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Cranfill, Tamara B.
Un estudio exploratorio sobre la seguridad alimentaria, la dieta y la percepcin de la salud nutricional en la zona de Monteverde.
An exploratory study on food security, diet, and perceptions of nutritional health in the Monteverde Zone.
A study of food security in the populations of Caitas and Cerro Plano and of what sound nutritional practices the population is aware of.
Un estudio de la seguridad alimentaria en las poblaciones de Caitas y Cerro Plano y de que sonido de las prcticas nutricionales esta la poblacin consciente de.
Nutrition and health--Costa Rica--Guanacaste--Caitas
Nutrition and health--Costa Rica--Puntarenas--Cerro Plano
Community Health 2003
Regional economics and food insecurity
t Community Health
AN EXPLORATORY STUDY ON FOOD SECURITY, DIET, AND PERCEPTIONS OF NUTRITIONAL HEALTH IN THE MONTEVERDE ZONE Tamara B. Cranfill Kate Bowler Kimberly Kossler Lynley Rappaport Meghan Reusser Garrett Feddersen David Himmelgreen Faculty Advisor Field Methods for Community Health Monteverde Institute June 21 to August 3, 2003
Research Team Background Our team consisted of five full-time members, one part-time member, and one faculty advisor. Tamara Cranfill is a doctoral student in Rehabilitation Sc iences at the University of Kentucky. Her research interests include the examination of social networks of i ndividuals with chronic illness and on the cultural influences on community health issues. Kate Bowler is pursuing a B.S. in anthropology and human biology and a minor in political sciences at Emory University. Upon graduation, she plans to earn a Masters in Public Health with a concentration on International Health. Kimberly Kossler completed her B.S. in Nutrition and Dietetics at East Carolina University in North Carolina. She plans to earn a Masters in Public Health at East Carolina University. Meghan Reusser graduated from the University of Vermont with a B.A. in Sociology. Her recent experience in Latin Ameri ca consisted of a 5 month study in Bolivia on the health care system. Lynley Rappaport is fluent in Spanish and Eng lish. She has a Masters in Education and is pursuing her MPH at Boston University. Garrett Feddersen is a senior at the Battle Creek-Ida Grove High School in Ida Grove, IA. He is a 2003 Ruan-Borlaug intern to the Monteverde Institute through the Worl d Food Prize Foundation Youth Institute. Introduction Recently, globesity has been used to describe the escalating worldwide epidemic of obesity and to underscore the need for immediate action to combat this largely preventable disease through alterations in dietary and physical activity behaviors (WHO, 2002, 1997). There is strong evidence that obesity is a risk fact or for chronic health conditions including cardiovascular disease, lipid di sorders, type II diabetes, ce rtain cancers, and physiological disorders (NIH, 1998). While the impact of obesity -related health problems is most severe in industrialized countries, countries undergoing rapid demographic and nutrition transition find increased consumption of high fat and carbohydrat e-dense foods and decreased consumption of grains, fruits, and vegetables along with decreas ed activity common. These changes in diet and physical activity are leading to skyrocketing in creases in the preval ence of overweight and obesity, especially in Latin America. The nutriti onal situation in Latin America has shifted away from under-nutrition, to one in which over-nutriti on and chronic disease (e .g., type II diabetes) are the predominant causes of death (Uauy et al ., 2001). Recently, studies in San Jose, Costa Rica, and its urban and rural environs demonstr ated a correlation betw een life style changes associated with the nutrition transition and obesity (Nunez-Rivas et al., 2003). Also, two recent health assessments by Monteverde Institute students in the Mont everde Zone show higher than expected prevalence for overweight and obesi ty for children and adults (MVI, 2002, 2001). Food insecurity, defined as limitations to the acquisition and availabi lity of nutritionally adequate and safe foods (Anderson, 1990), may be one factor leading to increases in the prevalence of overweight and obesity. The Radi mer/Cornell Scale (Frongillo et al., 1997) has been used to reflect the perspective of people, including Latino communities, who experience hunger and food insecurity (Himmelgreen et al., 2000).
Purpose While not systematically testing a hypothesis in this study, we did have a set of general research objectives. They are as follows: 1. Are there instances of food security in households of the two communities (i.e., Caitas and Cerro Plano)? 2. What are the characteristics of the diets of children ages 7 to 12 years in Caitas and Cerro Plano? 3. Are mothers perceptions of their children s diets differing from those reported by the children? 4. What, if any, obstacles exist to food access? 5. What is the knowledge base of mothers of children in this age group related to obesity, nutrition, and exercise? Finally, our last objec tive was to develop a coloring book rela ted to healthy nutritional choices for the children that participate in the schools. In addition to our pr imary findings, we would give back something to these communities in the form of an interactive activity that promotes healthy eating habits. Methodology The exploratory study used in quant itative and qualitative methods in data collection in one rural (Caitas) and one peri-urb an (Cerro Plano) area of the Monteverde Zone in the central mountain region of Costa Rica. Participants include nine mothers or adult fema le guardians and their children between the ages of 7 and 12 years (N =11). After obtaining informed consents, the Radimer/Cornell Hunger and Food Security Scale (Frongillo et al., 1997) and a semi-structured interview of each mother or adult female guardia n was performed in the home by an interviewer in Spanish (see Appendix 1). Thirty Children, 7 to 12 years of age, were provided activities at their respective schools in Caita s and Cerro Plano related to nutri tion. The activities included: 1) oral readings of fic tional childrens stories related to eating habits, 2) maintenance of daily food diaries for 3-4 consecutive da ys, and 3) development of a pr ototype for a coloring book for nutritional education (see Appe ndix 2 for specific activities). Variable measures included: 1) frequency of food consumption for children in 24 hour period collapsed into the Latin American Food Group Pyramid (2003) for comparative purposes (see Appendix 3 for food categories), 2) methods of food acquisition and pr eparation, 3) reported knowledge of obesity, nutrition, and exercise, and 4) demographic data. Data were analyzed using SPSS data entry statistical and software package. Descri ptive data for nine households were examined and comparisons made between different types of households (e.g., households that have full-time annual employment versus seasonal employment). Interview data were reviewed and themes related to the resear ch questions were qualitatively analyzed. Results Eighty-nine percent of the participating househol ds own their own home. Multiple motor vehicle modes of transportation (e.g., car truck, four-wheeler, motorcyc le) were reported by 33.3% of the households with 44.4% of the households having only one mode and 22% having no means
other than walking (Appendix 4, figure 5). Most of the women (88.9%) worked in addition to household duties to supplement household inco me. The education level ranged from no education to high school, with 77.8% having comple ted middle school level or less. Televisions were owned by 100% of the participating househ olds, telephones by 89%, stoves by 78%, ovens by 67%, microwaves by 44.4%, and computers by 22.2%. Food insecurity is divided into three categories according to the Radimer/Cornell Scales (Frongillo et al., 1997). Thir ty-three percent of households reported being food secure (Appendix 4, Figure 1). Household insecurity (e .g., suggests general foodanxiety) was reported by 34% of the households in Caitas and Ce rro Plano, noted from responses to the Radimer/Cornell Scale (Frongillo et al., 1997). Twenty-two percen t reported Adult Hunger (e.g., compromises in quantity and qua lity of food eaten by adults), and 11.1% reported Child Hunger (e.g., decreases in the quantity of food eaten by children). Reported obstacles to food access included: Limited transportation (e.g., have an unreliable car to get to th e store, walk and have to take a taxi home [33.3%]) Limited food variety (M11: Its not easy to have all ingredients in the house. / M2: I would like to buy more varied food but I dont have the resources. We only have meat 12 times a month. / M3: It is hard to eat bala nced because it is hard to get to the store because of time.) Food costs influenced by tourism (M4: I ge t food from [other communities] because its cheaper and its less far to travel to the store. / M6: there are some things I would like to give them, like vegetables a nd salads, but there is no way. The kids prefer rice, beans, eggs, bananas but they wont eat the vegetables.). (A ppendix 5 provides additional statements from the interviews). Sixty-seve n percent of food purchases are made at a grocery store while twenty-two percent ar e bought from a cooperative and a traveling produce vendor or neighbor (Appendix 4, Figure 4). Eighty nine percent of the mothers interv iewed were aware and knowledgeable about nutritional programs in Costa Rica and the Monteverde Zone, referring to a nutritionist on the news, and programs and lectures at clinic s. Mothers reported decreasing the amount of oils used in cooking, measuring amounts of oils and sugars in foods rather than random additions to dishes, decreasing the amount of candies and sweets consumed by their children, and decreasing th e use of salt. Nevertheless, mothers reported difficulties following recommendations. These difficulties are due to food preparation techniques and preferences, access to food variety, and a lack of compliance among the children. As quoted from one mother, Knowing what to do and actually doing it are different things. Significant differences were not noted between food consumption reported by the mothers and their children. One of the primar y sources of sugar in the diet was a variety of natural juice drinks with sugar added to taste. These frescos and agua dulce were generally consumed multiple times on a daily basis. The reported range of sugar consumption was 4 to 20 kilograms per month per household or 2.3 kilograms per person per month (Appendix 4, Figure 3). 1 M1, M2, M3, M4, M5, M6 indicate individual mothers responses
Conclusions Regional economics contribute to food ins ecurity indicated by influences of limited transportation and higher prices from tourism that impact food variety choices. These in turn may increase the likelihood that high sugar and high fat foods are consumed on a daily basis. Another related component of overweight and ob esity in the communities examined are limited opportunities for exercise outside of work and sc hool for families. Leisure time is limited and frequently spent watching television. Participants reported a lack of acc ess to recreational areas in the Monteverde Zone. The nutritional activities in the respective schools were met with positive responses from the children, parents and school staff. The childre n were actively engaged throughout the readings, the food diaries, and the development of th e coloring books. Final classroom discussions revealed basic knowledge related to food groups and awareness of he althier cooking methods (e.g., using low amounts of oil in empanada preparation, the importance of eating more vegetables and fewer sweets). This explorator y activity was an effective means of assessing simple nutritional understanding as well as to provide a permanent document (individual coloring book) to the pa rticipating students. Acknowledgements We also wish to acknowledge the individuals who contributed artwork for the coloring book, including Idal Santamara Porras, Mara Jesus Vargas Ovares, and Ana Laura Vargas. We also thank Magda and Alexis Torres Ortega, and Luz Ma rina Artavia for their assistance in obtaining contacts at the schools. Gricel Santamara Jimnez provided consultation to the team. Thanks also to the staff and student s at each school for their welcoming spirit and cooperation. Limitations of Study Time limitations resulted in completion of fe wer interviews than desired. Schools were on vacation for two weeks prior to data collection, resulting in delays in obtaining consents. Difficulties in food classificati ons, as was noted, were due to preparation differences and phrasing of survey questions that resulted in general rather than specific information. Specifically, high fat foods were difficult to identi fy because the amount and type of oil used in each dish varied. Additionally, Cerro Plano was chosen for comparison with Caitas because the students frequented a soda near the school dur ing the day. However, the week before our activities, the newly assigned Ce rro Plano school director prohibi ted the students from going to the soda during the school day. Of minor signi ficance, the children were observed copying data from each other during some of the activities. It was unclear whether their purposes were simply for spelling accuracy or expansion of ideas. Howe ver, this may have distorted the content of reported preferences and diets. Recommendations We believe it important to report recommendati ons suggested by mothers interviewed. They included: a) a desire for cooking classes, cookbo ok, and lectures held at community sites; b) a
need for school curriculums that encourage he althy food selection, cons umption and preparation from an early age; c) tools for behavior chan ge to better enable implementation of nutritional knowledge base; d) access to a broader variety of foods is needed in both communities; e) national programs are needed to balance current fast food advertising with healthy food choice advertising, particularly targe ting children; f) neighborhood walk ing groups for women; g) a need for recreational areas for children. Research with increased participant numbers, using this topic and de sign, is recommended to obtain data for determining significant relations hips between food insecurity, food access, and obesity. Participants were supportiv e of this effort and expressed a desire for further information and opportunities to communicate concerns. Qual itative methods (e.g. participant observations) for obtaining more accurate information on f ood preparations are recommended. Additional quantitative data from local gro cers related to volume of oil and sugar sales would offer another perspective on consumption.
References Anderson, S. E. (1990). Core indicators of nutriti onal status for difficult-to-sample populations. Journal of Nutrition, 120, 1559-1599. Andia, J., Davis, E., Klein, R., Wirsing, E. (2002) Assessing Food Securi ty in the Monteverde Zone: A Multi-Method Approach, 1-24. Frongillo E., A. Jr., Rauschenbach, S., Kendall, A., & Colomenares, A. (1997). Questionnairebased measures are valid for the identifica tion of rural households with hunger and food insecurity. Journal of Nutrition, 127, 699-705 Himmelgreen, D. A., Perez-Escamilla, R., SeguraMillan, S., Peng, Y., Gonzalez, A., Singer, M. & Ferris, A. (2000). Food Insecurity among lowincome Hispanics in Hartford, Connecticut: Implications for public health policy. Human Organization 59(3), 334342. Latin American Diet Pyramid. (2003). Obtained from the World Wide Web on July 2003 from www.eguana.net/organizations Monge, R., & Beita, O. (2000). Prevalence of corona ry heart disease risk fa ctors in Costa Rican adolescents. Journal of Adolescent Health 27(3), 210-217. National Institute of Health, (1998). Nationa l Heart, lung and blood institute, clinical guidelineson the identification, ev aluation, and treatment of overwe ight and obesity in adults: The evidence report. Nez-Rivas, H., P., Monge-Rojas, R., Len, & Ro sello, M. (2003). Prev alence of overweight and obesity among Costa Rican el ementary school children. Revista Panamericana de Salud Pblica. 13(1). Uauy, R., Albala, C. & Kain, J. (2001). Obesity epidemic puts millions at risk from related diseases, press release WHO/46. Obtained July, 2003, from www.who.int/archives/inf-pr1997/en/pr97-46.html World Health Organization. (2002) Controlling the global obesity epidemic. Obtained July, 2003 from www.who.int/nut/obs.htm
Appendix 1 Interviews for Mothers or Adult Female Guardians 1. Demographic information: *Age & sex *Education level *Household composition *Employment status Seasonal or year-round *Transportation sources *Length of living in the area *Where from originally *Have a phone? TV? Computer and/or intern et? Own or rent home? Microwave? Hot water system? 2. Examples of possible questions: *What would you want your children to eat to be healthy? *What do you often prepare for your family? *What types of oils are used? *What cooking methods do you use? How do you prepare your foods? *What are healthy ways to prepare foods? *How often do you use canned foods? Pro cessed foods? (Daily? Weekly? Monthly?) *Have you heard about the nutrition st udies in Costa Rica? If so, what? *Have you changed your methods or diets as a result? *Where do you buy your foods? *What do you think would be ideal ways of preparing foods and choosing foods? *How do you get there? Who buys the food for the family? *Are you able to get the foods you want? If not, why? *When are times you are unable to get the foods you want? *How many kilos of su gar are used each week? *How many hours of physical activity are pur sued each week? Hours of TV per week?
Appendix 2 Day 1: Team of investigators will go to the scho ols at Caitas and Santa Elena. At each location, a story will be read orally to the st udents. The book is entitled The Very Hungry Caterpillar, and is a story using the character of a caterpillar to illustrate the importance of healthy eating. The team will th en present the steps to maintaining a food diary. The students will be asked to document their food consumption each day on a provided sheet of paper and return the paper the following day. The student s will transfer the information daily from the individual sheets to a larger sheet. This permits week-l ong documentation of their food consumption that can be taken home by each student at the end of the activities. Days 2, 3, 4: Students' individual food documents will be placed by th e student in a communal envelope without identifiers. The daily logs wi ll be encoded to enable confidentiality. The communal envelope will be collected by team members each day from the teacher Day 5: Team of investigators will return to th e schools for a follow-up ac tivity reading the book, Mr. Sugar Comes to Town. This is another book that informs children about healthy nutrition practices. Using the data from the daily f ood diaries, team members will lead general discussions related to nutritional habits. Hea lthy foods identified by students will be used to develop a prototype coloring book us ing the character of a quetzal following the model of The Very Hungry Caterpillar. Illustrations for th e coloring book will be provided by local artists in the community. Every child in the study will receive a copy of the coloring book. Day 6: Team will complete interviews if needed. Data compilations and examination will begin. Day 7, 8, 9: Data analysis, report and public fo rum/poster presenta tion preparation. Day 10: Public forum including written report, colo ring book prototype, a nd poster presentation of data results.
Appendix 3 Food Categories Meat/Eggs: included salchicha (sausage), jamn (ham ), costillas (ribs), mortadela (bologna), torta de huevos (omelette), huevo (eggs), carne (meat), and empanadas. Fish: atn (tuna) Poultry: pollo (chicken) Dairy: helados (ice cream), queso (cheese), leche (milk), fresco de leche, quesito, pinito (powdered milk) Fruits: only included actual fruits (not juices). Fruits included pltanos, guayaba, banano, manzana, etc. Grains, breads, rice, beans: sandwich counted as 2 (for slic es of bread), avena (oatmeal), chorreadas (fried corn pancake), arroz (rice), pan (b read), gallo pinto (rice and beans) counted as 2, tortilla, frijoles, empanada, arepas, tamale s, empanadas de frijoles counted as 2, pizza. Vegetables: included picadillo de chayote o de ayote, papas Coffee: only included plain/black coffee, coffee ice cream Juice: frescos, jugos, (de pia, naranja, etc.) NOT fresco de chocolate, NOT fresco de leche. Soda: Coca-Cola, Fanta, etc. Sugar/Sweets: miel de abeja (honey), mermelada, jalea (jelly), cookies, ice cream, pan de chocolate, cakes, confites (candies), agua dulce (sugar water), frescos, jugos, hot chocolate, fresco de leche, fresco de chocolate, postres, sirope (syrup), azcar, crema de chantilly (whipped cream in canister), pltanos maduros. Fat/Sweets: galletas (cookies), ice cream, queque (cak e), postres, pan de chocolate (brownie), Numar (butter/margarine), frita (fried), pizza, empanadas. Water: only water Notes: We could not categorize food related to serving sizes or preparation of the food. However, we included juices (jugos, frescos) as a sugar/sweet because we observed numerous accounts of preparation with adding large amounts of sugar. Sopa (soup) was not categorized because the lack of description. Caf con lech e (coffee with m ilk) was not counted as a dairy because it was considered an insufficient am ount. Salsa was not categorized unless it specifically said it was ma de with a vegetable.
Appendix 5 Food Access Issues / Statements from Semi-Structured Interviews The kids are eating, but maybe are not getting the nutrients they need. Once a month I go to the supermarket because it is too expensive. We usually buy fruits and vegetables from the fruit and vegetables produce vendor. I have a car to go to the supermarket but it's not that reliable. Sometimes I go to other towns to by food because it is cheaper and it is not as far to travel. It is hard to eat balanced because it is hard to get to the store because of time. It is not easy to have all ingredients in the house. I would like to buy more varied food even though I dont think we eat bad, but dont have the resources. We eat meat maybe one or two times a month. All kids should be given breakfast at school so they can concentrate and learn without going hungry. Nutrition Knowledge and Education Issues / St atements from Semi-Structured Interviews I have seen a lot on television. I have gotten information at clinics, health fairs, and from television. It is easier for kids to learn and grow up with healthy behaviors than it is for adults to learn. I think that since the kids are in school a lot that the schools could utilize the time to teach children healthy behaviors and ways of living. I know a lot but its one thing to know and another to do it. I have knowledge of what are good and bad foods. Avoid sugar, salt, and fats as much as possibl e because I know it is no t good for our health. People need to do exercise and not eat a lot of meat. Dont reuse burnt oil because it is bad. Foods need to be fresh and not left in the refrigerato r for more than about eight days because they lose a lot of vitamins. Gallo pinto is good for kids to gain weight and it should not be given to fat people. Know where food comes from. For example, not in cans. Dont use too much of anything. Measure out oil, less frying, and dont cook vegetables all the way through to prevent loss of nutrients. Have everything natural and not a lot of salt, fat, or really spicy foods. Kids dont like vegetables. I know that meats arent good for the kids but they love them so I give them meat. Eat meat, beans, milk, fruit, and more of fruit, milk, and eggs. The problem is putting it into practice. Little fat, sugar, salt, not a lot of junk (only some cookies) vegetables, measure oil, and dont add oil to chicken because it has its own oil. Have seen nutritionists on television. Not a lot of fat and salt. More vegetables, salad, and white meat. If you need to lose some weight, eat less starch, more vegetables and fruits. There are things that I want to give the children but they wont eat vegetables or salads.
Appendix 6 Consent for Participation in Research Study Monteverde Institute Why am I being asked to be a part of this study? We are interested in finding out about the foods people eat in Monteverde communities, how they are cooked, and where they get their foods from. We are asking mothers of children from 7 to 12 years old in Caitas and Cerro Plano to take part in the study. What will I have to do? We will be asking you a series of questions about what kinds of foods you eat, how you prepare them, and other questions related to nutrition. We also will be asking your children what they like to eat, to write down what they eat for four days, and reading them books about food at school. It will take no more than one hour to ask you these questions. You are free to answer or not answer any questions asked of you. Your child will al so be asked to participate in activities for about one hour at school. They will also be asked to keep a food diary during the week. How will the information be used? The answers from you and your child (ren) will be put together with those received from other families to determine the f oods most often used. Once combined, the results will be reported at a public presentation at the Montever de Institute on July 30, 2003. We will also be writing a report that will be printed and kept in the lib rary at the Institute. You are free to come to the meeting and to read the report whenever you choose. Will my neighbors know what I have said? No. Your name and your childs name will not be used when reporting any of the information. Without usin g your name, it would be difficult to identify your answers from those of other Monteverde residents. What if I have questions about the study? If you have questions during or after we are done, or change your mind about including your answers, you can cont act David Himmelgreen or Sophia Klempner at the Monteverde Institute (506-645-5053). How will I benefit from the study? You will not receive compensation fo r participating in the study. But you will provide valuable information that can help in increasing knowledge about the nutrition strengths and needs of Monteverde. Yes___ No ____ I agree to participate fully in the study. Yes___ No ____I give permission for my child(ren) to participate in the study. Yes___ No ____I give permission to be photographed a nd understand the picture may be used as part of the report. _________ ___________________________________ Date Signature __________________________________________________ Printed Name of Participant __________________________________________________ Signature of Person Gaining Consent
Consentimiento Para Su Participaci n En Un Estudio de Investigacin Instituto Monteverde Por qu se me est pidiendo que participe en este estudio? Estamos interesados en identificar las comidas consumidas en las comunidades de Caitas y Cerro Plano, como se preparan, y dnde se consiguen. Estamos invitando a madres o responsables (adultas femeninas) de nios de 7 a 12 aos de edad en Caitas y Cerro Plano a ser parte de este estudio. Qu tendr que hacer? Le estaremos haciendo una serie de preguntas sobre las comidas que se consumen en su hogar, como las prepara, y otras preguntas relacionadas con la nutricin. Tambin le estaremos preguntando a sus hijos/hijas lo que les gusta comer, y les pediremos que registren lo que comen durante cuatro das. Como parte de la actividad le estaremos leyendo libros a sus hijos/hijas en la escuela acerca de la nutricin. Tomar no ms de una hora hacerle estas preguntas. Puede sentirse libre de contestar o no contestar las preguntas. A su hijo/hija tambin se pedir que participe en actividades por aproximadamente una hora en la escuela. Tambin se le pedir a sus hijos/hijas que apunten todas las comidas que comen en el da por cuatro o cinco das seguidos. Cmo se utilizar la informacin? Las respuestas obtenidas de usted y sus hijos/hijas sern juntadas con las recibidas de otras familias para identificar las comidas consumidas ms a menudo. Una vez analizados, los resultados sern presentados en un foro pblico en el Instituto Monteverde el 30 de julio de 2003. Tambin estaremos escribiendo un reporte que estar en la biblioteca del Instituto. Est invitada a participar en la presentacin y de leer el reporte. Mis vecinos sabrn lo que dije? No. Su nombre y el nombre de su hijo/hija no sern utilizados al reportar la informacin. Sin utilizar su nombre, sera di fcil identificar sus respuestas entre las de las otras participantes en Caitas y Cerro Plano. Y si tengo preguntas sobre el estudio? Si tiene preguntas mientras o despus del estudio, o si decide que no quiere incluir sus respuestas, puede contactar a David Himmelgreen o Sophia Klempner en el Instituto Monteverde (506-645-5053). Cmo voy a beneficiar de este estudio? No ser compensada por su partic ipacin en el estudio. Pero s proveer informacin importante para ayudar a aumentar el conocimiento de la bue na alimentacin y las necesidades acerca de la nutricin en Monteverde y Guanacaste. S_____ No_____ Yo quiero participar en el estudio. S_____ No_____ Doy permiso a mis hijos/hijas participar en el estudio. S_____ No_____ Estoy de acuerdo con que se tome n fotos y entiendo que mi foto (o el de mis hijos/hijas) podrn ser parte del reporte. _________ ___________________________________ Fecha Firma __________________________________________________ Nombre Escrito de la Participante __________________________________________________ Firma De La Persona Pidiendo El Consentimiento