to this

report, there were an estimated 110,986 families in Costa Rice (average

family size-6 persons) which were considered mas pobres ("more poor" or

"poor poor") with incomes of less than $825 per year. Of these families

40.6% (45,000) lived in greater San Jose. In addition, there were

197,268 other families who were considered pobres ("poor" or "rich poor")

with incomes below $1,395 per year. Of these families 53% (104,610)

lived in the greater San Jose area. The income figures are based on cen-

sus data and primarily refer to salary income. More recent data was

difficult to obtain because similar USAID reports and Costa Rican

government reports are now considered classified material and I was not

allowed access to them. It is doubtful if the situation described has

changed much for the better, however. If anything, things are prob-

ably worse because Costa Rica has suffered an economic crisis and in-

flation has changed the value of the colon from (12.50 per $1 to










(40-60 per $1 in 1981-82. Times are tougher and Costa Rica has been

hard pressed to try to pay off its foreign debt. It has also had a

tremendous influx of refugees from Nicaragua, El Salvador, and Guate-

mata, an additional drain on the economy.

Seven health centers were selected as sites for obtaining the

sample population. They were Hatillo, Alajuelita, Pavas, Tibas, Paso

Ancho, Guadalupe, and Cristo Rey. The areas selected were known to

have a high percentage of poor people. Figure 3 shows the distribution

of this population, Although each of these health center regions has

some more well-to-do neighborhoods included in its jurisdiction,

only areas noted as very poor were selected, e.g. Calle Blancos, Cinco

Esquinas, Concepci6n de Alajuelita, La Esperanza in Pavas. A sampling

frame was constructed from birth records kept by each health auxiliary

worker for his/her district. All the children born in 1980 in each of

the areas selected were placed on a list and given a number. A table

of random numbers was used in selecting over 200 children. After each

child was selected from the birth registry, his or her family record

was located and the address and other social data noted. About 50 to

60 of these could not be located in the files of the health auxiliary

workers. Another 25 to 30 were located in the file but when the health

auxiliary worker arrived in the neighborhood, they had moved and left

no forwarding address. The final large sample contained 107 children.

In each of these 107 families, a family registry, or listing, of all

members of the household, their ages, sex, education,and migration

history was taken. In addition to these data a medical history of the

child during the past year, an assessment of material level of living




























09
C









and quality of the environment, an examination of the child for clinical

symptoms of malnutrition, and anthropometric measurements of the index

child were obtained. The Denver Developmental Screening Test (DDST)

was also performed on this initial visit. (See Appendices 1-5 for

examples of the forms used.)


Anthropometry

The following measurements were carried out according to the IBP

Handbook protocols (Weiner and Lourie 1969).

Length. This was taken in centimeters by use of a headboard with a

metal tape measure attached which could be taped to a hard surface such

as the floor or a table. Another board was then held up to the bottom

of the feet to determine the length. This instrument was adapted to fit

into a shoulder bag because bus transportation was used at all times.

Weight. In the interest of making the instruments portable, it

was decided to use a bathroom-type scale. Most of the children being

measured could walk; therefore this was not a problem. Three scales were

obtained; each of these was tested with standard weights up to 30 kilos

and found to be accurate. Thereafter they were tested every 6 weeks.

Before use the scales were placed on zero. The weight was obtained with

the child wearing light clothing and without shoes.

Triceps and subscapular skinfolds. These measurements were ob-

tained in millimeters with Lange skinfold calipers. These measurements

were taken on the large sample at the beginning of the in-depth study

and at the end of the in-depth study. It was decided not to take them

each time because of the difficulty of doing this accurately with chil-

dren and because of the need to have only one person take the measure-

ments. Thus, I took all the skinfold measurements.









Arm and head circumference. These measurements were taken in cen-

timeters with a fiberglass nonstretchable measuring tape.


Denver Development Screening Test (DDST)

The Denver Developmental Screening Test is a simple and effective

way of assessing the developmental status of children during the first

6 years of life. It evaluates the following aspects of the child's

functioning: Gross motor, fine motor-adaptive, language, and personal-

social areas. The test relies on observations of what the child can do

and on reports by a parent or parent surrogate who knows the child.

Direct observation is used whenever possible. The younger child may be

tested while sitting on the mother's lap, which is the procedure we used.

The test is easy to administer, score, and interpret and is useful for

repeated evaluations of the same child. The test has a high rate of

validity and reliability (Camp et al. 1977; Frankenburg and Dodds 1967;

Frankenburg et al. 1971a, 1971b, 1971c). It is not an intelligence

test but is intended as a screening instrument for use in clinical prac-

tice to note whether the growth and development of a particular child

is within the normal range.

Because the DDST was standardized on the Denver population, it has

been noted that some of the norms are not applicable to children in other

cultural areas (Bryant et al. 1974; Solomons and Solomons 1975). It has.

been successfully adapted and standardized for use in Japan and Okinawa

(Ueda 1977a, 1977b). It has been translated into Spanish and has been used

to some extent in Guatemala, Chile (Fandal 1980), and Yucatan, Mexico

(Solomons and Solomons 1975 ). The test has also been used cross culturally

in the United States (Frankenburg etal. 1975). Upon arriving in Costa Rica,










I discovered that research conducted by the University of Costa Rica

had been carried out to standardize the DDST for use in Costa Rica and

Central America (Howard and Nieto de Salazar 1982). However, because

this standardization was not yet complete and because of what I per-

ceived as problems with the design of the standardization research, I

decided to use the official Spanish version of the DDST,which had been

obtained from the La Doca Foundation in Denver, Colorado. Because the

comparisons to be made were to be within a cultural group rather than

between cultural groups, I felt that the results from this point of view

would be valid in spite of any possible cultural biases inherent in the

test. However, many of the suggestions developed by the Costa Rican

group to facilitate administration of the test to the local population

were incorporated.

The DDST was given on the first visit to all 107 children included

in the sample. After it was explained and demonstrated, it was found to

be of great interest to the people and proved to be an excellent entree,

providing parents with graphic demonstrations of their children's

abilities in various areas. It was repeated once more,after at least

three months had passed,on the smaller group of 44 children included in

the in-depth study.


Material Level of Living:
Quality of Environment

A checklist was used to assess the material level of living, e.g.

presence or absence of radios, TV's, sewing machines, and other indica-

tors of quality of life. Quality of the living environment was also

assessed with an evaluation of the condition of the house, type of










construction, number of rooms, number of people per room, number of beds,

type of cooking facilities, disposition of excreta and garbage, light-

ing, ventilation, and other aspects of the environment (see Appendix 4).


Assessment of Clinical Signs
of Malnutrition

A list of symptoms of primary clinical malnutrition was developed

by use of the form suggested by Rawson (1975) which was then adapted

for use in San Jose with the aid of Dr. Carlos Diaz Amador, director of

the Department of Nutrition of the Ministry of Health. (See Appendix 6

for a copy of this list). I performed this examination on all the chil-

dren.


Phase III: In-Depth Longitudinal Study

Because the initial large sample showed very few children at or

below the fifth percentile of weight for height when the NCHS statistics

were used (probably because of the excellent national program of nutri-

tion, surveillance, and intervention), it was decided to focus on the

mildly to moderately undernourished child, victim of invisible malnutri-

tion,as it has been termed (International Health News 1983), currently

the major problem for Costa Rica and many other developing countries.

The criteria for severely undernourished children are quite clear,

e.g. fifth percentile or below on the growth charts of the National

Center for Health Statistics (NCHS), 80% of the median or below, again

on the NCHS growth charts (Mata 1978a; Waterlow and Rutishauser 1974),

or second and third degree malnutrition by the classification of G6mez

(1956). On the G6mez scale, which is based on weight for age, normal










is 91-110% of standard weight for age, first degree malnutrition is 79-

90% of standard weight for age, second degree malnutrition is 61-75% of

the standard, and third degree malnutrition is 60% or less of the stan-

dard (G6mez el al. 1956:77). In recent years the classification of

G6mez et al. has come under criticism because it is based on standards

developed among much heavier children than is the norm in Latin

America and other parts of the third world. Mata (1978a) notes that it

was developed more than 20 years ago as a means of categorizing children

admitted to the hospital for treatment of malnutrition and was not in-

tended to apply to the general population. Generally the trend has been

to use weight for height as the criterion for determining acute malnutri-

tion, and height for age as the indicator of long-term nutritional status.

Recently the concepts of wasting(deficit in weight/height) and stunting

(deficit in height/age) have been introduced to allow populations to be

classified in different groups for intervention purposes (Mata 1978b;

Waterlow and Rutishauser 1974).

As mentioned already, the criteria for severely undernourished

children are clear; however, the cut-off point for delineation of mildly

undernourished children with subclinical malnutrition is not so easily

determined. The Costa Rican Ministry of Health uses growth charts based

on NCHS standards and considers children to be moderately under-

nourished if they are at or below 90% of the median. Because of a

decision to focus on the mildly to moderately undernourished child, the

in-depth sample included all those children who were at or below 90%

of the median of NCHS standards and/or had at least first degree malnutri-

tion by the scale of G6mez et al. Originally there were 26children falling










into this category. Two were eliminated because they had had ill-

nesses shortly after birth (meningitis and encephalitis) which had left

such effects that it would have been impossible to say what retarda-

tion in growth and development was due to undernutrition and what was

due to disease processes and their residuals. Of the 24 left, only

19 agreed to participate. Another group of children was selected, by

use of the table of random numbers, from the remaining 81 normal weight/

height children. The families of 25 of these children agreed to let

them participate in the in-depth study. In the end there were 26 males

and 18 females participating. Ten of the females and 9 of the males

were in the low weight/height group. Eight of the females and 17 males

were in the normal weight/height group. Among the normal group, the ran-

dom selection yielded very nearly an equal number of boys and girls.

The difference apparently results from the fact that more of the parents

of boys were willing to let them participate then were parents of

girls. It is not certain whether this is a chance occurrence or some

cultural bias having to do with boys and their roles and position in

society.


Long-Term Data Gathering

The plan had originally been to pick up the children to be fol-

lowed in groups of 10, adding another increment of 10 each month until

all were being followed and then gradually tapering off as the 6 months

of surveillance were reached. At the time the in-depth portion of the

research was to begin, however, the political situation in Costa Rica

and all Central America seemed quite tense. It was just prior to the

elections, there had been some terrorist activity, arms caches had been










found, and there had been border incidents with Nicaragua. Because of

these factors and because the interviewers proved to be very capable

and easily trained, a decision was made to carry all the families simul-

taneously, visiting each family every month for measurements and addi-

tional data gathering. Each visit had to be made within six days

either before or after the date which equaled one month exactly from the

last visit. The object was to make the data-gathering period as compact

as possible in case there developed a situation in which the ability to

visit families living in slum areas would be interrupted. This arrange-

ment worked out well, proving to be a better plan than the original.

In addition to the family registry, anthropometry, medical history

of the child, checklist of material living conditions and quality of the

environment, and assessment of clinical malnutrition already mentioned,

several other types of data were obtained.


Assessment of Socioeconomic Status

This interview schedule included data about the occupations, in-

come, expenditures, gifts, etc., of all members of the household. Be-

cause of the sensitive nature of these data and our wish to keep every-

one in the study for all of the 6 months, this schedule was not adminis-

tered until we had been visiting the family about 4 or 5 months. Only

after that time did we feel enough rapport had been established to enable

us to attempt to elicit information about socioeconomic status with any

accuracy. (See Appendix 7 for a copy of this schedule.)

Weekly Marketing Items and Food Budget

With the help of the two interviewers, a schedule was constructed

which elicited the frequency, place of purchase, and cost of the foods










commonly purchased. This information was used to construct a monthly

food budget and was generally elicited at the same time as the socio-

economic data, both being rather sensitive in nature. In addition to

this information, shopping lists were obtained from several families

and other families were accompanied on food-buying trips by myself.

The object of this data was to determine what kind of access people had

to food supplies and how they allocated their resources with respect to

food purchasing (see Appendix 8).


Maternal Reproductive History

This schedule included data about parity, number of pregnancies,

complications of pregnancy, miscarriages, length of pregnancy, and pat-

terns of breast-feeding. This material was not deemed to be sensitive

because women tend to talk with each other and other people about their

ills and pregnancies, thus it was administered early in the study to the

mother of the index child. Generally, the women seemed to enjoy reminisc-

ing about their pregnancies and problems associated with them. (Appendix

9 contains a copy of this schedule.)


Dietary Data

In addition to buying patterns relative to food, dietary data were

elicited in two ways. The first was a 24-hour recall of what the index

child had eaten. Four of these were obtained, one for the weekend and

one for the weekday during the dry season (December to April) and one for

each weekend and weekday during the rainy season (May to November). Be-

cause of the difficulty of being able to arrive on the appropriate day

for the recall, some were done by us as 24-hour recalls and the rest










were left with the mother or mother substitute to be filled out as a

diary for the day needed, e.g. a Saturday or Sunday. We did not have

high hopes for the success of this method and only resorted to it

several months into the study when we lacked needed data. Much to our

surprise, the mothers were highly motivated and we received all but two

reports back. These data were not used as a way of determining indi-

vidual intake because of the errors inherent to recall data (Acheson

1980; Bernard et al. in press; Morrison et al. 1959) (e.g. 20-50%

rate of error in recording intake), but rather as a way to get an idea

of the typical diet of the child in relation to family food consump-

tion and customs associated with mealtimes.


Q-Sort Techniques

A Q-sort of 100 cards of local foods most frequently consumed was

devised. The Q-sort techniques have been adapted from Stephenson (1953).

Correlational methods for analysis of ordinal and nominal data were em-

ployed as suggested by Cohen (1957) and Wittenborn (1961). The Q-sort

used in this research was adapted from that described by Fitzgerald

(1977), who used it to develop a food choices game. The same type of

game was developed for this study and was adapted to local food habits.

Fitgerald noted that the advantage of using this type of approach rather

than just an interview to elicit recall data is that it is non-

threatening and involves active participation. We found this to be

true. Even though the mother, or the principal caretaker, of the index

child was the one asked to perform the sort with the food cards, many

times it ended being a family consensus, which is probably a more accu-

rate reflection of the food habits of the family anyway according to the










findings of Bernard et al. (in press) regarding the increased accuracy

of recall data among groups as compared to individuals. Five different

kinds of information about food habits were elicited by use of this

procedure (not all at the same time). First a food frequency test was

done. Then the mothers were asked to sort those foods most liked and

least liked, those considered most nutritious and least nutritious,

those most appropriate for the index child, and the informant's own

classification of the 100 cards by whatever criteria she cared to devise.


Observation of the Index Child

In addition to the data mentioned already, each child was observed

for 4-5 hours during the morning of one day. Procedures described by

Spradley (1980) and Wilson (1977) were incorporated into an adaptation of

child-following as described by Wilson (1974). The behavior of the child

and the family in general were the target of this observation. Although

what was eaten by the child during the time the observer was there was

recorded, these data were not used to determine the intake of the child

but rather to learn something about mealtimes, intrafamily food distri-

bution, how the child was cared for, how he/she ate, and family inter-

actions. Because of the large number of children to be observed in a

relatively short time, it was considered unfeasible to carry out child-

following as Wilson had described it. Instead an attempt was made to

observe during a similar period of time in each household in the same

way so that the observer bias at least would be the same and, it was

hoped, the data would provide a sample of what happened during the same pe-

riod of time in each child's day. This observation was done only after at

least 3 or 4 visits monthly had been carried out. Because it is rather










inconvenient for a family to have a stranger in their house for half a

day, appointments were set up in advance. The observations were car-

ried out only by myself. The people were very cooperative and, al-

though undoubtedly some things were changed because of prior knowledge

of the visits, i.e. the house was made cleaner and perhaps a special

effort with the food served was made, the observations were believed

to be of great value in understanding the family environment. The

cooperation of the family seemed to be enhanced also by the fact that

we made appointments with them. Although the sampling procedures may

have suffered because people knew an observer was coming, rapport with

and confidence in the researchers were increased.

The total observation period was usually 4-6 hours in length;

however, the child's behavior was recorded every 15 minutes for 3

minutes on a checklist during only 3 hours of that time. Ethnographic

notes were recorded every 15 minutes during the entire observation

period, and included information about behavior, food eaten, and any

other activities which were of interest (see Appendix 10 for a copy of

the checklist of behaviors). The family was informed before the obser-

vation was set up that I would be making notes of the child's behavior.

Because the focus of attention was on the index child, the pressure

was taken off the other family members to a large extent, thus making

them more at ease. A short, informal history of the family was also in-

cluded at the end of the observation because by that time I had been able

to elicit that kind of information. Photos were also taken to illustrate

some of the child's behaviors. Because photos are expensive, they were

taken only when the child changed behavior rather than every 15 minutes.










A copy of the photos was given to each family. This gesture was very

well received.

One of the interesting offshoots of this in-home observation was

a first-hand acquaintance with Costa Rican cuisine because I was expec-

ted to eat with each family. Because among Costa Ricans sharing food

is an integral part of social behavior, these invitations were not to

be taken lightly, even though most families could ill afford another

mouth to feed. I used the opportunity dining with each family pres-

ented to gather data about typical menus served. A wide range in the

quality of the cooking was noted; some food was excellent and some was

terrible. I found that good cooks can make tasty dishes with very

little money to spend.


Fees Paid to Subjects

In order to provide an incentive for each family to remain in the

study for the entire time, the project had been set up to pay a certain

fee each month. Originally this sum had been set at $5; inflation,

however, had so affected the exchange rate that this sum had become a

fairly large amount in colones. The project advisors, Dr. Diaz Amador

and Dr. Camacho, did not believe that it would be wise to pay that sum

because it would set a precedent which could make data gathering harder

for other individuals and organizations whose budgets did not include

money for fees to be paid to subjects. It was also feared that too

high an amount would affect socioeconomic status unduly. The sum

finally agreed upon was (125, which was at the time the equivalent of

$2 and was approximately the amount a semiskilled worker would receive

for a day's wages. The extra money was used to give each family the


I










photos mentioned earlier and for a small gift for each child at the end

of the study.

I believe that the monthly sum did help keep a number of the

families in the study, particularly those who were extremely poor. I

provided each family with my telephone number and instructions to call

me if they were going to move so that we could get directions to the

new home. Also they were to call if for some reason they could not be

there on the day we were to visit,because we were trying very hand to

be as precise as possible in getting measurements at one-month intervals.

I really had no great hopes that people would call because almost all

had to use public telephones, but much to my surprise I regularly got

calls advising me of changes needed in scheduling,and of changing

addresses from those three families who proved to be nomadic. Also a

number of the mothers began to call periodically to ask advice about

many things. One of the ideas I tried to impress upon each family was

how important the information they could give me was. Because I re-

garded their input as important, they too seemed to take things more

seriously. At any rate we lost none of the 44 families during the 6

months of observation.

Table 3 presents a summary of the various methods used, along with

their frequency, who performed them, and which informant was used.

Phase IV: Data Analysis

The data were coded and entered into the computer for data manipu-

lation and analysis. The Statistical Analysis System (SAS) was used for

descriptive and inferential statistical analyses, including multivariate

techniques for correlation, analysis of variance, and various





















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53



nonparametric statistical techniques. These statistical analyses, along

with a discussion of the results, will be discussed in more detail in

Chapters IV and V.















CHAPTER IV
SOCIOCULTURAL PARAMETERS AFFECTING THE NUTRITION, GROWTH,
AND DEVELOPMENT OF THE CHILD


Family Networks

Social interaction in Costa Rica is based on kinship. At all

levels of social class, the persons with whom an individual is most

likely to celebrate New Year's Eve or Christmas, or upon whom he or she

depends in times of emergency, are family members. First impressions

may lead the outsider to assume that there exists a great deal of

"neighboring," i.e. interaction between nonrelated individuals who live

close to one another. A closer look, however, will show that in most

cases where neighbors interact they are also related. The barrios in

which this study was carried out were dotted with clusters of two or

more related families. Over 50% of the 44 families in the in-depth

study had relatives as neighbors.

Although the scope of this research did not include a rigorous

description of the networks which do exist, an acquaintance of any depth

and over a length of time will automatically bring one in contact with

these kinship-based networks. Usually there are two major networks

within each household: one with the wife as a link to her family and

the other linking the husband to his family. Sometimes one of these two

networks may be nonfunctional, depending on the physical distance be-

tween family members and the strength of their relationship with one

another.










The basic importance of the family within the overall Costa Rican

social structure has ramifications for the nutritional status of the

child. Among the families followed, I found this kin-based network to

be the primary source of financial assistance in times of economic

depression, not unlike the situation observed by Safa (1974) in the

Shantytown families of Puerto Rico. It is also the main source of

mother substitutes or child caretakers should the mother of a child

need to work or should something happen to her. There is a lot of food

sharing, not only of foodstuffs but also of meals eaten at one another's

house. The latter is particularly important for children.

True (1976), in the study of marihuana users, mentions that

among the poor there are two social spheres, that of the woman and that

of her husband or companion. My research did not contradict this find-

ing but rather found the same kind of division. My experience, how-

ever, put me in contact primarily with the people included in the mater-

nal networks.


Family Structure

Of the 44 families in the in-depth study, 11, or 25%, were matri-

focal families. Only one did not fit the definition of the "Queen Bee,"

or "grandmother,"matrifocal family described earlier. The one which did

not fit was a "Queen Bee" type which had broken down; i.e. the grand-

mother and great grandmother had refused to let a granddaughter and her

children live with them any longer. However, she still spent most of

the day with them. It was also noted that "Queen Bee" families could

include grown sons who were not married.










Of the 44 families, 11, or 25%, were extended families. The

extended family as I found it included various persons from different

nuclear families, although these might not be complete families, e.g.

daughters or sons and their children and possibly a spouse. The

extended family always had a male as its head, however.

Of the 44 families, 22, or 50%, were nuclear families. In San

Jos6, however, the designation nuclear family can be misleading. For

example, I followed two children from nuclear families who lived in

one of the barrios of Alajuelita. The first family consisted of Miguel

and Antonia and their two children. They lived in a complex of three

other separate houses on the same block. Antonia's parents lived in

front; her sister, at one side; and her brother,in a house behind their

house. They all shopped together on Saturdays (at the farmer's market

or the central market) and the children were in and out of all the

houses and could eat at any of them. Goods, food, and services were

exchanged freely. For all practical purposes, they functioned as an

extended family but had separate dwellings.

Not far from Miguel and Antonia, another family lived in similar

circumstances. Jose and Sara Lived as a nuclear family with their three

children; however, they too lived in a family complex consisting of

several of Josd's brothers, a sister, and his parents. Figure 4 shows

this layout-a pattern frequently found among the families in this

study and also among many middle and upper class families who were

social acquaintances. Thus it seems to be that the term nuclear

family has a very different connotation in Costa Rica from that exist-

ing elsewhere. The main difference between the nuclear family and the

















Jose's
Brother




Jose Empty lot
and Sara proposed site
of house for
another brother



Jose's
Sister Courtyard





Jose's Jose's
Parents older Brother



Main Street


Figure 4. Diagram of the Family Complex of Jos6 and Sara.









extended family in many cases is that in the former the family members

have separate roofs and may cook separately; otherwise they act much

like a traditional extended family.

R. T. Smith (1970) had observed almost 30 years earlier that matri-

focality is associated with a class position at the lowest rank of

society. Vertical mobility is limited and the men are usually unskilled

laborers holding jobs which have little prestige. He sees matrifocality

as being the final phase of a cyclical process which includes a period

of sex experimentation and spouse selection, the nuclear family, and

finally the matrifocal household, which occurs when the role of wife-

mother gradually gains dominance over the role of husband-father.

In Costa Rica, as greater job opportunities have become available

for women in the textile and garment industries, women have become more

independent, a phenomenon Safa (1974) also found in Puerto Rico. With

this independence has come a decreased need for marriage to obtain

financial security and thus leaving little, in many cases, to hold a

man and his wife together. Here as in Puerto Rico, each is bound to

his/her own kin group, blood ties being more important than marriage.

Given this situation, marital problems such as alcoholism or unemploy-

ment on the part of the husband have tended to result in the formation

of the matrifocal family. The "Queen Bee," or "Grandmother," family

seems to result when daughters, able to obtain employment, find formal

marriage unnecessary or impractical because they can remain in their

mother's house and raise their children there. Increased availability

of employment for women may be encouraging a trend toward elimination

of the nuclear family phase of family evolution described by Smith.









The Program of Social Welfare and Family Aid (Programa de Desarrollo

Social y Asignaciones Familiares), which has been created to aid low-

income children and pregnant and lactating mothers, may have a ten-

dency to make poor families, particularly female-headed families, more

dependent on public aid, not unlike the situation described by Safa

(1974:46) for urban Puerto Rico.

As noted earlier, in Costa Rica the matrifocal family particularly

the "Queen Bee," or "Grandmother" variant, has been considered an excel-

lent adaptive mechanism enabling poor women to obtain economic necessi-

ties and care for their children and to educate them (Lopez de Piza

1979:15). The data gathered in this study tended to verify this find-

ing. Only 3, or 27%, of the matrifocal families had children in the

low weight/height group. Although income on the family level did not

differ significantly between male-headed and female-headed households,

per capital income did. Female-headed households had a per capital income

of t580/month ($14/month based on an exchange rate of $1/45) whereas

male-headed households had a per capital income of 821/month ($18/month).

The general linear model (GLM) (SAS, 1982) was used to run an analysis

of variance and a Duncan test of the means. This analysis indicated

that female-headed households were significantly larger, with a mean of

8.1 persons as opposed to 5.7 in male-headed households (F=7.34, pO.01).

In general, then, female-headed households had smaller individual

salaries but there were more persons working and pooling resources,

which compensated for the low salaries.

An example of this phenomenon is the household of Doia Pilar,

who left her husband years ago because of his drinking. She lives with

her daughters and three grandchildren. Three of her daughters work in









the garment industry, making clothing. Sara and Reina work in a factory;

Luz works in a smaller establishment. Yolanda, the youngest, has been

under treatment for psychiatric problems. Dona Pilar cares for the

children and also sews at home. (Figure 5 shows a diagram of this

family.) The three working daughters earn g2400, 02000, and (1200

respectively for a combined income of (5600 ($124) per month, which

puts them slightly above the mean for female-headed families (X=04697,

or $104) and for male-headed families (X=C4719, or $105). A total of

03742 ($83) is spent on food each month and (650 ($14) for rent and

utilities. This leaves &1208 ($27) to be spent on clothes and other

incidentals. They receive medical care through the social security

clinics and the neighborhood health center. They speak of wanting to

move to a new housing project but remain where they are because rent

is cheap, allowing them to spend more on food, clothing, and other

incidentals.


Food-Buying Patterns

Relating family structure to food-purchasing patterns, I found

that in the female-headed household the person in charge of purchasing

is usually also the principal child caretaker. This means that the

buyer for a female-headed household has much less mobility and greater

dependency on local corner grocery stores (pulperfas) and street vendors

whose products are usually more expensive. She has the alternative of

taking small children along, leaving them alone for a period of time,

or sending an older child to the store with a list of groceries.

In male-headed families, in contrast, 36% of the time the man is

the main buyer and 39% of the time both the husband and wife do the shop-

ping. Only 12% of the time is the wife the principal buyer.
















Doa Pilar
Doi~a Pilarl


Sara Reina Luz Yolanda




Juan Maria Jose


(Index Child)


A Absent


Figure 5. Kinship Chart of the Family of Doia Pilar. This is an
Example of the Extended Matrifocal, or "Queen Bee," Family.


t


-- --


----










In general, male-headed households were better able to patronize

the subsidized state-run food outlets, the central market, larger

grocery stores (almacenes), and other places which tend to offer better

prices, whereas female-headed families were dependent on what could be

bought within walking distance. Male-headed households spent an

average of 43884 ($86) per month on food, which was 82% of the total

family income. Female-headed families spent an average of t3790 ($84)

per month, or 81%, of their total family income. Per capital expenditure

on food, however, differed more. Male-headed families spent /670 per

capital ($14), whereas famale-headed families spent (468 per capital ($10)

per month (see Table 4). All families used bus transportation and most

bought groceries with cash (over 90%) rather than on credit. Family

members tended to get food or money to buy food from their kin networks

rather than having the local corner grocery store extend credit.


Child Rearing

Children occupy a favorable position in Costa Rica. The birth of

a child is usually a welcome event. Lomnitz (1977) notes that in

Mexico this attitude is common among members of marginal populations

because children represent a potential cheap source of income. Their

cooperation is dependable and the cost of their maintenance insignifi-

cant. The same is apparently true in Costa Rica among the poor, al-

though children also seem to be valued for themselves, as family mem-

bers and as sources of pride and prestige. Positive attitudes toward

children are evident throughout Costa Rican society. At the national

level the Patronato Nacional de la Infancia has been formed to serve

as the watchdog of children's rights. Over 60% of community health











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programs concern maternal and child health (Freer Miranda 1980). There

is a children's library in the main plaza of San Jos6 and a fine chil-

dren's hospital, as well as many other services for children.

Aside from these indications, I found the attitudes toward chil-

dren in most homes to be those of patience and warmth. During the

course of my observation I noted very little corporal punishment. In

only one case was discipline carried out in this manner. In general,

the behavior of children was controlled by diverting their attention or

by removing them from the immediate area. In response to my questions

mothers and caregivers told me that it was not customary to beat or

spank children. This contrasted with what I had observed in the United

States.

Family Interaction and Child Development

I spent time in each home observing the index child in the manner

described previously. Generally, after the first few minutes the child

ignored me and went on about his/her usual activities. In the physical

environment I noted a lack of high chairs or raised stools or other

equipment enabling the child to eat comfortably at the table. Children

ate sitting on their mother's lap, sitting on a low chair reaching up

to the table, standing on a chair, or sitting on top of the table or

on the floor. Only 11 families,or 25%,of those observed had special

furniture or made any provision for the child's comfort and ease while

eating. Most children were encouraged to eat by themselves although

some were completely fed and in the case of some a combination was

employed-the child eating alone and then the mother helping to make

sure that he/she had eaten enough. The lack of children's furniture









was probably the result of both tradition and low income. Locally made

wooden chairs and other furniture pieces were available and were rela-

tively inexpensive.

An analysis of variance obtained by use of the GLM procedure of

the Statistical Analysis System showed some significant differences in

certain activities observed in the home, based on the sex of the child.

Girls were observed more frequently than boys playing by themselves

(F=4.71, pO0.04), playing with toys which stimulate fine motor develop-

ment (F=9.47, p'O.004), and engaging in imitative play, e.g. playing

house, pretending to be an adult, etc. (F=9.96, plO.003). Boys were

more frequently observed running (F=4.44, pO0.04) and playing with toys

which stimulate gross motor development (F=8.43, pO.O06) than were

girls. Mothers were observed stimulating language development with

girls significantly more often than with boys (F=6.64, pO.01).

It is not surprising that boys were more often observed running

than were girls. Soccer is the national sport, and one of the first

skills a boy learns is to run and kick a ball. Girls in Costa Rica are

expected to be homemakers; therefore, it is not unexpected to find them

engaged in such activities as playing house or playing with dolls or

other toys requiring the use of fine motor coordination and imagination.

Also, some of the differences observed may result from the fact that boys

between the ages of 1 and 2 years may be a little behind girls in their

development. Observations at an older age might yield different results,

because playing with some toys requires more coordination which boys may

not develop until later. Distinguishing physiological causes from









culturally induced differences would require much more in-depth observa-

tion, however, and was not within the scope of this study.

Most children had access to toys and played with them, although

the variety was not as great as in the United States. Most of the chil-

dren customarily played with other children, usually brothers and sis-

ters or cousins. Twenty-five percent of children were observed playing

with an adult male at least once, usually another family member, i.e.

father, older brother, or uncle. Forty-five percent of mothers were

observed playing with the child. Although almost every family had a

TV, very few of the children watched. Because electricity is expensive,

the TV was usually turned on only at night and on special occasions when

a number of adults were present. It was not at all unusual to find a

family living in a shack but owning a television set.

Prior to beginning the research, I had been told by middle class

Costa Rican informants that children of poor people were not at all stimu-

lated and that it was common practice to leave babies in drawers or cribs

without attention. I had also observed during my time in South America

that, at least among the middle and upper classes, children were kept

dependent for a much longer period of time than in the United States,

probably because of the availability of servants. For example, they

were fed rather than taught to eat with spoons. The children I observed

in San Jose, however, were encouraged to be independent and to learn to

take care of themselves. Although some children customarily drink a baby

bottle of milk each night before bedtime until they are 5 or 6 years

old, they still know how to drink from a glass and to eat using uten-

sils. The baby bottle is a habit or treat. I also noted that the









index child received a good deal of physical and cognitive stimulation.

Sixty-eight percent of the mothers were observed cuddling their child

at least once during the visit. Forty-five percent were observed en-

couraging language development by talking with the child. Sixty-three

percent of the children were observed conversing with other children or

adults. In short, the majority of homes provided an environment that was

full of potential stimuli, certainly not what could be called a severely

deprived atmosphere.

Child Health

Based on my sample, I found children living in San Jos6 to have

good access to primary health care through the community health program

operating in each health center. As an indicator of the quality of

health care, over 90% of the initial 107 children were found to have had

their BCG, DPT, polio, and measles (rubella and rubeola) immunizations

completed for their age. In comparison, records show that in Florida

93.7% of all school entrants had been immunized. This higher value,

however, is undoubtedly influenced by the fact that obligatory immuniza-

tion begins to function at school entrance age in Florida. Nationally,

only 60% of the children aged 1-4 had been immunized. Although spe-

cific figures for children aged 1-4 or 1-3 were not available, the

Flroida State Health Plan indicated that immunization rates for this

age group are considerably below that of school entrants, probably more

in line with the national rate noted (Florida State Health Coordinat-

ing Council 1981). (Table 5 gives a breakdown of immunization figures

for the group followed in depth.)

Nine percent of the children in the longitudinal study were ob-

served to have dental caries upon a simple inspection. Other than this,






69



no clinical symptoms of malnutrition were observed. (Table 6 gives a

breakdown for the group as a whole.)


Table 5. Immunization Rates for Costa Rican Children from Poor Urban
Barrios


Type of Basic
immunization complete


Basic No
incomplete immunizations


--------------------.------- % .-------------------.__ .--------
BCG 95 5

DPT 93 7

Polio 98 2

Rubella 96 2

Rubeola 96 2

Note: Percentages are based on a sample of 44 children selected
at random from health center birth registers.


Table 6. Clinical Symptoms of Malnutrition in a Sample Population of
Children in San Jose


Longitudinal
study group
Symptom (N=44)


Group excluded
from longitudinal Total group
study (N=63) (N=107)


--------------------------- % -.----- .--------------------
Dental caries 9 11a 10

Apathy 2 1

Irritability 2 1

Lethargy 3 2

Dry hair 3 2

Scant hair 2 1

Diarrhea 3 2

aMost of the symptoms other than dental caries were observed in
two undernourished children eliminated from the study because of other
problems complicating their nutritional status.










The mother is the person who usually cares for the child when he/

she is ill, but grandmothers and aunts may also help. Fathers were

never indicated as being directly involved in child care. Most of the

families in the sample went to health centers, with a slightly smaller

number going to social security clinics for medical care. Private

physicians were used by a few and about 5% claimed to have no access

to medical care. (See Table 7 for a breakdown of these figures.)


Diet and Food Habits as They Relate to Children

Although breast-feeding was once the norm in many developing coun-

tries, including costa Rica, recent work has indicated that both the

incidence and the duration of maternal lactation are declining (Jelliffe,

E. F. P. 1979; Popkin et al. 1980). This trend was also noted in Costa

Rica (Mata et al. 1981), and programs have been begun to encourage in-

creased maternal lactation.

Data about maternal lactation were gathered on the 44 children in

the longitudinal study. In an effort to compare these data with earlier

information, Table 8 was constructed to show our results from 1982 as

compared to results for Region I (Metropolitan San Jos6) and the country

as a whole in the national survey of 1975 (Diaz Amador 1975). This in-

formation appears to indicate a decline in numbers of children never

breast-fed and a general trend toward longer periods of maternal lacta-

tion, although the percentage of children breast-fed more than one year

is reported to be the same.

Table 9 shows comparative data regarding the age at which bottle

feeding is begun and indicates a decline in babies never bottle fed and

more bottle feeding started in the first month of life. However, a










Table 7. Who Cares for the Sick and What Facilities Are Used


Longitudinal Group excluded
study group from longitudinal Total group
(N=44) study (N=63) (N=107)

------------------.- -.-.---- % ------- -.----_--------------

Caretaker

Mother 82 86 84

Grandmother 9 1 5

Aunt 2 5 4

Mother and
grandmother 5 5 4

Others 2 3 3

Total 100 100 100


Facility used

Health center 34 46 41

Social security 43 35 38
(CCSS)

Private
physician 7 5 6

Both health
center and
CCSS 5 5 5

None 7 3 4

Other 4 6 6

Total 100 100 100










Table 8. Comparative Data on Duration of Maternal Lactation


1975
Length 1982 1975 total
of time study Region I country

--------------- % ---------------

Not breast-fed
at all 9.1 16.0 13.3

Less than 1
month 6.8 12.2 13.3

1-3 months 25.0 30.2 20.3


4-6 months 13.6 3.7 4.3


7 months to
1 year 18.2 1.8 5.1

More than 1
year 27.3 27.4 34.1

Do not know 8.5 9.5


Note: Time periods given on the 1975 study have been combined so
that they are equivalent to the time periods used in this study.
aRegion I includes metropolitan San Jose.

bDiaz Amador, 1975.










Table 9. Age at Which Bottle-Feeding Is Introduced Among Costa Rican
Children-Comparative Data


Total
Length 1982 Region I country
of time study 1975a 1975b

---------.------- % -----------------

Not breast-fed
at allc 4.5 7.5 5.9

Less than 1
month 61.4 59.5 55.0

1-3 months 11.4 18.8 17.8


4-6 months 11.4 1.9


7 months to
1 year 6.8 2.8 3.1

More than one
year 4.5 -

Do not know 8.5 16.1



aRegion includes Metropolitan San Josd.

bDiaz Amador, 1975.

CTime periods have been combined in the 1975 study to make them
equivalent to the time periods used in the current study.










large number of mothers are apparently introducing bottle feeding later

as well. The changes shown in both Tables 8 and 9 may be the result of

Ministry of Health-sponsored campaigns to promote breast-feeding. It is

probably too soon, however, to say definitively that this is the case.

Data were also gathered about why mothers discontinued breast-

feeding. Table 10 shows a summary of these data compared to reasons

given in 1975. The basic reasons a mother decides not to breast-feed

are insufficient milk supply and child rejection of breast-feeding.

My research also indicated that 23% of the mothers had intro-

duced solid food within the first month of the child's life and by three

months of age 77% of the infants had been introduced to regular food.

By the end of the first 6 months, 93% of mothers had introduced their

infants to regular food. In fact, looking at the incidence of breast-

feeding without taking any of these other factors into account is mis-

leading and can give a false impression. What actually happens is that

most mothers are breast-feeding and bottle feeding simultaneously,

starting when the infant is very young. Regular food is added as soon

as the infant can tolerate it, beginning in the first month of life.

Infants are first fed bits of food from the table and then gradually

given their own portions.

Information about whether a child is being breast-fed is not as

important as estimating the amount of breast milk received. The latter

is difficult to do. There are mothers who report breast-feeding for

6 to 12 months, but after the first 2 or 3 months only once or twice

a day; in this way breast-feeding only makes a small contribution to










Table 10. Reasons Given for Discontinuing Breast-Feeding-Comparative
Data


Total
1982 Region I country
Reason study 1975a 1975b

------------------ % --------

Milk dried up or
did not have
sufficient supply 41.2 46.8 42.4

Child rejected
breast-feeding 14.7 15.6 14.5

Mother pregnant 11.8 -

Mother's illness 8.8 6.5 6.8

Mother's work 5.9 7.8 5.1

Physician's orders 5.9 1.3 2.9

Child biting 5.9 5.2

Child hospitalized 2.9 2.3

Child ill at home 2.9 0.6

Advice from friends
and relatives 1.0

Believe cow's milk
is better -- 0.6

Other -16.9 23.8


aRegion I includes Metropolitan San Jos6.

bDiaz Amador, 1975.










the child's diet. The scope of this study did not include estimating

the amount of breast milk received by the child.

Other information from 24-hour recalls for the index child show

two facts of special interest. First, milk, whether breast or bottle,

is the primary source of protein for the child under 3 years of age.

The second item of interest is that, although rice and beans are staples

of the Costan Rican diet and good sources of protein, the child under

3 years of age is by tradition fed rice and caldo de frijol, or the

juice in which the beans have been cooked. Although caldo de frijol

is a relatively good food from a nutrition point of view, it is not

equivalent in protein to the whole bean. Government policies which

seek to decrease milk available to small children from poor families

and substitute rice and beans could be detrimental for children under

3 years of age.

A brief discussion on some of the more pertinent social and cul-

tural factors which may have important influences on the nutritional

status of the urban poor child in San Josd, Costa Rica, has been pre-

sented. The next chapter will deal with the actual comparison in

growth and development between children of low weight/length and those

of normal weight/length.















CHAPTER V
RESULTS


Anthropometric Data

A total of 107 children, 54 males and 53 females, born in 1980

were chosen at random from birth registers in low income areas asso-

ciated with the health centers of Alajuelita, Hatillo, Pavas, Tibas,

Paso Ancho, Guadalupe, and Cristo Rey. In the initial survey, measure-

ments of length, weight, head circumference, arm circumference, tri-

ceps, and subscapular skinfolds were taken. In addition to these measure-

ments, the Denver Developmental Screening Test (DDST) was given to each

child and a family registry and assessment of the environment wenr done.

Table 11 shows the distribution of the children surveyed with respect


Table 11. Distribution of Weight/Length Percentile Rankings by Sex
of the Initial Sample of 107 Children from Poor Urban
Households in San Jose, Costa Rica


Percentile

Sex <5th 5th-10th >10th-25th >25th-50th >50th

Male 5 5 7 14 16

Female 3 3 8 19 18

Total 8 8 15 33 43

Percent 7.5 7.5 14 31 40

Note: Percentiles are.based on NCHS standards (National Center
for Health Statistics 1977).










to percentile rankings. As indicated, only 7.5% (n=8) of the children

were found to be below the 5th percentile. Another 7.5% (n=8) fell be-

tween the 5th and 10th percentiles. These findings indicate a low per-

centage of severely undernourished children. It was decided therefore

to focus on the moderately undernourished child. The ministry of

Health criterion of 90% of the median of National Center for Health

Statistics (NCHS) weight/height standards and/or first degree malnutri-

tion by Gomez's criterion was used to delineate a group of mildly under-

weight children to be followed and compared with normal weight/length

children. These criteria were used even though they included more chil-

dren in the low weight/length group than would occur by use of the 5th

percentile category. This was felt to be a reasonable division given the

fact that less is known about problems involving invisible or mild under-

nutrition in children, particularly the boundaries which define it.

The families of 19 of the children in the low-weight/length group

agreed to let them participate. Twenty-five normal weight/length chil-

dren were chosen at random and also were asked to participate. Although

the drawing was done randomly, more girls than boys of both the low

weight/length and the normal group were not allowed to participate. In

the case of the 25 normal weight children, substitutions were made by

drawing another random number. The result was 18 females and 26 males

in the final study, even though the initial group was evenly divided.

After the group for the longitudinal study was selected, six

additional monthly measurements of length, weight, head circumference,

and arm circumference were taken. Triceps and subscapular skinfold

measurements were taken at the beginning and at the end of the 6-month










longitudinal study. For the purposes of this particular study, only the

weight/length figures are analyzed. Table 12 shows the distribution of

the smaller group of 44 children with respect to percentile distribution

of the initial and final measurements.


Table 12. Distribution of Weight/Length Percentile Rankings of Initial
and Final Measurements by Sex in a Sample of 44 Children
from Poor Urban Households in San Jos6, Costa Rica, Who Were
Followed for 7 Months


Percentile

Sex <5th 5th-10th >10th-25th >25th-50th >50th

Initial measurement

Male 3 5 3 8 7

Female 1 3 5 7 2

Total 4 8 8 15 9

Percent 9 18 18 31 21


Final measurement

Male 3 5 6 5 7

Female 2 7 5 4

Total 5 5 13 10 11

Percent 11 11 30 23 25

Note: Percentiles are based on NCHS (National Center for Health
Statistics 1977).


Growth Patterns

As Table 12 indicates, there was some shifting in the percentile

rankings over time. Although there was a slight increase in the per-

centage of children under the 5th percentile at the end of the study,









there was also a decrease in children in the 5th-10th percentile cate-

gory and an increase in the number of children in the 10th-25th and

50th percentile categories. The overall impression is that growth

shows a great deal of individual variation and tends to occur as a

series of mini-catch-up spurts for both height and weight. Specific

illness episodes or other events (e.g. weaning) only partially explain

the observed variation in growth magnitude and velocity. Figure 6

illustrates this pattern well. The child is a female of normal

weight/length with no reported illnesses or unusual family circum-

stances, but whose growth velocity varies a great deal from month to

month. Figure 7 illustrates the classic pattern of the mother becom-

ing pregnant and weaning the child. The child, a male, was normal in

weight/length but dropped 0.5 kg. (4% of body weight) during the ad-

justment period. In this case the child suffered no severe effects

because he had reserved body fat. The underweight child in this same

situation would not be so fortunate. Figure 8 illustrates another

typical problem related to growth. The child, a male of normal weight/

length, was cared for by the grandmother while his mother worked. The

grandmother went to work, leaving a rather emotionally unstable aunt

in charge of the children. The index child of this family lost weight

(1.5 kg., 13% of body weight) rather abruptly and did not begin to re-

gain it until the grandmother returned to stay with the children.

These examples have been chosen as representative of typical

growth patterns found among the children followed and as such demon-

strate the need for many measurements over time in order to determine

the state of a child's health and nutritional status. Cross-

sectional studies do not necessarily reveal this individual variation.












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Maternal Reproductive History and Birth Weights

A SAS general linear model (GLM) analysis of variance showed that

no significant differences existed between mothers of low weight/length

children with respect to total number of pregnancies, age, the order of

the index child in terms of total pregnancies, or the order of the

index child in relation to living children.

Birth weight was found to be lower among the low weight/length

group as compared to the normal weight/length group (F=5.94, pCO.02).

Because of the large number of boys in the group, particularly the nor-

mal group, analyses were also done by sex. Low weight/length boys were

found to have significantly lower birth weights than normal weight/

length boys (F=4.64, p50.04). Low weight/length girls, however, were

not found to differ significantly from normal weight girls with respect

to birth weight, even though their average birth weight was lower

(2818 grams as compared to 3060 grams). In this study birth weight was

not controlled but rather was one of the parameters allowed to vary. In

an effort to determine to what extent birth weight was influenced by

genetic factors, the height and weight of each child's mother were also

obtained. An analysis of variance indicated no significant difference

between the height and weight of the mothers of low weight/length chil-

dren and those of the mothers of the normal children. In the former

group both weight and height tended to be lower but not significantly

so. This suggests that the low birth weight associated with the mildly

underweight child may be more related to maternal undernutrition during

pregnancy than to other factors.










Illness Classification

In addition to the health history obtained initially for the year

prior to the beginning of the study, health histories were elicited

monthly from primary caretakers. An illness classification was devel-

oped based on the work of Martorell and Yarborough (1983). Diarrheal

illnesses include diarrhea and gastroenteritis, including pega. Respira-

tory illnesses include bronchitis, cough, cold, asthma, flu, and grippe.

Selected common symptoms include all of the above diseases and symptoms

plus fever, vomiting, skin infections, tonsilitis, parasites, inflama-

tions, ear infections, allergy, kidney or bladder infection, loss of

appetite, and dyhydration.

There were not significant sex differences in the average number

of illnesses, although males had more diarrheal illnesses and illnesses

included in the selected common symptoms category. Slightly more

females were, on the average, reported as having respiratory illnesses.

A large number of children (23, or 52%) were reported as having no

diarrheal illnesses.

A total of 160 illnesses, including 74 respiratory illnesses and

30 dirrheal illnesses, were recorded for the sample over a consecutive

7-month period (Table 13); 50% of the illnesses occurred during the

rainy season and 50% during the dry season. There was no significant

difference in the occurrence of respiratory illnesses by season.

Diarrheal illnesses showed a significant seasonal trend with a mean of

X= 3.00 cases in the dry season and X = 6.00 cases in the rainy season

(t=2.60, pO0.05). Select common symptoms showed no significant










seasonal variation with means of X = 20.00 and X = 26.67 for the dry

season and rainy season respectively (t=0.544 N.S.). The mean number

of illnesses per child was X= 3.64.


Table 13. Seasonal Frequencies of Illness Among Low-Income Urban
Children in San Jos6, Costa Rica


Month and Selected common
season Diarrheal Respiratory symptoms

Month 1
Dry 1 6 7

Month 2
Dry 5 12 24

Month 3
Dry 1 15 26

Month 4
Dry 5 8 23

Month 5
Rainy 7 6 22

Month 6
Rainy 7 13 33

Month 7
Rainy 4 14 25

Total 30 74 160




With respect to elicited health histories for the year prior to

the initiation of the study, significantly more children in the low
2
weight/length group were reported as having fever ( 2=4.62, pO.03)

than in the normal weight/length group. Other than this there was no

appreciable difference between the two groups in the reported incidence










of illness according to the health histories. Table 14 gives a summary

of the illness episodes reported in the histories.


Psychomotor Development

Table 15 gives a summary of the group as a whole with respect to

the results of the Denver Development Screening Test (DDST). Twelve

percent (n=8) of the normal weight/length group and 17% (n=4) of the

low weight/length group had abnormal or questionable results on the

DDST. It is suggested that a more discriminating instrument may be

necessary to detect differences between mildly underweight children

and normal weight children. However, more interesting is the fact

that 50% (n=5) of the children who were short for their age but normal

in weight/length had abnormal or questionable results on the DDST.

Unfortunately, these children, because they were considered normal in

weight/length and because they represented a different nutritional

problem, were not included in the in-depth study. These results sug-

gest that an additional follow-up of short-for-age children may be war-

ranted, even though they may not be technically considered under-

nourished by weight/length criteria.


Socioeconomic Factors

There were slightly more (X=2.5) children under 6 per household

in the low weight/length group than in the normal group (X=2.0); this

difference, however, was not statistically significant (see Table 16).

Household size tended to be larger, mother and father older, household

income less, and education of both mother and father less in the low

weight/length group. Total household income was calculated by summing





















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all salaries of family members plus the value of food or other items

which were gifts, and any other support, i.e. government aid. Since

this information was collected after about 5 months of visits, it is

felt to be a reasonably accurate estimate. The exchange rate from

colones to dollars was calculated at 45/1 which was approximately what

it was when the questionnaires were answered.



Table 16. Means of Selected Social Characteristics of the Families
of Low and Normal Weight/Length Poor Children in San Jose,
Costa Rica


Low Normal
weight/length weight/length
Characteristic (n=19) (n=25)

Household size 6.6 6.2

Children 6 and
under 2.5 2.0

Father's age 32.4 31.1

Father's education
(no. of years
completed) 6.5 7.0

Mother's age 28.2 25.3

Mother's education
(no. of years
completed) 6.3 7.0

Total household 4505 04872
income per month ($100) ($108)

Total food cost 03991 l3761
per month ($89) ($84)










The cost of food was calculated on a per month basis according

to the frequency of purchase of food items as reported to the investi-

gators. The prices were as accurate as possible given the frequent

fluctuations caused by inflation during 1982. A greater proportion of

income was spent on food in the households of the low weight/length

group (89%) than in the households of the normal group (77%).

Fifty-three percent of the families of the low weight/length

group and 36% of those of the normal weight/length group either owned

or were buying their homes. Table 17 gives a summary of the type of

tenure of the dwelling. More families among the normal weight/length

group were renting, and fewer owned their own homes.



Table 17. Type of Tenure of Dwelling in a Sample of Low Weight/Length
and Normal Weight/Length Children from Low Income Families
in San Jose, Costa Rica


Low Normal
weight/length weight/length
Type of Tenure (n=19) (n=25)


------------- -------------
Own home 32 16

Buying home 21 20

Rent home 42 52

Borrowed home 5 12

Total 100 100


aIn this case families were usually living in a house belonging to
some other family member, i.e. mother, father. Rent was paid when funds
were available.










More of the parents of children in the low weight/length group

were married than in the normal weight/length group (68% as compared to

56%). Forty percent of the parents of the normal weight/length group

and 16% of the parents of the low weight/length group were single.

Thirty-two percent of the households of the normal weight/length group

were female headed, whereas 16% of the households in the low weight/

length group were of this type.

The sample was slightly biased toward families with a more

stable residence because of the method of selection. Those who had

moved within the previous year were not usually included in the birth

registers we used to select the sample. Eighty-four percent of the

families of children in the low weight/length group and 72% of those

of children in the normal weight/length group had lived in their present

residence for three years or more. Fifty-eight percent of the families

of the low weight/length group and 56% of the families of the normal

weight/length group had lived 5 or more years at the same residence.

Thirty-eight percent of the fathers of the low-weight/length group

and 11% of the fathers of the normal weight/length group were unemployed

or worked only occasionally or seasonally. Seventy-nine percent of the

mothers of the low weight/length group and 67% of those of the normal

weight/length group did not work outside the home. Thus, not only was

employment less for men but also for women in the families of the low

weight/length group.

Data collected about buying patterns indicated that most families

did not buy on time; however, more of the families of the low weight/

length group did-32% compared to 12% of the normal weight/length









group. Thirty-two percent of the families of the normal weight/length

group also reported having some savings as compared to 5% of the

families of the low weight/length group.

With respect to environmental conditions, wooden houses predomi-

nated in both groups (58% and 64% in the low and normal groups respec-

tively). A few were made of brick or cement block (42% and 32% res-

pectively) (see Table 18). Most had cement floors and zinc roofs.

Condition of housing was generally good. Approximately 26% of the

families of low weight/length children and 24% of the families of normal

weight/length children lived in government housing projects. The

houses had 1 to 5 rooms with an average number of 2 rooms in both

groups. The number of beds per family ranged from 1 to 6, with a mean

of 3.5 beds per household.

Most families in both groups cooked with electricity although gas

wood and/or charcoal, and kerosene were also used by a small number

(25%). During the course of the study a number of people began to use

wood and/or charcoal again because the cost of electricity had risen

as a result of inflation and the increased cost of importing petro-

leum to Costa Rica. A total of 15% of the families of the low weight/

length group and 24% of the families of the normal weight/length group

were either using charcoal exclusively or a combination of charcoal

and electricity and/or gas. Charcoal and wood are local products and

relatively cheap. When a combination of cooking methods was used,

usually for items requiring long cooking periods such as beans, rice,

soups, and stews, charcoal was used, whereas the electric stove or hot

plate was used for foods which could be cooked rapidly, i.e. eggs,




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PAGE 1

ilOCULTURAL CORRELATES OF CHILD NUTRITION AND GROWTH AND DEVELOPMENT IN COSTA RICA BY SHARLEEN HIRSCHI SIMPSON A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IIVERSITY OF FLORIDA 1984

PAGE 2

ACKNOWLEDGMENTS The data for this dissertatation were gathered between September 1981 and December 1982 under the auspices of a grant (#BNS8104679) from the National Science Foundation. I would like to thank all personnel from the Costa Rican Ministry of Health who aided in the data gathering. In particular, I wish to thank Dr. Carlos Diaz Amador, Dr. Enrique Freer Miranda, Doña Evelyn Jaensthke Magi akin, and Doña Juanita Alvarez Elizondo de Quiros. Dr. José Antonio Camacho was very helpful in advising me about the urban situation. To Flory Desanti Jimenez and Eulalia Obando Naranjo, who as former health auxiliary workers were of invaluable assistance, I give deepest thanks. Appreciation is also due Dr. Leslie S. Lieberman, chairman of my supervisory committee, for her support and comments, and the other members of my committee, Drs. H. Russell Bernard, Paul L. Doughty, James S. Dinning, and Helen I. Safa. A special thanks goes to Ron Thomas for his patience in advising me in the statistical analysis. I wish also to thank my parents. Donna and LaVell Hirschi, for giving me a great start in life and providing continuing emotional support. To Roderick and Randy Simpson I give thanks for being extremely supportive and loving to a frazzled mother trying to finish a dissertation, and for adapting so well in Costa Rica. Most of all, I wish to thank those Costa Rican families who with great kindness and patience allowed me to make innumerable interviews and observe them in action. A final thanks goes to the children; for them I have great love and respect. i i

PAGE 3

TABLE OF CONTENTS Page ACKNOWLEDGMENTS ""i ABSTRACT vi CHAPTER I OVERVIEW OF NUTRITION PROBLEMS WORLD-WIDE WITH A FOCUS ON THE SITUATION IN COSTA RICA 1 Causal Factors Related to Malnutrition 4 Socioeconomic Factors 6 Changes in Child-Feeding Practices 8 Changes in Family Structure and Women's Roles 9 Economic Development as a Contributing Factor 10 The Costa Rican Situation 13 II STATEMENT OF THE PROBLEM 25 III METHODS 33 Phase I: Setup 33 Contacts 33 Archival Research 33 Interviewers 34 Pretest 34 Phase II: Initial Survey Target Population and Sampling Design 35 Anthropometry 38 Denver Development Screening Test 39 Maternal Level of Living: Quality of Environment . . 40 Assessment of Clinical Signs of Malnutrition .... 41 Phase III: In-Depth Longitudinal Study 41 Long-Term Data Gathering 43 Assessment of Socioeconomic Status 44 Weekly Marketing Items and Food Budget 44 Maternal Reproductive History 45 Dietary Data 45 Q-Sort Techniques 46 Observation of the Index Child 47 Fees Paid to Subjects 49 Phase IV: Data Analysis 50 m

PAGE 4

CHAPTER Page IV SOCIOCULTURAL PARAMETERS AFFECTING THE NUTRITION, GROWTH, AND DEVELOPMENT OF THE CHILD 54 Family Networks 54 Family Structure 55 Food-Buying Patterns 60 Child Rearing 62 Family Interaction and Child Development 65 Child Health 68 Diet and Food Habits as They Relate to Children .... 70 V RESULTS 77 Anthropometric Data 77 Growth Patterns 79 Maternal Reproductive History and Birth Weights .... 84 Illness Classification 85 Psychomotor Development 87 Socioeconomic Factors 87 Dietary Data 99 Food Frequency 99 Breast-Feeding Patterns 102 Attitudes About Food 102 In-Home Observation of the Index Child 107 Multivariate Analyses H^ Stepwise Multivariate Regression 116 Stepwise Discriminant Analysis 116 VI DISCUSSION AND CONCLUSIONS 121 Socioeconomic Factors 122 Dietary Factors 125 Conceptual Model Describing Children at Nutritional Risk in the Urban Area 126 Conclusions • 128 REFERENCES 134 APPENDIX 1 FAMILY REGISTRY 147 2 MEDICAL HISTORY OF THE INDEX CHILD 149 3 HISTORY OF MATERNAL LACTATION 152 4 CONDITION OF HOUSING AND ENVIRONMENT 154 5 ANTHROPOMETRIC MEASUREMENT 158 TV

PAGE 5

APPENDIX Page 6 SYMPTOMS OF MALNUTRITION "160 7 SOCIOECONOMIC STATUS 162 8 FOOD BUDGET AND BUYING PATTERNS 165 9 REPRODUCTIVE HISTORY OF MOTHER 170 10 OBSERVATION OF INDEX CHILD'S BEHAVIOR 171 11 SELECTED FOODS THOUGHT TO BE APPROPRIATE AND INAPPROPRIATE FOR THE INDEX CHILD AMONG LOW INCOME FAMILIES IN SAN JOSE, COSTA RICA 175 BIOGRAPHICAL SKETCH 182

PAGE 6

Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Dcotor of Philosophy BIOCULTURAL CORRELATES OF CHILD NUTRITION AND GROWTH AND DEVELOPMENT IN COSTA RICA By Sharleen Hirschi Simpson August 1984 Chairperson: Leslie S. Lieberman Major Department: Anthropology Groups of low (n=19) and normal (n=25) weight for length children were selected from an initial random sample of 107 children from poor neighborhoods in San José, Costa Rica. These children were all born in 1980 and were between the ages of 1 and 2 years at initial measurement. They were than measured monthly for six additional months. Data were also collected about socioeconomic status, food habits, maternal reproductive history, medical history of the child, and food buying patterns. The Denver Developmental Screening Test (DDST) was administered and a clinical assessment of nutritional status was also made. In-home observations of child-rearing activities were made during which time nurturing or mothering behaviors were recorded. No significant differences between the two groups are reported with respect to total income, food costs, household size, environment, children under 6, birth order, or household food frequency. The matrifocal extended family was found to be an effective survival strategy for VI

PAGE 7

poor families. Low weight/length children were breast-fed slightly longer with later introduction of bottle feeding and solid foods and obtained slightly more abnormal or questionable scores on the DDST than normal weight/length children. Families of low weight/length children owned more material goods, spent more money on food, and tended to be less organized in their habits than were families of normal weight/ length children. By use of multivariate regression and discriminant function analyses a model was constructed to predict membership in the low or normal weight/length group. Birth weight, the number of children aged 6 years and under, and other variables representing maternal competence and economic managing abilities as well as material style of life were found to be significant predictors of low or normal weight for length status. Mothering or nurturing behaviors were found to be positively associated with height, weight, and growth in the low weight/ length group. The maternal factor, which includes adequate prenatal care and nutrition, as well as maternal competence, is suggested to be of great importance in determining whether low income families have normal or low weight/length children.

PAGE 8

CHAPTER I OVERVIEW OF NUTRITION PROBLEMS WORLD-WIDE WITH A FOCUS ON THE SITUATION IN COSTA RICA The incidence of undernourished children in the developing world is known to be high. The Commission on International Relations of the National Research Council (1977:63) cites FAO estimates that as many as 30% of preschool -aged children in low-income countries suffer from secondor third-degree malnutrition, and an additional 40-50/" have first-degree malnutrition based on weight for age standards such as those set by Gomez (1956). Jelliffe (1968) notes that the children most at risk nutritionally are between the ages of 6 months and 3 years. This observation has also been verified in nutritional surveys conducted in Africa (Khan and Gupta 1979; Omololu 1978), in Asia (Berg 1973; Winikoff 1978) and in Latin America (Home et al . , 1977; Monckeberg 1976; Schrimshaw and Béhar 1976). At this age breast-feeding no longer meets the child's needs. Weaning usually takes place during this time; the diet of adults is not adequate for the child; and the infant is more vulnerable to infections (Jelliffe 1968). Malnutrition may occur during or immediately after episodes of infectious disease, even though the child may have been in a state of adequate nutrition before and growing at a normal rate (Mata 1978b). Field studies in India and Guatemala have identified the interaction between malnutrition and infectious disease (Mata 1977; Wyon and Gordon 1971). Mortality in nearly all types of infectious disease is greater in nations with prevalent malnutrition 1

PAGE 9

because of a decreased ability among debilitated or malnourished children to fight off illness (Schrimshaw et al. 1968). More recently attention is turning to what has been called "invisible malnutrition." According to international health experts, the image of the starving baby is too often used to represent the developing world. Visible and obvious malnutrition occurs relatively rarely, mostly during times of famine and war. Invisible malnutrition, on the other hand, affects about one-fourth of the developing world's children, stealing their energy, lowering their resistance to disease, and thus retarding growth (International Health News 1983:1). Noting that the child's first reaction to the lack of energy intake is to reduce energy output, it is observed that by conserving health and growth at the expense of activity, the child can maintain a normal appearance. Studies have shown that "even children who are regularly eating only three-fourths as much food as they actually need can still maintain weight and growth by cutting out discretionary activity" (International Health News 1983:2). The report further notes that the mutually reinforcing relationship between invisible malnutrition and infection is responsible for the majority of the 40,000 deaths eyery day among the developing world's infants and children. Undernutrition of the preschool child has been found to have substantial long-term effects on the subsequent ability of the child to develop, to be educated, and otherwise to function as a useful member of society. Marcondes et al . (1973) found that children with histories of severe malnutrition have poor performances on the Gesell even after being rehabilitated. The Gesell test, developed by Arnold Gesell

PAGE 10

and Catherine Amatruda (Knoblock and Pasamanick 1974) is a timetable characterizing infant development during the first years. It includes the categories of physical, gross motor, fine motor, sensory, vocalization, and socialization. Richardson et al. (1972) and Cravioto and DeLicardie (1968, 1976) found that children who showed evidence of undernutrition in earlier years were less able to adapt and perform in school. Cravioto and Robles (1963) found the area of hearing and speech to be most retarded in the long run. Yatkin and McLaren (1970), comparing two groups of infants recovering from severe marasmus, found that stimulated children showed greater improvement than did the unstimulated group. Five mental functions comprising the development quotient given with the Griffiths Mental Development Scale were evaluated. These included the areas of locomotor, personal-social, hearing and speech, eye and hand, and performance. Neither group, however, attained the normal quotients by the end of the rehabilitation. The volume edited by Greene (1977) documents the long-term deleterious effects of malnutrition on the learning capacities and consequent socioeconomic development of whole societies, particular socioeconomic strata (i.e. peasants), and ethnic groups (i.e. Ladinos ) throughout the world. Thus, the problem is an important one, the effects of which are potentially very harmful to the well-being of a nation, particularly a developing nation (Aranda-Pastor 1975; Ashworth and Picou 1976; Berlin and Markell 1977; Burgess et al . 1972; Jelliffe 1966; Seth et al. 1979; Villarejos et al. 1971; Wray and Aguirre 1969). Although the existence of undernourished and malnourished children has been documented in developing countries the world over, and

PAGE 11

many important sociocultural variables have been identified, until recently there has been little work done at the household level on the behavioral, attitudinal, and habitat correlates of malnutrition. Most of the work which has been done has taken the form of cross-sectional surveys rather than longitudinal in-home observations. Surveys, however, often do not uncover the causal chain of events leading to consumption-related malnutrition. Causal Factors Related to Malnutrition Nutrition workers generally agree that malnutrition in developing countries is the result of many interrelated factors including low income and underemployment, ignorance, poor sanitation, lack of access to medical facilities, family instability (Beghin et al . 1979), changing women's roles in relation to urbanization and participation in the work force (Popkin 1980a; Uyanga 1980), and family structure (size, birthspacing, one-parent families, etc.). Taylor and Taylor (1976) constructed a model which, according to them, shows the interrelationships of factors that cause most of the malnutrition in the world. They group causal factors under three headings: the production of food, its distribution, and its utilization. Under production they include factors related to agricultural labor, distribution of land and technology which affects the level of productivity, thus determining the supply of food available. Under distribution are included economic factors (prices and income); demographic factors (population growth and urbanization); cultural factors (beliefs about food, childcare and feeding, social status); and health and nutrition services (feeding programs, integrated services). Under

PAGE 12

utilization are included physiological differences (vulnerable groups, e.g. pregnant women and children; malabsorption, genetic adaptation), level of activity, and infection and parasites. Taylor and Taylor note, however, that while they regard these as being general causes they must be adjusted to local situations. Similar patterns of malnutrition may result from different combinations of causes. Thus, they advocate nutrition surveys which go beyond standardized descriptive data to include information which will permit the development of a local causal profile. Brown and Brown (1977), in their paper giving guidelines for finding the causes of protein-calorie malnutrition in the community, suggest that adequacy of household food supplies, availability of food supplies (agriculture), food procurement (purchases), and food use and feeding practices are useful categories for evaluating the local situation. Fleuret and Fleuret (1980:250) suggest the following circumstances leading to what they term "consumption-related malnutrition": (1) Food production is inadequate due to lack of land, labor, capital, or any one of these; (2) food production is adequate but some people cannot afford enough food or the right kinds of food; (3) food production is adequate but cultural factors (e.g. food preferences, intrahousehold distribution) cause unhealthy consumption patterns; (4) both aggregate food production and overall income levels are adequate; beliefs and values are nutritionally neutral, but certain categories of the population are constrained by other social and economic factors to make consumption decisions that are inconsistent with good nutrition. Of these

PAGE 13

approaches, the latter seems to be the most useful in terms of developing countries. Reutlinger and Selowsky concur with this latter set of circumstances, noting that "at the global level malnutrition is the inequitable distribution of world income and not the result of an insufficient supply of food" (1979:21). Socioeconomic Factors Keeping in mind general guidelines and models, one can find a number of specific studies which illustrate in detail some of the causal factors included in the general framework already mentioned. Rawson and Valverde (1976) in San Ramon, Costa Rice, found that access to land, fathers who worked as day laborers, working mothers, physical condition of the house, and the number of children under 6 years of age negatively affected the nutritional status of children. Wray and Aguirre (1969) in Candelaria, Colombia, found that the income of the father, family size, birth spacing, and birth order were related to malnutrition in children. Increasing urbanization as a result of industrialization and the migration of rural people to the cities in developing countries have contributed to the development of malnutrition. Clark (1980) found urban preschoolers to be smaller and less physically developed than their rural counterparts. Villarejos et al . (1971) found the opposite in Costa Rica where rural children exhibited more retarded growth than did urban children. It seems that the change in environment caused by the move to an urban area combined with existing culturally determined food habits has created problems. In Costa Rica this is evidently

PAGE 14

mitigated by the existence of extensive health and social welfare programs. Specific customs of food consumption may interact with local conditions to produce childhood undernutrition. For example, among the Tongans Clark studied, the adult males began the meal, followed by adult females and younger males, with children eating last. When meat was consumed by the family, this was seldom reflected in the diet of the child. Although this custom was prevalent in the rural situation, in the city it created great problems because food items such as domestic meats were less available. Clark also notes that in rural areas where cash income levels were often lower, food purchases were supplemented by family production of meats, fish, and vegetables. Urban families, while enjoying higher cash incomes, lacked sufficient purchasing power to replicate the food variety and quantity available to rural families. Clark also notes that "bush foods" (wild foods which are hunted or collected) were constantly present in the rural diet and almost totally absent from urban diets. This decrease in variety of foods included in the diet seems especially significant in view of the work of Dewalt et al. (1980) in highland Mexico, which suggests that complex diets contain more of the essential nutrients than do more restricted diets. In addition to these socioeconomic factors a number of other parameters having biological and social significance have indicated that large families, short interpregnancy intervals, and a large number of preschool children at home are risk factors for malnutrition. MacCorquodale and Rondón de Nova (1977) found that in Santo Domingo

PAGE 15

malnourished preschool children were from families averaging 4.7 children, while well nourished children came from families with an average of 4.0 children. In Costa Rica, Rawson (1975) found that a significant risk factor for malnutrition v;as the presence of more than 2 preschoolage children in a household. In Haiti, Ballweg (1972) reported a greater likelihood of undernutrition associated with large families. In addition to family size, the sex of the infant may be a correlate of malnutrition. Dorjahn (1976) reported that infant mortality in Sierra Leone was higher for females in both the rural and urban areas and suggested sex differential feeding as a causal factor. Other researchers (Rawson 1975) have noted no sex differences in the frequency of malnourished children. Changes in Child-Feeding Practices Another important causal factor in the development of malnutrition is the changing pattern of infant feeding. In developing countries this is particularly important because, as Berg (1973) notes, the move away from traditional breast-feeding places a child in double jeopardy: first because of the loss of a high quality food supply (formulas are frequently mixed incorrectly) and secondly through the increased potential for contact with infection as formulas are mixed with unclean water and placed in dirty bottles. This gives rise to what E. F. P. Jelliffe (1979) calls "comerciogenic" malnutrition. Popkin et al. (1980) note that examination of worldwide data based on large nationally representative samples suggests that, although there has not been a widespread general decline in the prevalence

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of breast-feeding (the percentage of women who ever breast-fed), there has been a decline in the duration of breast-feeding, especially in urban areas of Latin America and the Caribbean. Changes in Family Structure and Women's Roles Changes in family structure and women's roles have directly affected child-care and thus child-feeding practices. One of the most significant changes in family structure has been the rise of the oneparent household, primarily with the migration of men or women to urban areas and/or the inability of the man to obtain an adequate job. The presence of only one parent has been found to have a negative effect on a child's nutritional status, primarily because a woman who has a child not supported by its father has little economic security. In Jamaica, Desai et al. (1970) found that presence of both parents, small family size, and birth intervals of at least 24 months were associated with high rates of weight gain in children. Of primary importance is the entry of women into the work force, particularly in urban areas where V7ork may be in factories and is not generally compatible with child care (as selling goods in a village market may be). Women's work hours and conditions have a great influence on child care. Uyanga (1980) notes that having a job which is compatible with child care is positively associated with breast-feeding behavioral changes. He also notes that in urban areas the presence of other members of the family, e.g. daughters, other nonnuclear family members (aunts, grandmothers, etc.), has a positive impact on childcare time and thus a potentially positive effect on nutritional status.

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10 Reutlinger and Selowsky (1976) have observed that infant malnutrition as a result of absence from the home of lactating mothers participating in the labor force is a case of income redistribution within the family in the face of urbanization. Unless sufficient food is purchased for the infant to compensate for the nutrients lost by reduced breast-feeding, the child suffers a negative income effect. Recent research from India according to Reutlinger and Selowsky suggests that a woman would have to spend 76% of her earnings to provide adequate quantities of formula or milk for a 4-monthold infant. In Kenya this would require 58% of the wage, and in Tanzania 51% (Latham 1979). Latham also points out that, since many tropical countries have rather small dairy industries, most of the manufactured milk formulas are imported, requiring the use of scarce foreign exchange. This also contributes to the dependency of developing countries on foreign capitalist powers and multinational corporations like Nestle. Economic Development as a Contributing Factor It is difficult to demonstrate a relationship between socioeconomic development and nutritional status because of the multifactoral etiology of malnutrition and because it is difficult to isolate the effect a specific program may have had. Commericalization of agriculture, long a favorite goal of third world economic development programs, is recognized as leading to a decline in nutritional status (Fleuret and Fleuret 1980; Gross and Underwood 1971). Commercialization of agriculture usually implies introduction

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11 of capital-intensive technology used for producing cash crops for export, e.g. coffee, soy beans, African palm, bananas, horticultural products. Along with this comes a decline in subsistence production as small farmers become involved as wage laborers on large plantations and agroindustrial plants or in producing cash crops on contracts. Women may be left to bear the burden of the garden, or subsistence farming, responsibilities for which they may be unprepared, as they may lack education or experience with gardening or farming. The result is a decline in both yields and in subsistence farming as a whole. Staples must then be purchased with hard earned cash, which tends to arrive in lump sums rather than being distributed throughout the year. This has the effect of making peasant households less selfsufficient and less able to withstand seasonal variations in the supply of staple foods. The net result is an increased vulnerability to malnutrition. This is especially true since private enterprise is rarely able or willing to provide directly for the reproduction of labor power which would entail paying wages sufficient to enable a worker to support a family and obtain adequate housing and health services (Roberts 1978). Certainly Gross and Underwood's (1971) study of the introduction of sisal agriculture in northeastern Brazil is an excellent example of this process. In this example the introduction of sisal, which employed men in the hard and exhausting labor of harvesting and processing, resulted in such increased energy costs in relation to the low wages that a systematic deprivation of adequate calories to the wives and children of the sisal workers was the result.

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12 In order to maintain physical strength, the male of the household had to eat the lion's share of the available food. Thus in the population studied, the children were exhibiting signs of malnutrition— retarded growth and development. The working poor were essentially subsidizing capitalist private enterprise. The implication of the preceding discussion is that malnutrition, especially infantile protein-energy malnutrition, has a complex etiology. Solutions based on food and nutrients alone are completely inadequate (Pellet 1977). Expecting malnutrition to disappear with economic development and increased GNP seems unrealistic also, in view of the past record and because evidence indicates that low-economic groups benefit unequally in the process of capitalist-oriented economic development (Cornelius and Trueblood 1975; Roberts 1978). According to Reutlinger and Selowsky (1979:22), empirical evidence suggests that the caloric intake will increase at approximately half the rate at which per capita income rises. On the basis of these assumptions it would take 30 years before the poorest 20% of the population of these countries could reach an adequate level of caloric intake. In their view the high incidence of malnutrition among children of developing countries is not likely to be reduced as part of the development process. The only effective solution according to them lies either in a more equitable income distribution or in supplying food to the target population at low prices. This view is echoed by Teller et al. (1979:21) who state that in general poor countries will attain an adequate nutritional status only when they can provide most of their people with a "minimum socioeconomic package" (permanent employment, adequate income, social security, housing, etc.).

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13 The Costa Rican Situation Costa Rica (see Figure 1) is unique in Central America because it has long had a democratic form of government, a social conscience among the upper classes, and a fairly large middle class. The Spanish settlers of Costa Rica, throughout the colonial period, found themselves forced to reside in the country where each family labored to produce its own food (Munroe 1918:140). As the population grew, the entire Meseta Central became divided into small farms. There were a few wealthy and influential families who had been given special privileges by Spain, but they never occupied the dominant position which the aristocracy of Guatemala and Nicaragua had been able to assume, and the land they held never amounted to more than a small portion of the cultivated area of the colony. In 1848 through a special decree the people were permitted to buy the land they had fenced and were using, a measure which had the effect of greatly increasing the number of landholders (Munro 1918:142-143). Costa Rica achieved independence from Spain in 1821 when she joined with seven other provinces of Central America to form the United Provinces of Central America, which was later disbanded in 1838 because of internal conflicts. Full national sovereignty was not established until 1848. The period between 1938 and 1902 was largely one of dictatorships succeeding one another through coups. Also, during this period Costa Rica had to defend herself against a Nicaraguan invading force in 1836 and from the troops of the North American adventurer William Walker in Nicaragua in 1853-57 (Fanger 1968). The radical transformation of Costa Rican geography since its independence can be attributed to the development of two agricultural

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u

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15 products, coffee and bananas (Hall 1976:14). Coffee reached Costa Rica some time before the end of Spanish rule in 1821. A letter from Governor Tomás de Acosta to the king in about 1808 mentions the plant, and by 1829 it was the most important produce of the country. A rush to plant coffee took place in 1841, and the country's economy and thinking became oriented around coffee growing and coffee prices (Lundberg 1976:114). During the 1940s large uncultivated tracts of land owned by the government were sold at low prices or given away as premiums to encourage the planting of coffee. During the last years of the 19th century many persons acquired land this way, and gradually a class of large landholders developed, although the Meseta Central was still composed largely of small farmers (Munro 1918). The banana has been cultivated since the end of the 19th century in the coastal regions of Costa Rica on great plantations, a system commonly associated with the cultivation of agricultural products for export in many developing countries. These regions have only recently been integrated into the Costa Rican economy and then with great difficulty. Communication and transport were and are major problems. Costa Ricans from the interior (Meseta Central) had little to do with the development of the banana regions. In the Atlantic zone, the north American fruit companies were responsible for developing plantations with labor provided by Negroes from the West Indies (Hall 1976:14). Although there is at present a small class of large landholders resulting at first from the introduction of coffee and bananas, as noted, and later extending to the Guanacaste area with the introduction of cattle raising for export of beef (Edelman 1983), there has always

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16 existed an egalitarian philosophy on the part of the government and the upper classes. Beginning, particularly in 1948, with the progressive reforms of Calderón Guardia, a series of enlightened social welfare programs have been enacted concerning social security, health, housing, and protection of children. At the present time, Costa Rica, with a population of slightly over 2 million people, has one of the most effective an aggressive health systems in Latin America, encompassing both curative and preventive medicine. An infant mortality rate in 1980 of 19.1 per 1000 population and a life expectancy at birth of 73.4 years (Ministerio de Salud 1982) reflect the general health status of the population. This is comparable to that of the United States in 1970 when the infant mortality rate was 20 per 1000 population. Life expectancy at birth in the United States in 1978 was 73 years. In 1978 the United States had an infant mortality of 12/1000 for whites, 23.1/1000 for blacks, and 21.1/1000 for blacks and other minorities. The infant mortality rate overall was 13.8/1000 (U.S. Dept. of Commerce, Bureau of the Census 1981). Other countries in Central and South America had the following infant mortality rates: El Salvador and Guatemala in 1979, 53 per 1000 and 70.1 per 1000 respectively; Colombia, 39.5 per 1000 in 1977; and Argentina, 40.8 per 1000 in 1978 (Demographic Yearbook-1 980, 1982). Mata et al . (1980a, 1981) notes that the diarrhoeal disease death rate was 11 per 100,000 with about 140 infant deaths per year due to diarrhea. No cases of poliomyelitis or diptheria have been recorded in recent years and few cases of measles and whooping cough, indicating a favorable national health immunization system. The health system, as it is currently organized, dates from the early 1970s when the National Plan of Economic and Social Development

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17 was implemented. This plan has as its goal the improvement of the quantity and quality of basic services available to Costa Rican citizens and was begun in rural areas in 1973 and in urban areas in 1974. In relation to health care, these basic services involve the cooperation of the Ministry of Health, the Costa Rican Social Security Administration, the Costa Rican Institute of Aqueducts and Sewers, and the National Insurance Institute. The goals of the program are as follows: 1. To extend basic health services to poor rural and urban communities using health auxiliary workers. 2. To control and reduce infectious diseases through immunization programs. 3. Referral of patients to either preventive or curative facilities, depending on medical diagnosis. 4. Planned visits to homes and businesses to evaluate health needs. 5. Emphasis on environmental health, health education, and community organization. (Freer Miranda 1980) In 1966 a national nutrition survey was conducted in Costa Rica by the Instituto de Nutrición de Centro América y PanamᗠINCAP (1959). Rawson (1975), Rawson and Valverde (1976), and Valverde et al. (1975) investigated the nutritional status of preschool children in the community of Concepción de San Ramón, Costa Rica. In general these studies indicated nutritional deficiencies in preschool children which were moderate but chronic. Deficiencies were more pronounced in low socioeconomic groups. According to the INCAP study (INCAP 1969), the four types of malnutrition which most frequently occur in Costa Rica

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are protein-energy malnutrition (PEM), nutritional anemias, vitamin A deficiency, and goiter (iodine deficiency). Mata (1979), however, notes that of these four the single most important deficiency is that of protein-energy malnutrition, or PEM. It is the most common and has the most complex etiology which makes its study and control more difficult. Results of the San Ramón study, in which the Gómez scale (Gomez et al . 1955) was used, revealed that 38.9% of 149 children aged 0-5 years were of normal weight, whereas 46.3% exhibited first degree malnutrition, 13.4% second degree malnutrition, and 1.3% third degree malnutrition. Therefore, more than half of the children (61%) were found to be below the normal weight range. Fifteen percent were in the lowest two groups (below 75% of normal weight). Contrary to findings already cited for other areas, the effects of malnutrition in San Ramón apparently become worse as the children grow older. This pattern of chronic rather than acute malnutrition in neonates and preschool-age children points to factors or interrelationships of causal factors different from those found in other developing countries. Rawson (1975) and Rawson and Valverde (1976) note a number of socioeconomic and cultural variables associated with nutritional status. Variables significantly (p 5 0.02) associated with childhood malnutrition were access to less than 1.4 hectares of land, more than one sibling under 6 years of age, father works as a day laborer, mother works outside the home, house in poor physical condition, poor stove quality, and little access to fresh milk. Variables not significantly associated with childhood nutritional status included education level of the parents, type of

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19 family unit (nuclear, extended, or single parent), sex of the child, age at weaning, and salary income. A more recent National Nutrition Survey (Ministerio de Salud 1978) also noted relationships between house conditions and nutritional status. Poor housing conditions were associated with poor nutritional status among preschool children (Table 1). The condition of the house was assessed on type of house construction, number of rooms, presence and condition of bathrooms and toilets, water supply, presence and condition of windows, quality of cooking facilities, etc. Table 1 indicates that the highest prevalence of malnutrition (Gdmez's first, second, and third degree combined) in children aged 0-5 years occurs among children in poor housing in the urban areas— 53.1% compared to 51.3% in the dispersed rural areas and 55.5% in concentrated rural areas. The overall national percentage of children and infants in poor housing with first degree malnutrition is 45.1%. As housing conditions improve, the proportion of children underweight for age decreases markedly. Some studies have suggested that malnutrition in Costa Rica is frequently the result of factors other than lack of food, such as passive child abuse manifested as neglect. Stunting and wasting were found to be much higher among abused children (Mata et al . 1980b). Mata, in another paper (1980), cites decreased maternal competence, failure of bonding, and infections as factors which are just as important as available food in the development of PEM. Salazar and Cervantes (1979), in a preliminary report based on the national survey, also note positive relationships between education of the

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20 Table 1. National Distribution of Children 0-5 Years by Weight for Age According to Condition of Housing and Degree of Urbanization

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21 head of the family and spouse and nutritional status of preschool children. In households where the head of the household is illiterate, 57.9% of the children 0-5 years of age are malnourished based on the Gómez scale. As the educational level increases, the proportion of malnourished children decreases: secondary-level education— 37% malnourished; university-level education— 20.2% malnourished. The 1978 survey also revealed a downward trend in the incidence of breast-feeding. Thirty-seven percent of infants in rural areas were weaned in the first month of life, often at birth, and by 5-6 months approximately 60% had been weaned to formula milks. Also, infants who were breast-fed frequently received supplements; only 19% were exclussively breast-fed at 4 months of age. In response to this problem Dr. Leonardo Mata and his team of workers from the Fvlational Institute for Health Research (INISA) have begun an innovative and very interesting nutrition-related project. The primary site of this work is the area of Puriscal, primarily involving dispersed and concentrated rural settlements. The Puriscal study was begun in September 1980 in conjunction with an intervention aimed at increasing breast-feeding. All the mothers in this area are included through the prenatal clinics. Eightyfour percent of deliveries are in the San Juan de Dios Hospital, 13% in maternities and clinics of San José, and 3 percent in the home. The objective of the project is to increase breast-feeding by increasing the opportunities for maternal/infant bonding in the hospital situation after birth. Attempts were made to change hospital policy to foster rooming-in to some degree. A milk bank was created to provide milk and colostrum for high-risk neonates. The project includes in-home surveillance as well as the hospital stimulation. The result has been a

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22 dramatic increase in the incidence of breast-feeding in the study population (Mata et al. 1981). Another program of great interest is that of the canasta básica alimentaria , or basic food basket program. This has been in the process of development since the survey of 1966. A basic diet was elaborated which as of 1981 included 12 basic food items considered necessary for an adequate diet (see Table 2). This list is used to determine the impact of cost-of-living increases and also to plan national food production with the aim of ensuring adequate supplies of these items. Another objective of the basic food basket concept is to control prices so that these items remain within the reach of the poor (Murillo et al. 1981). Until 1982 most of the items on this list were subject to controlled prices. At that time, inflation forced prices to be raised. The concept is still very useful, however, because it tends to focus national attention on the basic requirements for maintaining good nutrition for all population groups. Costa Rica also has a nutrition rehabilitation center housed in the facilities of the Costa Rican Institute of Investigation and Teaching in Nutrition and Health (INCIENSA) located in Tres Ríos. In addition to ongoing research projects, this institution is a referral center for severely undernourished children (3rd degree by Gomez standards). These children come from all over Costa Rica. Their numbers are relatively small, however, because of the ongoing surveillance program conducted by the community health workers. As part of the national nutrition surveillance program, the System of Nutrition Information (SIN) was set up to utilize the data which are

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23 Table 2. Structure of the Basic Costa Rican Food Basket in Grams per Person per Day (average for the country) Food

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24 constantly being collected locally by health workers to define and describe target groups of households at risk for undernutrition on a national level. The goal of SIN has been to develop a functional classification which involves describing categories of poor families and relating the prevalence of malnutrition with relevant specific social, economic, and cultural factors. A functional group is defined as a set of families sharing a similar pattern of living, that is, the same type of production, the same type of social and economic constraints and access to existing resources, and similar cultural practices (Valverde et al. 1981). Thus, while nutrition problems exist in Costa Rica, a number of very effective and sophisticated programs exist for the purpose of evaluation and surveillance of nutritional status. Nutrition problems in Costa Rica, while not severe, are complex, requiring subtle and innovative ways of measuring the extent of the problem and evaluating the progress already made. Subsequent chapters will deal in more depth with the statement of the problem and methods used in looking at the status of child nutrition among the urban poor in San José.

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CHAPTER II STATEMENT OF THE PROBLEM The major purpose of this research was to define biocultural causal factors in undernutrition and retarded growth and development in a sample of infants aged 12 to 24 months in the poor urban barrios of San José, Costa Rica. A holistic anthropological approach was used to elucidate the diverse strategies employed at the household level which lead to well or poorly nourished children. Undernutrition is most prevalent among poor people; yet, among the poor there are those who maintain good or excellent health and nutritional status. The underlying hypothesis of this research is that strategies of resource accrual and dispersion as well as absolute levels of nonshelter-related real income within a household are significant factors in the determination of nutritional status. It was anticipated that below a certain level of income, the proportion of undernourished children would increase dramatically with relatively small decreases in real income. The object of the research was to do in-depth, crosshousehold evaluation of resource utilization in poor households, comparing those with well nourished children to those with undernourished children. Nutritionally related high-risk factors and strategies have been identified for rural populations (Desai et al . 1970; Rawson and Valverde 1976). These factors tend to be related to ownership and access to farm lands. In the urban context, however, little work has been done to 25

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26 elucidate those factors which contribute to well or poorly nourished children. The urban populations are of special concern because as migration continues from rural to urban areas, the increased population size puts pressure on the economic system to provide more jobs and wage-related income for recent migrants. These migrants, usually young and within the growth phase of family development, are suddenly confronted with new economic and environmental stressors which require the development of new resource-related strategies and the development of new skills to enhance their wage-earning abilities. As a result, the more resourceful have developed coping mechanisms which enable them to survive on \/ery little, primarily within the informal economy or smallscale sector, e.g. lottery ticket sellers, street venders (Roberts 1978). This "tertiarization" of the economy— the expansion of employment in the commercial and service sectors rather than in manufacturing— has been associated with urban poverty as an adaptive mechanism allowing migrants to the city to eke out an existence. Peattie (1975) provides an excellent description of how this phenomenon works in a Latin American city. The resourcefulness of the poor is further emphasized by such works as that of Lomnitz (1977) describing mutual reciprocity networks and Arizpe (1980) who investigated relay migration (family members taking turns going to the city to live and work). Both of these works were carried out in Mexico and illustrate very well that if anyone can squeeze better nutrition out of a low income, these people can. One of the objectives of this research was to become more familiar with these strategies as they exist in Costa Rica and to glean knowledge which would be helpful in understanding this complex problem.

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27 In particular, the research focused on strategies of food acquisition and allocation within the household context and on the decisionmaking associated with these strategies. As noted earlier, malnutrition has a multifactorial etiology; nutritional and health surveys often do not uncover the underlying and/or intervening variables which are the essential links between access to food and the nutritional status of the child. In addition, survey data tend to obscure intracul tural diversity which accounts for the observation that among the poor some children are well nourished while others are not. In short, we know that malnutrition exists. We have many supposed causes. We do not understand very well how these causes relate to specific cases at the family and household level. In other words, we do not know much about the target group, particularly in the urban areas where most of the poor are now concentrating in developing countries. It may be that below a certain level of income the only way to improve nutrition is to increase income. Above this income level, however, there is a tremendous gray area which still includes many families in which there are undernourished children. This gray zone may be amenable to many kinds of programs, such as education, food subsidies, etc. The problem occurs when a program is aimed at those people below the crucial economic level but uses methods which are meant for the people in the gray zone. The program may then be evaluated as a failure when very few people in the target group respond to it. Or it may be judged as a success by the number of people participating but yet not reach those who are critically in need of assistance. This research, therefore, was aimed at investigating intracultural diversity at the household level byuseof

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28 a variety of research techniques to obtain a clearer picture of causal factors involved in undernutrition of specific groups. This research contributes methods for characterizing children at risk nutritionally which allows more effective targeting of nutrition intervention programs. Data indicating the importance of family structure to the survival of low income families came from an in-depth multidisciplinary study done in the urban barrios of San José which focused on marijuana use by adult males (Carter et al . 1976). This study contains some information on the nutritional status of adult males. More important for the purposes of this research was the information on family dynamics, kinship-based networks, and the general environment of lower-class neighborhoods. As described by the adult male informants in the study, a typical family of orientation has about five members, including both parents, two or three children, and occasionally a bilateral relative such as a sibling or an aging parent. The range in family size, however, is reported to be wide. A frequent pattern encountered was a periodic doubling up on space within an extended family group to reduce costs during periods of economic stress, which frequently occurs bocause many children and adults are seasonal laborers. In this study 20% of the marihuana users and 5% of the nonusers came from single parent households headed by the mother. Often surrogate parents, e.g. grandmothers, aunts, or uncles, were child caretakers. In contrast to other areas in Latin America, fictive kinship, godparents, and compadrazgo are relatively unimportant (True 1976:69). Although the households were found to be largely restricted to the immediate nuclear family, both marihuana users and nonusers were almost

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29 always in constant contact with extended kindred networks. These networks are potentially very important to the nutritional status of the child since they tend to be the source of most surrogate parents and kin may share food, material goods, and money. Costan Rican anthropologist Eugenia Lopez de Piza (1979:4-5) has described four family types which she had found to be common in Costa Rica: the nuclear family, consisting of father or father substitute, mother, and children; the extended family, consisting of related nuclear families; the matrifocal family centered around the mother and her children; and what she has termed the "Queen Bee" family, which is a variant of the matrifocal type and consists of the grandmother, her daughters, and their childern. In this latter family type, the daughters work and the grandmother cares for the children and controls the money. This extended matrifocal family is similar in structure and function to the three-generation family with a female head described by R. T. Smith (1956:106) for British Guiana. It is also similar to the "grandmother families" described by M. G. Smith (1962) for the West Indies. Lopez de Piza (1979:15) calls the matrifocal family in Costa Rica, particularly the "Queen Bee" variant, the best adaptive mechanism enabling poor women to obtain economic necessities and care for and educate children. Mothering ability or maternal competence is another factor which has been implicated as a risk factor for malnutrition. Mata (1979) in Costa Rica cites deficiencies in maternal technology and social pathology as becoming increasingly important causal factors in child malnutrition in modern times. Alvarez et al. (1977) in Chile found that

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30 maternal education levels were important in influencing the development of healthful food habits among children. Data from the study on marihauna consumption in San José indicated that while most subjects reported that meals were prepared and served at regular hours in their homes, because of employment hours at least half of the males did not eat at the same time as the rest of the family. The rest of the family (mother/wife, children, and other), however, generally followed a regular schedule for meals (Rawson and Phillips Arizmendi 1976:589-590). Alcohol use by a parent was cited as a cause for going hungry and other unhappy childhood experiences which could directly affect the nutritional status of young children. Slightly less than half of marihuana users and nonusers had fathers who drank heavily (True et al. 1976; True 1976). A model was developed based on prior work done in San Ramón, a small village, and the surrounding rural area by Rawson (1975). This model was modified to make it more appropriate for testing in the urban situation and to include most of the risk factors already mentioned. Figure 2 illustrates this model. The model was to be tested through the collection of extensive biocultural data and by use of a mixed cross-sectional and longitudinal design. Both the methodologies and the model were to be evaluated for applicability to other urban settings. Unlike Rawson's study (1975) in which the basic independent variable was access to an adequate amount of agricultural land (i.e. two manzanas, or 1.4 hectares), this study used a factor labeled "real

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31 V?. yed liomotor lopment

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32 income." "Real income" is composed of wages, credit, savings, monetary gifts, inheritance, etc., averaged weekly to allow for variations such as seasonal ones. There were a number of intervening variables involving the allocation of resources, the adequacy of the physical environment, and the quality of child care. These variables were directly observable and measurable and are described in Chapter III in the section on methods. One of the objectives of the study was to augment the communitybased nutritional research completed by the Ministry of Health, the National Institute for Health Research (INISA), and the Costa Rican Institute for Research and Training in Nutrition and Health (INCIENSA). The project emphasized a longitudinal, in-depth behavioral approach which was used to delineate the variables and diversity of coping strategies leading to poor and well nourished children among the urban poor. This information will be used to characterize that portion of the population which is at greatest risk for malnutrition and to assist in the development of intervention programs which are targeted specifically at the high risk group. This approach has as its goal the conservation of scarce resources by facilitating directed programs which provide the greatest return on invested materials and manpower. The identification of risk factors and strategies which lead to malnutrition on the basis of household data can be extrapolated for use on the community level .

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CHAPTER III METHODS Phase I: Setup Contacts In my position as field director of the project, I traveled to Costa Rica in August 1981. The appropriate contacts were made with the project consultants. Dr. Carlos Diaz Amador, director of the Department of Nutrition of the Ministry of Health, and Dr. José A. Camacho, professor of anthropology at the University of Costa Rica. Through these individuals, contacts were made with the director of the Community Health Program, Dr. Enrique Freer Miranda, and Dr. J. Manual Alvarado Obando, director of Health Region 1, which has metropolitan San José in its jurisdiction. After obtaining the appropriate authorization, contacts were made with the directors and personnel of all the health centers from which the samples of children were to be drawn. This selection was made with the aid of Dr. Diaz Amador and Dr. Camacho and by use of the criteria of a large population of poor people and, where possible, areas which had not been overstudied by various investigators in the past. Spanish translations of the proposed project and the permission form to be used for inclusion of each child in the study were presented to the Ministry of Health and were approved. Archival Research Archival research was carried out in the libraries of the University of Costa Rica, the National Children's Hospital, the Costa Rican 33

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34 Institute for Research and Teaching in Nutrition (INCIENSA) at Tres Ríos, the National Museum, and the Ministry of Health. Documents were also obtained from the National Office of Planning (OFIPLAN), the National Nutrition Information System (SIN), the Ministry of Health, and the National Institute for Research in Health (INISA). Interviewers Through the auspices of Dr. Enrique Freer Miranda, head of the Community Health Program at the time of this study, two women who had worked for four years as health auxiliary workers in the Hatillo Health Center were hired. These two women, Flory Desanti Jimenez and Eulalia Obando Naranjo, worked with me to develop the survey instruments, assisting particularly with translation of the language to the idiomatic Spanish of the urban lower class. They were also trained to conduct structured interviews, do anthropometric measurements, and give the Denver Developmental Screening Test (DDST). Pretest With the help of the two interviewers, 10 households were chosen from various neighborhoods which had people similar to the sample population but which were not to be included in the survey. In these households children were weighed and measured, interview schedules were filled out, and the Denver Developmental Screening Test (DDST) was given. Polaroid photos were taken and left with each family. In addition to this pretest situation, prior to the beginning of the formal study, about 70 children from a squatter settlement were measured and weighed to provide additional training in measurement techniques for the research assistants. These children are not included in

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35 this study, however. The DDST was also given to 30 children with myself, Flory, and Eulalia scoring each test simultaneously. By the time the formal investigation was begun, everyone was comfortable with all instruments and procedures. There was also ^ery little variance in the manner with which each procedure was carried out. Phase II: Initial Survey Target Population and Sampling Design Greater San José— San José and surrounding urban areas — had a population in 1973 of 837,000 which is projected to reach 1.8 million people by the year 2000, increasing the present labor force from 260,000 to 500,000 persons. In 1976 there were more than 240 slums in the metropolitan area in which there were one-room shacks occupied by several families, according to a USAID report (1976). According to this report, there were an estimated 110,986 families in Costa Rice (average family size— 6 persons) which were considered mas pobres ("more poor" or "poor poor") with incomes of less than $825 per year. Of these families 40.6% (45,000) lived in greater San José. In addition, there were 197,268 other families who were considered pobres ("poor" or "rich poor") with incomes below $1,395 per year. Of these families 53% (104,610) lived in the greater San José area. The income figures are based on census data and primarily refer to salary income. More recent data was difficult to obtain because similar USAID reports and Costa Rican government reports are now considered classified material and I was not allowed access to them. It is doubtful if the situation described has changed much for the better, however. If anything, things are probably worse because Costa Rica has suffered an economic crisis and inflation has changed the value of the colon from ?il2.50 per $1 to

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36 (¿40-60 per $1 in 1981-82. Times are tougher and Costa Rica has been hard pressed to try to pay off its foreign debt. It has also had a tremendous influx of refugees from Nicaragua, El Salvador, and Guatemata, an additional drain on the economy. Seven health centers were selected as sites for obtaining the sample population. They were Hatillo, Alajuelita, Pavas, Tibás, Paso Ancho, Guadalupe, and Cristo Rey. The areas selected were known to have a high percentage of poor people. Figure 3 shows the distribution of this population. Although each of these health center regions has some more well-to-do neighborhoods included in its jurisdiction, only areas noted as very poor were selected, e.g. Calle Blancos, Cinco Esquinas, Concepción de Alajuelita, La Esperanza in Pavas. A sampling frame was constructed from birth records kept by each health auxiliary worker for his/her district. All the children born in 1980 in each of the areas selected were placed on a list and given a number. A table of random numbers was used in selecting over 200 children. After each child was selected from the birth registry, his or her family record was located and the address and other social data noted. About 50 to 60 of these could not be located in the files of the health auxiliary workers. Another 25 to 30 were located in the file but when the health auxiliary worker arrived in the neighborhood, they had moved and left no forwarding address. The final large sample contained 107 children. In each of these 107 families, a family registry, or listing, of all members of the household, their ages, sex, education, and migration history was taken. In addition tothesedata a medical history of the child during the past year, an assessment of material level of living

PAGE 44

37 z

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38 and quality of the environment, an examination of the child for clinical symptoms of malnutrition, and anthropometric measurements of the index child were obtained. The Denver Developmental Screening Test (DDST) was also performed on this initial visit. (See Appendices 1-5 for examples of the forms used.) Anthropometry The following measurements were carried out according to the IBP Handbook protocols (Weiner and Lourie 1969). Length . This was taken in centimeters by use of a headboard with a metal tape measure attached which could be taped to a hard surface such as the floor or a table. Another board was then held up to the bottom of the feet to determine the length. This instrument was adapted to fit into a shoulder bag because bus transportation was used at all times. Weight . In the interest of making the instruments portable, it was decided to use a bathroom-type scale. Most of the children being measured could walk; therefore this was not a problem. Three scales were obtained; each of these was tested with standard weights up to 30 kilos and found to be accurate. Thereafter they were tested every 6 weeks. Before use the scales were placed on zero. The weight was obtained with the child wearing light clothing and without shoes. Triceps and subscapular skinfolds . These measurements were obtained in millimeters with Lange skinfold calipers. These measurements were taken on the large sample at the beginning of the in-depth study and at the end of the in-depth study. It was decided not to take them each time because of the difficulty of doing this accurately with children and because of the need to have only one person take the measurements. Thus, I took all the skinfold measurements.

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39 Arm and head circumference . These measurements were taken in centimeters with a fiberglass nonstretchable measuring tape. Denver Development Screening Test (DDST) The Denver Developmental Screening Test is a simple and effective way of assessing the developmental status of children during the first 6 years of life. It evaluates the following aspects of the child's functioning: Gross motor, fine motor-adaptive, language, and personal social areas. The test relies on observations of what the child can do and on reports by a parent or parent surrogate who knows the child. Direct observation is used whenever possible. The younger child may be tested while sitting on the mother's lap, which is the procedure we used. The test is easy to administer, score, and interpret and is useful for repeated evaluations of the same child. The test has a high rate of validity and reliability (Camp et al. 1977; Frankenburg and Dodds 1967; Frankenburg et al . 1971a, 1971b, 1971c). It is not an intelligence test but is intended as a screening instrument for use in clinical practice to note whether the growth and development of a particular child is within the normal range. Because the DDST was standardized on the Denver population, it has been noted that some of the norms are not applicable to children in other cultural areas (Bryant et al. 1974; Solomons and Solomons 1975). It has. been successfully adapted and standardized for use in Japan and Okinawa (Ueda 1977a, 1977b). It has been translated into Spanish and hasbeenused to some extent in Guatemala, Chile (Fandal 1980), and Yucatan, Mexico (Solomons and Solomons 1975). The test has also been used cross culturally in the United States (Frankenburg etal. 1975). Upon arriving in Costa Rica,

PAGE 47

40 I discovered that research conducted by the University of Costa Rica had been carried out to standardize the DDST for use in Costa Rica and Central America (Howard and Nieto de Salazar 1982). However, because this standardization was not yet complete and because of what I perceived as problems with the design of the standardization research, I decided to use the official Spanish version of the DDST, v;hich had been obtained from the La Doca Foundation in Denver, Colorado. Because the comparisons to be made were to be within a cultural group rather than between cultural groups, I felt that the results from this point of view would be valid in spite of any possible cultural biases inherent in the test. However, many of the suggestions developed by the Costa Rican group to facilitate administration of the test to the local population were incorporated. The DDST was given on the first visit to all 107 children included in the sample. After it was explained and demonstrated, it v^as found to be of great interest to the people and proved to be an excellent entree, providing parents with graphic demonstrations of their children's abilities in various areas. It was repeated once more, after at least three months had passed, on the smaller group of 44 children included in the in-depth study. Material Level of Living: Quality of Environment A checklist was used to assess the material level of living, e.g. presence or absence of radios, TV's, sewing machines, and other indicators of quality of life. Quality of the living environment was also assessed with an evaluation of the condition of the house, type of

PAGE 48

41 construction, number of rooms, number of people per room, number of beds, type of cooking facilities, disposition of excreta and garbage, lighting, ventilation, and other aspects of the environment (see Appendix 4). Assessment of Clinical Signs of Malnutrition A list of symptoms of primary clinical malnutrition was developed by use of the form suggested by Rawson (1975) which was then adapted for use in San José with the aid of Dr. Carlos Diaz Amador, director of the Department of Nutrition of the Ministry of Health. (See Appendix 6 for a copy of this list). I performed this examination on all the children. Phase III: In-Depth Longitudinal Study Because the initial large sample showed very few children at or below the fifth percentile of weight for height when the NCHS statistics were used (probably because of the excellent national program of nutrition, surveillance, and intervention), it was decided to focus on the mildly to moderately undernourished child, victim of invisible malnutrition, as it has been termed (International Health News 1983), currently the major problem for Costa Rica and many other developing countries. The criteria for severely undernourished children are quite clear, e.g. fifth percentile or below on the growth charts of the National Center for Health Statistics (NCHS), 80% of the median or below, again on the NCHS growth charts (Mata 1978a; Waterlow and Rutishauser 1974), or second and third degree malnutrition by the classification of Gdmez (1956). On the Gomez scale, which is based on weight for age, normal

PAGE 49

42 is 91-110% of standard weight for age, first degree malnutrition is 7990% of standard weight for age, second degree malnutrition is 61-75% of the standard, and third degree malnutrition is 60% or less of the standard (Gómez el al. 1956:77). In recent years the classification of Gómez et al . has come under criticism because it is based on standards developed among much heavier children than is the norm in Latin America and other parts of the third world. Mata (1978a) notes that it was developed more than 20 years ago as a means of categorizing children admitted to the hospital for treatment of malnutrition and was not intended to apply to the general population. Generally the trend has been to use weight for height as the criterion for determining acute malnutrition, and height for age as the indicator of long-term nutritional status. Recently the concepts of wasting (deficit in weight/height) and stunting (deficit in height/age) have been introduced to allow populations to be classified in different groups for intervention purposes (Mata 1978b; Waterlow and Rutishauser 1974). As mentioned already, the criteria for severely undernourished children are clear; however, the cut-off point for delineation of mildly undernourished children with subclinical malnutrition is not so easily determined. The Costa Rican Ministry of Health uses growth charts based on NCHS standards and considers children to be moderately undernourished if they are at or below 90% of the median. Because of a decision to focus on the mildly to moderately undernourished child, the in-depth sample included all those children who were at or below 90% of the median of NCHS standards and/or had at least first degree malnutrition by the scale of Gómez et al. Originally there were 26 children falling

PAGE 50

43 into this category. Two were eliminated because they had had illnesses shortly after birth (meningitis and encephalitis) which had left such effects that it would have been impossible to say what retardation in growth and development was due to undernutrition and what was due to disease processes and their residuals. Of the 24 left, only 19 agreed to participate. Another group of children was selected, by use of the table of random numbers, from the remaining 81 normal weight/ height children. The families of 25 of these children agreed to let them participate in the in-depth study. In the end there were 25 males and 18 females participating. Ten of the females and 9 of the males were in the low weight/height group. Eight of the females and 17 males were in the normal weight/height group. Among the normal group, the random selection yielded very nearly an equal number of boys and girls. The difference apparently results from the fact that more of the parents of boys were willing to let them participate then were parents of girls. It is not certain whether this is a chance occurrence or some cultural bias having to do with boys and their roles and position in society. Long-Term Data Gathering The plan had originally been to pick up the children to be followed in groups of 10, adding another increment of 10 each month until all were being followed and then gradually tapering off as the 6 months of surveillance were reached. At the time the in-depth portion of the research was to begin, however, the political situation in Costa Rica and all Central America seemed quite tense. It was just prior to the elections, there had been some terrorist activity, arms caches had been

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44 found, and there had been border incidents with Nicaragua. Because of these factors and because the interviewers proved to be ^ery capable and easily trained, a decision was made to carry all the families simultaneously, visiting each family e^ery month for measurements and additional data gathering. Each visit had to be made within six days either before or after the date which equaled one month exactly from the last visit. The object was to make the data-gathering period as compact as possible in case there developed a situation in which the ability to visit families living in slum areas would be interrupted. This arrangement worked out well, proving to be a better plan than the original. In addition to the family registry, anthropometry, medical history of the child, checklist of material living conditions and quality of the environment, and assessment of clinical malnutrition already mentioned, several other types of data were obtained. Assessment of Socioeconomic Status This interview schedule included data about the occupations, income, expenditures, gifts, etc., of all members of the household. Because of the sensitive nature of these data and our wish to keep everyone in the study for all of the 6 months, this schedule was not administered until we had been visiting the family about 4 or 5 months. Only after that time did we feel enough rapport had been established to enable us to attempt to elicit information about socioeconomic status with any accuracy. (See Appendix 7 for a copy of this schedule.) Weekly Marketing Items and Food Budget With the help of the two interviewers, a schedule was constructed which elicited the frequency, place of purchase, and cost of the foods

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45 commonly purchased. This information was used to construct a monthly food budget and was generally elicited at the same time as the socioeconomic data, both being rather sensitive in nature. In addition to this information, shopping lists were obtained from several families and other families were accompanied on food-buying trips by myself. The object of this data was to determine what kind of access people had to food supplies and how they allocated their resources with respect to food purchasing (see Appendix 8). Maternal Reproductive History This schedule included data about parity, number of pregnancies, complications of pregnancy, miscarriages, length of pregnancy, and patterns of breast-feeding. This material was not deemed to be sensitive because women tend to talk with each other and other people about their ills and pregnancies, thus it was administered early in the study to the mother of the index child. Generally, the women seemed to enjoy reminiscing about their pregnancies and problems associated with them, (Appendix 9 contains a copy of this schedule.) Dietary Data In addition to buying patterns relative to food, dietary data were elicited in two ways. The first was a 24-hour recall of what the index child had eaten. Four of these were obtained, one for the weekend and one for the v;eekday during the dry season (December to April) and one for each weekend and weekday during the rainy season (May to November). Because of the difficulty of being able to arrive on the appropriate day for the recall, some were done by us as 24-hour recalls and the rest

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46 were left vn'th the mother or mother substitute to be filled out as a diary for the day needed, e.g. a Saturday or Sunday. We did not have high hopes for the success of this method and only resorted to it several months into the study when we lacked needed data. Much to our surprise, the mothers were highly motivated and we received all but two reports back. These data were not used as a way of determining individual intake because of the errors inherent to recall data (Acheson 1980; Bernard et al. in press; Morrison et al . 1959) (e.g. 20-50% rate of error in recording intake), but rather as a way to get an idea of the typical diet of the child in relation to family food consumption and customs associated with mealtimes. Q-Sort Techniques A Q-sort of 100 cards of local foods most frequently consumed was devised. The Q-sort techniques have been adapted from Stephenson (1953). Correlational methods for analysis of ordinal and nominal data were employed as suggested by Cohen (1957) and Wittenborn (1961). The Q-sort used in this research was adapted from that described by Fitzgerald (1977), who used it to develop a food choices game. The same type of game was developed for this study and was adapted to local food habits. Fitgerald noted that the advantage of using this type of approach rather than just an interview to elicit recall data is that it is nonthreatening and involves active participation. We found this to be true. Even though the mother, or the principal caretaker, of the index child was the one asked to perform the sort with the food cards, many times it ended being a family consensus, which is probably a more accurate reflection of the food habits of the family anyway according to the

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47 findings of Bernard et al. (in press) regarding the increased accuracy of recall data among groups as compared to individuals. Five different kinds of information about food habits were elicited by use of this procedure (not all at the same time). First a food frequency test was done. Then the mothers were asked to sort those foods most liked and least liked, those considered most nutritious and least nutritious, those most appropriate for the index child, and the informant's own classification of the 100 cards by whatever criteria she cared to devise. Observation of the Index Child In addition to the data mentioned already, each child was observed for 4-5 hours during the morning of one day. Procedures described by Spradley (1980) and Wilson (1977) were incorporated into an adaptation of child-following as described by Wilson (1974). The behavior of the child and the family in general were the target of this observation. Although what was eaten by the child during the time the observer was there was recorded, these data were not used to determine the intake of the child but rather to learn something about mealtimes, intrafamily food distribution, how the child was cared for, how he/she ate, and family interactions. Because of the large number of children to be observed in a relatively short time, it was considered unfeasible to carry out childfollowing as Wilson had described it. Instead an attempt was made to observe during a similar period of time in each household in the same way so that the observer bias at least would be the same and, it was hoped, the data would provide a sample of what happened during the same period of time in each child's day. This observation was done only after at least 3 or 4 visits monthly had been carried out. Because it is rather

PAGE 55

48 inconvenient for a family to have a stranger in their house for half a day, appointments were set up in advance. The observations were carried out only by myself. The people were very cooperative and, although undoubtedly some things were changed because of prior knowledge of the visits, i.e. the house was made cleaner and perhaps a special effort with the food served was made, the observations were believed to be of great value in understanding the family environment. The cooperation of the family seemed to be enhanced also by the fact that we made appointments with them. Although the sampling procedures may have suffered because people knew an observer was coming, rapport with and confidence in the researchers were increased. The total observation period was usually 4-6 hours in length; however, the child's behavior was recorded every 15 minutes for 3 minutes on a checklist during only 3 hours of that time. Ethnographic notes were recorded e\ery 15 minutes during the entire observation period, and included information about behavior, food eaten, and any other activities which were of interest (see Appendix 10 for a copy of the checklist of behaviors). The family was informed before the observation was set up that I would be making notes of the child's behavior. Because the focus of attention was on the index child, the pressure was taken off the other family members to a large extent, thus making them more at ease. A short, informal history of the family was also included at the end of the observation because by that time I had been able to elicit that kind of information. Photos were also taken to illustrate some of the child's behaviors. Because photos are expensive, they were taken only when the child changed behavior rather than every 15 minutes.

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49 A copy of the photos was given to each family. This gesture was very well received. One of the interesting offshoots of this in-home observation was a first-hand acquaintance with Costa Rican cuisine because I was expected to eat with each family. Because among Costa Ricans sharing food is an integral part of social behavior, these invitations were not to be taken lightly, even though most families could ill afford another mouth to feed, I used the opportunity dining with each family presented to gather data about typical menus served. A wide range in the quality of the cooking was noted; some food was excellent and some was terrible. I found that good cooks can make tasty dishes with very little money to spend. Fees Paid to Subjects In order to provide an incentive for each family to remain in the study for the entire time, the project had been set up to pay a certain fee each month. Originally this sum had been set at $5; inflation, however, had so affected the exchange rate that this sum had become a fairly large amount in colones. The project advisors. Dr. Diaz Amador and Dr. Camacho, did not believe that it would be wise to pay that sum because it would set a precedent which could make data gathering harder for other individuals and organizations whose budgets did not include money for fees to be paid to subjects. It was also feared that too high an amount would affect socioeconomic status unduly. The sum finally agreed upon was ¡¿125, which was at the time the equivalent of $2 and was approximately the amount a semiskilled worker would receive for a day's wages. The extra money was used to give each family the

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50 photos mentioned earlier and for a small gift for each child at the end of the study. I believe that the monthly sum did help keep a number of the families in the study, particularly those who were extremely poor. I provided each family with my telephone number and instructions to call me if they were going to move so that we could get directions to the new home. Also they were to call if for some reason they could not be there on the day we were to visit, because we were trying very hand to be as precise as possible in getting measurements at one-month intervals. I really had no great hopes that people would call because almost all had to use public telephones, but much to my surprise I regularly got calls advising me of changes needed in scheduling, and of changing addresses from those three families who proved to be nomadic. Also a number of the mothers began to call periodically to ask advice about many things. One of the ideas I tried to impress upon each family was how important the information they could give me was. Because I regarded their input as important, they too seemed to take things more seriously. At any rate we lost none of the 44 families during the 6 months of observation. Table 3 presents a summary of the various methods used, along with their frequency, who performed them, and which informant was used. Phase IV: Data Analysis The data were coded and entered into the computer for data manipulation and analysis. The Statistical Analysis System (SAS) was used for descriptive and inferential statistical analyses, including multivariate techniques for correlation, analysis of variance, and various

PAGE 58

51 o -C C 4-> (D CL >, =S O) -O CTTD 3 O) I +-> SC 01 (T3 -rCU O c: I— o u o -a cu O) o ji: •Io o f) o 00 -!-> >1 S >,

PAGE 59

52 o +-> C CL >, 0) O) c «1 i-

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53 nonparametric statistical techniques. These statistical analyses, along with a discussion of the results, will be discussed in more detail in Chapters IV and V.

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CHAPTER IV SOCIOCULTURAL PARAMETERS AFFECTING THE NUTRITION, GROWTH, AND DEVELOPMENT OF THE CHILD Family Networks Social interaction in Costa Rica is based on kinship. At all levels of social class, the persons v/ith whom an individual is most likely to celebrate New Year's Eve or Christmas, or upon whom he or she depends in times of emergency, are family members. First impressions may lead the outsider to assume that there exists a great deal of "neighboring," i.e. interaction between nonrelated individuals who live close to one another. A closer look, however, will show that in most cases where neighbors interact they are also related. The barrios in which this study was carried out were dotted with clusters of two or more related families. Over 50% of the 44 families in the in-depth study had relatives as neighbors. Although the scope of this research did not include a rigorous description of the networks which do exist, an acquaintance of any depth and over a length of time will automatically bring one in contact with these kinship-based networks. Usually there are two major networks within each household: one with the wife as a link to her family and the other linking the husband to his family. Sometimes one of these two networks may be nonfunctional, depending on the physical distance between family members and the strength of their relationship with one another. 54

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55 The basic importance of the family within the overall Costa Rican social structure has ramifications for the nutritional status of the child. Among the families followed, I found this kin-based network to be the primary source of financial assistance in times of economic depression, not unlike the situation observed by Safa (1974) in the Shantytown families of Puerto Rico. It is also the main source of mother substitutes or child caretakers should the mother of a child need to work or should something happen to her. There is a lot of food sharing, not only of foodstuffs but also of meals eaten at one another's house. The latter is particularly important for children. True (1976), in the study of marihuana users, mentions that among the poor there are two social spheres, that of the woman and that of her husband or companion. My research did not contradict this finding but rather found the same kind of division. My experience, however, put me in contact primarily with the people included in the maternal networks. Family Structure Of the 44 families in the in-depth study, 11, or 25%, were matrifocal families. Only one did not fit the definition of the "Queen Bee," or "grandmother," matri focal family described earlier. The one which did not fit was a "Queen Bee" type which had broken down; i.e. the grandmother and great grandmother had refused to let a granddaughter and her children live with them any longer. However, she still spent most of the day with them. It was also noted that "Queen Bee" families could include grown sons who were not married.

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56 Of the 44 families, 11, or 25%, were extended families. The extended family as I found it included various persons from different nuclear families, although these might not be complete families, e.g. daughters or sons and their children and possibly a spouse. The extended family always had a male as its head, however. Of the 44 families, 22, or 50%, were nuclear families. In San José, however, the designation nuclear family can be misleading. For example, I followed two children from nuclear families who lived in one of the barrios of Alajuelita. The first family consisted of Miguel and Antonia and their two children. They lived in a complex of three other separate houses on the same block. Antonia 's parents lived in front; her sister, at one side; and her brother, in a house behind their house. They all shopped together on Saturdays (at the farmer's market or the central market) and the children were in and out of all the houses and could eat at any of them. Goods, food, and services were exchanged freely. For all practical purposes, they functioned as an extended family but had separate dwellings. Not far from Miguel and Antonia, another family lived in similar circumstances. José and Sara Lived as a nuclear family with their three children; however, they too lived in a family complex consisting of several of Jose's brothers, a sister, and his parents. Figure 4 shows this layout— a pattern frequently found among the families in this study and also among many middle and upper class families who were social acquaintances. Thus it seems to be that the term nuclear family has a very different connotation in Costa Rica from that existing elsewhere. The main difference between the nuclear family and the

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57 Jose's Brother

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58 extended family in many cases is that in the former the family members have separate roofs and may cook separately; otherwise they act much like a traditional extended family. R. T. Smith (1970) had observed almost 30 years earlier that matrifocality is associated with a class position at the lowest rank of society. Vertical mobility is limited and the men are usually unskilled laborers holding jobs which have little prestige. He sees matrifocality as being the final phase of a cyclical process which includes a period of sex experimentation and spouse selection, the nuclear family, and finally the matrifocal household, which occurs when the role of wifemother gradually gains dominance over the role of husband-father. In Costa Rica, as greater job opportunities have become available for women in the textile and garment industries, women have become more independent, a phenomenon Safa (1974) also found in Puerto Rico. With this independence has come a decreased need for marriage to obtain financial security and thus leaving little, in many cases, to hold a man and his wife together. Here as in Puerto Rico, each is bound to his/her own kin group, blood ties being more important than marriage. Given this situation, marital problems such as alcoholism or unemployment on the part of the husband have tended to result in the formation of the matrifocal family. The "Queen Bee," or "Grandmother," family seems to result when daughters, able to obtain employment, find formal marriage unnecessary or impractical because they can remain in their mother's house and raise their children there. Increased availability of employment for women may be encouraging a trend toward elimination of the nuclear family phase of family evolution described by Smith.

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59 The Program of Social Welfare and Family Aid (Programa de Desarrollo Social y Asignaciones Familiares), which has been created to aid lowincome children and pregnant and lactating mothers, may have a tendency to make poor families, particularly female-headed families, more dependent on public aid, not unlike the situation described by Safa (1974:46) for urban Puerto Rico. As noted earlier, in Costa Rica the matrifocal family particularly the "Queen Bee," or "Grandmother" variant, has been considered an excellent adaptive mechanism enabling poor v;omen to obtain economic necessities and care for their children and to educate them (Lopez de Piza 1979:15). The data gathered in this study tended to verify this finding. Only 3, or 27%, of the matrifocal families had children in the low weight/height group. Although income on the family level did not differ significantly between male-headed and female-headed households, per capita income did. Female-headed households had a per capita income of ¿580/month ($14/month based on an exchange rate of $1/45) whereas male-headed households had a per capita income of ¡ziSZl/month ($18/month). The general linear model (GLM) (SAS, 1982) was used to run an analysis of variance and a Duncan test of the means. This analysis indicated that female-headed households were significantly larger, with a mean of 8.1 persons as opposed to 5.7 in male-headed households (F=7..34, p<0.01). In general, then, female-headed households had smaller individual salaries but there were more persons working and pooling resources, which compensated for the low salaries. An example of this phenomenon is the household of Doña Pilar, who left her husband years ago because of his drinking. She lives with her daughters and three grandchildren. Three of her daughters work in

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60 the garment industry, making clothing. Sara and Reina work in a factory; Luz works in a smaller establishment. Yolanda, the youngest, has been under treatment for psychiatric problems. Doña Pilar cares for the children and also sews at home. (Figure 5 shows a diagram of this family.) The three working daughters earn ÍÍ2400, 02000, and iz!1200 respectively for a combined income of ?!5600 ($124) per month, which puts them slightly above the mean for female-headed families (X=í¿4697, or $104) and for male-headed families (X-i!:4719, or $105). A total of ¿3742 ($83) is spent on food each month and ízí650 ($14) for rent and utilities. This leaves ¿1208 ($27) to be spent on clothes and other incidentals. They receive medical care through the social security clinics and the neighborhood health center. They speak of wanting to move to a new housing project but remain where they are because rent is cheap, allowing them to spend more on food, clothing, and other incidentals. Food-Buying Patterns Relating family structure to food-purchasing patterns, I found that in the female-headed household the person in charge of purchasing is usually also the principal child caretaker. This means that the buyer for a female-headed household has much less mobility and greater dependency on local corner grocery stores ( pulperías ) and street vendors whose products are usually more expensive. She has the alternative of taking small children along, leaving them alone for a period of time, or sending an older child to the store with a list of groceries. In male-headed families, in contrast, 36% of the time the man is the main buyer and 39% of the time both the husband and wife do the shopping. Only 12% of the time is the wife the principal buyer.

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61 Doña Pilar =Ar)=ArS= Sara Reina Luz A Juan (Index Child) o Maria Jose Absent Figure 5. Kinship Chart of the Family of Doña Pilar. This is an Example of the Extended Matri focal, or "Queen Bee," Family.

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62 In general, male-headed households were better able to patronize the subsidized state-run food outlets, the central market, larger grocery stores ( almacenes ), and other places which tend to offer better prices, whereas female-headed families viere dependent on what could be bought within walking distance. Male-headed households spent an average of (¿3884 ($86) per month on food, which was 82% of the total family income. Female-headed families spent an average of ¡¿3790 ($84) per month, or 81%, of their total family income. Per capita expenditure on food, however, differed more. Male-headed families spent ^670 per capita ($14), whereas famale-headed families spent ¡¿468 per capita ($10) per month (see Table 4). All families used bus transportation and most bought groceries with cash (over 90%) rather than on credit. Family members tended to get food or money to buy food from their kin netv^orks rather than having the local corner grocery store extend credit. Child Rearing Children occupy a favorable position in Costa Rica. The birth of a child is usually a welcome event. Lomnitz (1977) notes that in Mexico this attitude is common among members of marginal populations because children represent a potential cheap source of income. Their cooperation is dependable and the cost of their maintenance insignificant. The same is apparently true in Costa Rica among the poor, although children also seem to be valued for themselves, as family members and as sources of pride and prestige. Positive attitudes toward children are evident throughout Costa Rican society. At the national level the Patronato Nacional de la Infancia has been formed to serve as the watchdog of children's rights. Over 60% of community health

PAGE 70

63 /"nq :;ou piQ (VBO) JopusA ueiu>|LLiij uaD0j6u38U9 doL|SU9L|3:^ng l^^j^Wijídáns YiJMYr^ I VO<^ COtNJ CTvljD C»00 ICO CO I * CvJ CNJ Un I — I r— I II II I I I I I I I I I I I I I I I I IT) to CO un O) cu cu CTi LO CT) UD nSCU raOlSiOO) tOOJ-QfOCU fOO) fOO) E.— -OErE-E.— (tíE^E.— Er-OOJfOT(U(aT3CUra+-'tlJ't3 a)n3 (ou-s: 3ij_s: culi-s: t/iu-s: cuu_5:-i-i-i_5: cu' I I (o cu E .— o

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64 X"nq %ou piQ jopuaA UBLU>|[,lig s,jaujje-| Á"ja>(Bg jaoojBuaajg dOLisjaqo^ng UaOBUllH q Lv :ta>|aBiu LB>^^Lia3 :;ai:;no :ia>)jBUjjadns pBLjadLnd 2 I I I I I I I to <~o en oo I I 1 I I I I I II II I I fO OJ n3 -a -1Qj rs s-o S>,r— QJ o S(O 4-M QJ t. M1/1 o 3 o o +-> o >, S.— sen 3 QJ QJ o TJ U TD •3 o O) SI— o T3 S(_> QJ "3 (TI

PAGE 72

65 programs concern maternal and child health (Freer Miranda 1980). There is a children's library in the main plaza of San José and a fine children's hospital, as well as many other services for children. Aside from these indications, I found the attitudes toward children in most homes to be those of patience and warmth. During the course of my observation I noted wery little corporal punishment. In only one case was discipline carried out in this manner. In general, the behavior of children was controlled by diverting their attention or by removing them from the immediate area. In response to my questions mothers and caregivers told me that it was not customary to beat or spank children. This contrasted with what I had observed in the United States. Family Interaction and Child Development I spent time in each home observing the index child in the manner described previously. Generally, after the first few minutes the child ignored me and went on about his/her usual activities. In the physical environment I noted a lack of high chairs or raised stools or other equipment enabling the child to eat comfortably at the table. Children ate sitting on their mother's lap, sitting on a low chair reaching up to the table, standing on a chair, or sitting on top of the table or on the floor. Only 11 families, or 25%, of those observed had special furniture or made any provision for the child's comfort and ease while eating. Most children were encouraged to eat by themselves although some were completely fed and in the case of some a combination was employed— the child eating alone and then the mother helping to make sure that he/she had eaten enough. The lack of children's furniture

PAGE 73

66 was probably the result of both tradition and low income. Locally made wooden chairs and other furniture pieces were available and were relatively inexpensive. An analysis of variance obtained by use of the GLM procedure of the Statistical Analysis System showed some significant differences in certain activities observed in the home, based on the sex of the child. Girls were observed more frequently than boys playing by themselves (F=4.71, p<0.04), playing with toys which stimulate fine motor development (F=9.47, p^O.004), and engaging in imitative play, e.g. playing house, pretending to be an adult, etc. (F=9.96, p<0.003). Boys were more frequently observed running (F=4.44, p<0.04) and playing with toys which stimulate gross motor development (F=8.43, p<0.006) than were girls. Mothers were observed stimulating language development with girls significantly more often than with boys (F=6.64, piO.Ol). It is not surprising that boys were more often observed running than were girls. Soccer is the national sport, and one of the first skills a boy learns is to run and kick a ball. Girls in Costa Rica are expected to be homemakers; therefore, it is not unexpected to find them engaged in such activities as playing house or playing with dolls or other toys requiring the use of fine motor coordination and imagination. Also, some of the differences observed may result from the fact that boys between the ages of 1 and 2 years may be a little behind girls in their development. Observations at an older age might yield different results, because playing with some toys requires more coordination which boys may not develop until later. Distinguishing physiological causes from

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67 culturally induced differences would require much more in-depth observation, however, and was not within the scope of this study. Most children had access to toys and played with them, although the variety was not as great as in the United States. Most of the children customarily played with other children, usually brothers and sisters or cousins. Twenty-five percent of children were observed playing with an adult male at least once, usually another family member, i.e. father, older brother, or uncle. Forty-five percent of mothers were observed playing with the child. Although almost e'^ery family had a TV, "^ery few of the children watched. Because electricity is expensive, the TV was usually turned on only at night and on special occasions when a number of adults were present. It was not at all unusual to find a family living in a shack but owning a television set. Prior to beginning the research, I had been told by middle class Costa Rican informants that children of poor people were not at all stimulated and that it was common practice to leave babies in drawers or cribs without attention. I had also observed during my time in South America that, at least among the middle and upper classes, children were kept dependent for a much longer period of time than in the United States, probably because of the availability of servants. For example, they were fed rather than taught to eat with spoons. The children I observed in San José, however, were encouraged to be independent and to learn to take care of themselves. Although some children customarily drink a baby bottle of milk each night before bedtime until they are 5 or 6 years old, they still know how to drink from a glass and to eat using utensils. The baby bottle is a habit or treat. I also noted that the

PAGE 75

68 index child received a good deal of physical and cognitive stimulation. Sixty-eight percent of the mothers were observed cuddling their child at least once during the visit. Forty-five percent were observed encouraging language development by talking with the child. Sixty-three percent of the children were observed conversing with other children or adults. In short, the majority of homes provided an environment that was full of potential stimuli, certainly not what could be called a severely deprived atmosphere. Child Health Based on my sample, I found children living in San José to have good access to primary health care through the community health program operating in each health center. As an indicator of the quality of health care, over 90% of the initial 107 children were found to have had their BCG, DPT, polio, and measles (rubella and rubeola) immunizations completed for their age. In comparison, records show that in Florida 93.7% of all school entrants had been immunized. This higher value, however, is undoubtedly influenced by the fact that obligatory immunization begins to function at school entrance age in Florida. Nationally, only 60% of the children aged 1-4 had been immunized. Although specific figures for children aged 1-4 or 1-3 were not available, the Flroida State Health Plan indicated that immunization rates for this age group are considerably below that of school entrants, probably more in line with the national rate noted (Florida State Health Coordinating Council 1981). (Table 5 gives a breakdown of immunization figures for the group followed in depth.) Nine percent of the children in the longitudinal study were observed to have dental caries upon a simple inspection. Other than this.

PAGE 76

69 no clinical symptoms of malnutrition were observed. (Table 6 gives a breakdown for the group as a whole.) Table 5. Immunization Rates for Costa Rican Children from Poor Urban Barrios

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70 The mother is the person who usually cares for the child when he/ she is ill, but grandmothers and aunts may also help. Fathers were never indicated as being directly involved in child care. Most of the families in the sample went to health centers, with a slightly smaller number going to social security clinics for medical care. Private physicians were used by a few and about 5% claimed to have no access to medical care. (See Table 7 for a breakdown of these figures.) Diet and Food Habits as They Relate to Children Although breast-feeding was once the norm in many developing countries, including costa Rica, recent work has indicated that both the incidence and the duration of maternal lactation are declining (Jelliffe, E. F. P. 1979; Popkin et al . 1980). This trend was also noted in Costa Rica (Mata et al. 1981), and programs have been begun to encourage increased maternal lactation. Data about maternal lactation were gathered on the 44 children in the longitudinal study. In an effort to compare these data with earlier information. Table 8 was constructed to show our results from 1982 as compared to results for Region I (Metropolitan San José) and the country as a whole in the national survey of 1975 (Diaz Amador 1975). This information appears to indicate a decline in numbers of children never breast-fed and a general trend toward longer periods of maternal lactation, although the percentage of children breast-fed more than one year is reported to be the same. Table 9 shows comparative data regarding the age at which bottle feeding is begun and indicates a decline in babies never bottle fed and more bottle feeding started in the first month of life. However, a

PAGE 78

71 Table 7. Who Cares for the Sick and What Facilities Are Used Longitudinal Group excluded study group from longitudinal Total group (N=44) study {N=63) (N=107)

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72 Table 8. Comparative Data on Duration of Maternal Lactation 1975 :otal of time study Region I" country Length 1982 1975 total ^ Not breast-fed at all 9.1 16.0 13.3 Less than 1 month 6.8 12.2 13.3 1-3 months 25.0 30.2 20.3 4-6 months 13.6 3.7 4.3 7 months to 1 year 18.2 1.8 5.1 More than 1 year 27.3 27.4 34.1 Do not know — 8.5 9.5 Note: Time periods given on the 1975 study have been combined so that they are equivalent to the time periods used in this study. Region I includes metropolitan San José. "^Diaz Amador, 1975.

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73 Table 9. Age at Which Bottle-Feeding Is Introduced Among Costa Rican Children— Comparative Data Total Length 1982 Region I country of time study 1975a 1975^ Not breast-fed at all^ 4.5 7.5 5.9 Less than 1 month 61.4 59.5 55.0 1-3 months 11.4 18.8 17.8 4-6 months 11.4 — 1.9 7 months to 1 year 6.8 2.8 3.1 More than one year 4.5 — — Do not know — 8.5 15.1 Region includes Metropolitan San José. '^Diaz Amador, 1975. ^Time periods have been combined in the 1975 study to make them equivalent to the time periods used in the current study.

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74 large number of mothers are apparently introducing bottle feeding later as well. The changes shown in both Tables 8 and 9 may be the result of Ministry of Health-sponsored campaigns to promote breast-feeding. It is probably too soon, however, to say definitively that this is the case. Data were also gathered about why mothers discontinued breastfeeding. Table 10 shows a summary of these data compared to reasons given in 1975. The basic reasons a mother decides not to breast-feed are insufficient milk supply and child rejection of breast-feeding. My research also indicated that 23% of the mothers had introduced solid food within the first month of the child's life and by three months of age 77% of the infants had been introduced to regular food. By the end of the first 6 months, 93% of mothers had introduced their infants to regular food. In fact, looking at the incidence of breastfeeding without taking any of these other factors into account is misleading and can give a false impression. What actually happens is that most mothers are breast-feeding and bottle feeding simultaneously, starting when the infant is very young. Regular food is added as soon as the infant can tolerate it, beginning in the first month of life. Infants are first fed bits of food from the table and then gradually given their own portions. Information about whether a child is being breast-fed is not as important as estimating the amount of breast milk received. The latter is difficult to do. There are mothers who report breast-feeding for 6 to 12 months, but after the first 2 or 3 months only once or twice a day; in this way breast-feeding only makes a small contribution to

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75 Table 10. Reasons Given for Discontinuing Breast-Feeding— Comparative Data Reason 1982 study Region I 1975^ Total country 1975^ Milk dried up or did not have sufficient supply Child rejected Advice from friends and relatives Believe cow's milk is better Other 41.2 breast-feeding

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76 the child's diet. The scope of this study did not include estimating the amount of breast milk received by the child. Other information from 24-hour recalls for the index child show two facts of special interest. First, milk, whether breast or bottle, is the primary source of protein for the child under 3 years of age. The second item of interest is that, although rice and beans are staples of the Costan Rican diet and good sources of protein, the child under 3 years of age is by tradition fed rice and caldo de frijol , or the juice in which the beans have been cooked. Although caldo de frijol is a relatively good food from a nutrition point of view, it is not equivalent in protein to the whole bean. Government policies which seek to decrease milk available to small children from poor families and substitute rice and beans could be detrimental for children under 3 years of age. A brief discussion on some of the more pertinent social and cultural factors which may have important influences on the nutritional status of the urban poor child in San José, Costa Rica, has been presented. The next chapter will deal with the actual comparison in growth and development between children of low weight/length and those of normal weight/length.

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CHAPTER V RESULTS Anthropometric Data A total of 107 children, 54 males and 53 females, born in 1980 were chosen at random from birth registers in low income areas associated with the health centers of Alajuelita, Hatillo, Pavas, Tibas, Paso Ancho, Guadalupe, and Cristo Rey. In the initial survey, measurements of length, weight, head circumference, arm circumference, triceps, and subscapular skinfolds were taken. In addition to these measurements, the Denver Developmental Screening Test (DDST) was given to each child and a family registry and assessment of the environment v/erc done. Table 11 shows the distribution of the children surveyed with respect Table 11. Distribution of Weight/Length Percentile Rankings by Sex of the Initial Sample of 107 Children from Poor Urban Households in San José, Costa Rica Percentile Sex <5th 5th-10th >10th-25th >25th-50th >50th Male 5 Female 3 Total 8 Percent 7.5 5

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78 to percentile rankings. As indicated, only 7.5% (n=8) of the children were found to be below the 5th percentile. Another 7.5% (n=8) fell between the 5th and 10th percentiles. These findings indicate a low percentage of severely undernourished children. It was decided therefore to focus on the moderately undernourished child. The ministry of Health criterion of 90% of the median of National Center for Health Statistics (NCHS) weight/height standards and/or first degree malnutrition by Gomez's criterion was used to delineate a group of mildly underweight children to be followed and compared with normal weight/length children. These criteria were used even though they included more children in the low weight/length group than would occur by use of the 5th percentile category. This was felt to be a reasonable division given the fact that less is known about problems involving invisible or mild undernutrition in children, particularly the boundaries which define it. The families of 19 of the children in the low-weight/length group agreed to let them participate. Twenty-five normal weight/length children were chosen at random and also were asked to participate. Although the drawing was done randomly, more girls than boys of both the low weight/length and the normal group were not allowed to participate. In the case of the 25 normal weight children, substitutions were made by drawing another random number. The result was 18 females and 26 males in the final study, even though the initial group was evenly divided. After the group for the longitudinal study was selected, six additional monthly measurements of length, weight, head circumference, and arm circumference were taken. Triceps and subscapular skinfold measurements were taken at the beginning and at the end of the 6-month

PAGE 86

79 longitudinal study. For the purposes of this particular study, only the weight/length figures are analyzed. Table 12 shows the distribution of the smaller group of 44 children with respect to percentile distribution of the initial and final measurements. Table 12. Distribution of Weight/Length Percentile Rankings of Initial and Final Measurements by Sex in a Sample of 44 Children from Poor Urban Households in San José, Costa Rica, Who Were Followed for 7 Months

PAGE 87

80 there was also a decrease in children in the 5th-10th percentile category and an increase in the number of children in the 10th-25th and 50th percentile categories. The overall impression is that growth shows a great deal of individual variation and tends to occur as a series of mini-catch-up spurts for both height and weight. Specific illness episodes or other events (e.g. weaning) only partially explain the observed variation in growth magnitude and velocity. Figure 6 illustrates this pattern well. The child is a female of normal weight/length with no reported illnesses or unusual family circumstances, but whose growth velocity varies a great deal from month to month. Figure 7 illustrates the classic pattern of the mother becoming pregnant and weaning the child. The child, a male, was normal in weight/length but dropped 0.5 kg. (4% of body weight) during the adjustment period. In this case the child suffered no severe effects because he had reserved body fat. The underweight child in this same situation would not be so fortunate. Figure 8 illustrates another typical problem related to growth. The child, a male of normal weight/ length, was cared for by the grandmother while his mother worked. The grandmother went to work, leaving a rather emotionally unstable aunt in charge of the children. The index child of this family lost weight (1.5 kg., 13% of body weight) rather abruptly and did not begin to regain it until the grandmother returned to stay with the children. These examples have been chosen as representative of typical growth patterns found among the children followed and as such demonstrate the need for many measurements over time in order to determine the state of a child's health and nutritional status. Crosssectional studies do not necessarily reveal this individual variation.

PAGE 88

IT) O) CO U5 00 81 O CO Iz HI :s UJ GC CO < LU O II © 1 — o

PAGE 89

82 V) o

PAGE 90

83 HjH-l xSSO ,_OouO S X UJ 2 5q>. c: Lu D lU << < EC Oooi< O C)5c\jqs;ir>c\Jo c\j r-' T-' TT-^ o ó o ó ~i 1 1 rU) O u> o K to CNj q O) 0> 0> O) lO

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84 Maternal Reproductive History and Birth Weights A SAS general linear model (GLM) analysis of variance showed that no significant differences existed between mothers of low weight/length children with respect to total number of pregnancies, age, the order of the index child in terms of total pregnancies, or the order of the index child in relation to living children. Birth weight was found to be lower among the low weight/length group as compared to the normal weight/length group (F=5.94, p:^0.02). Because of the large number of boys in the group, particularly the normal group, analyses were also done by sex. Low weight/length boys v^ere found to have significantly lower birth weights than normal weight/ length boys (F=4.64, p50.04). Low weight/length girls, however, were not found to differ significantly from normal weight girls with respect to birth weight, even though their average birth weight was lower (2818 grams as compared to 3060 grams). In this study birth weight was not controlled but rather was one of the parameters allowed to vary. In an effort to determine to what extent birth weight was influenced by genetic factors, the height and weight of each child's mother were also obtained. An analysis of variance indicated no significant difference between the height and weight of the mothers of low weight/length children and those of the mothers of the normal children. In the former group both weight and height tended to be lower but not significantly so. This suggests that the low birth weight associated with the mildly underweight child may be more related to maternal undernutrition during pregnancy than to other factors.

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85 Illness Classification In addition to the health history obtained initially for the year prior to the beginning of the study, health histories were elicited monthly from primary caretakers. An illness classification was developed based on the work of Martorell and Yarborough (1983). Diarrheal illnesses include diarrhea and gastroenteritis, including pega . Respiratory illnesses include bronchitis, cough, cold, asthma, flu, and grippe. Selected common symptoms include all of the above diseases and symptoms plus fever, vomiting, skin infections, tonsilitis, parasites, inflamations, ear infections, allergy, kidney or bladder infection, loss of appetite, and dyhydration. There were not significant sex differences in the average number of illnesses, although males had more diarrheal illnesses and illnesses included in the selected common symptoms category. Slightly more females were, on the average, reported as having respiratory illnesses. A large number of children (23, or 52%) were reported as having no diarrheal illnesses. A total of 160 illnesses, including 74 respiratory illnesses and 30 dirrheal illnesses, were recorded for the sample over a consecutive 7-month period (Table 13); 50% of the illnesses occurred during the rainy season and 50% during the dry season. There was no significant difference in the occurrence of respiratory illnesses by season. Diarrheal illnesses showed a significant seasonal trend with a mean of X = 3.00 cases in the dry season and X = 6.00 cases in the rainy season (t^=2.60, p<0.05). Select common symptoms showed no significant

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86 seasonal variation with means of X = 20.00 and X = 26.67 for the dry season and rainy season respectively (t,=0.544 N.S.). The mean number of illnesses per child was J = 3.64. Table 13. Seasonal Frequencies of Illness Among Low-Income Urban Children in San José, Costa Rica Month and season Diarrheal Respiratory Month 1 Dry 1 Month 2 Dry 5 Month 3 Dry 1 Month 4 Dry 5 Month 5 Ra i ny 7 Month 6 Rainy 7 Month 7 Ra i ny _4 Total 30 With respect to elicited health histories for the year prior to the initiation of the study, significantly more children in the low weight/length group were reported as having fever (x =4.62, p;:0.03) than in the normal weight/length group. Other than this there v;as no appreciable difference between the two groups in the reported incidence

PAGE 94

87 of illness according to the health histories. Table 14 gives a summary of the illness episodes reported in the histories. Psychomotor Development Table 15 gives a summary of the group as a whole with respect to the results of the Denver Development Screening Test (DDST). Twelve percent (n=8) of the normal weight/length group and 17% (n=4) of the low weight/length group had abnormal or questionable results on the DDST. It is suggested that a more discriminating instrument may be necessary to detect differences between mildly underweight children and normal weight children. However, more interesting is the fact that 50% (n=5) of the children who were short for their age but normal in weight/length had abnormal or questionable results on the DDST. Unfortunately, these children, because they were considered normal in weight/length and because they represented a different nutritional problem, were not included in the in-depth study. These results suggest that an additional follow-up of short-for-age children may be warranted, even though they may not be technically considered undernourished by weight/length criteria. Socioeconomic Factors There were slightly more (X=2.5) children under 6 per household in the low weight/length group than in the normal group (X=2.0); this difference, however, was not statistically significant (see Table 16). Household size tended to be larger, mother and father older, household income less, and education of both mother and father less in the low weight/length group. Total household income was calculated by summing

PAGE 95

c

PAGE 96

89 ^ CD u o U rO 1— m

PAGE 97

90 all salaries of family members plus the value of food or other items which were gifts, and any other support, i.e. government aid. Since this information was collected after about 5 months of visits, it is felt to be a reasonably accurate estimate. The exchange rate from colones to dollars was calculated at 45/1 which was approximately what it was when the questionnaires were answered. Table 16. Means of Selected Social Characteristics of the Families of Low and Normal Weight/Length Poor Children in San José, Costa Rica Low Normal weight/length weight/length Characteristic (n=19) (n=25) Household size 6.6 6.2 Children 6 and under 2.5 2.0 Father's age 32.4 31.1 Father's education (no. of years completed) 6.5 7.0 Mother's age 28.2 25.3 Mother's education (no. of years completed) 6.3 7.0 Total household sz:4505 ^4872 income per month ($100) ($108) Total food cost í¿3991 (J3761 per month ($89) ($84)

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91 The cost of food was calculated on a per month basis according to the frequency of purchase of food items as reported to the investigators. The prices were as accurate as possible given the frequent fluctuations caused by inflation during 1982. A greater proportion of income was spent on food in the households of the low weight/length group (89%) than in the households of the normal group (77%). Fifty-three percent of the families of the low weight/length group and 36% of those of the normal weight/length group either owned or were buying their homes. Table 17 gives a summary of the type of tenure of the dwelling. More families among the normal weight/length group were renting, and fewer owned their own homes. Table 17. Type of Tenure of Dwelling in a Sample of Low Weight/Length and Normal Weight/Length Children from Low Income Families in San José, Costa Rica Low Normal weight/length weight/length Type of Tenure (n=19) (n=25) Own home Buying home Rent home Borrowed home Total In this case families were usually living in a house belonging to some other family member, i.e. mother, father. Rent was paid when funds were available. 32

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92 More of the parents of children in the low weight/length group were married than in the normal weight/length group (68% as compared to 56%). Forty percent of the parents of the normal weight/length group and 16% of the parents of the low weight/length group were single. Thirty-two percent of the households of the normal weight/length group were female headed, whereas 16% of the households in the low weight/ length group were of this type. The sample was slightly biased toward families with a more stable residence because of the method of selection. Those who had moved within the previous year were not usually included in the birth registers we used to select the sample. Eighty-four percent of the families of children in the low weight/length group and 72% of those of children in the normal weight/length group had lived in their present residence for three years or more. Fifty-eight percent of the families of the low weight/length group and 56% of the families of the normal weight/length group had lived 5 or more years at the same residence. Thirty-eight percent of the fathers of the low-weight/length group and 11% of the fathers of the normal weight/length group were unemployed or worked only occasionally or seasonally. Seventy-nine percent of the mothers of the low weight/length group and 67% of those of the normal weight/length group did not work outside the home. Thus, not only was employment less for men but also for women in the families of the low weight/length group. Data collected about buying patterns indicated that most families did not buy on time; however, more of the families of the low weight/ length group did— 32% compared to 12% of the normal weight/length

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93 group. Thirty-two percent of the families of the normal weight/length group also reported having some savings as compared to 5% of the families of the low weight/length group. With respect to environmental conditions, wooden houses predominated in both groups {58% and 64% in the low and normal groups respectively). A few were made of brick or cement block (42% and 32% respectively) (see Table 18). Most had cement floors and zinc roofs. Condition of housing was generally good. Approximately 26% of the families of low weight/length children and 24% of the families of normal weight/length children lived in government housing projects. The houses had 1 to 5 rooms with an average number of 2 rooms in both groups. The number of beds per family ranged from 1 to 6, with a mean of 3.5 beds per household. Most families in both groups cooked with electricity although gas wood and/or charcoal, and kerosene were also used by a small number (25%). During the course of the study a number of people began to use wood and/or charcoal again because the cost of electricity had risen as a result of inflation and the increased cost of importing petroleum to Costa Rica. A total of 15% of the families of the low weight/ length group and 24% of the families of the normal weight/length group were either using charcoal exclusively or a combination of charcoal and electricity and/or gas. Charcoal and wood are local products and relatively cheap. When a combination of cooking methods v;as used, usually for items requiring long cooking periods such as beans, rice, soups, and stews, charcoal was used, whereas the electric stove or hot plate was used for foods which could be cooked rapidly, i.e. eggs.

PAGE 101

94 Table 10. A Comparison of Environmental Conditions in a Sample of Low Weight/Length and Normal Weight/Length Children from Low Income Families in San José, Costa Rica Item Low weight/length (fj=19) Normal weight/length (N=25) Construction of walls

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95 Table 18— (continued) Item Low

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96 Table 18— (continued) Low Normal weight/length weight/length Item (N=19) (N=25) Condition of sanitary facilities One family, good condition, clean 84 56 One family, good condition, dirty — 4 One family, poor condition, clear — 12 Multi family, good condition, clean 16 16 Multi family, poor condition, clean — 12 Bathing facilities (shower) One family 84 88 Multi family 16 12 Water supply City line in house 100 100 Pets Yes 53 36 No 47 64 Other animals None 100 92 Cow — 4 Chickens — 4 Radio Yes 95 92 No 5 8 Television Yes 95 88 No 5 12 Stereo Yes 47 24 No . .53 76

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97 Table 18— (continued) Low Normal weight/length weight/length Item (N=19) (N=25) Refrigerator Yes 47 56 No 53 44 Blender Yes 63 56 No 37 44 Tape recorder Yes 37 32 No 63 68 Sewing machine Yes 32 44 No 68 56 Percolater Yes 26 24 No 74 76 Toaster Yes 11 4 No 89 96 Wafflemaker Yes — 4 No 100 96 meats, macaroni, or spaghetti. The combination of cooking methods is an example of the adaptive measures families were using to survive the economic crisis. Service by the city of San José was seen to deteriorate in poor neighborhoods as compared to other areas of the city with respect to sewage disposal, garbage collection, and other sanitation measures. It was frequently possible to see open ditches with sewage or drainage areas in the community and in individual houses. Both groups were

PAGE 105

98 affected by these conditions, although environmental conditions among the families of the normal weight/length group tended to be slightly worse. However, most of the families with yery bad environmental conditions had healthy children who seemed to thrive regardless of their surroundings. This is probably the result of the excellent program of health and nutrition intervention already mentioned. All the families had pets, but more of the families of the low weight/length group had pets than did families of the normal weight/ length group. Domestic animals such as cows and chickens were encountered among a small percentage of the families of the normal weight/ length group. The animals in these cases were used to supplement the diet of the family. Only those families living on the periphery of the city were able to maintain animals. Most families had no place for animals or gardens. Three of the families of low weight/length children and three of the families of normal weight/length children had gardens which regularly produced food for consumption. Ninety-five percent of the households of the low-weight/length group and 88% of the households of the normal weight/length group had televisions. Over 90% had radios. More households of the normal weight/length group had refrigerators than did households of the low weight/length group— 56% compared to 47%. Slightly more households of the low weight/length group had stereos, tape recorders, blenders, and toasters than did the households of the normal weight/length group. Often these were given as gifts in a grand gesture. Most of these appliances had been purchased prior to the beginning of the economic crisis of 1981-82.

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99 Dietary Data Food Frequency The food frequency data obtained by using the Q-sort indicated that the basic daily diet among families of both groups included beans, rice, bread, banana, white sugar, coffee, butter or margarine, milk, tomato, onion, and sweet pepper (the latter three used as condiments in cooking other dishes) (see Table 19). In addition to these items, tubers such as manioc , potatoes, and spaghetti or macaroni were eaten at least two or three times per week. Cabbage salad, carrots, lettuce salad, and oranges were also commonly eaten at least two or three times per week. Meat was used as a flavoring in cooking soups and stews and other primarily vegetable dishes. Beef in the form of hamburger, stew meat, or steak was the most common meat eaten; however, processed luncheon meat was the single most frequently consumed meat item— 43% ate it daily or 2-3 times per week. Chicken and pork were eaten about once a week or once e^jery 2 weeks or less frequently. Fish was eaten monthly or seasonally by most families. A Wilcoxon 2-sample test (t test approximation) and a KruskalWallis test (chi square approximation) were run on the food frequency data comparing the consumption of the families of the low weight/ length group with the families of the normal weight/ length group. The results were significant only for the frequency of consumption of liver, mustard greens, and oranges. The families of the normal weight/length 2 group reported consuming significantly more of these items (x =7.04, p<Ü.008; x^"4.07, p<0.04; x^=.4.32, p50.04 respectively). Because all of these are relatively inexpensive items which are readily available,

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102 this finding may represent an adaptive strategy used by the families of the normal weight/length group to enhance their diet. Breast-Feeding Patterns Table 20 compares data representing the breast-feeding history of low and normal weight/length children. More of the normal weight/ length children had never been breast-fed; however, there was a slight tendency toward longer duration of breast-feeding among low weight/length children. Sixty-eight percent of low weight/length children and 52% of normal weight/length children were breast-fed 4 months or more. The low weight/length group also tended to have been introduced to bottle feeding and regular foods later. Approximately 31% of the low weight/ length group and 16% of the normal weight/length group viere not introduced to bottle feeding until the age of 4 months or more. Thirtyseven percent of the low weight/length group and 12% of the normal weight/length group were not introduced to regular food until age 4 months or more. A Wilcoxon 2-sample test (t^ test approximation) showed no significant differences between the two groups. Attitudes About Food Table 21 shows a summary of the most liked/least liked, most nutritious/least nutritious food Q-sort. In general, the subjects regarded the foods they liked most as being less nutritious (beans, rice, beef stew, ice cream). Foods which were regarded as highly nutritious were invariably placed much lower on the most liked-least liked scale (liver, spinach, red beets, and fish). The overall impression is that subjects tended to consider foods eaten every day as being less

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103 CO CO r-

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104 Table 21. A Comparison of Selected Foods Considered Most and Least Nutritious and Those Most and Least Liked

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105 Table 21 — (continued)

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106 Table 21 — (continued)

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107 nutritious than some more exotic foods which perhaps have received more attention from nutrition education programs, e.g. liver, spinach, fish, orange juice, and carrots). The Q-sort of foods considered appropriate for the index child showed that mothers of both groups were unanimous in considering as proper foods ripe plantain, tubers ( manioc , etc.), liver, chicken, milk, egg, banana, carrot, vegetable beef stew, orange juice, oranges, and soup. The groups disagreed about such foods as green mango, watercress, sausage, lunchmeat, peas, corn, corn flakes, and canned tuna. More of the mothers of the low weight/length group thought these latter foods were appropriate than did the mothers of the normal weight/length group (see Appendix 11). Almost all mothers agreed that liquor, beer, coffee, and coke were not good for children. A chi square test of independence was run on those food items which seemed to show the most variation between groups. Luncheon meat and watermelon were the only two which showed a significant result (x^=4.02, p-0.05 and x -4.48, p$0.03 respectively). Because of the distribution, over 20% of the cells had counts of less than 5; therefore chi square was not considered valid. A Fisher's exact test was run on the same items. None of the results were significant. Thus, it was concluded that, although there were some differences between the groups, they were not great enough to warrant further consideration. In-Home Observation of the Index Child In-home observation was carried out to learn something about child-rearing practices and the general environment of the home in which each child lived. The list of behaviors selected for counting was

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108 developed after some initial observation. The behaviors included items related to each of the four sections of the Denver Development Screening Test (DDST), e.g. personal-social (playing with other children and adults), fine motor (playing with toys which stimulate fine motor development), gross motor (running, walking), and language development (mother stimulating language development). In addition to items related to these four areas, other behaviors were counted which were considered nurturing or mothering, e.g. mother cuddling, holding the child for feeding, etc. (A complete list of the items can be seen in Appendix 10. ) One of the purposes of the observation was to determine the frequency of nurturing behavior among mothers and caretakers of children in low income families. Several of the behaviors measured which were thought to be particularly indicative of this phenomenon were analyzed in more detail. A Pearson product moment correlation was run on these items, correlating them with length, weight, and growth velocity (length and weight gains). Table 22 shows significant positive correlations between the frequency with which the index child was observed eating while being held and length and weight. Positive correlations were also observed between the child's being fed and his or her weight and length. A correlation was also noted between the child's eating sitting down (as compared to his eating while running around or standing) and total length gain. Being fed was positively correlated with total weight gain. Behaviors associated with increased activity, e.g. playing with other children, climbing, and playing with toys which stimulate gross motor function, were negatively associated with length, weight, total length increase.

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109 <: m +J -o en O) o > o iOJ •> ui M) J3 (/) O O X) CU C +-> fO (J 00 CU I — E S oí C E fO CU •rU Oí "O •rC 00 fO oo

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no and total weight gain respectively. A negative association was also observed between eating with a spoon and length. The positive correlations associated with being fed, eating while being held, and eating sitting down suggest a pattern in which much more attention is being paid to the child at meal times to ensure that intake is sufficient. The negative correlations suggest that increased activity, such as occurs with climbing and playing with other children, leads to decreased weight gain. All of the children were between the ages of 1 and 3 years of age, which is precisely the time a child usually starts to learn to use a spoon. It is also a time when many become independent about eating and want to feed themselves. The child may eat less because of fatigue or frustration in manipulating the spoon. An adaptive behavior noted with some mothers as a compensation for this learning period was to let the child eat with a spoon while simultaneously feeding him or her, or to feed the child when he or she become tired of eating with the spoon. In the low weight/length group, the presence of mother cuddling, father cuddling, and continued bottle feeding were all positively associated with length and/or weight (see Table 23). Handwashing was negatively associated with weight. Environmental sanitation conditions were not good in many homes because of the problems with sewage and garbage disposal already mentioned. Usually children were observed to have their hands washed only if they had been outside playing in mud or dirt. Those whose hands were more frequently washed may also have been exposed more frequently to illness-causing organisms. There was probably also an adaptive increase in resistance to these illnesses among children in the poorest environments.

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Ill I I r^ CO ro r— LD o CO OO CM C\J C\J CM ÍD o en o c •!0) a: I I <=d¡XI UD -— U-> o cj o to «* «^ o I I ^ o 1 — IT) I — CM Ln o o o 00 1—
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112 The case of Julia illustrates, a case where '>jery little nurturing behavior was noted, no cuddling, feeding, etc., by either the mother or the father or other adults v;ere noted during the time of observation. Julia was 16 months old at the initiation of the observation period and 23 months old at the time of the final measurement. She was included in the low weight/length group. She had a brother who was about 10 months younger than she and who was obviously already favored by the mother. At the final measurement the younger brother out-weighed Julia by about a kilo. Julia's father worked irregularly as a welder. He also worked at odd jobs and seasonal labor when welding was not available. Julia's mother took her to her grandmother's house almost every day. The grandmother lived about three blocks away in a nicer house. Julia usually ate at her grandmother's house. The grandmother, who was very religious and belonged to a fundamentalist cult, spent a great deal of time reading the Bible and praying with friends. At the time of the observation, Julia was pretty much left on her own to eat what she could, which she did standing up at a chair or running around the house. She was also left to play alone and entertain herself most of the time. The mother spent a great deal of time with Julia's brother. Figure 9 shows the growth pattern which v;as observed for Julia. Another child in the low weight/length group was called Catia. She was 20 months old at the beginning of the study and 29 months old at the end. Mother cuddling and other nurturing behaviors such as mother feeding were observed. Catia had five brothers and sisters; her father worked as a chauffer but was out of work sporadically.

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113 Q. C/) a: ^^ o CO o CO 0+ CO z LLI LU CE CO < LU "~T 1 1 1 1 1 1 r— inoLOOinOLOo CVJON-inCVJON; lO óóaia>aiaia¿có in

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114 Her mother was extremely conscientious about keeping the children clean and fed. The older sisters were encouraged to help with the younger ones. Figure 10 shows the growth pattern observed for Catia. Both children had about the same incidence of illness except that Julia had some diarrhea. I suggest that the extra attention given by the mother and the older sisters and a better diet made the difference in how well Catia thrived in comparison to Julia. The families were Mery similar in terms of per capita income. Multivariate Analyses A multivariate stepwise regression analysis and a stepwise discriminant function analysis were performed to formulate an overall view of the effect of many variables on the nutritional status of the children. An attempt was made to develop a model which could predict a child's nutritional status. The procedure was carried out according to that recommended by Afifi and Azen (1979) and the SAS Institute (1982). The variables analyzed included those concerned with biological characteristics such as birth weight; those having to do with family structure, e.g. sex of the head of the household and the number of children 6 years or age and under; and those related to socioeconomic status such as total income and the amount of money spent on basic food items. Included in the analysis were characteristics of the environment, e.g. number of rooms, number of persons per bed, presence of radios, television, wafflemakers, and blenders, and the frequency with which certain mother/caregiver behaviors were observed during the in-home observation period. The regression analysis included both intervallevel variables and nominal variables whereas the discriminate function was performed by use of interval-level variables only.

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115 oy

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116 Stepwise Multivariate Regression The multivariate regression analysis was run with the weight/ length percentile ranking of each child as the dependent variable. Table 24 shows these results. Birth weight, frequency with which a child was observed being fed by the mother or principal caregiver, amount of money spent on dried milk, number of children aged 6 and under, and whether or not the family had a wafflemaker were the five variables which emerged as best for predicting the percentile ranking of each child in the study. The information supplied by these variables explains 47% of the variability between the weight/length percentile rankings of the children in the study population. Stepwise Discriminant Analysis A discriminant analysis was performed with low or normal weight/ length group membership as the dependent variable. Interval-level variables included the frequency of observed behaviors such as mother cuddling and feeding of the child, monthly cost of certain key food items, number of rooms, number of persons per bed, presence of diarrhea and other illnesses, number of pregnancies, and birth order of the index child. Table 25 shows the results of this analysis. Birth weight, frequency with which the mother was observed feeding the child, number of children 6 years of age or under, number of persons per bed, and cost of purchasing processed foods (i.e. cooking oil, canned foods, and coffee) emerged as the variables having the most ability to discriminate between children likely to be in the low or normal groups.

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118 fd (/I "O >> •1T4-1/1 Q. to CO to

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119 To interprest these results the following ethnographic explanation of the variables is provided: 1. In previous studies (cited in Moore, 1978) there was a positive relationship between the total weight gain of the mother during pregnancy and the birth weight of the baby. In the present study, as previously discussed, there was a significant difference in birth weight between the low and normal weight/length groups, with the children in the low weight/length group having lower birth weights. 2. The frequency with which a mother or principal caretaker was observed feeding the index child was one of the behaviors counted during the in-home observation period. As mentioned earlier in Table 22, there was a positive correlation between length, weight, and total weight gain and the frequency with which the mother/caretaker was observed feeding the child. In the multiple regression analysis this variable had a negative relationship to the weight/length percentile ranking, suggesting that more frequent feeding of the child by the mother, rather than allowing self-feeding exclusively, was an adaptive strategy used by mothers who realized their children were underweight. Such families also may have had few resources at their disposal, thus necessitating the reduction of possible waste which may occur in greater amounts with selffeeding. Thus feeding of the child by the mother was observed more often among families of children in the low weight/length group, making it a discriminating factor predicting membership in that group. It also had an overall positive effect on growth, as shown by other measurements. 3. The amount of money spent on dried milk was a measure of food budget management related to the diet of the index child.

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120 Ethnographic data revealed that milk, particularly dried milk, was purchased almost exclusively for children, as v;ere eggs. Thus, this variable can be considered a measure of the orientation toward the dietary needs of the child. In the present study it had a positive relationship to the weight/length percentile ranking. There was also a positive correlation between the amount of money spent on dried milk and that spent on eggs (r=0.31, p<0.04). 4. The number of children aged 6 years and under appeared in both analyses and had a negative relationship to the weight/length percentile ranking. 5. The presence or absence of a wafflemaker was one of the nominal variables related to material standard of living. Items such as a stereo, television, radio, or blender were too common for their presence to serve as a discriminating variable. However, the presence of a wafflemaker is thought to be a more discriminating measure of economic status than is total household income. 6. The number of persons per bed also proved to be a more discriminating measure of economic status than total household income because it reflects the density of the household population. 7. The amount of money spent each month on processed food is considered to be a measure of both economic status and ability to manage the food budget.

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CHAPTER VI DISCUSSION AND CONCLUSIONS In an effort to understand some of the underlying causes of undernutrition in Costa Rica, this study has focused on an in-depth investigation of individual children in the context of the household. A model of factors leading to undernutrition developed from prior research carried out in rural areas of Costa Rica (Rawson 1975; Rawson and Valverde 1976) was presented in Chapter II as a possible explanation of the etiology of undernutrition in the urban context (see Figure 2). The small number of children falling below the 5th percentile in the random sample of 107 children born in 1980, which was selected, indicated that the excellent program of health maintenance and nutritional surveillance operating in Costa Rica identified most children who were severely undernourished, as well as most children at risk for mild undernutrition. These children were being referred to the appropriate programs according to their needs, e.g. Tres Rios for the treatment of severely undernourished children, and a community meal site and/or free milk from the health center for children who had become slightly undernourished. High immunization rates of over 90% indicated a successful program of primary health care intervention with regard to children. 121

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1 22 Socioeconomic Factors With respect to occupational and economic factors, the model was found to be particularly inadequate in accounting for strategies employed by female-headed households to enable the families to adequately carry out child-rearing activities. The model presented the mother's working outside the home as a high risk factor for malnutrition of her child (Rawson and Valverde 1976). The data gathered in this study, however, indicated that families where this was more likely to occur were usually in female-headed households. In fact, 73% of the female-headed households had children in the normal weight/length group. What actually happens is that, when a mother works outside the home, caretaking duties are assumed by another female relative, usually an aunt or the grandmother of the child. This situation appears to be a particular characteristic of the extended matrifocal family described as the "Queen Bee," or "Grandmother," family in Chapters I and IV (López de Piza 1979; R. T. Smith 1956), but also sometimes exists in the male-headed extended family. Thus, it would appear that, in contrast to the findings of Rawson and Valverde (1976) in San Ramón, the family organization and structure setup to care for childern is more important than whether or not the mother works outside the home. The data appear to indicate that nuclear families may be more at risk for having low weight/length children (54% of these families had children in the normal weight/length group). In fact, as noted earlier, more mothers of low weight/length children than of normal weight/length children did not work outside the home. Formal marriage was more prevalent among parents of children in the low weight/length group, although the majority of the parents of both groups were married.

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123 These figures suggest that a nontraditional family structure which may be rather fluid in nature— expanding in times of need when resources may need to be pooled and decreasing in times of economic well-beingis an effective adaptation that many poor families make which directly contributes to the maintenance of a good nutritional status among dependent children. This family structure includes the kinship support networks in which most families are involved. Contrary to the findings of True (1976:77), alcoholism was not found to be a major problem among the families followed. In several cases, however, alcoholism was responsible for the split-up of spouses which resulted in the formation of matri focal, extended families. More of the fathers of children in the low weight/length group worked seasonally or occasionally or were unemployed. Whether the father had a regular job seemed to be of more importance than the kind of occupation. The problem is, however, that unskilled workers are more likely to occupy temporary or seasonal jobs. This fact does not contradict Rawson and Val verde' s (1976) finding that whether the father was self-employed or a day laborer was significantly associated with nutritional status. Ownership of the home was not as important as it had been thought to be. More of the families of normal weight/length children rented or borrowed homes. Fewer actually owned or were buying their homes (36% as compared to 53% among the families of low-weight/length children). In fact, what seems to have happened is that many families of the normal weight/length children continued to live in extremely low rent districts, when they probably could have afforded better housing,

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124 simply because they preferred to use the money saved to eat better or to educate their children. As inflation increasingly affected Costa Rica's economy, however, those families who had bought houses earlier were beginning to have a great advantage because their payments had not increased with inflation whereas rents had. At the time of the study some families had ridiculously low payments, but others could not afford to acquire their own homes. Thus, ownership of the home may become a more important factor in the future. Although total household income was lower among families of children in the low weight/length group, the difference was not significant. Families of normal weight/length children spent less on food and had twice as much money left over after food costs were deducted than did families of low weight/length children. It should be noted here that the concept of "real income" originally used in the model was discarded in favor of total income, which includes the combined incomes of all household members plus gifts, allowances, and other payments. The data indicate that, in general, except for sewing machines and refrigerators, the families of low weight/length children tended to possess more material goods such as stereos, tape recorders, and blenders. Thus, an orientation toward upward mobiliby, involving the acquisition of material goods to obtain status, may have been more prevalent among families of low weight/length children. The preceding data also suggest that the crucial soeioeconomic factor differentiating the families of low weight/length children from

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125 families of normal weight/length children is management. Knowing where and how to obtain the best buys on food and housing are important factors. Decision making which leads to the purchase of a refrigerator or sewing machine rather than a stereo or television may contribute to family nutrition and income and was part of the home management skills exhibited by mothers of children in the normal weight/length group. These kinds of decisions appeared to enhance the ability of the families to provide adequate nutrition for their children. Dietary Factors The condition of the environment proved to be of little importance in distinguishing the low weight/length children from the normal weight/length children. Diet, as assessed by household food frequency data, was also by and large insignificantly differentiating. Further diet analyses based on the division of foods into groups, such as that done by Abramson et al . (1963), and further analyses of 24-hour recall data gathered for each child might indicate some differences. Those analyses, however, will be undertaken elsewhere. Duration of breast-feeding, age at which bottle feeding was introduced, and age at which regular foods were introduced did not differ significantly between the two groups. There was, however, a tendency toward a longer duration of breast-feeding and a later introduction of bottle feeding and regular foods in the low weight/length group. These data do not dispute the value of breast feeding per se but rather may raise some questions about the quality of extended breast-feeding without the introduction of supplementary foods as needed.

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126 Conceptual Model Describing Children at Nutritional Risk in the Urban Area A multivariate regression analysis and a discriminant function analysis were performed, as mentioned in Chapter V. A conceptual model was developed based on these analyses. This model, I believe, more accurately describes the processes which result in low weight/length children in the urban sector than does the original adapted model proposed at the beginning of the study (see Chapter II). The conceptual model (illustrated in Figure 11 in detail) suggests that low birth weight, primarily resulting from maternal undernutrition, is related to mild undernutrition of children in Costa Rica. The subsequent prognosis for these children is determined primarily by maternal competence and management ability, coupled with aspects of family structure such as the number of children 6 years of age and under in the family. An analysis of variance described earlier revealed that children, particularly boys, in the low weight/length group had birth weights significantly lower than those in the normal weight/length group. According to Mata (1978a), Ounsted et al . (1982), and Villar et al. (1982), children of low birth weight tend to remain in the growth pattern defined by birth characteristics, a finding which supports the model suggested. The earlier work of Rawson and Val verde (1976) in Costa Rica does not mention birth weight. Because there was no significant difference between the height and weight of mothers of children in the low weight/length group and the height and weight of mothers of children in the normal weight/length group, the chance that the lower birth weight is purely genetic in origin is greatly diminished.

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127
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128 The conceptual model is suggested as being more appropriate than previous models, which were oriented to factors found to be important to child nutrition in rural areas. Whereas the rural model tends to concentrate on the importance of resources such as "bush foods" and home gardens, for the urban mother equivalent resources may be how well she learns to utilize the health and welfare services available, including aid through the Family Aid Program, and how well she learns to plan meals and buy food. The data on food-purchasing patterns mentioned earlier in Chapter IV, show that there is a tendency for female-headed families, compared to male-headed families, to benefit less from subsidized government food sources. The ability of poor families to take advantage of government subsidized stores was limited in some neighborhoods, such as in Villa Esperanza in Pavas and Copei , because there was no easy access to them or to other large markets offering cheaper prices. Conclusions Traditionally, factors such as women working outside the home, female-headed households, and so-called family instability (Beghin et al. 1979; Popkin 1980; Uyanga 1980) have been considered detrimental to the nutritional status of children. My data, however, suggest that an across-the-board condemnation of nontraditional family structure as pathological is not rational given the effective survival strategies demonstrated by the matri focal extended family, including its apparent ability to expand and contract according to economic needs.

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129 The data gathered in this study suggest that mild undernutrition among children in Costa Rica, given governmental intervention programs, results primarily from low weight at birth and from subsequent deficiencies in maternal competence and management. This finding raises questions about the general orientation of existing nutrition intervention programs. It may be that the problem would be better dealt with if more attention were placed on what I shall call the "maternal factor." This factor includes biological aspects, such as prenatal nutrition and overall maternal health, and sociocultural aspects, such as maternal competence, or what Mata (1980) has called "maternal technology." Maternal competence includes managing abilities such as knowledge of how to shop and make rational decisions about what foods and other necessities are most economical and beneficial. It v;as noted, for example, that many mothers of children in the low weight/length group tended to buy expensive processed foods such as luncheon meat, potato chips, and cookies rather than taking the time to cook rice and beans and other more nutritious foods. Factors probably contributing to this tendency are television and radio advertising, the availability of processed foods, and increases in the cost of electricity and other fuels used in cooking. Buying patterns are also important. Some families were well organized in their buying habits, regularly buying staples as soon as they received their wages and before the money could be spent on other items. Other families were more disorganized in their buying habits, tending to buy when they ran out of food even though they had access to a regular paycheck. Still other families had no regular

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130 income and of course had to buy when they had money. Most of the families of children in the low weight/length group did have regular paychecks coming in (12, or 63%); however, most were not well organized in their buying habits. Another area of maternal competence has to do with nurturing, or mothering behavior. Mother cuddling, feeding the child, and other types of nurturing behavior were found to be positively correlated with height, weight, and growth, particularly among children in the low weight/length group. This relationship would probably be more pronounced if behaviors related to nurturing had been followed in more detail. I suggest that, although passing on mothering skills has in the past been part of the enculturation process for girls, today's changing society has tended to disrupt this process. Women's roles are changing in all countries as more and more women enter the formal working world of industry. With mothers spending less time with their children, mothering skills are less likely to be passed on informally and may even be viewed in a negative light; witness attitudes toward breast-feeding. Thus, the task of teaching women to be mothers or how to parent may fall to the schools and/or the institutions involved in health maintenance. Because social change has been so rapid, in many cases the skills a mother learned may seem irrelevant to her daughter. Certainly the project begun in the Puriscal area of Costa Rica by the National Institute for Health Research (INISA) (Mata et. al 1981) to encourage maternal -infant bonding, i.e. a strong attachment of the mother to her child (Claus and Kennel 1976), and to promote breast-feeding is a step in the right direction. It may be

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131 necessary, however, to carry this intervention further, including the teaching of home management and child-rearing techniques applicable to toddlers as well as infants. The Puriscal program at present seems to be more oriented toward nonworking mothers. Because of the importance that family structure seems to have in child rearing, however, it is important to recognize other potential caregivers in the family and to include them in whatever educational efforts are made. The training of mothers in home health care techniques, such as the care of children with diarrhea by use of oral rehydration and good hygiene, is one possibility. Another might be teaching mothers how to use growth charts to keep track of their children's growth, I found mothers to be very interested in monitoring the growth and development of their children. Women also need to be taught more about their own health. It is quite possible for a woman who is competent in the care of her children to fail to take care of herself adequately during pregnancy. Thus, mothers who are intelligent enough to be competent managers of their children's health and nutrition should be able to apply to themselves similar skills if they understand the need for doing so. Certainly most health and nutrition programs tend to ignore the tremendous potential resource represented by a well-informed mother. The in-home observation done as part of this study was merely a beginning and should be followed by a more in-depth, long-term evaluation of the home environment and maternal behaviors related to child growth and development (including intellectual stimulation). Behaviors

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132 specifically related to the transmission of such illnesses as diarrhea and respiratory problems were not the main focus; they also should be studied because they represent an area in which maternal competence is a key factor in any preventive efforts. In summary, the data raise questions about the importance of maternal input in a variety of areas and how it relates to the nutritional status of the child in urban Costa Rica. The size of the sample population, necessary because of the in-depth nature of the data collection, precludes sweeping conclusions. The data do, however, suggest the following directions in which future research and intervention could be directed. 1. More detailed study of the etiology of low birth weight babies and the development of preventive measures, including sociocultural as well as biological measures. 2. Additional study of child-rearing and maternal-nurturing behaviors in both urban and rural areas to develop adequate ways of evaluating maternal coping behaviors, especially as they are affected by rapid social change. 3. Further evaluation of the geographical placement of government subsidized food outlets in terms of their accessibility to low income families, especially female-headed, low income families. In terms of nutrition intervention programs, the data suggest that in future planning in Costa Rica more emphasis should be placed on the maternal factor. Good prenatal care (especially adequate nutrition) and education of mothers in mothering skills, home management, and care of their own health are important aspects of this factor, and

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133 appear to be necessary complements to existing programs in the elimination of chronic mild undernutrition in low income urban children.

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REFERENCES Abramson, J. H. , C. Slome, and C. Kosovsky 1963 Food Frequency Interview as as Epidemiological Tool. American Journal of Public Health 53(7) :1Q93-1100. Acheson, K. J., I. T. Campbell, 0. G. Edholm, D. S. Miller, and M. J. 1980 Stock The Measurement of Food and Energy Intake in Man— An Evaluation of Some Techniques. American Journal of Clinical Nutrition 33:1147-1154. Afifi, A. A. , and S. P. Azen 1979 Statistical Analysis: A computer Oriented Approach. New York: Academic Press. Alvarez, M. L. , M. T. Guzman, M. Vial, G. Jaque, and V. Gattas 1977 Hábitos Alimentarios. Archivos Latinoamericanos de Nutrición 27(1):125-139. Aranda-Pastor, José 1975 Indicadores Mínimos del Estado Nutricional, Revista Colegio Médico de Guatemala 36(l):20-28. Arizpe, L. 1980 Rotating Urban Labour: Relay Migration as a Strategy for Survival Among Peasant Households. Mineographed paper. Ashworth, A., and D. Picou 1976 Nutritional Status in Jamaica— 1968-74. West Indian Medical Journal 25(l):23-34. Ballweg, J. A. 1972 Family Characteristics and Nutritional Problems of Preschool Children in Fond Parisién, Haiti. Journal of Tropical Pediatrics, Monograph No. 23, Beghin, I., J. del Canto, and C. Teller 1979 Malnutrition, National Development, and Planning. Bulletin Pan American Health Organization 13(3):285-292. Berg, A. 1973 Nutrition and Nations. Brookings Research Report 134. Washington, D.C.: Brookings Institution. 134

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135 Berlin, E. A., and E. K. Markell 1977 An Assessment of the Nutritional and Health Status of an Aguarana Jívaro Community, Amazonas, Peru. Ecology of Food and Nutrition 6(2):69-81. Bernard, H. R. , P. Killworth, D. Kronenfeld, and L. Sailer In On the Validity of Retrospective Data: The Problem of press Informant Accuracy. To be published in Annual Reviews in Anthropology. Jiesanz, R. , K. Z. Biesanz, and M. H. Biesanz 1982 The Costa Ricans. Englewood Cliffs, N.J. Prentice-Hall Inc. Brown, J. E., and R. C. Brown 1977 Finding the Causes of Protein Malnutrition in a Community. Journal of Tropical Pediatrics 23(5) :247-261 . Bryant, G. M. , K. J. Davies, and R. G. Newcombe 1974 The Denver Developmental Screening Test: Achievement of Test Items in the First Year of Life by Denver and Cardiff Infants. Developmental Medical Child Neurology 16:475-484. Burgess, H. J. L. , S. Cole-King, and A. Burgess 1972 Nutritional Status of Children at Nami tambo, Malawi of Tropical Medicine and Hygiene (August) :143-148. Journal Camp, B. W. , J. Van Doorninck, W. K. Frankenburg, and J. M. Lampe 1977 Preschool Developmental Testing in Prediction of School Problems. Clinical Pediatrics 16(3) :257-263. Carter, W. E. , W. J. Coggins, P. L. Doughty 1975 Chronic Cannabis Use in Costa Rica. Gainesville: Latin American Studies, University of Florida. Center for Clark, W. F. 1980 The Rural to Urban Nutritional Gradient: Application and Interpretation in a Developing Nation and Urban Situation. Social Science and Medicine 14D:31-36. Cohen, J. 1957 An Aid in the Computation of Correlations Based on Q-Sorts. Psychological Bulletin 54:138-139. Commission on International Relations— National Research Council 1977 Supporting Papers: World Food and Nutrition Study. Vol. IV Study Team 9— Nutrition. Washington, D.C.: National Academy of Sciences. Cornelius, W. A., and F. M. Trueblood 1975 Urbanization and Inequality: The Political Economy of Urban and Rural Development in Latin America. London: Sage Publications.

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136 Cravioto, J., and E. R. DeLicardie 1968 Intrasensory Development of School-Age Children, hi ^s^"^^'^''" tion, Learning and Behavior in Children. N. S. Schrimshaw and J. E. Gordon, eds. pp 252-269. Cambridge, Mass.: MIT Press. 1976 Microenvironmental Factors in Severe Protein-Calorie Malnutrition. Xü Nutrition and Agricultural Development. N. S. Scrimshaw and M. Behar, eds. pp. 25-35. New York: Plenum Press. Cravioto, J., and B. Robles 1963 The Influence of Protein-Calorie Malnutrition on Psychological Test Behavior, hi ^"'^^"'^O'^s'"^^^ Forms of Protein-Calorie Malnutrition. G. Blix, ed. pp. 115-126. Uppsala: Sweden Nutrition Foundation. Desai, P., K. L. Standard, and W. E. Miall 1970 Socio-Economic and Cultural Influences on Child Growth in Rural Jamaica. Journal of Biosocial Science 2:133-143. DeWalt, K. M. , P. B. Kelly, and G. H. Pelto 1980 Nutritional Correlates of Economic Microdifferentiation in a Highland Mexican Community. In Nutritional Anthropology. N. W. Jerome, R. F. Kandel , and G. H. Pelto, eds. pp. 205-221. Pleasantville, N.Y.: Redgrave Publishing Co. Diaz Amador, C. 1975 Encuesta Nacional Antropométrica y de Hábitos Alimentarios en Costa Rica. San José, C.R.: Dept. de Nutrición Ministerio de Salud. Dorjahn, V. R. 1976 Rural -Urban Differences in Infant and Child Mortality Among the Temne of Kolifa. Journal of Anthropological Research 32(1): 74-103. Edelman, M. 1983 Recent Literature on Costa Rica's Economic Crisis. Latin American Research Review 18(2) :166-180. Fandal , A. 1980 Personal Communication. Ladoca Foundation, Denver, Colorado. Fanger, U. 1968 Costa Rica. ln_ Latin America and the Caribbean; A Handbook. Claudio Velez, ed. pp. 80-105. New York: Frederick A. Praeger, Pub. Fitzgerald, T. K. 1977 Anthropological Approaches to the Study of Food Habits: Some Methodological Issues. Xü ^'^^'^^t^^" ^"'^ Anthropology in Action. T. K. Fitzgerald, ed. pp. 69-78. Amsterdam: Van Gorcum & Co.

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137 Fleuret, P., and A. Fleuret 1980 Nutrition, Consumption, and Agricultural Change. Human Organization 39(3) :250-260. Florida State Health Coordinating Council 1981 1981 Florida State Health Plan. Vol. II. Health Status and Health System Assessment. Tallahassee: Office of Health Planning and Development, Florida Department of Health and Rehabilitative Services. Frankenburg, W. K. , B. W. Camp, and P. A. Van Natta 1971a Validity of the Denver Developmental Screening Test. Child Development 42:475-482. Frankenburg, W. K. , B. W. Camp, and P. A. Van Natta, J. A. Demersseman, 1971b and S. F. Voorhees The reliability and Stability of the Denver Developmental Screening Test. Child Development 42:1315-1320. Frankenburg, W. K. , N. P. Dick, and J. Carland 1975 Development of Preschool -Aged Children of Different Social and Ethnic Groups: Implications for Developmental Screening. Behavioral Pediatrics 87(1 ) :125-132. Frankenburg, W. K. , and J. B. Dodds 1967 The Denver Developmental Screening Test. Journal of Pediatrics 71(2):181-191. Frankenburg, W. K. , A. Goldstein, and B. W. Camp 1971c The Revised Denver Development Screening Test: Its Accuracy as a Screening Instrument. Journal of Pediatrics 79(6) :988955. Freer Miranda, E. 1980 Estensión de los Servicios de Salud en Costa Rica. Escuela de Medicina. Cátedra Medicina Preventiva. San José: Universidad de Costa Rica. Gdmez, F. , R. R. Galvin, S. Frenk, J. Cravioto, R. Chaves, and J. 1956 Vasquez Mortality in Second and Third Degree Malnutrition. Journal of Tropical Pediatrics 2(2):77-83. Greene, L. , Ed. 1977 Malnutrition, Behavior and Social Organization. New York: Academic Press. Gross, D., and B. A. Underwood 1971 Technological Change and Caloric Cost: Sisal Agriculture in Northeastern Brazil,. American Anthropologist 73(3) :725-740. Hall, C. 1976 El Café y el Desarrollo Histórico-Geográfico de Costa Rica. San José: Editorial Costa Rica y Universidad Nacional.

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138 Horner, M. R. , W. S. Harris, B. J. Brownlee, R. S. Goldstein, and A. K. 1977 Taylor Anthropometric and Dietary Study of Miskito Indian Children in Rural Nicaragua. Ecology of Food and Nutrition 6(3):137146. Howard, D. P., and M. Nieto de Salazar 1982 The Adaptation, Standardization and Development of Costa Rican Norms for the Denver Developmental Screening Test. Final Report. Mimeograph. University of Costa Rica, San Pedro. Instituto de Nutrición de Centro América y Panamá (INCAP) 1969 Evaluación Nutricional del Población de Centro América y Panamá: Costa Rica. Guatemala: INCAP. International Health News 1983 The Real Energy Crisis: Invisible Malnutrition Impedes Development of Third World Children. International Health News. National Council for International Health 4(l):l-2. Jelliffe, D. B. 1956 The Assessment of Nutritional Status of the Community. WHO Monograph Series No. 53. 1968 Child Nutrition in Developing Countries. Washington, D.C. : USDHEW. PHS No. 1822. Jelliffe, E. F. P. 1979 The Impact of the Food Industry on the Nutritional Status of Young Children in Developing Countries. Ijn Food and Nutrition Policy in a Changing World. J. Mayer and J. Dwyer, eds. pp. 138-151. New York: Oxford University Press. Khan, A. A. , and B. M. Gupta 1979 A Study of Malnourished Children in Children's Hospital, Lusaka, Zambia. Journal of Tropical Pediatrics 25(2 and 3): 42-45. Klaus, M. H. , and J. H. Kennell 1976 Maternal -Infant Bonding. Saint Louis: The C. V. Mosby Co. Knoblock, H. , and B. Pasamanick 1974 Gesell and Amatruda's Developmental Diagnosis. Harper and Row Publishers. New York: Latham, 1979 M. International Perspectives on Weaning Foods: The Economic and Other Implications of Bottle Feeding and the Use of Manufactured Weaning Foods. ^Breastfeeding and Food Policy in a Hungry World. D.Raphael, ed. pp. 119-135. New York: Academic Press.

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139 Lomnitz, L. A, 1977 Networks and Marginal ity: Life in a Mexican Shantytown. New York: Academic Press. Lopez de Piza, E. 1979 La Familia Matrifocal Como Mecanismo de Adaptación de la Mujer a su Marginal idad. Vínculos— Revista de Antropologia del Museo Nacional de Costa Rica 5(1-2):1018. Lundberg, D. E. 1976 Costa Rica. San José, Costa Rica: Juan Mora. MacCorquodale, D. W. , and H. Rondón de Nova 1977 An Epidemiological Study of Pre-School Child Malnutrition in Santo Domingo. Archivos Latinoamericanos de Nutrición 27(4): 505-519. Marcondes, E., A. Branco LeFeure, D. V. M. Machado, N. Garcia de Barros, 1973 A. Cavallo, S. Gazal , G. Quarentei , N. Setian, M. I. Valente, and D. Barbieri Neuropsychomotor Development and Pneumoencephalographic Changes in Children with Severe Malnutrition. Journal of Tropical Pediatrics 19(2):135-139. Martorell, R. , and C. Yarborough 1983 The Energy Cost of Diarrheal Diseases and Other Common Illnesses in Children. Jn. Diarrhea and Malnutrition. C. Chen and N. S. Scrimshaw, eds. pp. 125-141. New York: Plenum Publishing Co. Mata, L. J. 1977 The Children of Santa Maria Cauque: A Prospective Study of Health and Growth. Cambridge, Mass.: MIT Press. 1978a Criterios Para Evaluar el Estado Nutricional del Nino en Costa Rica. Revista de Biología Tropical 26(2) :415-430. 1978b The Nature of the Nutrition Problem, ^n Nutrition Planning, The State of the Art. L. Joy, ed. pp. 91-99. Surrey, England: IPC Science and Technology Press Limited. 1979 Desnutrición Energetico-Proteinica en Costa Rica, 1979. Revista Médica Hospital Nacional de Niños (Edición Extraordinaria): 55-78. 1980 Child Malnutrition and Deprivation: Observations in Guatemala and Costa Rica. Food and Nutrition 6(2):7-14.

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140 Mata, L. J., P. Jiménez, M. A. Alien, W. Vargas, M. E. Garcia, J. J. 1981 Urrutia, and R. G. Wyatt Diarrhea and Malnutrition: Breastfeeding Intervention in a Transitional Population, jjl ^^ute Enteric Infections in Children, New Prospects for Treatment and Prevention. T. Holme, J. Holmgren, M. H. Merson, and R. Mollby, eds. pp. 233-251. Elsevier: North-Holland Biomedical Press. Mata, L. J., R. A. Kronmal, and H. Villegas 1980a Diarrheal Diseases: A Leading World Health Problem. j£ Cholera and Related Diarrheas, 43rd Nobel Symposium, Stockholm, 1978. pp. 1-14. Basel: Karger. Mata, L. J., A. V. Quesado, F. Saboria, and E. Mohs 1980b El Niño Agredido y la Desnutrición: Observaciones Epidemiologican en Costa Rica. Revista Médica Hospital Nacional de Niños, Costa Rica 15(1 ):137-148. Ministerio de Salud Pública 1978 Encuesta Nacional de Nutrición. Department de Nutrición. San José, C.R. : Ministerio de Salud Pública. 1982 Memoria 1981. San José, Costa Rica: Ministerio de Salud Pública. Monckeberg, F. 1976 Definition of the Nutrition Problem— Poverty and Malnutrition in Mother and Child. j£ Nutrition and Agricultural Development. N. S. Scrimshaw and M. Behar, eds. pp. 13-23. New York: Plenum Press. Moore, M. S. 1978 Realities in Childbearing. Philadelphia: W. B. Saunders Co. Morrison, S. D. , F. C. Russell, and J. Stevenson 1949 Estimating Food Intake by Questioning and Weighing: A OneDay Survey of Eight Subjects. British Journal of Nutrition 3:v. Munro, D. G. 1918 The Five Republics of Central America: Their Political and Economic Development and Their Relations with the United States. New York: Oxford University Press. Murillo, S., and L. J. Mata 1980 Canasta Básica del Costaricense, 1980. Revista Médica Hospital Nacional de Niños, Costa Rica 15(1 ):101-104. Murillo, S. , R. M. Novygrodt, and M. Tristan 1981 Canasta Básica del Costaricense. Una Estrategia en Política Alimentaria. ^íl Análisis de la Situación AlimentariaNutricional en Costa Rica. Lenín Saenz, ed. pp. 79-95. San José: Secretaría de la Política Nacional de Alimentación y Nutrición.

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141 National Center for Health Statistics 1977 NCHS Growth Curves for Children, Birth-18 Years, United States. Pub. No. PHS 78-1650. Hyattsville, Md.: U.S. Department of Health, Education and Welfare, National Center for Health Statistics. Omololu, A. 1978 Nigeria. Jn^ Nutrition and National Policy. B. Winikoff, ed. pp. 109-122. Cambridge, Mass.: MIT Press. Ounsted, M. , V. Moar, and A. Scott 1982 Growth in the First Four Years: II. Diversity Within Groups of Small -for-Dates and Large-for-Dates Babies. Early Human Development 7:29-39. Peattie, L. R. 1975 Tertiarization and Urban Poverty in Latin America. ln_ Urbanization and Inequality: The Political Economy of Urban and Rural Development in Latin America. W. A. Cornelius and F. M. Trueblood, eds. pp. 109-123. Beverly Hills: Sage Publications. Pellett, P. L. 1977 Marasmus in a Newly Rich Urbanized Society, and Nutrition 6:53-55. Ecology of Food Popkin, B. M. 1980 Time Allocation of the Mother and Child Nutrition, of Food and Nutrition 9:1-14. Ecology Popkin, B. M., R. E. Bilsborrow, M. E. Yamamoto, and J. Akin 1980 Breast-feeding Practices in Low Income Countries: Patterns and Determinants. Mimeographed Paper. Carolina Population Center, University of North Carolina, Chapel Hill. Rawson, I. G. 1975 Cultural Components of Diet and Nutrition in Rural Costa Rica. Ph.D. Dissertation. University of Pittsburgh, Rawson, I., and L. Phillips Arizmendi 1976 Diet and Nutrition. ln_ Chronic Cannabis Use in Costa Rica. W. E. Carter, W. J. Coggins,and P. L. Doughty, eds. pp. 587601. Gainesville: Center for Latin American Studies, University of Florida. Rawson, I. G. , and V. Valverde 1976 The Etiology of Malnutrition Among Preschool Children in Rural Costa Rica. Journal of Tropical Pediatrics 22(1):12-17. Reutlinger, S., and M. Selowsky 1976 Malnutrition and Poverty: Magnitude and Policy Options. (Published for the World Bank) World Bank Staff Occasional Papers No. 23. Baltimore: Johns Hopkins University Press.

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142 Reutlinger, S. , and M. Selowsky 1979 The Economic Dimensions of Malnutrition in Young Children. Finance and Development (June) :21-24. Richardson, S. A., H. G. Birch, E. Grabie, and K. Yoder 1972 The Behavior of Children in School Who Were Severely Malnourished in the First Two Years of Life. Journal of Health and Social Behavior 13(3):276-284. Roberts, B. 1978 Cities of Peasants. Beverly Hills: Sage Publications. Safa, H. I. 1974 The Urban Poor of Puerto Rico: A Study of Development and Inequality. New York: Holt, Rinehart and Winston, Inc. Salazar, S. , and S. Cervantes 1979 Relación Entre el Nivel de Instrucción y el Estado Nutricional Basado en los Datos de la Encuesta Nacional de Nutrición, 1978. San José, C.R.: Sistema de Información en Nutrición (SIN). SAS Institute 1982 SAS User's Guide: Statistics. Cary, N.C.: SAS Institute, Inc. Scrimshaw, N. S., and M. Behar, Eds. 1976 Nutrition and Agricultural Development. New York: Plenum Press, Scrimshaw, N. S. , C. E. Taylor, and J. E. Gordon 1968 Interactions of Nutrition and Infection. WHO Monograph. Geneva: World Health Organization. Seth, v., K. R. Sundarim, and M. Gupta 1979 Growth Reference Standards for Developing Countries: Determination of Criteria for India. Journal of Tropical Pediatrics 25(2-3):37-41. Smith, R. T. 1956 The Negro Family in British Guiana. New York: Grove Press Inc. 1960 The Family in the Caribbean, jji Caribbean Studies: A Symposium. Vera Rubin, ed. pp. 67-75. Seattle: University of Washington Press. Smith, M. G. 1962 West Indian Family Structure. Seattle: University of Washington Press. Solomons, G. , and H. C. Solomons 1975 Motor Development in Yucatan Infants. Developmental Medical Child Neurology 17:41-46.

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143 Spradley, J. P. 1980 Participant Observation. New York: Holt, Rinehart and Winston. Stephenson, W. 1953 The Study of Behavior: Q-Technique and Its Methodology. Chicago: University of Chicago Press. Taylor, C. E. , and E. M. Taylor 1976 Multifactorial Causation of Malnutrition. j£ Nutrition in the Community. D. S. McLaren ed. pp. 75-85. New York: John Wiley and Sons. Teller, C. H. , I. Beghin, and J. del Canto 1979 Population and Nutrition Planning: The Usefulness of Demographic Discipline for Nutrition Policy in Latin America. Bulletin Pan American Health Organization 13(l):21-32. True, W. R. 1976 Chronic Cannabis Use Among Working-Class Men in San Jose, Costa Rica. Ph.D. Dissertation, University of Florida, Gainesville. True, W. R. , P. L. Doughty, and W. E. Carter 1976 The Subjects as Children. Ijl Chronic Cannabis Use in Costa Rica. W. E. Carter, W. J. Coggins, and P. L. Doughty, eds. pp. 170-213. Gainesville: Center for Latin American Studies, University of Florida. Ueda, R. 1977a Characteristics of Child Development in Okinawa: The Comparisons with Tokyo and Denver and the Implications for the Developmental Screening. Proceedings of the Second International Conference on Developmental Screening. JFK Child Development Center. Denver: University of Colorado Medical Center. 1977b The Standardization of the Denver Developmental Screening Test on Japanese Children. Iji Proceedings of the Second International Conference on Developmental Screening. JFK Child Development Center. Denver: University of Colorado Medical Center. United Nations 1982 Demographic Yearbook— 1 980. 32nd Issue. New York: United Nations. U.S. Agency for International Development 1982 Programa de Desarrollo Urbana: Documento Preliminar. San José, C.R.: USAID. U.S. Department of Commerce,' Bureau of the Census 1981 Statistical Abstract of the United States: National Data Book and Guide to Sources. Washington, D.C.: U.S. Department of Commerce, Bureau of the Census.

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144 Uyanga, J. 1980 Rural-Urban Differences in Child Care and Breast Feeding Behaviour in Southeastern Nigeria. Social Science and Medicine 140:23-29. Valverde, V., Z. Rojas, P. Vinocur, P. Payne, and A. Thomson 1981 Organization of an Information System for Food and Nutrition Programmes in Costa Rica. Food and Nutrition: 32-40. Valverde, V., W. Vargas, I, Rawson, G. Calderón, R. Rosabal , and R. Gutiérrez La Deficiencia Calórica en Preescolares de Area Rural de Costa Rica. Archivos Latinoamericanos de Nutrición 25(4): 251-361. Villar, J., J. M. Belizan, J. Spalding, and R. E. Klein 1982 Postnatal Growth of Intrauterine Growth Retarded Infants. Early Human Development 6:265-271. Villarejos, V. M. , J. A, Osborne, F. J. Payne, J. A. Arguedas, R. Umano, 1971 C. L. Salas, V. Avila, and B. Munoz Heights and Weights of Children in Urban and Rural Costa Rica. Journal of Tropical Pediatrics 17(l):32-43. Waterlow, J. C, and I. H. E. Rutishauser 1974 Malnutrition in Man. ln_ Symposium on Early Malnutrition and Mental Development. Swedish Nutrition Foundation Symposia No. 12:13-26. Weiner, J. S., and J. A. Lourie 1969 Human Biology: A Guide to Field Methods. IBP Handbook No. 9. Oxford: Blackwell Scientific Publications. Wilson, C. S. 1974 Child Following: A Technique for Learning Food and Nutrient Intakes. Journal of Tropical Pediatrics 20:9-14. 1977 Research Methods in Nutritional Anthropology: Approaches and Techniques. Ir^ Nutrition and Anthropology in Action. T. K, Fitzgerald, ed. pp. 62-68. Assem/Amsterdam: Van Gorcum. Winikoff, B., Ed. 1978 Nutrition and National Policy. Cambridge, Mass.: MIT Press. Wittenborn, J. R. 1961 Contributions and Current Status of Q Methodology. Psychological Bulletin 58(2):132-142. Wray, J. D, , and A. Aguirre 1969 Protein-Calorie Malnutrition in Candelaria, Colombia. I. Prevalence; Social and Demographic Causal Factors. Journal of Tropical Pediatrics 15(3):76-98.

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145 Wyon, J, B. , and J. E. Gordon 1971 The Khanna Study. Cambridge, Mass: Harvard University Press. Yatkin, U. S. , and D. S. McLaren 1970 The Behavioral Development of Infants Recovering from Severe Malnutrition. Journal of Mental Deficiency Research 14:25-31.

PAGE 153

APPENDIX 1 FAMILY REGISTRY

PAGE 154

-^— -V t ^ "D "c s: 13 ; o c o : v¡ u tr. w > w ; -^[^^lL¡ — tj^O^— UtJ 1-1 — C C iC 3 3U <0 C II. ( CC C O C -Q C C C 3 -H -H 4J > O U O 12 c; lep

PAGE 155

APPENDIX 2 MEDICAL HISTORY OF THE INDEX CHILD

PAGE 156

HISTORIA MEDICA DEL NINO (Niño índice— Primera Visita) 1. Código Individual 2. Fecha 3. Sexo (1) M (2) F 4. Edad (meses) VACUNACI"N 5. BCG 6. DPT 7. Polio 8. Sarampión 9. Sarampidn-rubeola ENFERMEDADES DURANTE EL 10. Diarrea n. Vómitos 12. Parásitos 13. Fiebre 14. Tos (1 (3 (5 (1 (3 (5 (1 (3 (5 (1 (3 (5 (1 (3 (5 ULT básico-completo (2) básico-incompleto completo-refuerzo (4) sin ningún vacunación otro básico-completo (2) básico-incompleto completo-refuerzo (4) sin ningún vacunación otro Básico-completo (2) básico-incompleto completo-refuerzo (4) sin ningún vacunación otro básico-completo (2) básico-incompleto completo-refuerzo (4) sin ningún vacunación otro básico-completo (2) básico-incompleto completo-refuerzo (4) sin ningún vacunación otro MO ANO 1) si (2) no 1) si (2) no 1) si (2) no 1) si (2) no 1) si (2) no Cuantas veces 149

PAGE 157

150 15. Gripe 16. Resfrio 17. Alergia 18. Falta de apetito 19. Dermatitis-granos 20. Sarampión 21. Rubeola 22. Paperas 23. Varicela 24. Estomatitis 25. Hepatitis viral 26. Heridas acidentales 27. Otras (1 ) SI

PAGE 158

APPENDIX 3 HISTORY OF MATERNAL LACTATION

PAGE 159

HISTORIA DE LACTANCIA MATERNA (Niño índice) 1 . Código individual 2. Edad (meses) 3. Cuanto tiempo fué amamantado? (1) continúa amanantando (2) menos de un mes (3) 1-3 meses (4) 4-6 meses (5) 7 meses a un año (6) no le dio (7) mas que un año (8) otro 4. A que edad le dio el primer chupón de leche? (1) menos de un mes (2) 1-3 meses (3) 4-6 meses (4) 7 meses a un año (5) mas que un año (6) otro 5. Porque se dejó de amamantar al niño?_ 6. A que edad le empezó a dar comida? (1) menos de un mes (2) 1-3 meses (3) 4-6 meses (4) 7 meses a un año (5) mas que un año (6) otro 7. Que tipo de alimentos le da al niño? _ 8. Quién prepara la comida del chiquito? (1) madre (2) padre (3) abuela (4) hermana o hermano mayor (5) tia (6) china o empleada (7) otro Observaciones: 152

PAGE 160

APPENDIX 4 CONDITION OF HOUSING AND ENVIRONMENT

PAGE 161

CONDICI"N DE LA VIVIENDA 1. Código familiar ____^ 2. Construcción de paredes (1) ladrillo o block (2) madera (3) bahareque (4) zinc (5) baras o palma (6) deshechos (7) otro 3. Condiciones de las paredes (1) buena condición (2) pintura mala (3) huecos en las paredes (4) sucias (5) 2 y 3 (6) 2 y 4 (7) 3 y 4 (8) 2, 3, y 4 (9) otro 4. Construcción de pisos (1) cemento (2) madera (3) tierra (4) otro 5. Condición de pisos (1) bueno--limpio (2) bueno--sucio (3) regular-limpio (4) regular--sucio (5) malo— limpio (6) malo--sucio (7) otro 6. Construcción del techo (1) teja (2) zinc (3) abastecimiento (4) palma (5) deshecho (6) otro 7. Condición del techo (1) bueno (2) malo (tiene huecos) (3) otro 8, Ventilación (1) buena (2) mala (3) otro_ 9. Número de cuartos (1) 1 (2) 2 (3) 3 (4) 4 (5) 5 o mas (6) otro 10. Numero de camas (1) 1 (2) 2 (3) 3 (4) 4 (5) 5 (6) 6 or mas (7) otro 11. Número de personas por cama _^__ 154

PAGE 162

155 12. Duerman en el suelo? (1) si (2) no (3) otra 13. Tipo de cocina (1) gas (2) leña-carbón (3) canfín (4) electricidad 14. Condición de la cocina (1) buena (2) regular (3) malo (4) otro 15. Tipo de alumbrado (1) electricidad (2) lámpara de canfín (3) vela (4) otra 16. Eliminación de excretas (1) alcantarillado (2) tanque séptico (3) letrina sanitaria (4) pozo de absorción (5) desagüe corriente de agua (6) campo (7) otro 17. Condición de eliminación de excretas (1) individual--bueno y limpio (2) individual--bueno y sucio (3) individual--malo y limpio (4) individual--malo y sucio (5) colective--bueno y limpio (6) colectivo--bueno y sucio (7) colectivo--malo y limpio (8) colectivo-malo y sucio (9) otro 18. Baño (1) individual (2) colectivo (3) no hay (4) otra 19. Abastecimiento de agua (1) cañería (2) fuente público (3) pozo (4) bomba (5) lluvia (6) río o quebrada (7) otro 20. condición de abasticimiento de agua (1) bueno (2) regular (3) mala 21. Animales domésticos permitidos (1) si (2) no 22. Animales domésticos no permitidos (1) vacas (2) chanchos (3) caballos (4) pollos (más que 4) (5) cabras (6) otro 23. Radio (1) si (2) no 24. Televisión (1 ) si (2) no 25. Equipo de sonido (1) si (2) no 26. Refrigeradora (1) si (2) no 27. Licuadora (1) si (2) no

PAGE 163

156 28. Grabadora (1) si (2) no 29. Máquina de coser (1) si (2) no 30. Percolador (1) si (2) no 31. Toastodor de pan (1) si (2) no 32. Waflera (1) se (2) no

PAGE 164

APPENDIX 5 ANTHROPOMETRIC MEASUREMENTS

PAGE 165

to

PAGE 166

APPENDIX 6 SYMPTOMS OF MALNUTRITION

PAGE 167

síntomas de^malnutricion (Niño índice) 1 . Código individual COMPORTAMIENTO 2. 3. 4. 5.

PAGE 168

APPENDIX 7 SOCIOECONOMIC STATUS

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ESTATUS SOCIOECON"MICO 1. Código familiar 2. Ocupación padre (calificado) 3. Ocupación padre (actual) 4. Patrón de empleo (1) asalariado estable (2) trabaja por cuenta propio (3) de vez en cuando (4) desempleado (5) por temporadas (6) otro 5. Cuanto gana por mes? 6. Ocupación madre (calificado)_ 7. Ocupación madre (actual) 8. Patrón de empleo (1 ) asalariado estable (2) trabaja por cuenta propio (3) de vez en cuando (4) desempleado (5) por temporadas (6) otro 9. Cuanto gana por mes? 10. Trabaja algunos otros mienbros de la familia? (1) si (2) no 11. Quiénes y cuanto ganan? 12. Otras entradas (IMAS, Asignaciones Familiares, regalos, etc.) 13. Ahorros (1) si (2) no Cuanto? 14. Compran artículos a largo plazo? (1) si (2) no 15. Cuanto se paga de mensualidad? 162

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163 GASTOS MENSUALES RELACIONADOS A LA VIVIENDA 16. Tenencia de la casa (1) propia (2) amortizada (3) alquilada (4) prestada (5) otra 17. Gastos mensuales de vivienda (alquiler, etc.) 18. Gastos mensuales de luz 19. Gastos mensuales de agua_ 20. Gastos mensuales de gas 21. Gastos mensuales de telephono_ 22. Gastos mensuales municipales (basura, alcantarillado, limpieza, etc.) 23. Otras gastos

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APPENDIX 8 FOOD BUDGET AND BUYING PATTERNS

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PATRONES DE COMPRA Y PRESUPUESTO DE ALIMENTOS 1. Código familiar_ 2. Fecha 3. Pan— frecuencia de compra 4. Pan— donde se compra 5. Pan— costo (1) 1 o mas veces diaria (2) 2-3 veces por semana (3) semanalmente (4) por quincena (5) por mes (5) nunca (7) otro (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) pandería (9) otro 6. Leche (1 iquido)— frecuencia (1) 1 o mas veces diaria (2) 2-3 veces de compra por semana (3) semanalmente (4) por quincena (5) pro mes (6) nunca (7) otro Leche (liquido)— donde se compra 8. Leche (liquido)— costo (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) lechero (9) otro 9. Leche en polvo— frecuencia (1) 1 o mas veces diaria (2) 2-3 veces por semana (3) semanalmente (4) por quincena (5) por mes (6) nunca (7) otro 10. Leche en polvo— donde se compra 11. Leche en polvo — costo (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) otro 165

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166 12. Huevos— frecuencia de compra 13. Huevos— donde se compra 14. 15. 16. (1) 1 o mas veces diaria (2) 2-3 veces por semana (3) semanalmente (4) por quincena (5) por mes (6) nunca (7) otro (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) otro Huevos— costo Verduras— frecuencia de compra (1) 1 o mas veces diaria (2) 2-3 veces por semana (3) semanalmente (4) por quincena (5) por mes (6) nunca (7) otro Verduras— donde se compra (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) Feria del agricultor (9) otro 17. Verduras— costo Frutas— frecuencia de compra 19. Frutas— donde se compra (1) 1 o mas veces diaria (2) 2-3 veces por semana (3) semanalmente (4) por quincena (5) por mes (6) nunca (7) otro (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) Feria del agricultor (9) otro 20. 21. Frutas— costo Arroz — frecuencia de compra 22. Arroz— donde se compra (1) 1 o mas veces diaria (2) 2-3 veces por semana (3) semanalmente (4) por quincena (5) por mes (6) nunca (7) otro (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) otro 23. 24. Arros— costo Carne de res — frecuencia de compra (1) 1 or mas veces diaria (2) 2-3 veces por semana (3) semanalmente (4) por quincena (5) por mes (6) nunca (7) otro

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167 37. Maíz— costo 38. Frijoles— frecuencia de (1) 1 o mas veces diaria (2) 2-3 veces compra por semana (3) semanalmente (4) por quincena (5) por mes (6) nunca (7) otro 39. Frijoles— donde se compra (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) Feria del agricultor (9) otro 40. Frijoles— costo 41. Alimentos procesados (1) 1 o mas veces diaria (2) 2-3 veces (azúcar, café, aceite, por semana (3) semanlmente (4) por etc.) — frecuencia de quincena (5) por mes (5) nunca compra (7) otro 42. Alimentos procesados— (1) pulpería (2) supermercado donde se compra (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) otra 43. Alimentos procesadoscosto 44. Licor— frecuencia de (1) 1 o mas veces diaria (2) 2-3 veces compra por semana (3) semanalmente (4) por quincena (5) por mes (6) nunca (7) otro 45. Licor— donde se compra (1) bar (2) cantina (3) deposito de licores (4) supermercado (5) almacén (6) pulpería (7) otro 46. Licor— costo 47. Quién compra los alimentos por lo general? (1) madre (2) padre (3) abuela (4) abuelo (5) hermana (6) hermano (7) hijo, hija (8) otra 48. Como se pagan los alimentos (1) al contado (2) fiado (3) otro 49. Costo total de alimentos durante la semana

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168 25. Carne de res— donde se compra (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) otro 26. Carne de res— costo_ 27. Cerdo-frecuencia de compra 28. Cerdo— donde se compra (1) 1 o mas veces diaria (2) 2-3 veces por semana (3) semanalmente (4) por quincena (5) por mes (6) nunca (7) otro (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) otro 29. Cerdo— costo 30. Pollo— frecuencia de compra 31. Pollo— donde se compra (1) 1 o mas veces diaria (2) 2-3 veces por semana (3) semanalmente (4) por quincena (5) por mes (6) nunca (7) otro ___^ (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) otro 32. 33. Pollo— costo Pescado o mariscosfrecuencia de compra (1) 1 o mas veces diaria (2) 2-3 veces por semana (3) semanalmente (4) por quincena (5) por mes (6) nunca (7) otro .^ 34. Pescado— donde se compra (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) pescadería (9) otro 35. Maíz— frecuencia de compra 36. Maíz— donde se compra (1) 1 o mas veces diaria (2) 2-3 veces por semana (3) semanalmente (4) por quincena (5) por mes (6) nunca (7) otro (1) pulpería (2) supermercado (3) estanco (4) mercado (5) almacén (6) carnicería (7) verdulería (8) otro

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APPENDIX 9 REPRODUCTIVE HISTORY OF MOTHER

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APPENDIX n SELECTED FOODS THOUGHT TO BE APPROPRIATE AND INAPPROPRIATE FOR THE INDEX CHILD AMO^|G LOW INCOME FAMILIES IN SAN JOSE, COSTA RICA Low weight/ Appropriate length weight/length Food (N=19) (N=25) Green mango Appropriate 79 56 Inappropriate 16 20 Don't know 5 24 Ripe plantain A 100 100 I — DK Pineapple A 84 84 I 11 12 DK 5 4 Guineo verde (green banana) A 95 1 ÜÜ I 5 — DK — — Tangerine A 84 96 I 5 DK n 4 Tapa dulce (brown cane sugar) A 74 76 I 16 20 DK 10 4 Sweet lemon A 100 96 DK _ 4 Yam A 95 96 DK 5 4 175

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176 Low weight/ Appropriate length weight/length Food (N-19) (N=25) Tubers (manioc, etc. ) A 100 100 I — — DK — — Watercress A 95 68 I 5 24 DK _ 8 Papaya A 95 100 DK 5 — Liver A 100 100 I — — DK — — Sausage A 89 68 I 8 DK 11 24 Chicken A 100 100 DK — — Milk A 100 100 DK — — Tomato A 100 88 I 8 DK 4 Lettuce salad A 95 80 I 12 DK 5 8 2 8 Hamburger A 100 92 I — DK — — Lunchmeat A 100 68 I _ 16 DK — 16

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177 Low weight/ Appropriate length weight/length 89

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178 Low weight/ Appropriate length weight/length Food (N=19) (N=25) Pork A 74 68 I 21 12 DK 5 20 Corn A 79 60 I 16 16 DK 5 24 Soda crackers A 95 100 DK 5 — Bread A 90 100 I 5 — DK — — Rice A 95 100 I 5 — DK — Chocolate A 84 72 I 11 12 DK 5 16 Corn flakes A 95 76 I 5 16 DK _ 8 Egg A 100 100 I — — DK — Mustard greens A 74 68 I 16 16 DK 10 16 Orange juice A 100 100 I — — DK — — Liquor* A — — I 84 80 DK 16 20

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179 Low weight/ Appropriate length weight/length 95

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Low weight/ Appropriate length weight/length Food (N=19) (N=25) Spinach A 100 92 I 4 DK 4 Banana A 100 100 I — DK Cantal ope A 74 92 I 5 DK 21 8 Cabbage salad A 79 72 I 11 20 DK 10 8 Carrots A 100 100 I — DK White sugar A 79 80 I 5 4 DK 16 16 Red beets A 95 92 I 5 4 DK — 4 Pancakes A 79 76 I 5 15 DK 16 8 Fish A 100 96 I DK _ 4 Tuna (canned) A 79 60 I 5 16 DK 16 24 Beefsteak A 100 96 I 4 DK —

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181 Low weight/ Appropriate length weight/length Food (N-19) (N=25) Vegetable beef stew A 100 100 DK — — Potato chips A 100 84 I 12 DK 4 Gerber fruit A 74 72 I 16 20 DK 10 8 Sour cream (na tilla) "A 90 84 I 5 8 DK 5 8 Blackberries A 84 88 I 5 4 DK 11 8 Marañon (cashew fruit) A 74 68 I _ 16 DK 26 16 White cheese A 95 92 I 4 DK 5 4 Ripe mango A 1 00 96 I — — DK 4 Apple A 100 92 I 8 DK — — *Foods most people considered unsuitable for children.

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BIOGRAPHICAL SKETCH Sharleen Hirschi Simpson, born and reared on a farm in Idaho, was the oldest of eight children. A career in nursing seemed a natural choice. She studied first at Ricks College in Idaho and than at the University of Utah, graduating in 1962 with the degree of Bachelor of Science with a major in nursing. After graduation she entered the Peace Corps during its first year of existence, serving for two years as a nurse in eastern Bolivia. After her Peace Corps experience she obtained the degree of Master of Science with a major in community health nursing at the University of California-San Francisco. She then studied anthropology at the University of Arizona and in 1970 obtained the degree of Master of Arts with a major in anthropology, she has spent about nine years in South and Central America and the Caribbean, living in Paraguay, Chile, Costa Rica, and Puerto Rico, as well as Bolivia. She is fluent in Spanish. She has approximately 15 years of experience in all aspects of nursing. She has two sons, Roderick and Randall, aged 13 and 10, who have also spent considerable time in Latin America. Her hobbies include playing the piano and guitar, singing barbershop harmony, and watercolor painting. 182

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Ú O 'i/---? -íoM /Má--. Leslie S. Lieberman, Chairperson Associate Professor of Anthropology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. '/UA.W ii..J:i ell Bernard or of Anthropology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Paul L. Doughty Professor of An'thropology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. •VvL/o f/James S. Dinning Professor of Food Science and Human Nutrition

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. L / Helen I. Safa Professor of Latin American Studies This dissertation was submitted to the Graduate Faculty of the Department of Anthropology in the College of Liberal Arts and Sciences and to the Graduate School, and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy. August 1984 Dean for Graduate Studies and Research

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