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The political ecology of intestinal parasites among Nicaraguan immigrants in Monteverde, Costa Rica

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Title:
The political ecology of intestinal parasites among Nicaraguan immigrants in Monteverde, Costa Rica
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English
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Lind, Jason D
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University of South Florida
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Medical anthropology
Health disparaties
Immigrant health
Global public health
Infectious disease
Dissertations, Academic -- Applied Anthropology -- Doctoral -- USF   ( lcsh )
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non-fiction   ( marcgt )

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Abstract:
ABSTRACT: Over the past 15 years Monteverde, Costa Rica has undergone rapid economic, social, political, and environmental change due to a flourishing ecotourism economy. While the effects of ecotourism development in Monteverde are many, two important consequences have been: 1) the immigration of Nicaraguan nationals to the area seeking low-skilled wage labor; and 2) compromised water resources management due to pollution and rapid population growth. The objective of this research is to investigate and identify the inter-relationships between ecotourism development in Monteverde and its affect on infectious diseases outcomes within the context of immigration and water resources management. Specifically, this dissertation uses both anthropological and public health methods within a political ecology of health framework to compare prevalence rates of intestinal parasites between Nicaraguan immigrants and Costa Rican residents living in Monteverde. Results indicate that Nicaraguan immigrants suffer disproportionately from infections with intestinal parasites compared to Costa Rican residents. The results further indicate that community based water resources are not a significant source of infection. Instead, the prevalence of intestinal parasites is most likely the result of fecal-oral transmission at the household level and is related to indicators such as access to health care, underemployment, home ownership, and household sanitation infrastructure.
Thesis:
Dissertation (Ph.D.)--University of South Florida, 2009.
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Includes bibliographical references.
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by Jason D. Lind.
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Includes vita.

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The Political Ecology of Intestinal Para sites Among Nicaraguan Immigrants in Monteverde, Costa Rica by Jason D. Lind A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Applied Anthropology College of Arts and Sciences University of South Florida Major Professor: Linda M. Whiteford, Ph.D., M.P.H. Nancy Romero-Daza, Ph.D. David Himmelgreen, Ph.D. Ann C. DeBaldo, Ph.D. Ricardo Izurieta, M.D., Dr.PH. Date of Approval: November 16, 2009 Keywords: medical anthropology, health disp araties, immigrant health, global public health, infectious disease Copyright 2009, Jason D. Lind

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Acknowledgments I would first like to thank all of the people I lived among and worked with in Costa Rica, especially those who took the time to participate in this research. Special thanks go to Lucas and David Lopez for trus ting in me and for introducing me to the Nicaraguan community in Monteverde, and to Virginia Soto, Edith Rogama, and Marlin Salazar for introducing me to the Tico comm unity. I would also like to give special thanks to all the staff and volunteers at the Monteverde Institute, especially Nat Scrimshaw, Stewart Dallas, and Nacho for granting me access to laboratory space in addition to the many human and physical resour ces. I would also like to thank my Tico friends Victor Barrantes and Marvin Jimenez for always offering me a warm and friendly place to stay in San Jose with included a nd much needed Imperial entertainment. This research would not have been possi ble without the financial, intellectual, logistical and social suppor t of the USF-Globalization Re search Center where Mark Amen, Rebecca Harris and Marilyn Leon played integral roles. I would also like to extend my gratitude to Carol Bryant and th e Florida Prevention Research Center for giving me the opportunity to gain valuable research experience while I wrote this dissertation. I also thank my current employer, the Center of Excellence at the Tampa VA Medical Center for providing me the time and space to finish this dissertation. Recognition must also be given to the USF Department of Anthropology for their support of my journey through the PhD program over the years. Special recognition goes to my dissertation committee; to Linda Wh iteford for giving me so many opportunities, for being patient, and for believing in this research; to Nancy Romero-Daza and David Himmelgreen for their support and friendship wh ile in the field; to Ricardo Izurieta and Ann DeBaldo on the Public Health side of thi ngs for their support and suggestions to the manuscript; and finally to the memory of Dr. Donald L. Price who taught me in the “old school” way everything I ever wanted or needed to know about parasitology, this dissertation is just a very small piece of his legacy.

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Finally, I would like to dedi cate this dissertation to al l of my family and friends who have been there to support me throughout this long and arduous process, especially to my mom, Julie and my dad, Dennis for thei r love, concern and support, and also to my new Colombian family for treating me as one of their own and for cheering me on. Most of all I would like to dedicate this dissertation to my wife Angela, who in addition to her hard work and expertise in creating the maps, tables, and diagrams that appear in this manuscript, provided me the inspiration and n eeded spark to finish this dissertation. Her inalienable love, compassion, trust, creativit y, and companionship have been the most valuable lessons I have gained from this expe rience, and for that I am forever grateful.

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i Table of Contents List of Tables ................................................................................................................ ... viiiList of Figures ............................................................................................................... .......xAbstract ...................................................................................................................... ....... xiiChapter One – Introduction .................................................................................................1Background to the Problem ........................................................................................2The USF-Globalization Research Center ...........................................................6Preliminary Studies ............................................................................................7Political Ecology as a Framework fo r Understanding the Prevalence of Intestinal Parasites .......................................................................................9Research Objectives and Methods ...................................................................11Research Findings ............................................................................................12Importance of the Study ...................................................................................15Chapter Two – Review of the Literature ...........................................................................17Globalization and Health ..........................................................................................17Globalization and Infectious Diseases ......................................................................20Intestinal Parasites ....................................................................................................24Key Concepts and Definitions .........................................................................24Sources of Infection and Modes of Transmission: ..........................................25The Natural Environment and the Distribution of Parasites: ...........................27Human Ecology and Behavior in th e Transmission of Parasites: ....................28Personal Hygiene and Waste Management: ....................................................29

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ii Water – Supply, Distribution & Management: ................................................29Travel, Migration, and Transportation: ............................................................30Urbanization:....................................................................................................30Human Culture and Behavior: .........................................................................31Anthropology and Parasitic Diseases........................................................................31Political Ecology as a Framework for Understanding Infectious Diseases ..............33The Political Ecology of Health ................................................................................35Political Ecology as a Framework fo r Studying Intestinal Parasites ........................37Chapter Three – Description of the Research Site .............................................................39A Brief Look at Costa Rica .......................................................................................39The Health Care System in Costa Rica .....................................................................41Development of the Costa Rican Health System .............................................43The Role of the CCSS and the Ministry of Health ..........................................44Primary Health Care Initiatives in Costa Rica .................................................45The Health Transition in Costa Rica ................................................................46Health Care Reform in Costa Rica...................................................................48Implementation of Health Care Reforms .........................................................49Impact of Health Care Reforms .......................................................................50Water Management in Costa Rica ............................................................................50Water Management and Intestinal Parasites in Costa Rica .............................52Nicaraguan Immigrants in Costa Rica ......................................................................53Intestinal Parasites in Costa Rica ..............................................................................55The Monteverde Zone ...............................................................................................58The Study Site: Santa Elena de Monteverde....................................................60

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iii Health and Health Serv ices in Monteverde .....................................................61Water Resources Management in Santa Elena ................................................63Nicaraguan Immigrants in Monteverde ...........................................................65Chapter Four Research Objectives and Methods ............................................................67Research Objectives ..................................................................................................67Overview of Research Methods ................................................................................69Public Health and Laboratory Methods ...........................................................70Research Timeline ...........................................................................................70Research Team .................................................................................................70Selection of the Research Community .............................................................71Recruitment of Participants ..............................................................................72Sampling ..........................................................................................................74Informed Consent, Confidentiality and Study Permission ..............................76Field and Laboratory Procedures for the Diagnosis of Intestinal Parasites ..............77Collection of Fecal Samples ............................................................................78Handling and Organization of Fecal Specimens ..............................................80Sample Preparation ..........................................................................................82Concentration Procedures and Wet-Mount Slide Preparations .......................82Staining Procedures for the Identifi cation of Cryptosporidium parvum .........83Analysis of Fecal Samples ...............................................................................83Dissemination of Results .................................................................................83Anthropological Methods .........................................................................................84Archival Data ...................................................................................................85Semi-Structured Interviews .............................................................................85

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iv Semi-Structured Demographic Intervie ws for Costa Rican Households .........86Semi-Structured Demographic Interv iews for Nicaraguan Households ..........87Semi-Structured Interviews: Parasite Perceptions and Knowledge .................88Semi-Structured Interviews: Household Water Management .........................89Participant Observation ....................................................................................90Key Informant Interviews ................................................................................90Health Education ..............................................................................................91Data Analysis ...................................................................................................91Chapter Five – Data Analysis ............................................................................................92Analysis of Biological Samples to Determine the Prevalence of Intestinal Parasites ..............................................................................................................92Qualitative Data Analysis of Semi-Structured Interviews ........................................94Data Analysis of Demographi c and Epidemiological Data ......................................98Chapter Six – Qualitative Results: Knowledge, Perceptions and Behaviors Related to Intestinal Parasites .................................................................................................102Defining Parasites ...................................................................................................103Source of Infection and Mode of Transmission ......................................................107Domain: Animals and Insects ........................................................................108Domain: Food ................................................................................................109Domain: Walking on Ground or Dirt .............................................................110Domain: Hygiene/Sanitation ..........................................................................112Domain: Hand Washing Behaviors ...............................................................113Domain: Water ...............................................................................................114Symptoms of Parasites ............................................................................................116Illnesses from Parasites ...........................................................................................120

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v Treating Parasites ....................................................................................................122Preventing Parasites ................................................................................................127Knowledge of Parasites...........................................................................................132Knowledge of Parasites between Nicaraguans and Costa Ricans ..........................136Summary of Qualitative Results .............................................................................139Chapter Seven – Quantitative Results Relating to Parasite Prevalence ...........................141Household Demographic Data ................................................................................141Household Water and Sanitation Data ....................................................................152Period Prevalence of In testinal Parasites ................................................................158Factors Associated with the Individual Prevalence of Intestinal Parasites ...................................................................................................162Factors Not Associated to Individual Prevalence of Intestinal Parasites .......170Factors Associated to the Household Prevalence of Intestinal Parasites .......172Factors Associated to Household Parasite Prevalence and Household Conditions ................................................................................................173Factors Not Associated with Hous ehold Parasite Prevalence and Household Conditions ..............................................................................178Association between Household Cond itions and Household Ownership ......179Household Parasite Prevalence and H ousehold Health Care Coverage ........181Household Variables Not Associated with Household Parasite Prevalence ................................................................................................183Chapter Eight – Discussion of the Research Results .......................................................186Research Objective (O-1) .......................................................................................189Research Question (RQ-1) .............................................................................189The Alternative Hypothesis (H-1) .................................................................189

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vi Research Question (RQ-2) .............................................................................192The Null Hypothesis (H-2) ............................................................................192Research Objective (O-2) .......................................................................................193Research Question (RQ-3) .............................................................................193The Alternative Hypothesis (H-3) .................................................................193Research Question (RQ-4) .............................................................................196The Alternative Hypothesis (H-4) .................................................................196Water Resource Management and Water Quality: ........................................198Research Objective (O-3) .......................................................................................201Research Question (RQ-5) .............................................................................201The Alternative Hypothesis (H-5) .................................................................201Access to Health Care Among Nicaraguans ..................................................205Access to Health Care a nd Parasite Prevalence .............................................208Research Question (RQ-6) .............................................................................210The Alternative Hypothesis (H-6) .................................................................210Research Question (RQ-7) .............................................................................215The Alternative Hypothesis (H-7) .................................................................215Research Objective (O-4) .......................................................................................219Chapter Nine – Conclusions, Recommendations and Limitations ..................................221Toward a Political Ecology of Intestinal Parasite Infecti ons in Monteverde, Costa Rica .........................................................................................................222The Role of Water and Water Resource Management in Disease Transmission ............................................................................................223The Systematic Underreporting of Pa rasitic Infections as a Macro Cause of Disease ......................................................................................224

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vii Immigration as a Macro, Social Structural Cause of Disease ........................227The Household Ecology as an Inte rmediate Cause of Disease ......................228The Role of Knowledge, Beliefs and Behaviors on Parasite Transmission ............................................................................................231Implications of a Political Ecology of Health .........................................................233Recommendations ...................................................................................................236National Level Recommendations .................................................................236Community Level Recommendations............................................................237Limitations of the Research ....................................................................................239A Suggestion for Future Research ..........................................................................241Summary .................................................................................................................241References Cited .............................................................................................................. 243Appendices .................................................................................................................... ...266Appendix A: Combined Informed Consent (Spanish) ............................................267Appendix B: Instructions for Collecting Fecal Specimens (English) .....................271Appendix C: Costa Rican Household Demographic Interview (Spanish) ..............272Appendix D: Nicaraguan Household De mographic Interview (Spanish) ...............276Appendix E: Household Water Management Interview (Spanish) .........................282Appendix F: Semi-Structured Interview Guide Parasite Perceptions and Knowledge (Spanish) ........................................................................................285Appendix G: Parasite Education Handout for Study Participants (Spanish) ..........289About the Author ................................................................................................... End Page

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viii List of Tables Table 3-1. Primary Causes of Morbidity in the Monteverde Zone (2002) ....................... 63Table 4-1. Summary of Research Methods ........................................................................69 Table 4-2. Research Tasks and Timeframe of the Parasite Prevalence Study .................. 70Table 4-3. Number of Participants Recruited ................................................................... 75Table 4-4. Field and Laboratory Procedures ..................................................................... 77Table 4-5. Anthropological Methods ................................................................................ 84Table 7-1. Age and Gender Distribution of Study Population .........................................142 Table 7-2. Age and Gender Distribution of Monteverde, Costa Rica, 2001 .................. 143Table 7-3. Years of Education Attain ed among Costa Rican and Nicaraguan Adults ........................................................................................................................ .144Table 7-4. Mean Years of Educatio n Attained Among Adult Women ........................... 144Table 7-5. Mean Size of Costa Rican and Nicaraguan Households ............................... 146Table 7-6. Home Ownership by Nationality ................................................................... 147Table 7-7. Reported Monthly House hold Income by Nationality .................................. 148Table 7-8. Most Common Jobs among Adu lt Costa Rican and Nicaraguan Men .......... 149Table 7-9. Most Common Jobs among Adu lt Costa Rican and Nicaraguan Women ..... 149Table 7-10. Reported Unemployed in th e Past Year by Nationality .............................. 150Table 7-11. Household Health Coverage by Nationality ................................................ 151Table 7-12. Individual Health Coverage by Na tionality ................................................. 152Table 7-13. Type and Condition of Household Bathroom ............................................. 156Table 7-14. Percentage of House holds with Septic Tanks ............................................. 157Table 7-15. Graywater Disposal and Condition of Graywater System .......................... 157Table 7-16. Condition of Household K itchen and Presence of Vectors ......................... 158Table 7-17. Age and Gender Distribution of Participants of the Parasite Study ............ 159Table 7-18. Distribution of Intestinal Parasites among Study Participants .................... 160Table 7-19. Prevalence of Multiple Para site Infections by Nationality .......................... 162

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ix Table 7-20. Period Prevalence of Intestin al Parasites by Na tional Origin ..................... 163Table 7-21. Parasite Prevalence by Age and National Origin ........................................ 165Table 7-22. Parasite Prevalence by Hous ehold Size and National Origin ...................... 167Table 7-23. Parasite Prevalence by Presen ce of Infected Family Member .................... 168Table 7-24. Parasite Prevalence by Health Care Coverage and National Origin ........... 170Table 7-25. Parasite Prevalence by Gender and National Origin ................................... 171Table 7-26. Parasite Prevalen ce by Mothers Education ................................................. 171Table 7-27. Period Prevalence of Intes tinal Parasites by Household National Origin ........................................................................................................................ .173Table 7-28. Household Parasite Prev alence by Bathroom Conditions ........................... 174Table 7-29. Household Parasite Pr evalence by Kitchen Conditions .............................. 176Table 7-30. Household Parasite Prevalence by Observed Vectors in Household .......... 177Table 7-31. Household Parasite Prev alence by Graywater Disposal .............................. 178Table 7-32. Household Parasite Prev alence by Septic Tank Condition ......................... 178Table 7-33. Household Bathroom Cond itions by Household Ownership ...................... 179Table 7-34. Household Kitchen Conditi ons by Household Ownership .......................... 179Table 7-35. Household Parasite Prev alence by Household Ownership .......................... 181Table 7-36. Household Parasite Prevalen ce by Household Health Coverage ................ 182Table 7-37. Household Parasite Pr evalence by Household Size .................................... 183Table 7-38. Household Parasite Prevalence by Mothers Years of Formal Education .... 184Table 7-39. Household Parasite Preval ence by Household Unemployment .................. 184Table 7-40. Household Parasite Preval ence by Household Monthly Income ................ 185

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x List of Figures Figure 3-1. Map of Costa Rica .......................................................................................... 40Figure 3-2. Map of the Monteverde Zone ......................................................................... 59Figure 4-1. Map of the Study Commun ities and Selected Households .............................73 Figure 5-1. Network View of Qualitative Data Analysis ..................................................97 Figure 6-1. Network View of M odel of Qualitative Analysis .........................................103 Figure 6-2. Network View Defining Parasites ................................................................ 104Figure 6-3. Network View of Source of In fection and Mode of Transmission .............. 108Figure 6-4. Network View of Symptoms of Parasites .................................................... 117Figure 6-5. Network View of Treating Parasites ............................................................ 122Figure 6-6. Network View of Parasite Prevention .......................................................... 128Figure 6-7. Network View of Parasite Knowledge ......................................................... 133Figure 7-1. Reported Source of Household Water ...........................................................153 Figure 7-2. Reported Qualit y of Local Aqueduct ........................................................... 154Figure 7-3. Reported Quality of Househol d Water Quality by Nationality .................... 155Figure 7-4. Prevalence of Intestinal Pa rasite Species by National Origin ...................... 161Figure 7-5. Period Prevalence of Intestin al Parasites by Na tional Origin ...................... 163Figure 7-6. Parasite Prevalence by Age Group and Nationality ..................................... 164Figure 7-7. Parasite Prevalence by Household Size and Nationality.............................. 166Figure 7-8. Parasite Prevalence by Infect ed Family Member and Nationality ............... 168Figure 7-9. Parasite Prevalen ce by Individual Health Cove rage and Nationality .......... 169Figure 7-10 Period Prevalence of Intestinal Parasites by Household Nationality .......... 172Figure 7-11 Household Parasite Pr evalence by Bathroom Condition ............................ 174Figure 7-12 Household Parasite Prevalence by Kitchen Condition and Nationality ...... 175Figure 7-13 Household Parasite Prev alence by Presence of Vectors and Nationality..................................................................................................................17 7Figure 7-14 Household Parasite Pr evalence by Home Ownership ................................. 180

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xi Figure 7-15 Household Parasite Prevalen ce by Household Health Coverage ................ 182Figure 8-1. Distribution of Parasite s in Households by Nationality ................................192 Figure 9-1. The Political Ecology of Intestinal Parasites Framework .............................234

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xii The Political Ecology of Intestinal Parasi tes Among Nicaraguan Immigrants in Monteverde, Costa Rica Jason D. Lind ABSTRACT Since the mid-1990s Monteverde, Cost a Rica has undergone rapid economic, social, political, and environmental change due to a flourishing ecotourism economy. While the effects of ecotourism developmen t in Monteverde are many, two important consequences have been: 1) the immigration of Nicaraguan nationals to the area seeking low-skilled wage labor; and 2) compromi sed water resources management due to pollution and rapid population grow th. The objective of this res earch is to investigate and identify the inter-relationships between ecotourism development in Monteverde and its affect on infectious diseases outcomes w ithin the context of immigration and water resources management. Specifically, this di ssertation uses both anthropological and public health methods within a political ecology of health framework to compare prevalence rates of intestinal parasites between Nicaragua n immigrants and Costa Rican residents living in Monteverde. Results indicate that Nicaraguan immigrants suffer disproportionately from infections with inte stinal parasites comp ared to Costa Rican residents. The results further indicate that community based water resources are not a significant source of infection. Instead, the prevalence of inte stinal parasites is most likely the result of fecal-ora l transmission at the househol d level and is related to indicators such as access to health care, underemployment, home ownership, and household sanitation infrastructure.

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1 Chapter One – Introduction Once thought to be on verge of eradication, in fectious diseases still remain one of the major causes of morbidity and morta lity among the world’s population. Both the emergence and re-emergence of infectious diseases has been closely linked and associated with the processes of globaliz ation. While definitions of globalization are often based on academic interests and perspectives, this dissertation is interested in how globalization as a process of interactions and inter-relationships between politicaleconomic, social and environmental systems a ffects human health by increasing levels of infectious diseases. One of the most conspi cuous manifestations of globalization with specific implications for emerging and re -emerging infectious diseases is the unprecedented movement of people, goods and capitol (Knobler 2006). As economic, social and environmental disparities grow within and between countries, the number of migrants seeking work and a better quality of life will continue to grow. According to Knobler et al. (2006), “migra nt populations are among the mo st vulnerable to emerging and re-emerging infectious disease and have been implicated as a key causal factor in the spread of such diseases” (2006:21). In their seminal book “The Anthropol ogy of Infectious Disease” Inhorn and Brown (1997) contend that, because of their expertise in understanding human behavior couched within a mixed methods approach, medical anthropologist s are well suited to study infectious diseases by providing critical perspectives that can be used to reduce their burden on human suffering. Inhorn and Brown describe the anthropology of infectious disease as “the broad area wh ich emphasizes the interactions between sociocultural, biological and ecological variables relating to the etiology a nd prevalence of infectious disease” (1997: 14). They later call on anthropo logists to conduct research focusing on how infectious diseases are manife st in different cultural, political-economic and ecological settings, especially in terms of identifying individual, community and ultimate risk factors of disease (1997). The authors also express the need for medical

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2 anthropologists to explain how patterns of inf ectious disease are not only influenced by proximate causes, but how they are also in fluenced by political-economic processes of globalization. Employing perspectives from anthropology and public health, this dissertation attempts to answer the ca ll from Inhorn and Brown by comparatively studying the prevalence of intestinal parasi tes among Nicaraguan immigrants and Costa Rican residents living in a rural Costa Rican community that has significantly changed in the past decade as a result of its burgeoning internationa l ecotourism economy and the resulting immigration of Nicaraguan nationa ls to the area seeking employment and a better quality life. Background to the Problem The Monteverde Zone is situated in th e Tilarn Mountains of Northwest Costa Rica and refers to several communities situat ed along a rough gravel road extending from the Pan-American Highway up to the M onteverde Cloud Forest Reserve. The communities of Santa Elena, Cerro Plano and Monteverde are currently centers of ecotourism1 development, local governance, a nd settlement. Other communities including San Luis, Caitas and Los Llanos are smaller rural communities where agriculture production and dairy farming are prev alent. Together, it is estimated that the Monteverde Zone has a population between 5,000 and 6,000 permanent inhabitants with Santa Elena being the largest community (AAASE 2003). The Monteverde Zone was first settled in the early decades of the 1900's by gold miners, settlers, and farmers. Later, in th e 1950’s American Member s of the Society of Friends (Quakers) established the comm unity known as Monteverde. The Quakers established dairy farming in the region and al so set aside about 550 hectares of primary forest to protect their watershed. Toda y, over 50,180 hectares of forest are under protection in four formal re serves, including the Monteverde Cloud Forest Preserve and 1 Ecotourism as defined by The International Ec otourism Society is “res ponsible travel to natural areas that conserves the environm ent and improves the well-being of local people” (TIES 1990).

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3 other private and public land holdings (Haber 2000; Honey 1999). These forests are home to enormous biodiversity, which has attracted researchers and tourists for several decades and today provide the basis of M onteverde’s ecotourism industry. The primary threat to the sustainability of the Monteverde Zone has been the recent explosive growth of the ecotourism i ndustry. As an example, in the 1980’s it was estimated that approximately 15,000 tourists visited Montev erde annually while in 2003 the Santa Elena aqueduct estimated that Montev erde receives more that 200,000 tourists a year (AAASE 2003). Tourism has now surpasse d dairy farming as the areas primary source of income. More than 80% of the hot els, restaurants, and businesses in the Monteverde zone have been built sin ce 1990. In a recent survey of the areas 93 businesses, 85% are directly related to the tourism and service sector economy and 73% are located either in Santa Elen a or Cerro Plano (Amador 2004). The impact of increased ecotourism development has been mixed. On the positive side there have been benefits in overall employment and improvements in education and health facilities. In a recent survey by the USF-GRC, Amador (2004) reports that respondents overwhelmingly stated the benefits of ecotourism were the availability of work and increased economic growth. Reside nts also cited the 2001 construction of a well equipped and staffed medical clinic which has increased health services and coverage as another bene fit of ecotourism (2004). On the flip side, ecotourism development is threatening forest resources through the creation of new pasturelands as a result of increased construction to make way for new homes and ecotourism based businesses. The depletion of forest resources is threatening biodiversity which has been exem plified by the disappearance of the golden toad, a species thought to only have exis ted in Monteverde (Honey 1999; Nadkarni 2000). Another important impact of ecotourism has been the pollution of local rivers and streams as a result of graywater2 contamination from homes and businesses. In addition, 2 Graywater is defined as non-industrial domestic wastewat er generated from domestic processes such as dish washing, laundr y and bathing (The Groundwater Foundation 2009).

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4 the continued growth of the ecotourism sect or has increased demands for fresh potable water and has resulted in water shortages for local residents. These threats to local water resources in terms of water quality and quantity have potential human health and environmental consequences. Another consequence of ecotourism has been the immigration of Nicaraguan nationals to the area seeking employment in s easonal agricultural (the coffee harvest) or the tourism economy; specifically construc tion and domestic services. Until recently, very little was known about the Nicaraguan population in Monteverde. A pilot study done by students during the USF Globalization and Community Health Summer Field School in 2003 was the first to interview househol ds headed by Nicaraguan immigrants in Monteverde. The preliminary findings of th is pilot study indica te that Nicaraguan immigrants living in Monteverde have significantly lower educational levels; tend to live in substandard and/or crowded living conditi ons; tend to be paid lower wages and suffer from job insecurity; and are more likely not to have health coverage compared with their Costa Rican neighbors. Although the pilot study lacks external validity, the resu lts are consistent with other national level studies including the annua l “State of the Nation Report” (Proyecto Estado de la Nacin 2002); the International Organization for Migr ation’s bi-national study of migration between Nicaraguan a nd Costa Rica (OIM 2001) ; the Costa Rican Ministry of Health’s report concerning health care in areas of hi gh migration (Ministerio de Salud de Costa Rica 2002); and an indepe ndent report about Nicaraguan immigrants in Costa Rican from Marquette (2006). These repo rts all cite similar tendencies relating to the health and social status of Nicaraguan immigrants living in Costa Rica; the reports emphasize that: 1) 25% of Nicaraguan headed households live poverty; 2) up to 40% of Nicaraguans live in substandard housing; 3) Nicaraguans are more likely than Costa Ricans to be underemployed; 4) over 50% of Nicaraguans do not have CCSS health insurance coverage; and 5) it is believed that Nicaraguans exhibit a higher prevalence of infectious diseases as a result of th ese health and social inadequacies. Of special concern here is the disparit y in health insurance coverage and its potential impact on health outcomes. In the 1960’s and 1970’s Costa Rica passed a

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5 National Health Plan that mandated universal health care and recognized the populations’ right to health care and the governments obl igation to organize and provide health services (Vargas 1995:62). As a result of th is policy, today over 90% of Costa Ricans have health insurance coverage through the Co sta Rican Social Security Institute (CCSS) while others are covered through private health insurers (Proyecto Estado de la Nacin 2002). However, in Costa Rica the idea of access to health care as a human right is not automatically extended to Nicaraguan immigr ants, especially those who are in the country illegally. In fact, a Co sta Rican Ministry of Health reports sites that without proper documentation, immigrants do not qualify for any CCSS health benefits (except for emergency care), even if they are dependa nts of legal immigrants or even if they wished to purchase an indivi dual health insuranc e policy (Ministerio de Salud de Costa Rica 2002). The contradictions in health policy to pr ovide access to basic health services for one group but exclude other groups are based on ethnicity and immigration status. These inequalities are based on soci al, historical, and political pr ocesses that amount to what Farmer (2005), describes as “structural violence”, where access to health care, like health outcomes, is never randomly distributed ac ross society, but instead is concentrated among certain groups. As a result, this disserta tion is interested in linking the units of analysis between health dispar ities and health outcomes within the context of health policy and social and politic al economic processes. By doing this, I hope to identify whether health and other disparities exis t between Nicaraguan im migrants and Costa Rican residents living in the same community and whether or not they translate into differential health outcomes. Another concern is that while Costa Ri ca has been successful at significantly reducing rates of preventable in fectious diseases like intestin al parasites and others (Mata 1998), it raises serious concerns over whether the unequal access to basic health care and public health initiatives among Nicaragua n immigrants has implications for the emergence or re-emergence of preventable inf ectious diseases that ultimately threaten both the immigrant and host populations (Inhorn and Brown 1997; Knobler 2006).

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6 While the context of national health policy, ecotourism development, and immigration forms the basis of this dissertati on research; it was my graduate studies in anthropology and public health in addition to my graduate research fellowship at the University of South Florida – Globalization Rese arch Center that were critical in defining the central thesis of this dissertation. The USF-Globalization Research Center Established in 2001 as part of a four university Globalization Consortium that included UCLA, The University of Hawaii and George Washington University; the University of South Florida Globalization Research Center (USFGRC) was created to study the phenomenon of economic, social, and cultural globalization. The primary academic mission of the USF-GRC was to focu s research efforts on the effects of and responses to globalization in the overlapping areas of health, water, and development with a geographic concentration on Latin Amer ica and the Caribbean. Within this context and in collaboration with the Monteverde Inst itute the USF-GRC selected a core research project called The Triangulation Study to identify and investigate the inter-relationships between ecotourism development in Montev erde, Costa Rica and its affect on local political, economic, and social instituti ons; the local environment including water resources; and finally on community health in cluding infectious dis eases and nutrition. At the time of this research, the U SF-GRC consisted of a center director, Dr. Mark Amen, and three USF faculty research coordinators responsib le for coordinating research for The Triangulation Study pertaining to their areas of expertise. In this capacity, Dr. Trevor Purcell was the developm ent coordinator; Dr. Linda Whiteford was the health coordinator; and Dr Mark Stewart was the water resources coordinator. This dissertation research was carried out as part of a three year graduate fellowship (20012004) with the USF-GRC during which time I was assigned to work as a research assistant for Dr. Linda Whiteford, the Triangulation Study health coordinator. In my graduate studies at USF, my e ducation as a dual degr ee student in the Applied Anthropology Ph.D. program with an emphasis in Medical Anthropology, and the M.P.H program in Tropical Public Health and Communicable Diseases combined the

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7 theoretical and methodologi cal frameworks of anthropology and public health. Coursework in anthropological methods, me dical anthropology, infectious disease surveillance, emerging infecti ous diseases and parasitol ogy; in addition to a mixed methods field course and labor atory training in diagnostic pa rasitology provided me with the methodological and theoretical foundation to better understand and carry out research focusing on the relationships between polit ical economy, the environment, ecotourism development and infectious diseases. A more in depth discussion of my various field experiences and their specific influence on this dissertation will be discussed next. Preliminary Studies While a graduate fellow at the USF-G RC three experiences helped shape the development of this dissertati on research. First, was the oppor tunity to participate as a Graduate Assistant for the newly created “Gl obalization, Nutrition a nd Infectious Disease Field School” in Monteverde, Costa Rica be tween June and July 2001. The Globalization and Community Health Field School (as it wa s later called), was collaboration between the USF-GRC, the USF Department of Applie d Anthropology, the Monteverde Institute, and the University of Illinois at Chica go School of Public H ealth. The experience introduced me to the Monteverde community in addition to providing me with a good background in anthropology and pub lic health field methodology. The second opportunity was part of my required Public Health field experience which I conducted in diagnostic parasitology at the USF Donald L. Price Parasitology Repository and Training Laboratory betw een 2002 and 2003. During this laboratory experience I worked closely with Dr. Donald L. Price who taught me the fundamentals of diagnostic parasitology including laboratory and field techniques that I would eventually apply in this dissertation research. The third experience was my invol vement on a pilot study called “The Household Management of Health, Water a nd Waste Project” which was conducted as part of the USF-GRC Triangulation Study. Th is project was directed by Dr. Linda Whiteford with funding from the Hewlet t-Packard Foundation via Michigan State University and the USF-GRC. The purpose of “The Household Management of Health,

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8 Water and Waste Project” was to use Rapid Assessment Procedures (RAP) to analyze the variation of knowledge, attitude s and behaviors relating to household water management, sanitation and wastewater di sposal and the potential fo r its impact on household and environmental health outcomes including wa ter-borne and water-washed infectious diseases among families in the Monteverde Zone. The results of “The Household Manageme nt of Health, Water and Waste Project” helped, in part formulate the objectives and research hypotheses by identifying four topics for dissertation research: 1) that inte stinal parasite infec tions were a commonly reported health problem among participants of the RAP study; 2) that household hygiene and sanitation behaviors along with graywate r pollution are likely s ources of water-borne, water-washed, and parasitic diseases; 3) that significant differences in health outcomes may exist among Costa Rican residents and Nicaraguan immigrants; and 4) that the community of Santa Elena provided the best fi eld site to study the relationships between these variables. It was decided that based on the resu lts of “The Household Management of Health, Water and Waste Project” that th is dissertation focus on a common community health problem in order to determine whethe r disparities in health outcomes differed significantly between Nicaraguan immigrants and Costa Rican re sidents. Specifically, the use of prevalence rates of intestinal parasi tes as a comparative health outcome between Nicaraguans and Costa Ricans was the result of conversations with members of my dissertation committee; my laboratory training in dia gnostic parasitology; and a Monteverde Clinic report (ASI S 2002) citing that parasitic infections, together with diarrhea and gastrointestinal problems account fo r 6% of all medical consultations at the Monteverde Clinic (second only to consultations relating to acut e respiratory infections). In addition, key informant interviews w ith physicians at the Monteverde Clinic during data collection for the “The Househol d Management of Health, Water and Waste Project” in February, 2003 revealed that wh ile parasites are not considered a severe public health threat, it is likely that parasi tic infections are considerably underreported. Furthermore no comprehensive study or invent ory of intestinal pa rasitic species, their prevalence, epidemiology, or etiology had b een carried out in th e Monteverde Zone.

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9 Finally, it is widely accepted among public health scholars and researchers that parasites are good indicators of basic health, in that their pr esence are closely associated with conditions of poverty, including poor sani tation and hygiene, a lack of wastewater treatment, low levels of edu cation, a lack of health care a ccess, and economic and social alienation (Esrey 1991; Inhorn and Brown 1997; Levine 1995; Mayer 2000; Vecchiato 1997). It was within this scholar ly context that the dissertation research topic was created to gather data to compare intestinal pa rasite prevalence rates between Nicaraguan immigrants and Costa Rican residents within the context of ecotourism development and immigration in the Monteverde Zone. Political Ecology as a Framework for Unde rstanding the Prevalence of Intestinal Parasites In order to understand th e why some populations suffe r disproportionately from intestinal parasites compared to other groups it is necessary to move beyond the traditional epidemiological paradigm of host, vector, and ecology in understanding disease etiology by including social and po litical-economic inquiries (Whiteford and Cortez-Lara 2005). In their book “ Globalization, Water and Health ” Linda and Scott Whiteford (2005) note that as a result of the complex in teractions between global processes and health, anthropol ogists must be able to make connections between global and local levels of analysis. This dissertation attempts to connect the complex interactions between disparities in para site prevalence and the political-economic processes of health policy, im migration and ecotourism at th e local and national levels by using a political ecology of health framework. As a theoretical and methodological mode l, political ecology has been used to explain the historical and political anteced ents of environmental degradation and its effects on human social or ganization (Stonich 1993; 1998). More recently however, political ecology has become a useful tool to better understand how political and environmental interactions affect human health; includ ing nutrition (DeWalt 2003); HIV/AIDS (Singer 2007); infectious di sease (Mayer 1996); and water resources management (Whiteford and Whiteford 2005). The political ecology of health framework

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10 was developed out of a synthesis between medical ecology and critical medical anthropology (Baer 1996a; Baer 1996b; L eatherman 1998; McElroy 2009). The growing interest in the ways in whic h political economic factors inte ract with environmental and biological agents within the c ontext of local and global reali ties that have an impact on health outcomes has been of growing inte rest to medical anth ropologists including (Brown 1996; DeWalt 1998; Goodman 1998; Guest 2005; McElroy 2009; Singer 2007; Stonich 1998; Whiteford and Hill 2005). However, perhaps the best attempt to use political ecology as a framework for better understanding infectious diseases with in a political-economic and environmental context comes from Mayer (1996; 2000) whos e approach is based in disease ecology. Mayer’s approach attempts to study infectious disease in terms of th e interaction between host, vector and agent within the context of human-environment intera ction; specifically, how culture, political-economy and biol ogy, including vector and pathogen ecology interact together in an evol ving and interactive system to produce a foci of disease. Mayer calls this approach the politi cal ecology of disease (Mayer 1996). Another focus of the political ecology of health framework that has implications for this dissertation is its emphasis on microlev el and macrolevel linkages that attempt to understand the interconnections between the pr oximate causes of disease and the social, political-economic, and environmental relations that are the ultimate causes of disease (Baer 2003; Goodman 1998; Mayer 2000; McElroy 2009; Whiteford and Hill 2005). As Goodman and Leatherman (1998) and Whitefo rd and Whiteford (2005) suggest, this dissertation “focuses upstream” to the larger “macro” level fact ors that influence parasite prevalence, not least because the results may provide new strategies to prevent disease transmission and provides anth ropologists and public health practitioners a framework with which to better understand health outcomes. Another component of the political ecology of health framework used in this dissertation is the addition of the househol d ecology of disease transmission framework proposed by Coreil, Whiteford, and Salazar (1996). This framework suggests that, in terms of intestinal parasites, household ecology provides a link between both macro and micro level phenomena by means of defining household ecology as an intermediate

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11 pathway of disease between larger political economic factors and the proximate determinants of disease including the actual exposure to intestinal parasites. In light of a political ecology of health framework, this dissertation contextualizes how political economic processes are linked to disparities in health outcomes between Nicaraguan immigrants and Costa Rican resi dents. Specifically, it look at how microlevel or proximate causes of intestinal parasi tes (characterized by f ecal-oral transmission) at the household level can be ultimately linked to and contextualized within the political economic processes of immigration, immigr ation status, underemployment, access to credit, home ownership, living conditions, and access to critical health and social services. Research Objectives and Methods The overall objective of this research is to use the prevalence of intestinal parasites as a basic health indicator to compare health outcomes between Nicaraguan immigrants and Costa Rican residents in Monteverde within the context of politicaleconomic, social, and ecological processes. As a result of previous research and the scholarly literature, the research objectives that form the basis for this dissertation research are: (O-1) Determine the period prevalence of intestinal parasites among the study population (O-2) Determine the distribution and the most likely sources of infection and modes of transmission of intes tinal parasites among the study population (O-3) Describe the factors associated to the prevalence of in testinal parasites among study participants at th e individual and household level. (O-4) Provide a general po litical ecological framewor k that explains the prevalence of intestinal parasi tes among the study population in Monteverde, Costa Rica. As noted by Whiteford and Whiteford (2005) and Inhorn and Brown (1997), the complexity of the issues relating to the inte ractions between globali zation and health call for a diversity of methodological strategies. In order to addr ess these research objectives,

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12 this dissertation employs a mixed methods appr oach that includes bot h public health and anthropological methods. Public health met hods include the following: 1) the collection of fecal samples from both Costa Ri can and Nicaraguan study populations; 2) microscopic diagnostic techniques are used to analyze participant fecal samples in order to evaluate the source of infection and mode of transmission of endemic parasites. Anthropological methods include part icipant observation, semi-structured, indepth, and key informant interviews to better understand the cultural, behavioral, and the political-economic context of parasitic infections. In addi tion, both laboratory analysis and ethnographic methods are used to evalua te the source of infection and mode of transmission of intestinal parasites with the ultimate goal of providing research participants with relevant health educa tion regarding the prev ention of intestinal parasites. Secondary data from the Monteverde Clinic and the Santa Elena Aqueduct are also collected and analyzed for this res earch. Specifically, data regarding rates of intestinal parasites from the Monteverde C linic are gathered and compared with the prevalence rates from this study. Finally, publical ly available data regarding water quality testing of the Monteverde potable water supply is collected from the Santa Elena Aqueduct in order to help determine whether or not water quality plays an important role in parasite transmission. Research Findings Based on epidemiological data gathered fr om this research, intestinal parasite infections were significan tly underreported by the Montever de Clinic when compared with prevalence rates of intestinal parasite s gathered by this research during the same time period. Underreporting parasites has serious implications for the implementation of local public health campaigns aimed at redu cing parasite transmission. However, perhaps the most significant finding of this re search was that among the study population, Nicaraguans were five times as likely to have intestinal parasite infections compared to Costa Ricans; constituting a si gnificant health disparity. Th is finding contradicts the 1996 National Survey of Intestinal Parasites (M ata 1998), which concl uded that parasite

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13 prevalence in Costa Rica is below 3% for th e population. As such, the results of this research make a contribution to the growing body of Costa Rican public health literature that indicates parasite prev alence rates remain high among marginalized populations in Costa Rica; including indige nous groups (Hernandez-Chavarri a 2005), school children in Limon Province (Abrahams-Sand 2005), and residents living in urban slums in San Jose, Costa Rica (Hernndez 1998). In terms of the principal sources of in fection and mode of transmission, the data indicate that intestinal prot ozoa accounted for 87% of all parasitic infections among the study population; whereas infections with inte stinal helminths accounted for only 13% of infections. This evidence st rongly suggests that solid wast e and wastewater management do not play a significant role in parasite transmission. In ad dition, the low prevalence of common water-borne intestinal protozoa and the high water qu ality standards of the Santa Elena Aqueduct indicate that th e potable water supply does not play a significant role in transmission. The data also show a relatively high prevalence of the pathogenic amoebae E. histolytica and similar commensal intestinal prot ozoa and that individuals living in household with infected family members are at greater risk of being infected with similar parasites. These results are important b ecause they indicate that among the study population, intestinal parasites are not spread via water-borne tran smission, but rather through fecal-oral transmission at the household level; most likely the result of a range of poor hygiene behaviors and poor household sanitation infrastr ucture. These findings are also important because it establishes an a ssociation between Nicaraguan households that are more likely to have poor household sanita tion infrastructure, and higher parasite prevalence rates compared to Costa Ricans. Additional findings suggest that household environmental conditions, namely unsanitary bathroom and kitchen conditions we re significantly associ ated with parasitic infections among individuals regardless of nationality. Da ta from household surveys show that Nicaraguans were significantly more likely to live in poor household conditions compared to Costa Ricans. Intervie ws with heads of household revealed that ecotourism development was a significant f actor in limiting affordable housing options for Nicaraguan immigrants. For example, Ni caraguans who immigrated to Monteverde

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14 looking for work often find themselves underemployed. Both underemployment and immigration status precludes most Nicaragua n household from access to credit or from receiving housing subsidies. Without cred it or government support, many Nicaraguan families have no other choice but to rent s ubstandard housing with inadequate sanitation infrastructure. These factors, coupled with th e fact that Nicaraguan households tend to be larger, and thus more crowded, than Costa Rican households provides both the social, behavioral and environmental conditions that promote the transmission of intestinal parasites at the household level. Another important finding of this resear ch was that regardless of nationality, individuals with no health in surance coverage were more likely to be infected with intestinal parasite compared to individuals with health insurance coverage. Reasons for not having access to health care varied fr om underemployment to immigration status. However, the fact that Nicaraguans had signifi cantly higher prevalence rates of intestinal parasites can be partially explai ned by the fact that they were almost 5 times as likely to not have access to health care compared to Costa Ricans. According to interviews with heads of households, a lack of access to health care create s barriers to testing and treatment of intestinal parasites. These fi nding are important on two levels; first because they support the literature suggesting that access to health care is a associated with health disparities (Singer 2007); and second that Costa Rican health policy which excludes illegal immigrants from access to basic health care may play a role in the emergence of intestinal parasites and other preventa ble infectious diseases among immigrant populations, and thus inadvertently put th e host population at risk (Knobler 2006; Ministerio de Salud de Costa Rica 2002). In summary, the results of this research support the literature in defining parasitic infections as a “disease of poverty” in that the factors associated with parasitoses correlate with underdevelopment and social injustice (Inhorn and Brown 1997; Knobler 2006; Kreier 2002; Mata 1998; Vecchiato 1997). In addition, the medical anthropology literature related to infectious disease, incl uding intestinal parasites tend to stress the importance of culturally determined beliefs, knowledge and behavior s as integral to increased disease transmission (Green 1999; Inhorn and Brown 1997; Nichter 2008).

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15 However, the data from this research demons trate a departure from the literature in that research participants exhibited an extremel y high level of knowledge about parasites, including their prevention and treatment. This finding is significant because it suggests that political ecological factor s best explain the intensity a nd prevalence of intestinal parasites among the study population than do culturally determined beliefs and knowledge. Importance of the Study This dissertation research is important on a number of levels. First, this research helps to fill a critical gap in the Costa Rican public health literature by comparing rates of infectious disease between Nicaraguan im migrants and Costa Rican residents and demonstrating that intestinal parasites ra tes continue to be high among marginalized populations in Costa Rica. As a result, the re search helps shed light on one of the most controversial issues facing Costa Rican soci ety; the medical and financial impact of Nicaraguan migrants on Costa Rica’s national he alth care system. Based on this research, this dissertation suggests policy level reco mmendations that focus on reducing health disparities by bringing Nicaraguan migrants into the health care system rather than continuing their exclusion. At the local level, this dissertation provi des a glimpse into the health and social situation of the Nicaraguan community in Mo nteverde, providing invaluable information to local primary health care providers. On an individual level, th e research provided a viable option for many Montever de residents, both Nicarag uan and Costa Rican to get tested for intestinal parasites in addition to providing them with relevant health education that was specifically tailored to their level of health literacy. This dissertation also contri butes to the li terature of the anthropology of infectious disease; thus answering a call by Inhorn and Brown (1997) to study infectious diseases as they are manifest in different ecological cultural and political-economic settings. Specifically, this dissertation exemplifies th e relevance of using a political ecology of health framework to help cont extualize how the proximate caus es of parasitic disease are linked to global phenomena related to ecot ourism development in Monteverde, Costa

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16 Rica. Thus, this dissertation demonstrates how the political ecology of health framework can become an invaluable theoretical and methodological perspective in the applied medical anthropology tool kit in its potential to go beyond the proxima te associations of disease transmission by suggesting health in terventions based on m acro level phenomena.

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17 Chapter Two – Review of the Literature Globalization has been extensively studied during recent decades by scholars in the fields of political science, internat ional relations, and economics. However, Lee (2000a) contends that it has only been since the mid-1990s that hea lth researchers and policy makers have begun to explore the extent to which globalizati on effects health. This sudden interest has been due, in part, to a sh ift from an internati onal to a global public health agenda spearheaded by the World Health Organization and other UN related groups (Walt 1998). As a result, the globali zation and health lit erature has grown extensively over the past decade and covers di verse issues such as global health policy (Lee 1998; 2000a; Whiteford and Manderson 200 0); international and global health (Banta 2001; Howson 1998); th e globalization of public health (Yach 1998a; 1998b); health and global trade (Baris 2000); technol ogy and health care de livery (Chandrasekhar 2001); health equity and inequalities (Far mer 1999; Farmer 2004; Navarro 1999); global health law (Fidler 1998); environmental ch ange and health (Guest 2005; McMichael 1999; 2004); chronic diseases (Beaglehole 2003; Lang 1999); the globalization of water resources and health (Whiteford and Whitefo rd (2005); the effects of global warming on health (Baer 2009); and emerging and reemer ging infectious diseases (Knobler 2006; Kombe 2001; Morse 1995). In short, the health field has been globalized. Globalization and Health As in other bodies of literature, health scholars differ in the ways they define the relationship between globaliza tion and health. Specifically, ma ny health scholars seem to define globalization in economic terms. David Dollar, a health scholar at the World Bank, defines globalization in terms of “increas ed integration of different economies and societies as a result of greater flows of goods, capital, people, and ideas” (2001:827). Similarly, Feachem defines globalization as “openne ss to trade, to ideas, to investment, to people, and to culture” (2001:504). The tendenc y of contextualizing globalization and

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18 health in economic terms can, as Cornia (2001) notes, be attributed to the fact that many health researchers tend to view health as an independent variable of economic growth, income distribution, and economic stability (2001). On the other hand, Waters (2001) provi des a more holistic view, saying that “globalization refers to the forging of new global economic, financial, social, cultural, and political links by which societies and na tions have been brought into increasingly closer contact and interaction” (2001:80). Other disc ussions have lead to a debate as to whether globalization has “good” or “bad” e ffects on human health (Cornia 2001; Dollar 2001; Feachem 2001; Waters 2001). However, Lee (2000a; 2000b) aptly notes that globalization affects groups and individuals in different ways and contends that one of the principal challenges is to better unders tanding how processes of globalization are affecting people and groups differently and how these inequalities can be ameliorated. Anthropologists, most notably (Cle veland 2000; Hackenberg 1999; Kearney 1995; Lewellen 2002; Mintz 1998; Tsing 2000) have also been interested in globalization. For the most part, these aut hors tend to view gl obalization within a theoretical-historical framework related to classic development studies including Wallerstien’s world systems theory (1974), and Eric Wolf’s “Europe and the People without History” (Wolf 1982). However, anthropologists like Hackenberg and Hackenberg (2004), and Cleveland (2000) ha ve encouraged an applied, practical understanding of globalization in order to focus on how it affects people at the local level. This applied approach is based on Giddens’ vi ew that globalization is the “intensification of worldwide social relations which link di stant localities in such a way that local happenings are shaped by events occurring many miles away and vice versa” (Giddens 1990:7). McElroy and Townsend contend that a pplied anthropologists are especially interested in how the “global” and “local” levels of analysis are affected by and interact with each other and how they come to imp act people’s lives (McElroy 2009). This is especially true of medical anthropologists who are specifi cally interested in how the processes of globalization have local level implication in terms of political-economic, cultural and environmental change, which in tu rn, can affect human health. This interest

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19 is expressed in the growing medical anth ropology literature including Whiteford and Manderson (2000), Whiteford and Whiteford (2005), Goodman and Leatherman (1998), Guest (2005), Baer and Singer (2003; 2009), and McElroy and Townsend (2009). While health scholars and medical an thropologists are in terested in better understanding and analyzing how the processe s of globalization are affecting health, perhaps the best attempt to create a working framework for conceptualizing the relationship between globaliza tion and health comes from Lee (2000a; 2000b). First, Lee identifies three key features of globalizati on that distinguish it from other similar phenomena: 1) that globalization should be understood as a process rather than an object or outcome. In this respect, Lee contends th at the processes of globalization are changing the nature of human interac tion by eroding boundaries of time and space that separate individuals and societies; empha sizing that these processes ar e not new, but in fact are part of a much longer historical process; 2) that globalization is a social rather than natural process; that it is actually driven by individua l and collective actions and therefore can ultimately be guided and cont rolled; and 3) that globalization impacts individuals and groups differently; there are both winners and losers. Lee further contends that one of the principal challe nges is better understanding how processes of globalization is affecting people and groups di fferently and how these inequalities can be ameliorated (Lee 2000a; 2000b). From this di scussion Lee defines globalization as “a process which is changing the nature of huma n interaction across a wide range of spheres including the economic, political, social, technological and environmental” (Lee 2000a:19). In terms of the spheres of globalization, Lee (2000b) explains that the economic sphere concerns the creation of a global ec onomy, characterized by greater trade in goods and increased labor mobility. The political sphe re concerns the distribution of power and emerging forms of political representation and authority. The social sphere relates to what some scholars call “global community”, that is, the proliferation of cultural values, beliefs and ideas through channels of mass media. The technological sphere can be understood as the development and applica tion of knowledge in industry, commerce, science and art. Finally the environmental s phere concerns how local environments are

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20 affected by the global. For instance, how ec onomic, social, and tec hnological spheres can positively or adversely affect our physical environment (i.e., climate change and the global environmental movement) (Lee 2000b). W ith this basic definition and framework of globalization in place it is possible to expl ore how the processes of globalization can have a potential affect on the determinants of health and, in turn, on crucial areas of public health. Health researchers and anthropologists have published widely concerning the impact that the processes of globalization have on different health outcomes. For example, a lot of attention has been given to the way gl obalization affects noncommunicable diseases such as cancer, diabet es and cardiovascular disease. Beaglehole (2003), Bettcher (2000) and Lang (1999) have focused on the impact of diets high in saturated fat, sugars and low in complex ca rbohydrates in addition to reduced physical activity which are associated w ith an increased rates of obe sity; a know risk factor for chronic heart disease and diabetes. Simila rly, David Himmergreen et al. (2006) has studied the effects of ecotourism developm ent on food security and nutrition in rural Costa Rica, while Daltabuit and Leatherman (1998) studied the effects of tourism on nutrition among the Maya in Mexico. Finally, Yach (1999) has focused on the effects of the global marketing of tobacco and alc ohol, while Loewenson (2001) has focused on environmental carcinogens in rela tion to cardiovascular disease. While the implications regarding the effects of globalization on noncommunicable diseases are far reaching a nd complex, this dissertation will focus attention on the impact that globalization has on infectious diseases with particular attention given to intestinal parasites. Globalization and Infectious Diseases As discussed earlier, glob alization affects the proce sses of human interaction across political, economic, social, technologica l, and environmental spheres thus making it an important determinant of infectious disease outcomes. Health researchers have become increasingly interested in the direct and indirect links betw een globalization and infectious disease (Barrett 1998; Cash 2000; CDC 2002; Davis 2001; Knobler 2006;

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21 Kombe 2001; McMichael 2001; Saker 2004). Of pa rticular concern is that globalization is impacting the epidemiology and specific risk factors associated with many infectious diseases in addition to our cap acity to prevent, control, a nd treat those diseases (Saker 2004). The World Health Organization (2004) reports that while morbidity from noncommunicable diseases is high, infectious dise ases still account for a large proportion of mortality worldwide. For example, infectious diseases remain the most important cause of ill health in developing regions (W HO 2004). Not surprisingly, they have a considerable higher burden on low-income count ries compared to high-income countries (Gwatkin 1999). David Satcher (1995), former director of the CDC, comments that in addition to their human burden, infectious di seases deplete scarce economic and social resources, impede development, and c ontribute to global instability (1995). Based on Lee’s (2000b) definition, globali zation is driven and constrained by a number of factors including pol itical-economic processes, so cial and cultural factors, technological developments, and environmenta l changes. According to Woodward et al. (2001), these spheres of globalizat ion have both direct and indi rect impacts on health at a number of different levels. For example, Saker (2004) explains that globalization can affect health status through economic change s that are reflected in living conditions and government expenditure on sanitation infrastr ucture and access to health care. Mayer (2006) adds that environmental changes affect vector ecologies through deforestation, the construction of dams, and rapid urbanization. In turn, these factors can promote the mass migration of people from one region to anot her and provide an oppor tunity for pathogens to come into contact with new populations (Mayer 2006; Saker 2004). In general, experts contend that there ar e five major aspects of globalization that both directly and indirectly affect inf ectious diseases: economic, demographic, technological, political economic and envir onmental change (Guest 2005; Knobler 2006; Saker 2004). However, Saker et al. (2004) cau tions that this ca tegorization of the processes of globalization and their affect on health is ove r simplistic; when in fact globalization is a complex set of interrelated processes. For exampl e, the links between environmental change, immigration and infectio us disease have ante cedents in, and must be understood within a political economic context. With this in mind, Sacker et al. (2005)

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22 point out that is it useful to consider each sphere or aspe ct of globalization in terms of risk factors, epidemiology and disease transmission. Knobler et al. (2006) and Sacker (2005) broadly refer to economic globalization as the increasing linkages of the world’s financ ial system resulting in the restructuring of a new world economy. This new world economy is characterized by neoliberal free trade agreements and the accessibi lity of capitol through centr alized lending banks including the IMF (International Monetary Fund) and th e World Bank. While it is outside the scope of this dissertation to discuss the imp lications of economic globalization on human health, suffice it to say that it has far r eaching implication on th e other aspects of globalization including demographics, enviro nmental change, and politics. For example, Guest (2005) notes the linkages between ec onomic globalization and political economy stating that the loss of governmental power to multinational corporations, who often ignore labor and environmental laws, pose seri ous implications for human health. For an in-depth discussion on how economic policie s including those of various free trade agreements, the IMF and the World Bank see the book “Dying for Growth: Global Inequality and the Health of th e Poor” by Yong Kim et al. (2000). Of critical importance to the epidemiology of infectious diseases is the environment, precisely because it acts as re gulator of interactions between humans and pathogens. The environment in this case not on ly refers to the natural environment, but also to built and social environments. The implications of envir onmental change on the epidemiology of infectious diseases are dive rse and far reaching. Morse (1995), notes that ecological changes related to economic deve lopment, global warming, changes in land use, and changes in water resources manage ment contribute to the emergence and reemergence of infectious diseases. For exampl e, climate change is likely to expand the geographical distributio n of several vector borne diseas es including malaria, dengue, and leishmaniasis (Satcher 1995), while dam c onstruction and irriga tion projects have increased the prevalence of schistosomiasi s (Strickland 1982). Fina lly, McMichael (2001; 2004) suggests that the worldwide incidence of diarrhea may increase with global warming.

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23 Changes in global environmental conditions can derive from natural disasters that in turn can create health emergencies due to a sudden lack of clean water, sanitation and basic health services. For example, Whitefo rd and Tobin (2004) studied the increased incidence of acute respiratory infections due to ash fallout of recently activated volcanoes in Ecuador. While these natural disaster s are generally dealt with by national governments, they can prompt the mass migra tions of people into neighboring countries leading to increased environmental damage a nd in turn serious h ealth risks such as cholera and dysentery. Such was the case af ter hurricane Mitch where thousands of Nicaraguan migrants sought relief in Costa Rica (Ministerio de Salud de Costa Rica 2002) For an in-depth discussion on the im plications of envir onmental change on the epidemiology of infectious dis eases see Sacker et al. (2004). One of the most conspicuous manifest ations of globalizat ion with specific implications for infectious di seases and this dissertation is population mobility. While humans have always been on the move, mi gration over the past 50 years has been unprecedented in terms of the volume, speed, and geographical range of travel. It was estimated that in 2000, some 185 million people were living outside of the country of their birth. While the causes and reasons of migration are complex, people most often move in search of a better life and employmen t opportunities, or to escape an insecure situation (UNFPA 2003). Knobler et al. (2006) st ates that migrant populations are among the most vulnerable to emerging and re-emerging infectio us disease and are often implicated as a key factor in the spread of infectious diseases around the globe. Indeed, migrant health remains one of the major unresolved public health issues worldwide. According to Knobler et al. (2006) migrant population are more vulnerable to infectious diseases for several reasons: first, because they often lack access to health care and social services in the receiving countries; second, migrant populations are more subject to social instability, poverty, discrimination, and lack legal protections; and third, be havioral changes can also place migrants at higher risk of infectious diseases. In addition, immigration brings people into contact w ith new microbes and vectors whic h can increase the risk of spreading infectious to both migrant and host populations (Knobl er 2006; Saker 2004).

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24 Intestinal Parasites Apart from economic, social, demographic and environmental change, the extent to which the processes of globalization affect the epidemiology of infectious diseases also depends on the specific characteristics of th e disease pathogen. A variety of pathogens cause human infection including viruses, bacter ia, and parasites. This dissertation focuses on one group of pathogens known as intestinal parasites. The following is a discussion that provides the reader with a basic understa nding of intestinal parasites and how their transmission is influenced by processes of globalization. Key Concepts and Definitions In the field of parasito logy, the term symbiosis refe rs to the relationship or association (primarily for acquiring food) be tween two animals of a different species. One form of symbiosis is called parasitism in which one animal, the host, is injured as a result of the activities of the other animal (the parasite). Another form of symbiosis is called commensalism, meaning a relationship th at is beneficial for one species and at least not harmful for the other species (M arkell 1999). In this dissertation, such organisms are referred to as commensals In addition, this dissertat ion only deals with the intestinal parasites and commensals of hu mans, of which two phyl a are considered: the helminths and the protozoa. The helminths or “worms” are a diverse group of multicellular parasitic animals. Th ere are four phyla of helminths, but only two of these are considered to be important parasites of humans; the Platyhelminthes known as flatworms; and Nematoda known as round worms (Price 199 4). In this dissertation, the word helminth or intestinal helminth will be used to describe species of either phylum; whereas individual species will be called by their Genus species name (i.e., Taenia solium – Common Tapeworm). Intestinal protozoa are unicellular an imals that commonly parasitize humans. The protozoa are represented in four groups: intestinal amoebae, intestinal ciliates, intestinal flagellates, and intestinal coccidia (Price 1994) Based on the results of this dissertation, only two of these groups were present; parasi tic and commensal species of intestinal

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25 amoebae and intestinal flagellates. In this dissertation, the word “intestinal protozoa” will be used to generally describe species of e ither group; whereas indi vidual species will be called by their Genus species name (i.e., Entamoeba histolytica – Intestinal amoebae). Sources of Infection and Modes of Transmission: One of the obvious requirements of parasi tism is the continuation of the parasites life-cycle which includes effectively exiting one host and entering a susceptible host. To do this, the parasite must produ ce an infective stage that must eventually find its way into a different susceptible host and cause infection. For example, the amoeba Entamoeba histolytica produces an infective cyst that is passed in human feces, which, when inadvertently ingested by another suscep tible host can produce an infection. Thus, opportunities for contact between parasite and susceptible host and s ubsequent infection are necessary for the successful continuation of the parasite’s life-c ycle. Parasites have evolved both simple and extremely complex me chanisms in order to accomplish this goal (Price 1994; 2003). In most cases, parasites reach the host through the external environment via a variety of transmission systems. This proce ss can be understood in terms of the “source of infection” and the “mode of transmission” and must be understood within the context of the environment, human behavior and th e broad processes of globalization discussed earlier. The mode of transmission influences which factors have an effect on the spread of the parasite to its human host and are essential for understanding the underlying risk factors of parasitic infect ions and their effective c ontrol (Price 2003; Saker 2004). According to Dr. Donald L. Price (Price 1994; 2003), the source of infe ction refers to the medium (water, soil, food, utensils, etc.) or the host organism (vector, or intermediate host) on which or in which the infective st age of the parasite is found. The mode of transmission refers to the precise circumstan ces and means by which the infective stage is able to come in contact with, gain entry to, and initiate an infection within the host (Price 1994; 2003). In general, there are three types of sour ces of the infective stage of parasites, however, only the first two are relevant to in testinal parasites. First, “contaminated

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26 sources” are those where the infective stage of th e parasite is located. Usually this type of source is an inanimate object such as food, wate r, kitchen surfaces, or eating utensils that have come into contact with human feces car rying the infective st age of the parasite. Subsequently, if the infective stage of the parasite is immediately infective when passed in the feces it is called an immediatel y infective contaminated source (cysts of Entamoeba histolytica and Giardia lamblia are such examples). In some cases, the infective stage is not immediately infective wh en it is passed with the feces. For example, the eggs of the helminth Ascaris lumbricoides must develop to the infective stage outside the body of the host (usually in soil). This pr ocess can take anywhere from a couple days to several months depending on environmenta l conditions. This type of source is known as a “delayed infective contaminated source.” The second type of source is called an “i nfested source” and refers to those where the infective stage of the parasite is free liv ing and can actively move about; in this case, the infested source is usually water, vegeta tion or soil. For example, the eggs of the helminth Necator americanus (hookworm) that are passed in human feces are not the infective form of the parasite. Instead, the e ggs must hatch and develop into an infective third stage filariform juvenile which is the in fective stage of the parasite. These juveniles then move about in the soil or grass looking for a suitable host which they then penetrate through the skin, enter the body and continue thei r development. In this case, the soil or vegetation on which the infectiv e juveniles move about is cons idered an “infested source of infection” (Price 2003). According to Dr. Donald L. Price (Pri ce 2003) there are two ki nds of transmission mechanisms: “passive transmission” and “act ive transmission”. Passive transmission refers to the fact that neither the infective agent itself nor the host or vector on which the infective stage infection resi des plays an active role in transmission, and thus only the actions or behavior of the sus ceptible individual play a role in infection. Usually this is done when the susceptible individual inadvert ently ingests the infective stage of the parasite regardless of whether it resides on an inanimate object or within an intermediate host. Drinking water containing cysts of Giardia lamblia would be considered passive transmission of an immediately infective co ntaminated source. Another example involves

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27 eating food contaminated with cysts of Entamoeba histolytica which would also be considered passive transmission. Finall y, ingesting eggs of the helminth Ascaris lumbricoides that reside on food or soil would be considered passive transmission of a delayed infective contaminated source since the eggs are not immediately infected but must develop into the infective stage in the soil for a specific period of time (Levine 1995; Olsen 1967; Price 2003). The transmission of parasites like Giardia lamblia, Entamoeba histolytica, and Ascaris lumbricoides is often referred to as “fecaloral transmission” because the infective stage of the parasites are passed in human feces and must be ingested by another susceptible host. In addition, th e infective stage of these pa rasites can also make their way into human water supplies. Thus, a sus ceptible host can become infected by drinking water contaminated with the infective stage of the parasite; this form of transmission is often referred to as “wate r-born transmission”. Although fecal-oral transmission and water-borne transmission of intestinal parasi tes are essentially the same, the distinction becomes important in terms of control and prevention efforts. In contrast to passive tr ansmission, active transmission implies that the infective stage of the parasite actively pursues and enters the susceptible individual. The only example of active transmission in relation to intestinal parasites is that of several helminth species. For example, hookworm juve niles living in the so il actively seek out and penetrate a suitable host through the skin in order to establish infections. This is an example of active transmission of an infested source (Price 2003). The Natural Environment and the Distribution of Parasites: For several reasons, the distribution of parasites is highly sensitive to their environment. First, their abil ity to survive and multiply is heavily dependent on climatic conditions; second, the local environmental cond itions must also support the survival of both humans and in some cases a secondary host and or vector; third, the environment must support the means for the parasite to come into contact with the host. For example, parasites that require a special type of intermediate host such as a mollusk in the case of Schistosomiasis, or vectors such as the tset se fly in the case of African Trypanosomiasis

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28 are limited to the particular environmen tal and geographic distribution of that intermediate host or vector. In cont rast, intestinal parasites such as Entamoeba histolytica and some helminths that only require an infected and susceptible human host are ubiquitous where human overcrowding is pres ent, where clean potable water, human waste management, and basic sanitation is lack ing. As a result, intestinal parasites have the greatest geographical distri bution compared to other kind s of parasites (Price 1994; 2003; Saker 2004). In addition, understanding the source of infection, mode of transmission and the unique environmental factors associated with certain parasites also helps in understanding how infections can be contro lled and prevented. For example, eliminating sources of infection and interrupting the transmission of parasites to susceptible hosts will prevent the parasite from spreading. Also, treatmen t of an infected in dividual prevents the parasite from being spread to another person. In many cases, however, it is not the environmental conditions alone that determine an increased or decreased risk of transmission but rather a combination of environment, human ecology, and human behavior which together create risk factors for parasitic infections. Human Ecology and Behavior in the Transmission of Parasites: Apart from the source of infection an d mode of transmission, human ecology and human behavior are important risk factors in the transmission of intestinal parasites. According to Levine (1995), while sources of infection and m odes of transmission remain relatively finite, the processes by wh ich human ecology and behavior influences disease transmission are nearly infinite. Parasi tes, like other infecti ous agents do not just infect people randomly; rather, infection is usually the culmination of specific interactions of biology, human ecology, and be havior in time and space. While the etiology of most parasitic di seases are well understood, we ar e far from being able to understand and deal effectively with the im pact human behavior and ecology has on the transmission, incidence and spread of para sites (Levine 1995). The following are factors

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29 related to human ecology and behavior that incr ease the risk of transmission of parasites among human populations. Personal Hygiene and Waste Management: Personal hygiene and waste management is perhaps the most important factor contributing to the transmission of intestin al parasites. Touching or handling food or objects such as utensils, pl ates and doorknobs without pr oper hand washing and waste disposal can easily place a hous ehold at risk for any numb er of parasites that are transmitted in the feces. The practice of impr oper disposal of human excrement including open-air defecation and using human waste as a fertilizer also increases the risk of transmission (Byers 2001). In these cases, pa ssive transmission of a contaminated source is commonly observed in crowded living c onditions where there is a lack of hand washing, waste disposal, potable water, and general sanitation (Gir ges 1949; Price 1994; 2003). Some studies have pointed to the fact that water ins ecurity (not having sufficient water for domestic use on a regular basis) decreases the frequenc y with which people wash their hands and utensils; thus creating a situation of increased risk for fecal-oral transmission of intestinal parasites (Ennis-McMillan 2001). Water – Supply, Distribution & Management: For many parasites, water is an excelle nt source and vehicle of transmission. Parasites such as Giardia lamblia (Craun 1978) and Cryptosporidium parvum (Schmunis 2002) are primarily spread through water distri bution systems and have been implicated with large outbreaks. Infections with G. lamblia have been attributed to faulty purification or chlorination syst ems and untreated water. Anothe r concern is that the cysts of G. lamblia and the oocysts of Cryptosporidium parvum are said to be resistant to chlorine treatment creating the potential risk for all people in the distribution system (Byers 2001). The case of cryptosporidio sis that affected some 300,000 people in Milwaukee is an excellent example (Mayer 2000). Similarly, in places where leaks in water distribution pipes are common, the distribution system s itself can be a source of infection. It has been shown that main br eaks, sudden changes in demand, pump outages,

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30 or power failures create transient pressure events (excessive positive or negative pressure within the water pipe). Negative pressure tr ansients cause suction whereby leaks in the pipeline provide a potential portal of entry of contaminated groundwater into treated drinking water. This situati on is especially problematic where open defecation is common (LeChevallier 2003). According to Schmunis (2002) Cryptosporidium parvum is often transmitted by contact and subsequent ingestion with surface water run-off contaminated by feces of infective cattle (Schmunis 2002). Th is is a particular concern in Monteverde, Costa Rica where cattle freely roam the country side near water di stribution pipes and holding tanks. Travel, Migration, and Transportation: The globalization of the world econo my has made it possible for goods and people to transverse the world in a rema rkably short period of time creating an interdependency of virtually all regions of the world. People traveling from one area to another can introduce a disease to a particular region or become infected and return home to serve as a source of infection to ot hers (Knobler 2006; Saker 2004). Large scale migration from areas of high endemicity to areas of low endemicity can also spread parasitic diseases. Faust (1949) asserts that hookworm and schistosomiasis were introduced to the new world through the slave trade. Similarly, a Costa Rican Ministry of Health report cited that the incidence of ma laria increased among Costa Ricans living in a Northern Costa Rica shortly after the area had been inunda ted by Nicaraguan refugees coming from areas of high malaria endemicity after Hurricane Mitch in 1998 (Ministerio de Salud de Costa Rica 2002). Urbanization: Migration, as a result of economic ins ecurity, political instability, or violence from armed conflicts can result in rapid, and in many cases unplanned development of urban and peri-urban areas. In the developing world, local governments are often not able to deal with the influx of people in term s of basic services including health care, infrastructure, and employment. The resul ting poverty creates many risk factors for

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31 disease transmission including high population densities and crowding, lack of potable water and waste management, poor nutritional status, and low education levels. All of these factors have been demonstrated to increase disease transmission of intestinal parasites (Esrey 1991; Levine 1995). Human Culture and Behavior: For many reasons, human culture and behavior has important implications for the spread of infectious disease, including para sitic diseases, in terms of the interactions between infectious agents, their human or reservoir hosts and the environment. Indeed, the links between human behavior and the mode of transmission of in fectious agents has been well documented in the literature (Brown 1996; Dunn 1986; Geissler 1998; Inhorn and Brown 1997; Levine 1995; Vecchiato 1997). The influence that culturally coded patte rns of behavior have on the transmission of infectious disease is fa r reaching and, like culture, c onstantly changing. Arguably, understanding the cultural practices, beliefs, a nd values of humans in relation to disease transmission is as important as understa nding the specific biol ogical life-cycle and ecology of the parasite itself. Without a comprehensive knowledge of culture and its relation to disease transmission all other measur es to control parasitic disease, including vector control and sanitation programs will be of little value. Thus anthropology, with it wide disciplinary boundaries is in a place to provides critical contributions to better understand and prevent infec tious diseases of all ki nds (Inhorn and Brown 1997). Anthropology and Parasitic Diseases While anthropologists have been conducti ng research on infectious diseases, mostly as consultants or cultural brokers on international health teams for some time, it was not until the early 1980’s that the fiel d of anthropology of infectious disease was formalized (Brown 1981; Schwartz 1979). This group defined the anthropology of infectious disease as the broad area that deal s with the relationships among sociocultural, biological, and ecological va riables and the etiology, pr evalence and incidence of infectious disease. Furthermore, the group c onsidered the theoretica l and applied aspects

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32 of interdisciplinary issues of anthropologist s and health scientists in the fields of epidemiology, environmental health, and paras itology in addition to dealing with health planning, prevention and health education (Schwartz 1979). Inhorn and Brown (1997) identify three principal domains of anthropological research in infectious disease; biological approaches, ecological approaches, and sociocultural approaches. Biol ogical approaches to infec tious diseases include both micro-evolutionary and macro-evolutionary studies. The former focuses on human adaptive or genetic factors th at may confer resistance or immunity to infection; the condition known as sickle-cell tr ait and its role in conferring resistance to Malaria is one example. The latter focuses on understandi ng epidemiological disease patterns in prehistoric and historic human populati ons; the impact of disease on indigenous populations through colonizati on is one example of this kind of research (1997). Ecological approaches, according to Inhorn and Brown (1997) focus on the interaction between pathogen and host in a gi ven environmental context. Classic disease ecology developed by May (1958) considered bo th the physical and sociocultural aspects of the environment which, together with disease pathogens, human hosts and the cultural/behavioral aspects of the host intera ct to form a loci of disease. A classic example of disease ecology was the spread of schistosomiasis around the Nile delta region after the building of the Aswan dam which seriously altered water resource ecology (Heyneman 1984). Finally, the sociocultural a pproach to infectious dis ease focuses on the importance of understanding culturally based behavioral practices and perceptions and their affect on the transmission of disease pathogens (I nhorn and Brown 1997). The early work of Alland (1969) and Dunn (1979) examined and cla ssified health behavior in terms of their effect on the transmission of infectious dis ease agents. Ethnomedical studies of infectious diseases went beyond that of traditional so cio-behavioral studie s to ask why people behave the way they do, since any effort to change behavior must be based on such knowledge. Some examples of ethnomedical resear ch related to this di ssertation relates to the work done on folk beliefs related to the diagnosis, preventi on, and health seeking behavior of diarrheal illn esses (Kendall 1988; Nations and Rebhun 1988; Scrimshaw and

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33 Hurtado 1988). For a comprehensive review of the literature rela ting to anthropology and infectious diseases see Inhorn and Brown (1997) and Br own et al. (1996). Relevant to this dissertation, it is impo rtant to note that wh ile anthropologists have conducted research on the vast majority of infectious dis ease, relatively few anthropologists have specifical ly studied intestinal parasites. Some examples include Moffat (2003) who studied the effects of intestin al parasite infections on child growth in Nepal. In terms of ecological approaches Alland (1969), Brown ( 1987; 1996), and Levine (1995) have discussed intestinal parasites, especially helminth infections, within a disease ecology perspective. Much mo re common have been sociocultural or ethnomedical studies of intestinal parasites; again, the major ity of which deal with intestinal helminths. For example, Dunn’s (1979) clas sic article identifies behavior al categories that impact the mode of transmission and their relevance for disease prevention along with providing methodological suggestions for studying human behavior. Other re searchers Geissler 1998; Green 1999; Vecchiato 1997) have conducted on ethno medical studies on the perceptions and beliefs of inte stinal worms in different cult ural contexts. Finally, Logan and colleagues conducted an intestinal para site prevalence study to determine how well participants implemented health educati on messaged designed to prevent cholera (Faulkner 2003). While the an thropological contributions to the study of intestinal parasites has been minimal compared to that of other infectious dis ease, the contributions of anthropological research on disease control and preven tion have been significant (Manderson 1998). Political Ecology as a Framework for Understanding Infectious Diseases Understanding the links and interrelations betw een political-economic, social, and environmental variables that affect human h ealth demands the ability to contextualize these variables among local, regional, national, and international levels This agenda also necessitates using a multidisciplinary appro ach which includes the social, health and natural sciences. Subseque ntly, a theoretical and me thodological framework that addresses these concerns must be employed, specifically, one that looks at social, political, environmental, and health phenomena within variou s levels of analysis. With

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34 this objective, this dissertation employs political ecology as a theoretical and methodological framework. While political ecology has its roots in anthropology and geography, political ecology has mainly been employed within geography to provide an explanatory model of land and environmental degradation within a social and political context (Blaikie 1988; Stonich 1993). Recently however, political ecology has emerged as a useful tool to better understand the political-economic context of environmental changes and subsequent health im plications (Turshen 1977; 1984). As a theoretical framewor k, political ecology is an in tegrative approach that intersects a variety of academ ic disciplines. However, two pr incipal theoretical paradigms have most influenced the development of political ecology. These include political economy and cultural ecology. Political econom y focuses on the link between power and production and human/cultural ecology, with its broader focus on bio-environmental relationships (Greenberg 1994). As further explained by Stonich (1993), the political economic model seeks to understand and expl ain the roles that social and political institutions (at local, regional, national and international levels) play in creating limitations and/or opportunities that influence human agency, which in turn affect those same institutions as well as the natural environment and human health. Similarly, cultural ecology takes into account several factors su ch as human demographics, environmental concerns, as well as health a nd nutrition, all factors which aff ect both social and political institutions (Stonich 1993). According to Bryant (1998), the political ecology approach developed out of the perceived lack of political analysis and cont ext in environmental research (Bryant 1993; Peet 1996) as well as the fact that political economy gave scant attention to ecological factors that influence social and political organization (B ryant 1992). The integration of ecology and environmental concerns with poli tical economy has been utilized in several studies to provide an explanatory model of how social, economic, and political processes affect the way in which na tural resources are used a nd distributed (Schmink 1987; Sheridan 1988; Stonich 1993), while others have used the model to explain and understand environmental destruction in th e third world (Blaik ie 1987; Little 1987; Redclift 1984).

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35 The eminent anthropologist Eric Wolf has been credited with coining the term “political ecology” based on a critique of ecological anthropology; citing that local ecological contexts needed to be elucidated within a wider political economy (Wolf 1972). However, Wolf never elaborated on usin g political ecology with in a theoretical or methodological framework. Instead, researchers in geography have been credited with developing a theoretical and methodologica l model based in political ecology to understand the political and social reasons for environmental destruction and land degradation. Most notably, Blaikie (1985; 1988) and Blaiki e and Brookfield (1987) have been credited for developing political ecol ogy as a theory and me thod for studying land degradation. Of interest of this dissert ation is how the processes of globalization affect rates of parasitic infections within a context of ecotourism devel opment and immigration. While little research has been done on the effects of tourism development on infectious disease and immigration, several studies have used political ecology to examine the environmental and health consequences of t ourism within the context of water resources management, most notable from Stonich (1998) ; Stonich et al. (1998) and Hunter (1995). In addition, numerous studies have been conducted showing that tourism development has affected local water quality due to impr oper disposal of human waste (Archer 1985; Hunter 1995; Kocasoy 1989; 1995). Tourism has al so been cited as a major consumer of scarce water resources and in many places th e tourism industry and the local community compete for water resources and water access (Miller 1991). However, these studies stop short of liking issues of wate r resources management and rates of infectious disease. The Political Ecology of Health As expressed by Mayer (1996), political ecology has seldom been used as framework to understand patterns of health a nd disease. However, since political ecology focuses on political interests, social institutions, and human-environment interaction this approach has great potential l eading to a greater systematic understanding of health and disease.

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36 While medical anthropology has been instrumental in developing an ecological/evolutionary approach to health on one side, and a political -economy of health approach on the other, rarely have these concepts been synthesized to encompass a theoretical and methodological framework. However, the term political ecology has been used to suggest a revision of the ecological /evolutionary approach that incorporates political-economic forces and social relations into the an alysis of health (Baer 1996a; Baer 1996b; McElroy 2009a). Recently, political ecology has become a useful tool to better understand how political and environmen tal interactions a ffect human health; including nutrition (D eWalt 2003); HIV/AIDS (Singer 2007); infectious disease (Mayer 1996); and water resources management (Whiteford and Whiteford 2005). The political ecology of health was deve loped out of a synthesis between medical ecology and critical medical anthropology (Baer 1996a; Baer 1996b; Leatherman 1998; McElroy 2009). Baer (1996a; 1996b ) states that the synthe sis developed out of the realization that medical ecol ogy tends to downplay the poli tical-economic factors that affect health and that critical medical anthr opology has paid little attention to ecological factors that affect human health (1996a; 1996b). This idea was first championed by Turshen (1977; 1984) who cri tiqued the ecology of disease framework (which used the classic epidemiological triad of host, pat hogen, and environment) as being inadequate because it failed to consider the political-economic factor s which she considered the ultimate causes of disease. As such, the growing interest in the ways in which political economic factors interact with environmental and biological agents w ithin the context of local and global realities that have an imp act on health outcomes has been of growing interest to medical anth ropologists including (Brown 1996; DeWalt 1998; Goodman 1998; Guest 2005; McElroy 2009; Singer 2007; Stonich 1998; Whiteford and CortezLara 2005). Influenced by Turshen’s work, probably the best attempt to develop a framework of analysis using a political ecology of health model has come out of medical geography (Gatrell 2002; Mayer 1996; 2000; Meade 1988). This approach is based in disease ecology, which attempts to study disease in the context of human-environment interaction. This approach pr imarily concerns itself with “understanding how humans,

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37 including culture, society and behavior ; the physical world, including topography, vegetation, and climate; and biology, includ ing vector and pat hogen ecology, interact together in an evolving and interactive syst em, to produce foci of disease” (Mayer 1996). Political Ecology as a Framework fo r Studying Intestinal Parasites In order to understand why some popul ations suffer disproportionately from intestinal parasites compared to other groups it is necessary to move beyond the traditional epidemiological paradigm of host, vector, and ecology in understanding disease etiology by including social and po litical-economic inquiries (Whiteford and Cortez-Lara (2005). In their book “ Globalization, Water and Health ” Linda and Scott Whiteford (2005) note that as a result of the complex in teractions between global processes and health, anthropol ogists must be able to make connections between global and local levels of analysis. This dissertation attempts to connect the complex interactions between disparities in para site prevalence and the political-economic processes of health policy, im migration and ecotourism at th e local and national levels by using a political ecology of health framework. Perhaps the best attempt to use poli tical ecology as a framework for better understanding infectious diseas es within a political-economic and environmental context comes from Mayer (1996; 2000) whose appro ach is based in disease ecology. Mayer’s approach attempts to study infectious diseas e in terms of the inte raction between host, vector and agent within the c ontext of human-environment in teraction; specifically, how culture, political-economy and biology, including vector a nd pathogen ecology interact together in an evolving and interactive system to produce a foci of disease. Mayer calls this approach the political ecology of disease (Mayer 1996). Another focus of the political ecology of health framework that has implications for this dissertation is its emphasis on microlev el and macrolevel linkages that attempt to understand the interconnections between the proximate causes of disease (fecal-oral transmission) and the social, political-economic, and environm ental relations that are the ultimate causes of disease (Baer 2003; Goodman 1998; Mayer 2000; McElroy 2009; Whiteford and Whiteford 2005). As Goodman and Leatherman (1998) and Whiteford and

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38 Whiteford (2005) suggest, this dissertation “f ocuses upstream” to the larger “macro” level factors that influence parasite prevalen ce, not least because the results may provide new strategies to prevent di sease transmission and provide s anthropologists and public health practitioners a framework with wh ich to better understand health outcomes. Another component of the political ecology of health framework used in this dissertation is the addition of the househol d ecology of disease transmission framework proposed by Coreil, Whiteford, and Salazar (1996). This framework suggests that, in terms of intestinal parasites, the house hold ecology model provide s a link between both macro and micro level phenomena by means of defining household ecology as an intermediate pathway of disease between larger political economic factors and the proximate determinants of disease including th e actual exposure to intestinal parasites. In light of a political ecology of health framework, this dissertation contextualizes how political economic processes are linked to disparities in health outcomes between Nicaraguan immigrants and Costa Rican resi dents. Specifically, it look at how microlevel or proximate causes of intestinal para sites characterized by fecal-oral transmission at the household level can be ultimately linked to and contextualized within the political economic processes of immigration, immigr ation status, underemployment, access to credit, home ownership, living conditions, and access to critical health and social services.

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39 Chapter Three – Description of the Research Site This chapter provides a brief description of Costa Rica and of the research site of Monteverde. However, because of this disserta tion’s interest in issues of health access, environmental health and immigration, the cr ux of this chapter will focus on the Costa Rican health care system as well as health care issues both on the national and local levels. In that sense, this ch apter will provide the reader with a better understanding of Costa Rican health care policy and organization w ith special attention to issues critical to this dissertation; specifically that of acce ss to health care, water resources management, and the health of Nicaraguan immigrants. A Brief Look at Costa Rica The Republic of Costa Rica is a country in Central America that shares borders with Nicaragua to the northwest and Panama to the southeast. Costa Rica enjoys two coastal regions with the Caribbean Sea to th e east and the Pacific Ocean to the west (see Figure 3-1). With a total land mass of onl y 51,000 square kilometers, Costa Rica is slightly smaller that the US State of West Virginia. The estimate d population in 2000 was 3.8 million (PAHO 2002) and had an estimated 2009 population of just over 4.2 million (CIA 2009). The country is divided into seve n provinces, San Jose, Alajuela, Heredia, Cartago, Puntarenas, Limon and Guanacaste which are further divided into 81 secondlevel administrative areas called cantons which are further divided into districts (note that the cantons posses local governments called muni cipalities). For example, the dissertation research site of Santa Elena is located in the province of Puntarenas, Canton Central, District Ten. In terms of health, th e Costa Rican Ministry of Health divides the country into 83 health areas, of which Sant a Elena and Monteverde are located in the health area number three (A SIS 2002; CIA 2009; PAHO 2002).

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40 Figure 3-1. Map of Costa Rica Lonely Planet Costa Rica (2009) Since its independence in 1838, Costa Rica, in stark contrast to its Central American neighbors has enjoyed a deeply rooted democratic tradition with stable political systems in which transparent elec tions are held every four years (PAHO 2002). Among its unique and well know characteristics Costa Rica is known as Latin America’s most environmentally friendly country; char acterized by 5% of the worlds biodiversity and an increasing pattern of environmenta l resource protection where over 25% of its land is under protection (The Nature Conservancy 2009). E nvironmental protection has also had economic dividends; tourism, especially ecotourism has supplanted the agriculture sector and now ranks as the country’s primar y source of foreign exchange earnings (de Camino 2000). Thanks in part to tourism, foreign technology investment and agriculture, Costa Rica has a relatively stab le economy. For example, per capita GDP is roughly $10,800; unemployment between 4.5 and 5.5%; an estimated 64% of the

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41 workforce is employed in the service sector, while 14% still work in agriculture; finally an estimated 16% of the population live below the poverty line (CIA 2009; PAHO 2002). Another unique characteristic of Costa Ri can was the abolition of the military in 1949 in favor of investing t hose resources in education and health (Mohs 1995). As a result of its dedication to pr oviding universal health care, Co sta Rica boasts some of the highest health indicators in Latin America and has served as a model for other countries because it has achieved such status through a democratic process with a relatively low economic budget (Morgan 1987; Morgan 1993; Munoz 1995; PAHO 2002). Finally, as a result of its political an d economic stability Costa Rica has become a primary receptor country of Central American immigrati on; especially Nicaraguan immigrants seeking employment and better life opportunities. While the estimated 300, 000 to 500,000 Nicaraguans, both legal and ille gal, provide an important source of unskilled labor in the agricultural and servic e sector, there are ever growing concerns about the impact Nicaraguan immigration is having on social services including education and health care as well as on society in general (M orales 2002; OIM 2001; Sandoval-Garcia 2004a; 2004b). With specific rele vance to this diss ertation, Nicaraguan immigrants living in Costa Rica suffer so cial discrimination characterized by high poverty levels, underemployment, low education levels in addition to facing barriers in health care access and health disparities compared to Costa Ricans (Marquette 2006; OIM 2001). A more in-depth story of the Costa Ri can health care systems as it pertains to the objectives of this dissertation will follow. The Health Care System in Costa Rica The Costa Rican health care system has received international attention for the dramatic improvements in its basic health indicators during the 1970’s and early 1980’s. The result of this dramatic health trans ition was the culminatio n of the government’s rural primary health care program initiated in 1973 that emphasized universal coverage and primary health care (Hill 1986; Morgan 1989; Munoz 1995). By the early 1980’s Costa Rica’s primary health care progra m had been considered a success and was credited with reducing infant mortality and preventable infectious disease, increasing life

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42 expectancy, and bringing primary health se rvices to rural areas for the first time (Jaramillo Antilln 1984; Munoz 1995; PAHO 1994). Public health officials, policy makers and medical anthropologists have been interested in the Costa Rican health experime nt. For example, public health officials have touted the fact that despit e being a relatively poor, devel oping country, Costa Rica enjoys a health profile similar to that of other industrialized nations. Others point to the “progressive nature” and “dedic ation to the health of its ci tizens” of Costa Rica’s health care system citing the implementation of a ru ral health program under the rubric of its national primary health care plan several y ears before the Alma-Ata proclamation of “Health for All by 2000” (Munoz 1995; Senz 1995; Vargas 1995). Health policy makers have emphasized that while Costa Rica, Cuba and Chile enjoy some the best health indicators in Latin America; Costa Rica is unique in that these goals were achieved within a democratic, cap italist framework (Miranda 1995; Mohs 1983; Mohs 1995; Munoz 1995). Conversely, medical anthropologists and other social scientists have been more critical of Costa Rica’s health success by pointing to failures of community based health care as a result of po litical partisanship (Barrett 1996; Morgan 1989; Morgan 1993) and continued health disparities am ong minorities and women (Abrahams-Sand 2005; Roses 2003). In this brief overview I will outline the hist orical health policy factors that led to a rapid epidemiological transition in Costa Rica and will discuss some of the most significant changes in the health profile that took place. Next, I will describe the basic structure of the Costa Rican health care system and some of its most important institutions including the agency responsible for providing potable water and waste water management services. Next I will discuss th e health care reforms that took place in the 1990’s and their implication on primary health ca re in Costa Rica. Next I will discuss the emerging interest and relevant literature re garding the health of Nicaraguan immigrants in Costa Rica. Finally I will briefly discuss th e health situation in Monteverde including available services and most prevalent health problems.

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43 Development of the Costa Rican Health System Clark (2002) explains that prio r to the formation of the CCSS “ Caja Costarricense del Seguridad Social ” (Costa Rican Social Security Institute) in 1942, citizens had to pay for health care out-of poc ket or work for a company that had its own doctors or rely on charity hospitals. Th e Caldern Guardia administration (1940-1944) played a significant role in initiating the pr ocess toward universali zed health care when it drafted legislation creating the CCSS in 1942. Health coverage, c onsisting of curative health care, grew slowly over the next two decades and only included workers that earned below a certain salary cap. It was not until the 1960s that the national constitution was amended and legislation passed that mandated universal heal th coverage under the CCSS. Under the new law, health coverage was extended to the families of employees and the self-employed. Still, the CCSS was una ble to expand health coverage as it had intended because enrollment was still limited to a salary cap and because the state failed to meet its budget requirements to the inst itute (Clark 2002). As a result health and pension coverage had only increased fr om 17% in 1961 to 46% in 1970 (Clark 2002; Miranda 1995; Rosenberg 1983). Although this a ttempt at extending health coverage did not live up to expectation it wa s significant on ac couple levels First, it solidified Costa Rica’s political commitment to universalized health care and set the country down the path of attaining a true social security stat e; and Second, it legitimi zed the creation of the necessary infrastructure to attain and suppor t such a system; the creation of the medical school and other medical training institutions and the construction of more hospitals and clinics. Finally, in 1970 the full expression of Cost a Rican social security in the form of universal health care took shape as the ad ministration of Jose Fi gueres (1970-1974) of the PLN “ Partido Liberacin Nacional ” (National Liberation Party) pushed to consolidate the nationalization of the health and pension programs. At his direction, both the Ministry of Health and the CCSS sat dow n to elaborate a joint “Natio nal Health Plan” that would use resources from both institutions resulting in a complete restructuring of the national health care system. In the end, the Ministry of Health would assume responsibility for preventative measures at the individual and population level. The CCSS, on the other

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44 hand, took responsibility for curative care of the population (Clark 2002; Miranda 1995). In 1971, legislation was passed to pl ace all hospitals and clinics under the authority of the CCSS and to officially remove the salary cap for enrollment into social security to include all wage earners, th eir dependants, the self employed, and the unemployed. As a result, much of the states portion of social securi ty quotas shifted to employers while the state remained respons ible for the unemploye d (Miranda 1995). For example, employers pay an additional 9.25% above their employees’ salaries, while employees pay an additional 5.5% from their salaries to the CCSS. Self employed and informal sector workers are encouraged to enroll in the CCSS’s voluntary plans where workers pay between 5.75% and 13.75% of th eir salaries depending on their income. The government uses about 1.5% of the total salari es paid to the CCSS in order to cover the uninsured (Biesanz 1999; Clark 200 2; Mata 1988; Morgan 1993). The Role of the CCSS and the Ministry of Health Today, the Costa Rican state dominates th e health sector. The Costa Rican Social Security Institute (CCSS), a public institution, virtually monopolizes the health insurance market, administers the nationa l pension system in addition to providing most of the country’s curative health serv ices via a comprehensive system of clinics and hospitals (Clark 2002:3). The CCSS is considered a semi-autonomous institution, meaning that both its budget and decision and policy making powers are completely separate from that of the central government. The CCSS employs over 31,000 people and manages a annual budget equivalent to nearly one-quarter of that of the central government (CCSS 2001). Over the years, the CCSS has gradually incor porated more citizens from different social classes in an attempt to universalize the h ealth care system. Today, the CCSS claims to have 87.7% of the population covered under its services (Estado de la Nacin 2002:55). Since the 1970s, virtually all the nation’s hos pitals (29) and clin ics (240) have been transferred to the administrati on of the CCSS and as a result, 90% of physicians and other health care workers work under the auspices of the CCSS (Clark 2002; Miranda 1995; Rosenberg 1983).

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45 Though the Ministry of Health lost control of its fundi ng and administration to the CCSS as a result of the passing of the National Health Plan in the early 1970’s, it still retained its primary respons ibility for public health. U nder this new framework, the Ministry of Health is responsible for form ulating public health policy, regulating medical markets, coordinating disease eradication e fforts, food and water quality monitoring, and conducting public health campaigns. The Ministry of Health is the primary institution of the National Health System. Although the Mini stry of Health only receives on average 7% of the total health budget, its aim is to cover the entire population through programs of infectious disease cont rol and to promote health through community organization based on preventive and curati ve measures (Clark 2002). Primary Health Care Initiatives in Costa Rica The most important Ministry of Health programs that had significant impact on improving Costa Rica’s health profile were the “The Rural Health Program” for rural communities; “The Community Health Progr am” for underprivileged urban populations; and “The Nutrition Program” which targeted children less than 6 years of age, school children and pre and post natal mothers. A ccording to Vargas (1995) these programs were designed and implemented within the framework of the National Health Plan’s vision of the populations’ right to health care and the governments obligation to organize and provide health serv ices (Vargas 1995:62). One of the Ministry’s major programs and of particular interest to this dissertation was the Rural Health Program (RHP), which was implemented in the early 1970s. The RHP initiative was the result of a meeting of the Ministries of Health of the Americas and the Pan-American Health Organization (PAHO) which solidified the idea that health was a human right and that the state was res ponsible for insuring that right. Though Costa Rica had been working toward this end, the meeting spearheaded political measures to develop a comprehensive, state-sponsored rura l health program, of wh ich the Ministry of Health was responsible (Morgan 1993). According to Jarimillo (1984) and Mohs (1983) the rural health care program was responsible for building rural h ealth centers and for training community health workers to

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46 provide primary health care and referral serv ices. The primary functions of the rural health program are as follows: 1) ce nsus and mapping of the community; 2) immunization; 3) treatment of intestinal parasites; 4) prim ary diagnosis and referral; 5) family planning; 6) promotion of breast feed ing and child nutrition; 7) food distribution; 8) promotion of family health; and 9) co mmunity organization (Jaramillo Antilln 1984; Mohs 1983; Vargas 1995). The rural health pr ogram is fundamental to the primary and secondary health levels and has been instrument al in improving the he alth status of Costa Ricans. Mata (1988) argues that there are ma rked differences in the health status of communities that received the rural hea lth program and those that did not. The Health Transition in Costa Rica According to Jaramillo Antilln (19 93) the government made good on their commitment of universalizing health servic es by increasing Ministry of Health budgets for preventive care and nutriti onal assistance to marginal rural and urban populations (1993). Miranda (1995) insists that it was the re direction of the Ministry of Health and the development of the CCSS that set the stag e for a series of changes which included a shift from an individual system of health ca re coverage to that of the social security model which took into account the rights of citizens ( 1995). These rights included universal access to health care and well -being, adequate housi ng, education, nutrition, and clothing (Miranda 1995). Other authors agree that the focus on preventive medicine and nutrition programs, the construction of regional hospitals and rural health posts which extended primary health care into the ru ral sectors for the first time were principal factors that precipitated the gigantic strides in Costa Rica’s health profile between 1973 and 1984 (Barrett 1996; Clark 2002; Hill 1986; Miranda 1995; Morgan 1993; Vargas 1995). In little over ten years (1970-1983), as a result of improved health care coverage and organization, Costa Rica underwent a rapid epidemiological transition where diseases characteristic of underdeveloped countrie s gave way to diseases prevalent in industrialized countries (Senz 1995). During th is period, for example, the average life expectancy increased from 65 to 73.7 years. Mo st impressively, infant mortality rates per

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47 1000 live births decreased from 61.5 to 18.6. Like wise, infectious and parasitic disease mortality rates per 10,000 decreased from 13.6 to 1.7. As a result, diseases of the circulatory and respiratory system, includi ng cancer and other degenerative diseases became the top causes of mortality thereby displacing infectious diseases (Jaramillo Antilln 1984). In addition, see Saenz (1995) fo r a comprehensive review of the health transition in Costa Rica that ta kes into account the various stag es of the disease transition. Of specific interest for this overview, was the dramatic decrease in diarrheal, parasitic, and other infecti ous diseases. According to Ma ta (1988), the significant decrease in rates of infectious morbidity and mortality was directly correlated to health care expenditure and coverage which transl ated into improvements in nutrition, water supply, education, and preventative and curative public health services ; specifically those relating to preventable inf ectious diseases including intestinal parasites. The primary health care campaigns impl emented in the 1970’s played a major role in significantly reduci ng rates of intestinal parasi tes among the general population (Mata 1988). The primary health care campa igns focused on waste disposal, personal hygiene education and intestinal parasi tes along with an improved laboratory infrastructure (Blanco 2007). With particular interest to this di ssertation, Costa Rica has conducted three national parasite surveys; 1966, 1982, and 1996. In all three, the coll ection and analysis methods have been the same allowing the resu lts to be compared. Results from the first national survey of intestinal parasites demonstrated a global infection ra te of intestinal helminths at over 50% (Mata 1998). The s econd survey conducted in 1982 saw a dramatic reduction in prevalence rates of in testinal parasites to around 5%. For example, between 1966 and 1982, the prevalence rate of Ascaris went from 12.2% to 3.8%; the prevalence of Tricuris went from 10.2% to 4.85%; and the prevalence of hookworm ( Nector ) went from 60% to 3.29%. The latest nati onal survey of intestinal parasites saw prevalence rates of intestinal helminths dr op even further compared with the 1982 study. For example, in 1996 the prevalence rates of Ascaris was 1.35%; Trichuris was 2.79% and hookworm was a mere 0.3% (Mata 1998; Sa nchez 1999). See the di scussion later in

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48 this chapter concerning recent parasite preval ence studies in Costa Rica that demonstrate much higher rates of intestinal parasites, especially among marginalized populations. While the Costa Rican health care syst em has improved health standards for a majority of its residents, some areas of th e country have traditionally been ignored and excluded. Hill (1986), for example, describes in her field study how primary health care services were all but absent and uncoordin ated in Limon province in the Early 1980's compared to the rest of the country wh ere PHC services were more reliable and accessible. For example, Hill (1986) notes that basic health promotion programs that were commonplace in other parts of the count ry were virtually absent in Limon. If doctors did exist, there were lik ely to be no equipment or medi cine and thus patients were often referred to the clinic in Puerto Limon. As a result, pr eventable paras itic infections were a common health problem at the time in Limon due to the lack of primary health care infrastructure (Hill 1986:133). Health Care Reform in Costa Rica Health reforms during the late 1990’s were common among many Latin American nations. In a general trend, Mi nistries of Health were ad vised by donors and international experts including the World Bank and the Worl d Health Organization to make significant health sector changes including decentraliza tion, privatization and regulation (Bossert 1998). Costa Rican health care reforms that were initiated in the 1990’s shared some similarities to other Latin American nati ons with the exception that the government resisted recommendations from the World Bank to privatize both the CCSS and the Ministry of Health; as a result both institu tions remain public (Rodrguez Herrera 2006). There are many reasons that led to the health care reforms of the 1990’s. Clark (2002) and Rodriguez Herrera (2006) summar ize that despite the achievements, by the late 1980’s, the Costa Rican heath care system showed signs of problems common among other health care systems in the region: long wa iting lists for diagnostic tests, surgery and specialist care; deteriorated hospitals and medical equipment; and demoralized physicians and health care workers. Other problems related to the dramatic rise in health care costs in Costa Rica; such as antiquated and h eavily bureaucratic top-down accounting and

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49 management systems which gave hospital a nd clinic directors little incentive to economize. Another impetus and objective fo r health care reform were overlapping health services. In the 1970’s the Ministry of Health expa nded its Rural Health Program by building rural health posts a nd mobile health teams. Over time, CCSS clinics came to operate in many of the same areas as the Mini stry of Health. Thus, one of the objects of health reform was to eliminate overlappi ng health services (Clark 2002; Rodrguez Herrera 2006). Implementation of Health Care Reforms In response to these problems, as early as the 1980’s, Costa Rican health officials tested alternative primary health care deliver y models in both rural and urban settings. For the most part, these plans consisted of a mixture of private/public partnerships that included physician’s cooperatives, various co -pay systems, and private company doctors. For a description of these models see Clar k (2000) and Vargas (1995). In the end, Costa Rican health officials worked out a reform program with the World Bank in 1993. One of the major changes in the Costa Rican health car e system as a result of health care reform was the reorganization of the pr imary care model (Clark 2000). According to Clark (2000) and Rodriguez (2006), the major issue was the overlapping and random distribut ion of the CCSS primary care system that was curative, and the Ministry’s preventative health care services. The proposed solution to this dilemma was to replace the old system with in tegrated basic health care teams known as Equipos Bsicos de Atencin Integral de Salud (EBAIS) which were envisioned to provide integral care that w ould attend to the physical, so cial, and physiological health needs of the community. As a result of much political wrangling with congress and workers unions, the first EBAIS was created in 1995. Each EBAIS consists of a medical doctor, nurse, and a technician and is intended to cover a population of approximately 4,000 people. The EBAIS in turn are supported by personnel from nearby CCSS clinics located in the same health area. These clinic s usually consist of a family practitioner, nurse, laboratory technician, social worker, dentist, nutri tionist, pharmacist, and medical

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50 records specialist. Later on, psychologists were added to some EBAIS on a part time basis (Clark 2002; PAHO 2002; Rodrguez Herrera 2006). Impact of Health Care Reforms As far as the impact that the Costa Rican health reforms have had on morbidity and mortality, few studies have been publishe d. Most notably, however, are two articles by Rosero-Bixby that demonstrate how im proved access to health care has reduced morbidity rates and increased life expectan ce rates. In one study Rosero-Bixby (2004b) uses GIS data from the 2000 census to compare supply and demand of health care services. The study reported significant im provements in access to outpatient care between 1994 and 2000 as a result of health care reform implemented in 1995. RoseroBixby (2004b) also claims that increased acces s to health care wa s achieved by targeting communities that were in greatest need and that this was accomplished through the establishment of the EBAIS in those communities (2004b). A 2002 PAHO report notes that in the areas of the country where it has been implemented the EBAIS strategy has helped reduce health inequity; citing that th e population with insufficient and inadequate access to health care services was reduced from 20% to 15% (PAHO 2002). According to Rosero-Bixby (2004a), the increase in access to health care saw a si gnificant reduction of mortality of 8% among children and 2% among adults. Finally, mortality rates due to infectious diseases were reduced by 14% (2004a). Water Management in Costa Rica In Costa Rica, the Costa Rican Ins titute of Aqueducts and Sewers (ICAA), commonly known as Aqueductos y Alcantarillados or (AyA) was established in 1961 and is responsible for providing potable water s upplies and the collection and assessment of sewage and liquid industrial wastes throughout the country (Biesanz 1999; Mata 1988; Mohs 1995). The AyA, however, is characterized by a different institutional evolution compared to the CCSS and the Ministry of Health. According to Morgan (1992), the development and organization of AyA was heavily influenced by international

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51 development agencies such as the Inte r-American Development Bank and the U.S. Agency for International Development (USA ID). At the time, these agencies had changed their agenda from health and e ducation to industrial and infrastructure development. Though Costa Rica received only a fraction of available funds from these lending agencies, the government was still able to garner funds from other loans to establish the Institute of A queducts and Sewers in 1961. While Costa Rica was able to take advantage of these loans and present th em as principal components of the state’s social services (which in this case redu ce water related diseas es by providing potable water to a greater proportion of the populat ion), the loans heavily influenced the organizational structure of AyA. As a resu lt, AyA was forced to adopt a policy where beneficiaries, not provincial governments woul d pay for water. Thus, AyA adopted a feefor-service approach to water management, thereby turning water into a commodity; a policy that continues to this day (Morgan 1993). Today, AyA has serious problems keep ing up with demands of the growing population and water shortages ar e frequent, especially in th e dry season. Still, according to Mora Alvarado (2003), Costa Rica ranks high among other Latin American countries in terms of potable water distribution and waste treatment. For example, 97% of Costa Ricans have access to water, 76% of which is considered potable. Similarly, 98% of Costa Ricans have some sort of waste disposa l; however, 77% is through septic tanks and only 4% of human waste is treated with sa nitary treatment methods. Similarly, only 4% of graywater receives any treatment at al l; the majority drains directly into the environment. While there are shortcomings, esp ecially in terms of wa stewater treatment, the general availability of clean drinking wa ter and waste disposal measures has reduced the incidence of water-borne and diarrheal diseases (Mor a Alvarado and Portuguez 2000; Mora Alvarado 2003). Costa Rica has also cont inually increased coverage of potable water for the general population; in 1 991 only 50% of the population had access to potable water compared to 78% in 2002 (Mora Alvarado and Portuguez 2003).

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52 Water Management and Intestin al Parasites in Costa Rica In Costa Rica, research has also been done looking at water quality management and its impact on human health, especially in relation to water-borne diseases including parasites, bacteria and viruses; many of thes e articles appear in the Costa Rican Journal of Public Health ( Revista Costarricense de Salud Publica ). Valiente (1999), discusses the developmen t of the sanitary vi gilance program for water quality that was implemented in Costa Rica in 1996. In contrast to traditional water quality monitoring programs, the sanitary vigi lance program determin es the quality of a community’s aqueduct in terms of its health ri sk to humans as a way to identify priorities for improvement and to avoid water-borne diseases (1999). Following this methodology, Valiente a nd Mora (2002) analyzed diarrhea outbreaks in Costa Rica direc tly related to water quality from 1999 to 2001. Out of 21 documented diarrhea outbreaks, investigators were able to iden tify the responsible pathogen in 11 cases; in the ot her cases no pathogen was identified. In the each of the documented diarrhea outbreaks where the pa thogen was found, that pathogen was identified as a bacteria or a virus; intestinal parasites such as Giardia lamblia or Cryptosporidium parvum were not found to be the pat hogen in those outbreaks (2002). According to Gonzalez and Umaa ( 1996), Costa Rica has been extremely successful in its implementation of control meas ures to prevent helminth infections such as Ascaris lumbricoides, Trichuris trichiura, Necator americanus and other common species. Still, there are some marginalized popul ations in Costa Rica th at still experience high prevalence rates of helminth infections. In contrast, not the same is true with parasitic infections of inte stinal protozoa, especially Giardia lamblia and Entamoeba histolytica which, according to Monge et al. (1996) are much more common than helminth infections based on labor atory tests throughout the country. According to Peinador and Murillo (2000) th e fact that infections with intestinal protozoa are much more common than helminth infections coincides w ith his research of water quality monitoring that demonstrated the high prevalence of protozoa cysts found in some water treatment systems (2000). In a similar study, Peinador and Quirs (2000) found that many water treatment plants that provided water for human consumption had

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53 very poor rates of eliminating these parasite s during treatment. These results demonstrate that potable water from treatment facilities, in some cases, can serve as a source of infection of intestin al protozoa (2000). Nicaraguan Immigrants in Costa Rica During the past 30 years the surge of migratory movements in Central America has been characterized by armed conflict, natural disasters, a nd resulting economic instability. Many immigrants in Central Ameri ca have sought refuge in the United States and to a lesser extent Mexico and Canada. For example, as a result of a 12 year civil war, it is estimated that 2.4 million or 28% of El Sa lvadorians reside outside the country (OIM 2001). In contrast, migratory movements w ithin Central America are increasingly significant; most notably between Nicaragua and Costa Rica. According to the 2000 census, Nicaraguans comprised 6% of the population in Costa Rica and it is estimated that so me 350,000 Nicaraguans live in Costa Rica; approximately half of which may be c onsidered illegal im migrants (OIM 2001). However, the CIA reports that anywhe re between 300,000 and 500,000 Nicaraguans live in Costa Rica (CIA 2009). Ultimately, it is un clear as to how many Nicaraguans reside in Costa Rica at any one time. According to a study of Nicaraguan immigration to Costa Rica by the International Organization for Migration (2001), while many Nicaraguan immigrants have come to Costa Rica for political and environmental reasons (Hurricane Mitch), the majority of Nicaraguans have decided to im migrate and reside in Costa Rica because of the continued stagnation of Nicaragua’s economy characterized by high rates of unemployment, underemployment, and the lack of social services. The pull of migration is also related to Costa Rica’s sustained de mand for unskilled labor in its agriculture, construction, and service sectors. It is estimated that some 25% of Nicaraguan immigrants work in the agricultural sector (pineapple, coffee, sugar, and bananas); 18% work in the service sector (hotels and restau rants); and 17% work in construction. It is also estimated that 62% of Nicaraguan wome n work in the service sector. Nicaraguan immigrants have much lower levels of edu cation compared to their Costa Rican cohorts;

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54 are more likely to live in poverty (25% of Nicaraguan households) and in substandard housing (35 – 40%); and are paid less than th eir Costa Rican counter parts who engage in the same line of work (Marquette 2006; OIM 2001). While it is clear that Nicaraguan immigran ts tend to be economically and socially marginalized, it is unclear how these phenomena are manifest in terms of health status. This is primarily due to the fact that census data collected in Cost a Rica did not start to register individual nationality until the year 2000. In addition, health statistics in Costa Rica do not gather data con cerning patient nationality. This has made it difficult to comparatively study health outcomes between Nicaraguan immigrants and Costa Rican residents. Marquette (2006) estimates that more th an half of all Nicaraguan immigrants living in Costa Rican do not have access to CCSS health care, and notes that the percentage of uninsured may be much hi gher among illegal Nicaraguan immigrants. In comparison, almost 90% of Costa Ricans ar e currently insured through the CCSS, not counting those who have private health insu rance. Marquette (2006) notes that while many Nicaraguans may have access to health se rvices in Costa Rica regardless of their insurance or legal status, the qua lity of care they receive may be lower. This is evidenced by the fact that Nicaraguans have lower levels of health care use than Costa Ricans in terms of the number of annual clinic consultations (Marquette 2006). While access to health care for legal im migrants is garnered through the same pathways as for normal residents, a Costa Ri can Ministry of Health report notes that illegal immigrants have no viable way to acquire health insurance through the CCSS because affiliation requires legal documentati on. Even preventative and referral services offered by the integrated basic health care teams (EBAIS) require CCSS affiliation. As a result, illegal immigrants only have access to emergency services since immigration status is not required. The only other option in terms of access to health care available to many illegal immigrants is to pay up-front and out-of-pocket for health services; a situation made difficult considering the fact that over a quarter of Nicaraguans live below the poverty line (Ministerio de Sa lud de Costa Rica 2002).

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55 Among Nicaraguan immigrants, women and children and individuals employed in seasonal labor and the informal service sector are more likely to not to have access to health care. Furthermore, while the Costa Ri can state absorbs costs for those citizens who cannot afford health coverage, the non-le gal status of many Ni caraguan immigrants prevents them from accessing these forms of h ealth coverage. Other health issues facing Nicaraguan immigrants include access to fam ily planning services, pediatric services, preventative screening procedures and o ccupational health services (CCSS 2002). Furthermore, Marquette (2006) and the OIM (20 02) report suggests that there is a higher prevalence of infectious diseases associated to poor living cond itions among Nicaraguans and points out that Nicaraguan immigrants tend to suffer from diseases that were common among the Costa Rican population duri ng the 1960’s (i.e., diar rheal, parasitic, and viral infections) As a result, both th e OIM (2002) and Marque tte (2006) suggest the need of researchers to compare disease out comes between Nicaraguans and Costa Ricans. Intestinal Parasites in Costa Rica Apart from the three national intestinal parasite surveys, researchers have continued to conduct research on parasite pr evalence rates in Costa Rica among marginal and special populations. Many of these artic les were published (in the Costa Rican Journal of Medical Sciences and the Costa Ri can Journal of Public Health) after the 1996 National Parasite Survey. These studies empha size the continued high prevalence rates of intestinal parasites in marginal communities in Costa Rica, pointing to significant health disparities among Costa Ricans. In a recent study of intestinal parasite prevalence, Blanco and Calderon (2007) studied the marginalized urban communities of La Barva, Heredia. The global period prevalence of intestinal parasites between January and November, 2004 was 41.2%; though the vast majority of positive cases of in fection were with commensal species, the most common being Blastocystis hominis (27.4%), Endolimax nana (16.5%), and Entamoeba coli (7.4%). Infection with pathogenic in testinal parasites was much lower; Giardia lamblia (2.1%) and Entamoeba histolytica (1.7%). In this study, there were only a few cases of intestinal helminths.

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56 Blanco and Calderon (2007) state that while intestinal parasites are often spread by fecal-oral transmission, it is possible that wa ter plays a significant role as a source of infection. The authors noted that the water supply in the study community did not have adequate safeguards to prevent intestinal parasites from being transmitted through the water supply. In addition, the st udy points to continued health disparities of marginalized urban communities in Costa Rica (Blanco 2007). In another parasite prevalence study am ong school age children in five rural communities of Limon province, Abrhams et al. (2005), discovered very high rates of infection with parasitic commensals; 47.6% on average. Also, infec tions with helminths were very high; Ascaris lumbricoides (16.6%) Trichuris trichiura (18.6%). Infection with the pathogenic intestinal parasite Giardia lamblia was (7%). The highest rates of infection were among children in third and fi fth grades (20%). The 1996 National Survey of Intestinal Parasites reported global preval ence rates of intestinal helminths well below 3%. This study demonstrates that dramatic disparities in intest inal helminth rates exist in marginal areas of Costa Rica. The authors point out that Limon province still lacks proper sanitary and hygienic infrastructure, access to prevention programs, and suffers from high rates of poverty and unemployment. The aut hors call upon Costa Rican health officials to take notice of the health needs in these a nd other marginalized areas of the country (Abrahams-Sand 2005). Hernandez et.al (1998) collected stool sa mples from 76 inhabitants of a squatter settlement near San Jose, Costa Rica. Resu lts showed that 45% of the study population was infected with at least one kind of intestinal parasi te. The most common parasites found were Entamoeba coli (27%), and the helminths Trichuris trichiura (18%) and Ascaris lumbricoides (15%). Again, the data show very high rates of intestinal helminths compared to rates reported in the National Pa rasites Survey and thus reiterate that the problem of intestinal parasites is ongoi ng. The authors note that the continued high prevalence rates of intestinal parasites in ma rginalized communities in Costa Rica have been masked by national surveys that show fi ctitiously low rates of infection (Hernndez 1998).

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57 In a larger study of an urban health cl inic near Hatillo, Costa Rica, Pardo and Hernandez (1997) analyzed 3,506 samples fo r intestinal paras ites between 1995 and 1996. Results showed relatively high rates of Ascaris lumbricoides (8.2%), Trichuris trichiura (4.1%) and Giardia lamblia (9.3%). Rates of commensal parasites Entamoeba coli and Endolimax nana were higher at 17.4% and 14.7% respectively. The authors note that the rates are similar to those found in the area 10 years earlie r, attesting to the continued lack of poor sanitary infrastructure, insufficient potable water and a lack of prevention programs Pardo and Hernandez (1997). The authors go on to discuss the fact that the study of intestinal parasites in Costa Rica has been perceived as irrelevant and rele gated to a lower professional status in many clinical laboratories. For example, clinic al technicians are often times not properly trained in the handling and dia gnostics of intestinal parasites. This situatio n could result in significant underreporting of pr evalence rates in certain area s that lack properly trained staff and equipment Pardo and Hernandez (1997). Sanchez et.al (1999) analyzed 151 elderl y patients (60 years and over) from an outpatient hospital near San Jose and found a global prevalence rate of 26.5%. Rates of G. lamblia and C. parvum were both 5.3% respectively. The study also found a 2% prevalence rate of Strongyloides stercoralis an intestinal helminth not reported on in the last National Parasite Survey. Strongyloides stercoralis is significant for the elderly because it often accompanies long term chroni c infections common among the geriatric population. In Costa Rica, the majority of intestinal parasite survey studies focus on pediatric and or general populati ons. This study demonstrates th at the elderly are also at risk for parasitic dis eases. Infection with Strongyloides stercoralis is significant for the elderly because of its association with immune-suppressed patients (Sanchez 1999). Cerdas et.al (2003) analyzed 320 sa mples from school aged children in Curridabat, a suburb outside of San Jose Costa Rica. Results found an alarming prevalence rate of 45% for all parasites; a pr evalence of 28% with pathogenic species and 16.9% with commensal species. The most frequent helminth was Trichuris trichiura (12.2%), followed by Ascaris lumbricoides (6.9%). The most frequent protozoan pathogen was Giardia lamblia with a prevalence of 7.8%. The study demonstrates

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58 continued high prevalence rates co ntrary to results from natio nal surveys. In addition the authors attribute the high prevalence rates with poor hygienic pr actices; washing hands and fruits and vegetables (Cerdas 2003). Finally Hernandez-Chava rria (2005) analyzed the pr evalence of intestinal parasites among an indigenous community in the South of Costa Ri ca. The researchers gathered 45 fecal samples from children under 15 years of age. The results show that 38 of the 45 samples (84%) were positive for at least one parasite. The prevalence for helminths was as follows: Ascaris lumbricoides (36%), Necator americanus (22%) and Trichiura trichiura (2%). For intestinal protozoa, prevalence rates were as follows: Endolimax nana (33%), Entamoeba coli (27%), and Entamoeba histolytica (11%). The authors point to lack of potab le water, the lack of latrin es, high household density, and the fact that many children do not us e shoes (Hernandez-Chavarria 2005). These studies clearly demons trate that the problem of intestinal parasites is far from over, especially among marginalized a nd poor communities. These articles suggest that researchers are becomi ng more aware of health di sparities among diverse and marginalized populations in Costa Rica. Howeve r, until this time, no formal research has been done to analyze prevalen ce rates intestinal parasites among Nicaraguan immigrants living in Costa Rica; this study pretends to be the first to provide data on that population. This chapter will now turn to focus attention on the health conditions in Monteverde, Costa Rica with specific atten tion to the study site of Santa Elena. The Monteverde Zone The Monteverde Zone is situated in the Tilarn Mountains of Northwest Costa Rica in the department of Puntarenas and re fers to several human communities including Monteverde, San Luis, Cerro Plano, Santa Elen a, Caitas, Los Llanos and others (see Figure 3-2). The Monteverde area was first settled by Cost a Ricans in the 1920’s and 1930’s by gold miners, settlers, and farmers. However it was not until the 1950’s, with the arrival of a group of 12 North American Quaker families, that it became known by the name of Monteverde, with schools and the characteristics of a community. The

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59 Quakers established a cheese factory suppor ted by a network dairy farms located among neighboring communities. Figure 3-2. Map of the Monteverde Zone Map Courtesy of the Monteverde Institute (2001) Later, in an effort to protect the community water supply from threats of deforestation, the Quakers se t aside about 550 hectares of cloud forest. Today, over 50,180 hectares of forest are under protection in four formal reserves, including the Monteverde Cloud Forest Pres erve and other private and public land holdings (Haber 2000; Honey 1999). These forests are home to e normous biodiversity, for example, more that 3,000 plant species, several hundred avia n species, and 500 bu tterfly species are

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60 found in the Monteverde area alone, many of whic h are unique to this area (Haber 2000; Nadkarni 2000). The presence of these pristine forests w ith their biological diversity has created a vibrant and growing ecotourism industry in the Monteverde region. As a result, the region began to experience rapid growth (s tarting the in the mi d 1990’s and continuing through the mid 2000’s) in the t ourist sector, concentrated pr incipally in the communities of Santa Elena, Cerro Plano and Monteverde which border on the three most important biological reserves. As a re sult, the local economy has si gnificantly shifted from agriculture to ecotourism. For example, in the early 1990s an estimated 50,000 people visited Monteverde; in the late 1990’s Hone y (1999) estimated that over 70,000 tourists visited Monteverde; and in 2003, the Sant a Elena aqueduct reported that over 200,000 tourists visit the Monteverde zone every year (ICEA 1998). Tourism has now surpassed dairy farming as the areas primary source of income. More than 80% of the hotels, restaurants, and businesses in the Monteverde zone have been built since the mid 1990’s. In a recent survey of the areas 93 businesses, 85% are directly relate d to the tourism and service sector economy and 73% are located ei ther in Santa Elena or Cerro Plano. See Amador (2005) for a comprehensive review of the impact of ecot ourism development on area households and businesses. In addition, see Nadkarni and Wheelwright (2000) for a comprehensive discussion concerning the bi ological and ecological impact of ecotourism development in Monteverde. The Study Site: Santa Elena de Monteverde The research site for this dissertation took place in and around the community of Santa Elena de Monteverde. Santa Elena is th e political and economic center in addition to being the largest community in the M onteverde Zone. Santa Elena is located approximately thirty-five kilometers eas t of the Inter-American Highway and 160 kilometers northwest of the capitol, San Jo s. At the time of this research it was composed of approximately 311 househol ds and had a population of roughly 3,100 people (Amador 2004).

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61 Santa Elena is the seat of the new Muni cipal Government. It houses the offices of the governmental agencies AyA (Aqueduc ts and Sewers), MAG (Ministry of Agriculture), ICE (Electricity Institute), the Banco Nacional (National Bank), the post office and a CCSS (Social Secu rity) clinic. It has an elementary school and a professional and technical high school. There is private dentist, physician and pharmacy, several restaurants and intern et cafes, a supermarket, a book and stationery store, a bakery, bus station, hardware st ores and other stores and busin esses related to tourism. In the center of Santa Elena there is nearly c onstant movement of vehicles, people, dogs, and an occasional horse. The other community included in this research is Los Llanos, a small rural settlement just a few kilometers southeast of the center of Santa Elena. Several families started settling Los Llanos in the 1990’s as an alternative to living in Santa Elena because land and housing is much cheaper. According to the Monteverde Institute there are 59 households and an estimated population of 231 people in Los Llanos which include the recently constructed low income housing neighborhood called La Colina (Amador 2004). Los Llanos has only one small store that se lls basic supplies and a small primary school. For this reason, the majority of the inhabitants of Los Llanos go to Santa Elena or Cerro Plano for school, work and to buy food and suppl ies. In spite of th e lack of economic activity, Los Llanos is on the same electric, water and telecommunica tions grid as Santa Elena. Health and Health Se rvices in Monteverde Due to its relative isolation and inaccessi bility, the Monteverde Zone lacked basic health services for most of its history. Only until recently have health services improved in terms of coverage and ambulatory care. For example, while a small clinic was built in 1971, Monteverde did not receive a full time physician and nurse from the CCSS until 1983; before that, the community relied on mobile health teams who visited the community only a few times a year. Gradually, more health services were added to the clinic including a dentist and a pharmacist. In 1995, Monteverde received an integrated basic health care team (EBAIS #9) that provided primary heal th care and referral services

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62 to Santa Elena, Cerro Plano and Monteverde in addition to the services already provided by the clinic. In 1997, the EBAIS #8 was stationed to the Mont everde Clinic to provide health services to the communities of Guacimal, San Luis and Santa Rosa (located between Monteverde and the Inter-American Highway). As a result of the rapid growth in th e ecotourism sector and an increase in population, the demand for more health services grew. Finally, a new, larger and modern CCSS clinic opened in the spring of 2002. Locat ed in Santa Elena, the new Monteverde Clinic has substantially increa sed health care access and the variety of services available to the local population. Apart from housing th e EBAIS #8 and #9, the Monteverde Clinic is considered a primary health care facil ity whose function is to provide health promotion, prevention, treatment and referral servi ces to higher levels of health care. At the time of this research the Monteverde Clinic provided the fo llowing services: 1) a basic pharmacy with general medicines in stoc k; 2) dentistry services offered twice a week based on referral; 3) gyneco logical services offered once every two weeks; 4) social services focusing on various social issues including domestic violence, drug and alcohol addiction, teen pregnancy, and general counselin g; 5) laboratory services, lab samples are taken to Puntarenas once a week for anal ysis; and 6) emergenc y services, however, medical emergencies are generally referre d to Puntarenas. In addition, the CCSS maintains one ambulance that is in good conditi on as well as a second ambulance that is property of the Red Cross. On an interesting note, the Monteverde C linic does not have a pediatrician and therefore expect ing mothers are expected to tr avel to Puntarenas to give birth. At the time of this research, the 2002 lo cal health profile (ASI S) reported that the principal health problems of the community (bas ed on the volume of clinic consultations) included respiratory infections, back problems and diarrheal di seases (see Table 3-1). The report states that these morbidity statistics are most likely attributed to environmental factors as in the case of respiratory illnesse s which are associated with extreme climate changes, high humidity and frequent rain. Back problems may be related to road and work conditions which typically involve ma nual labor. Finally, diarrheal illnesses, including intestinal paras ites accounted for over 6% of clinic consultations in 2002

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63 making gastrointestinal diseases the sec ond most prevalent health condition in the community. The ASIS report suggests that gast rointestinal diseases may be linked to environmental conditions including climate, sanitation, and possible contamination of local water supplies. Other health concerns of the community that are recognized by the ASIS include drug and alcohol abuse, dom estic violence, and teen pregnancy (ASIS 2002). Table 3-1. Primary Causes of Morbid ity in the Monteverde Zone (2002) Diagnosis No. of Consultations Percent of Consultations Upper Respiratory Infections 617 13.89% Back Problems 183 4.11% Diarrheal Diseases 159 3.57% Accidents 113 2.54% Acute Ear Infections 111 2.49% Intestinal Parasites 110 2.47% Viral Infections 104 2.34% Urinary Tract Infections 100 2.18% Asthma 97 2.1% Hemorrhoids 93 2.09% Another important health statistic in rela tion to this dissertation is the percent of the population with access to he alth care (i.e., having health care coverage through the CCSS). According to the 2002 ASIS report, 93% of the residents livi ng in Santa Elena, Cerro Plano, Monteverde, Los Llanos and Ca itas have health care coverage through the CCSS. The majority of the insured are de pendants (children, family and spouses) of primary policy holders. In addition, approximate ly 8% of residents receive their health coverage through a state subsidy based on th eir low income status (ASIS 2002). For a more comprehensive discussion of Monteverde h ealth profile see the 20 02 ASIS report. Water Resources Management in Santa Elena Santa Elena first organized a water co mmittee in 1980 with the goal of providing water to Santa Elena, Cerro Plano and Ca itas. The committee was officially recognized as an administrative entity of The Costa Ri can Institute of Aqueducts and Sewers (AyA) in 1998 when three distinct water distributi on systems were consolidated into a single aqueduct named The Santa Elena Aqueduct Administration ( Asociacin Administradora

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64 del Acueducto de Santa Elena ). Currently, the Santa Elena aqueduct consists of three integrative water distribution systems that serve the communities of Santa Elena, Cerro Plano, Caitas and Los Llanos providing services to approximately 4,655 permanent residents and more than two hundred t housand annual tourists (AAASE 2003). All households that participated in this res earch received water from the Santa Elena aqueduct. The Santa Elena aqueduct captures a nd distributes water from 17 naturally occurring springs that are located in the mountains a bove and around Santa Elena and Cerro Plano. The springs themselves produce hi gh quality drinking water that is safe for human consumption without the need of secondary treatment. The 17 springs comprise three principal distribution systems that suppl y water to different pa rts of the community; System #1 consists of 10 natural springs and two holding tanks and provides water to residents of Caitas and North Santa Elena; System #2 consis ts of 2 natural springs and one holding tank and provides water to central Santa Elena and nei ghborhoods to the east near the cemetery; System #3 consists of 5 natural springs and three holding tanks and distributes water to Cerro Plano, South Santa Elena and Los Llanos. Although the spring water is safe for human consumption, in order to reduce the risk of possible contamination, the Santa Elena Aqueduct applie s chlorine to the water at its point of distribution via automated chlorinati on machines (AAASE 2003; ICEA 1998). Upon the initiation of this research in 2003, the Santa Elen a Aqueduct received the prestigious “ Sello de Calidad Sanitaria ” (Seal of [Water] Quality Sanitation) as a result of an external evaluation by AyA technicians (AAASE 2003). According to Feoli Boraschi (2007), the AyA initiated the Sello de Calidad Sanitaria program in 2001 as an incentive to local aqueduct ope rators in Costa Rica to prov ide high quality water to local populations in a sustainable and environmenta l friendly manner. The program consists of 6 parameters that local aqueduct operators mu st follow in order to receive recognition as having a Sello de Calidad Saniaria ; they are as follows: 1) An active program that protects local water sources, including maintenance in and around springs, reforestation, spring flow measurement and periodic spring in spection; 2) A program that periodically cleans water storage tanks and di stribution tubing; 3) A system to chlorinate all water and

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65 at the same time monitor residual chlorination levels; 4) A plan to implement environmental education programs in th e local community and to disseminate information about the aqueduc t publically; 5) A program to periodically measure water quality at different points th roughout the entire aqueduct and to maintain specific water quality standards at all times; 6) A compre hensive risk assessment and water mediation program in addition to futures planning (Feoli Boraschi 2007). At the time of this research, the Sa na Elena Aqueduct was one of only 13 local aqueducts in the entire country to receive this distinction; de monstrating that the aqueduct provides high quality water to the local population and maintains a high standard of quality control and assessment measures to ensure the consistency of services. Results from independent laboratory testing from Janua ry to June 2004 demonstrated that potable water from the Santa Elena aqueduct met wate r quality standards and residual chlorine levels for human consumption. Nicaraguan Immigrants in Monteverde In Monteverde, Nicaraguan immigrants have come to the area seeking seasonal agricultural work (the coffee harvest) and lowskill wage labor jobs (hotels, restaurants, and construction). However, it is unclear exactly how many Nicaraguan immigrants reside in and around Monteverde and how ma ny are employed in seasonal work. In addition, data on the health status of Nicara guan immigrants living in Monteverde is not available because the Monteverde Clinic does not collect data on pa tient nationality. A recent pilot study done by students of the 2003 USF-GRC/Monteverde Institute Globalization and Community Health Field Sch ool interviewed 19 households (a total of 71 individuals) headed by Nicaraguan immi grants in Monteverde. However, their research cited that due to tim e constraints, they were unabl e to make contact with all Nicaraguan households and much less with those who were engaged in seasonal employment. In any case, their report is cons istent with other national studies, including (Marquette 2006; Ministerio de Salud de Costa Rica 2002; OIM 2001) that Nicaraguan immigrants living in Monteverde have signifi cantly lower educational levels (18% had no schooling while 41% had not finished primary school); tend to live in substandard and/or

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66 crowded living conditions; tend to be paid lower wages and suffer from job insecurity; and are more likely not to have health c overage compared with their Costa Rican neighbors (over half of the individuals interviewed had no health insurance). Furthermore, interviews with Nicaraguan residents raised concerns relating to a lack of information about immigrant rights, health car e, and a general mistrust in accessing social services as a result of their immigration status. This research is the first know atte mpt to compare health outcomes between Nicaraguan immigrants and Costa Rican reside nts in Monteverde. It is hoped that the research will contribute to the knowledge of immigrant health status in Monteverde by determining whether Nicaraguan immigrants have a higher prevalence of parasitic infections and to better unde rstand the political economic, environmental and cultural conditions in which they are manifest.

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67 Chapter Four Research Objectives and Methods This chapter outlines the four primary research objectives of this dissertation including specific research questions and hypot heses. Following this will be a discussion of the research methodology that is organize d in terms of the pub lic health/laboratory methods and procedures used to determine parasite prevalence, and the anthropological methods used to inform the political eco logy framework. Included is an in-depth discussion of data collection techniques and instruments used to c onduct the research as well as a discussion of the research timelin e, the research team, selection criteria, sampling, and informed consent. Research Objectives The overall objective of this research is to determine how in teractions and interrelationships between political -economic, social and environmental variables affects disease outcomes by increasing levels of intestinal parasi tes Nicaraguan immigrants and Costa Rican residents in Monteverde. The fo llowing is an outline of the four primary research objectives in add ition to their specific resear ch question and hypotheses. Research Objective (O-1) : Determine the period prevalen ce of intestinal parasites among the study population Research Question (RQ-1): Are infections with intestinal parasites significantly underreported by the Monteverde Clinic? Alternative Hypothesis (H-1): Infections with intestinal parasites are significantly underreported by the Monteverde Clinic. Research Question (RQ-2): Within the study population, do Nicaraguan immigrants have higher prevalence ra tes of intestinal parasites compared to Costa Ricans?

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68 Null Hypothesis (H-2): There is no difference in the period prevalence of intestinal parasites between Nicar aguan and Costa Rican participants. Research Objective (O-2) : Determine the distribution and the most likely sources of infection and modes of transmission of intestinal parasi tes among the study population Research Question (RQ-3): Among the study populati on, are infections with intestinal protozoa more comm on than infections with intestinal helminths? Null Hypothesis (H-3): There is no significant difference in the prevalence of intestinal protozoa and intestin al helminths among the study population. Research Question (RQ-4): Are parasites primarily transmitted as waterborne infections, or through the fecal-oral route of transmission? Null Hypothesis (H-4): There is no difference in para site transmission; that is, intestinal parasites are just as likely to be transmitted via water as they are via the fecal-oral route of transmission. Research Objective (O-3) : Determine the significant socio-demographic, economic and cultural factors associated with the prev alence of intestinal parasites among the study population at the i ndividual and household level. Research Question (RQ-5): Are infections with intestinal parasites more common among study participants with no access to health care? Alternative Hypothesis (H-5): A lack of access to health care among study participants is associated with a hi gher prevalence of intestinal parasites Research Question (RQ-6): Is the household hygiene en vironment associated with the prevalence of intestinal parasites? Alternative Hypothesis (H-6): Inadequacies in household hygiene infrastructure are associated with a higher preval ence of intestinal parasites among study participants. Research Question (RQ-7): Is knowledge of intestinal parasites and prevention strategies associated with lower household rates of infection?

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69 Alternative Hypothesis (H-7): Significant knowledge of pa rasite etiology and prevention will be associated with lower prevalence rates at the household level. Research Objective (O-4) : Provide a general political ecological framework that explains the prevalence of intestinal parasites among the study population in Monteverde, Costa Rica Overview of Research Methods This research combined public health and anthropological methods. First, a crosssectional study design to determine the period prevalence of intestinal parasites among a study population of Nicaraguan and Costa Rican study participants was developed. In addition, anthropological methods such as se mi-structured interviews, observation, and key informant interviews were conducted to further explore and understand the cultural, behavioral, and political-economic context of parasitic infections a nd the relevant risk factors attributed to each study population. Table 4-1 summarizes the main elements of both the public health and anthropological methods. Table 4-1. Summary of Research Methods Public Health/Laboratory Methods Anthropological Methods Objective: To determine the period prevalence of intestinal parasites among a study population of Nicaraguans and Costa Ricans. Methods: Collection of Fecal Samples Analysis on Fecal Samples using Microscopic Diagnostic Techniques Diagnosis of Intestinal Parasites in Participant Fecal Samples Participants: Volunteer Participants (Nicaraguan and Costa Rican) from Santa Elena and Los Llanos. Objective: To better understand the demographic, cultural, behavioral, and the political-economic context of parasitic infections and the relevant risk factors attributed to each study population. Methods: Household Demographic Interviews Semi-Structured Interviews Key Informant Interviews Participant Observation Participants: Volunteer Participants (Nicaraguan and Costa Rican) from Santa El ena and Los Llanos

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70 Public Health and Laboratory Methods This research uses the prevalence of inte stinal parasites as a basic health indicator to compare Nicaraguan and Costa Rican study participants in Monteverde within a political-economic and social context. The principal objective of this aspect of the research was to contribute to the knowledge of immigrant he alth status in Monteverde by determining whether Nicaraguan immigrants suffer disproportionately from parasitic infections compared to Cost a Ricans and to better understa nd the social and economic conditions in which they are manifest. Research Timeline Research for this dissertation was co nducted from November, 2003 to July, 2004. Table 4-2 depicts the research tasks and the timeframe according to the sequence in which they were carried out. Table 4-2. Research Tasks and Timefram e of the Parasite Prevalence Study Research Task Description Timeframe Site Visits, Gaining Permission and Informed Consent This time was spent making site visits to neighborhoods and communities in and near Santa Elena. Special Permissions and Ethical Review applications were completed. November 2003 – January 2004 Participant Selection, Collection and Analysis of Biological Samples Participants were selected and fecal samples were taken and analyzed for intestinal parasites. February 2004 – June 2004 Education and Dissemination Based on observation and interviews concerning parasite knowledge and attitudes, educational information concerning parasites and prevention was given to all participants. May 2004 – July 2004 Research Team This research was financially suppor ted by the USF Globalization Research Center through a graduate rese arch assistantship. However, there were insufficient funds with which to hire a research assistant to help with data co llection or laboratory procedures. As a result, I took on all research responsibilities involved in this research. In

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71 retrospect, the lack being able to hire at least one research assistant was a major limiting factor on two aspects of the study: site selection and sample size. Selection of the Research Community The community of Santa Elena de Monteverde was chosen as the primary research site. This decision was based on the fo llowing characteristics: 1) Santa Elena is the focal point of poor waste water mana gement, water insecurity, water pollution, urbanization, and tourism; and 2) in the M onteverde Zone, Santa Elena is the community where the majority of the Nicaraguan immigr ant population resides. Thus, the research site made it possible to compare prevalence rates of intestinal parasites among a group a Nicaraguans and a group of Costa Ri cans living in the same community. Since the selection of stu dy participants had to be chosen from Santa Elena, it became necessary to define community bounda ries because it was often difficult to determine where one community ends and anot her begins. As a result, household were selected from neighborhoods that were political ly defined as part of Santa Elena. The other criterion was that the household rece ive water from the Santa Elena Aqueduct. Under this rubric it was ensured that all participants selected for the study received their water from the same central source. The st andardization of the household water source was an important considerat ion for household selecti on since the study sought to determine the prevalence of water-borne para sites. Santa Elena has a centralized water distribution system which is managed by th e Costa Rican Institute of Aqueducts and Sewers (AyA). As explained in chapter thr ee, the community’s potable water originates from several mountain springs located in and around the community. The Santa Elena Aqueduct is responsible for water allocation, distribution, quality control, chlorination, and metering of the communities water supply. Due to the difficulty of locating Nicara guan households, the Monteverde Institute recommended including the nearby communities of Los Llanos and Caitas in addition to Santa Elena. Due to the fact that the Nicaraguan population living in Caitas was mostly made up of temporary laborers, Caitas was not chosen as a research site from which to choose the study participants. Los Llanos, on th e other hand was eventu ally included as a

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72 research site because the Nicaraguan populat ion living there were more sedentary and because the community was serviced by the Santa Elena Aqueduct. Recruitment of Participants Study participants were chosen based on th e following criteria: 1) the Participant must be of either Costa Rican or Nicaraguan national origin; 2) that participants live in households representing a variety of neighbor hoods throughout Santa Elena; 3) that participants’ households be at risk for parasite transmission (i.e., proximity to gray water pollution, poor sanitary conditions, wa ter insecurity, poverty, crowded housing conditions etc.); 4) that reside nts have lived in Monteverde fo r at least a year prior to the study and that they remain in the community for the duration of the study; 5) that both an adult and a child under 17 years of age livi ng in the same household participate in the study; and 6) that each household receive their potable water from the Santa Elena Aqueduct Association. One of the most important criteria for selection was the participants’ national origin. For this reason, only Nicaraguans and Costa Ricans were asked to participate in the study. The definition of a Nicaraguan or Co sta Rican was defined as having been born in their respective countries a nd self identifying as either Nicaraguan or Costa Rican. In this study, children of Nicaraguan born pare nts who were born in Costa Rica, (making them legal Costa Rican citizens) were consid ered to be Nicaraguan because the family self identified as being culturally Nicaraguan. Another criterion for selec tion was that the study partic ipants lived in household’s located in a variety of different neighbor hoods throughout Santa Elena and Los Llanos (see Figure 4-1). The geography of settleme nt in Santa Elena does not revolve around a central area, but rather is spread out along a main road. As a result of increased urbanization, settlement patterns in and around Santa Elena are unorganized and often do not follow zoning standards. New neighborhoods and settlements are continuously being developed around the Monteverde Clinic, the cemetery, and along the main road. Thus, in Santa Elena, it was attempted to choose participants living in households located in the upper, middle and lower parts of the community. In Los Llanos, participants were chosen

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73 from that community’s cent ral settlement as well as from a new low-income housing neighborhood called “ La Colina ”. Identifying households in different sect ors of Santa Elena and Los Llanos was facilitated by commun ity maps from the Monteverde Institute. Figure 4-1. Map of the Study Communi ties and Selected Households In addition, to selecting pa rticipants living in househol ds located throughout Santa Elena and Los Llanos, it was attempted to sel ect households with ch aracteristics that put

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74 them at risk for intestinal parasites. Factor s of increased risk for intestinal parasites included the following: a close proximity to wastewater pollution, past experience of water insecurity, poor san itary conditions, crowded liv ing conditions, and limited financial resources. Another criterion for sel ection was that participants had been a resident of Monteverde for the past year and that they pl anned to stay in Monteverde for the duration of the study. This was important because peop le who had recently arrived in Monteverde could be hosting parasitic infections they contracted in other locations. Finally, it was important th at children under 17 years of age participate in the study since they are more susceptible to and adversely affected by parasitic infections compared to adults. In this case, it was attemp ted to select at least one adult and one child under 17 living in the same househol d to participat e in the study. Sampling The study enrolled two study populations one Nicaraguan and the other Costa Rican. The goal was to recruit 50 particip ants for each respective study population. Participants were identified and asked to participate in the st udy by using separate snowball samples for each group (one for Nicaraguan households and one for Costa Rican households). The researcher continued to identify and enroll participants from each group to the study until 50 participants for each study population had been selected. Identifying and enrolling participants through the snowball samples were done on a continual basis between Februa ry and June, 2004 as the researcher processed the fecal samples. The snowball method of sampling was used because it was the only way to locate Nicaraguan households. Thus, one snowball sa mple was started with a Nicaraguan key informant and continued until enough participan ts had been selected. For the Costa Rican population, three snowball samples were star ted in three neighborhoods along the main road; one from the North part of town, one fr om the South end, and one from Los Llanos. Each snowball sample was started with a Co sta Rican contact and was done in order to

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75 identify households from different areas of Sa nta Elena. See table 4-3 for a description of the number of participan ts in each sample. Key informants used to start each snowball sample were identified using the researchers own contacts or based on sugges tions from the Monteverde Institute. All interviews were administered to the ma le and/or female head of household, though preference was given to the female head of household whenever possible because they are most involved in household water handli ng and health care. Finally, all household members were be invited to participate in the study, though the final decision as to which household members participate in the prevalence study was up to the head of household. Table 4-3. Number of Participants Recruited Study Group Participants Recruited (N=126) No. of Participants in Prevalence Study (n=84) No. of Refusals # lost to follow-up Costa Rican 76 49 0 2 Nicaraguan 50 35 10 7 As mentioned earlier, due to the difficu lty of locating Nicaraguan Households, researchers from the Monteverde Institute suggested focusing on two small settlements, one in the community of Caitas and the other in the community of Los Llanos. It turned out that there was a significant population of Nicaraguans living in Caitas employed as temporary agricultural workers, mostly fo r the coffee harvest. While this population would have been interesting to study it turned out to be im possible due to their migratory nature. Since the Nicaraguan population in Caitas was constantly moving, and was mostly made up of men, it was decided not to include this populat ion. On the other hand, there were several Nicaraguan families liv ing in Los Llanos who were long term residents. It was decided to ask these familie s to participate in the study. For comparative reasons, several Costa Rican families from Los Llanos were also asked to participate. One of the biggest challenges of worki ng with the Nicaraguan population in terms of sampling was the refusal rate to participate in the study and loss to follow-up. Due to IRB standards, written informed consent was required for participation in the study. For the Costa Rican families, this was not a problem as no individuals rejected participation.

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76 In contrast, ten Nicaraguan i ndividuals refused to particip ate in the study specifically because of the requirement of written inform ed consent. These individuals and families expressed a desire to particip ate in the study, saying that th ey were interested to know whether their children had parasi tes, but that they would not pa rticipate if they had to sign “a piece of paper.” In all cas es, these individuals and fam ilies were extremely poor; were of low literacy; had dubious legal status in the country, and cited having gotten into “problems” in the past for signing papers that they did not fully understand. This researcher thus perceived the written info rmed consent process as a limitation when working with the Nicaraguan community because the families who refused to participate in the study expressed a desire to do so. Another issue in the sampling was loss to followup. While some participants ag reed to partake in the study, many participants did not end up providing a fecal sample. Informed Consent, Confidentiality and Study Permission A protocol for this research was submitted to and approved by the University of South Florida’s Institutional Review Boards (IRB) divisi on of biomedical research involving human subjects. For this researc h, a biomedical research IRB had to be submitted because the study involved collecti ng, handling and analyzing infectious agents. A waiver of informed consent was s ubmitted because the researcher believed that the Nicaraguan community would be skeptical of signing consent forms. However, the request for a waiver of informed consent was eventually denied because the study was biomedical in nature. Thus, a combined informed consent document requiring the signature of both adult partic ipants and the guardian of child participants, and the researcher was created and used for the study (See Appendix A for a copy of the Combined Written Informed Consent Form). In addition to the USF-IRB process, th e research proposal was also submitted to an informal ethical review board at the Monteverde Institute. Upon review, the MVI ethical review board suggested that the pr oposal be submitted and approved by an incountry scientific ethical review board befo re the MVI gave permi ssion to carry out the study. At the time of this study, Costa Rica did no t have an official IRB process or policy

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77 for independent researchers ca rrying out research in Costa Rica. Permission to carry out biomedical research is usually obtained by official international research groups in conjunction with the Ministry of Health. Instead, it was s uggested that this research proposal be submitted for IRB approval from an ad-hoc ethical committee housed at the National University of Costa Rican in Heredi a. As a result, this research proposal was submitted to the “Comit tico Cientfico Del Instituto Regional de Estudios en Sustancias Txicas” (CEC-IRET). Finally, the proposal to carry out the study was approved and permission to conduct the study was granted in November, 2003 by the Monteverde Institute. Field and Laboratory Procedures for th e Diagnosis of Intestinal Parasites Determining the period prevalence of intestinal parasites among the study population incorporated collection and handli ng procedures of biological samples in addition to laboratory procedures to identif y and diagnose intestin al parasites. Both collection and laboratory procedures and met hods were based on Dr. Donald L. Price’s book called “ Procedure Manual for the Diagnosis of Intestinal Parasites ” (1994). Table 4-4 outlines the field and laboratory procedures us ed to collect and analyze fecal samples. Table 4-4. Field and Laboratory Procedures Field/Laboratory Procedure Description Collection of Fecal Samples Specimen vials were provided to all study participants to collect fecal samples for analysis of intestinal parasites. Handling and Organization of Fecal Specimens The specimen vials were collected by the researcher and later coded and stored in the MVI laboratory until analysis. Sample Preparation Samples were prepared for analysis using concentration and staining methods. Examination and Diagnosis of the Specimen Samples were analyzed and diagnosed using microscopic techniques. Positive samples, along with a percentage of negative samples were taken to a private laboratory for confirmation. Dissemination of Results Participants were later given the official laboratory results and its implication was discussed.

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78 Collection of Fecal Samples In traditional laboratory settings, including the ones used in Costa Rica, unpreserved fecal specimens are collected a nd submitted for examination of intestinal parasites. Unpreserved fecal specimens refer to those that are collected directly and which have not been placed in a preservation solution to prevent prem ature desiccation of parasite cysts, trophozoites, eggs, and larv ae. According to Price (1994), the cysts and trophozoites of intestinal parasites start to break down in unpreserved specimens within 30 minutes of being passed and after seve ral hours, unpreserved specimens in field conditions can completely break down a nd become unidentifiable. Thus, field circumstances where fecal specimens ar e unpreserved can significantly reduce the probability of finding and identifying parasite s in collected specimens. The practice of collecting unpreserved fecal specimens has theref ore been criticized as contributing to the underreporting of parasi tic infections (1994). Several methods exist to preserve fecal specimens in field settings. According to Price (1994), specimens that are immediatel y placed in a fixation/preservation solution significantly increase the chance of identifying positive samples compared with those samples that are unpreserved. This study used “PIF” solution to collect and preserve all fecal samples collected in the field. PIF solu tion contains formalin, glycerin, alcohol, and formaldehyde and is mercury free, unlike ot her commonly used collection/preservation solutions. The PIF solution is effective fo r collecting, fixing, pr eserving, and staining trophozoites, and cysts of protozoa; eggs of trematodes, cestodes, nematodes; and juveniles of nematodes in bulk feces. Organi sms are killed and preserved once they come into direct contact with the chemical solu tion. Mixed specimens can be examined an hour after they have been collected. Another advantag e is that specimens retain indefinitely the diagnostic features present at the time of fixation and thus can be analyzed at the convenience of the researcher. This resear cher used a commercially available PIF collection and preservation system called ProtoF ix that is manufact ured and distributed by Alpha-Tec Systems, Inc. The ProtoFix system consists of a 20ml plastic vial with a screw on cap that contains 13ml of the PIF solution.

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79 In traditional laboratory settings that test for parasites, including those in Monteverde, it is the responsibility of the pati ent to bring the fecal sample to the clinic for testing. Because time is an important el ement in the identification of parasites in unpreserved specimens, patients are usually told to arrive at the clinic early in the morning, while fasting, and provide a fecal sample on the spot that is then transferred to the lab for analysis. If the patient is unable to provide a fecal sample on the spot, they are given a container with which they are supposed to collect the sample at home and bring it in right away the next morning. This proce ss is time consuming for the adult and can be stressful for the child. At the Monteverde Clin ic, laboratory specimens must be sent to the Puntarenas hospital for analysis, increasi ng the time between passing the specimen and analysis; therefore reducing th e probability of encounteri ng parasites in the sample. The procedure used in this study enabled participants to coll ect fecal samples in the comfort of their own home and at their own convenience; samples could be collected any time of the day and did not require the individual to fast before producing the specimen. Thus, the procedure used by this researcher eliminated the inconvenience of the parent of having to go to the clinic, and stress on the child to produce a specimen on the spot. This procedure also eliminated th e urgency with which the sample had to be returned to the laboratory for analysis sin ce preserved samples can be analyzed at any time without risking the quality of the sample. The procedure used to collect fecal samples was as follows: After a household agreed to participate in the study and after consent forms had been signed, the head of household was provided with a ProtoFix kit for each family member who wished to participate. Each kit consisted of a plastic zip-lock baggie that c ontained one ProtoFix vial and three wooden sticks. I was extremely careful to provide a detailed explanation to participants on how to collect the fecal sa mples. Written instructions that included drawings on how to collect the sample were also provided to participants (See Appendix B for a copy of the written instructions that were given to participants). To ensure that participan ts fully understood the proce dure, I asked the head of household in charge of collecti ng the samples to explain the pr ocedure. In addition, I also stressed that the preservation solution in the vi al was poisonous and that it was to be kept

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80 under strict parental supervisi on at all times to prevent sma ll children from inadvertently playing with or drinking the so lution. Instruct ions and contact number s were given to the head of household with instructions in case of accidental ingestion. At the outset of this research there was doubt as to how participants would respond to the research and the process of coll ecting fecal samples. I was relieved to hear positive feedback from heads of household w ho had successfully collected fecal samples for themselves and their children. Many part icipants commented that the ProtoFix collection system was easy and much more conve nient compared with going to the clinic since samples could be collected in the hom e under natural circumstances. This was especially the case with small children who would stress at th e clinic and fail to produce a sample. One mother stated that this was the first time that her son had been tested for parasites explaining that all previous attempts had been thwarted by clinic related stress. In general, the study participants were not put out by the proce ss of collecting fecal samples because the majority of them had been exposed to the procedure in the past; most of them equated providing a fecal sample with testing for parasites and perceived the procedure itself as commonplace. Due to time constraints, each participan t was asked to provide one fecal sample. In some cases I asked that the participant collect an additional sample. This was only done in the following circumstances: 1) when the initial sample provided was of poor quality (i.e., when the sample was inadequate ly mixed; when there was too much sample or too little sample collected in the vial); 2) when the initial sample tested negative for parasites while the participant had symptoms th at could be related to parasitic infections; and 3) when the sample tested positive for parasitic commensals (non-pathogenic species) including Entamoeba coli and Endolimax nana This was done to ensure that no pathogenic species were missed upon the firs t analysis since pathogenic parasites like Entamoeba histolytica often coexist with commensal species. Handling and Organization of Fecal Specimens Once the specimen vials had been given to the head of household, I discussed an appropriate time frame to retu rn to the home to collect the samples. In most cases, I

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81 would call the head of household to see if th e samples were ready to be picked up. In other cases where the household had no phone serv ice, I agreed to return on a certain day to collect the samples. Once collected, th e sample vials were transported to the Monteverde Lab for stor age and organization. This method of collecting the sample vial s turned out to have its advantages and disadvantages. The disadvantage was that not all household members produced samples at the same time often requiring multiple visi ts to the household to collect all of the samples. As was the case in many households all the participants produced a sample on time, save for one or two individuals who would take up to several weeks to produce a sample. In a few cases, participants failed to provide a sample altoge ther and were thus considered lost to follow-up. Reasons varied for the extreme delay in producing a viable sample. In some cases it was due to an un-cooperating child and in other cases, a forgetful adult. Some households produced all samples in a matter of days, while others delayed more than a month to provide all of the house hold samples to the researcher. While the delay in producing samples wa s a disadvantage in terms of time. The advantage was that this gave me an excuse to make continued visits to the household to check on the status of the samples and allo wed me to spend time within the household and to get to know the particip ants better. I also took advantage of this time to conduct observations and to conduct in terviews with participants. When participants finally did provide th e researcher with a sample it was taken back to the laboratory at the Monteverde Inst itute. Back at the laboratory, the sample was assigned a code number that identified it w ith both to the household and the sample population. To ensure patient c onfidentiality, the names that were written on the sample vials were blocked out and replaced by c ode numbers. The code numbers were then entered into a computer data base. Before and after the samples were processed for analysis they were placed in a box and were lo cked in cabinet to en sure that they would not be tampered with.

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82 Sample Preparation Once at least 6 specimens had been collected they were prepared together for microscopic analysis. All samples underwent a concentration process from which wetmount preparations were made to be analy zed under the microscope. In addition, a small specimen left over from the concentrati on procedure was applied to a separate microscope slide and stained for cryptosporidium parvum. Concentration Procedures and Wet-Mount Slide Preparations In most laboratory settings, concentra tion methods are used to increase the probability of finding eggs, cyst s, trophozoites, and larvae of parasites in preserved and unpreserved specimens. Concentration methods are essential for locating parasites when the parasitic load in an individual is low. For this study, the CONSED system was the concentration method used to facilitate the identification of parasites. The CONSED system is a relatively new procedure that wa s designed specifically to concentrate fecal specimens that have been collected and preser ved in ProtoFix solution. Like ProtoFix, the CONSED solution is commercially avai lable from Alpha-Tec Systems, Inc. The CONSED system uses the princi pals of sedimentation (as opposed to flotation) and is often referred to as gravity sedimentation because th e specific gravity of parasite eggs, cysts, and trophozoites play a role and because the process requires the use of a centrifuge. The system uses a unique sediment solution, straining funnel, and centrifuge. After each sample had been concentrat ed using the CONSED procedure, wetmount slides were prepared and later analyzed with a microscope. The wet-mount procedure used in this research was as fo llows: After the concentration procedure had been performed, a small specimen was taken from the centrifuge test tube and placed onto a microscope slide. Cover glass was th en placed over the specimen and excess liquid or material was wiped off. The edges of the cover glass were then sealed using vaspar, a heated mixture of 50% Vaseline and 50% para ffin wax. Sealing the edges of the cover glass preserved the specimen for up to a week making it possible to examine the slide at a later date when it was convenient.

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83 Staining Procedures for the Identification of Cryptosporidium parvum In addition to preparing wet-mount slides for the examination of common intestinal parasites, a special staining procedure to examine all specimens for Cryptosporidium parvum (an intestinal coccidian parasi te that is of increasing public health importance) was performed. It was decided to test specimens for C. parvum because it is considered to be an important wate r-borne parasite that is able to persist in chlorinated water systems. For example, C. parvum was implicated as the pathogen that infected more than 300,000 residents of Milwaukee, Wisconsin in 1996 due to contaminated drinking wa ter (Mayer 2000). Since C. parvum is too small to be identified using traditional microscopic techniques, a staining procedure has been invented to facilitate its identification. A small part of the concentrated specimen was taken and spread over a microscope slide, thereaft er, each slide underwent a simple two part staining process to test for C. parvum. The staining kit used in th is research is available from Alpha-Tec Systems, Inc. to be used with specimens that have been collected and preserved in ProtoFix solution. Analysis of Fecal Samples The microscopic analysis procedures used to determine the presence of intestinal parasites as well as the qualit y assurance measures employed to ensure proper diagnosis is discussed in the following chapter. Dissemination of Results The results of all samples were given to participants as soon as possible after they had been properly examined. In the case of positive samples, the results were given to them as soon as they had been verified by th e private laboratory. In all cases, a results sheet was given to the head of household with the name of each part icipant, the date, and the results of the laboratory examination along with the researcher’s signature. When the results dealt with positive samples, the origin al result sheet from the private laboratory in Puntarenas was presented and gi ven to the head of household.

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84 In the case of positive samples I was careful to provide the participant or head of household with comprehensive information as to the meaning of the results and whether or not the species tended to be pathogenic or non-pathogenic. W ith all participants, regardless of whether the results from their sample were positive or negative, I took as much time as necessary to explain the nature of the parasites and their infections. I was also careful to explain concepts such as s ources of infection, m odes of transmission and prevention strategies particular to different species of parasites. Anthropological Methods In addition to the public health field and laboratory procedures, I also relied heavily on anthropological methods incl uding semi-structured interviewing and participant observation to be tter understand the cultural, be havioral, and the politicaleconomic context of parasitic infections (see Table 4-5 for an overview). For this study, anthropological methods were an invaluable t ool to evaluate the source of infection and mode of transmission of parasitic infections with in the household setting. Table 4-5. Anthropological Methods Method Description Archival Data Collection Documents containing local and national health statistics, local water quality reports, and newsletters were collected to provide background information for the study. Semi-Structured Household Demographic Interviews for Costa Ricans and Nicaraguans This interview was conducted with all Costa Rican and Nicaraguan households to gather information regarding household structure, income, employment, education, migration/immigration, and remittances. Semi-Structured Health Interviews This interview was conducted with all households in order to elucidate knowledge, attitudes, and behaviors relating to intestinal parasite. Semi-Structured Water Security Interviews This interview was conducted with all households to gain information concerning house hold water use, access, cost, water quality, water security, sanitation, wastewater management and perceptions about water services. Participant Observation Observations were conducted during household visits to identify household conditions relating to potential sources of infections and modes of transmission of parasites.

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85 Key Informant Interviews Community leaders, water managers, and clinic staff were interviewed to better understand community water security and local health issues. Health Education All households that participat ed in the study receive basic information about how to prevent parasitic infection including common modes of transmission and sources of infection. Archival Data The majority of Archival data for this phase of the research had already been collected during “The Household Manageme nt of Health, Water and Waste Project.” However, more secondary and archival data was gathered and used to compare and place local reality within national and historical context. Documents such as national health statistics, studies of immigrant health, ne wsletters, newspaper articles, historical documents and records were used to provide background and historical information for the parasite prevalence study. In addition, local health statistics, most importantly, the period prevalence of intestinal parasites from the Monteverde Clinic was collected. This data provided a point of comparison between my data and the clinic data regarding parasite prevalence at the time of this resear ch. Records of water qua lity analysis of the Santa Elena Aqueduct were also collected in order to determine potable water quality standards at the time of this research. Semi-Structured Interviews Because this research was not only intere sted in parasite prevalence rates between Costa Ricans and Nicaraguans, but also the political, economic, cultu ral and historical factors that influence risk factors for infectio n; a series of 3 semi-structured interviews aimed at better understanding these factors were administ ered to each participating household. Each of the three semi-structured in terviews focused on a different theme that coincided with the research objectives su ch as: household demographics, household water management, and knowledge, attitudes and behaviors relati ng to parasites. The interview guides, while structured, a llowed me to pursue relevant leads from the participant. In addition, all of the interview guides were developed based on past research carried out in the community incl uding the GRC development survey and “The

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86 Household Management of Health, Water and Waste Project.” All of the semi-structured interviews were briefly piloted for conten t and language and changes were made where necessary during the research as well. The interviews were administered duri ng household visits th at were scheduled around the collection, retrieval, and disseminatio n of results of the fecal specimens. This method of administering the interviews was both convenient for me and for the participant since it spread the interviews out over the period of a couple weeks. In this way, the participants felt that each intervie w was part of each household visit relating to the handling of the fecal specimens. In addi tion, the researcher made an attempt to maintain the time needed to conduct each inte rview to a minimum so that participants would not feel that each household visit was so time consuming. In general, all three of the semi-structured interviews took appr oximately between 30 to 45 minutes to administer. It should also be noted that two separa te demographic interviews were designed for both Costa Rican and Nicaraguan households The researcher de cided that household histories and structures differed greatly between the two groups and that administering the same instrument to both populations w ould risk being irrelevant to one group. However, the interview maintained continu ity by asking relevant questions to both groups. For example, virtually all questions th at were asked of Co sta Rican Households were also asked of Nicaraguan households. The interviews only diverg ed in topics that are relevant to Nicaraguan households, for exam ple, immigration to Costa Rica, access to community services, and finally perceptions an d experiences of social acceptance within the Costa Rican community. Semi-Structured Demographic Interv iews for Costa Rican Households This was the first of the three semi-structured interviews administered to Costa Rican families. In most cases it was conducted on either the first or second visit to the household. The interview was designed to be s imple and straightforward and in general took approximately 30 minutes to administer. Demographic interviews were administered to each of the 18 Costa Rican households in the study. This interview asked participants

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87 about their place of origin and their current household structure including the number of people who inhabit the home during the enti re year. Information relating to current employment/income and past unemployment for all household members was collected. In addition, several questions were aimed at co mmunity participation and their perceptions of tourism in the area including whether th e household perceived itself as benefiting directly from tourism. Finally, participants were asked to express their opinions of the community’s health services and were aske d to share both good and bad experiences and whether all household members had health in surance (See Appendix C for a copy of the actual interview). Semi-Structured Demographic Interv iews for Nicaraguan Households As discussed above, the same questi ons asked to Costa Rican households including household structure, employment, perceptions of to urism, and health services were also asked to Nicaraguan households. In addition, a series of questions aimed at better understanding the reality and uniqueness of Nicaraguan households were added to this semi-structured interview. As a result, th is interview took a b it longer to administer; usually about 45 minutes. This was the first of the three semi-structured interviews administered to Nicaraguan families. In most cases it was conducted on either the first or second visit to the household. Demographic interviews were administered to all 11 Nicaraguan families in the study. The additional questions included topics of the hous ehold’s first migration to Costa Rica and continued movement between the two countries. In addition to asking their opinions about local health services, Nicaraguan residents we re asked about the level of access they had to community servic es in general. The in terview also included questions concerning remittances sent to family and friends in Nicaragua. Finally, questions relating to perceptions and experien ces of social acceptance within the Costa Rican community were asked (See Appendix D for a copy of the actu al interview). The ideas for additional questions came in part from a questionnaire that was used for a transnational study on th e immigration situation between Costa Rican and Nicaragua. The

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88 research for that study was carried out in 2000 by the International Organization for Migration (OIM 2001). Semi-Structured Interviews: Para site Perceptions and Knowledge This was the second semi-structured inte rview administered to study participants. In general it was administered on the second or third visit to the participants’ household. The household health interview was specifically developed and admini stered to heads of household in order to elucidate individual knowledge, perceptions, and behaviors relating to parasites etiology, symptoms, and treatmen t pathways. In addition, participants were asked to provide a detailed household parasite infection history and participant’s history of taking anti-parasitic medication. Out of the three semi-structured interviews administered, this one tended to last the longest, taking on average 45 minutes. In total, 18 health interviews were administered to Costa Rican families and 10 were administered to Nicaraguan families (See Appendix F for a copy of the actual interview). Specifically, heads of household were asked to talk freely about their understandings of what parasites are, the diffe rent species they knew of, where they come from, how they are transmitted, and how one can prevent getting them. Participants were also asked to talk about past experiences with parasites, how they identify persons infected, and what they do to get rid of them; paying special attention to both western and folk medicine. Participants were also asked to talk about parasite s in the community, if seasonality or weather plays a role, and whether they perceive parasites as a public health problem. The interview ended by asking a series of yes/no questions that were designed to test specific knowledge concerning comm on parasite etiology and to verify whether these answers coincided with statements they had made at the beginning of the interview. This activity proved to be helpful in clarifyi ng ideas and in getting participants to offer more information. The main purpose of this interview was to create and better understand how participants construct parasite related doma ins and to see whether these domains differed significantly between Costa Ri can and Nicaraguan households. The researcher felt that this information was relevant since partic ipant knowledge, percep tions and behaviors

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89 related to parasites were completely unknown. Th e researcher was also interested in this information because all partic ipants would be provided with education materials relating to parasites at the end of the study, and in or der to provide particip ants with relevant information regarding parasites, domains of knowledge and perceptions had to be understood. Semi-Structured Interviews: Household Water Management This was the last of the three semi-str uctured interviews administered to study participants. In most cases it was administered on the third or fourth visit to the household. This interview tended to be the shortest of the th ree semi-structured interviews; taking on average 15 minutes to complete. In total, 18 water interviews were administered to Costa Rican families and 10 water interviews were administered to Nicaraguan families. Since this research was interested in whether there was an association between local water management and the prevalence of intestinal parasites, interviews were conducted with all heads of household in orde r to ascertain inform ation about household water use, water supply, access, cost, per ceptions of water quality, water security, sanitation, wastewater management and the qua lity of water services (See Appendix E for a copy of the actual interview) These interviews were ex tremely similar to the ones conducted in “The Household Management of Health, Water and Waste Project.” For example, observations regarding household wate r infrastructure both in and outside the household were conducted during th e interview. The decision to follow the format of the interview guide used in previous study was twofold. First, the que stions asked in the interview efficiently cover a wide spectrum of issues related to household water use and perceptions. Second, the researcher wished to know whether there was a difference between water use, access and handli ng between Nicaraguan and Costa Rican households.

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90 Participant Observation Although participant observation was not pl aned as being a major method of data collection of this research, observations conducted during household visits provided valuable information. Apart from the formal observations conducted during the household water interview, informal observa tions were conducted during most other household visits. These informal observati ons related to sanitary conditions and behaviors, possible sources of infection, a nd potential modes of tr ansmission in addition to household structure and family dynamics. Key Informant Interviews Key informants including community lead ers, water managers, and clinic staff were interviewed to better understand these issues within the community context. The researcher was also lucky to count on a key informant from the Nicaraguan community who helped place the community into politic al, economic, and cultural perspective as well as introduce the researcher to other members of the community. Key informants were chosen based on their abil ity to provide information that reflects broad consensus or official policy in their field of expertise. One of the important key informants interviewed was a community health specialist from the Monteverde EBAIS who was familiar with the Nicaraguan community and the health issues that affect them. This particular key informant shed light on many issues important to the research and was al so helpful in providing me with parasite prevalence data from the Monteverde Clinic. Other key informants included the director of the Santa Elena Aqueduct, water researchers from the Monteverde Institute and a local water committee member. These key informants provided me with a better understanding of community water issues and also provided me with community based water quality data.

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91 Health Education Based on interviews with participants concerning knowledge, perceptions, and behaviors of parasite etiology, an inform ation brochure was designed, prepared, and explained to participants in the form of an educational discussion (See Appendix G for a copy of the educational brochure). In most cases the discussion was conducted during the last household visit. The broc hure and discussion touched on and explained all of the topics of the health interview. It was discove red that the majority of participants had a relatively high level of sophi stication when it comes to knowledge about parasite. The education discussion served to correct common misconceptions about parasites and focused on sources of infection, modes of transmission, and prevention. Data Analysis A discussion of laboratory analysis procedures and both qualitative and quantitative data analysis procedures is presented in the following chapter.

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92 Chapter Five – Data Analysis This chapter will briefly describe the pr ocess of data analysis of both the public health based research methods and the an thropology based research methods. This discussion of the research analysis will be or ganized in three sections: 1) analysis of biological samples to determine the pres ence of intestinal parasites among study participants; 2) analysis of ethnographic data collected from semi-structured interviews concerning participants’ perceptions and know ledge of intestinal parasites; and 3) statistical analysis of dem ographic and epidemiological da ta from household surveys and laboratory results of fecal samples. Analysis of Biological Samples to Determin e the Prevalence of Intestinal Parasites For this part of the research, an Amer ican Optical, Model 110, compound clinical microscope was used to examine the prepared fecal specimens. The microscope was set up for Khler illumination in order to examine all wet-mount samples under bright-field illumination (Price 1994). Setting up the micros cope for Khler illu mination facilitates locating potential cysts and tr ophozoites of intestinal prot ozoa through their refractive index. This was achieved by scanning each wet mount specimen under the 10x ocular objective while quickly moving the fine focus of the microscope in and out of focus to look for objects to “flash” in the field. Wh en a suspicious object was observed, the researcher switched to the 40x or 100x objectives to better observe the object. In most cases, species identification was determined using the 100x objective and by using the microscope’s eyepiece micrometer for the precise measurement a nd identification of parasite cysts, trophozoites, and eggs. Iden tification of parasite species was based on morphological characteristics including si ze and internal cell structure. When parasites species identification was questionable, the researcher used the CDC parasite bench aids and Pr ices’ key for differentiating sp ecies of intestinal amoebae and helminth eggs found in feces preserved in PIF solution. Parasite identification was

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93 made directly from the wet-mount concentrated slides. While it is s uggested that slides should be stained with Polychrome IV or Trichrome-PLUS to ensure species identification, I found that iden tifications from wet-mounts were more than sufficient and much less time consuming. One of the major conditions imposed by the CEC-IRET (the Costa Rican IBR Committee) to the parasite prev alence study was that all fecal samples that tested positive for parasites, and a random selection of samp les that tested negative for parasites, be verified by a licensed microbiol ogist in Costa Rica. This c ondition was imposed, in part, because the researcher was not a microbiol ogist by training and was therefore not licensed to provide laboratory re sults to Costa Rican citizens. As a result, all positive lab results obtained by the researcher had to be confirmed by a licensed Costa Rican microbiologist. In order to accommodate the confirmati on of positive lab resu lts, the researcher adhered to the following protoc ol: 1) once the researcher identified a positive sample all of the details were noted in a laboratory diary and logged into a computer spreadsheet and digital photographs were taken for addi tional documentation; 2) once several positive samples were identified, the original sample vials were taken to a licensed microbiology laboratory in Puntarenas for secondary conf irmation; 3) for every three positive samples submitted for confirmation, the researcher included a random negative sample to be confirmed as a quality control measure. Secondary laboratory confirmation of for intestinal parasites wa s carried out by the Laboratorio Quimico Clinico, Dra. Zoila Torres located in Puntarenas. This private labo ratory was chosen because the turnaround time for sample confirmation was much fast er (just a few hours) compared to a CCSS clinical laboratory where the turnaround tim e was several days at best. Once laboratory confirmations were completed, the microbiol ogist provided the re searcher a signed document stating the official diagnosis w ith the name of the corresponding patient. Copies of these documents were made and the researcher later disseminated the original form to the patients.

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94 Qualitative Data Analysis of Semi-Structured Interviews Analysis of semi-structure d interviews of participants’ perceptions of intestinal parasites was done entirely using a grounded th eory approach with the qualitative data analysis software ATLAS.ti 5.0. In total, 28 in terview transcripts we re assigned into the ATLAS.ti primary document manager and a he rmeneutic unit (project document) was created. Later, each transcript, or primary document was further assigned into primary document families; appropriately named Costa Rican households and Nicaraguan households using the primary document fam ily manager. Each primary document was assigned a family in order to facilitate queries that later reveal differe nces and similarities both among and between groups. The next analytical step was to code the primary documents. Codes, in this case were understood as names for pieces of data ( quotations) that have specific meaning and can that can be organized into thematic gr oups. In order to facil itate data analysis, primary documents were coded and organized within the specific parameters of the interview objectives: 1) how participants desc ribe what parasites ar e in general; 2) how participants understand the source of infection and mode of transmission of parasites; 3) how participants identify common symptoms a nd illnesses relating to parasites; 4) to know what illnesses or diseases are caused by pa rasites; 5) what participants do to treat parasites; 6) what participants do to prev ent parasites; and finally 7) to explore community perceptions of parasi tes and areas of folk knowledge. While the process of coding primary documents followed the structure of the research objectives, the actual codes themselv es were based on careful reading of each document. In this sense, it was the intent of the researcher to “gr ound” the codes as close as possible to the data. Also, when possible, codes were given pr ocedural labels. As explained by Charmaz (2006), procedural codi ng uses the gerund to label codes (i.e., walking with bare feet) in order to elucidate structures of process in the data, not just explanations. This method of coding proved to be relevant because the interviews sought to understand what mothers do, would do, or sh ould do in hypothetical situations. In the end, the researcher created approximately 174 codes from the 28 primary documents.

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95 Another important aspect of coding and of data integration in general, is creating families of codes. In ATLAS.ti, code families represent related codes that when combined, form thematic groups; sometime s referred to in ethnography as cultural domains (Spradley 1980). In this research, c ode families were developed as a result of analysis of the codes themselves and from the interview objectives. As part of the analysis, code families were constructed, modified and used as a tool to further code interview transcripts. In total, 25 code families were constructed; 7 of which were considered primary code families that represented the interview objectives and served as a guide to writing up the data. The researcher also implemented the us e of writing tools in ATLAS.ti such as comments and free memos; the cornerstones of data analysis. In ATLAS.ti, each analytical object (primary documents, quotat ions, codes, and network views etc.) is accompanied with an optional comment box. The researcher used comment boxes to write field notes of specific interviews re lating to the corresponding primary document (notes relating to household c onditions or about the interview itself). Comments were also used by the researcher to define and justify codes, to comment on the importance of specific quotations, and as reminders to pursu it different methodological and analytical phenomena. Memos are similar to comments, but differ in the fact that they can be linked and integrated to multiple analytical objects su ch as quotations, codes and other memos. Memos represent a space where the resear cher writes observational, analytical, theoretical, and methodological ideas about the data. For example, a single memo linked to three quotations provides a space to disc uss the relationship between those quotations. In this research, memos were employed as the primary means of data analysis, data integration, and write up. The researcher used memos as a space to construct ideas and theory while working with the data. For exam ple, reading a certai n passage or quote from an informant would jar the memory of similar or different quotes from other informants; memos provided the space for this researcher to think about and question similarities and differences in the data which in turn lead to theory construction. In this research, memos were also linked to codes as a way to theo rize about their inclusion or exclusion into

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96 certain code families. As a result, this researcher wrote memos throughout the coding process as a means to analyze the data. The researcher even created memo families that consisted of comment memos, analysis memos, methodological memos and write-up memos to organize and faci litate this process. Another important process of the qualitativ e analysis in this research was to link codes with other codes using the relation mana ger. In ATLAS.ti, the relation manager is used to define the semantic relationship between codes. For example, the two codes “ padra ” and “ lombrices ” were linked with the semantic linear designation “is treatment for”. Another example, “grinding teeth” and “ lombrices ” was linked with the semantic relation “is symptom of”. In this researc h, semantic relations were applied by asking questions of the data, for example, “how do mothers know when their children have parasites?” These questions were answered by going back to the data and analyzing existing relationships between quotations, code s and memos relating to specific research questions and by applying the appropri ate semantic links to those codes. Another analytical tool used for data analysis was the use of Network views. Quite simply, network views provide a visual look at the data and can be the result of linked elements such as a code family or constructed manually. Graph 6-1 provides an example of a network view taken from th e research. This network shows a graphic representation of the code fam ily “description of parasites” and shows the 11 codes that are inclusive to that code family. This netw ork view shows that th e code “eat food in intestine and blood” has 17 relate d quotations attached to it (t wo of which can be seen in the network view), while the code “ larva ” has only one quotation attached to it. Thus, the network view demonstrates that informants overwhelmingly tend to de scribe parasites as “things that eat food in the intestine and blood” compared to describing parasites as “ larva ”. Memo “distinguishing parasites” 12/06/07 12:34:13 PM Participants often differentiate parasites primarily through morphology. For example, people note that "amoebas" are so small th at one can't see them. "Lombrices" on the other hand are bigger to where one can se e them and resemble common earth worms.

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97 The memo “distinguishing parasites” in this network view is linked to several codes and provides insights about their relati onships. This particular memo was written during the coding process. The previous ex cerpt was taken from the actual memo in Figure 5-1. As a result, the network view in ATLAS.ti was used by the researcher as a way to visually represent code families and as a way to determine the relevance of each code relative to other codes in the famil y, and finally as a way to easily view the researchers comments about certa in aspects of the network. Figure 5-1. Network View of Qualitative Data Analysis Another important analytical tool in used in this res earch was the “query tool.” The query tool in ATLAS.ti is a powerful search engine that can accommodate both simple and complex search procedures. For this research, the query tool was used primarily to compare and contrast the knowle dge, beliefs and behaviors of Costa Rican and Nicaraguan mothers who participated in the survey. In ATLAS.ti, filters can be applied to virtually any analyt ical object including primary documents and codes, as well Commentary Commentary Commentary Commentary Commentary CF:Description of Parasites Amoebas {5-6} Lombrices {6-6} Living in your stomach {9-0}~ bad things {1-0} Living in your Intestine {2-0}~ little worms {1-0} Lombrices are Bigger {8-0}~ Larva {1-0} bichos {6-0} Eat Food in Intestine and Blood {17-0}~ Parasites are Microscopic {6-0} 1:4 12:2 16:3 Distin g uishin g Parasites

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98 as document families and code families. For example, the researcher used filters to only show the primary documents of Nicaraguan mo thers and then asked the query tool to show all quotations re lated to the code “ ataque de lombrice ”. This would provide all of the quotations where Nicaraguan mothers talked about worm attack. These results were then copied into a memo named “comparing beliefs about ataque de lombrice ”. Next, the filter was changed to only show the primary documents of Costa Rican mothers and the query tool was asked the same question wher eby producing quotations relating to worm attack from Costa Rican mothers. These results were copied into the same memo. This information allowed the researcher to co mpare differences and similarities between Nicaraguan and Costa Rican mothers’ knowledge and beliefs and behaviors of intestinal parasites; the conclusions of which we re written in the same memo. Data Analysis of Demographic and Epidemiological Data Analysis of quantitative data from ho usehold demographic interviews, household water interviews and epidemiological data rela ting to the period prevalence of intestinal parasites were done using the statistical software package SPSS 13.0. Data and notes collected from interviews were taken on paper and then transferred into an SPSS database. Originally, four databases were cr eated: 1) basic demographic data of all household residents (including name, age, sex, education); 2) household demographic data (household income, indivi dual health care co verage); 3) house hold water data; and 4) epidemiological data of participants who provided fecal sa mples for testing. Later, these four databases were modified into three main databases that were used as the basis for statistical analysis: 1) basic demographic and household data for all study participants; 2) basic demographic, hous ehold, water, and epidemiological data of participants who provided a f ecal sample; and 3) household level demographic, water, and epidemiological data. In addition, some data from the Monteverde Clinic (ASIS 2002) were converted into an SPSS database an d used to create comparative statistics such as age distributions. The first step in data analysis wa s to examine the basic demographic and household data for all study participants. To facilitate analysis, ma ny variables in the

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99 database were converted into nominal cate gories including age, education, household size and home ownership. Using SPSS, simple sta tistical procedures such as frequency outputs and cross tabulations were performed in order to calculate th e frequency, percent, mean, median, and range of all relevant variables. Later, statistical tests of association were performed on the data. This research assumes that the Costa Rican and Nicaraguan study populations constitute two independent samples that were collected at two different locations in the same community. For this reason, unpa ired independent sample t tests were used to test for any significant difference in the mean age of Nicaraguan and Costa Rican participants and to test for any significant difference in the mean age of male and female participants from within nationality group s and between nationality groups. In addition, t -tests were also used to test for any significant difference in mean years of education obtained, mean household size, and mean household income between Costa Rican and Nicaraguan households. The following standard formul a to conduct the independent sample t test was calculated using SPSS (Kinnear 2006): For t tests, the level of significance ( was set at 0.05. The null hypothesis stated that there is no difference in th e mean scores between the two groups ( ). Thus, when the probability associated with a certain t score was less than or equal to 0.05, the scores difference from the mean will be declared statistically significant and the null hypothesis rejected. Because the majority of variables analyzed for this research consisted of nominal or categorical data, Pearson’s chi-square ( tests were used to test the statistical association of parasitic infection with other nominal and discrete variables (e.g., nationality, gender, household si ze category, the presence of infected family members, health care coverage, unemployment status education category, household conditions,

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100 home ownership, and household income cate gory). The following standard formula was used to conduct chi-square test fo r association using SPSS (Kinnear 2006): For chi-square tests, the null hypothesis st ated that there is no association between the two variables and th e level of significance ( was set at 0.05. That is, if the value indicated a p value of 0.05 the null hypothesis was rejected and a significant association assumed. In cases where the expected frequencies of the test were less than 5, the statistic was correct ed (Madrigal 1998). For this re search, Fisher’s Exact Test was used as the standard correction because it was auto matically generated when calculating 2x2 contingency tables in SPSS. Epidemiological statistics su ch as prevalence and prevalence odds ratios were also used to explain rates of parasitic infections and risk. For this study, period prevalence was calculated in order to kn ow the prevalence of intestinal pa rasitic infections present in the population from January 1st, 2004 to June 30th, 2004. Period prevalence was calculated with the following formula: Because this research is considered a case/control study, odds ratios were calculated to determine the odds of having te sted positive for intestinal parasites and having certain characteristics (e.g., educati on categories, home ownership, household conditions, health insurance, household size, an d presence of infected family members) between Costa Ricans and Nicaraguans. Odds ratios were calculated using the same 2x2 contingency table as the Pearson’s chi-squa re test for association. The formula to calculate the odds ratio is the following:

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101 For the Odds Ratio, a 95% Confiden ce Interval was used to determine significance. Since an odd ratio value of 1.0 means that each group has the same odds of having disease, or whatever characteristic, the odds rati o calculation was considered significant if the 95% confidence leve l did not include the number 1.0. Chapter six will focus on the results of the qualitative data regarding participants’ perceptions and knowledge of intestinal para sites while Chapter seven will discuss the results of the quantitative da ta; specifically the epidemio logical data and the household survey data.

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102 Chapter Six – Qualitative Results: Know ledge, Perceptions and Behaviors Related to Intestinal Parasites In addition to epidemiological data rega rding the period preval ence of intestinal parasites, semi-structured interviews were conducted with each head of household to gather qualitative data regarding Nicaragua n and Costa Rican participants’ knowledge, perceptions, and behaviors relati ng to intestinal parasites. The semi-structured interview was specifically developed and administered to heads of household in order to elucidate individual knowledge, percep tions, and behaviors relating to the following interview objectives: 1) how participants describe what parasites are in general; 2) how participants understand the source of infection and mode of transmission of parasites; 3) how participants identify common symptoms and illn esses relating to parasites; 4) to know what illnesses or diseases are caused by pa rasites; 5) what participants do to treat parasites, 6) what participants do to preven t parasites; and finally 7) explore community perceptions of parasites and ar eas of folk knowledge. In add ition, participants were asked to provide a detailed househol d parasite infection history and participant’s history of taking anti-parasit ic medication. Specifically, heads of household were asked to talk freely about their understandings of what parasites are, the diffe rent species they knew of, where they come from, how they are transmitted, and how one can prevent getting them. Participants were also asked to talk about past experiences with parasites, how they identify persons infected, and what they do to get rid of them; paying special attention to both western and folk medicine. Participants were also asked to talk about parasite s in the community in terms of which people are most likely infected, if seasonality or weat her plays a role, and whether they perceive parasites as a pub lic health problem. The interview ended by asking a series of yes/no que stions that were designed to test specific knowledge concerning common parasite etiology and to ve rify whether these answers coincided with statements they had made at the beginning of the interview. These yes/no questions

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103 proved to be helpful in clarifying ideas a nd in getting participants to offer more information. The following network view depi cts the principal domains of qualitative analysis used in this part of the research. Figure 6-1. Network View of Model of Qualitative Analysis Finally, the main purpose of this interview was to better understand how participants construct parasite related doma ins and to see whether these domains differed significantly between Costa Rican and Nicara guan households that would ultimately help to inform and ground the epidemiological da ta within the cont ext of cultural and household level realities. The researcher felt that this information was relevant since participant knowledge, perceptions and behaviors related to parasites were completely unknown. The researcher was also interested in this information because all participants would be provided with educati on materials relating to parasite s at the end of the study. A total of 28 interviews were conducted with heads of household; 18 interviews were administered to Costa Rican families and 10 were administered to Nicaraguan families. Defining Parasites When participants were asked to "des cribe what parasites are?" two primary domains appeared that were simila r among both Nicaraguan and Costa Rican participants. The first domain was related to where parasites reside and what they do within the human organism; the second doma in was related to specific morphology, or a CF:Description of Parasites CF:Illnesses From Parasites CF:Preventing Parasites CF:Knowledge about Parasites CF:Treating Parasites CF:Symptoms of Parasites Model of Qualitative Analysis {0-0} CF:Source of Infection/Mode of Transmission

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104 physical description of parasites. In addition, se veral participants were able to list a good number of parasite species by name indicating that knowledge of partic ular parasites have been passed down from past generations as we ll as learned as a result of local primary health promotion/education. A view of this ne twork can be seen in the following graphic. The network depicts the domain “description of parasites” that is connected with relating codes elicited from interviews. The graphic is followed by a more in -depth description of the domain along with quotes that illu strate codes and domain structure. Figure 6-2. Network View Defining Parasites First, participants tended to define parasi tes in terms of where parasites reside and what they do within the human organism. The most common example of this appears when participants state that parasites are "things" or "bichos" (bugs) that reside in ones stomach or intestine. Take the following quotes as an example; the first from a Costa Rican woman and the second from a Nicaraguan woman: “They are little bichos in your stomach.” (8:1 13) “Well, I know that they live in your stom ach, and that there are lots of different kinds, I mean species.” (19:1 17) CF:Description of Parasites Amoebas {5-6} Lombrices {6-6} Living in your stomach {9-0}~ bad things {1-0} Living in your Intestine {2-0}~ little worms {1-0} Lombrices are Bigger {8-0}~ Larva {1-0} bichos {6-0} Eat Food in Intestine and Blood {17-0}~ Parasites are Microscopic {6-0}

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105 While these simple definitions of pa rasites were commonplace, the most common way used by participants to de fine parasites was to describe both where they live and what they do within the human organism. Partic ipants stated that para sites either eat one's food in the intestine before the body can use or process it or that parasites eat blood and suck nutrients from a person’s intestine or stomach. This was a common theme described in 17 of the 28 participant interviews. Th ese views are expressed in the following participant quotes: “They are little bichos that live in ones intestine and live off the food that one eats." (6:2 13) “Well they say that the parasites or whatever eats the food that yo u eat; they also eat vitamins from the food you eat." (10:8 39) In addition, participants of ten related that parasites eating food and nutrients in ones stomach or intestine was directly related to both symptoms or illnesses such as stomach aches, diarrhea, not gaining weight, being listless, and ma lnutrition. These ideas are well illustrated in th e following quotes from both Nicaraguan and Costa Rican participants. “They are bichos that live inside you and live off th e food that one eats. They cause stomach aches, vomiting, and malnutrition in kids, especially the lombrices (worms)." (12:2 13) “I guess that the parasites, since they live in people’s stomachs that they eat all the food or nutrients that the person eats, so that’s why they don’t gain any weight." (19:6 33) Several participants were even able to identify parasites by name and link it with where they live and what kind of sympto ms and illnesses they cause. For example: “I know that this one parasite Giardia clings to your intestine and eats the food that a person eats before they can digest it. They also cause vomiting and dizziness." (2:6 25) “Then there is the La Solitaria which is very long, like meters long and it eats your food and you can’t gain any weight; you get skinny." (23:7 15)

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106 The second way participants described parasites was to di stinguish specific morphology or physical descripti on of parasites. For example, informants recognize that there are "microscopic" parasite s that you can't see and that there are parasites that are "bigger" that you can see. This knowledge most likely comes from both folk knowledge based on experience with lombrices and biomedical knowledge from primary health campaigns that describe parasites as "microsc opic." Virtually all of the participants made the distinction that "amoebas" are small or "microscopic" and that one can't see them while lombrices or worms are bigger to where one can see them and resemble common earth worms. These descriptive domains we re constant between both Nicaraguan and Costa Rican residents as illustrated in the following quotes. “I know that they are really small and that you need a microscope to see them. The lombrices however are bigger." (2:2 13) “I know that they [ lombrices ] are big, they are like the wo rms that live in the ground. I remember that when I was a kid my mother would give me a purgante in the morning and all of them would come out.” (21:1 37) “Well, amoebas are small and they eat away at your intestine and blood and stuff like that. Let’s see, and lombrices are bigger and they so metimes rise up from the stomach and get into your lungs. You need to treat them with medicine otherwise you can choke on them.” (20:3 23) In addition to describing parasites in terms of where they reside and their morphology, several participants were able to identify parasites by name, often including specific details relating to size, symptoms, s ource and mode of transmission and ways to treat them. In total, participants were able to name eight different sp ecies of parasites; the most common parasites named, as in the numbe r (N) of interviews the code appeared were “ La Solitara ” (N=9) or tape worm; followed by “ Giardia ” (N=6); “Pin Worm” (N=2); “Hookworm” (N=1); and “ E. nana ” (N=1) a common commensal parasite. The following quotes demonstrate the detailed knowle dge that some participants had obtained about specific parasite species. "I know that this one parasite, Giardia clings to your intestine and eats the food that a person eats before they can digest it. They also cause vomiting and dizziness.

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107 There is also one called E. nana but I don’t remember what it does. I know that the amoebas, when there are a lot of them th ey give you a stomach aches and your feces can have blood in them.” (2:6 25) "There is one that I know of, pinworm [E. vermicularis] that makes your anus itch really bad.” (6:2 13) "When people eat lots but are still really skinny. That is caused by La Solitaria my brother had it and he went to the doctor and they gave him medicine and then it came out of him and it was huge.” (4:3 30) These statements taken on a whole i ndicate that while participants have constructed detailed descriptions of para sites their knowledge wa s based primarily on word of mouth, from primary health campaigns and in the case of lombrices from experience. However, none of the participants was able to provide a solid biomedical definition of a parasite apart from noting that lombrices are worm like and amoebas are "microscopic". Interestingly, knowledge and de scriptions regardi ng parasites between Nicaraguan and Costa Rican partic ipants were very similar. Source of Infection and Mode of Transmission Both Nicaraguan and Costa Rican particip ants portrayed a deep and broad range of knowledge and perceptions re garding the source of infec tion and mode of transmission of intestinal parasites. To reiterate, the s ource of infection refers to the medium (water, soil, utensils, etc.) or the host organism (v ector, or intermediate host) on which or in which the infective stage of th e parasite is found. The mode of transmission refers to the precise circumstances and means by which the infective stage is able to come in contact with, gain entry to, and initiate an infecti on within the host (Price 2003). In order to understand how participants conc eptualized and constructed id eas regarding the source of infection and mode of transmission the rese archer asked simple questions including "where do parasites come from?" and "how does one get or c ontract parasites?" Based on qualitative analysis using ATLAS.ti, a total of 26 codes emerged relating to the source of inf ection. The most common source of infection, as in the number (N) of interviews the code appear ed were "Flies" (N= 18); "Poor Hygiene" (N=16); "Water" (N=13); "Animals" (N=10) ; "Insects" (N=8); "Feces" (N=7); and "Dirtiness" (N=5). An analysis of the mode of transmission revealed 17 different codes,

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108 the most common being "Eating Contaminated Food" (N=20); "Eating with Dirty Hands" (N=14); "Walking Barefoot or Walking on th e Ground" (N=12); "Drinking Contaminated Water" (N=11); and "Putting Dirt y Objects in Mouth" (N=9). After further analysis in ATLAS.ti, si x principal domains emerged from grounded codes that exemplified the scope of knowledge and perceptions rega rding the source of infection and mode of transmission. The six domains include the following: 1) “Animals and Insects; 2) Food; 3) Th e Ground and/or Dirt; 4) Genera l Hygiene; 5) Hand Washing; and 6) Water. A view of this network can be seen in the following figure followed by a short description of each domain. Figure 6-3. Network View of Source of Infection and Mode of Transmission Domain: Animals and Insects The emergent domain "Animals and Insects" in reference to the source of infection and mode of transmission relate s to the common perception that insects, including flies and cockroaches, can cause a wide range of illnesses and can transmit parasites. Among participants, "flies" constituted the most common culprit. In addition, many participants demonstrated a comple x understanding of how one can contract parasites from flies; stating that flies ofte n carry feces on their feet and then land on food Source of Infection / Mode of Transmission {0-0} CF:SoI/MoT Animals/Insects CF:SoI/MoT Food CF:SoI/MoT Ground/Dirt CF:SoI/MoT Hygiene CF:SoI/MoT Washing Hands CF:SoI/MoT Water

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109 which is later ingested causing infection. This understanding can be observed in the following quotes: “Yes, from flies, they can transmit parasite s on their feet and then land on your food and you can get parasites like that. You can also get parasites from cockroaches the same way.” (3:28 89) “Well, flies usually land on excrement and then if they walk all over your food and if you eat it you can get parasites and get sick.” (14:34 85) Another common theme was that one can ge t parasites from animals, most often from domestic animals and rats. Some partic ipants explained that one can get parasites from animals that are dirty and that are not well taken care of, while other participants explained how one can get parasites from the feces and urine of common animals. The following quotes demonstrate these perceptions. “Yes, especially street animals because they are dirty. Animals like cats, dogs, rats, cows; you can get parasites from th eir feces and urine.” (2:19 -71) “Yes, especially from domestic animal s like cats and dogs.” (19:24 111) “From animals I guess, like when rats craw l over your plates and silverware. I am always careful about that...Or like, you know how when dogs roll around on the ground; you can get parasites like that.” (24:3 29) These common perceptions held by both Nicaraguan and Costa Rican households are exemplified in the fact that even house hold pets such as dogs and cats are rarely handled and are most often kept outside and are not allowed inside the living quarters. Domain: Food The emergent domain "Food" as source of infection and mode of transmission was the most common and best understood by participants. In f act, all of the 28 interviews mention at least some aspect of "f ood" as a source of infections or mode of transmission. The most common code that emer ged from the data as in the number (N) of interviews the code appeared was "Eati ng Contaminated Food" (N=20); followed by "Improper Food Handling" (N=7 ); and "From not Washing Food" (N=5). Again, many

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110 participants exhibited a high degree of understanding of sp ecific modes of transmission regarding food, hinting at the various ways food can become contaminated and thereby transmitting parasites when ingested. These concepts are exemplified in the following quotes. “Well with food, when you eat food like vegetables you have to be careful because if the food is dirty it can have parasites and then if you eat it you can become infected.” (2:4 21) “Yes, especially like I said from food that has been lying out. Oh, and from fruits and things like that, you have to be sure to wash those kinds of things well before you eat them.” (27:19 67) “Improper handling of food also causes parasites. Especially things like fruit if you don’t wash it." (11:16 41) "They can be caused by the poor handling of food and by not washing plates and your hands. If you don’t cook food well, especially meat you can get parasites as well." (12:3 17) “From bad handling of food and by not washing your hands before you eat. You should always wash fruit before you eat it for example because it could have been on the ground or whatever and if you eat it you can get parasites. A good thing to do is to wash that stuff with water that has a little chlorine in it to make sure that you kill the bichos .” (23:5 23) While these quotes demonstrate the leve l of knowledge and un derstanding as to how parasites can be contracted from food, there were also several cases in which participants confused other in fectious agents as causing parasites. For example in these two quotes: “Yes, especially from vegetables that are no t washed well or from meat that is not cooked well or if it has been lying out for a while it can get bacteria.” (5:6 70) "And with things like meat too, you shou ld only let it thaw out once otherwise it can go bad. You also have to be careful with food because flies can get on them and they have bacteria and when they land on your food you can get [parasites] from that.” (11:18 41) Domain: Walking on Ground or Dirt Next, the emergent domain "Walking on the Ground or Dirt" as a source of infection or mode of transmission is intere sting with is obvious relation to helminth

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111 infections, most notably hookworm. Participants identified seven codes that related to coming into contact with dirt. The most common codes that emerged from the data as in the number (N) of interviews the code a ppeared was "Walking Barefoot/Walking on the Ground (N=12); and "Playing with Dirt" (N=6). Some participants even noted that "Parasites Enter Your Foot" (N=5) an obvious hookworm reference. The following quotes represent this domain. “They say that you can get them from walking around with bare feet. The parasites can be in the ground and enter your body through your feet." (3:5 21) “From walking around barefoot; the cold gets into your feet and then the parasites get in. They are also caused from playing or handling dirt. Parasites are pretty much everywhere where it is dirty or where there is no sanitation.” (8:2 17) "I think you can also get them from walking around in puddles and from the ground, you know like when kids sometimes eat dirt, well there are vitamins in the dirt but there are parasites too and if kids eat dirt they can get parasites.” (27:5 26) “I know that some parasites come from the ground and then enter the bottom of your foot." (16:9 31) This detailed knowledge expressed by partic ipants in reference to "walking on the ground or dirt" are for the most part due to primary health campaigns in Costa Rica that sought to eradicate or seriously reduce the incidence of common preventable helminth infections like Ascaris and Hookworm. These campaigns started in the late 60's early 70's and were met with much success mainly due to the fact that meas ures were taken to improve basic sanitation infrastructure and to dramatically increase the access to primary health care including anti-parasitic medication such as Albendazole. Many participants demonstrated knowl edge regarding the cause and effect relationship of "walking on the ground/dirt" and parasites. Ho wever, I believe that the specific knowledge to not let their children wa lk barefoot on the gr ound is directly based on primary health care education campaigns While participants knew not to walk barefoot, they had no idea what kind of para sites one could get fr om the ground or dirt. Interestingly, while many participants cited "walking barefoot" or "dirt" as a source of infection or mode of transmission, none of th e participants made the connection between dirt and helminth infections. This can be illust rated by the fact that almost all participants

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112 mentioned the phenomena Ataque de Lombrice or worm attack (which will be explained later) in the interv iew, but none made the connect ion between that ubiquitous disease manifestation and walking on the ground or playing with di rt. This raises the question of the effectiveness and sc ope of health education campaigns. Domain: Hygiene/Sanitation The next emergent domain to come out of the data is Hygiene/Sanitation in terms of source of infection and m ode of transmission was very common among both groups of participants. It is widely believed that maintaining good personal and household hygiene is an excellent way to prevent different diseases and illnesses. There are even common sayings that refer to the perceived importance and practicality of good hygiene. For example, one common phrase used by a Costa Rican mother said "good hygiene is the best vaccination against disease". While in theo ry this perception best represents the gold standard, the reality of hous ehold hygiene can perhaps best be represented in this common refrain also used by Costa Rican moth ers "one cleans-up only where the motherin-law is sure to pass by". This i ndicates that while good hygiene and household cleanliness reflects on the mother the reality is that one usually only cleans on the surface as a result of other life demands. Within this domain the most common code s that emerged from the data as in the number (N) of interviews the code appeared was "Getting Parasites from Poor Hygiene" (N=16); "Putting Dirty Objects in Mouth" (N =9); "Getting Parasites from Feces" (N=7); and "Getting Parasites from Dirtiness" (N=5 ). Like the domain "food" this domain was ubiquitously found in virtually all interviews as an explanation of where parasites come and how they are contracted. While participan ts often referred to hygiene as a culprit, they often vague in their statements; talking of hygiene in general as illustrated in the following quotes. "A general lack of hygiene can also cause them [parasites].” (12:3-17) “Well, mostly from a lack of hygiene and general dirtiness. Especially from places like drainage ditches and places like that.” (19:7-37)

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113 Another common perception was that one could get parasites from putting dirty objects on your mouth. Mothers emphasized the fact that this was one of the most common ways that children get parasites sayi ng that "children don't know any better" and that "they are always putting thing into thei r mouths." Dirty objects, as perceived by mothers also include dirty fingers and eating with dirty hands, esp ecially after handling dirty objects. These ideas are i llustrated in the following quotes. “Anyone can get them but it is more common in kids because they don’t know any better and they always have thing in their mouths and eat with dirty hands and things like that.” (2:8-29) "It especially happens with children because they always put things in their mouths and don’t ever want to wash their hands.” (4:2-25) “Well if you touch the dog and then you if you put your fingers in your mouth, you know how kids are always putting things in their mouths." (24:4-33) Again, it is most likely that the emphas is that mothers place on poor hygiene as a source of infection/mode of transmission is most likely a result of public health campaigns that targeted general cleanliness, hand washing and not walking on the ground as means of prevention. Domain: Hand Washing Behaviors The next emergent domain to come out of the data was hand washing in terms of source of infection and mode of transmission. The most common codes that emerged from the data as in the number (N) of inte rviews the code appeared was "Eating with Dirty Hands" (N=14); "Not Washing Your Ha nds after Going to the Bathroom" (N=8); "Getting Parasites from Feces" (N=7); and fi nally "Getting Parasites from not Washing Your Hands" (N=6). In many cases, participants made more th an one reference to different kinds of hand washing activities, or lack thereof as a mode of transmission for parasites. For example, there was a high co-occurrence of the codes "eating with dirty hands" and the code "not washing your hands after going to the bathroom". There was also a high cooccurrence of codes referring to hand washing and general hygiene. Several participants

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114 also made the connection among hand washing, hygiene and food. All of these concepts can be illustrated in the following quotes. “Well, if you go to the bathroom and don’t wash your hands and then you go and eat with dirty hands you can get parasites." (2:3-17) "From not washing your hand before you eat especially after you go to the bathroom.” (22:3-28) "You can get them, for example, if your hands are dirty, especially if they are dirty from the bathroom, you know, when you don’t wash your hands after going to the bathroom." (11:2-13) “Oh, well mostly from fecal material, like when you don’t wash your hands or have good hygiene practices." (19:8-41) "From not washing your hands and things like that; from not washing things and from bad food...they say it’s important to keep everything clean.” (26:1-82) Again, this knowledge is most likely a re sult of primary health campaigns that targeted maintaining general hygiene practic es that related to food, hand washing. This domain resembled the hygiene/sanitation dom ain in terms of its ubiquitous nature; virtually all participants, both Nicaragua n and Costa Rican households mentioned something about hand washing in rela tion with contracting parasites. Domain: Water The final domain that emerged from the data relating to source of infection/mode of transmission family was water. The most common codes that emerged from the data as in the number (N) of interviews the code a ppeared were "Getting Parasites from Water" (N=13); "Drinking Contaminated Water" (N =11); and "Getting Parasites in the Wet Season" (N=10). Water, in contrast to c odes like food, hand washing, and hygiene, was not mentioned by participants with the same intensity. Many of the references that came from water were initiated by the researcher as a result of asking a series of yes/no questions, one of which was directed at wate r. Some participants were unsure in their assessment of water being a possible cause, whil e other participants were more assertive and made a connection between the local a queduct, contamination and disease. These variations can be seen in the following quotes.

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115 “They come from water maybe, like from dirty or contaminated water." (22:3-28) “I have no idea really, maybe from water, like cholera, from c ontaminated water." (13:7-17) “Through bad handling of community water supply, contaminated water, but I really don’t know which parasites come from water specifically." (15:7-16) “One of the main causes of parasites co mes from the water, supposedly the water here in Monteverde is potable, that’s what they tell us anyway, but actually they have to put chlorine in the water.” (11:10-29) The last quote presented here (11:10-29) delves into an emerging contrasting domain that was discovered in the analysis and related to the questioning the quality of the community water supply on one hand and bei ng completely confident in the fact that the local aqueduct provides potable water, t hus excluding water as a potential source of infection in Monteverde. Intere stingly, some participants who held this view were quick to point out that, while it is unlikely to get parasites from the water in Monteverde, it was in fact possible to get para sites from the water supply in communities with poor water management such as Puntarenas. This seems to be a slight point of contention in the community, one that will be discussed at gr eater depth in the anal ysis of the household water use interviews. Another interesting domain that emerged fr om analysis of water was the fact that many of the Nicaraguan participants made th e connection between the poor water quality in Nicaragua and higher prevalence of parasi tes on one hand and the better water quality in Monteverde and a lower prevalence of parasites on the other. This issue will also be examined at greater depth when comparing th e two countries. An example of this can be seen in the following quote. “Yes, here [Monteverde] the water is pre tty clean, much more than in Nicaragua anyway. Where we lived in Nicaragua we would often have to take water out of the lake for drinking water and there was much less hygiene there." (20:21-71) Finally, although not directly related to contaminated water, many participants were under the impression that there were mo re parasites during th e wet season and that

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116 parasites are also more common in humid c onditions. This can be illustrated in the following quotes. “I think that there must be more parasites in the wet season, I don’t know, maybe because of the humidity." (14:33-73) “I think in the wet season when there is a lot of rain and humidity there gets to be a lot of stagnant water and that can cause parasites too." (6:4-32) Symptoms of Parasites Both Nicaraguans and Costa Rican head s of household expressed very similar views relating with how they determine whet her someone has parasites. This domain was constructed by asking participan ts "how do you know if someone has parasites?" after the researcher discovered that this question was more effective at eliciting information than was the question "tell me the symptoms you get from parasites." The information elicited in the interviews includes common symptoms th at may or may not directly point to an infection with intestinal parasites. In addi tion, participants explic itly made a distinction between the symptoms related to infections with "amoebas" and symptoms that are attributed to infections with intestinal worm s or helminths. The distinction made between symptoms that are attributed to either intestinal amoebas or worms are related, in part, to perceptions and knowledge of wh ere parasites reside and what they do within the human organism as well as the specific morphology, or physical characteris tics attributed to different kinds of parasites. The relationship made between an individual’s symptoms and the behavior of specific parasites is well illustrated in the following quote. The network view shown in Figure 6-4, depicts the domain “symptoms of parasites” and distinguishes the two sub domains (symptoms of lombrices and symptoms of amoebas) and includes th e relating codes that construc t each domain and also shows two codes that are common to each domain. Analysis in ATLAS.ti also showed that while participants listed common symptoms for both lombrices and amoebas (for example, stomach aches, were listed as a sy mptom of both lombrices and amoebas) there were several symptoms that were specific to either lombrices or am oebas. See the graphic networks of both symptoms of lombri ces and symptoms of amoebas below.

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117 Figure 6-4. Network View of Symptoms of Parasites By looking at the graphic networks relate d to symptoms it becomes clear that the symptoms “being skinny”, “loss of appetite” and “not gaining weight” tend to be associated with lombrice infection and the perception that lombrices live in the intestine and eat the food in ones intestine before they can digest it. Other symptoms specifically related to infections with lo mbrices include “coughing up worms” “feeling worms move in your stomach” “pieces come out” and “worms coming out of one’s body” refer to knowledge gained through lived experience w ith having worm infections in the past. Other symptoms that were related with lombrices were “grinding teeth” “insomnia” and “sleeping with your eyes open”, relating specifically with a certain kind of infection with lombrices commonly known as ataque de lombrice which I will discuss later. The graphic network also shows several sy mptoms that are specifically related to infections with amoebas incl uding “having blood in stool” “diarrhea” “constipation” and “sunken eyes”. Furthermore, symptoms that were common to both lombrices and amebas included “fever” “stomach aches” “inflated stomachs” and “vomiting” While these were the most common codes expressed in interviews, it was common for participants to provide a list of several symptoms at once that was not CF:Symptoms of Amoebas CF:Symptoms of Lombrices Symptoms of Parasites {0-0} Being Skinny {7-0} Coughing Up Worms {9-0} Feel them Moving in Stomach {1-0} Grinding Teeth {7-1}~ Having Insomnia {1-0} Having Sunken Eyes {2-0} Inflated Stomach {11-0} Lombrices Pieces Come Out {1-0} Looking Pale {5-0} Loss of Apetite {7-0} Not gaining Weight {12-0} Sleeping with Eyes Open {4-1}~ Vomiting {10-1} Worms Coming out of Body {5-0} Causing Ass to Itch {4-0} Dizziness {2-0} Fever {3-0} Having Blood in Stool {2-0} Having Constipation {1-1} Having Diarrhea {14-2} Having Stomach Aches {16-0}

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118 specifically related to a particul ar species of parasite, but that related to a broad spectrum of potential symptoms related to parasite s. The following quotes demonstrate this practice. “Things like fever, diarrhea, and stomach aches.” (22:12-65) “They can have a fever, vomiting, diarrhea; maybe they don’t have an appetite. Oh, and like I said before maybe they eat lots but don’t gain any weight." (23:4-27) “Well the person, like I said is usually skinny, or sometimes they even have big stomachs, and they usually have stomach aches.” (19:10-49) “When one sleeps with their eyes open, or when they have problems falling asleep, and things like stomach aches and diarrhea.” (27:6-30) While it was common for participants to provide a general list of symptoms not linked to any specific parasite species; it was also common for participants to be more specific in terms of relating di fferent symptoms to specific ki nds of parasites. The quotes below demonstrate how participants connected specific symptoms to specific parasites. "Other symptoms can be that one looses their appetite or when people eat lots but are still really skinny. That is caused by the solitaria ." (4:3-30) "Parasites can cause you to have stomach aches and some cause you ass to itch, that’s from tricocephalo .” (2:1-13) "Then there is Giardia That is another illness that you can get from parasites. With that [ Giardia ] you do not eat anything and have diarrhea and vomiting and everything." (5:3-49) In addition, the quotes presented below dem onstrate that particip ants also made a further connection between the kind of parasi te and specific sympto ms, by relating those symptoms to the specific characteristics of the parasite. The quotes below demonstrate this point. “They are bichos that live inside you and live off th e food that one eats. They cause stomach aches, vomiting, and malnutrition in kids, especially the lombrices ." (12:213)

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119 “Oh, their skin is usually pale, their eyes too. When they don’t feel like playing. Or when they don’t gain any weight, like when their skinny, the parasites suck blood and nutrients from the kind so they don’t grow or gain weight." (24:5-37) “Well the person doesn’t have an appetite and can be pale. I know that this one parasite, Giardia clings to your intestine and eats the food that a person eats before they can digest it and it also causes vom iting and dizziness...I know that the amoebas, when there are a lot of them th ey give you stomach aches and your feces can have blood in them.” (2:6-25) It is interesting to note that most all pa rticipants were able to list a variety of symptoms for parasites in general and in so me cases for specific kinds of parasites. However, of special interest to this study was that fact th at Nicaraguan and Costa Rican participants listed many of the same symptoms and in fact listed the same symptoms related to similar kinds of parasites. For example, the symptoms listed by Nicaraguans related to lombrices and amoebas were the same symptoms listed by Costa Ricans. Again, this shows that there was no significan t difference in the knowledge of symptoms between the two groups despite there being a si gnificant difference in levels of formal education. These similarities can be seen by co mparing these two quotes; the first by a Nicaraguan mother, and the sec ond from a Costa Rican Mother. “Oh, their skin is usually pale, their eyes too. When they don’t feel like playing. Or when they don’t gain any weight, like when their skinny, the parasites suck blood and nutrients from the kind so they don’t grow or gain weight." (25:5-37) “Well they say that the parasites or whatev er eats the food that you eat; they also eat vitamins from the food you eat. They also say that you have pale skin or that you don’t have any energy or happiness.” (10:8-39) More similarities can be seen by co mparing these two quotes; the first by a Nicaraguan mother, and the sec ond from a Costa Rican Mother. “Things like fever, diarrhea, and stomach aches.” (22:12-65) “Oh, [parasites can cause] diarrhea, vomiting, and fever." (11:34-78)

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120 Illnesses from Parasites Both Nicaraguan and Costa Rican participants reported knowing few illnesses related to infections with intestinal parasi tes. In fact, when excluding reported illnesses such as vomiting, diarrhea, and fever; which ar e better described as symptoms, and not as illnesses, participants only listed five illnesses that one can get form parasites. However, only one illness was reported with any frequency, while others were mentioned only rarely. For example, the most common repor ted illness reported among these as in the number of times it occurred in interviews was “Anemia” (N=5); “Malnutrition” (N=3); “Blood in Stool” (N=2); “ Ausemia ” (N=1); and “ Paludismo ” (N=1). Whereas anemia, malnutrition, and dysentery all potential illnesses related with parasites; ausemia (a defined cancer of the blood) and paludismo (an illness that resembles the flu) are most likely not related to infections with parasites. Interestingly, the most common illness reported among participants was “ Ataque de lombrice or literally, "worm attack". This il lnesses was reported ubiquitously (N=15) among all participants, both Ni caraguan and Costa Rican. A ccording to participants, ataque de lombrice is the name given to specifically defined group of symptoms that are the result of infections with an intestinal worm. While ataque de lombrice shares many characteristics with worm infections in te rms of the mode of transmission/source of infection, and available treatment pathways, participants made several distinctions between the symptoms related to ataque de lombrice and infections with worms in general. For example, ataque de lombrice is characterized by having a heavy infection or having many worms in one’s body. The result of having many worms is that the worms try to "come up" or escape from the body. An example can be seen in the following quotes from mothers describing what happens during a worm attack. “Then there are lombrices there is a disease called lombrice attack and it’s when people have a lot of lombrices and those lombrices come up and try to come out of your mouth and your nose and ears." (3:18-55) “Oh, and there is something that a lot of people talk about called ataque de lombrice that’s when the lombrices try to come out of you.” (19-13-57)

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121 “It’s when there are lots of lombrices in your stomach and the lombrices try to come up into your lungs and throat and they try to come out." (2:15-49) The other unique symptom related to ataque de lombrice is when people choke on or cough-up worms. Participants described that people feel as if they were suffocating on the worms when they came up or that they we re going to vomit. Descriptions of chokingon or coughing-up or vomiting-up worms can be seen in the following quotations. “Sometimes if you have a cough and it’s not a cold it could be that you have lombrices If there are lots of them they can come up from the stomach and it feels like they are going to choke or vomit." (10:18-80) "People cough a lot and have a feeling like th ey are going to choke to death and they usually have inflated stomachs." (3:18-55) Lombrices can come up and make you feel like you are choking." (8:1-13) "I know that when people have lots of lombrices that some of them try to escape, like they cough them up and stuff." (19:14-65) While almost all of the participants interviewed made reference to ataque de lombrice in way or another, none of the participants interviewe d specifically identified the species of intestinal worm that caus ed this well known illness. In fact, what participants was most likely referring to wa s an infection related to the life-cycle of Necantor americanus (hookworms) or Ascaris lumbricoides (roundworms). In order for both of these species of helm inths to complete their life-cycle the larva must migrate from the lungs to the throat where they are swallowed into the stom ach and later into the intestine where they mature into adults and reproduce. Another interesting result of the interview data revealed that virtually none of the participants interviewed specifically identi fied the source of in fection or mode of transmission relating to infections with worms or in relation to ataque de lombrices ". As stated in the discussion related to symptoms, many informants discusse d the fact that one could get parasites from "wal king barefoot", "playing with dirt", and "walking on the dirt" but none of the participants made th e direct relationship between the source of infection and intestinal worms.

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122 Treating Parasites When participants were asked how they treated or how they would treat parasitic infections in their househol d, two obvious domains appeared. The first, and most common, were biomedical medications that we re available through the clinic and local pharmacies. The second treatment domain related to home remedies that reflected locally available plants and herbs (See Figure 6-5 for an illustration of the domains and subdomains of treatment pathways). In general, younger participants were more aware of and tended to administer biomedical medications while older particip ants tended to be more familiar with home remedies. This pattern reflect s a generational gap between pa rticipants who grew up with greater access to health care and those who grew up in very rural settings where access to health care was sparse. The same pattern was reflected in Nicaraguan participants; older Nicaraguan mothers who spent the majority of th eir lives in Nicaragua were more able to identify a wider variety of home remedies used to treat intestinal parasites compared to younger Nicaraguan mothers who have sp ent less time living in Nicaragua. Figure 6-5. Network View of Treating Parasites Treating Parasites {0-0} CF:Home Remedies for Parasites CF:Medications for Parasites Albendazol {4-0}~ Getting Checked for Parasites {6-0}~ Giving Medications from Clinic/Doctor/Pharmacy {26-0}~ Giving Purgantes {6-0}~ Magnesia {1-0}~ Mebendazol {2-0} Sentel {10-0}~ Taking Antibiotics {1-0} Vermil {1-0} Acetun {1-1} Aciete de Comer {3-0}~ Almidon {2-1}~ Apazote {9-1}~ Cascara de Maraon {1-1} Coconut Milk {5-1}~ Cojoyos {2-1}~ Guaro {3-0} Guaro Charral {3-1}~ Guava Leaves {4-1}~ Hombre Grande {3-0}~ Juanilama {1-0}~ Limon {1-0}~ Padra {5-0}~ Rice Water {1-0}~ Sornia {1-0}~ Using Garlic {9-1}~

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123 The most common response participants ga ve when asked what they do to get rid of parasites was to take a pill from either the clinic of from one of the local pharmacies. Most participants in this case could not provi de the name of these pills but they were clear that they were indeed used to treat intes tinal parasites. Examples of this can be seen in the following two quotes by participants. “There are medications that you can take from the clinic and the pharmacy but I can’t remember what they are called. There are those pills that the clinic gives people to get rid of parasites.” (3:12-41) “There is medicine and one should go to the clinic or pharmacy to get something in order to get rid of them.” (23:2-35) Some participants mentioned that in order to treat parasites it was important to get checked first in order to make a positive diagnosis to ensure administration of the correct medication. “First I would probably take the person to the clinic to make sure they were parasites and then give them the right medicine." (25:10-41) “You can get checked at the clinic and then take medication to get rid of them." (8:837) While many participants were not speci fic in terms of identifying medication by name, other participants were able to iden tify the names of specific pharmaceuticals used to treat parasitic infections The most commonly identified and administered medication for parasites are Albendazole and Sentel ". Albendazole is given as a general anti -parasitic medication by the Monteverde Clinic when in actuality it is primarily for he lminth infections and is not effective against amoebic protozoa like E. histolytica and G. lamblia The Monteverde Clinic distributes Albendazole to school children twice a y ear. In addition, the EBAIS distributes Albendazole to both adults and children duri ng household visits when needed. In this case, people are often given Albenda zole based on related symptoms a priori to any positive laboratory diagnosis.

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124 However, Sentel is the most common over the co unter anti-parasitic medication and is available at all local pharmacies. Sentel is basically a commer cially available form of Albendazole that is intende d as general anti-parasitic medication but which is effective primarily against helminth infections. In addition, Sentel is very accessible to the general population because it is inexpensive; at th e time of this study, a dose cost around $4 USD making it affordable to even low income families. Another medication that is used as an anti-parasitic is Mebendazole that specifically targets intestinal protozoa instead of intestinal helminths. Based on observation and interviews it appears that this medication is used much less than Albendazole and is only prescribed to a pati ent with a positive dia gnosis of intestinal protozoa. It is not, to my know ledge, distributed by the EBAIS as part of the Ministry of Health's anti-parasite protocol which relies exclusively on distributing Albendazole to school children and to in dividuals at the household level. This seems to be a remnant and or indicative of anti-parasite campaigns of the past which focused on helminths due to their ubiquity and epidemiological and pat hological importance at the time. Today however, this approach seems out of touch with the epidemiological profile of the community which shows that intestinal protoz oa, not intestinal helminths, are of much greater epidemiological signi ficance. This research for example shows that among all participants a period prevalence of intestinal protozoa was approximately 15% compared to a period prevalence rate of 2.3% for intestin al helminths. This indicates that among the study population intestinal protoz oa were seven times more likely to occur compared to intestinal helminths. In addition to biomedical medicines, part icipants were able to identify a diverse collection of home remedies used to get rid of and treat symptoms related to intestinal parasites. In total, 18 different home remedies were identified between all participants relating to parasites. While some home remedi es were only rarely mentioned there were several that were mentioned with more frequency indicating co mmon knowledge among participants. The most common home remedies mentioned in terms of the number of times it was mentioned in interviews were “ Apazote ” (N=9); “Garlic” (N=8); “ Guaro ” (N=6); “ Purgantes ” (N=6); “ Padra ” (N=5); and “ Leche de Coco ” (N=5). All of these

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125 remedies were identified by both Costa Rican s and Nicaraguans at approximately the same frequency. Apazote also known as pazote is a plant that grows locally and is readily available; it is used to treat lombrices and in particular is used to treat ataque de lombrice according to participants. Garlic was also used primarily for lombrices and in particular to make lombrices go back down to the stomach during an ataque de lombrice A couple participants even remembered wearing garlic necklaces when they were young in order to prevent lombrices The locally grown herb Padra was described as being used for getting rid of amoebas as well as being used as a purgante Giving purgantes or purges was also common practice to clean out the stomach a nd get rid of a variety of non-descript parasites. With purgantes participants noted that they ar e mostly used to clean out the stomach but that they do not ki ll all kinds of parasites. Participants also made the distinction between purgantes that can be bought from a pharmacy or recommended by a doctor and those made as a home remedy de rived from medicinal plants and herbs including Apazote and guaro While biomedicine and home remedies repr esent different treatment systems, they are often used interchangeably and even in conjunction with each other. Some participants discussed the pluralistic and flex ible nature in which treatment is applied. Take the following quote as an exam ple of this complex interaction: “When the lombrices start to move around and go up (to the lungs and windpipe) you have to give the person a bath with guaro, apazote, and ajo This bath settles the lombrices and makes them go back down to your intestines and stomach. Then you have to treat them with medicine. You can’t take medicine when they are up or they will go all over and you can die. You have to take the medicine when they are down. That will get rid of them. After that you have to take vitamins.” (20:13-39) “The lombrices when they want to come up you should eat garlic, then they will settle down. My mother would also give us a bath of Guaro and ajo she would do that and then give us some pills in order to get rid of the lombrices. When the lombrices come up that’s called ataque de lombrices and it’s pretty serious and can even kill kids.” (22:13-69) “For the kids you always have to be giving them a purgante for the lombrices You can use either padra (an herbal medicine) or Vermil (a drug). I don’t think Sentel (Albendazole) works at all. I gave it to my kids and it didn’t get rid of the parasites." (20:14-43)

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126 Older participants almost always expre ssed or noted the transition between using home remedies in the past a nd the use of biomedicine in the present. This transition coincides with the expansion of greater acce ss to primary health care for rural residents over the past several decades. This transition also relates to the ear lier discussion of wide spread Albendazole distribution aims at reduci ng the incidence of pa rasitic helminths as a national primary health care campaign. Older pa rticipants that were interviewed would note that home remedies were once used b ecause there was no other alternative and coincidently because many of them were indeed effective at getting rid of and treating the symptoms of intestinal parasites. What wa s lacking in these cont exts was the knowledge and adequate sanitation infrastructure to prevent re-infection. The following quotes made by older female participants characterize in some ways the transition that took place between the administration of home remedies and biomedicine used to treat intestinal parasites. “Nowadays people take pills you get at the clinic or the pharmacy like Sentel Before people used more home remedies like garlic people used to put garlic necklaces on their kids. Also I remember there is a leaf called pazote which people used to get rid of lombrices With the pills you get you can kill the lombrices but I can’t remember which ones.” (4:4-42) “Yes before that’s all people used were hom e remedies but nowadays people just go to the clinic for that stuff. There are just a few people th at really know about that.” For home remedies for parasites there is: guaro chakal which was used for la solitaria ; apazote ; yerba buena ; massages with alcohol; esencia for stomach ache; and padra for amoebas.” (7:1-41) This transition from home remedies to biomedicine is also evident in the following quotes by younger female participan ts who relied on knowledge passed down to them from their mothers, but that they themselves rarely employed. This again stems from the fact that their mothers lived in a time when the use of home remedies was standard due to the lack of access to primary health care services. "For lombrices there was Guaro Charral and Apazote which you would also give in the mornings while fasting...These are all things I remember my mom telling me.” (14:20-45)

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127 “Um, there is pazote and you take that for lombrices ; my mom told me about that one, that is what she used to use. There are also other ones like with coconut milk and things like that. My mom knows a lot more…I just don’t remember all that well.” (3:13-45) Do you know of any home remedies that one can use to get rid of parasites? “Me? No, my mom knew all that stuff.” (29:1-39) While the use of biomedicine to treat intestinal parasites has become institutionalized for the majority of households the application of ho me remedies to treat the same parasites has not disappeared but remains an important part of the medical toolkit employed by mothers in spite of the dominance of the biomedical model. In fact, Lind et.al (2001) carried out an informal res earch project aimed at looking at health access issues in the Monteverde Zone including the use of alternative medicine. The study collected an impressive list of 54 herbal home remedies that are used in the region; the majority 43% were said to be used to treat stomach aches, diarrhea, and similar gastro-intestinal problems. Another 7% of th e home remedies listed in the study was used as purges for parasites including apazote and garlic. The study c oncluded that the use of home remedies in the community was near ly ubiquitous and that in general home remedies were used as a first choice ove r biomedicine for minor health problems, stomach aches, colds, and diarrhea. Illnesses that were perceived as being serious were more likely treated at the clinic. Preventing Parasites Similar to their knowledge regarding th e source of infection and mode of transmission, participants were equally as knowledgeable about what they could do to prevent getting parasites in the first pl ace. Logically, the domains relating to the knowledge of prevention strongly reflected the knowledge doma ins related to source of infection and mode of transm ission. To reiterate, the domains relating to the source of infection and mode of transmission were in sects and animals, ground/dirt, food, washing hands, water, and hygiene. Based on qualitati ve analysis, a total of 13 codes emerged relating to the prevention of parasites. The most common codes, based on the number (N)

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128 of interviews the code appeared were "W ashing Hands" (N=11); "Maintaining Hygiene" (N=10); "Washing Food" (N=9); and “Boiling Water” (N=7). Further analysis of the data revealed 4 principal domains that emerged from the codes that exemplified the scope of knowle dge, practices and pe rceptions regarding preventing infections with intestinal parasite s. The four domains in cluded the following: 1) avoiding the ground or dirt; 2) ensuring wa ter quality; 3) pract icing good hygiene; and 4) practicing food hygiene. A view of this ne twork can be seen in the following graphic followed by a short description of each domain. Figure 6-6. Network View of Parasite Prevention The emergent domain "dirt" and its role in preventing parasites is directly related to the same domain found in source of inf ection and mode of transmission. In that domain, participants noted that walking on th e ground barefoot or playing with dirt was a potential source of infection; a reference relating to helm inth infections such as hookworm. When asked about how they coul d prevent parasite infections a few participants (N=5) mentioned "Not Letting Kids Play w ith Dirt" (N=2) and "Wearing Shoes" (N=3). These participants made the cognitive link between source of infection and prevention demonstrating a high level of understanding which is apparent in the following quotes. “Well it’s really hard to prevent getting them, you have to be careful. One shouldn’t play around in the dirt or touch things in the street and then put their fingers in their mouth.” (22:10-58) CF:Prevention-Dirt CF:Prevention-Food CF:Prevention-Hygiene CF:Prevention-Water Preventing Parasites {0-0}

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129 “Yes, they say that you should wash your hands, always wear shoes outside, wash your food well, and maintain this in the house as clean as possible.” (3:14-49) The domain "water" and its ro le in preventing parasites we re also directly related to its role as a source of in fection. Participants cited that drinking contaminated water was the main way that one could get parasites. As mentioned earlier, participants did not mention water as a source of infection with the same intensity as they did with other domains such as hygiene or food. Still, partic ipants identified three codes that made a connection between water and prevention. Th e most common way to prevent parasites mentioned by participants related to water was "Boiling Water" (N=7). The practice of boiling water as a way to eliminate pote ntial water-borne pathogens is well known, especially in places with compromised wate r quality. In Monteverde however, residents do not regularly boil water due to the percep tion that their water is already potable because AyA chlorinates the local water supply. Still, residents are very familiar with the practice, especially if they grew up in rural areas with no potable water supply. The following quotes characterize how participants conceptualize the utility of boiling water as a way to prevent parasites. “Yes, although the water here has chlori ne people should still boil it because you never know; the water can still have parasites.” (7:2-64) “Yes, and if you have to use water from another source you should always boil it first.” (8:7-71) “Boiling the water makes it safe and kills stuff that might be in the water, but the problem here is that people are not used to boiling their water because they [AyA] tell us that it is safe and that the people here take it for granted. In any case many people say that boiled water tastes different and that’s why people don’t do it. If you have to give someone suero for diarrhea or vomiting, that you have to use boiled water to make sure that it is good, otherwise if the water you are using to make the suero is bad you will just make the person sicker.” (11:46-37) Similar to boiling water, participants also mentioned that one could prevent parasites by putting chlorine in the water supply. The idea of putting chlorine in the water comes from actual water management practi ces in Monteverde where the AyA oversees water chlorination in Santa Elena and Cerro Plano. Other participants were also familiar with the practice of putting a few drops of chlori ne in the water to be used to wash fruits

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130 and vegetables to kill parasites and ba cteria residing on food. The following quotes demonstrate this knowledge of using chlorina ted water to wash fruits and vegetables. “Well, you can put chlorine in the water to wash fruit and other foods before eating them, that’s supposed to kill all the bugs and stuff.” (14:22-53) "A good thing to do is to wash that stuff [fruits and vegetables] with water that has a little chlorine in it to make sure that you kill the bichos. ” (23:14-23) Finally, some participants stated that an obvious way to prevent parasites was to simply avoid drinking contaminated water. This of course is directly related to the mode of transmission of drinking contaminated water. Participants often mentioned not drinking contaminated water with a host of other common knowledge and practices used to prevent parasites. The followi ng quotes illustrate this idea. “Things like not eating with dirty hands, not drinking contaminated water. If the water is bad you should boil it. You should also wash your fruits and vegetables. The water here is good, it’s potable.” (2:14-45) “Well you need to have good hygiene and pretty much keep everything clean. Wash hand before eating and you should only drink good water. The water here is from springs and AyA has filters on all of the tubes, they put chlorine in the water and they clean the storage tanks and tu bes on a regular basis.” (9:5-45) The domain "food" and its role in preventi ng parasites were also directly related to perceptions and knowledge of food as a pr incipal source of in fection and mode of transmission of parasites. To reiterate, part icipants noted that "eat ing contaminated food"; "improper food handling"; and "not washi ng food" as the most common mode of transmission in terms of f ood and parasites. Within the prevention domain "food" three principal codes emerged including "Was hing Food" (N=9); "Cooking Food Thoroughly" (N=3); and "Not Eating Contaminated Food" (N=2 ). In this sense, pa rticipants were more likely to emphasize proper food handling as a way to avoid eating contaminated food. The following quotes provide a look at the leve l of participants' know ledge regarding this domain. “You should also wash fruits and vegetables, like cabbage, with water with a little chlorine in it. With food that is eaten raw one should really be careful to wash it.

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131 Those things are exposed to the environment and bugs and bacteria and things like that can land on it. And if you don’t wash it would get sick.” (5:5-43) “You also have to be careful with food and make sure you handle it well and cook it enough. I have been cooking in restaurants for a long time and you have to be careful otherwise you can get people sick and that’s bad for business.” (23:1-43) These quotes demonstrate a high level of knowledge about food hygiene. In addition, these quotes also mention using chlori nated water to wash fruits and vegetables as a means to kill parasites and bacteria that may reside on them. This of course directly related to the prevention doma in "water" described earlier. The most common prevention domain to emerge from the data was "hygiene" which was strongly related to the same domains of source of infection and mode of transmission. To reiterate, the hygiene domain relating to source of infection and mode of transmission includes a variety of general hygiene concepts and specific behaviors; "getting parasites from dirtines s/poor hygiene" and "putting dirty objects in mouth" are good examples of codes that constructed th is domain. The emerging prevention domain "hygiene" follows a similar pattern and include s codes relating to general hygiene as well as more specific practices including hand wash ing as means to prevent parasites. The most common codes to emerge as in the number (N) of interviews where it was mentioned include "Washing Hands" (N= 11); "Maintaining Hygiene" (N=10); Maintaining Personal Hygiene (N=3); and "N ot Eating with Dirt y Hands" (N=3). The following quotes illustrate participant’s view of hygiene as an integrated concept of behaviors and ideals. “Well you need to have good hygiene and pretty much keep everything clean and wash hand before eating." (9:6-45) “One should practice good hygiene; washing your hands before eating, wash food like fruits. If the water is contaminated you should boil it.” (13:5-45) “You should wash your hands and bathe every day and things like that, oh and maintain everything clean around the house…just good hygiene.” (16:19-53) “You have to practice good hygiene lik e cleaning your house and washing your hands and things like that." (23:1-43)

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132 The codes relating to "hand washing" we re included in the "hygiene" domain in contrast to the source of infection/mode of transmission domain where they were separate. In this case, hand washing was included in the hygiene domain because hand washing behavior was expressed as a part of maintaining both general and personal hygiene. Knowledge of Parasites One of the most important domains to emerge from the data that was not explicitly asked as part of the interview wa s the source of particip ants’ knowledge about parasites in general. While the semi-structu red interview asked part icipants about their knowledge and perceptions regarding parasite s, it became clear in the analysis that participants obtained their knowledge through various sources. Based on this analysis, participants referred to seven di fferent sources of information that they used to construct their understanding of parasites. The most common source of knowledge, as in the number (N) of interviews the code app eared was "Knowledge from Ones Mother" (N=12); followed by "Knowledge from Experience" (N=10); "Knowledge from Neighbors or Other Family Member" (N=9); "Knowledge from TV or Books" (N=3); "Knowledge from Nicaragua" (N=3); and fina lly "Knowledge from the Clinic" (N=2). A view of this network can be seen in Figure 6-7. The emergent domain "knowledge from mo ther" appeared in 12 of 28 interviews. Taking into account that 4 of the interviews were conducted primar ily with men who did not mention their mothers, half all of the women interviewed (12 out of 24) mentioned their mother as a source of information con cerning parasites. Based on analysis from the interviews, knowledge that was passed down from mother to daughter was related to illnesses from parasites, symptoms, treating parasites, and describing parasites. For example, much of the narration from participants regarding ataque de lombrice originated from their mothers telling them stories a bout their personal expe riences with that particular condition. In fact, many of the stor ies told by participants mothers related to when they themselves or their si blings had parasites as children.

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133 Figure 6-7. Network View of Parasite Knowledge Interestingly, the majority of participan ts interviewed had ne ver experienced their children having ataque de lombrice as mothers themselves due primarily to better access to primary health care that ta rgeted helminth infections. St ill, this knowledge had been passed down to them from their mothers and ma ny participants were able to talk about it at length. The following quotes illustrate this. “Then there are lombrices there is a disease called lombrice attack and it’s when people have a lot of lombrices and those lombrices come up and try to come out of your mouth and your nose and ears. People cough a lot and have a feeling like they are going to choke to death and they usually have inflated stomachs. It’s a very serious illness. My mom knows about that because she said that one of my brothers had it.” (3:18-55) “My mom used to talk about the lombrice attack. She says that there were a couple of her cousins that died from lombrices. ” (13:3-61) In addition to knowledge about specific il lnesses, many participants also noted that some of their knowledge of specific symp toms related to parasites such as grinding teeth, sleeping with eyes ope n and having inflated stomachs originated with their mothers. While mothers are very attune to ch anges in their children’s behavior and their relation to certain illnesses, much of the know ledge used to correlate specific symptoms with disease or illness is passed down from their mothers. However, knowledge of folk CF:Knowledge about Parasites Knowledge from Clinic {2-0} Knowledge from Neighbors {7-0} Knowledge from Experience {11-0} Knowledge from Nicaragua {3-0}~ Knowledge from Mother {21-0} Knowledge from TV/Book/Etc. {3-0} Knowledge from Family Member {2-0}

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134 symptoms seems to be more and more devalued as mothers become more dependent on laboratory and other means of testing. “My mom told me all about that but I can’ t remember. Like when a kid doesn’t want to eat because they are already full of lombrices or when they have big stomachs.” (13:1-25) “Parasites cause things like stomach aches a nd like my mom said they caused kids to grind their teeth.” (14:29-65) In terms of treating parasites it was cl ear that much of the knowledge regarding biomedical medication such as Albendazole had been gained through relatively recent interaction with the modern health care se rvices. Knowledge of home remedies on the other hand is almost invariably passed down from generation to generation. Many participants talked readily a bout using home remedies noting that they had learned about their application from their mothers, while some participants admitted knowing nothing about home remedies and that their mother's would best answer questions about home remedies. "When I was little my mother would give us a remedy called padra it’s a plant and it is supposed to be good for getting rid of parasites, especially when you have an inflated stomach like that." (11:25-58) For lombrices there was Guaro Charral and Apazote which you would also give in the mornings while fasting. These are all things I remember my mom telling me.” (14:20-45) The following quote sums up quite ni cely how knowledge through experience about certain illnesses, symptoms, and trea tment are passed down from mother to daughter. “My mom always used to say that when ki d’s grinded their teeth it was an indication that they had parasites. Mom also talked about ataque de lombrices ; that was when there was so many worms that they would get into all parts of your body that kids would cough them up. Mom said that they used garlic to make the worms go back down.” (14:10-27)

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135 Other emergent domains of knowledge re garding household hea lth and parasites follow similar lines as knowledge passed dow n from mother to daughter. For example, knowledge from experience, knowledge from neighbors and other family members, knowledge from Nicaragua, and knowledge fr om media sources such as TV and magazines all point to a communal knowledge th at is deconstructed and shared in one way or another among members of close-kn it communities. This spirit of communal knowledge is still alive and we ll in the Monteverde Zone wh ere people tend to know their neighbors well and have family that live nearby. The following quotes illustrate the different kinds of knowledge expressed by participants. “I read in a book about one called “pin wo rm” they are the ones that suck blood I think and they can actually come out of you r body. That’s what my mom used to say anyway, that when we were kids we would have lombrices coming out of us.” (45:161) “You have to purge them, clean out their stomach. Here they always use Albendazole; I remember in Nicaragua th at we always used home remedies. I remember that my mother would always use Apazote con Guaro which is like a plant mixed with strong cane liquor that's usually taken for worms." (27:8-33) “[My son] had lombrices when he was three months old. People use garlic to make them go back down. This causes stomach ache and the person can get dehydrated. You should be sure not to give them milk. It’s a serious illness, my mother in law told me that he had worms and that if they came up he could choke to death. I remember we gave him some home remedies but that did not do the trick and we had to bring him to the doctor. He got medicine there and then he got better.” (5:1-47) Finally, the domain “knowledge from the clinic” appears not to be very significant compared to the other domains in this network; only two participants mentioned explicitly that thei r knowledge of parasites came from the clinic. However, the fact that only two participants mentioned th at their knowledge of parasites came from the clinic fails to recognize that participants were extremely knowledgeable about preventing parasitic infections. Analysis demonstrates that participants’ know ledge about prevention bore an exact reflection to participants’ dom ain structures of source of infection and mode of transmission. Participants’ prevention models were similar in many ways to common public health campaigns; not walking barefoot and wearing shoes; washing your hands before you eat and after you go to the bathroom; careful food handling; and

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136 practicing general hygiene are examples of pa rticipants’ mantras on preventing parasites that strongly resemble public health parasi te prevention campaigns. See the analysis on parasite prevention for a more detailed analysis. Knowledge of Parasites between Nicaraguans and Costa Ricans A domain that emerged from qualitative analysis and that was not part of the interview guide but relevant to this resear ch was the contrast between Nicaraguans and Costa Ricans in terms of knowledge and experi ence with parasites. This small domain emerged from the data based on comments and narratives by Nicaraguan participants during the interviewing. In many cases, Nicaragua n participants would offer insights into this domain in reference to related questi ons about treatment practices and questions about the prevalence of parasites in the community. As mentioned earlier, Nicaraguan participant’s knowledge and conceptions a bout parasites was influenced by their experience living in Nicaragua. Interestingly, comments made by Nicara guan's reflect a deep understanding of how political economic and social infrastruc ture play an important role in the epidemiologic make-up of parasitic infecti ons. This understanding of how parasites are found at a higher prevalence in re lation to certain socio-economi c realities. This idea can be seen in the following quotes by two Nicara guan mothers when asked why they thought there were more parasites in Nicaragua. “Well, it has to do with the environment and everything, I mean Nicaragua is worse off, people are poor, the kids walk around without shoes and without clothes, and the people don’t have work. The food there as well, people just have to eat what is available to them, the situation is much more difficult. I remember when there was hardly any food and all we ate was watermelon and bananas and things we could gather.” (27:13-49) “Well you know, Nicaragua is a really pret ty place with the lakes and everything but there have been lots of problems, like the wa r, land mines, contamination. Lots of the rivers are really contaminated so if you drink water from the rivers or lakes you can get sick. There are more illnesses and diseases. Compared to here [Costa Rica] the water is really bad, it’s not treated and if you drink bad water you can get sick with parasites and viruses and such.” (11:37-88)

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137 These quotes illustrate the level of knowledge of these participants to be able to draw conclusions between social and economic infrastructure and epidemiological trends of parasitism and other related health issu es. Another Nicaraguan participant discussion this same subject made mention of how lacki ng primary health servi ces and potable water systems can increase disease incidence. “Well, lots of people just went to the bathroom outside and there is just less sanitation and the people walk around withou t shoes lots. In Nicaragua there are also less health services, people have to use na tural medicine because it’s hard sometimes to get drugs, I mean the health services would rarely give you anything like that. And here [Costa Rica] kids are better attended. There are better health services here in general and you can get medicine for parasites. The guy from the EBAIS comes and gives the kids medicines for parasites.” (20:19-59) “Well, Nicaragua is a lot poorer and lots of people live in really bad conditions. It’s common for the water to be contaminated an d things are just dirtier and there is a real lack of hygiene and th ere aren’t lots of health programs like there are here [Costa Rica]." (25:2-72) “Yes, here [Costa Rica] the water is pre tty clean, much more than in Nicaragua anyway. Where we lived in Nicaragua we would often have to take water out of the lake for drinking water and there was much less hygiene there." (20:21-71) These mothers note that primary health se rvices and water quality are much better in Costa Rica compared to the situation in Nicaragua. These participants make a tacit connection between lacking health services and poor water and sani tation conditions as an explanation as to why there are more para sites in Nicaragua compared to Costa Rica. While many Nicaraguan participants ma de a comparison between Costa Rica and Nicaragua in terms of economic and social in frastructure and the prevalence of intestinal parasites, Costa Rican participants also made similar comparisons of past and present day Costa Rica in terms of parasite prevalence. When asked whether intestinal parasites were common in the community several Costa Rican participants mentioned that parasites were much more common in the past compared to the present. When asked to further explain their analysis of w hy parasites were common in th e past and less common in the present many Costa Rican participants cited th e poor economic and social infrastructure; specifically the lack of access to health care (especially in ru ral areas) and the lack of clean potable water and water sanitation infrastructure that existed in the past. The

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138 following quote is from a Costa Rican mother when asked to explain why she thought parasites were more common in the past compared to the present. “Before the people lived in bad conditions; they had dirt floors, the kids would drink water from the river, they didn’t know about good hygiene, they cooked with wood, and the people had pit latrines. When I lived in [town] we had a pit latrine. But back then there were not control measures, there were no doctors, and people didn’t have transportation to go to a doctor. Nowadays, people live in better conditions and are better educated and there is better access to doctors and medication.” (13:4-65) This is an excellent explanation as to why there were more parasites in the past compared to the present time. This mother describes everything regarding poor living conditions of the past: dirt floors, drinki ng water from the river, lack of knowledge, having pit latrines, lack of medical controls and programs from the clinic. She also talks about the fact that there were no doctors and that people did not have transportation to get to a doctor. She goes on to say that nowadays people live in bette r living conditions, are more educated about hygiene and that they have better access to doctors and medication. Other participants shared these views when asked the same question. The comparisons made between past and present center around access to primary health care, potable water, and good sanitation infrastructure. “The government has more control now with things like that. They come to the schools now and give the kids medication to get rid of parasites and nowadays there is better access to doctors and medicati on than there was before.” (15:9-56) “Yes, you can also get parasites from the fe ces of animals; that’s why it’s important to wear shoes, back then the people walked around barefoot and most of the people had pit latrines or the people just went to the bathroom outside. We had a pit latrine until the 70’s when we got a regular bath room. There are still people here with pit latrines though and I think that the CAJA should invest in providing materials so that people can have regular bathrooms...The community needs to have a good water source, before people used to drink water from shallow wells but now the water is treated and everything. It seems like the government has really made an effort to provide good water." (15:5-42) “Yes before there were more parasites it seems. I think that parasites are more common in very rural areas where the water supply might not be that good.” (9:9-61) “I don’t know, before people had more parasites but now there is better health care and the clinic provided people with pills and all that.” (1:2-60)

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139 In historical context of th e evolution of the Costa Rican primary health care these are excellent explanations as to why parasite s were more common in the past. This shows that informants are cognizant of the change s and improvements to basic primary health care of the rural population that the Costa Rican health care sy stem has made. It is very telling that this concept came through in interviews. Summary of Qualitative Results The knowledge demonstrated here in this semi-structured interview of parasite knowledge and perception clea rly show that participan ts have a high level of understanding of etiologic pathways of parasi tes (what parasites ar e, what causes them, how they are transmitted and how they can be prevented). In addition, and of importance to this study was that Nicaraguan participants share this high leve l of knowledge with their Costa Rican counterparts, thus dem onstrating that a lack of understanding or knowledge about parasite etiology cannot, in part, explain the difference in prevalence rates among the two study populations. While participants exhibit a high level of knowledge regardin g the specifics of symptoms, source of infection, mode of transmission, treatment, and prevention of parasites, this knowledge appeared to be isolated into separa te pieces of information that did not appear to be connected. For example, participants were able to name and talk about different symptoms of parasites; co mmon sources of infec tion; common modes of transmission; biomedical and alternative tr eatment pathways; and prevention strategies. However, for the most part, participants were unable to connect the dots between parasite, source of infection and preven tion. For example, many participants knew explicitly the symptoms and treatment pathways of hookworm infection; they also knew that one could prevent “parasites” by not walk ing barefoot in the di rt, but they did not specifically know that hookwor m infection was caused by walking barefoot in infected soil. Another example of this disconnect was th at participants were very aware of the fact that parasites were a result of ba d hygiene and sanitation in general and that consistent hand washing and maintaining good hygiene prevented one from getting

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140 parasites. The general perception here was that parasites always exist in un-hygienic environments. However, for the most part, part icipants were unclear about the fecal-oral route of transmission where pa rasites are primarily passed in the feces of an infected individual that are la ter ingested by non-infected indivi duals as a result of poor personal and household hygiene.

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141 Chapter Seven – Quantitative Results Relating to Parasite Prevalence Presented here are the quantitative results of data gathered to determine factors associated with the prevalence of intestinal parasites among the study population. The results are presented in three distinct sect ions according with how they were gathered. First, basic household demographic data wi ll be presented fro m household surveys; second, data concerning household water supply and sanitation will be presented; finally, epidemiological data will be presented re garding factors associ ated to the period prevalence of intestinal parasites. Household Demographic Data In total, demographic data was co llected on 126 individuals from two study populations; data was collected on 76 Costa Ricans taken from 18 households, and on 50 Nicaraguans taken from 11 households. The me an age for the two study populations was similar. For Costa Rican participants the mean age was 20.1 years; for Nicaraguans the mean age was 18.3 years; and the mean ag e for the entire study population was 19.4 years. The median age for all participants was 14.5 years. According to Table 7-1, the difference in mean age between Costa Rican and Nicaraguan study participants was not significant. The mean age of all male participants was 18.2 years and 20.6 years for all female participants. For Costa Rican males the mean age was 18.8 years, while for females the mean age was 21.4 years. For Nicaraguan males the mean age was 17.3 years and for females the mean age was 19.4 years. According to Table 7-1, the difference in mean age between males and females was not significant. In the total study population, children 0 to 5 years of age made up approximately 20% of the population; school age children 6 to17 years of age made up 34% of the population; and adults 18 years of age a nd older made up 46% of the study population. The distribution of age categories was sim ilar for both Costa Rican s and Nicaraguans.

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142 Table 7-1. Age and Gender Distribution of Study Population Age Category All Participants: n=126 Costa Rican Participants: n=76 Nicaraguan Participants: n=50 Mean Age 19.4 Years 20.1 Years 18.3 Years Median Age 14.5 Years 14.5 Years 14.5 Years 0 to 5 Years 19.8% (25) 17.1% (13) 24.0% (12) 6 to 17 Years 34.1% (43) 35.5% (27) 32.0% (16) 18 and > Years 46.0% (58) 47.4% (36) 44.0% (22) Mean Age Male 18.2 Years (62) 18 .8 Years (37) 17.3 Years (25) Mean Age Female 20.6 Years (64) 21.4 Years (39) 19.4 Years (25) Differences in mean age of Costa Rican and Nicar aguan study participants were not statistically significant based on a two-tailed independent sample t -test ( t = .661, p = .510, df = 124, Mean Difference = 1.792, Standard Error = 2.712). Differences in mean age of male and female partic ipants was not statistically significant based on a twotailed independent sample t -test ( t = .887, p = .377, df = 124, Mean Difference = 2.352, Standard Error = 2.651) Table 7-1 shows that th e distribution of gender am ong the total study population was extremely similar; females accounted for 50.8% (N=62) while males accounted for 49.2% (N=64). The gender distribution between Costa Ricans and Nicaraguans was also extremely similar; Costa Rican females ma de up 51.3% while Costa Rican males made up 48.6%. The gender distribution was split ev enly between Nicaraguans; females made up 50% while males made up 50%. According to Table 7-2, demographic data collected by the Monteverde Clinic in 2001 show that children 0 to 5 years of age made up 12.8% of the population; whereas school aged children 6 to 17 years of age made up 28.7% of the population; finally, adults 18 years of age and older accounted for 59% of the population in the Monteverde Zone (ASIS 2002). These findings support the Monteverde Clin ic data which reported that females represented 51.4% of the to tal population while males ma de up 48.6% of the total population in Monteverde. The distribution of age categories wa s similar among both male and females in the total study populat ion. Unfortunately, data provided by the Monteverde Clinic was unable to pr oduce mean ages of the population.

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143 Table 7-2. Age and Gender Distributio n of Monteverde, Costa Rica, 2001 Age Category Total Population Freq. | Percent Male Population Freq. | Percent Female Population Freq. | Percent 0 to 5 Years 383 12.8% 178 12.2% 205 24.0% 6 to 17 Years 844 28.7% 416 28.6% 428 32.0% 18 and > Years 1,767 59.0% 862 59.2% 905 44.0% Total 2,994 100% 1,456 48.6% 1,538 51.4% It should be noted that demographic data collected by the Monteverde Clinic does not distinguish national origin. As such, the number of Nicaraguans living in the area and information regarding their ag e is unknown. However, a stu dy of Nicaraguans living in Costa Rica in 2001, directed by the Interna tional Organization fo r Migration (OIM), estimates that there is a higher presence of Nicaraguan adults than children; adults 20 years of age and older make up approximate ly 67.4% of the total Nicaraguan population living in Costa Rica. In cont rast, only 4.8% of the total Ni caraguan Population living in Costa Rica are children between the ages of 0 and 5 years. Comparatively, school aged children 6 to 19 years of age make up an estimated 27.8% of the total population (OIM 2001). The distribution of gender in the total study population compared to the nation as a whole is similar. According to the 2 001 national household survey, females made up 50.8% of the population while males make up 49.2% of the entire national population (Proyecto Estado de la Nacin 2002). For th e Nicaraguan population living in Costa Rica the 2001 IOM study estimates that females represent 50.9% of the population while males make up 49.1% of the total Nicaraguan immigran t population (OIM 2001). In terms of gender distribution, the study populatio ns are extremely similar to the both local and national level data. Table 7-3 shows the mean years of edu cation obtained between Costa Rican and Nicaraguan adults. Among the total study popula tion, adult Costa Ricans, 18 years of age and older (n=36), had attained an average of 5.97 years of schooling with a median of 6 years of schooling. In contra st, adult Nicaraguans, 18 years of age and older (n=22), had attained an average of 3.82 years of schooli ng with a median of 4 years. On average,

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144 adult Costa Ricans had attained 2.15 more years of schooling compared to adult Nicaraguans. Table 7-3. Years of Education Attained am ong Costa Rican and Nicaraguan Adults Group Mean Years of Education Median Years of Education Adult Costa Ricans 5.97 years 6 years Adult Nicaraguans 3.82 years 4 years Differences in mean years of education between adu lt Costa Ricans 18 years of age and older compared to Nicaraguan adults 18 years of age or older was statistically significant based on a two-tailed independent sample t -test ( t = 2.78, p = .007, df = 56, Mean Difference = 2.154, Standard Error = .772). According to Table 7-3, there is a sign ificant difference in the mean years of education obtained by adult Costa Ri cans compared to adult Nicaraguans. The difference in mean years of formal e ducation between Costa Rican and Nicaraguan adult women within the study populations is es pecially marked. On average, Costa Rican women had attained 3.3 more years of edu cation compares to Nicaraguan adult women. Table 7-4 shows that on average, adult Ni caraguan women had atta ined 2.55 years of formal education with a median of 2.0 year s. In contrast, adult Costa Rican women had attained 5.86 years of formal education w ith a median of 6 years of education. Table 7-4. Mean Years of Education Attained Among Adult Women Group Mean Years of Education Less than 6 years of Education Freq. | Percent 6 years of Education Freq. | Percent More than 6 years of Education Freq. | Percent Costa Rican Women 5.86 5 25% 9 45% 6 30% Nicaraguan Women 2.55 10 83.3% 2 16.7% 0 0% Differences in mean years of education between adult Costa Rican women 18 years of age and older compared to adult Nicaraguan women 18 years of age or older was statistically significant based on a twotailed independent sample t -test ( t = 3.640, p = .001, df = 30, Mean Difference = 3.312, Standard Error = .910). Odds Ratio of Costa Rican women who have obtained 6 or more years of education compared to Nicaraguan women = 11.250; CI 95 %, Lower = 1.858, Upper = 68.132 Table 7-4 demonstrates that the majority of adult Costa Rican women (75%) have completed at least 6 or more years of e ducation. In contrast, only 16.7% of adult Nicaraguan women had completed 6 years of education. In fact, Costa Rican women were more than 11 times as likely to have co mpleted at least 6 years of formal education

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145 compared to Nicaraguan women. Furthermor e, none of the Nicaraguan women in this study population had completed more that 6 y ears of education compared to 30% of Costa Rican women. According to the data, there is a signifi cant difference in the mean years of education obtained by Costa Ri can women compared to Nicaraguan women. Local data collected by the Monteverde Clinic regarding education is limited; data was only collected in terms of lite racy among persons 12 years of age and older. According to the clinic data, only 4% of th e entire local populati on is “illiterate” wh ile the rest (96%) are considered “literate” (ASIS 2002). It is unclear what criteria were used to assess literacy among the population. On the national level, the 2001 IOM st udy reports that Costa Rican adults 15 years of age or older had completed on av erage 7.2 years of sc hooling. In contrast, Nicaraguan adults 15 years of age or older living in Costa Rica had completed on average 5.4 years of education; 1.8 years less than th eir Costa Rican peers. The IOM study states that 16.1% of Nicaraguans living in Costa Rica have no formal training compared to 5.6% of Costa Ricans; 25.9% of Nicaraguans living in Costa Rica have not finished elementary school compared to 18.3% of Co sta Ricans; and only 11.1% of Nicaraguans had finished high school or have higher educ ation studies compared to 23.6% of Costa Ricans (OIM 2001). The 2001 OIM study points out that Nicar aguans living in Costa Rica have significantly lower levels of education comp ared to Costa Ricans. In comparing the national education sta tistics with data from the tota l study population, Nicaraguans in Monteverde have significan tly lower levels of educa tion compared Costa Ricans. However, both Nicaraguans and Costa Ricans in Monteverde have lower levels of education compared to their coun terparts on the national level. It should also be mentioned that Nicaraguans living in Costa Ri ca tend to have higher education standards in all categories compared to Nicaraguans living in Nicaragua. Among the total study population, Nicaragua ns tended to have larger households (the total number of people living within a single dwelling) compared to Costa Ricans. According to Table 7-5, the mean household size for the total study population was 4.9 people per household with a median of 5.0 people per household. The average Costa

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146 Rican household had 4.29 people with a medi an of 4 people per household while the average Nicaraguan household had 5.73 people with a median of 6 people per household. On average, Nicaraguan households had near ly 1.5 more people per household compared to Costa Rican households. Table 7-5. Mean Size of Costa Ri can and Nicaraguan Households Group Mean Household Size Median Household Size Costa Ricans 4.29 people per HH 4.0 people per HH Nicaraguans 5.73 people per HH 6.0 people per HH Total 4.9 People per HH 5.0 People per HH Differences in mean household size of Costa Rican households compared to the mean household size of Nicaraguan households was statistically significant based on a two-tailed independent sample t -test ( t = 2.295, p = .030, df = 26, Mean Difference = 1.433, Standard Error = .624). Odds Ratio of Nicaraguan households with more that 6 people per household compared to Costa Rican households with 6 or more people per household = 9.000; CI 95 %, Lower = 1.355, Upper = 59.783 According to Table 7-5, the difference in mean household size between Costa Rican and Nicaraguan households was significan t. In fact, Nicaraguan households were 9 times as likely to have 6 or more people per household compared to Costa Rican households. According to local data from the M onteverde Clinic, 41.6% of households in Monteverde are made up of 2-3 people, while 40.5% of households have between 4 and 5 people. In contrast, only 12% of all households have 6 or more people. The data shows that Costa Rican households in the study popul ation are more or less the same size as households reported by the Monteverde Clinic while the Nicaraguan households in the study population are larger than the aver age household in the region (ASIS 2002). National level data report an average of 3.9 people per household; a number relatively close to that of the local population in M onteverde and to the study population (Proyecto Estado de la Nacin 2002). In addition, the IO M study reports that households where at least one head of household is Nicaraguan have on average 4.8 people per household (OIM 2001). Thus, the Nicaraguan households of the study population tented to be much larger on average than other Nicaraguan househol ds in Costa Rica. Interestingly, the IOM study reports that an averag e Nicaraguan household of 4.8 pe ople, two are Costa Rican citizens; many of which are children born in Costa Rica of Nicaraguan parents (OIM

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147 2001). In the study population, there were on average 5.73 people per Nicaraguan household; 2.27 of which are Costa Rican citi zens. Again, the majority of Costa Ricans living in Nicaraguan households are children born in Costa Rica to Nicaraguan parents. To reiterate, for this research children bor n to Nicaraguan parents were categorized as Nicaraguan regardless of whether or not they were born in Costa Rica. Table 7-6 demonstrates that househol d ownership among the study population is extremely divergent. The majority of Co sta Ricans (72%), own their own home; 44.5% claimed to have their home paid for in full while 27.5% owned their own home with a mortgage. In contrast, only 36.4% of Nicar aguans households own their own home; all which had their home paid for in full; none had a mortgage. The majority Nicaraguans (64%) rent their home, compared to only 28% of Costa Ricans. Table 7-6. Home Owners hip by Nationality Group Home Owners Freq. | Percent Rent Home Freq. | Percent Costa Rican Households 13 72% 5 28% Nicaraguan Households 4 36% 7 64% The frequency of Costa Rican households that own their own home compared to Nicaraguan households that own their own home was not statistically significant for nonrandom association based on Fisher’s exact test (p = 0.119, df = 1). Odds Ratio of Costa Rican households that own their home compared to Nicaraguan households that own their own home = 4.550; CI 95 %, Lower = .915, Upper = 22.627 According to the data in Table 7-6, Co sta Ricans were 4.5 times as likely to own their own home compared to Nicaraguans. However, the association between home ownership and nationality was not significan t for nonrandom association. Data from the Monteverde Clinic concerning home owners hip show that 69.5% of homes in the Monteverde Zone are owned wher eas 25.5% are rented (ASIS 2002). Data regarding the reported monthly house hold income from all household workers was collected for the entire study population. Table 7-7 shows that reporte d household income among Nicaraguan and Costa Rican households is similar. However, it should be noted that the author believes the da ta to be highly variable from month to month and that in some cases informants may have exaggerated their monthly incomes to a high or low degree.

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148 Table 7-7. Reported Monthly Hous ehold Income by Nationality Group Reported Monthly Income Colones | U.S. Dollars Costa Rican Households C.104,647 261.00 USD Nicaraguan Households C.118,181 295.00 USD Differences in reported household income of Co sta Rican households co mpared to the reported household income of Nicaraguan households was not statistically significant based on a two-tailed independent sample t -test ( t = .734, p = .470, df = 26, Mean Difference = $33.80, Standard Error = 46.139). On average, Nicaraguan households repor ted a slightly high er monthly income than did Costa Rican households. However, according to table 7-6, the difference in reported household income be tween Costa Rican and Nicaraguan households was not significant. It should be noted in terms of repor ted monthly income that on average, Nicaraguan households had 1.55 workers per household, whereas Costa Rican households had an average of 1.1 worker s per household. This may explain why Nicaraguan households reported a slightly hi gher monthly income compare to Costa Ricans. Still, there was a wi de range of reported househol d income among Nicaraguans and Costa Ricans. For example, both Nicara guans and Costa Ricans reported a monthly income between 100 and 500 USD. To reiterat e, the sample of Costa Rican households were selected to represent low income hous eholds and that no high income households were chosen to partic ipate in the study. Table 7-8 shows the three most comm only held jobs between Nicaraguan and Costa Rican men. The majority of Nicara guan men, 63.7% work as construction day laborers, carpenters, or similar jobs. To a lesser degree only 26.7% of Costa Rican men worked in a construction related field. The Ma jority of Costa Rican men (40%) worked in the business or tourism sector as restaurant operators, hotel workers, and tour guides. Comparatively, only 9.1% of Nicar aguan men worked in business of tourism related jobs. Another popular line of employment in the Monteverde area is driving taxi. In this field, 18.2% of Nicaraguan men drove taxi comp ared to 6.7% among Costa Rican men. Interestingly, 13% of Costa Rican men in the study sample worked in Agriculture, whereas none of the Nicaraguan me n worked in Agriculture.

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149 Table 7-8. Most Common Jobs among Adult Costa Rican and Nicaraguan Men Most Common Jobs Among Costa Rican Men Percentage Most Common Jobs Among Nicaraguan Men Percentage 1. Business/Tourism: 40.0% 1. Cons truction: 63.7% 2. Construction: 26.7% 2. Taxi Drivers: 18.2% 3. Agriculture: 13.4% 3. Tourism: 9.1% Employment numbers for the study populat ion vary greatly compared to national statistics. According to the 2001 IOM report, almost 25% of Nicaraguans living in Costa Rica work in agriculture, compared to only a fraction of Costa Ricans who still work in the agriculture sector. In addi tion, the IOM reports that only 16% of Nicaraguans work in construction related fields (OIM 2001). Howe ver, the employment numbers gathered for this research follow in line with recent ch anges in the Monteverde economy; a significant reduction in the agricultural sector and a s ubsequent increase in th e development of the tourism sector. In Monteverde, Costa Rican men tend to hold the most valued tourism jobs, working as guides or in restaurant s, whereas Nicaraguan tend to work in construction. Table 7-9 shows the most commonly held jobs between Costa Rican and Nicaraguan women. Table 7-9. Most Common Jobs among Adul t Costa Rican and Nicaraguan Women Employment Among Costa Rican Women Percentage Employment Among Nicaraguan Women Percentage 1. In the Home: 42.9% 1. In the Home: 72.7% 2. Restaurants: 14.3% 2. Restaurants: 18.2% 4. Domestic Employee: 14.3% 3. Hotel 9.1% The majority of Nicaraguan women (72.7 %) worked in the home, compared to 42.9% of Costa Rican women. In Monteverde 18.2% of Nicaraguan women worked as restaurant cooks and 9.1% worked in hotels. For Costa Rican wome n, 14.3% worked as restaurant cooks, 14.3% worked as artisans and 14.3% worked as domestic employees. According to national sta tistics, 49.9% of Nicaraguan wo men living in Costa Rica participate in the labor market, whereas nationally, only 38.2% of Costa Rican women

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150 participate in the labor market (Proyecto Estado de la Nacin 2002). This means that, compared to national statistics, in Montev erde, fewer Nicaraguan women participate in the local labor market, whereas more Costa Ri can women work in the local labor market. Interestingly, more Costa Rican and Nicara guan women are working outside of the home than were 5 years ago; an indication that employment opportunities in the Monteverde area have opened up for all women as a result of the growing tourism sector. Table 7-10 shows reported cases of unemployment among the adult study population. Adult participants were asked whether any household worker had been unemployed at any time during the past year Also, women who repor ted staying at home were not included in unemployment statistics. Table 7-10. Reported Unemployed in the Past Year by Nationality Group Unemployed Last Year Freq. | Percent Not Unemployed Last Year Freq. | Percent Nicaraguan Workers 7 53.8% 6 46.2% Costa Rican Workers 7 25.9% 27 74.1% Total 14 29.8% 33 70.2% The frequency of Nicaraguans workers who reported being unemployed during the past year compared to Costa Rican workers was not statisti cally significant for nonrandom associ ation based on Fisher’s exact test (p = 0.155, df = 1) Odds Ratio of Nicaraguans workers who reported be ing unemployed in the past years compared to Costa Rican workers = 3.333; CI 95 %, Lower = .831, Upper = 13.372 Table 7-10 shows 29.8% of adult worker s reported being unemployed at some point during the past year compared to 70.2% who reported being fully employed. In terms of nationality, 53.8% of Nicaraguan wo rkers reported being unemployed at some point during the past years compared to 25.9% of Costa Rican workers. According to the data, Nicaraguan workers are 3.3 times as like ly to have been unemployed in the past year compared to Costa Rican workers. Ho wever, according to a 2X2 contingency table the frequency in the number of cases of une mployed adult Nicaraguan workers compared to unemployed adult Costa Rican workers wa s not statistically si gnificant for nonrandom association. Although not significant, reported unemploy ment can perhaps be explained by the high number of adult workers employed in cons truction related fields. While construction

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151 work in Monteverde is ample, it is often uns table. As such, workers are forced to work from one contract to the next. A constructi on worker may be employed on a contract full time for several months and then be unempl oyed for several weeks as the workers looks for a new contract. Jobs outside of constructi on tend to be more stab le but can still wax and wane in relation to the high and low tour ist season; a good example are hotel staff. Another important consideration is whethe r household members have access to health insurance through the Costa Rican Social Se curity Fund (CCSS). Table 7-11 shows the disparity between Nicaraguans and Costa Ricans in the percent of hous eholds in the study population that have uninsured household memb ers. In this case, 81.8% of Nicaraguan households had at least one household member that did not have health care coverage compared to 35.3% of Costa Rican households. Table 7-11. Household Health Coverage by Nationality Group % of Households with Uninsured Members Freq. | Percent % of Households where all Members are Insured Freq. | Percent Nicaraguan Households 9 81.8% 2 18.2% Costa Rican Households 6 35.3% 11 64.7% The frequency of Nicaraguan households with uninsured members compared to Costa Rican households with uninsured members was statistically significant for nonrandom association based on Pearson (1) = 5.815; p = 0.016. Odds Ratio of Nicaraguans households with at least one uninsured household member compared to Costa Rican household members = 8.250; CI 95 %, Lower = 1.328, Upper = 51.263 According to Table 7-11, Nicaraguan households in the study population are 8.3 times as likely to have household members th at are uninsured compared to participants living in Costa Rican households. Again, cros s-tabulations of a 2X2 contingency table show that the frequency of uninsured Ni caraguan households compared to uninsured Costa Rican households was statistically significant for nonra ndom association. Table 7-12 demonstrates a large disparity in the percent of individual health care coverage by nationality. Among the tota l study population, 54% of Nicaraguan participants did not have h ealth coverage at the time of this study, whereas 46% of Nicaraguans reported having h ealth coverage. In contrast only 20% of Costa Rican

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152 participants reported not ha ving health coverage, while 80% of Costa Ricans reported having health care coverage. Table 7-12. Individual Health Coverage by Nationality Group Uninsured Individuals Freq. | Percent Insured Individuals Freq. | Percent Nicaraguan Households 27 54% 23 46% Costa Rican Households 15 20% 61 80% The frequency of uninsured Nicaraguan individuals compared to uninsured Costa Rican individuals was statistically significant for nonrandom association based on Pearson (1) = 15.932; p = < 0.001 Odds Ratio of Nicaraguan individuals with no health insurance compared to Costa Rican individuals with no health insurance workers = 4.774; CI 95 %, Lower = 2.161, Upper = 10.547 According to Table 7-12, Nicaraguans were almost 5 times as likely to not have health care coverage compared to Costa Rican s. Cross-tabulations of a 2X2 contingency table show that the frequency of uninsur ed Nicaraguan individuals compared to uninsured Costa Rican individua ls was statistically significa nt for nonrandom association. Although no local data exists as to the per centage of the local population covered under a CCSS health plan, national statistics point out that 87.7% of the Costa Rican population was covered (no data for Nicar aguan nationals exists) under some sort of CCSS health insurance (Proyecto Estado de la Nacin 2002). Household Water and Sanitation Data Semi-structured interviews were conducte d with all heads of household in order to gain information concerning household wa ter use, access, cost, water quality, water security, sanitation, wastewater management and perceptions about water services. In total, data from this interview was collected for 17 Costa Rican households with a total of 69 people as well as 11 Nicaragua n households with a total of 53 people. In total, the household water and sanitation interview corres ponds to a total of 122 individuals from the two study populations. One purpose of the household water and sa nitation interview was to determine whether both study populations in study ha d equal access to water and sanitation infrastructure. According to Figure 7-1, all respondents (100 %) stated that their water

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153 came from local springs and that the Sant a Elena Aqueduct was responsible for the distribution and quality of the local water supply. Figure 7-1. Reported Source of Household Water When asked their opinion regarding the qua lity of the water di stribution services they receive from AyA, the majority of res pondents replied that the services were either excellent of satisfactory. Figur e 7-2 shows the distribution of reported satisfaction with the local aqueduct. The majority of Costa Ricans (82.4%) classified their local aqueduct as satisfactory, while 17.6% classified thei r aqueduct as excellent. None of the Costa Rican households classified their local aque duct as “poor”. Similarly, the majority of Nicaraguans (72.7%) classified their aqueduct as satisfact ory, while 18.6% said it was excellent. Only one Nicaraguan household cate gorized their aqueduc t as “poor”, citing the frequent cuts in wate r supply to their household. It is interesting that the majority of respondents had a posi tive opinion of their local water distribution services when in fact almost all of the respondents reported that they have experienced cuts in their water se rvices. Cuts in water service refer to the common occurrence that the hous eholds’ water supply is cut off without prior notice for an indefinite amount of time (ranging from several minutes to several hours). Cuts in water services can be the result of many f actors, the most common being repairs to the

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154 distribution system itself and less commonly to water shortages during the dry season. Cuts in water supply are extremely common in Santa Elena; in fact, all of the households that participated in this study (with the exception of one) repo rted that their water is cut off periodically. Figure 7-2. Reported Quality of Local Aqueduct Despite frequent cuts in the household wa ter supply, when asked to describe the quality of water they receive from AyA all participants were positive about the quality of water they received from AyA. Figure 73 shows the distribution of responses by Nationality. The majority of Costa Ricans 58.8% reported that their water quality was buena or muy buena (good or very good), while 29.3% said that their water was limpia or clean; and 11.8% described their water as potable water that is treated and piped to the house. Nicaraguans had very similar opinions of their water quality; 63% said that their water quality was buena or muy buena while 27.3% said that their water was limpia and 9.1% described their water as potable. Participants were also asked on averag e how much they spend on their monthly water bill. For Costa Rican households, the mean reported monthly water bill was 5.35 USD. For Nicaraguan households, the mean reported monthly wate r bill was 6.38 USD.

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155 The difference of close to one dollar per month is most likely related to the larger mean household size between the two groups. Figure 7-3. Reported Quality of Hous ehold Water Quality by Nationality Data were gathered concerning the pr esence and condition of household sanitation infrastructure including bathroom, kitche n, graywater system, and septic tank. For example, the majority of households in the region and in this study population enjoy modern flush toilets. However, according to Table 8-1, three households in the study report using a pit latrine. Based on repeated direct observation me thods by the researcher, bathrooms were categorized as “unsanitary” if any one of the following criteria were met upon observation: the absence of a sink to wash hands; the absence of soap to wash hands; exposure of dirty toilet paper; and dirt floors. Pit latrines were automatically categorized as “unsanitary”, while bathrooms that met a ll of these criteria were categorized as “sanitary”. According to Table 7-13, the majo rity of bathrooms in Nicaraguan households (72.7%) were classified as “uns anitary”. In contrast, the majority of bathrooms in Costa Rican households (76.5%) were classified as “sanitary”.

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156 Table 7-13. Type and Condition of Household Bathroom Group Type of Bathroom Freq. | Percent Condition of Bathroom Freq. | Percent Costa Rican Households Flush Toilet: 15 88.2% Latrine: 2 11.8% Adequate: 13 76.5% Inadequate: 4 23.5% Nicaraguan Households Flush Toilet: 10 90.9% Latrine: 1 9.1% Adequate: 3 27.3% Inadequate: 8 72.7% The frequency of Nicaraguan households with unsanitary bathrooms compared to Costa Rican households with unsanitary bathrooms was statistically significant for nonrandom association based on Fishers Exact Test p = 0.019, df = 1) Odds Ratio of Nicaraguan households with inadequate bathrooms compared to Costa Rican households = 8.667; CI 95 %, Lower = 1.526, Upper = 49.220 Table 7-13, shows that Ni caraguans were 8.66 times more likely to have an unsanitary bathroom compared to Costa Rican s. In addition, crosstabulations of a 2X2 contingency table show that the frequenc y of unsanitary bathrooms in Nicaraguan households compared to the frequency of unsanitary bathrooms in Costa Rican households was statistica lly significant for nonra ndom association. Due to the fact that the AyA does not have the infrastructural capacity to treat solid waste, most all of the households in th e Monteverde area have septic tanks. Septic tanks in Monteverde have drainage fields and are i ndependently constructed and maintained by each household. As shown in Table 7-14, the number of hous eholds with septic tanks is in direct correlation to the number of households with fl ush toilets. Septic ta nks were categorized as “inadequate” if any one of the follo wing criteria were met upon observation: not working properly, not draining properly; over flowing; broken; expos ed to the elements. Septic Tanks that met all of these crit eria were categorized as “adequate”. Based on inspections by the researcher, Table 7-14 shows that 80% of household septic tanks (both among Ni caraguan and Costa Rican hous eholds) were considered adequate. In contrast, only 20% septic tanks were deemed inadequate; either they were not sealed properly and thus exposed, or th ey were full and not properly draining. As a result, there was no significant association be tween septic tank conditions and household nationality.

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157 Table 7-14. Percentage of Hous eholds with Septic Tanks Group Households with Septic Tanks Freq. | Percent Condition of Septic Tank Freq. | Percent Costa Rican Households Yes: 15 88.2% No: 2 11.8% Adequate: 12 80% Inadequate: 3 20% Nicaraguan Households Yes: 10 90.9% No: 1 9.1% Adequate: 8 80% Inadequate: 2 20% The frequency of Nicaraguan households with adequate septic tanks compared to Costa Rican households with adequate septic tanks was not statistically si gnificant for nonrandom association based on Fishers Exact Test p = 1.000, df = 1) Graywater (water from sinks and showers) disposal is also a sanitation concern in the Monteverde Zone as it is not disposed of or treated by AyA. Graywater systems were classified as “inadequate” if they were dis posed of openly into the environment in a way that facilitated human contact (for example, onto the gr ound where children play). According to Table 7-15, 47% of Co sta Rican households had designated graywater drainage systems consisting of a concrete holding tank a nd drainage field. In contrast, only 9% of Nicaraguan households had such graywater drainage boxes. The majority of Nicaraguan households (91%) disp ose of graywater into streets and rivers, compared to 53% of Costa Rican households. Table 7-15. Graywater Disposal and Condition of Graywater System Group Graywater Disposal Freq. | Percent Condition of Graywater System Freq. | Percent Costa Rican Households Graywater Box: 8 47% Street/Ground: 8 47% River: 1 6% Adequate: 11 65% Inadequate: 6 35% Nicaraguan Households Graywater Box: 1 9% Street/Ground: 3 27% River: 7 64% Adequate: 5 45% Inadequate: 6 55% The frequency of Nicaraguan with inadequate gray water disposal systems compared to Costa Rican households with inadequate graywater systems was not statistically significant for nonrandom association based on Fishers Exact Test p = 0.441, df = 1) Odds Ratio of Nicaraguans households with inad equate graywater systems compared to Costa Rican households with inadequate graywater systems = 2.200; CI 95 %, Lower = .468, Upper = 10.350 According to Table 7-15, 35% of Co sta Rican households had inadequate graywater disposal systems, compared to 55% of Nicaraguan households with inadequate

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158 graywater disposal systems. Also, Nicaragua ns were 2.2 times more likely to have an inadequate graywater system compared to Costa Ricans. Cross-ta bulations of a 2X2 contingency table the frequency of inade quate graywater systems in Costa Rican households was not statistically signi ficant for nonrandom association. An assessment of household kitchen condi tions was also taken by the researcher based on multiple visits to the home; kitchens were rated as sanitary if countertops and eating utensils were clean, if food were properl y stored, if soap or detergent were readily available, and if there was few or an absen ce of vectors such as flies or cockroaches. Kitchens were rated as unsanitary if one or more of these conditions were not met. Table 7-16 Shows that 55% of kitchens in Ni caraguan households were categorized as unsanitary compared to 24% of Costa Rican kitchens. In add ition, the researcher observed the presence of vectors in 64% of Nicaraguan kitchens compared to 41% of Costa Rican kitchens. Based on Table 7-16, Nicaraguans were 3.9 times as likely to have an unsanitary kitchen compared to Costa Ricans. Cross-ta bulations of a 2X2 contingency table the frequency of unsanitary kitchen conditions in Nicaraguan households compared to the frequency of unsanitary kitchen conditions in Costa Rican households was not statistically significant for nonrandom association. Table 7-16. Condition of Household Kitchen and Presence of Vectors Group Condition of Household Kitchen Freq. | Percent Presence of Vectors in Household Freq. | Percent Costa Rican Households Sanitary: 13 76% Unsanitary: 4 24% No Vectors: 10 59% Vectors Present: 7 41% Nicaraguan Households Sanitary: 5 45% Unsanitary: 6 55% No Vectors: 4 36% Vectors Present: 7 64% The frequency of Nicaraguan with unsanitary kitchens compared to Costa Rican households with unsanitary kitchens was not statistically significant for nonrandom association based on Fishers Exact Test p = 0.125, df = 1) Odds Ratio of Nicaraguans households with unsanitary kitchens compared to Costa Rican households with unsanitary kitchens = 3.900; CI 95 %, Lower = .762, Upper = 19.951 Period Prevalence of Intestinal Parasites Out of the total study population of 126 people, a total of 84 participants; 35 Nicaraguan participants from 11 households and 49 Costa Rican par ticipants from 17

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159 households provided fecal samples that were collected and analyzed to determine the period prevalence of intestinal parasites. In all cases, fecal sample s were prepared and tested for the presence of intestinal protozoa, helminths and Cryptosporidium parvum using procedures described in the methodology chapter. Table 7-17 demonstrates the age dist ribution for all 84 participants and by national origin. The investigat or attempted to include par ticipants representing a wide diversity in age. As a result, participants range in age from 1 year ol d to 61 years of age. The mean age for those who participated in the parasite preval ence study was 16.4 years with a median age of 11 years. Table 7-17. Age and Gender Distribution of Participants of the Parasite Study Age Category Total Participants (n=84) Costa Rican Participants (n=49) Nicaraguan Participants (n=35) Mean Age 16.37 Years 16.1 Years 16.74 Years Median Age 11 Years 11 Years 11 Years 0 to 5 Years 25% (21) 22.4% (11) 28.6% (10) 6 to 17 Years 40.5% (34) 44.9% (22) 34.3% (12) 18 and > Years 34.5% (29) 32.7% (16) 37.1% (13) Males 10.6 Years (36) 9.4 Years (22) 12.4 Years (14) Females 20.6 Years (48) 21.6 Years (27) 19.6 Years (21) Differences in mean age of Costa Rican and Nicar aguan participants from whom fecal samples were examined were not statistically significant based on a two-tailed independent sample t -test ( p = .846, df = 82). Differences in mean age of female and male partic ipants from whom fecal samples were examined was statistically significant based on a two-tailed independent sample t -test ( p = .002, df = 82). As demonstrated in Table 7-17, the ag e distribution between Costa Rican and Nicaraguan participants was similar. The mean age for Costa Rican participants was 16.1 years while the mean age of Nicaraguan partic ipants was 16.7 years; the median age was 11 years for both groups. However, there was a significant difference in mean age by gender in the study population; female particip ants were older (20.6 years) than male participants (10.6 years). In terms of gender distri bution, slightly more female s (N=48) participated by providing fecal samples than male particip ants (N=36). Among Costa Ricans, males represented 45.8% (n=22) and females 55.1% (n=27) of the group study population.

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160 Among Nicaraguans, males represented 40% (n =14) and females 60% (n=21) of the group study population. Finally, Ta ble 7-18 and Figure 7-4 dem onstrates the distribution and intensity of intestinal parasites, including pathogeni c intestinal protozoa and helminths and commensal (non-pathogenic) intestinal protozoa among Nicaraguan and Costa Rican participants. Table 7-18. Distribution of Intestinal Parasites among Study Participants* Pathogenic Parasites Costa Rican Participants n=49 Nicaraguan Participants n=35 Global Prevalence Parasites n=84 Freq. | p % Freq. | p % Freq. | p % Intestinal Protozoa E. histolytica 3 6.1% 4 11.4% 7 8.3% G. lamblia 1 2.0% 1 2.9% 2 2.4% C. parvum 0 0% 0 0% 0 0% Intestinal Helminths Uncinarias 0 0% 2 5.7% 2 2.4% T. trichiura 0 0% 1 2.9% 1 1.2% A. lumbricoides 0 0% 0 0% 0 0% Comensel Parasites Intestinal Protozoa E. coli E. nana I. butschlii 3 6.1% 1 2.0% 0 0% 8 22.9% 4 11.4% 0 0% 11 13.1% 5 6.0% 0 0% *Including multiple infections among participants The period prevalence of pathogenic protozoa was E. histolytica (8.3%) and G. lamblia (2.4%), while the period prevalence of commensal intestinal protozoa was E. coli (13%) and E. nana (6.0%). The period prevalence of intestinal helminths was Uncinarias (2.4%) and T. trichura (1.2%). In addition, there were no (0) positive cases of other common parasites such as C. parvum (0%) and A. lumbricoides (0%). Figure 74 shows the distribution and inte nsity of intestinal parasites that were significant and excludes parasites not found in the study population. Figure 7-4, provides a graphic representation of Table 7-18.

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161 Figure 7-4. Prevalence of Intestinal Pa rasite Species by National Origin Table 7-19 demonstrates the frequency and prevalence of multiple parasitic infections among Costa Ricans a nd Nicaraguans. All of the Cost a Rican participants that tested positive for intestinal parasites (n=4) had multiple parasitic infections, that is, the individual was infected with more than one pa rasite at the same ti me. In addition, all of the Costa Rican participants who tested pos itive for parasites were infected with pathogenic species, specifically, E. histolytica and G. lamblia In three specific cases, the pathogenic intestinal protozoa E. histolytica was found along with the non-pathogenic parasite E. coli In the other positive cas e the pathogenic parasite G. lamblia was found along with the non-pa thogenic parasite E. nana It should be noted th at none of the Costa Rican participants were found to be infected with any species of helminths, including hookworms ( Uncinarias ), whipworms ( T. trichiura ), or roundworms ( A. lumbricoides ). Among the Nicaraguan participants, seven out of the eleven cases positive for intestinal parasites had multiple infections and two cases that tested positive for three parasite species. In additi on, six out of the eleven cases positive for parasites among Nicaraguan participants were infected w ith pathogenic species. Common multiple infections among Nicaraguan participants consisted of the pathogenic parasite E.

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162 histolytica appearing along with th e non-pathogenic parasite E. coli ; the two nonpathogenic parasites E. coli and E. nana ; and the two pathogenic helminths species N. americanus and T. trichiura Table 7-19. Prevalence of Multiple Pa rasite Infections by Nationality Multiple Parasite Infections Costa Rican (n=4) Freq. | p% Nicaraguan (n=11) Freq. | p% Total (n=15) Freq. | p% Infected with 1 Parasite 0 0% 4 36.4% 4 26.7% Infected with 2 Parasites 4 100% 5 45.5% 9 60.0% Infected with 3 Parasites 0 0% 2 18.2% 2 13.3% Of public health interest, it should be emphasized that there were only two cases positive for intestinal helminths; both cases were from adult women. This epidemiological pattern indicates that helmin th infections are unde r control thanks to preventive primary care measures. It is qui te possible that both women positive for helminth infection were chronic sufferers and that they became infected in a geographical location with endemic helminths, either in Ni caragua or in another area of Costa Rica. Factors Associated with the Individual Prevalence of Intestinal Parasites In this study, 84 fecal samp les were collected and analy zed for intestinal parasites from a study population of Nicaraguan and Cost a Rican participants. Laboratory results conducted between January 1st, 2004 to June 30th, 2004 confirmed that 15 (18%) individuals in the study populati on were positive for at leas t one parasite, and 11 (13%) of the samples had multiple infections (73.3% of infected individuals). The other 69 (82%) individuals were considered uninfect ed based on a negative fecal examination. Figure 7-5 shows that the period preval ence for Costa Ricans was 8.3% and that 91.7% of Costa Ricans were nega tive for intestinal parasites. The period prevalence rate for Nicaraguans was 31.4%, whereas 68.6% of Ni caraguans were negative for intestinal parasites. The period prevalence rate for the entire study population (n=84) was low (15%) compared to other similar studie s done in Costa Rica (Abrahams-Sand 2005; Blanco 2007; Hernndez 1998).

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163 Figure 7-5. Period Prevalence of Intest inal Parasites by National Origin However, period prevalence rates of inte stinal parasites calculated by national origin demonstrate significantly divergent pr evalence rates. Table 9-20 demonstrates the period prevalence (from January 1st, 2004 to June 30th, 2004) of intestinal parasites as calculated for both the Costa Rican and Nicaraguan study populations. Results in Table 7-20 show that Nicaraguans were 5.2 times as likely to be positive for parasites as compared to Costa Ricans. Among the study population, infection status with intestinal parasites was significantly associated with nationality. In terms of period prevalence of intestinal pa rasites, the results obtained from this study of parasite prevalence are significantly diffe rent from those results obtained from the Monteverde Clinic during the same time period (January 1st, 2004 to June 30th, 2004). Table 7-20. Period Prevalence of Intest inal Parasites by National Origin Group Positive for Parasites Rate | Prevalence Negative for Parasites Rate | Prevalence Costa Ricans 4/49 8.3% 45/49 91.7% Nicaraguans 11/35 31.4% 23/35 68.6% Total 15/84 17.9% 69/84 82.1% The frequency of Nicaraguans infected with intes tinal parasites compared to the frequency of Costa Ricans not infected with intestinal parasites was statis tically significant for nonrandom association based on Pearson (1) = 7.534; p = 0.006. Prevalence Odds Ratio of Nicarag uans infected with intestinal pa rasites compared to Costa Ricans infected with intestinal parasites = 5.156; CI 95 %, Lower = 1.482, Upper = 17.943

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164 Though it is difficult to determine the exact period prevalence rates for parasites gathered during that time by the Montever de Clinic, the results can be inferred. According to the Monteverde Clinic (Per sonal Communication) approximately 40 fecal samples per week are transported to the Puntarenas Hospital for analysis. Therefore, between January and June, 2004 approximately 960 fecal samples were analyzed from the Monteverde Clinic. Of those 960 samples, only 24 were positive for any kind of parasitic infection. These numbers indicate an approximate period prevalence rate of 2.5% for those samples test ed by the Monteverde Clinic. It should be noted that the clinic data does not specif y or publish the national origin, gender, or species of parasite among its results. Clinic data regarding the period prevalence of intestinal parasites, though not reliable, provide nonetheless an indication that parasite infections are under dete cted among the population. Figure 7-6. Parasite Prevalence by Age Group and Nationality Age of participants also appears to be associated with the infection status of individual participants. Figur e 7-6 shows the distribution an d prevalence of intestinal parasites by age and national origin. Among Costa Rican participants there were no positive cases of intestinal parasites in children between 1 and 5 years old.

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165 In contrast, the prevalence rate among Costa Rican school children between 6 and 17 years of age was 5.9% while the prevalence rate among Costa Rican adults 18 years of age and over was 6.9%. Among the Nicaraguan participants that were positive for intestinal parasites, the period prevalence ra te for children between 1 and 5 years of age was 4.8%; the prevalence rate in school ch ildren between 6 and 17 years of age was 14.7%; finally, the prevalence ra te in Nicaraguan adults 18 years of age or older was 17.2%. For all participants posi tive for intestinal parasite s the period prevalence among children 1 to 5 years of age was 4.8%; the prevalence for school age children 6 to 17 years of age was 20.5%; and the prevalence rate for adults 18 years of age and older was 24.1%. According to Table 7-21, school children aged 6 to 17 years of age are 5.2 times as likely to be infected with intestinal parasi tes compared to children 1 to 5 years of age. Likewise, Adults aged 18 years of age and up were 6.4 times as likely to be infected with intestinal parasites compared to children 1 to 5 years of age. Table 7-21. Parasite Prevalence by Age and National Origin Age Group Costa Rican Cases Rate | p% Nicaraguan Cases Rate | p% Total Rate | p% 1 5 years 0/21 0% 1/21 4.8% 1/21 4.8% 6 > 17 years 2/34 5.9% 5/ 34 14.7% 7/34 20.5% 18 years 2/29 6.9% 5/29 17.2% 7/29 24.1% Mean Age Positive 26.7 Years 15 Years 17.6 Years 16.3 Years 20.1 Years 15.6 Years Mean Age Negative Prevalence Odds Ratio of children ages 6>17 compar es to children ages 1<5 years of age = 5.185; CI 95%, Lower = 0.590, Upper = 45.587 Prevalence Odds Ratio of Adults ages >18 compared to children ages 1<5 years of age = 5.156; CI 95 %, Lower = 0.119, Upper = 56.363 Difference in the mean age of Costa Rican participants positive for intestinal parasites compared to Costa Rican participants negative for intestinal parasites was not significant based on a two tailed independent sample t -test ( p = .119, df = 47). Difference in the mean age of Nicaraguan particip ants positive for intestinal parasites compared to Nicaraguan participants negative for intestinal pa rasites was not significant based on a two tailed independent sample t -test ( p = .820, df = 33). Difference in mean age of participants positive for in testinal parasites compared to participants negative for intestinal parasites were not statistically si gnificant based on a two-tailed independent sample t -test ( p = .290, df = 82).

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166 Independent sample t -tests were done to determine whether the age of infected individuals compared to non-infected indivi duals differed significan tly. Table 7-21 shows the mean age of Costa Rican participants infe cted with intestinal parasites was 26.7 years while the mean age Costa Rican participants not infected with intestinal parasites was 15 years of age. The difference in mean age between infected Costa Rican participants and non-infected Costa Rican particip ants was not significant. The mean age of Nicaraguan participants infected with intestinal parasites was 17.6 years compared to a mean age of 16.3 year s for those not infected. The difference in the mean age between infected and non-in fected Nicaraguan participants was not significant. Finally, the mean age for all infected particip ants was 20.1 years while the mean age of participants that tested negative for intestinal parasites was 15.6 years of age. The difference in mean age of participants pos itive for intestinal parasites compared to those negative for intestinal parasites was not significant. In order to test for association betw een parasite prevalence and household size, data were simplified into binary categorie s; living in a household with 5 or fewer residents and living in households with 6 or more residents. Figure 7-7. Parasite Prevalence by Household Size and Nationality

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167 According to Figure 7-7, the prevalence of intestinal parasites of Costa Rican individuals living in households of 5 people or less was 7.7% while the prevalence rate for Costa Rican individuals living in households with 6 people or more was 10%. The prevalence of intestinal parasite s of Nicaraguan indi viduals living in households of 5 people or less was 7.7% wh ile the prevalence rate for Nicaraguan individuals living in house holds with 6 people or mo re was 45.5%. Finally, the prevalence of intestinal parasites of all par ticipants living in households of 5 people or less was 9.1% while the prevalence rate for al l participants living in households with 6 people or more was 34.5%. According to Table 7-22, participants living in households with 6 or more inhabitants compared to participants living in households with 5 pe ople or less were 5.3 times as likely to be infected with intestin al parasites, thus there is a significant association between parasite prevalence a nd household size. As association between national origin and household size is evident; Nicaraguans were 6.6 times as likely to live in a household with 6 or more household member compared to Costa Ricans. The data show an association between infection stat us and the number of household residents and that Nicaraguans are more likely to live in households with 6 or more residents. Table 7-22. Parasite Prevalence by Ho usehold Size and National Origin Household Size Costa Rican Rate | p% Nicaraguan Rate | p% Total Rate | p% Households < 5 3/39 7.7% 1/13 7.7% 4/52 7.7% Households 6 > 1/10 10.0% 10/22 45.5% 11/32 34.4% The frequency in the number of samples positive fo r parasitic infection between participants living in households with 6 or more residents compared to those living in households with 5 or fewer residents was statistically significant for nonrandom association based on Pearson (1) = 8.346; p = 0.004. Prevalence Odds Ratio of individuals living in househol ds with 6 or more people infected with intestinal parasites compared to individuals living in households with 5 people or fewer infected with intestinal parasites = 5.263; CI 95 %, Lower = 1.591, Upper = 17.412 Prevalence Odds Ratio of Nicaraguans living in households with 6 or more people with compared to Costa Ricans living in households with 6 or more people = 6.600; CI 95 %, Lower = 2.487, Upper = 17.517 Living in a household with an infected fa mily member was also associated with individual infection status. Fi gure 7-8 shows that the period prevalence for infected Costa Ricans living with other infected family members was 22.2% and just 5.0% for those

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168 living in households without ot her infected family members. The period prevalence for infected Nicaraguans living in households with other infected family members was 38.1%, while for infected Nicaraguans livi ng in households without other infected household members was 21.4%. In total, th e period prevalence ra te for infected participants living in househol ds with other infected fa mily members was 33.3%, while the prevalence rate for infected participants living in households w ithout other infected family members was only 9.3%. Figure 7-8. Parasite Prevalence by Inf ected Family Member and Nationality Table 7-23. Parasite Prevalence by P resence of Infected Family Member Presence of Infected Family Member Costa Rican Rate | p% Nicaraguan Rate | p% Total Rate | p% Infected Family Member 2/9 22.2% 8/21 38.1% 10/30 33.3% No Infected Family Member 2/40 5.0% 3/14 21.4% 5/54 9.3% The frequency of infected individuals residing in households with other infected family members compared to uninfected participants residing in households with uninfected family members was statistically significant for nonrandom association based on Pearson (1) = 7.620; p = 0.006. Prevalence Odds Ratio of individuals that tested positive for intestinal parasites and living in households with infected family members compar ed to individuals that tested negative for intestinal parasites and living in households uninfected family members = 4.900; CI 95 %, Lower = 1.486, Upper = 16.153

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169 According to the data in Table 7-23, th ere was a significant association between the prevalence of participants with intestin al parasites and the frequency of infected individuals residing in house holds with other infected family members compared to participants uninfected with intestinal para sites residing in house holds with uninfected family members. Finally, the data represented in Tabl e 7-23 shows that participants who were living with an infected family member were 4.9 times as likely to be infected with intestinal parasites compared to those partic ipants who did not live with another infected family member. Figure 7-9. Parasite Prevalence by Indivi dual Health Coverage and Nationality Not having individual health care covera ge through the CCSS was also associated with individual prevalence for intestinal parasites. According to Figure 7-9, the prevalence for Costa Ricans infected with intest inal parasites that di d not have individual health coverage was 14.3%, while the preval ence for those with individual health coverage was 5.7%. The prevalence for Nicaraguans infected with intestinal pa rasites who did not have individual health cove rage was 41.2%, while the preval ence of those who did have

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170 individual health insurance wa s 22.2%. In total, the period pr evalence for all participants infected with intestinal parasites that did not have health coverage was 29% while the prevalence for those that did have health coverage was 11.3%. Based on Table 7-24, the frequency of i ndividual participants infected with intestinal parasites that do not have health coverage compared to individual participants not infected with intestinal parasites and who have health coverage was statistically significant. Thus, the data show that there is an association between the lack of individual health coverage and individuals pos itive for intestinal parasites. Table 7-24. Parasite Prevalence by Health Care Coverage and National Origin Status of Health Care Coverage Costa Rican Rate | p% Nicaraguan Rate | p% Total Rate | p% No Health Care Coverage 2/14 14.3% 7/17 41.2% 9/31 29.0% Health Care Coverage 2/35 5.7% 4/18 22.2% 6/53 11.3% The frequency of individual participants infected with intestinal parasites that do not have health coverage compared to individual participants not infected with intestinal parasites that have health coverage was statistically significant for nonrandom association based on Pearson (1) = 4.183; p = 0.041. Prevalence Odds Ratio of individuals that tested positive for intestinal parasites that do not have health care coverage compared to individuals that tested nega tive for intestinal parasites that have health care coverage = 3.205; CI 95 %, Lower = 1.114, Upper = 10.125. The prevalence odds ratio in Table 7-24 de monstrates that participant’s positive for intestinal parasites were 3.2 times as lik ely to not have indivi dual health coverage compared to those that were negative for intestinal parasites. Factors Not Associated to Individual Prevalence of Intestinal Parasites The prevalence of intestinal parasite inf ections was not associ ated with the gender of the individual. According to Table 725, the prevalence rate among Costa Rican males was 9.1% and 7.4% for female participants. The prevalence rate among male Nicaraguan participants was 28.6% while for female Nicar aguan participants the prevalence rate was 33.3%. In total, the period prevalence rate for females was 18.8% while for males it was 16.7%. Cross-tabulations of a 2X2 table to calc ulate Chi-square stat istics were done to determine whether there was a significant a ssociation in terms of gender and period

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171 prevalence of intestinal parasites. Accord ing to the data in Table 7-25, there was no significant difference in the frequency of intestinal para sites and gender. Table 7-25. Parasite Prevalence by Gender and National Origin Gender Costa Rican Rate | p% Nicaraguan Rate | p% Total Rate | p% Males (n=36) 2/22 9.1% 4/14 28.6% 6/36 16.7% Females (n=48) 2/27 7.4% 7/21 33.3% 9/48 18.8% The frequency in the number of samples positive fo r parasitic infection between male and female study participants was not statistically significant for nonrandom association based on Pearson (1) = 0.061; p = 0.805. Prevalence Odds Ratio of females infected with in testinal parasites compared to males infected with intestinal parasites = 1.154; CI 95 %, Lower = 0.370, Upper = 3.598 According to the prevalence odds ratio in Table 7-25, Costa Rican males were just as likely as Costa Rican females to have inte stinal parasites; and Nicaraguan males were just as likely as Nicaraguan females to ha ve intestinal parasites. Among both study populations, males were just as likely to have intestinal parasites as females. Table 7-26 shows that the prevalence of a ll participants infected with intestinal parasites living in a household where the mo ther had less than 6 years of formal education was 23.3%. In contrast, the period prev alence of all particip ants infected with intestinal parasites liv ing in households where the mother had at least 6 years of formal education or more was 12.2%. Table 7-26. Parasite Prevalence by Mothers Education Level of Education Costa Rican Rate | p% Nicaraguan Rate | p% Total Rate | p% < 6 Years of Education 3/10 23% 7/23 28.3% 10/33 29.0% 6 > Years of Education 1/35 2.9% 4/1 80% 5/36 12.2% The frequency of individual participants infected w ith intestinal parasites living in a household where the mother has less than 6 years of formal education compared with individual participants not infected with intestinal parasites and who live in households where th e mother has 6 or more years of formal education was not statistically significant for nonrandom association based on Pearson (1) = 1.750; p = 0.186 According to Table 7-26, there was no significant association between intestinal parasite infections among study participants and the formal e ducation levels of the female head of household.

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172 Factors Associated to the Household Prevalence of Intestinal Parasites According to Figure 7-10, the household period prevalence rate for intestinal parasites, where at least one household member tested positive for inte stinal parasites was 32% (n=9). The other 68% (n=19) of house holds were considered negative when all household members tested negative for intes tinal parasites. The household prevalence rate among Nicaraguan households was 54.5% (n=6). The other 45.5% (n=5) of Nicaraguan households were considered nega tive because all household members tested negative. The household prevalence rate fo r Costa Rican households was 17.6% (n=3) and whereas 82.4% (n=14) were considered negative because all household members tested negative for intestinal parasites. Figure 7-10 Period Prevalence of Intestin al Parasites by Household Nationality Among the Nicaraguan households, the 11 participants who te sted positive for intestinal parasites were concentrated in 5 households; 2 households had only one infected household member; 2 households ha d 2 infected household members; and 1 household had 4 infected members. Am ong the Costa Rican study population, the 4 participants who tested positive for intest inal parasites were concentrated in 3

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173 households; that is, 2 households had1 inf ected member each while 1 household had 2 infected members. According to the data in Table 727, the prevalence odds ratio shows that Nicaraguan households were 5.6 times as likely to have at least one household member who was positive for intestinal parasites compared to Costa Rican households. However, the frequency of Nicaraguan households wh ere at least one household member was positive for intestinal parasites compared to Costa Rican households where at least one household member was positive for intestinal parasites was not significant for random association. Table 7-27. Period Prevalence of Intestinal Parasites by Household National Origin Group Positive for Parasites Rate | Prevalence Negative for Parasites Rate | Prevalence Costa Ricans 3/17 17.6% 14/17 82.4% Nicaraguans 6/11 54.5% 5/11 45.4% Total 9/28 32.1% 19/28 68.9% The frequency of Nicaraguan households with at least one member positive for parasite compared to Costa Rican households was not significant for random association based on Fisher’s exact test (p = 0.095, df = 1). Prevalence Odds Ratio of Nicaraguan households with at least one infected household member compared to Costa Rican households with at least one infected member = 5.600; CI 95 %, Lower = 1.001, Upper = 31.319 Factors Associated to Household Parasite Prevalence and Household Conditions Household conditions, including condition of kitchen, condition of bathroom and the presence of vectors were associated w ith households that had at least one household member test positive for intestinal parasites. According to Figure 7-11 the household prevalence of intestinal parasites was associated with unsanitary bathroom conditi ons. For example, the household prevalence rate for Costa Rican households with unsan itary bathrooms was 50%, while for Costa Rican households with sanitary bathrooms the household prevalence rate was 7.7%. The household prevalence rate for Nicaraguan hous eholds with unsanitary bathrooms was 62.5% while for Nicaraguan households with sa nitary bathrooms the prevalence rate was 33.3%. For the entire study population, the hous ehold parasite prevalence rate for

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174 households with unsanitary bathrooms was 41.7% and 12.5% for households with sanitary bathrooms. Figure 7-11 Household Parasite Prevalence by Bathroom Condition Table 7-28 demonstrates that the fr equency of households with unsanitary bathrooms that had at least one household member positive for intestinal parasites compared to households with sanitary ba throoms and no household members positive for intestinal parasites was statistically significant. Table 7-28. Household Parasite Pr evalence by Bathroom Conditions Condition of Bathroom Costa Rican Rate | p% Nicaraguan Rate | p% Total Rate | p% Unsanitary Bathroom 2/4 50% 5/ 8 62.5% 7/12 58.3% Sanitary Bathroom 1/13 7.7% 1/ 3 33.3% 2/16 12.5% The frequency of households with unsanitary bathrooms that had at least one household member positive for intestinal parasites compared to households with sanitary bathrooms and no household members positive for intestinal parasites was statistically significant for nonrandom association based on Fisher’s exact test (p = 0.017, df = 1) Prevalence Odds Ratio of households with unsanitary bathrooms and at least one infected household member compared to households with sanitary bathrooms = 9.800; CI 95 %, Lower = 1.504, Upper = 63.846 Prevalence Odds Ratio of Nicaraguan households with unsanitary bathrooms compared to Costa Rican households = 8.667; CI 95 %, Lower = 1.526, Upper = 49.220

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175 According to the prevalence odds ratio, Table 7-28 demonstrates that households with unsanitary bathrooms were almost 10 times as likely to have at least at least one household member test positive for intestinal parasites compared to households with sanitary bathrooms. Furthermore, Nicaraguans were more than 8 times as likely to have unsanitary bathrooms compared to Costa Ricans. According to Figure 7-12 the household prevalence of intestinal parasites was associated with unsanita ry kitchen conditions. Figure 7-12 Household Parasite Prevalen ce by Kitchen Condition and Nationality For example, the household prevalence ra te for Costa Rican households with unsanitary kitchens was 50%, while for Costa Rican households with sanitary kitchens the household prevalence rate was 7.7%. Th e household prevalence rate for Nicaraguan households with unsanitary kitchens was 83.3% while for Nicaraguan households with sanitary kitchens the prevalence rate was 20%. For the entire study population, the household parasite prevalence rate for househol ds with unsanitary kitchens was 70% and 11.1% for households with sanitary bathrooms. Table 7-29 shows that the frequency of households with unsanitary kitchens that had at least one household member positive for intestinal parasites compared to

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176 households with sanitary kitchens and no household members positive for intestinal parasites was statistically significant. Table 7-29. Household Parasite Pr evalence by Kitchen Conditions Condition of Kitchen Costa Rican Rate | p% Nicaraguan Rate | p% Total Rate | p% Unsanitary Kitchen 2/4 50% 5/6 83.3% 7/10 70% Sanitary Kitchen 1/13 7.7% 1/5 20% 2/18 11.1% The frequency of households with unsanitary kitchens that had at least one household member positive for intestinal parasites compared to households with sa nitary kitchens and no household members positive for intestinal parasites was statistically significant for nonr andom association based on Fisher’s exact test (p = 0.003, df = 1) Prevalence Odds Ratio of households with unsanitary kitchens and at least one infected household member compared to households with sanitary kitchens = 18.667; CI 95 %, Lower = 2.533, Upper = 137.587 Prevalence Odds Ratio of Nicaraguan households with unsanitary kitchens compared to Costa Rican households = 3.900; CI 95 %, Lower = .762, Upper = 19.951 The prevalence odds ratio in Table 7-29 demonstrates that households with unsanitary kitchens were 18 times as likely to have at least at least one household member test positive for intestinal parasite s compared to households with sanitary kitchens. Furthermore, Nicaraguans were almo st 4 times as likely to have unsanitary kitchens compared to Costa Ricans. According to Figure 7-13 the household prevalence of intestinal parasites was associated with the presence of vectors (flie s and/or cockroaches) in the household. For example, the household prevalence rate fo r Costa Rican households with observed vectors was 42.9%, while for Costa Rican hous eholds with no observed vectors the household prevalence rate was 0%. The hous ehold prevalence rate for Nicaraguan households with observed vectors was 85.7% while for Nicaraguan households with no observed vectors the prevalence rate wa s 0%. For the entire study population, the household parasite prevalence rate for house holds with observed vectors was 64.3% and 0% for households with no observed vectors.

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177 Figure 7-13 Household Parasite Prevalence by Presence of Vectors and Nationality According to Table 7-30, the frequenc y of households with the presence of vectors where at least one household member pos itive for intestinal parasites compared to households with no vectors present and no household member positive for intestinal parasites was statistically si gnificant for nonrandom associati on. It should be noted that since there were no cases of households wh ere there were no observed vectors and positive parasites it was impossible to calcu late the prevalence odds ratio for this association. Table 7-30. Household Parasite Prevalen ce by Observed Vectors in Household Presence of Vectors Costa Rican Rate | p% Nicaraguan Rate | p% Total Rate | p% Vectors Observed 3/7 42.9% 6/7 85.7% 9/14 64.3% No Vectors Observed 0/10 0% 0/4 0% 0/10 0% The frequency of households with the presence of vectors where at least one household member positive for intestinal parasites compared to households with no vectors present and no household members positive for intestinal parasites was statistically significant for nonrandom association based on Fisher’s exact test (p = 0.001, df = 1) Prevalence Odds Ratio unable to calculate Prevalence Odds Ratio unable to calculate

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178 Factors Not Associated with Househol d Parasite Prevalence and Household Conditions Household conditions including the di sposal of household graywater and household septic tank conditions were not asso ciated to household parasite prevalence according to 2x2 contingency tables. According to Table 7-31, the household parasite prevalence rate of households with poor graywater disposal systems was 50%. In contrast, households with good graywater di sposal systems had a household parasite prevalence rate of 17.6%. However, this a ssociation was not significant based on a 2x2 contingency table. Table 7-31. Household Parasite Pr evalence by Graywater Disposal Graywater Disposal Positive for Parasites Rate | Prevalence Negative for Parasites Rate | Prevalence Adequate Disposal 3/16 17.6% 13/16 81.3% Inadequate Disposal 6/12 50.0% 6/12 50.0% The frequency of households with inadequate graywater disposal systems and at least one household member positive for intestinal parasites compared to households with adequate graywater disposal systems and no household members positive for intestinal pa rasites was not statistically significant for nonrandom association based on Fisher’s ex act test (p = 0.114, df = 1) According to Table 7-32, the household parasite prevalence rate of households with inadequate septic tank systems was 50% In contrast, households with adequate septic tank systems had a household parasite prevalence rate of 25.0%. However, this association was not significant based on a 2x2 contingency table. Table 7-32. Household Parasite Pre valence by Septic Tank Condition Septic Tank Condition Positive for Parasites Rate | Prevalence Negative for Parasites Rate | Prevalence Adequate Condition 5/20 25.0% 15/20 75.0% Inadequate Condition 4/8 50.0% 4/8 50.0% The frequency of households with inadequate septic tank systems and at least one household member positive for intestinal parasites compared to households with adequate septic tank systems and no household members positive for intestinal parasites was not statistically significant for nonrandom association based on Fisher’s ex act test (p = 0.371, df = 1)

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179 Association between Household Conditions and Household Ownership Household conditions, including condition of bathroom and condition of kitchen were strongly associated with the type of home ownership. Table 7-33. Household Bathroom Co nditions by Household Ownership Home Ownership Unsanitary Bathroom Frequency | Prevalence Sanitary Bathroom Frequency | Prevalence Rent Home 7 75.0% 3 18.8% Own Home 3 25.0% 13 81.3% The frequency of households that rent their home and had unsanitary bathrooms compared with households that owned their own home and had sanitary bathrooms was statistically significant for nonrandom association based on Fisher’s exact test (p = 0.006, df = 1) Prevalence Odds Ratio of households with unsanitary bathrooms who rent their home compared to households that own their own home = 13.000; CI 95 %, Lower = 2.123, Upper = 79.594 According to the data in Table 7-33, 75% of households in the study population that rented their home had an unsanitary ba throom, while only 25% of households that owned their home had an unsanitary bathr oom. The data show that the frequency of households that rent their home and had uns anitary bathrooms compared with households that owned their own home and had sanitary bathrooms was statis tically significant for nonrandom association. According to an odds ratio shown in Table 7-33, households that rented their home were 13 times as likely to have unsanitary bathrooms compared to households that owned their own home. The contrast between home ownership and kitchen condition was even greater. According to the data in Table 7-34, 90% of households in the study population that rented their home had an unsanitary kitche n, while only 10% of households that owned their home had an unsanitary kitchen. Table 7-34. Household Kitchen Condi tions by Household Ownership Home Ownership Unsanitary Kitchen Frequency | Prevalence Sanitary Kitchen Frequency | Prevalence Rent Home 9 90.0% 3 7.7% Own Home 1 10.0% 15 83.3% The frequency of households that rent their home and had unsanitary kitchens compared with households that owned their own home and had sanitary kitchens was statistically significant for nonrandom association based on Fisher’s exact test (p > = 0.001, df = 1)

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180 Prevalence Odds Ratio of households with unsanitary kitchens who rent their home compared to households that own their own home = 45.000; CI 95 %, Lower = 4.044, Upper = 500.693 The data show that the frequency of hous eholds that rent their home and had unsanitary kitchens compared with house holds that owned their own home and had sanitary kitchens was statistically signifi cant for nonrandom association. According to the odds ratio in Table 7-34, househol ds that rented their home were over 45 times as likely to have an unsanitary kitchen compared to household that owned their own home. Home ownership was also associated with household prevalence of intestinal parasites. Figure 7-14 show s that the household prevalence rate among Costa Rican households who rent their home was 40% while the prevalence rate for Costa Rican households that own their own home was 8.3%. Figure 7-14 Household Parasite Prevalence by Home Ownership The household prevalence rate for Nicara guan households that rent their home was 71.4% while the household prevalence for Nicaraguans who own their own home was 25%. In total, the house hold prevalence rate for househol ds that rent their home was 58% while for those that rent their home the prevalence rate was 12.5%.

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181 Table 7-35. Household Parasite Pr evalence by Household Ownership Home Ownership Costa Rican Rate | p% Nicaraguan Rate | p% Total Rate | p% Rent Home 2/5 40% 5/7 71.4% 7/12 58.3% Own Home 1/11 8.3% 1/3 25% 2/14 12.5% The frequency of households where at least one resident tested positive for intestinal parasites and who rent their home compared to households where no residents tested positive for intestinal parasites and who own their own home was statistically significant for nonrandom association based on Fisher’s exact test (p = 0.017, df = 1) Prevalence Odds Ratio of households with at least one infected household member and who rent their home compared to households that own their own home = 9.800; CI 95 %, Lower = 1.504, Upper = 63.846 Prevalence Odds Ratio of Nicaraguan households that rent their home compared to Costa Rican households = 4.200; CI 95 %, Lower = .838, Upper = 21.047 Table 7-35 shows that the frequency of households where at least one resident tested positive for intestinal parasites and w ho rented their home compared to households where no residents tested positive for intestin al parasites and who owned their own home was statistically significant for nonrandom a ssociation. According to the prevalence odds ratio in Table 7-35, households that rent thei r home were 9.8 times as likely to have at least one family member tested positive for intestinal parasites compared to households that own their own home. Also, Nicaraguan hous eholds were more than 4 times as likely to rent their home compared to Costa Rican households. Household Parasite Prevalence and Household Health Care Coverage Household health care coverage was al so associated to household parasite prevalence rates. Households were considered to have “full health care coverage” if all household residents were covere d. In contrast, households were considered to have “inadequate health care covera ge” if at least one household member was not covered. According to Figure 7-15, he household pa rasite prevalence rate for Costa Rican households with inadequate health coverage was 33.3% and just 9.1% for households with full health care coverage. For Nicaragua n households, the paras ite prevalence rate among households with inadequate hea lth care coverage was 66.7%, while for Nicaraguan households with full health care coverage the parasite prevalence rate was 0%. In total, the parasite pr evalence rate among households w ith inadequate health care coverage was 53.3% and just 7.7% for house holds with full health care coverage.

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182 Figure 7-15 Household Parasite Preval ence by Household Health Coverage Table 7-36 illustrates that the frequenc y of households that had at least one household member test positive for intestinal in addition to having uninsured household members compared with households where al l household members tested negative for intestinal parasites in addition to all household memb ers having health coverage was statistically significant for nonrandom association. Table 7-36. Household Parasite Preval ence by Household Health Coverage Household Health Coverage Costa Rican Rate | p% Nicaraguan Rate | p% Total Rate | p% Full Health Coverage 1/9 9.1% 0/2 0% 1/13 7.7% Inadequate Health Coverage 2/6 33.3% 6/3 66.7% 8/15 53.3% The frequency of households that had inadequate health care coverage and at least one resident tested positive for intestinal parasites compared to households that had full health coverage and no residents that tested positive for intestinal parasites was statistically significant for nonrandom association based on Fisher’s exact test (p = 0.016, df = 1) Prevalence Odds Ratio of households that had inadequa te health care coverage and at least one infected household member compared to households with full h ealth care coverage = 6.933; CI 95 %, Lower = .995, Upper = 48.238 The prevalence odds ratio in Table 7-36 s hows that households where at least one resident tested positive for intestinal para sites were 7 times as likely to also have

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183 household members that did not have state health coverage compared to households where no residents tested positive for intes tinal parasites and where all household residents had state health coverage. Household Variables Not Associated with Household Parasite Prevalence Factors such as household size, mother s’ formal education level, household unemployment, and household in come were not significantly associated with households where at least one household member tested posit ive for intestinal para sites. For example, according to Table 7-37, the household parasite prevalence rate for households with 6 or more household residents was 62.5 %, whereas for households with 5 residents or less the parasite prevalence rate was 20%. Table 7-37. Household Parasite Prevalence by Household Size Household Size Positive for Parasites Rate | Prevalence Negative for Parasites Rate | Prevalence 6 > People per Household 5/8 62.5% 3/8 37.5% < 5 People per Household 4/20 20.0% 16/20 80.0% The frequency of households with 6 or more residents that had at least one household resident positive for intestinal parasites compared to households with 5 or fewer residents was not st atistically significant for nonrandom association based on Fisher’s exact test (p > = 0.068, df = 1) Prevalence Odds Ratio of households with 6 or more residents that had at least one household resident positive for intestinal parasites compared to households with 5 or fewer residents = 6.667; CI 95 %, Lower = 1.099, Upper = 40.434 According to a 2x2 contingency table th is association between household size and household parasite prevalence was not signifi cant. Still based on a prevalence odds ratio, households with 6 or more reside nts were more than 6 times as likely to have at least one household member test positive for intestinal parasites compared to households with 5 residents or fewer. Table 7-38 shows that the household pa rasite prevalence rate for households where the mother had obtained 5 or fewer years of formal education was 50%, whereas for households where the mother had obtained 6 or more years of formal education the parasite prevalence rate was 18.8%.

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184 According to a 2x2 contingency table the association between the mothers’ years of formal education and household parasite prevalence was not significant. Still based on a prevalence odds ratio, households where the mother had obtained 5 years of formal education or less were more than 4 times as likely to have at least one household member test positive for intestinal parasites comp ared to households where the mother had obtained 6 or more years of formal education. Table 7-38. Household Parasite Prevalence by Mothers Years of Formal Education Household Size Positive for Parasites Rate | Prevalence Negative for Parasites Rate | Prevalence 6 > Years of Education 3/16 18.8% 13/16 81.3% < 5 Years of Education 6/12 50.0% 6/12 50.0% The frequency of households where th e mother achieved 5 or fewer years of formal education 6 that had at least one household resident positive for intestinal parasites compared to households where the mother achieved 6 or more years of formal education was not statistically significant for nonrandom association based on Fisher’s exact test (p > = 0.114, df = 1) Prevalence Odds Ratio of households where the mother achieved 5 of fewer year s of formal education and where at least one household resident positive for intes tinal parasites compared to mothers with 6 or more years of formal education residents = 4.333; CI 95 %, Lower = .799, Upper = 23.487 Table 7-39 shows that the household pa rasite prevalence rate for households where at least one household member had b een unemployed in the past 6 months was 50%, whereas for households where all hous ehold members had been employed the parasite prevalence rate was 14.3%. Accordi ng to Table 7-39, the association between household unemployment and household parasite prevalence was not significant. Still based on a prevalence odds ratio, households where at least one household member had been unemployed in the past year were 6 ti mes as likely to have at least one household member test positive for intestinal parasites compared to households where all household members were employed. Table 7-39. Household Parasite Pre valence by Household Unemployment Household Size Positive for Parasites Rate | Prevalence Negative for Parasites Rate | Prevalence Employed in Last Year 2/14 14.3% 12/14 85.7% Unemployed in Last Year 7/14 50.0% 7/14 50.0% The frequency of households where at least one household member was unemployed in the last 6 months at where at least one household resident was positive fo r intestinal parasites compared to households where

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185 all adults were fully employed was not statistically significant for nonrandom association based on Fisher’s exact test (p > = 0.103, df = 1) Prevalence Odds Ratio of households where at least one household member was unemployed in the last 6 months at where at least one household resident was positive for intestinal parasites compared to households where all adults were fully employed = 6.000; CI 95 %, Lower = .965, Upper = 37.296 Finally, Table 7-40 shows that the h ousehold parasite prevalence rate for households with a monthly income between $100 and $250 dollars was 40%, whereas for households where the monthly income was between $251 and $500 dollars the parasite prevalence rate was 23.1%. Table 7-40. Household Parasite Preval ence by Household Monthly Income Household Monthly Income Positive for Parasites Rate | Prevalence Negative for Parasites Rate | Prevalence $251 $500 USD 3/13 23.1% 10/13 76.9% $100 $250 USD 6/15 40.0% 9/15 60.0% The frequency of households where the monthly income was between $100 and $250 and where at least one household resident was positive for intestinal parasites compared to households with a monthly income between $251 and $500 was not statistically significant for nonrandom association based on Fisher’s exact test (p > = 0.435, df = 1) Prevalence Odds Ratio of households where the monthly income was between $100 and $250 and where at least one household resident was positive for intestinal parasites compared to households with a monthly income between $251 and $500 = 2.222; CI 95 %, Lower = .426, Upper = 11.603 According to Table 7-40, the asso ciation between household income and household parasite prevalence was not signifi cant. The prevalence odds ratio shows that households with a monthly income between $100 and $250 dollars where were 2.2 times as likely to have at least one household member test posit ive for intestinal parasites compared to households where the monthl y income was between $251 and $500 dollars. A summary of the quantitative research results will be presented in the following chapter.

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186 Chapter Eight – Discussion of the Research Results This chapter discusses the results of th e research relating to the period prevalence of intestinal parasites and w ill focus on the significant findings of this research following the research objectives described in Chapte r 4. To reiterate, the following research objectives were addressed in this research: (O-1) Determine the period prevalence of intestinal parasites among the study population (O-2) Determine the distribution and the most likely sources of infection and modes of transmission of intes tinal parasites among the study population (O-3) Describe the factors associated to the prevalence of in testinal parasites among the study population at th e individual and household level. (O-4) Provide a general po litical ecological framewor k that explains the prevalence of intestinal parasi tes among the study population in Monteverde, Costa Rica. The significant findings of this res earch are outlined as follows. Based on epidemiological data gathered from this research, intestinal parasite infections were significantly underreported by th e Monteverde Clinic when compared with prevalence rates of intestinal parasites gathered by this research dur ing the same time period. This finding follows a trend in the Costa Rican public health literature (see Chapter 3) that questions the findings of the National Survey of Intestinal Parasites (Mata 1998) and demonstrates that intestinal parasites conti nue to be a public hea lth concern, especially among marginalized populations in Costa Rica. Perhaps the most significant finding of this research was that among the study populatio n, Nicaraguans were 5 times as likely to have intestinal parasite in fections compared to Costa Ricans; thus constituting a significant health disparity. Apart from gathering epidemiological da ta on parasite prevalence, one of the main objectives of this research was to char acterize the principal s ources of infection and modes of transmission of intestinal parasites among the two study populations.

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187 Epidemiological data show that intestinal protozoa accounted for 87% of all parasitic infections among the study population; whereas infections with intestinal helminths accounted for only 13% of infections. This ev idence strongly suggests that solid waste and wastewater management do not play a significant role in parasite transmission. Furthermore, the low prevalence of common wa ter-borne intestinal protozoa and the high water quality standards of the Santa Elena Aqueduct indicate that potable water does not play a significant role in tran smission. In contrast, epidemio logical data show a relatively high prevalence of the pathogenic amoebae Entamoeba histolytica and similar commensal intestinal protozoa. This, coupled with data showi ng that individuals living in household with infected family members are at greater risk of being infected with similar parasites strongly indicates that the fecal-oral rout is the principal mode of transmission and that the primary locus of infection occu rs at the household level; most likely the result of a range of poor hygien e behaviors and infrastructure. Another principal objective of this resear ch is to discuss the social and political economic factors associated with the prevalen ce of intestinal para sites among the study population. Based on household surveys and epid emiological data, three primary factors were associated with parasite infections: 1) a lack of access to health care; 2) household ownership; and 3) poor hous ehold environmental conditions. Reasons for not having access to health care vary from underemploym ent to immigration status. Results of the survey data show that individuals without ac cess to health care, regardless of nationality, were more likely to have parasitic infections compared to those individuals with access to health care. However, the fact that Nicara guans had significantly higher prevalence rates of intestinal parasites can be partially explained by the fact th at they were almost 5 times as likely to not have access to health car e compared to Costa Ricans. According to interviews with heads of households, a lack of access to health care creates barriers to testing and treatment of intestinal parasites. Household ownership, speci fically living in a rented home, was significantly associated with inadequate household envi ronmental conditions, namely unsanitary bathroom and kitchen conditions. These condi tions were then significantly associated with parasitic infections among individuals regardless of nati onality. However, data from

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188 household surveys show that Nicaraguans we re more likely to live in a rented home compared to Costa Ricans and thus were mo re likely to live with inadequate household sanitation conditions compared to Costa Ricans. Interviews with heads of household pr ovide context in he lping explain the complex reality of housing inequalities between Nicaraguans and Costa Ricans. International tourism in the Monteverde re gion has created a shortage of affordable housing. Nicaraguans who immigrated to M onteverde looking for work often find themselves underemployed. Both underemployment and immigration status precludes most Nicaraguan households from access to cr edit or from receiving housing subsidies. Without credit or government support, many Nicaraguan families have no other choice but to rent substandard housing, many of which have inadequate san itation infrastructure. These factors, coupled with the fact that Nicaraguan households tend to be larger, and thus more crowded, than Costa Rican households provides both the so cial, behavioral and environmental conditions that promote the tr ansmission of intestinal parasites at the household level. The results of this research support the lite rature in defining para sitic infections as a “disease of poverty” in that the factors associated with paras itoses correlate with underdevelopment and social injustice (V ecchiato 1997). In addition, much of the medical anthropology literature rela ted to infectious disease, in cluding intestinal parasites tend to stress the importance of culturally determined beliefs, knowledge and behaviors as associated with increased disease tr ansmission (Inhorn and Brown 1997). However, the results from this research demonstrate a significant departure from the literature in that research particip ants exhibited an extremely high le vel of knowledge about parasites, including their prevention and treatment. This finding is significant because it suggests that political ecological factor s best explain the intensity and prevalence of intestinal parasites among the study population than does culturally determined beliefs and knowledge. As such, the principal themes outlined here will be examined in greater depth in the following discussion.

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189 Research Objective (O-1): Determine the peri od prevalence of intestinal parasites among the study population One issue this research sought to addre ss were the conflicting reports from local residents who claimed that intestinal pa rasites are common in the community and interviews with local phys icians who, based on laborat ory results, claim that the prevalence of intestinal parasites is extrem ely low in the community and thus does not constitute a public health concern. As such, the following research question was asked: Research Question (RQ-1): Are infections with intestinal parasites significantly underreported by the Monteverde Clinic? The Alternative Hypothesis (H-1): Infections with intestinal parasites are significantly underreported by the Monteverde Clinic. Unfortunately, it was impossible to dete rmine the exact period prevalence of intestinal parasites for samples collecte d and analyzed by the Monteverde Clinic. However, it is possible to speculate with relative accuracy the period prevalence of intestinal parasites for the same time period as this st udy. According the Monteverde EBAIS (Primary Health Care Team), each week approximately 40 fecal samples are taken to the hospital in Puntarenas for an alysis. Based on these approximations, between January and July, 2004 approximately 960 fecal samples were taken from Monteverde to Puntarenas to be examined for intestinal pa rasites. Results show that only 24 of these samples were positive for any kind of parasi te. These numbers indicate an approximate period prevalence rate of 2.5% for the samples an alyzed from the Monteverde Clinic. It is worth mentioning that these numbers are cons istent with the data from the 1996 National Survey of Intestinal Parasites (Mata 1998). Unfortunately, the Monteverde Clinic doe s not report the species of parasite for the infected patient making it impossible to know whether infection was the result of pathogenic or commensal species or even whethe r infection was the resu lt of an intestinal protozoa or intestinal helm inth. Making matters worse, the results do not specify the national origin, age, or gender of infected indi viduals. At best, data from the Monteverde Clinic provide a rough estimate of parasi te prevalence among clinic patients who

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190 volunteered fecal samples for analysis duri ng the months that this research was undertaken. In comparison, from January to July, 2004, the period prevalence rate of intestinal parasites reported from this research was 18%; considerably higher compared to data from the Monteverde Clinic. While it is diffi cult to compare these two data sets because of the difference in selection criteria, the prevalence odds ratio show s that participants who submitted fecal samples for analysis in this study were over 8 times as likely to have been diagnosed with intestinal parasites compared to patients who submitted fecal samples to the Monteverde Clinic. While the prevalence rates from this study are lower than those reported in other community studies in Costa Rica, they follow a trend in the Costa Rican public health lit erature (Abrahams-Sand 2005; Blanco 2007; Cerdas 2003; Gonzlez 1996; Hernandez-Chavarria 2005; Hernndez 1998; Pardo 1997; Sanchez 1999) who’s findings regarding parasite preval ence differs significantly from those of the 1996 National Survey of Intestinal Parasites (Mata 1998), demonstrati ng that intestinal parasites continue to be a public health concern, esp ecially among marginalized populations in Costa Rican. How can the differe nce in prevalence rate s be explained? One explanation is that the difference in the collection and preservation methods of fecal specimens employed by the Monteverde Clinic compared with the methods used in this study had significant consequences on the sensitivity/specificity of the results obtained. As explained in Chapter 4, this study employed the use of a PIF collection and preservation kit in which participants were instructed to immediat ely place stool samples into the collection/preservation vials. This process is effective for collecting, fixing, preserving, and staining the trophoz oites, cysts and eggs of in testinal parasites, thus significantly increasing the chances of obser ving parasites upon microscopic analysis. In contrast, stool specimens collected by the Monteverde Clinic are not placed in preservation solution; but rather collected and stored up to 5 days before they are taken to Puntarenas for analysis. Research has show n that cysts and trophoz oites of intestinal protozoa, if not preserved pr operly, start to desiccate and break down several hours after being passed, making them difficult to id entify through normal diagnostic microscopy (Price 1994). Thus, the practice of not preservi ng stool specimens can seriously affect the

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191 specificity of the results, thereby increasing the probability of a false-negative (type II error) diagnosis which could potentially l ead to significant underreporting of positive results and thus explain the low prevalence rates reported by the Monteverde Clinic. Another consideration regarding the signi ficant difference in prevalence rates is the potential for selection bias Selection bias occurs when the relationship between exposure and disease in a study is not representative of the true relationship of exposure and disease in the general popul ation because the study populati on had been selected in a non-representative way (Frumkin 2005). This re searcher believes that parasite prevalence rates determined by the Monteverde Clinic su ffer from selection bias because they only represent a cross section of clinic patients who volunteer fecal samples and not the population in general. For example, the clinic ’s parasite prevalence rate excludes those who are healthy, those who self-medicate, those who seek diagnosis and treatment elsewhere, and those who lack health insura nce. While it is impossible to determine the age, gender and nationality of patients w ho provided fecal samples at the Monteverde Clinic, evidence from clinic staff suggests that young children make up the majority of those who volunteer fecal samples. Conse quently, adolescents and adults may be significantly underrepresented in the in the clinic sample. This finding is significant considering that the results of this study concluded that adul ts and adolescents were five times as likely to be positive for parasite s compared to children under 5 years old. In contrast, participants who volunteered fecal samples in this study did not differ significantly by age or gender. Therefore the researcher believes that prevalence rates obtained by this research more accurately reflec t the actual prevalence rate of the study population. In conclusion, while there are significant comparative differences, the researcher is confident to accept the Alternative Hypothesis (H-1): infections with intestinal parasites are significantly u nderreported by the Monteverde Clinic. Underreporting parasitic infec tions can have serious pub lic health consequences including the discontinuation of public health prevention efforts such as education, screening, and suppressive drug therapy which in time can lead to the reemergence of parasitic infections.

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192 Research Question (RQ-2): Within the stud y population, do Nicaraguan immigrants have higher prevalence rates of intestinal parasites compared to Costa Ricans? The Null Hypothesis (H-2): There is no di fference in the prevalence of intestinal parasites between Nicaraguan an d Costa Rican participants. Laboratory results from the study po pulation who provided fecal samples for analysis of intestinal parasites concluded that the prevalence ra te among Costa Ricans was 8.3% while the prevalence rate am ong Nicaraguan immigrants was 31.4%. Figure 8-1. Distribution of Parasite s in Households by Nationality

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193 The difference in prevalence rates betw een the two populations was statistically significant and according to an odds ratio cal culation, Nicaraguans were more than 5 times as likely to be positive for parasite s compared to Costa Ricans during the study period. Figure 8-1 shows a map of the di stribution of infect ed vs. non-infected households by nationality. Based on these results, the research er rejects the Nu ll Hypothesis (H-2) : that there is no difference in the prevalence of intest inal parasites between Nicaraguan and Costa Rican participants. Moreover, these results pr ovide an excellent in dicator of the overall health status and environmental conditi ons experience by each group, indicating that serious health disparities exist between Ni caraguan and Costa Rican s study participants. How can these significant differences in basic health outcomes among Nicaraguan immigrants and Costa Rican residents be e xplained, especially when these two groups live side by side in the same small rural community? What are the socio-demographic, economic and cultural variables associated with these differe ntial health outcomes? These questions will be examined as part of th e discussion of Research Objective (O-3) Research Objective (O-2): Determine the dist ribution and the most likely sources of infection and modes of transmission of intestinal parasites among the study population While it is impossible to determine with certainty the precise source of infection and mode of transmission of any one infection due the study design, knowing how parasites are distributed among the study population provides signi ficant insights as to the most likely source of infection and mode of transmission. As a result the following question was asked: Research Question (RQ-3): Among the study po pulation, are infections with intestinal protozoa more common than infectio ns with intestinal helminths? The Alternative Hypothesis (H-3): There is no significant differen ce in the prevalence of intestinal protozoa and intestinal helminths among the study population.

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194 Data from this research show that th e prevalence of intestinal protozoa among study participants was 15%, (accounting for 87% of infected indivi duals), whereas the prevalence rate for intestinal helminths was only 2.4%. According to the prevalence odds ratio, participants in this study were 8.2 times as likely to be infected with intestinal protozoa compared to intestinal helminths. This conclusion leaves the question; how can the difference in the prevalence between intestinal protozoa and intestinal helminths among the study population be explained? Data from the household water survey show s that nearly 90% of households in the study population have flush toilets and septic ta nks, while only three households had a pit latrine. This finding is supported by a Mont everde Clinic report (ASIS 2002), indicating that over 98% of households in Santa Elena ha ve working flush toilet s and septic tanks. The ubiquity of flush toilets and septic tanks almost eliminate the practice of defecating in the open environment, thus effectively brea king the cycle of helminth transmission. It is also worth noting that while pit latrines can be extremely unsanitary, they are effective at breaking the mode of transmission of inte stinal helminths while at the same time facilitating fecal-oral transmi ssion of intestinal protozoa. In addition to supporting the epidemiological results, this explanation is supported by data that re ported no significant association between household septic tank cond itions and household parasite prevalence. Another explanation of the disparity in prevalence rates between protozoa and helminths is that the Monteverde EBAIS actively promotes suppressive drug therapy among school age children in the Monteverde Zone. School age children are treated at least once a year with a single dose of Al bendazole (it should be noted that both Nicaraguan and Costa Rican children have acce ss to this program). In addition, the community health promoter from the EBAIS distributes Albendazole pills to family members during his annual household visit. Al so, data from qualitative interviews on knowledge, perceptions and behavi ors of intestinal parasites revealed that mothers will sometimes purchase Albendazole pills over th e counter as a purge when they suspect their children may have parasi tes. The extremely low rates of helminth infection may be an indicator of the success of thes e blanket prevention strategies.

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195 While Albendazole is known to be effectiv e against helminths, it is often given to treat intestinal protozoa. Howe ver, this practice most likel y has little effect on reducing rates of intestinal protozoa because the drug has been shown to have limited efficacy against these parasites (Fau lkner 2003). Other drugs, such as Metronidazole and Iodoquinol are known to be more eff ective against parasites such as Entamoeba histolytica. Another consideration is that compared to helminths, intestinal protozoa require a relatively short time to establish infection suggesting that semi-annual drug treatment would do little to br eak the life-cycle of the parasi te without sustained personal hygiene measures. Epidemiological data reported that only two study participants tested positive for intestinal helminths. A closer look at these two cases indicate that both participants were Nicaraguan mothers ages 39 and 42. One of the women was infected with Uncinarias (hookworm) while the other woman was infected with both Uncinarias and Trichiura trichiura (whipworm). Both of the women had m oved to Monteverde with their families approximately 3 years ago. Since it has b een documented that it is possible for an individual to be continually infected with helminths for many years, it is possible that both women arrived in Montever de already infected, having acquired their infections in Nicaragua or in their previous home in Co sta Rica. In addition, the fact that both participants’ households in Monteverde had fl ush toilets, thus breaking the parasites lifecycle would explain why no other household members living with these women tested positive for helminth infections. Based on epidemiological data and the ev idence presented here the researcher rejects The Null Hypotheses (H-3) : that there is no signifi cant difference in the prevalence of intestinal protozoa and intes tinal helminths among the study population. In Monteverde at least, prevalence of intestinal helminths are similar to those reported in the 1996 National Survey of Intestinal Para sites (Mata 1998) which reported a global prevalence rate of intestinal helminths of less than 3%. It is also worth noting that results of this study differ significantly from t hose recently published in Costa Rican public health journals including Abrahams-Sandi (2005), Cerdas (2003), Hernandez-Chavarria (2005), and Hernandez (1998) which report pr evalence rates of intestinal helminths

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196 between 10% and 24%. These stud ies report higher prevalence rates of helminths that are most likely linked to significant deficiencies in the community waste water and sanitation infrastructure. In contrast, results of this study suggest that M onteverdes’ sanitation infrastructure (the ubiquity of flush toile ts and septic tanks), along with effective suppressive drug therapy among school age ch ildren have been extremely effective at breaking the life-cycle of intestinal helminth s. However, the lack of effective control strategies has given rise to the continued prevalence of intestinal protozoa. The following research question addresses this issue. Research Question (RQ-4): Are parasites primarily transmitted as water-borne infections, or through the fecal-oral route of transmission? The Alternative Hypothesis (H-4): There is no difference in parasite transmission; that is, intestinal parasites are just as likely to be transmitted via wate r as they are via the fecal-oral route of transmission. To answer this question, it is necessary to know the prevalence of individual species of parasites and how they are di stributed throughout the study population. This information is a good predictor of transmission because different parasites exhibit different etiological life-cycle s that are associated with co mmon sources of infections and modes of transmission. In this study, Entamoeba histolytica, a common intestinal am oeba associated with producing diarrheal related diseases, was th e most common pathogenic parasite with a global prevalence of 8.3%. This parasite was found in 6.1% of Costa Rican participants and 11.4% of Nicaraguan particip ants. While transmission of E. histolytica can be waterborne, it is most commonly asso ciated with fecal-oral transm ission and tends to cluster in households and schools. Results show that individuals infected with E. histolytica were more likely to have family members infected with parasites; while all participants infected with E. histolytica also tested positive for other commensal parasites like Entamoeba coli, and Endolimax nana a trend which is consistent with fecal-oral transmission.

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197 Giardia lamblia a flagellated protozoan associ ated with producing severe diarrhea and dysentery, was the other pathoge nic parasite found in the study population with a global prevalence of 2.4%. While G. lamblia can be spread th rough the fecal-oral route of transmission much like E. histolytica this parasite is co mmonly associated with water-borne transmission where it has been documented infecting water distribution systems worldwide due to its resistance to chlorination. The low prevalence of G. lamblia suggests that water-born transm ission of parasites in M onteverde is not common and related to isolated cases. Notably absent was the intestinal coccidian, Cryptosporidium parvum which is associated with severe diarrhea and gastroin testinal illnesses. This small intestinal parasite is associated with contaminated wa ter supplies and has been implicated in largescale water-borne outbreaks worldwide, incl uding reported outbreaks in Costa Rica. The absence of C. parvum in this study suggests that water-bor n transmission of parasites in Monteverde is not common and provides a good indicator of water quality management in Monteverde. The prevalence of commensal (nonpathoge nic) protozoa was 19% when counting multiple parasite infections among individuals. Entamoeba coli were the most common commensal parasite found in this study w ith a global prevalence rate of 13.1%. This parasite infected 6.1% of Costa Rican partic ipants and 22.9% of Nica raguan participants. Another common commensal parasite, Endolimax nana was found in 6% of the study population; 2% of Costa Rican participants and 11.4% of Nicar aguan participants. Although they do not cause disease, nonpathoge nic parasites are of significant public health interest because they serve as biological indicator s of how well individuals and households follow and practice public hea lth recommendations aimed at preventing infectious diseases that stem from fecal-oral transmission. Commensal parasites such as E. coli and E. nana are especially good indicators of personal and household hygiene precisely becaus e they do not cause clinical disease and are not targeted for treatment by physicians or school based suppressive drug campaigns. More importantly, commensal parasites shar e the exact same source of infection and mode of transmission as pathogenic species of intestinal protozoa ( E. histolytica and G.

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198 lamblia ). It is worth noting that while E. histolytica and G. lamblia are known as pathogenic parasites in humans, asymptoma tic infections with these parasites are extremely common, especially with E. histolytica Often, individuals with asymptomatic E. histolytica act as important reservoirs that can spr ead infective cysts of the parasite to susceptible persons. The co-occurrence of both commensal and pathogenic protozoa in the feces of individuals is indirect eviden ce of a range of behaviors necessary to maintain fecal-oral transmission of parasites between infected and susceptible pers ons. In addition, the presence of commensal parasites significantly increases the probability that pathogenic parasites will spread among household member s. In this study, epidemiological data indicate that participants living with infect ed family members were almost 5 times as likely to be infected with intestinal parasi tes compared to those participants who do not. This evidence suggests that the primar y mode of transmission among the study population is through the fecal-oral route of transmission or through water-borne transmission. The likelihood that parasite transmission among the study population is primarily water-born is discu ssed in the following section. Water Resource Management and Water Quality: It should be noted that this research did not conduct independent water quality testing. As a result, the discussion regardi ng the potential association between water quality and parasite transmission is based en tirely on secondary data sources. For study participants, the biggest risk in terms of wate r-borne transmission of intestinal parasites is the potential contamination of the Santa Elena Aqueduct. As mentioned earlier, water is an excellent vehicle of transmission for parasites like Giardia lamblia and Cryptosporidium parvum. Both species have been shown to be resistant to chlorine and as a result, can easily spread through water suppli es with faulty chlorination systems (Byers 2001; Craun 1978; Schmunis 2002). A report written in 1998 by La Asociacin Administradora del Acueducto de Santa Elena (The Santa Elena Aqueduct Association) suggested that one of the potable water distribution systems in Santa Elena wa s at high risk due to surface water run-off

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199 contaminated with cattle feces (ICEA 1998). In Santa Elena, broken and leaky water pipes are common; a situation that can produ ce transient pressure events (excessive positive or negative pressure within the water pipe) caused by sudden changes in demand and pump outages. Negative pressure transien ts cause suction whereby leaks in water pipes provide a potential portal of entry for parasites and other pathogens that are present in the soil; especially C. parvum which has been linked to surface water run-off contaminated by cattle feces (LeChevallier 2003). Similar studies of parasite prevalence conducted in Costa Rica including Blanco (2007), Hernandez-Chavarria (2005), and Pardo (1997) reported significantly higher rates of infection with G. lamblia, (between 5% and 10%) compared with 2.3% reported in this research. These studies cite a lack of access to potable water supplies in the study communities as being partially responsible for the high prevalence of G. lamblia. In contrast, residents of Monteverde enjoy access to high quality potable water which significantly reduces the probability of water-bor ne transmission of intestinal parasites. Currently, The Santa Elena Aqueduct Asso ciation consists of three integrative water distribution systems that serve the communities of Santa Elena, Cerro Plano, Caitas and Los Llanos provi ding services to approximate ly 5,000 permanent residents and more than two hundred thousand annual tourists (AAASE 2003). All households that participated in this research received water from the Santa Elena Aqueduct. Upon the initiation of this research (2 003), the Santa Elena Aqueduct received the prestigious “ Sello de Calidad Sanitaria ” (Seal of [Water] Quality Sanitation) from the Instituto Costarricense de Acueductos y Alcantarillados (The Costa Rican Institute of Aqueducts and Sewers) also known as AyA. According to Feoli (2007), the Sello de Calidad Sanitaria program was initiated in 2001 by AyA as an incentive to local aqueduct operators in Costa Rica to provide high quality wate r to local populations in a sustainable and environmental friendly ma nner. The program consists of 6 active parameters that local aqueduct operators must follow in order to receive this distinction; 1) to protect local water sources includi ng areas around springs through reforestation efforts and periodic spring inspection; 2) to periodically clean water storage tanks and distribution tubing; 3) to chlo rinate all water and monitor re sidual chlorination levels; 4)

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200 to implement environmental education progr ams and to disseminate information about the aqueduct to the local community; 5) to periodically measure wa ter quality throughout the entire aqueduct and maintain specific water quality standards at all times; 6) a comprehensive risk assessment and water mediation program in addition to futures planning. The Sello de Calidad Sanitaria distinction demonstrates that the Santa Elena Aqueduct provides high quality water to the local population and maintains a high standard of quality control to ensure the consistenc y of service. For example, results of independent laboratory testing from January to June 2004 dem onstrate that potable water from the Santa Elena Aqueduct met water qualit y standards and residu al chlorine levels for human consumption. From a behavioral standpoint, research findings indicate th at households do not engage in point source chlorination of tap water, thus excluding the possibility of a protective behavior in terms of water contam ination. In addition, data from the household water survey suggest that periodic water shor tages do not appear to force residents to store water, nor does it appear to alter basic hygienic behavi ors such as hand washing and bathing. The data show that water shortages are predictable and ar e of short duration; therefore reducing the possibility that parasite transmission is associated with personal hygiene behaviors related to water insecurity. While water-borne transmission of intestin al parasites in Monteverde is possible, the high prevalence of E. histolytica and other commensal species like E. coli and E. nana coupled with the low prevalence of G. lamblia and an absence of C. parvum are clear indicators that water from the Santa Elena Aqueduct is not a primary source of infection among the study population. Had the primary source of infection been potable drinking water, one would expect a higher prevalence of G. lamblia and C. parvum distributed randomly throughout the study population because all study participan ts had access to the same potable water. In conclusion, the researcher rejects the Null Hypothesis (H-4) : that intestinal parasites are just as likely to be tr ansmitted via water as they are via fecal-oral transmission. In terms of parasite transmission, the data clear ly indicate that intestinal parasites are

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201 primarily transmitted through fecal-oral transmis sion and that infections primarily cluster at the household level. Evidence discussed in the next research obj ective confirms that parasite infections were not random, but ra ther significantly associated with certain household sanitation conditions and other socio-demographic variables. Research Objective (O-3): Determine the significant socio-demographic, economic and cultural factors associated with the p revalence of intestinal parasites among the study population at the indivi dual and household level. Results presented in chapter 8 conclude that serious health disparities exist between Nicaraguan and Costa Rican study partic ipants in terms of parasite prevalence. How can these significant differences in basi c health outcomes be explained, especially when these two groups live side by side in the same rural commun ity? The objective here is to discuss the socio-demographic, econom ic and cultural variab les associated with disparities in parasite prevalence as well as those common to all study participants. Research Question (RQ-5): Are infections with intestinal parasites more common among study participants with no access to health care? The Alternative Hypothesis (H-5): A lack of access to health care among study participants is associated with a high er prevalence of intestinal parasites. Of significant interest to medical anthropology, and the political economy of health in particular, are the structural cause s of disease distribution, commonly referred to as “health inequalities” According to Singer and Bear ( 2007) health inequalities, most notably unequal access to health care, are re sponsible, in part, for continued health disparities among marginalized populations. Lack of health insurance coverage is a significant barrier to the prev ention and management of dise ase which carry significant health related consequences bot h in the short and long term. Household demographic data show si gnificant inequalities between Nicaraguan and Costa Rican study participants in terms of ov erall access to health care (defined as an individual having up-to-date health insura nce through the CCSS providing access to all levels of health care). Demographic data re port that Nicaraguans were almost 5 times as

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202 likely to not have health cove rage compared to Costa Rican s. In addition, participant’s positive for intestinal parasites were 3.2 times as likely to not have individual health coverage compared to those that were negative for intestinal parasites. These results raise several questions: 1) what are the principal barriers to health care coverage for Costa Ricans? 2) what are the barriers to health car e coverage for Nicaraguans and why are they more likely to not have health insurance? a nd 3) how is a lack of health care access associated with para site prevalence? Based on ethnographic interviews and house hold health surveys with Costa Rican heads of household, three principal barriers to health care emerged. They are explained in detail as follows. Barrier #1 ) new CCSS qualification requireme nts for recipients of state sponsored health insurance and the time a nd money required to obtain the documentation. As explained in the description of the research site (Chapt er 3), access to the CCSS based health insurance is employer base d. However, the state offers free health insurance (similar to Medicaid in the U.S.) to qualifying single mothers, the poor, the mentally and physically disabled and school age children not covere d by their parents’ health insurance. It is worth noting that 8 out of the 18 Costa Rican households that took part in this research relied on state health insurance as their primary access to health care. While this research was being conducted, th e CCSS was in the process of revising its inclusion requirements for recipi ents of state sponsored health care as part of its overall health reform measures. As a result, state health insurance recipients were asked to resubmit documentation to the CCSS as a way to justify their conti nued inclusion in the program. According to informants, the CC SS required the following documentation to confirm their continued eligibil ity: 1) proof of real estate /property holdin gs; 2) local electric, water and phone bills; 3) documentati on of civil status; 4) birth certificates for all household members; 5) documentation of home rental contract from landlord (if renting home); and 6) a bank statement of home mortgage. During interviews, several mothers complained that the new CCSS requirements were too strict. The following is a quote fr om a Costa Rican mother explaining why she no longer qualified for stat e health care insurance.

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203 “I am the only one who doesn’t have health insurance. [My husband] has insurance through the UPA but it only covers him and the kids. I have gone to try to see if I could get insurance through the state because we are pretty poor but they kept giving me the run around and making me fill out a ton of paperwork. Then they finally told me that I couldn’t receive the health in surance because I own a house…that is, our house is in my name.” The quote above was common among part icipants who were denied health insurance because they no longer met econom ic requirements stipulated by the CCSS. Making matters worse, many informants explained that the required CCSS documentation was only obtainable by going to the provincial capital of Puntarenas. For poor families, round trip bus fare to and fr om Puntarenas can be a serious financial burden. As a result, the lack of time and money needed to obtain the required documentation was a significant barrier. The following quote provides a good example. “Well right now none of us has health insurance. We have been without health insurance for the last 5 months. We had insurance through the state but since they started asking people for paperwork and February was the deadline to turn all that stuff in and I have not been able to do it. I still have to go to Puntarenas one of these days to get all the papers. The clinic said that until we get the papers in they could not insure us. They also said that once we get the papers in then they do a review to see if we still qualify for state insurance. It is too bad but luckily they [her children] have not gotten sick enough to have to take them to the clinic. If they do get sick we’ll have to pay for it.” In this case, the barrier of traveling to Puntarenas left an entire family, including 5 children without health care; not to menti on financially vulnerable if someone in the family required medical treatment. Barrier #2) domestic issues resulting in in complete CCSS documentation prevent children access to health care. This was the case in two Costa Rican families who participated in this research. The following quote sums up the dilemma. [My daughter] is supposed to have insurance through her father, but he has not done anything with the papers, it’s as if he never had her! The CAJA told me that [her father] has to be responsible, and since he has insurance, [her daughter] should automatically be covered through his insu rance. The problem is that he won’t complete the paperwork to make it happen. Until then I have to pay out of pocket for both of our medical expenses. She has been without insurance for 6 months now. And I don’t have any insurance because I don’t have a job yet that provides it and I can’t afford to pay for it on my own.”

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204 While this barrier is not as common, it points out inconsistencies in Costa Rican health care policy claiming that all children de serve access to health care. This quote also provides insight into the next barr ier relating to underemployment. Barrier #3) limited employment options open to mothers and young adults that provide health insurance benefits. As stated earlier, CCSS health insurance is primarily employer based, however, to avoid paying expensive employee health care benefits, employers often hire employees part-time or on a contract only basis. This practice is especially notorious among small employers in the service sector; the primary type of employment in Monteverde. The follow ing quote provides a good example of the challenges many workers face in dealing wi th employers, the CCSS system, and the health consequences of not having affordable access to health care. “I don’t have any insurance. I have not had insurance for about 6 years now or so because of my age (24 years old). And the [housekeeping] job that I have does not provide insurance at all because it is considered hourly work and it is not full time. When I have gone [to the clinic] they threaten you that they are going to make you pay and that you should have insurance and that you have to get it worked out, otherwise they won’t attend you the next time It has affected me lots. I can’t really pay to go to the clinic. I have only been there 2 times in the last 6 years because I know I can’t pay. It affects my total health becau se I know that there are certain tests that I should get done every year but I can’t do it.” In 2002, the CCSS claimed that 87.7% of all citizens had access to health care (Proyecto Estado de la Nacin 2002). In contra st, 80% of Costa Rican s who participated in this research reported having health covera ge. However, it should be noted that rates of health care coverage would have been significantly higher among Costa Rican study participants had it not been for the new documentation requirements. For Costa Ricans, the biggest barriers in terms of access to health insurance are underemployment, including employer refusal to provide health insurance, and the new documentation requirements for recipients of st ate insurance. With regard to the latter, several parents who participated in this research were told by the Monteverde Clinic that their children no longer qualified for health care coverage. However, Costa Rican law states that children have the right to health care until they turn 18 years of age, or until

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205 they acquire their own health coverage. Ba sed on ethnographic interv iews, it appears that the clinic may knowingly deny children access to health care based on the pretext of their parents’ insurance status. In other words, th e clinic may be threatening parents by telling them that their children will not be attended at the clinic until the parent’s secure health care coverage when this is simply not the cas e. As a result, some children may be denied access to health care through scare tactics aimed at their parents. While the new requirement policies undertaken from the CCS S are understandable gi ven the health care reform goals to cut down on costs, the conse quences of denying basic health services to women and children is neither cost effective nor ethical. The former is also disconcerting b ecause Costa Rican health insurance is employer based, that is, both employers and em ployees pay a percentage of wages to the state to provide health coverage. However, some employers intentionally use illegal tactics to avoid paying empl oyee health benefits. For example, some employers only employ on a part time basis because they are on ly forced to pay health benefits if the employee works over a certain number of hours. Other employers hire employees on the condition that they not ask for health covera ge. Others hire employees on a trial basis saying that they will pay for health coverage after the employee has worked 6 months, only to be laid off before they have comple ted 6 months on the job. While these practices are illegal, informants claim that they would lose their job if they spoke out. Access to Health Care Among Nicaraguans While access to health care can be challenging for Costa Ricans, Nicaraguans face even greater challenges accessing health care According to demographic data, 54% of Nicaraguans who participated in this study di d not have any kind of health insurance. Moreover, 9 out of the 11 Nicaraguan households that participated in this study had at least one family member who did not have in surance. These results are consistent with those reported by Marquette (2006) who clai ms that over 50% of Nicaraguans do not have health insurance; suggesting that Nicar aguan nationality has an independent effect in reducing insurance coverage.

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206 Based on ethnographic interviews and hous ehold health surveys with Nicaraguan heads of household, three principal barriers to health care emerged. Th ey are explained as follows. Barrier #1 ) new CCSS qualification requiremen ts for recipients of state sponsored health insurance and the time a nd money required to obtain the documentation. Like many Costa Ricans, Nicaraguans who did not have health coverage claimed that they were recently denied coverage as a result of the new CCSS documentation requirements. This category included individu als who at one time received state health care insurance, but who were now unable to produce the proper paperwork and those who were told that they no longer qualified for such services because of their financial status or their ability to find work. For example, one Nicaraguan mother who stayed at home to care for her four young children explained that she was told that her state health insurance had been denied because the CCSS de termined that she was able to work full time and therefore should obtain hea lth insurance through an employer. Barrier #2) Underemployment and limited employment opportunities for Nicaraguan workers that provide health care Data show that 64% of Nicaraguan men who participated in this research worked in construction related fi elds. While Monteverde was experiencing a constructi on boom around the time of this research, the majority of construction jobs available to Nicaraguans consisted of short term contracts and low-skill wage labor. According to Marquette (2006), unemployment levels te nd to be higher for Nicaraguans who work in lower skilled occ upations, including c onstruction, due to the rapid influx of low-skilled workers into the country. Because the majority of construction contracts are short term, typica lly lasting a few weeks or several months, employers do not offer workers health insu rance. The following quote from a Nicaraguan construction worker sums up this experience well: “Right now I am working construction, I pretty much work with one contractor here in town, I have worked with him for a long time…When there is work I work more than full time but when there is no work I just work a little here and there. If the contractor does not have any work then I really don’t have work…Like most of us workers we have a contract for hours that means that the employers don’t have to provide us with [health] insurance.”

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207 Information gathered from ethnographi c interviews and household surveys found that Costa Rican construction workers more of ten hold skilled construction jobs, such as crew leader or site supervisor which tend to be more secure over the long term and offer full health insurance for workers and their fa milies. One explanation for this discrepancy is that many Nicaraguan workers are “irre gular” immigrants. As explained by Marquette (2006), irregular migrants have no recourse to formal protection or rights enforcement in the workplace. Thus, immigration status may contribute to lower wages and prevent them from negotiating better contract and work conditions including health care benefits. Barrier #3) For Nicaraguans, the most signifi cant barrier to health care is immigration status. In Costa Rica, foreign na tionals who are in the country legally can apply for health insurance while those w ho are in the country illegally, or whose immigration documents have expired are not able to apply for, or re ceive health coverage through the CCSS. Interviews with Nicaraguans concerni ng their “irregular” immigration status showed that some had no documentation what soever, having entered the country illegally while others had expired immigration documentation. In Costa Rica, Nicaraguan immigrants are supposed to renew their residency each year. However, residency renewals can only be done at Nicaraguan consulates a nd can cost over $100 USD per individual. As a result, time and money pr esent significant barriers that prevent many Nicaraguans from renewing their immigration status. The following quotes exemplify the difficulties Nicaraguans face accessing health care. “Well, the girls (all born in Costa Rica) have health insurance through the state until they are 18 years old, but we [my wife a nd I] don’t have insurance here because we don’t have our [immigration] papers in or der, and we haven’t had insurance since 1994… It’s really hard for us, whatever we need we have to pay for it, no matter what, and usually [the clinic] wants the money up front or they won’t even let you in for a consultation with the doctors so we usually don’t have any money to pay for medical attention. Only when it’s something serious will we go in, otherwise we just try to stick it out or go to the pharmacy and buy some medication if we can.” The following is a quote from a young undocumented Nicaraguan female who described the difficulties she had receiving pre-natal care from the Monteverde Clinic during her recent pregnancy due to her immigration status.

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208 “I never had any pre-natal doctor visits here in Monteverde during my pregnancy. I tried to go to the clinic here on severa l occasions for pre-natal care but each time they turned me away at the door saying that I had to agree to pay for the consultation (which cost around $25 US). I told them that I did not have any money to pay and that I wanted to apply for coverage through the state but the people at the clinic told me that I had to get my [immigration] papers in order before I could do anything.” Another barrier to renewing immigrati on papers was the possibility of being detained by immigration police while traveli ng outside of the Monteverde Zone. Several informants expressed this concern saying that busses going into San Jose are often stopped and passengers are asked to produce pa pers. The fear of possible detention by immigration police prevents many Nicaraguans from traveling freely about the country; some Nicaraguans even said they feared going to San Jose to renew their immigration documentation because of the possi bility of being detained. For many Nicaraguans, access to health care is complicated by immigration politics which deny them the right to qualif y for affordable health care. In fact, Nicaraguans who lack essential documentation li ke passports or birt h certificates have little hope of ever bei ng able to apply for health insu rance under current law. Although officials at the Monteverde Clinic maintained that they do not deny health services to Nicaraguans, evidence collected from interv iews suggests that Nicaraguans who are unable to prove immigration status are often ha ssled and repeatedly denied basic services unless they agree to pay expensive consulta tion fees up front. For many, this precludes them from accessing basic health services leav ing them vulnerable to significant health consequences. Access to Health Care and Parasite Prevalence Results presented in Chapter 8 show that access to health care is an important predictor of parasite prevalence amo ng Costa Ricans and Nicaraguans alike. Epidemiological results demonstrate that prev alence rates for Costa Ricans with access to health care was 5.7%, while those with no h ealth coverage had a prevalence rate of 14.3%. Likewise, the prevalence rate for Nicar aguans with access to health care was 22.2%, while those with no health coverage had a prevalence rate of 41.2%. These

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209 statistics represent a signif icant association between para site prevalence and access to health care among study participants. While access to health care is not dir ectly related to parasite prevalence, individuals with no health coverage tend to be poor, underemployed, and in the case of many Nicaraguan participants, illegal immigrants. Based on evidence from ethnographic interviews, individuals who do not have health insurance are less likely to go to the clinic for basic health services, c hoosing to go to the clinic only under extreme medical cases. In terms of intestinal parasites, individuals with no access to basic health care are much less likely to get tested and treated for intestinal parasites because common symptoms are usually perceived as not bei ng serious. While anti-parasite medication is inexpensive even by Costa Rican standards, it is not commonly sold over the counter without a doctor’s prescription, making access to suppres sive drug therapy for parasites difficult. Without suppressive drug therapy, infected i ndividuals may harbor parasitic infections for long periods of time, increasing the probabi lity that the infection be transmitted to other household members thr ough fecal-oral transmission. Another important consideration is acce ss to health care at the household level. For instance, many households had at least one member with no health insurance. Epidemiological results show that househol ds with inadequate health care coverage (where at least one household member was unins ured) were 7 times as likely to have at least one family member test positive for in testinal parasites compared to households where all members were insured. According to several personal accoun ts, the presence of uninsured family members can significantl y influence the way in which insured household members access health care. Informants noted that the staff at the Monteverde Clinic sometimes hassle the non-insured about getting their insuranc e paperwork in order by threatening denials in service. As a result parents with no health insurance are less likely to take their insured children to the cl inic for fear of being confronted by clinic staff about their insurance status. The fo llowing is a quote illus trates this point. “When I have needed to go [to the clin ic] they hassle me about getting my paperwork done and stuff like that. So I d on’t like to go because of that. Well, I mean, I go [to the clinic] and take the kids and stuff like that but for my part I don’t go [because] I have to pay for it and we really don’t have anything to pay with.”

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210 Although her children are insu red, the fact that the clin ic confronts her about her insurance papers ultimately affects her decisi on to take her children to the clinic. While she would not hesitate to take her children to the clinic fo r a serious health concern, she may think twice about taking her children for routine health checkups and screenings in order to avoid hassles with clin ic staff. While cases like this cannot be generalized to the entire population, they do provide a glimpse as to how the lack of health care coverage of household members affects the way insured household members assess health care. In conclusion, the researcher accep ts the Alternativ e Hypothesis (H-5) : the lack of access to health care among participants is associated with a higher prevalence of intestinal parasites. A lack of access to health care was significantly associated with increased prevalence rates of intestinal parasites among both Nicaraguans and Costa Ricans. This situation placed both Costa Ricans and Nicaraguans alike in difficult and unstable positions regarding bot h individual and household he alth by creating barriers that prevented the access of simple diagnos tic and treatment procedures that could otherwise treat existing infections an d eliminate further transmission. Research Question (RQ-6): Is the household hygiene environment associated with the prevalence of intestinal parasites? The Alternative Hypothesis (H -6): Inadequacies in househol d hygiene infrastructure are associated with a higher prevalence of intestinal parasites. Here, the research focuses on household e nvironmental factors to help explain the significant disparities in parasite prevalen ce rates between Nicaraguan and Costa Rican study participants. Results presented in Chapte r 8 show that households with unsanitary bathrooms were almost 10 times as likely to have at least one household member infected with intestinal parasites compared to house holds with sanitary bathrooms. Unsanitary bathrooms were typically characterized by insu fficient or absent hand washing facilities, a lack of soap, and exposure to soiled toilet paper. This hygienic environment promotes fecal-oral transmission of intestinal pa rasites among household members by reducing frequent hand washing behavior s, especially if infected fa mily members reside in the

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211 household. Furthermore, exposure to dirty toil et paper can also serve as a source of infection for non-infected family members sin ce it is common to pl ace dirty toilet paper in the waste bin instead of disposi ng it directly in the toilet bowl. Again, results presented in Chapter 8 show that households with unsanitary kitchens were 13 times as likely to have at least one household me mber infected with intestinal parasites compared to households w ith sanitary kitchens. Unsanitary kitchens were characterized by dirty countertops, dirty pl ates and utensils, a lack of soap, and the presence of vectors. It is widely accepted that improper food handling coupled with improper hand washing promotes fecal-oral tran smission of intestinal parasites and other viruses and bacteria (Byers 2001). Dirty count ertops and utensils can also serve as sources of infection when infected family members who do not routinely wash their hands inadvertently touch these and other surfaces. In additi on, vectors such as flies and cockroaches can increase the transmission of in testinal parasites by transporting infected cysts of protozoa to inanimate objects which can then be transmitted when individuals inadvertently ingest the cysts from a contaminated source. Epidemiological results show that ho usehold bathroom and kitchen conditions were particularly good indicators of parasite prevalence regardless of national origin. However, the data show that Nicaraguan hous eholds were 8 times as likely to have an unsanitary bathroom; 4 times as likely to ha ve an unsanitary kitchen; and 3 times as likely to have had vectors present in thei r home compared to Costa Rican households. The difference in bathroom and kitchen conditi ons is significant because it is linked, in part to disparities in preval ence rates of parasites at the household level. What factors explain the significant inequa lities in household conditions? The best explanation of inequalities relating to household conditions between Nicaraguan and Costa Rican households is hom e ownership; (i.e., whether the home is owned or rented). Data from household surv eys demonstrate a signi ficant association between rental homes and unsanitary bathr oom and kitchen conditions. For example, 75% of rented homes had unsanitary bathrooms and 90% had unsanitary kitchens. These results also show a significant associati on between household owne rship and parasite

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212 prevalence; households that rented their home were almost 10 times as likely to have at least one household member test positive for intestinal parasites. In this study, rental homes were ch aracterized by small and cramped living spaces, a limited number of faucets and hand washing facilities, limited and inadequate food storage space, limited countertop space, limited protections from the outside environment, and other infrastructural inadeq uacies. For example, bathrooms in rental homes often had few faucets which discourag ed hand washing, while kitchens lacked space for food storage and preparation. To pr ovide the reader with an example of household conditions, the following is an excerpt from my field notes written after a visit to a rented Nicaraguan home The living conditions presen ted here were common among Nicaraguan households that pa rticipated in this study. February, 18th 2004 – Santa Elena – Initial visit to household 41.0 I entered into a tiny dark room with a low hanging ceiling were a young women sat at a sewing machine and wher e another young woman was lying on the bed. There was just enough room between the bed and sewing machine and the wall made of corrugated tin to pass into the next room which was smaller than the first. In the second room there was just enough room for a bed and a couple chairs and a crib shared by two babies! And there were three people sitting on the bed. This room then connected to the kitchen which was dark, dirty, extremely clu ttered and extremely small. The makeshift countertops were dirty and covered with dirty kitchen items and food. A refrigerator was noticeable missin g from the kitchen; instead there was a small wooden shelf to store food. The kitchen sink was also used to wash clothes; it was very dirty and there were pots and pans hanging around but there was no storage space and you could see through the walls to the outside. Behind the kitchen was the bathroom which was barely big enough for the toilet. It was dark and dirty with dirty toilet paper piled in the corner. Needless to say, my urge to pee subsided after taking a look at the bathroom! In all, I counted 8 or 9 people living in the house with another baby due in April. This home was an obvious departure from the previous Costa Rican households I have visited; a fact that reconfirmed my decision to include Nicaraguan households in the study. From this visit, it is clear that another world existed apart from that of the [Costa Ricans]; one similar to that of immigrant families all over the world. A world where they lived in substandard housing, poverty, crowded living conditions, lacked access to basic services, and where fear of deportation create a sense of uncertainty and helplessness. It was in stark contrast to the commercial pictures of the beautiful, peaceful, and ec ologically conserva tive Monteverde. In many ways it was the antithesis of Monteverde. While the conditions of rental homes we re similar despite nationality, the data show that Nicaraguans were more than 4 times as likely to rent their home compared to

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213 Costa Rican households. These data are supported by a recent study from Marquette (2006) who reports that 40% of Nicaraguans live in inadequate living conditions compared to only 13% of Costa Ricans. What factors help explai n the inequalities in home ownership and living conditions? One explanation is the shortage of a ffordable housing in the Monteverde region. Every year, some 250,000 international tourists visit Monteverde in addition to a sizable foreign community that lives in the region. Th e influx of tourists and foreign nationals has, in part, contributed to a housing shortage; a factor that has even driven up the price of substandard housing. For many Nicaraguan families, underemployment and immigration status leave them with no othe r choice but to rent substandard housing which almost always have inadequate sanitati on infrastructure; often times from absentee landlords who charge excessive rent. It should also be me ntioned that the Nicaraguans households who owned their own home had adeq uate kitchen and bathroom sanitation conditions just like Costa Rican counterparts who owned their own home. Another explanation, based on ethnographic interviews, suggests that Nicaraguans have very limited access to formal lines of credit compared to Costa Ricans, while the reasons for this are varied. First, Nicaraguans who have irregular im migration status are automatically excluded from qualifying for any ki nd of formal loans. This was the case in approximately 5 out of the 11 Nicaraguan hous eholds that participated in this study. However, Nicaraguan immigrants who are lega l residents in Costa Rica described how underemployment is the primary factor that prevents them from accessing bank loans for home mortgages. Only two Nicaraguan househol ds that participated in this study owned their own homes and were able to do so because they paid cash for them, (with help from personal loans through other family members) attesting that they too were unable to acquire formal bank loans. In addition, it was no coincidence that Nicaraguan homeowners were all long time residence of Monteverde and Costa Rica in general, having lived in Monteverde fo r an average of 18 years. In terms of access to credit, interview da ta suggests that low income Costa Ricans have an easier time securing quality housing compared to Nicaraguans. In 2003, a low income housing project called “ La Colina ” was developed and built along the road

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214 between Santa Elena and Los Llanos with help from a Canadian NGO consisting of approximately 27 units. At the time of this research all of the families living in La Colina were low income Costa Rican families who me t certain financial criteria. Families were given a government housing subsidy to purchas e the home with no inte rest and extremely low monthly payments. The homes themselves were simple, yet comfortable, complete with potable water and built-in graywater disposal systems. Interestingly, no Nicaraguan families lived in La Colina I later learned that government housing subsidies were only availa ble to Costa Rican citizens, essentially excluding Nicaraguan families from living in La Colina and exemplifying the unequal access to quality, affordable housing betw een Nicaraguans and Costa Ricans. Another important aspect of the house hold hygiene environment associated with parasite prevalence is household size and liv ing with infected family members. Results showed that individuals who lived in a household with 6 or more family members were over 5 times as likely to have been diagnosed with intestinal parasites compared to individuals living in a househol d with 5 or fewer family me mbers. Results presented in Chapter 8 show that Nicaraguan households we re statistically larger than Costa Rican households and were more like ly to have household members infected with parasites. Because intestinal protozoa are primarily transmitted through fecal-oral transmission, the combination of crowded living conditions, inf ected family members, and poor sanitation infrastructure provide the pe rfect socio-environmental c onditions needed to sustain parasite transmission at the household level. Similar to results reporte d by Marquette (2006), demogr aphic data reveal that Nicaraguan households were larger because they were more likely to include both extended family members and unrelated indivi duals compared to Costa Rican households which tend to consist of nuclear families. One reason for this is that Nicaraguan families are tied into immigration networks whereby settled families offer short term shelter to extended family members and friends. Although it was beyond the scope of this research to test these individuals for parasites, these temporary household members can serve as a source of infection to the host family if th ey arrive from areas where parasites are endemic.

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215 In conclusion, the researcher accep ts the Alternativ e Hypothesis (H-6) : Inadequacies in household hygiene infrastructure are associated with a higher prevalence of intestinal parasites. The da ta discussed here clearly indica te that parasite prevalence is significantly associated with household envi ronmental conditions and accounts for the disparity in parasite prevalence betw een Nicaraguans and Costa Ricans. This conclusion supports a large body of literature including McElroy (2009), Inhorn and Brown (1997) and Vecchiato (1997) claiming th at human parasitoses is related to poor socio-economic conditions, de ficiencies in sanitary facilities, poor personal hygiene, and substandard housi ng among other variables. However, the conclusions presented here contribute to the literature by going a step further in explaining housing inequalities and health disparities as hi gher level political economic phenomena relating to immigration status, access to credit, home ownership and underemployment. These conditions foster the transmission of intestinal parasites and help explain why Nicaraguans experience higher rates of intestinal parasite infections compared to their Costa Rican counterparts. Research Question (RQ-7): Is knowledge of intestinal parasites and prevention strategies associated with lower household rates of infection? The Alternative Hypothesis (H-7) states: Sign ificant knowledge of parasite etiology and prevention will be associated with lower pr evalence rates at the household level. A common assumption of medi cal anthropology is that infectious diseases are not the result of simple host, parasite, and e nvironmental relationships, but instead are complex and precipitated by deliberate a nd non-deliberate behaviors which are influenced by cultural knowledge, percep tions, and behaviors (Inhorn and Brown 1997). As described in chapter 7, qualitative domain analysis revealed significant similarities between Nicaragua n and Costa Rican participants from both “infected” and “uninfected” households regardi ng their understanding of intestinal parasites, their source of infection/mode of transmission, treatmen t and prevention strategies. In terms of defining intestinal protozoa, both groups pr ovided simplistic descriptions; using words like “ bichos ” and “microbes” that “live in your stom ach or intestine”. In contrast, it was

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216 easier for participants to define intestinal helminths, describing them as being larger, worm-like organisms that interfere with digestion and nutrition. While participants were somewhat vague about their definitions of intestinal parasites, all participants e xhibited a high degree of understa nding of sources of infection and modes of transmission of both intestinal protozoa and helminths. When asked where parasites come from, Nicaraguan and Costa Ri can participants from both “infected” and “uninfected” households explaine d that parasites primarily co me from a lack of personal and household hygiene; from infrequent hand washing; from not washing food; from drinking contaminated wate r; and from walking bare foot in the dirt. When asked how to prevent parasites, Nicaraguan and Costa Rican participants from both “infected” and “uninfected” househol ds cited public health campaign slogans like “maintain good overall hygiene”; “wash your hands after you go to the bathroom and before you eat”; “wash fruits and vegetables ”; “avoid contaminated water”; and “don’t walk around barefoot in the dirt”. These simple, primary health care messages have become the mantra of many mothers, alt hough many admit that their children don’t pay attention to these rules and therefore are mo re likely than adults to get parasites. Among this study population, knowledge about parasites did not differ between Nicaraguan and Costa Rican partic ipants in spite of the fact that Nicaraguan participants had significantly less formal education comp ared to Costa Ricans. Qualitative data analysis revealed that the majority of partic ipants were much more likely to obtain their knowledge about intestinal parasites from info rmal sources such as family, neighbors and first-hand experience, as they were from more formal sour ces of information. In fact, none of the participants interv iewed in this study mentioned learning about parasites from school and only a few participants mentione d obtaining knowledge about parasites from their doctor or the local clin ic. In many cases, knowledge of parasites among Nicaraguan and Costa Rican heads of household was a resu lt of first-hand e xperience, either as children or as mothers. Many recounted stories of how they themselves, their siblings or their children had parasites. Knowledge of parasites based on experience and informal social sources was evident in their deta iled knowledge of parasite symptoms and treatment pathways.

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217 In terms of specific treatment pathways Nicaraguan and older Costa Rican heads of household were much more familiar with alternative medicines; whereas knowledge of treatment pathways among younger Costa Ri can heads of household were almost exclusively based on biomedical treatments This phenomenon is best explained by greater access to health care services in Monteverde in the past 5 years. Nicaraguan participants along with older Co sta Rican participants explaine d that in the past, doctors and medicines were not readily available, forcing them to deal with intestinal parasites using a variety of home remedies. Evidence fo r this exists in the vast ethno-botanical knowledge regarding treatments for intestinal parasites expressed by both Nicaraguan and older Costa Rican participants in this study. Qualitativ e analysis revealed at least eighteen different home remedies used to treat intest inal parasites. In contrast, younger heads of household noted that parasites can be treated with readily available medicine from the local clinic. Another explanation based on qualitative an alysis was that in the past, parasite infections were much more common because of poor sanitary conditions, a lack of prevention efforts and limited access to health care. As a result, older participants were more likely to have experience dealing with intestinal parasites. Similarly, Nicaraguan participants attested to the fact that pa rasite infections are much more common in Nicaraguan than they are in Costa Rica and noted that treating a nd diagnosing parasite infections was the norm rather that the exception. While participants exhibited a high leve l of knowledge regardi ng the specifics of symptoms, source of infection, mode of transmission, treatment, and prevention of parasites, qualitative analysis showed th at participants’ knowledge appeared to be categorized into separate and unconnected pieces of information. For example, many participants knew explicitly the symptoms and treatment pathways of hookworm infection; they also knew that one could pr event “parasites” by not walking barefoot in the dirt, but they did not specifically know that hookworm infection was caused by walking barefoot in infected soil. In another example of this disconne ct, participants were unclear about the fecal-oral route of transm ission. Participants we re generally unaware

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218 that transmission is contingent on infected individuals, believi ng instead that parasites are ever present in unhygienic environments. The disconnect in knowledge about parasite s and their specific source of infection and mode of transmission is most likely the result of what Nichter (2008) refers to as “message crossover”. Nichter observes that communities are exposed to an enormous amount of health education messages. Me ssage crossover occurs when messages concerning one health problem influence or confound thinking about other health problems. An example of message crossover can be observed in health messages from both doctors and public hea lth practitioners which ar e often isolated and decontextualized. For example, public health messages often focus on preventive behaviors like consistent hand washing but rarely e xplain precisely how or why hand washing prevents the transmissi on of parasites. In addition, doctors may tell parents that their child is infected with parasites but not tell them which specific parasite caused th e infection or what they can do to prevent the parasite. Participants in th is study complained about the fa ct that doctors at the clinic would withhold information about parasites after having received a positive diagnosis, claiming that doctors at the clinic would onl y prescribe anti-parasite medication and not say anything about the infection. A possible explanation is that doctors w ithhold specific clinical information about parasites from patients because they feel that patients are incapable of understanding medical concepts and terminology. In this ca se, medical knowledge is the explicit domain of physicians, where patients ar e not privy to information c oncerning the clinical details of disease etiology and are only told what medication they can take to treat their infection. In fact, informati on regarding source of infecti on and prevention is often relegated to the ranks of public health pract itioners. This relationship is specifically expressed in the organization of the Costa Rican health care system where the CCSS is in charge of providing health care and treatment, while the Ministry of Health is charged with prevention. As a result, information about disease etiolo gy and prevention are learned from public health campaigns rather from ones primary physician.

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219 Still, this disconnect in knowledge ab out parasite etiology does not appear to significantly affect parasite prevalence among study participants It appears that almost all participants have significant knowle dge about preventive behaviors such as maintaining general hygiene, frequent hand washing, proper food preparation, and wearing shoes. Whether participants always practice these behavior s is another question and outside the scope of this research. In conclusion, the researcher reje cts the Alternative Hypothesis (H-7) : Significant knowledge of parasite etiology and preventi on is associated with lower parasite prevalence rates at the household level. Inst ead, the data suggest that knowledge about parasites does not appear to be associated with lower parasite prevalence rates. This finding is significant because it suggests that political ecological fact ors best explain the intensity and prevalence of intestinal parasites am ong the study population than do culturally determined beliefs and knowledge as suggested in the medical anthropology literature. These conclusions are important because they add a significant piece to the literature by suggesting that household envi ronmental conditions may significantly influence the way in which participants im plement preventive behaviors. For example, participants who live in househol ds where kitchens are lacking in sanitary infrastructure may have a more difficult time putting into practice preventative behaviors; whereas participants who live in househol ds with adequate infrastructu re may have an easier time implementing preventative behaviors. As a result, it is hypothesized that household sanitary infrastructure has a greater impact on parasite transmission than does knowledge about preventative behaviors. This woul d explain why household sanitary conditions were significantly associated with disparitie s in parasite prevalence whereas critical knowledge concerning parasites does not appear to significantly differ among study participants. Research Objective (O-4): Provide a gen eral political ecologi cal framework that explains the prevalence of intestinal parasites among the study population in Monteverde, Costa Rica.

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220 The following chapter will attempt to cont extualize the principal results of this dissertation using a political ecology of health framework. Political ecology, with its focus on macro and micro levels of analysis within a historical context provide an excellent framework for understanding para site prevalence and transmission among the study population. Most importantly, this fr amework provides a means to go beyond the proximate causes of disease by examini ng macro level political economic and environmental phenomena which can be considered the ultimate causes of disease. Lastly, the political ecology approach to understanding disease transmission has significant potential for identifying interventions that point to political economic, social and environmental changes aimed at dis ease prevention that extend beyond a more traditional public health approach which fo cuses almost exclusively on the locus of infection.

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221 Chapter Nine – Conclusions, Recommendations and Limitations In this study, fecal samples were collect ed and analyzed for intestinal parasites among a small study population consisting of a group of Nicaraguan immigrants and a group of Costa Rican resident s living in and around Santa Elena de Monteverde, Costa Rica. Without a doubt, the intense migration of Nicaraguans to Costa Rica over the past two decades has been one of the most conten tious issues confronting modern Costa Rican society (Morales and Castro 2002; Sandova l-Garcia 2004a; 2004b). Among one of the most controversial issues has been the financ ial and social impact of Nicaraguan migrants on the national health care system (Segnini 1999). Thus, it is surprising that there are so few studies that have comparatively st udied differential health outcomes among Nicaraguans and Costa Ricans. At the time of this research, Costa Rican health institutions did not routinely collect data regarding the natio nality of patients, making it difficult to assess health or other social inequalities experienced among Nicaraguans or other marginalized populations. As a result, there ar e very few studies that have comparatively examined the health of Nicaraguan immigrants living in Cost a Rica. A case in point is that before this study, virtually nothing was known about the health or social conditions of the Nicaraguan population living in Monteverde. The decision to comparatively study the prevalence of intestinal parasites was an attempt to answer the call expressed by Marquette (2006) and the OIM report (2001) to compare health outcomes of Nicaraguans and Costa Ricans in order to determine whet her significant health disparities exist. While the parasite prevalen ce results of this research contradict those reported by the Monteverde Clinic and in part by t hose presented by the 1996 National Survey of Intestinal Parasites, they support a growing body of Costa Ri can public health literature which indicate that parasites prevalence ra tes are high among marginalized populations (Abrahams-Sand 2005; Blanco 2007; Cerd as 2003; Hernandez-Chavarria 2005; Hernndez 1998; Pardo 1997; Sanchez 1999). One of the most significant results of this

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222 current study was that Nicaraguan study partic ipants suffered signifi cantly higher rates of intestinal parasites compared to Costa Rican study participants. These results provide primary evidence to suggest that significant health disparities exist between Nicaraguans and Costa Ricans and thus support earlier reports from the OIM (2001), CCSS (2002), and Marquette (2006). The results of this research serve to fill a critical gap in the Costa Rican health literature by comparing rates of intestinal paras ites between Nicaraguan immigrants and Costa Rican residents at the local level. This research also answers the call by Inhorn and Brown (1997) in their book “The Anthropology of Infecti ous Disease” to examine infectious diseases as they manifest in different ecological and cultural settings. The authors express the need for researchers to explain how patterns of infecti ous diseases are not only influenced by local variables but also, how they are influenced by political-economic (or political-ecological) policies and processes of globali zation. As such, this research lends itself to a political ecology framework as a way to explain dispar ities in parasite prevalence rates. Toward a Political Ecology of Intestinal Pa rasite Infections in Monteverde, Costa Rica For the most part, parasite prevalence studies, including the Costa Rican studies cited here do a good job at describing the di stribution and intensity of parasites among the study population. These studies are also e ffective at identifying the most probable sources of infection and mode s of transmission; often poin ting to contaminated water, poor household and personal san itation, low socioeconomic stat us, a lack of education and cultural behaviors as the primary causes of disease. Armed with this information, these studies then propose public health interventions aimed at reducing disease transmission. However, as noted by Goodman and Leatherman (1998), these studies have rarely “focused upstream” to the larger “m acro” or “intermediate” level factors that influence parasite prevalence. For example, it is well known that inadequate household sanitation is often associated with increased parasite prevalence; however, it is rare that the origins of inadequate household sanita tion are addressed in relation to disease transmission. As such, the political ec ology of health framework goes beyond the

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223 proximate determinants of disease tran smission in order to identify and better contextualize the macro and intermediate leve l determinants of disease as a means to suggest structural changes and related st rategies aimed at disease prevention. As explained by Singer (2008), McElr oy and Townsend (2009) and Mayer (1996) politics, economics and the environment play a major role in community health and must be considered in any health model. As suc h, the political ecology of health framework is similar to that of critical medical anthr opology, but adds environmental factors to the analysis by understanding that poor health is a product of development and transformed environments that have roots in poli tical economic policie s and realities. One of the principal concepts of politic al ecology is its focus on micro and macro level linkages (i.e. local, regi onal, and global inter actions) with attention to historical processes in order to contextu alize disease outcomes. This research follows the assertion by Singer (2003) that the political ecology of h ealth framework gives attention to both the social and biological origins of disease. Specifically the model tries to understand the nature of the proximate (micro) causes of disease as well as the social, politicaleconomic, and environmental relations that ar e the ultimate (macro) causes of disease. The following conclusions are an attempt to c ontextualize parasitic infections within a political ecology of health framework. The Role of Water and Water Resource Management in Disease Transmission One of the original objec tives of this research was to determine whether community based water resources management was linked in any way with community health outcomes; specifically parasitic inf ections that are often caused by both waterborne and water-washed modes of transmissi on. Based on water quality analysis reported by the Santa Elena Aqueduct and the microscopi c analysis of participant fecal samples, this research concluded that potable water was not significantly associated with parasite transmission among study participants. These findings are contrary to those reported by Peinador and Murillo (2000b), who found high prevalence of protozoan cysts in water treatment plants in several municipalities throughout Costa Rican ; thus demonstrating that water may be a primary source of infecti on of intestinal parasites in those areas of

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224 Costa Rica. However, as mentioned in the pr evious chapter, the Santa Elena Aqueduct is fortunate to have an excellent and adequate so urce of spring water that is accessible to the entire population. Thus, the source of wate r and its distribution in Monteverde is significantly different compar ed to those reported by Pein ador and Murillo (2000). Evidence from this research and from s econdary data of water quality suggests that the primary mode of transmission is through fecal-oral contact at the household level rather than water-borne transmission at the community level. These conclusions serve to calm the fears of researchers at the USF-Gl obalization Research Center who initially suggested that the process of rapid economic developmen t in Monteverde may have serious consequences to water quality and heal th. On the contrary, the results demonstrate that at the time of this research, water quality, graywater disposal, and wastewater disposal was not a significant source of intestinal parasite transmission or other common water-borne diseases. Second, water scarcity does not appear to significantly alter hygiene behaviors or water management beha viors that can contri bute to common waterwashed diseases. Third, while the contamina tion of local waterways from both household and small business waste is of environmental co ncern, there is no evidence to suggest that this type of contamination has a significan t impact on human health. Finally, one of the major concerns in terms of water resources ma nagement in Monteverde is the ability of the Santa Elena Aqueduct to keep up with demand of the rapidly growing population while at the same time maintaining water qu ality. Based on secondary evidence from this research, the Santa Elena Aqueduct appears to be administered by a skilled group of technicians who are well aware of the future challenges. Moreover, at the time of this research, the Santa Elena Aqueduct was one of only 13 community aqueducts in Costa Rica to receive the “ Sello de Calidad Sanitaria ” (Seal of [Water] Quality Sanitation). The aqueduct continues to invest in evidence based evaluation of its water management infrastructure to ensure that the future water needs of the community are met. The Systematic Underreporting of Parasitic Infections as a Macro Cause of Disease The “political” in the political ecology of health model focuses on the idea that disease is often the ultimate result of social relations which, in this case, determine how

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225 the knowledge, control, and production of criti cal health resources are distributed among the population in a way that has consequences on disease outcomes. Therefore, the unequal distribution in parasite prevalen ce between Nicaraguans and Costa Ricans reported in this research must be unders tood within the context of significant underreporting of intestinal parasites by the Monteverde Clinic. As described in the discussion, underreporting is likely the result of both inadequate laboratory testing procedures and selection bias that inadvertently discounts the uninsur ed population who are unlikely to get tested for intestinal parasites. Since th e public health response to any disease is often based on its epidemiologi cal profile within a certain population, the inverse is also true, where in this case the low reported prevalence of intestinal parasites is justification for publ ic health inaction. As Nichter (2008) points out, the collecti on of public health/e pidemiological data and the production of knowledge about disease are not neutral, nor are they produced in a vacuum, but rather are the result of national health politics. Thus, the underreporting of intestinal parasites by the Monteverde Clinic ha s two consequences: 1) it forfeits the need of a community based public health response to address intestinal parasites; and 2) it ignores the fact that the Ni caraguan community suffers from significantly higher rates of parasite infections and justifies their conti nued exclusion from the medical system. This situation provides a good example of how the political economy of the Costa Rican medical establishment inadvert ently ignores the high parasite prevalence rates among the Nicaraguan community in Monteverde. Underreporting parasites, whether uninte ntional or not, influences the medical importance given to parasites, thus having a di rect impact on the public health response in terms of diagnosis, treatment and prev ention. Inhorn and Brown (1997) have implied that infectious diseases are likely to emer ge or reemerge when public health measures slacken or break down. Though it is beyond the scope of this study, the evidence collected from this research introduces th e hypothesis that the c ontinued underreporting of parasites along with the systematic poli tical economic barriers that prevent many Nicaraguans access to basic health services ma y result in a continued increase of parasite prevalence among the Nicaraguan community. As such, it is hypothesized that the

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226 uninsured Nicaraguan community poses a perm anent risk to the host community as a significant reservoir of intestinal parasites. Th at is to say, the high pr evalence of parasites among the Nicaraguan community in Montever de has serious implications for the potential re-emergence of parasites among th e general population which currently exhibit low parasite prevalence. It is further hypothe sized that the complacency in underreporting parasites can help explain, in part, the heal th disparities between Nicaraguans and Costa Ricans living in Monteverde. Singer (2007) defines health disparities as disproportionate or excess morbidity or mortality among disadvantaged groups in soci ety. The literature of ten points out that poverty is one of the principal predictors of health disparities. However, the findings of this research suggests that structural caus es, including access to health care, immigrant status, and the inadvertent underreporting of intestinal parasites by the medical establishment provide a better e xplanation of disparities in pa rasite prevalence than does poverty. This hypothesis follows with Singer’s soci al structural view of health disparities which are seen as the product of social inequities and injustice; not merely the consequences of individu al decisions and actions. Within a political ecology of health framework, the systematic, albeit inadvertent underreporting of intestinal parasites is rela ted to and perpetuated by denying access to basic health services based on immigrant status and the inability to pay for consultation fees and are hypothesized to be the ultimat e or macro causes of health disparities exhibited between Nicaraguan and Costa Rican study participants. In turn, the absence of a public health response to address this commun ity level health disparity is justified by continued underreporting. In this case, disparities in parasite prevalence among Nicaraguan immigrants are the result of et hnic discrimination, either conscious or unconscious, on the part of health care pr oviders. Singer (2007) describes this as institutional racism in which health care providers see ethnic minorities as less worthy patients, an idea grounded in power imbalances between minorities and medical elites.

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227 Immigration as a Macro, Social Structural Cause of Disease The political ecology of health framew ork was also used to understand how macro level processes such as immigration ar e intrinsically linked to intermediate and proximate causes of disease. The movement of people and capital is perhaps the most obvious connection between globalization and infectious diseases. Inhorn and Brown (1997) and the IoM report (2006) state th at migrant populations are among the most vulnerable to emerging and reemerging infectious diseases. Indeed, migrant health issues have become among the most contentious health issues in countries that receive migrants, not least in Costa Rica. In terms of macro level analysis, disp arities in parasite prevalence between Nicaraguan and Costa Ricans study participants must be unders tood within the context of large scale immigration of Nicaraguans into Co sta Rica in general a nd specifically to the growth of the ecotourism sector in Monteverde The conclusion that i mmigration status is connected to a set of consequences that ma ke migrants more vulnerable to infectious disease is well accepted in th e literature (Knobler 2006; Mini sterio de Salud de Costa Rica 2002; Singer 2007). According to Knobler et al. (2006) migration is propelled by a complex and dynamic interplay of various push and pull factors indicative of a differential power hierarchy with in and between nation states. For Nicaraguans in general, the push f actor is a result of civil unrest, high poverty, unemployment, and natural disasters, while the geographic proximity, political stability and continued demand for cheap labo r in the agriculture and service sector economies of Costa Rica provide the pull f actor. On the local level, the growing ecotourism economy in Monteverde has steadily attracted Nicaraguan migrants in order to meet growing demands for low-skill constr uction, service sector, and domestic service employment. One of the significant findings of this research was that immigrant status has serious impacts and consequences on the so cial, political economic and environmental variables that were associated with an in creased risk of parasitic infections. The consequences of immigrant status are, in many ways, analogous to what Singer (2003) describes as “a syndemic set of relationships” that, in this case, we re found to influence

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228 the distribution of parasitic infections. This research found the following syndemic set of relationships related to increased parasite infection: 1) immigrants faced significant barriers to health care which affected health seeking behavior su ch as screening and treatment of parasitic and other common illn esses; 2) immigrant workers had greater difficulty negotiating higher wages, basic work protections, and health benefits and as a result were more likely to be underemploye d; 3) immigrants did not have access to formal credit or government housing subsid ies because of their employment and or residency status which consequently posed a serious barrier to home ownership; 4) growth of the ecotourism economy increased the demand and price for quality housing as well as the prices of everyday goods and servi ces; 5) job insecurity and barriers to credit force many immigrant families to rent substandard housing; 6) rental properties were significantly associated inade quate kitchen and bathroom sa nitation infrastructure. This coupled with the fact that immigrant families tend to be larger than typical Costa Rican families create household ecologies that promot e the fecal-oral transmission of parasites. Figure 9-1 demonstrates, in part this syndemic set of relationships based on immigration status that is ultimately associated to disparities in health outcomes. As Nichter (2008) points out, this set of syndemic relationships appeal to a political ecology of health framework because they emphasizes the interactions between health and social inequality within historical context while paying attention to modes of transmission that cluster among migrants. Th is research concluded that compromised household ecologies including sanitation infras tructure, household size, and the presence of infected individuals were all significantly associated w ith higher parasite prevalence rates. The importance of household ecology in te rms of parasite transmission is treated as an intermediate cause of disease and is discussed in the following section. The Household Ecology as an In termediate Cause of Disease A main concern of the po litical ecology of health fr amework is linking the macro or ultimate causes of disease to the micro or proximate causes of disease. It is the hypothesis of this research that the house hold ecology provides the primary link between both macro and micro level disease pathways. In this case for example, how immigration

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229 status is linked to substandard household ecologies including inadequate bathroom and kitchen sanitation infrastructure, as well as household size, which in turn is associated with an increased prevalence of parasite infections thr ough fecal-oral transmission (See Figure 9-1 for a graphic representation of these linkages). In the political ecology framework, the environment is understood in br oad terms; from traditional ecological habitats including tropical rain forests to built environments that include human dwellings. For anthropologists, the household environment is important to the study of infectious disease because of how it inters ects with biological, physical, and cultural characteristics to encompass an ecological system (Wilk 1991). The political ecology of health framewor k proposed in this dissertation borrows from “the household ecology of disease tr ansmission” model suggested by Coreil, Whiteford and Salazar (1996) in order to help explain how the house hold determinants of disease are linked to both macro and micro levels of analysis that he lp explain patterns of disease transmission. The household ecology mo del provides a link between both micro and macro level phenomena by means of defining the household ecology as an intermediate pathway of disease between larger political economic factors and the proximate determinants of disease including the exposure to pathogens (Millard 1994). Coreil and colleagues (1996) propose that the household ecology of disease transmission framework consists of three ba sic components; the bi ophysical environment, the social environment, and the culturally constructed environment. In this study, the biophysical environment refers to poor household conditions, specifically unsanitary kitchens and bathrooms as well as the presence of vectors. In terms of kitchen conditions, inadequate or poorly positioned sinks create a barrier to frequent ha nd washing; a lack of quality counter space can comp romise food preparation; and inadequate storage space for food and utensils encourages vector (flies and cockroach) contamination. All of these factors, especially infrequent hand washi ng, increase the risk of the fecal-oral transmission of intestinal para sites at the household level. In terms of bathroom conditions, the ab sence or poor positioning of hand washing facilities creates a significant barrier to frequent hand washing. In addition, small, cramped and dark bathroom conditions increase the likelihood that fecal matter or other

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230 pathogens are picked up and distributed throughout the household. When infected household members fail to wash their hands after using the bathroom they risk inadvertently infecting other household member s. In addition, the st orage of soiled toilet paper in the waste bin may also contribute to fecal-oral tran smission in some cases. Both poor kitchens and bathroom conditions ar e good examples of intermediate household conditions that directly affect the proximate level of disease causation (See Figure 9-1 for a graphic representation of these linkages). In this study, the household social cond itions relating to parasite transmission were significantly associated with the pr esence of infected household members and increased household size. Firs t, infected household member s serve as hosts and are a necessary component of succe ssful fecal-oral transmission. Furthermore, the probability of transmission increases with the presence of infected household members, especially when household hygiene infrastructure a nd practices are compromised. Household density, when coupled with a cramped living sp ace increases the probability of person to person contact, a necessary condition of f ecal-oral transmission. Finally, fecal-oral transmission is further exacerbated when inadequate sanitation infrastructure is compounded by large household size and the pr esence of infected family members. One of the main conclusions of this re search was that the household ecological factors mentioned here (i.e. inadequate hous ehold sanitation infras tructure) were not significantly associated with hous ehold income, but rather to variables such as immigrant status, underemployment, and access to cred it. These connections demonstrate how household infrastructure is much more than just a result of household economics; but in fact must be understood within the cont ext of more complex political economic relationships that result from social injust ice. As such, the hous ehold ecology of disease transmission model proves to be adequate in terms of providing an intermediate explanatory link between the macro, political economic causes of disease and the micro level pathways (i.e. fecal-oral transmission) which represents the proximate levels disease causation.

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231 The Role of Knowledge, Beliefs and Be haviors on Parasite Transmission Within the household ecology of disease transmission framework, Coreil and colleagues (1996) refer to the shared house hold beliefs, knowledge and behaviors as the culturally constructed househol d environment. A host of medi cal anthropology literature points to the importance that beliefs, pe rceptions and knowledge has on risk and treatment seeking behaviors (Green 1999; Inhorn and Brown 1997; Nichter 2008; Vecchiato 1997). A critical finding of this research showed that, despite minor disconnects, heads of household have a high le vel of knowledge regarding the source of infection, mode of transmission and relevant prevention strategies regarding intestinal parasites. In fact, there was no discerna ble difference in knowle dge about parasites concerning sources of infection, modes of transmission and prevention between Nicaraguans and Costa Ricans or between head s of household who lived in infected or uninfected households. Thus, it is not surp rising that beliefs, knowledge regarding intestinal parasites was not associated with a lower prevalence of intestinal parasites among study participants at the household level. This finding is significant because it indicates, at least among this study population, that political economic and ecol ogical variables at both the macro and intermediate levels of analysis (i.e., access to health care, home ow nership, inadequate household sanitation infrastructure, househol d size and the presence of infected household members) are better predictors of parasite pr evalence than are culturally constructed beliefs and knowledge concerning parasite prevention. The hypothesis ascertained from these conc lusions suggests that both the physical and social domains of the household ecol ogy may significantly influence the way in which prevention related behavi ors are practiced. As a result living in a household with inadequate sanitary infrastr ucture and crowded living condi tions may significantly reduce the ability of household members to pract ice known preventative strategies. The following examples illustrate this point: 1) an absence of conveniently located sinks would likely decrease hand washing freque ncy among household members; 2) similarly, a lack of kitchen countertop and food storag e space is likely to adversely affect proper food preparation; 3) old wooden countertops can provide an ex cellent source of infection

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232 because they are more difficult to clean comp ared to countertops made with impervious materials found in higher quality homes; and 4) an household size increases the likelihood of spreading contaminated sources throughout the household, especially when the household sanitation infrastructure is inadequate to begin with. In contrast, individuals who live in households with adequate sanitation infrastructure may have an easier time pr acticing known prevention related behaviors. For example, the presence of sinks where soap is present is likely to promote increased hand washing among household members; just as the presence of quality countertops and other kitchen infrastructure is likely to improve food handling methods. This hypothesis also supports previous conclu sions that demonstrated a si gnificant associ ation between rented homes, poor sanitary infrastructure, crowded living conditions and an increased prevalence of parasite infections in spite of the fact that the head of household possesses significant knowledge regard ing parasite prevention. According to Inhorn and Brown (1997) one of the most important contributions of medical anthropology to the study of infectious disease has been its ability to produce an “infectious disease ethnography” noting that in most infect ious disease studies, human behavior and cultural percepti ons are decontextualized from larger political economic context (1996:20). Additionall y, both Inhorn and Brown (1997) and Coreil et al. (1996) argue that by providing descri ptions of cultural knowledge perceptions and behaviors relating to infectious disease, anthropologists can point to the relevance of culture for public health interventions aimed at reduci ng the burden of those diseases. While the methodology employed in this research did not focus on observed human behavior in relation to disease transmi ssion, the insights gained from interviews focusing on knowledge and perceptions provide s valuable insights in terms of realistic public health interventions to reduce parasite prevalence in the study population. Th e results of these interviews coupled with a poli tical ecology analysis suggest that educational messages or behavior change interventions aimed parasite prevention would not achieve its intended goals as long as the intermediate and macr o level determinants of disease were not addressed first. Based on this conclusion, it is argued that changes to the macro and intermediate level determinants of disease (i.e., access to health care, home ownership,

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233 inadequate household sanitation infrastruct ure, household size and the presence of infected household members) would do more to prevent parasite transmission at the micro level than would community based publ ic health messages. Specific changes to both intermediate and macro level determinants will be discussed as recommendations. Implications of a Political Ecology of Health The political ecology of health framew ork provides critical information on how parasite prevalence is intertwined with m acro, intermediate, and micro level political economic, cultural and environmental realities. The addition of the household ecology of disease transmission framework proposed by Core il et al. (1996) provides the necessary focus on household level phenomena that ar e related to disease transmission. The political ecology of health m odel answers the call from Inhorn and Brown (1997) to look at how disease outcomes at the local leve l are connected to macro level political economic and environmental phenomena; and that of Goodman and Leatherman (1998) to “look upstream” and understand how social and political economic processes affect human biologies and health outcomes. Figure 9-1 provides a graphic representa tion of the political ecology framework related to intestinal parasites and outlines the linkages between the macro, intermediate, and micro level determinants of parasite transmission based on the findings of this research. This model outlines how immigration st atus is linked to barriers in access to health care and to the system atic underreporting intestinal parasites which are ultimately associated with health disparities betw een Nicaraguans and Costa Ricans. Also, immigration status is linked to underemploym ent which is associated with a lack of access to formal credit and government housing subsidies. These factors are associated with household ownership and ul timately household sanitation infrastructure; specifically how renting is associated w ith inadequate bathroom and kitchen conditions. Finally, inadequate household sanitation infrastructur e coupled with large household size and the presence of households with infected family members is associated with the fecal-oral transmission of intestinal pa rasites at the household level.

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234 Figure 9-1. The Political Ecology of Intestinal Parasites Framework

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235 The political ecology of intestinal pa rasites framework presented here is significant because it can be considered “an a pplied political ecology of health model” in that it identifies the macro, intermediate, and proximate determinants of disease which can then be targeted for public health inte rventions aimed at reducing the prevalence of intestinal parasites. Another important public health implicati on to emerge from this framework is the significant disparity in parasite prevalen ce between the Nicaraguan and Costa Rican study participants. These disparities are, in part the result of health and social inequalities that prevent many Nicaraguans from having access to basic health care and disease prevention programs. Following Inhorn and Brown’s (1997) claim, denying access to basic care and prevention services may promot e the emergence of a reservoir of intestinal parasites that poses a risk to the host populat ion. A similar case occurred in a northern region in Costa Rica after hurricane Mitch when Nicaraguan refugees from endemic malaria regions of Nicaragua settled in the re gion. Serving as reservoirs of the malaria parasite, the incidence of the disease subsequently started to rise among the Costa Rican host population (CCSS 2002). The case of increa sed prevalence of malaria eventually drove the CCSS to invest in early detection kits to prevent further dissemination of the disease. In order to prevent the potential reem ergence of intestinal parasite among the local Costa Rican community, health officials must take the initiative to ensure health care access to “irregular” immigrants and othe rs who lack health coverage. By providing a mechanism through which immigrants and ot her can have easy and non discriminatory access to basic public health services, screening and timely treatment of intestinal parasites will help reduce risk of con tinued transmission amo ng both populations. The following are various recommenda tions that outline action that should be taken from the national to the local level in order to preven t the reemergence of intestinal parasites in Monteverde

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236 Recommendations The recommendations discussed here w ill be juxtaposed according to their corresponding level of analysis following th e political ecology of health framework. National Level Recommendations One of the most pressing factors facing Nicaraguan immigrants in Costa Rica is access to health care services through the CCSS. At the time of this research, “irregular” immigrants did not have viable options to access basic health se rvices through the CCSS system (exceptions only existed for emergenc ies and for children and pregnant women as long as it does not interfere with the hea lth access of the insured population). In addition, it is estimated that approximately 50% of Ni caraguans living in Costa Rican do not have access to health care. Based on findings that found a significant association between access to health care and parasite prevalen ce, one of the principal recommendations of this research is to create a mechanism to integrate “irregular” immigrants into the CCSS system to ensure that they rece ive access to basic health care. Because of the organizational and hierar chical nature of the CCSS, even the smallest changes to health policy require major political agreements. Unfortunately, passing health legislation to gr ant access to health care for il legal immigrants would most likely require a major shift in national level politics. One alternative recommended by this dissertation is to promote the establishment of both national and international level NGO’s that focus their attention on providing access to health care to immigrants. One successful program developed in Limon province called “consultorio para migrantes” (consultations for migrants) is a public/private collaboration between the Catholic Church and the CCSS which provides access to basic he alth services for migrants regardless of their immigration status. Such a program is needed to ensure that Nicaraguans have their basic health care needs met which includes the screening and trea tment of preventable infectious disease as well as appropriate care for women and child ren. Such a program would help prevent the spread of infectious agents between populations that come from areas of high endemicity and those of the host population.

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237 At the time of this research, vital medi cal statistics did not include the patients’ nationality thus making it difficult to co mpare health outcomes of the Nicaraguan community compared to other groups. One recommendation this dissertation proposes is to develop standard medical registration pr ocedures for hospitals, clinics, EBAIS and other health service providers to record patien t nationality along with other vital statistics. This will allow better comparability of health outcomes between Costa Ricans and Nicaraguans and provide a more valid assessment of the health of the Nicaraguan community in Costa Rica. This measure would he lp in part to identify health disparities and help inform health practitioners where resourced need to be focused. Community Level Recommendations It must be acknowledge that many of the conclusions drawn from this dissertation, especially those relating to th e underreporting of intestinal parasites and issues surrounding the access to health care of Nicaraguan immigrants may come off as being extremely critical of the Monteverde Cl inic. It is likely that these conclusions would be sharply contested by the clinic sta ff and thus seriously obs truct any beneficial dialogue in terms of developing a public health intervention that woul d be beneficial to all stakeholders. One recommendation of this dissertation is to present the results and conclusions to the Monteverde Clinic in a way that encourages dialogue. One way would be to eliminate the accusatory tone of the c onclusions, and to instead present the parasite prevalence data as simple epidemiological fa cts for the clinic to discern. For example, instead of placing blame on either the clinic or the Nicaraguan community, the results should be used as a means to promote the idea that the clinic must take up public health initiatives in order to prev ent the re-emergence of intes tinal parasites among the Costa Rican community. At the community level, another reco mmendation if for the EBAIS to become active in addressing the health needs of th e Nicaraguan community and other marginal groups, with the ultimate goal of identifying community hea lth disparities. The EBAIS were created in the late 1990’s to address ga ps in primary health care access for the rural population in general and their creation has significantly increased basic health care

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238 coverage on a dramatically. Nationally, the EB AIS only provides servi ces to “irregular” Nicaraguans in the case of emergencies. However, one way increase access to basic health care for immigrants and others without access to health care would be to expand EBAIS coverage to these populations. This act ion could provide an excellent alternative for Nicaraguans who have no other health care options while in theory could drastically improve health outcomes while at the same time reduce health care spending. Another effective measure would be to utilize the EBAIS as mechanis m to implement target of outreach programs focusing on maternal and child health, family planning, immunizations, and intestinal para sites to the Nicaraguan community. The community ASIS (Community Health Analysis Report) is a report produced every year that summarizes basic community h ealth statistics and outcomes. This report, written by the local EBAIS, outlines both heal th outcome achievements and areas that need more attention. It is the recommendati on of this dissertation that the local EBAIS should give special attention to community health disparities among the Nicaraguan community in Monteverde (or other margina lized populations). The ASIS should be used as a tool for reporting local health outcomes, especially those relevant to marginalized populations which can then be used to propose medical or public health strategies aimed at reducing health disparities and improving health outcomes. Another recommendation at the community level is to modify the fecal sample collection procedures currently used at the Monteverde Clinic to collect stool samples for screening of intestinal parasites. As de scribed in both the methods and discussion chapters, fecal samples collected at the M onteverde Clinic are not preserved, thus promoting the desiccation of samples which reduce the specificity of screening tests which ultimately lead to th e significant underrep orting of intestinal parasites. This dissertation recommends that the Monteverde adopt collectio n procedures that preserve fecal specimens in orde r to ensure the specificity of th e results. Commercially available preservation solutions are currently availabl e at very low costs; however, it is possible that similar preservation could be produ ced by the CCSS at an even lower cost. Another related recommendation targeted at the Monteverde Clinic is to modify its suppressive drug therapy protocol which relies exclusively on the annual distribution

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239 of Albendazole The results of this research dem onstrate that the global prevalence of intestinal helminths in the community is extremely low compared to the global prevalence of intestinal protozoa. Becaus e Albendazole has been shown to be an ineffective drug therapy for treating intestin al protozoa, the Monteverde Clinic would significantly increase the efficacy of its para site control measures by distributing more appropriate drugs such as Metronidazole and Iodoquinol which specifically target intestinal protozoa. Implementing this measur e would significantly reduce the risk for a potential re-emergence of intestin al parasites in Monteverde. Limitations of the Research The conclusions drawn from this research are subject to several limitations. The snowball sampling methodology used for part icipant selection and the convenience sampling method for collecting fecal sample s and interviewing household informants limits the ability to generalize the results from this study to the rest of the population in Santa Elena and Los Llanos. I attempted to address this concern by adhering to the selection criteria explained in the methods ch apter in order to incr ease the comparability of the two study populations. An important char acteristic for participation in the study was that: 1) each household receive their pota ble water from the Santa Elena Aqueduct; 2) that households be chosen to represent a cross section of neighborhoods in Santa Elena and Los Llanos; 3) that both an adult and a child from each household provide fecal samples for analysis; and 4) that selected households were of roughly the same socioeconomic status. Based on findings presente d in Chapter 8, the socio-demographic characteristics of the study population do not di ffer significantly in te rms of age or gender and are similar to both local and national le vel data in terms of socio-demographic characteristics. This suggests that the results described for the two study populations provide a good proximate to the Monteverde community in terms of health outcomes at the time of the investigation. The cross sectional study design limits th e ability to ascertain if the onset of parasitic infection is the result of exposure variables de scribed in this study. For this reason, the prevalence odds ratio is the prefer red measure of association because it is not

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240 dependent upon the onset or duration of dis ease. Still, it is impossible to determine whether any infection was the result of fecal -oral, water-born, or any other mode of transmission. In most cases, this study relied on a single f ecal sample to differentiate infected and uninfected study participants, which may introduce a misclassification bias. While the sensitivity of a single fecal sample is an accepted means of identifying infected individuals, it has been shown that analysis of multiple fecal samples collected on successive days increases the sensitivity to identifying infected persons (Price 1994). As a result, the global parasite prevalence reported in th is study may be underreported because in most cases only one fecal sa mple was collected and analyzed for each participant. One significant limitation in this study was ascertaining the parasite infection status on the household level. For example, househol ds in which only 1 or 2 participants provided fecal samples for analysis are most pr one to a misclassification bias as being an uninfected household. Thus, results indicating an association between exposure variables and household prevalence rates should be accepted with caution; whereas results demonstrating an association between exposur e and the prevalence ra tes of individuals should be given more weight in terms of true associations. Another limitation of this research was th at temporary household residents were not included in the study and thus were not tested for intestinal parasites. As discussed earlier, it was common for Nicaraguan households to provide temporary shelter to family or friends for short periods of time. By not testing these temporary household residents, this research failed to ascertain whether or not these individuals played a role in household disease transmission. It is possible for individuals coming from areas of high disease endemicity to act as a reservoir host and thus increase the risk of transmission among a susceptible host population. This may especially be significant for Nicaraguan households. Household health behaviors discussed in this dissertation are based on reported health behaviors captured in face to face interv iews. Indeed, discrepancies in reported and observed health knowledge and behavi or are well documented in both the

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241 anthropological and public health literature However, it was beyond the scope of this dissertation to systematically study househol d health behavior. Instead, the objective of the research was to capture a general picture of the principa l discrepancies in knowledge, perceptions and reported behaviors between Nicara guan and Costa Rican study participants in terms of their associat ion to parasite prevalence rates. A Suggestion for Future Research Although it was beyond the scope of this re search, the public health importance given to intestinal parasites is often related to its co-morbidity status of other health issues; specifically malnut rition, child growth, and i mmune suppression which was pioneered by the work of Nevin Scrimshaw and colleagues (Scrimsh aw et al. 1957). The logical next step in this research would be to take a multidisciplinary approach and examine whether or not intestinal parasite infections in Monteverde affect nutritional status, growth trends, and rates of other in fectious diseases like HIV/AIDS, and whether these co-morbid trends differ significan tly among Nicaraguans and Costa Ricans in Monteverde. Summary Despite the limitations, the political ecology of health framework used to understand parasitic infections in this res earch provides a theore tical and methodological framework that transcends our understanding of the simple proximate causes of disease by pointing to the social, polit ical-economic and environmenta l determinants of parasitic disease that can be used by both medical anthropologists a nd public health policy makers to better identify and address health disparities in Costa Ri ca and in other settings. Furthermore, the political ecology of hea lth framework offers critical insights regarding the implementation of public hea lth interventions aimed at reducing the transmission of infectious diseases that go beyond the proximate level determinants. The results of this dissertation s uggests that efforts to reduce he alth disparities in parasite prevalence among Nicaraguan immigrants would be best accomplished by implementing policy that would allow the Nicaraguan commun ity access to critical primary health care

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242 and other needed social services. It is hypothesized that doing so would reduce the burden of disease of the Nicaraguan commun ity, reduce health care costs, and protect Costa Rican citizens from the potential reemer gence of preventable infectious diseases.

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243 References Cited AAASE, Asociacin Administradora del Acueducto de Santa Elena 2003 Sello de Calidad Sanitara Santa Elena de Monteverde. Abrahams-Sand, Elizabeth, Mayr a Solano, and Beatriz Rodrguez 2005 Prevalencia de Parsitos Intestinales en Escolares de Limn Centro, Costa Rica. Revista Costarricense de Ciencias M dicas 26(1-2). Alland, Alexander Jr. 1969 Ecology and Adaptation to Parasitic Diseases. In Environment and Cultural Behavior: Ecological Studi es in Cultural Anthropology. A.P. Vayda, ed. Pp. 80-89. Garden City, NY: The Natural History Press. Amador, Edgar A. 2004 Globalization, Ecotourism and Deve lopment in the Monte Verde Zone, Costa Rica. M.A. thesis, Department of Applied Anthropology, University of South Florida. Archer, E. 1985 Emerging Environmental Problems in a Tourist Zone: The Case of Barbados. Caribbean Geography 2:46-55. ASIS, Atencin de la Situacion Integral de Salud 2002 Equipo Bsico de Atencin de la Salud (EBAIS), No.8 & 9 del Area 3. Santa Elena, Puntarenas: Clnica Monteverde, Caja Costarricense de Seguro Social. Baer, Hans A. 1996a Bringing Political Ecology into Critical Medical Anthropology: A Challenge to Biocultural Appro aches. Medical Anthropology 17:129-141. 1996b Toward a Political Ecology of H ealth in Medical Anthropology. Medical Anthropology Quarterly 10(4):451-454.

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244 Baer, Hans A., Merrill Singer, and Ida Susser 2003 Medical Anthropology and the Worl d System. 2nd Edition. Westport, CT: Praeger. Baer, Hans, and Merrill Singer 2009 Global Warming and the Political Ecology of Health. Walnut Creek, CA: Left Coast Press. Banta, James E. 2001 From International Health to Globa l Health. Journal of Community Health 26(2):73-76. Baris, Enis, and Kari McLeod 2000 Globalization and Inte rnational Trade in the Twenty-First Century: Opportunities for and Threats to the Health Sector in the South. International Journal of H ealth Services 30(1):187-210. Barrett, Bruce 1996 Integrated Local Health Systems in Central America. Social Science and Medicine 43(1):71-82. Barrett, Ronald, Christopher W. Kuzawa, T homas McDade, and Ge orge J. Armelagos 1998 Emerging and Re-Emerging Infectious Diseases: The Third Epidemiologic Transition. Annual Review of Anthropology 27:247-271. Beaglehole, R., and D. Yach 2003 Globalisation and the Prevention and Control of Non-Communicable Disease: The Neglected Chronic Dis eases of Adults. The Lancet 362:903908. Bernard, Russell 1996 Research Methods in Anthropology: Qualitative and Quantitative Approaches. 2nd ed. Wallnut Creek, CA: AltaMira Press. Bettcher, D.W., D. Yach, and G.E. Guindon 2000 Global Trade and Health: Key Linka ges and Future Challenges. Bulletin of the World Health Organization 78:521-534. Biesanz, Mavis H., Richard Biesanz, and Karen Z. Biesanz 1999 The Ticos: Culture and Social Ch ange in Costa Rica. Boulder: Lynne Rienner Publishers.

PAGE 260

245 Blaikie, Piers 1985 The Political Economy of Soil Eros ion in Developing Countries. London: Longman. 1988 The Explanation of Land Degradation in Nepal. In Deforestation: Social Dynamics in Watersheds and Mountain Ecosystems. J. Ives and D.C. Pitt, eds. Pp. 132-158. London: Routledge. Blaikie, Piers, and Harold Brookfield 1987 Land Degradation and Society. London: Methuen. Blanco, Karol Andrea, and Olger Caldern Arguedas 2007 Perfil de Parsitos y Comensales En tricos de Comunidades del Cantn de Barva, Heredia, Costa Rica. Revi sta Costarricense de Salud Pblica 16(30):27-31. Bossert, Thomas 1998 Transformation of Ministries of Heal th in the Era of Health Reform: The Case of Colombia. Health Po licy and Planning 13(1):59-77. Brown, Peter 1981 Working Group on Anthropology and Infectious Disease. Medical Anthropology Quarteley 12(7). 1987 Microparasites and Macroparasi tes. Cultural Anthropology 2:155-171. Brown, Peter, Marcia C. I nhorn, and Daniel J. Smith 1996 Disease, Ecology, and Human Behavior. In Medical Anthropology: Contemporary Theory and Method. C.F. Sargent and T.M. Johnson, eds. Westport, CT: Praeger. Bryant, Raymond L. 1992 Political Ecology: An Emerging Research Agenda in Third-World Studies. Political Geography 11(1):12-36. 1998 Power, Knowledge and Political Ec ology in the Third World: A Review. Progress in Human Geography 22(1):79-94.

PAGE 261

246 Bryant, Raymond L., and S. Bailey 1993 Third World Political Ecology. London: Routledge. Byers, Karin E., Richard L. Guerrant, and Barry M. Farr 2001 Fecal-Oral Transmission. In Epidemiologic Methods for the Study of Infectious Diseases. James C. Thomas and David J. Weber, eds. Pp. 228248. New York: Oxford University Press. Cash, Richard A., and Vasant Narasimhan 2000 Impediments to Global Surveillance of Infectious Diseases: Consequences of Open Reporting in a Global Ec onomy. Bulletin of the World Health Organization 78:1358-1367. CCSS, Caja Costarricense del Seguridad Socical 2001 Plan Anual Operativo Institutio nal: Ao 2002. Pp. 1-68. San Jos, Costa Rica. CCSS, Caja Costarricense del Seguridad Socical 2002 Fortalecimiento del Sector Salud en Zonas de Alta Inmigracin. Pp. 5-67. San Jos, Costa Rica. CDC, Centers for Disease Control and Prevention 2002 Protecting the Nation's Health in an Era of Globalization: CDC's Global Infectious Disease Strategy. Atlanta, GA. Cerdas, Carlos, Edna Araya, and Susana Coto 2003 Parsitos Intestinales en la Escuel a 15 de Agosto, Tirrases de Curridabat, Costa Rica. Mayo-Junio de 2002. Revi sta Costarricense de Ciencias Mdicas 24(3-4):127-133. Chandrasekhar, C.P., and J. Ghosh 2001 Information and Communication Tec hnologies and Health in Low Income Countries: The Potential and the Constr aints. Bulletin of the World Health Organization 79:850-855. Charmaz, Kathy 2006 Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. London: SAGE.

PAGE 262

247 CIA, Central Intelligence Agency 2009 The World Factbook: Costa Rica. Electronic Document, www.cia.gov/library/publications/th e-world-factbook/geos/cs.html accessed on September 28, 2009. Clark, Mary A. 2002 Health Sector Reform in Costa Rica: Reinforcing a Public System, 2002. Report. Washington D.C.: Woodrow Wilson Center Workshops on the Politics of Education and Health Reforms. Cleveland, David A. 2000 Commentary: Globalization and Anthropology: Expanding the Options. Human Organization 59(3):370-374. Coreil, Jeannine, Linda Wh iteford, and Diego Salazar 1997 The Household Ecology of Disease Transmission: Dengue Fever in the Dominican Republic. In The Anthropology of Infectious Disease: International Health Perspectives. Ma rcia C. Inhorn and Peter J. Brown, eds. Pp. 145-171. The Netherlands: Gordon and Breach Publishers. Cornia, Giovanni Andrea 2001 Globalization and Health: Results and Options. Bulletin of the World Health Organization 79:834-841. Craun, Gunther F. 1978 Waterborn Outbreaks of Giardiasis. In Waterborn Transmission of Giardiasis. W. Jakubowski and J.C. Hoff, eds. Pp. 127-147. Cincinnati: U.S. Environmental Protection Agency. Davis, Jonathan R., and Joshua Lederberg, eds. 2001 Emerging Infectious Disease from the Global to the Local Perspective. Washington D.C.: National Academy Press. Daltabuit, Magal, and Thomas Leatherman 1998 The Biocultural Impact of Tourism on Mayan Communities. In Building a New Biocultural Synthe sis: Political-Economic Perspectives on Human Biology. Alan H. Goodman and Thomas L. Leatherman, eds. Ann Arbor: The University of Michigan Press.

PAGE 263

248 de Camino, Ronnie, Olman Segura, Luis Guillermo Arias, and Isaac Perez 2000 Costa Rica: Forest Strategy and the Evolution of Land Use. Report. Washington D.C.: The World Bank. DeWalt, Billie R. 1998 The Political Ecology of Population In crease and Malnutrition in Southern Honduras. In Building a New Biocultural S ynthesis: Political-Economic Perspectives on Human Biology. Al an H. Goodman and Thomas L. Leatherman, eds. Ann Arbor: Un iversity of Michigan Press. Dollar, David 2001 Is Globalization Good for Your Heal th? Bulletin of the World Health Organization 79:827-833. Dunn, Frederick L. 1979 Behavioural Aspects of the Control of Parasitic Diseases. Bulletin of the World Health Organization 57(4):499-512. Dunn, Fredrick L., and Craig R. Janes 1986 Introduction: Medical Anthropology and Epidemiology. In Anthropology and Epidemiology: Interdisciplinary Approaches to the Study of Health and Disease. Craig R. Janes, Ron St all and Sandra M. Gifford, eds. Pp. 334. Dordrecht: D. Reidel. Ennis-McMillan, Michael C. 2001 Suffering from Water: Social Origin s of Bodily Distress in a Mexican Community. Medical Anthropol ogy Quarterly 15(3):368-390. Esrey, S.A., J. B. Potash, L. Roberts, and C. Schiff 1991 Effects of Improved Water Supp ly and Sanitation on Ascariasis, Diarrhoea, Dracunculiasis, Hookwor m Infection, Schistosomiasis, and Trachoma. Bulletin of the World Health Organization. 69(5):609-622. Farmer, Paul 1996 Social Inequalities and Emerging Inf ectious Diseases. Emerging Infectious Diseases 2(4):259-269. 1999 Infections and Inequalities: The Mode rn Plagues. Berkeley: University of California Press.

PAGE 264

249 2004 Global Health Equity. The Lancet 363:1832. 2005 Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press. Faulkner, Charles T., Benito Borrego Garc ia, Michael H. Logan, and John C. New 2003 Prevalence of Endoparas itic Infection in Childre n and its Relation with Cholera Prevention Efforts in Mexic o. Pan American Journal of Public Health 14(1):31-41. Faust, Ernest C. 1949 Human Helminthology: A Manual for Physicians, Sanitarians and Medical Zoologists. Philadelphia: Lea & Febiger. Feachem, Richard G.A. 2001 Globalization is Good for Your Heal th, Mostly. British Medical Journal 323:504-506. Feoli Boraschi, Hector, a nd Darner Mora Alvarado 2007 El Programa Sello de Calidad Sanita ria: Calidad del Aguay el Servicio. Revista Oficial del PBAE, 5ta. Edicion. Fidler, David P. 1998 Legal Issues Associated with An timicrobial Drug Resistance. Emerging Infectious Diseases 4(2):169-177. Frumkin, Howard, ed. 2005 Environmental Health: From the Global to the Local. San Francisco: Jossey-Bass Gatrell, Anthony C. 2002 Geographies of Health: An Intr oduction. Oxford: Blackwell Publishers. Geissler, P. Wenzel 1998 "Worms are our Life", Part I: Understandings of Worms and the Body among the Luo of Western Kenya. An thropology and Medicine 5(1):6379. Giddens, Anthony 1990 The Consequences of Modernity. Stanford: Stanford University Press.

PAGE 265

250 Girges, Rameses 1949 Entamoebiasis and its Treatment. Basle, Switzerland: CIBA. Gonzlez, J., and C. Umaa 1996 Incidencia Parasitaria Referida al Centro de Salud de Coronado. Revista Mdica de Costa Rica 537:153-155. Goodman, Alan H., and Thomas L. Leatherman, eds. 1998 Building a New Biocultural Synthesi s: Political-Economic Perspectives on Human Biology. Ann Arbor: Univer sity of Michigan Press. Green, Edward C. 1999 Indigenous Theories of Contagious Disease Walnut Creek, CA: AltaMira Press. Greenberg, James B., and Thomas K. Park 1994 Political Ecology. The Journal of Political Ecology 1:1-12. Guest, Greg, ed. 2005 Globalization, Health, and the Enviro nment: an Integrated Perspective. Lanham, MD: AltaMira Press. Gwatkin, D.J. 1999 The Burden of Disease among the Global Poor. Lancet 354:586-589. Haber, William A., Willow Zuchowski, and Erick Bello 2000 An Introduction to Cloud Forest Trees: Monteverde, Costa Rica. Monteverde de Puntarenas : Mountain Gem Publications. Hackenberg, Robert A. 1999 Globalization: Touchstone Policy Concept or Sucked Orange? Human Organization 58(2):212-215. Hackenberg, Robert A., and Beverly H. Hackenberg 2004 Notes Toward a New Future: Applied Anthropology in Century XXI. Human Organization 63(4):385-400.

PAGE 266

251 Herman, Elizabeth, and Margaret Bentley 1993 Rapid Assessment Procedures (RAP): To Improve the Household Management of Diarrhea. Boston, MA: International Nutrition Foundation for Developing Countries. Hernandez-Chavarria, Francisco, and Maria Fernanda Matamoros-Madrigal 2005 Parsitos Intestinales en una Comunidad Amerindia, Costa Rica. Parasitologia Latinoamericana 60:182-185. Heyneman, D. 1984 Development and Disease: A Dual D ilemma. Journal of Parasitology 70:317. Hill, Carole E. 1986 Translating Primary Health Care Policies to the Local Level: A Comparison of Rural Communities in the United States and Costa Rica. In Current Health Policy Issues and Al ternatives: An Applied Social Science Perspective. Carole E. Hill, e d. Pp. 123-144. Athens: University of Georgia Press. Himmelgreen, D., N. Romero-Daza, M. Ve ga, H. Cambronero, and E. Amador 2006 The Tourist Season Goes Down but not the Prices: Tourism and Food Security in Rural Costa Rica. Ecol ogy of Food and Nutrition 45(4):295321. Honey, Martha 1999 Ecotourism and Sustainable Development: Who Owns Paradise? Washington D.C.: Island Press. Howson, Christopher P., Harvey V. Fineberg, and Barry R. Bloom 1998 The Pursuit of Global Health: The Relevance of Engagement for Developed Countries. The Lancet 351:586-590. Hunter, C., and H. Green 1995 Tourism and the Environment: A Sustainable Relationship? London: Routledge. ICEA, Ingenieros Consultores y Ejecutores de Acueductos 1998 Evaluacin del Acueducto de Santa Elena y Cerro Plano de Monteverde, Puntarenas. Santa Elena de Montev erde: Asociacin Administradora del Acueducto.

PAGE 267

252 Inhorn, Marcia C., and Peter J. Brown 1990 The Anthropology of Infectious Dis ease. Annual Review of Anthropology 19:89-117. Inhorn, Marcia C., and Peter J. Brown, eds. 1997 The Anthropology of Infectious Disease: Intern ational Health Perspectives. The Netherlands: Gordon and Breach Publishers. Jaramillo Antilln, Juan 1984 Los Problemas de la Salud en Cost a Rica. San Jos, Ministerio de Salud de Costa Rica. Kearney, M. 1995 The Local and the Global: Th e Anthropology of Globalization and Transnationalism. Annual Re view of Anthropology 24:547-565. Kendall, Carl 1988 The Implementation of a Diarrheal Disease Control Program in Honduras: Is it "Selective Primary Health Care" or "Integrated Primary Health Care?" Social Science & Medicine 27(1):17-23. Kim, Jim Yong, Joyce V. Millen, Alec Irwin, and John Gershman, eds. 2000 Dying for Growth: Global Inequality and the Health of the Poor. Maine: Common Courage Press. Kinnear, Paul R., and Colin D. Gray 2006 SPSS 14 Made Simple. New York: Psychology Press. Knobler, S., A.A.F. Mahmoud, and S.M. Lemon, eds. 2006 The Impact of Globalization on Infe ctious Disease Emergence and Control Exploring the Consequences a nd Opportunities: Workshop Summary Washington D.C.: National Academic Press. Kocasoy, G. 1989 The Relationship Between Costal Tourism, Sea Pollution and Public Health: A Case Study From Turkey. The Environmentalist 9(4):245-251. 1995 Effects of Tourist Population Pr essure on Pollution of Costal Seas. Environmental Management 19:75-79.

PAGE 268

253 Kombe, Glibert C., a nd Danielle M. Darow 2001 Revisiting Emerging Infectious Dise ases: The Unfinished Agenda. Journal of Community Hea lth 26(2):113-122. Lang, Tim 1999 Diet, Health and Globalization: Fi ve Key Questions. Proceedings of the Nutrition Society 58:335-342. LeChevallier, Mark W., Richard W. Gullic k, Mohammad R. Karim, and James E. Funk 2003 The Potential for Health Risks from Intrusion of Contaminants into the Distribution System from Pressure Transients. Journal of Water and Health 1(1):3-14. LeCompte, Margaret D., and Jean J. Schensul 1999 Designing and Conducting Ethnographi c Research. Walnut Creek, CA: AltaMira Press. Lee, K. 1998 Shaping the Future of Global Heal th Cooperation: Where can we go from here? The Lancet 351:899-902. 2000a Globalization & Health Policy: A Conceptual Framework and Research and Policy Agenda. In Health & Human Development in the New Global Economy: The Contributions and Pers pectives of Civil Society in the Americas. Alexandra Bambas, Juan Antonio Casas, Harold A. Drayton and America Valdez, eds. Washington D.C.: Pan American Health Organization, pp. 15-42. 2000b The Impact of Globalization on Publ ic Health: Implications for the UK Faculty of Public Health. Journal of Public Health Me dicine 22(3):253262. 2004 20 Best Resources on Globaliza tion. Health Policy and Planning 20(2):137-139. Lee, K., Sue Collinson, Gill Walt, and Lucy Gilson 1996 Who Should be Doing What in In ternational Health : a Confusion of Mandates in the United Nations? Br itish Medical Journal 312:302-307.

PAGE 269

254 Levine, Myron M., and Orin S. Levine 1995 Changes in Human Ecology and Behavi or in Relation to the Emergence of Diarrheal Diseases, Including Cholera. In Infectious Diseases in an Age of Change. Bernard Roizman, ed. Pp. 31-42. Washington D.C.: National Academy Press. Lewellen, Ted 2002 Groping Toward Globalization: In Search of an Anthropology Without Boundaries. Reviews in Anthropology 31:73-89. Lind, Jason D., Santiago Ruiz, and Heidi Heuchan 2001 The Interaction Between Access to H ealth Care and Alternative Medicine in Monteverde, Costa Rica. 2001, Report. Monteverde, Puntarenas: Monteverde Insititue, Globalizati on, Nutrition and Infectious Disease Field School. Little, Peter D., a nd Michael Horowitz 1987 Social Science Perspectives on Land, Ecology and Development. In Lands at Risk in the Third World: LocalLevel Perspectives. Peter D. Little and Michael Horowitz, eds. Pp. 1-16. Boulder: Westview Press. Loewenson, Rene 2001 Globalization and Occupa tional Health: A Perspective from South Africa. Bulletin of the World Health Organization 79:863-868. Madrigal, Lorena 1998 Statistics for Anthropology. Camb ridge: Cambridge University Press. Manderson, Lenore 1998 Applying Medical Anthropology in th e Control of Infectious Disease. Tropical Medicine and Intern ational Health 3(12):1020-1027. Manderson, Lenore, and Linda M. Whiteford 2000 Introduction: Health, Globalization, a nd the Fallcay of the Level Playing Field. In Global Health Policy, Local Reali ties: The Fallacy of the Level Playing Field. Linda Whiteford a nd Lenore Manderson eds. Boulder: Lynne Rienner Publications. Markell, Edward K., David T. John, and Wojciech A. Krotoski 1999 Markell and Voge's Medical Parasi tology, 8th Edition. Philadelphia: W.B. Saunders Company.

PAGE 270

255 Marquette, Catherine M. 2006 Nicaraguan Migrants in Costa Ri ca. Poblacin y Salud en Mesoamrica 4(1):1-30. Mata, Leonardo, and Luis Rosero-Bixby 1988 National Health and Social Develo pment in Costa Rica: A Case Study of Intersectoral Action. Washington D.C.: Technical Paper No. 13. Pan American Health Organization. Mata, Leonardo, F. Hernandez, and V. Pardo 1998 Encuesta Nacional de Nutricin. Fasc culo 5: Helmintos intestinales. San Jose, Costa Rica: Ministero de Salud. May, J.M. 1958 The Ecology of Human Diseas e. NewYork: MD Publications. Mayer, Jonathan D. 1996 The Political Ecology of Diseas e as one New Focus for Medical Geography. Progress in Hu man Geography 20(4):441-456. 2000 Goegraphy, Ecology and Emerging Infectious Diseases. Social Science and Medicine 50(7/8):937-952. 2006 Changing Vector Ecologies: Po litical Geographic Perspectives. In The Impact of Globalization on Infectio us Disease Emergence and Control Exploring the Consequences and Opportunities: Workshop Summary. S. Knobler, A.A.F. Mahmoud, and S.M. Lemon, eds. Washington D.C.: The National Academies Press. Miller, M.L., and J. Auyong 1991 Costal Zone Tourism: A Potent Force Affecting the Environment and Society. Marine Policy 15(2):75-99. Miranda, Guido 1994 La Seguridad Social y el Desarroll o en Costa Rica. San Jos: Editorial Nacional de Salud y Seguridad Social.

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256 1995 Development of the Social Security Institute. In The Nutrition and Health Transition of Democratic Cost a Rica. Carlos Munoz and Nevin Scrimshaw, eds. Pp. 33-59. Boston: INFDC. McElroy, Ann, and Patricia K. Townsend 2009 Medical Anthropology in Ecological Perspective. Boulder: Westview Press. McMichael, Anthony J., and Bert Bolin 1999 Globalization and the Sustainabil ity of Human Health: An Ecological Perspective. BioScience 49:205-210. McMichael, Anthony J., and C.D. Butler 2004 Climate Change, Health, and De velopment Goals. The Lancet 364:20042005. Meade, Melinda S., John W. Flor in and Wilbert M. Gesler 1988 Medical Geography. New York: The Gilford Press. Millard, A.V. 1994 Causal Model of High Rates of Child Mortality. Social Science and Medicine 34(7):253-268. Ministerio de Salud de Costa Rica 2002 Fortalecimiento del Sector Salud en Zonas de Alta Inmigracin. Pp. 5-67. San Jos, Costa Rica. Mintz, Sidney W. 1998 The Localization of Anthropological Practice: From Area Studies to Transnationalism. Critique of Anthropology 18(2):117-133. Moffat, Tina 2003 Diarrhea, Respiratory Infections, Prot ozoan Gastrointestinal Parasites, and Child Growth in Kathmandu, Nepal. American Journal of Physical Anthropology 122:85-97. Mohs, Edgar 1983 La Salud en Costa Rica. San Jos: Editorial UNED.

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257 1995 Health Policies and Strategies. In The Nutrition and Health Transition of Democratic Costa Rica. Carlos Muno z and Nevin Scrimshaw, eds. Pp. 132. Boston: INFDC. Monge, R., M. Chinchilla, and L. Reyes 1996 Estacionalidad de Parsitos y Bacter ias Intestinales en Hortalizas que se Consumen Crudas en Costa Rica. Revista Costarricense de Biologia Tropical 44(2):369-375. Mora Alvarado, Darner 2003 Agua Para Consumo Human y Dis posicin de Excretas: Situacin de Costa Rica en el Contexto de Amrica Latina y el Caribe, 1960-2000. Revista Costarricense de Salud Pblica 12(21):31-46. Mora Alvarado, Darner, and Carols Felipe Portuguez 2000 Diagnstico de la Cobertura y Ca lidad del Agua para Consumo Humano en Costa Rica a Principios del A o 2000. Revista Costarricense de Salud Pblica 9(16):1-15. 2003 Evolucin de la Cobertura y Calid ad del Agua para Consumo Humano en Costa Rica Perodo 1989-2002. Revista Costarricense de Salud Pblica 12(22):29-41. Morales, Abelardo, and Carlos Castro 2002 Redes Transfronterizas: Sociadad, Empleo y Migracin Entre Nicaragua y Costa Rica. San Jos, Costa Rica: F acultad Latinoamericana de Ciencias Sociales (FLACSO). Morera, Carlos Manuel 1998 Tourismo Sustentable en Costa Ri ca. Quito, Ecuador: Abya-Yala Editing. Morgan, Lynn M. 1987 Health Without Wealth? Costa Ri ca's Health System Under Economic Crisis. Journal of Public Health Policy 8(1):86-105. 1989 The Importance of the State in Prim ary Health Care In itiatives. Medical Anthropology Quarterly 3(3):227-231. 1993 Community Participation in Health: The Politics of Primary Health Care in Costa Rica. Cambridge, UK: Cambridge University Press.

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258 Morse, Stephen S. 1995 Factors in the Emergence of Inf ectious Diseases. Emerging Infectious Diseases 1(1):7-15. Munoz, Carlos, and Nevin Scrimshaw, eds. 1995 The Nutrition and Health Transiti on of Democratic Costa Rica. Boston: INFDC. Nadkarni, Nalini M., and Nathaniel T. Wheelwright 2000 Monteverde: Ecology and Conserva tion of a Tropical Cloud Forest. New York: Oxford University Press. Nations, Marilyn K., and L.A. Rebhun 1988 Mystification of a Simple Solu tion: Oral Rehydration Therapy in Northeast Brazil. Social Scie nce & Medicine 27(1):25-38. Navarro, Vicente 1999 Health Equity in the World in th e Era of "Globaliza tion". International Journal of Health Services 29(2):215-226. Nichter, Mark 2008 Global Health: Why Cultural Per ceptions, Social Representations, and Biopolitics Matter. Tucson: The University of Arizona Press. OIM, Organizacin Internaci onal para los Migrantes 2001 Estudio Binacional: Situacin Migrat oria Entre Costa Rica y Nicaragua. Pp. 1-83. Ginebra, Suiza. PAHO, Pan American Health Organization 1994 Health Conditions in the Americas, Volume 1. Washington D.C. PAHO, Pan American Health Organization 2002 Health in the Americas 2002 Edition, Volume II. Scientific and Technical Publication No. 587. Washington D.C. Pardo, Veko, and Francisco Hernandez 1997 Prevalencia de Parsitos Intestinal es en una Poblacin Atendida en la Clnica de Hatillo del Mini sterio de Salud, 1995-1996. Revista Costarricense de Cienci as Mdicas 18(2):45-50.

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259 Peinador, Mariano, and Jos Quirs 2000a Nematodos en las Plantas de Trat amiento de Agua para Consumo Humano en Costa Rica. Revista Costarri cense de Salud Pblica 9(17):33-44. Peinador, Mariano, and Juan Murillo 2000b Enteroparsitos: Deteccin y Vigila ncia en Aguas Residuales de Costa Rica Durante 1999. Revista Costarrice nse de Salud Pblica 9(17):26-32. Peet, R., and M. Watts 1996 Liberation Ecology: Development, Su stainability, and Environment in an Age of Market Triumphalism. In Liberation Ecologies: Environment, Development, Social Movements. R. Peet and M. Watts, eds. Pp. 1-45. London: Routledge. Price-Smith, Andrew T. 2002 The Health of Nations: Indectious Disease, Environmental Change, and their Effects on National Security and Development. Cambridge, MA: The MIT Press. Price, Donald L. 1994 Procedure Manual for the Diagnosis of Intestinal Parasites. Boca Raton, FL: CRC Press. 2003 Sources of Infective Stages and Modes of Transmission of Parasites (Unpublished Document): Dr Donald L. Price Center for Parasite Repository and Education, College of Public Health, University of South Florida. Proyecto Estado de la Nacin 2002 Estado de la Nacin en Desarroll o Humano Sostenible: Noveno Informe. San Jos, Costa Rica. Purcell, Trevor, Edgar Amador, and C. Sophia Klempner 2002 Development Survey in Montever de Costa Rica: Ph ase 3, Triangulation Project. Tampa, FL: University of South Florida, Globalization Research Center. Redclift, Michael 1984 Development and Environmental Crisis. New York: Methuen.

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260 Rodrguez Herrera, Adolfo 2006 La Reforma de Salud en Costa Rica. In Serie Financiamiento del Desarrollo. Santiago de Chile : Naciones Unidas, CEPAL. Rosenberg, Mark 1983 Las Luchas por el Seguro Social en Costa Rica. San Jo se: Editorial Costa Rica. Rosero Bixby, Luis 2004a Evaluacin del Impacto de la Refo rma del Sector de la Salud en Costa Rica Mediante un Estudio Cuasiexperimental. Revista Panamricana de Salud Pblica 15(2):94-103. 2004b Spatial Access to Health Care in Costa Rica and its Equity: A GIS-Based Study. Social Science and Medicine 58:1271-1284. Roses, Mirta 2003 Desigualdades Ocultas: Gne ro y Reforma del Sector Salud. In Le Monde Diplomatique. Pp. 1-3, Vol. 43. Senz, Lenin 1995 Evolution of an Epidemiological Profile. In The Nutrition and Health Transition of Democratic Cost a Rica. Carlos Munoz and Nevin Scrimshaw, eds. Pp. 119-143. Boston: INFDC. Saker, Lance, Kelley Lee, Barbara Cannito, Anna Gilmore, and Diarmid Campbell 2004 Globalization and Infectious Diseases : A Review of the Linkages. Geveva: World Health Organization, Speci al Programme for Research and Training in Tropical Diseases. Sanchez, Antonio, Juan Mora and Francisco Hernandez 1999 Prevalencia de Parsitos Intestinal es en Adultos Mayores, Hospital Ral Blanco Cervantes. Revista Costar ricense de Ciencias Mdicas 20(34):167-173. Sandoval-Garcia, Carlos 2004a Contested Discourses on Nationa l Identity: Representing Nicaraguan Immigration to Costa Rica. Bulletin of Latin American Research 23(4):434-445.

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261 2004b Threatening Others: Nicaraguans a nd the Formation of National Identities in Costa Rica. Athens: Ohio University Press. Satcher, David 1995 Emerging Infections: Getting Ahead of the Curve. Emerging Infectious Diseases 1(1):1-6. Schensul, Stephen L., Jean J. Sche nsul, and Margaret D. LeCompte 1999 Essential Ethnographic Methods: Observations, Interviews, and Questionnaires. Walnut Creek, CA: AltaMira Press. Schmink, Marianne, and Charles H. Wood 1987 The "Political Ec ology" of Amazonia. In Lands at Risk in the Third World: Local-Level Perspectives. Peter D. Little and Michael Horowitz, eds. Pp. 38-57. Boulde r: Westview Press. Schmunis, Gabriel A. 2002 Epidemiology, Disease Transmission, Prevention, and Control. In Infection, Resistance, and Immun ity. Julius P. Kreier, ed. Pp. 435-458. New York: Taylor and France. Schwartz, Ronald A. 1979 New Working Group: Anthropology and Infectious Disease. Medical Anthropology Newsletter 10(2):8-10. Scrimshaw, Nevin S., Carl E. Taylor, and John E. Gordon 1957 Interactions of Nutrition and Inf ection. The American Journal of the Medical Sciences (March):367-397. Scrimshaw, Susan, and Elena Hurtado 1987 Rapid Assessment Procedures for Nutrition and Primary Health Care: Anthropological Approaches to Improving Programme Effectiveness. Tokyo: United Nations University. 1988 Anthropological Involvement in th e Central American Diarrheal Disease Control Project. Social Scie nce & Medicine 27(1):97-105. Segnini, Giannina 1999 Nicaragenses Impactan Salud. La Nacin, Diciembre 7. San Jose de Costa Rica.

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262 Sheridan, Thomas E. 1988 Where the Dove Calls: The Politic al Ecology of a Peasant Corporate Community in Northwestern Mexico Tucson: University of Arizona Press. Singer, Merrill, and Hans Bear 2007 Introducing Medical Anthropology: A Discipline in Action. Lanham, MD: AltaMira Press. Spradley, James P. 1980 Participant Observation. New York: Holt, Rinehart and Winston. Stonich, Susan C. 1993 "I Am Destroying the Land!": Th e Political Ecology of Poverty and Environmental Destruction in H onduras. Boulder: Westview Press. 1998 Political Ecology of Tourism. Anna ls of Tourism Research 25(1):25-54. Stonich, Susan C., Jerrel H. Sorensen, and Gus W. Salbador 1998 Water, Power, and Environmental Health in Tourism Development. In Water, Culture, and Power: Local Struggles in a Global Context. John M. Donahue and Barbara Rose Johnston, eds. Pp. 263-284. Washington D.C.: Island Press. The Groundwater Foundation 2009 Electronic Document, http://www.groundwater.org/gi/gwglossary.html accessed on October 25, 2009. The Nature Conservancy 2009 Costa Rica: A Country with a Re putation for Enlightened Conservation. Electronic Document, http://www.nature.org/centralamerica/costarica/ accessed on July 2nd, 2008. TIES, The International Ecotourism Society 1990 Electronic Document, www.ecotourism.org accessed on June 10, 2008. Tomianovic, D., L. Choi, and K. Barrantes 2001 Morbidity, Respiratory Compla ints and Diarrhea. 2001, Report. Monteverde, Puntarenas : Monteverde Insititue, Globalization, Nutrition and Infectious Disease Field School.

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263 Trostle, James A., and Johannes Sommerfeld 1996 Medical Anthropology and Epidemiology. Annual Review of Anthropology 25:253-274. Tsing, Anna 2000 The Global Situation. Cultu ral Anthropology 15(3):327-360. Turshen, M. 1977 The Political Ecology of Disease. The Review of Radical Political Economics 9(1):45-60. 1984 The Political Ecology of Diseas e in Tanzania. New Brunswick, NJ: Rutgers University Press. UNFPA, United Nations Population Fund 2003 Annual Report 2003, Millennium Development Goals. New York. Utarini, A., A. Winkvist, and G.H. Pelto 2001 Appraising Studies in Health Using Rapid Assessment Procedures (RAP): Eleven Critical Criteria. Hu man Organization 60(4):390-400. Valiente, Carmen 1999 Vigilancia Sanitaria del Agua: Un Nuevo Enfoque para Municipalidades de Costa Rica. Revista Costarri cense de Salud Pblica 8(15):2-11. Valiente, Carmen, and Darner Mora 2002 El Papel del Agua para Consum o Humano en los Brotes de Diarrea Reportados en el Perodo 1999 2001 en Costa Rica. Revista Costarricense de Salud Pblica 11(20):26-40. Vargas, William 1995 Development and Characeristics of Health and Nutition Services for Urban and Rural Communities of Costa Rica. In The Nutrition and Health Transition of Democratic Cost a Rica. Carlos Munoz and Nevin Scrimshaw, eds. Boston, MA: INFDC. Vecchiato, Norbert L. 1997 "Digestive Worms": Ethnomedical Appr oaches to Intestinal Parasitism in Southern Ethiopia. In The Anthropology of Infectious Disease: International Health Perspectives. Ma rcia C. Inhorn and Peter J. Brown, eds. Pp. 241-266. The Netherlands: Gordon and Breach Publishers.

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264 Wallerstein, I. 1974 The Modern World System: Capitalist Agriculture and the Origins of the European World Economy in the Sixteenth Century. New York: Academic. Waters, William F. 2001 Globalization, Socioeconomic Rest ructuring, and Community Health. Journal of Community Health 26:79-92. Weiss, William., P. Bolton, and A.V. Shankar 2000 Rapid Assessment Procedures (RAP): Addressing the Perceived Needs of Refugees & Internally Displaces Pe rsons Through Participatory Learning and Action. Pp. 1-25: Center for Ref ugee and Disaster Studies. The Johns Hopkins University School of Public Health. Whiteford, Linda, and Lenore Manderson, eds. 2000 Global Health Policy, Local Realitie s: The Fallacy of the Level Playing Field. Boulder: Lynne Rienner Publications. Whiteford, Linda, and Graham Tobin 2004 Chronic Hazards: Health Impacts Associated with On-Going Ash-Falls Around Mt. Tungurahua, Ecuador. Pa pers of the Applied Geography Conferences 27:84-93. Whiteford, Linda, and Scott Whiteford, eds. 2005a Globalization, Water and Health: Resource Management in Times of Scarcity. Santa Fe, NM: School of American Research Press. Whiteford, Linda M., and Beverly Hill 2005b The Political Ecology of Dengue in Cuba and the Dominican Republic. In Globalization, Health, and the Environment: an Integrated Perspective. G. Guest, ed. Pp. 219-239. Walnut Cree k, California: Altamira Press. Whiteford, Scott, and Alfonso Cortez-Lara 2005c Good to the Last Drop: The Politic al Ecology of Water and Health on the Border. In Globalization, Water and Hea lth: Resource Management in Times of Scarcity. Linda M. Whitefo rd and Scott Whiteford, eds. Santa Fe, NM: School of American Research Press.

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265 WHO, World Health Organization 2004 Globalization and Infectious Diseases : A Review of the Linkages. Geneva: Special Programme for Research and Training in Tropical Diseases (TDR). Wilk, R. R. 1991 Household Ecology: Economic Change and Domestic Life Among the Kekchi Maya in Belize. Tucson: University of Arizona Press. Wolf, Eric R. 1982 Europe and the People without Histor y. Berkeley: University of California Press. Woodward, David, Nick Drager, Robert Beaglehole, and Debra Lipson 2001 Globalization and Health: A Framew ork for Analysis and Action. Bulletin of the World Health Organization 79:875-881. Yach, Derek, and Douglas Bettcher 1998a The Globalization of Public He alth, I: Threats and Opportunities. American Journal of Pub lic Health 88(5):735-738. 1998b The Globalization of Public Health, II: The Convergence of Self-Interest and Altruism. American Journal of Public Health 88(5):738-741. 1999 Globalization of Tobacco Marketing, Research and Industry Influence: Perspectives, Trends and Impacts on Human Welfare. Development 42(2):25-30.

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266 Appendices

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267 Appendix A: Combined Informed Consent (Spanish) Documento de Consentimiento para Adultos y Padres Ciencias Sociales y del Comportamiento Universidad del Sur de la Flor ida y El Instituto Monteverde Informacin para adultos e hijos a quienes se les ha pedido tomar parte en un estudio de investigacin Los investigadores en la Universidad del Sur de la Florida (USF) estudiamos enfermedades y otros problemas relacionados con la salud. De esta forma, queremos encontrar las mejores formas de tratar estos problemas. Por ello, necesitamos la ayuda de gente que est de acuerdo en participar en estudios de investigacin. La siguiente informacin se le presenta para ayudarla a deci dir si quiere o no participar y que su hijo/a tome parte en un estudio de investigaci n de riesgo mnimo. Por favor, lea esta informacin cuidadosamente; si hay algo que no entienda, pregntele a la persona a cargo del estudio al respecto. Ttulo del estudio de investigacin: Estudio de Prevalencia de Parsitos Intestinales en Monteverde, Costa Rica. Persona a cargo del estudio: Jason Lind Sitio del estudio: Zona de Monteverde, Costa Rica Quin va a pagar por el estudio: USF Facultad de Salud Publica y Globalization Research Center Por qu se est llevando a cabo esta investigacin? El propsito de este estudio es saber que tan comunes son los parsitos intestinales en las personas y en las/os nias/os de la zona de Monteverde y hallar su origen y la ruta de transmisin. Este estudio tambin buscar co mpartir informacin y materiales educativos con las familias acerca de cmo prevenir la s infecciones de parsitos intestinales. Por qu se le ha pedido su participacin? Le hemos pedido que usted o miembros de su familia participe en este estudio porque vive en la zona de Monteverde y porque mu chas personas han expresado su preocupacin acerca de infecciones parasticas. Cunto tiempo se le pedir permanecer en el estudio? El estudio durar seis meses. En el transcur so de ese tiempo, se les pedir dos muestras de materia fecal a usted y a los miembros de su familia. Tambin se le pedir unas entrevistas para obtener informacin familiar e informacin relacionada con infecciones y su conocimiento que les haya ocurrido.

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268 Appendix A (Continued) Combined Informed Consent (Spanish) Plan de Estudio: El investigador visitar su hogar varias veces, con previo aviso. Puede ser que le pida una breve entrevista durante cad a visita. En la primera, el investigador le explicar el estudio y recoger informaci n bsica acerca de su hogar. Tambin el investigador le explicar cmo recolectar su muestra de materia fecal. Se le dar un frasquito y palillos para que r ecoja la muestra. El frasqu ito donde usted depositar la muestra est esterilizado. Uste d realizar este procedimient o en su propio tiempo. En la segunda visita, el investigador recoger los frasquitos con las muestras. Las muestras sern analizadas por el investigador principal. Si las muestras resultan positivas, sern confirmados por el Colegio de Microbiologa de la Universidad de Costa Rica. En la tercera visita, el investigador le dar los result ados del test. Si su resultado o el de alguno de los miembros de su familia es positivo, es posible que la persona sea entrevistada con ms detenimiento ese mismo da u otro que sea de su conveniencia. Finalmente, en caso de que haya miembros de su familia infectada con parsitos, el investigador visitar su hogar para brindarle informacin y educacin ace rca del origen, cmo se transmite y de cules medidas de prevencin puedan tomar. Este proceso ser repetido aproximadamente dos meses ms tarde. Si su infeccin o la de un miembro de su familia es de naturaleza seria, la informacin acerca de l estatus de la infeccin puede ser pasada a su mdico de la Clnica de Monteverde, c on su consentimiento para que tomen medidas apropiadas de tratamiento. Pago por su participacin No hay pago por su participacin. Su participac in es voluntaria y no se le pagar por el tiempo que usted de a este estudio. Beneficios por tomar parte en este estudio investigativo Al participar en este estudi o, usted contribuir a un mejo r entendimiento de cmo los parsitos intestinales afectan la salud de la s personas, tambin usted brindar informacin que permita prevenir esas infecciones en el futuro con respecto a su familia y a su comunidad. Riesgos relacionados con su participacin en este estudio Este estudio presenta riesgos mnimos para us tedes y/o sus hijos. Pueden haber preguntas en las entrevistas que le sean incmodas, si es as entonces est en libertad de no contestarlas. Asimismo, usted est en libertad de abandone este estudi o si as lo deseara. Confidencialidad de los archivos de su hijo/a Su privacidad y la de sus hijos/as, as co mo los archivos de la investigacin sern mantenidas en la ms estricta confidencialida d, segn lo exige la ley. Los archivos de este proyecto de investigacin pueden ser revisa dos por personal investigativo autorizado, empleados del Departamento de Salud y Recurs os Humanos y el Comit Institucional de tica de la Universidad del Sur de la Florida, pero ellos no tendrn acceso a los nombres

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269 Appendix A (Continued) Combined Informed Consent (Spanish) de las participantes. Los resultados generale s de este estudio podrn ser publicados. Los resultados publicados no incluirn sus nombr es ni cualquier tipo de informacin personal que los pueda identificar, se usar n cdigos para identificarlos. Se dejarn copias de toda la informacin y sus muestras en el Instituto Monteverde. Estos pueden ser vistos slo por el investigador principal y su mdico. Su participacin es voluntaria La decisin de que sus hijos/as participen en este estudio es completamente voluntaria. Asimismo, usted es libre de retirarse o retira rlos/las en el momento deseado. Si decide no participar o que sus hijos/as no participen o si se retira o los/la s retira durante el transcurso del estudio, no habr consecuenci a alguna por ello. Ustedes recibirn los beneficios establecidos previamente. Preguntas y contactos Si tiene alguna pregunta acerca de este estudio, por favor, comunquese con Jason Lind, Investigador Principal, al telf ono 645-5053 Extensin 120 en el Instituto Monteverde o en su casa al 645-6685. Si tiene preguntas acerca de sus dere chos como participante en un estudio investigativo, puede com unicarse con CEC-IRET de la Universidad Nacional Autnoma de Costa Rica al 277-3584 o 262-2073. Tambin se puede comunicarse con la Divi sin de Conformidad con la Ley de los Estudios Investigativos de la Universida d del Sur de la Florida, telfono (813) 974-5638. Consentimiento para participar en este estudio de investigacin Al firmar este formulario, estoy de acuerdo conque He ledo completamente o me han ledo y explicado este formulario de consentimiento. He tenido la oportunidad de hacerle pregunt as a uno/a de los responsables de esta investigacin y he recibido respuestas satisfactorias. Entiendo que se me ha pedido participar en esta investigacin. Comprendo los riesgos y beneficios que esto trae, y libremente doy mi consentimiento para participar en la investigacin que ha sido presentada en este formulario, bajo las condiciones indicadas en el mismo. Se me ha entregado una copia firmada de es te formulario de consentimiento para mi uso personal. Consentimiento para que su hijo/a pa rticipe en este estudio investigativo Libremente doy mi consentimiento para que mi hijo/a participe en este estudio. He recibido una copia de este fo rmulario de consentimiento.

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270 Appendix A (Continued) Combined Informed Consent (Spanish) ______________________ __________________________ _______________ Firma del participante/ Nombre del participante en le tra Fecha padre imprenta ______________________ _________________________ _______________ Firma del padre del nio/ Nombre del padre/participante Fecha participante en letra imprenta Declaracin del investigador Le he explicado cuidadosamente a la persona este documento. Por lo tanto, reconozco que a mi juicio la persona que firma este formulario de consentimiento comprende la naturaleza, exigencias, riesgos y bene ficios que este estudio incluye. ______________________ __________________________ _______________ Firma del investigador Nombre del investigador en Fecha o persona autorizada letra imprenta por el investigador principal

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Ap p p endix B: I n n structions 271 for Collect i i n g Fecal S p p ecimens ( E E n g lish)

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272 Appendix C: Costa Rican Household Demographic Interview (Spanish) Cdigo del Hogar: _____________ Comunidad: ______________________________ Persona a Cargo: _______________________ Persona Entrevistado: ___________________ Fecha: __________ Hora Em pezado: __________ Hora Terminado: __________ Hogar: La vivienda donde usted habita actualmente es: Por tipo: a. Individual _____ b. Colectiva _____ b1. Nmero de familias _____ b2. O personas sin vnculo familiar que reside ______ Por su forma de tenencia: c. Propia ya pagada _____ d. Propia con hipoteca _____ e. Alquilada viviendo slo con familiares _____ f. Alquilada compartida con no familiares _____ g. En precario _____ h. Otra (prestada, cedida) ____________________________________________ El dueo es. . a. Costarricense residente de la zona de Monte Verde [1] b. Costarricense no residente de la zona de Monte Verde [2] c. Extranjero residente de la zona de Monte Verde [3] d. Extranjero residente de Costa [4] e. Extranjero no residente de Costa Rica [5] f. Otro [0] ___________________________________________________________ Indicar el nmero total de personas residentes en la vivienda ______, cuntas de ellas son familiares _____, as como el nmero total de aposentos en la vivienda _____, y el nmero de ellos que se utiliza slo para dormir _____. Todos los residentes de esta casa viven aqu por todo el ao?: S [1] No [2] Si no, cuantos residentes de la casa no viven aqu todo el ao?: 1 [1] 2 [2] 3 [3] 4 [4] 5 [5] Durante cuales partes del ao no viven aqu?:__________ ______________________________________ Las personas que no residen aqu todo el ao, en qu otra parte residen?: ___________________________ ______________________________________________________________________________________ Por qu residen algunos en dos o ms lugares?: Trabajo [1] Pasatiempo [2] Otro [0] _____________________ Ha vivido en la zona Monteverde de sde su nacimiento?: S [1] No [2]

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273 Appendix C (Continued) Costa Rican Household Demographic Interview (Spanish) Si no, cul fue la ltima comunidad/pas en que Ud. vivi?: _____________________________________ ______________________________________________________________________________________ En qu ao llego? Historia: _______________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Por qu decidi venir a esta comunidad en particular?: Trabajo [1] Visit y qued [2] Familia [3] Amigos [4] Otro [0] _________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Perfil socio-laboral: Desde el punto de vista laboral, actualmente est: Ocupado _____ Desocupado, buscando trabajo _____ ---pase a la pregunta 10. Dedicado a actividades no laborales (inactivo) _____ --pase a 10. Ocupacin que desempea el trabajador principal: _____________________________________________ Actividad de la empresa o lugar donde trabaja: ________________________________________________ El nmero total de horas que trabaja por semana es: ____________________________________________ El salario o ganancia (monto en colones) que recibe es: a. por semana __________ b. por quincena __________ c. por mes __________ Tiene otras fuentes de ingresos? (periodicidad) ______________________________________________________________________________________ ______________________________________________________________________________________ Cmo ganan la vida los residentes de su casa? Cdigo Trabajo Sitio de trabajo Salario por empleo especfico (por mes) Variacin estacional del empleo Esta Asegurado por el INS o CCSS 1. 2. 1. 2. 1. 2. 1. 2. 1. 2.

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274 Appendix C (Continued) Costa Rican Household Demographic Interview (Spanish) Durante el ltimo ao, alguien en la casa ha estado desempleado? S: _____ No: _____ Cdigo Cundo? Por Cunto Tiempo? Razones Hace cinco aos, a que actividades econmicas principales se dedica ba su familia: _________ ___________ ______________________________________________________________________________________ ______________________________________________________________________________________ Acceso a Servicios Comunitarios: Hay personas en la casa que no tienen seguro por el INS o la CAJA? -Si -No Quin? _______________________________________________________________________________ Por qu no estn asegurados? _____________________________________________________________ ______________________________________________________________________________________ Cunto tiempo han estado sin seguro? ______________________________________________________ ______________________________________________________________________________________ Cmo les afecta? _______________________________________________________________________ ______________________________________________________________________________________ Cmo clasificara los servicios de salud en la comunidad? ___________________________________ ______________________________________________________________________________________ Cosas positivas: ________________________________________________________________________ ______________________________________________________________________________________ Cosas Negativas: ________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Experiencias: ___________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Ud. o alguien de su familia est involucr ada o participa en algn servicio pblico?: Agua [1] Transporte [2] Electricidad [3] Salud [4] Aguas residuales [5] Caminos [6] Educacin [7] Recolecci n de basura [8] Reciclaje [9] Qu tipo de transporte tiene acceso Ud.? Caminar [1] Motocicleta [2] Taxi [3] Carro/Jeep [4]

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275 Appendix C (Continued) Costa Rican Household Demographic Interview (Spanish) De las instituciones costarricenses con las que ha tenido contacto o de las que tiene referencias… Cul le tiene mejor confianza y credibilidad? _________________________________________________ ______________________________________________________________________________________ Cul no le tiene confianza? _______________________________________________________________ ______________________________________________________________________________________ Qu tipo de apoyo o servicios le gustara recibir o ver para mejorar su situacin actual? a. Crdito: _____ b. Capacitacin para el trabajo: _____ c. Vivienda: _____ d. Salud: _____ e. Seguro social: _____ f. Asesora legal: _____ g. Orientacin religiosa: _____ h. Otra: ___________________________________________________________ Percepciones del Turismo: Qu es su opinin en general sobre cmo el turismo afecta la zona de Monte Verde?: Muy positivo [1] Algo positivo [2] Neutral [3] Algo negativo [4] Muy negativo [5] No se [6] No responde [00] ______________________________________________________________________________________ ______________________________________________________________________________________ Qu beneficios (si hay) ha trado el turismo a su familia ?: Empleo de tiempo completo [1] Empleo temporal [2] Empleo de tiempo parcial [3] Vivienda [4] Entretenimiento [5] Educacin/Escuelas [6] Oportunidades para compras [7] ______________________________________________________________________________________ ______________________________________________________________________________________ Qu han sido los efectos positivos del turismo en esta rea?:_____________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Qu han sido los efectos negativos del turismo en esta rea?:___________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

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276 Appendix D: Nicaraguan Household Demographic Interview (Spanish) Cdigo del Hogar: _____________ Comunidad: _______________________________ Nombre de Persona a Cargo: _______________________________________________ Nombre del Entrevistado: __________________________________________________ Fecha: __________ Hora Em pezado: __________ Hora Terminado: __________ Hogar: Cdigo y Lugar de Nacimiento de los miembros de la casa: C"DIGO LUGAR DE NACIMIENTO 4. La vivienda donde usted habita actualmente es: Por tipo: a. Individual _____ b. Colectiva _____ c. Propia ya pagada _____ d. Propia con hipoteca _____ e. Alquilada viviendo slo con familiares _____ f. Alquilada compartida con no familiares _____ g. En precario _____ h. Otra (prestada, cedida) ____________________________________________ El dueo es. .__________________________________________________________________________ Indicar el nmero total de personas residentes en la vivienda ______, cuntas de ellas son familiares _____, as como el nmero total de aposentos en la vivienda _____, y el nmero de ellos que se utiliza slo para dormir _____. Todos los residentes de esta casa viven aqu por todo el ao?: S [1] No [2] Si no, cuantos residentes de la casa no viven aqu todo el ao?: __________________________________ Durante cuales partes del ao?: ____________________________________________________________ Las personas que no residen aqu todo el ao, en qu otra parte residen?: ___________________________ ______________________________________________________________________________________ Por qu residen algunos en dos o ms lugares?: Trabajo [1] Pasatiempo [2] Otro [0]

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277 Appendix D (Continued) Nicaraguan Household Demogr aphic Interview (Spanish) Perfil socio-laboral: Desde el punto de vista laboral, actualmente est: Ocupado _____ Desocupado, buscando trabajo _____ ---pase a la pregunta 10. Dedicado a actividades no laborales (inactivo) _____ --pase a 10. Ocupacin que desempea el trabajador principal: _____________________________________________ Actividad de la empresa o lugar donde trabaja: ________________________________________________ El nmero total de horas que trabaja por semana es: _____ El salario o ganancia (monto en colones) que recibe es: a. por semana __________ b. por quincena __________ c. por mes __________ Indicar si tiene otras fuentes de ingresos (periodicidad) ______________________________________________________________________________________ ______________________________________________________________________________________ Cmo ganan la vida los residentes de su casa? Cdigo Trabajo Sitio de trabajo Salario por empleo especfico (por mes) Variacin estacional del empleo Estaba Asegurado por el INS o CCSS 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. 1. 2. Durante el ltimo ao, alguien en la casa ha estado desempleado? S: _____ No: _____ Cdigo Cundo? Por Cunto Tiempo? Razones

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278 Appendix D (Continued) Nicaraguan Household Demogr aphic Interview (Spanish) Hace cinco aos, a que actividades econmicas principales se dedica ba su familia: _________ ___________ ______________________________________________________________________________________ ______________________________________________________________________________________ Acceso a Servicios Comunitarios: Hay personas en la casa que no tienen seguro por el INS o la CAJA? -Si -No Quin? _______________________________________________________________________________ Por qu no estn asegurados? _____________________________________________________________ ______________________________________________________________________________________ Cunto tiempo han estado sin seguro? ______________________________________________________ ______________________________________________________________________________________ Cmo les afecta? _______________________________________________________________________ ______________________________________________________________________________________ Cmo clasificara los servicios de salud en la comunidad? ___________________________________ ______________________________________________________________________________________ Cosas positivas: ________________________________________________________________________ ______________________________________________________________________________________ Cosas Negativas: ________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Experiencias: ___________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Ud. o alguien de su familia est involucr ada o participa en algn servicio pblico?: Agua [1] Transporte [2] Electricidad [3] Salud [4] Aguas residuales [5] Caminos [6] Educacin [7] Recolecci n de basura [8] Reciclaje [9] Qu tipo de transporte tiene acceso Ud.? Caminar [1] Motocicleta [2] Taxi [3] Carro/Jeep [4] Caballo [5] Bus [6] Bici cleta [7] Cuadriciclo [10] Cuantos de cada uno tiene? _______________________________________________________________ De las instituciones costarricenses con las que ha tenido contacto o de las que tiene referencias… Cul le tiene mejor confianza y credibilidad? _________________________________________________ ______________________________________________________________________________________ Cul no le tiene confianza? _______________________________________________________________

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279 Appendix D (Continued) Nicaraguan Household Demogr aphic Interview (Spanish) Qu tipo de apoyo o servicios le gustara recibir o ver para mejorar su situacin actual? a. Crdito: _____ b. Capacitacin para el trabajo: _____ c. Vivienda: _____ d. Salud: _____ e. Seguro social: _____ f. Asesora legal: _____ g. Orientacin religiosa: _____ h. Otra: ___________________________________________________________ Percepciones del Turismo: Qu es su opinin en general sobre cmo el turismo afecta la zona de Monte Verde?: Muy positivo [1] Algo positivo [2] Neutral [3] Algo negativo [4] Muy negativo [5] No se [6] No responde [00] ______________________________________________________________________________________ ______________________________________________________________________________________ Qu beneficios (si hay) ha trado el turismo a su familia ?: Empleo de tiempo completo [1] Empleo temporal [2] Empleo de tiempo parcial [3] Vivienda [4] Entretenimiento [5] Educacin/Escuelas [6] Oportunidades para compras [7] ______________________________________________________________________________________ ______________________________________________________________________________________ Qu han sido los efectos positivos del turismo en esta rea?:_____________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Qu han sido los efectos negativos del turismo en esta rea?:___________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Sobre la Migracin a Costa Rica y a Monteverde: Cundo fue la primera vez que vino a Costa Rica a trabajar-buscar trabajo, de qu parte de Nicaragua vino, y dnde se qued residiendo? a. Mes y ao: __________ b. Lugar de residencia en Nicaragua: __________ c. Lugar de residencia inicial en Costa Rica: __________ Por qu motivo o motivos principales se vino para Costa Rica? __________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ La primera vez que vino a Costa Rica, lo hizo: (solo, con familia) _________________________________ ______________________________________________________________________________________

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280 Appendix D (Continued) Nicaraguan Household Demogr aphic Interview (Spanish) Estaba asegurado? Si: _____ No: _____ Desde esa fecha hasta ahora: Cuntas veces ha re gresado a Nicaragua, y cunto tiempo ha permanecido all (en promedio por vez)? a. Nmero de veces: __________ b. Estada promedio: __________ En qu mes y ao se traslad a Monteverde para establecer residencia o trabajar? a. Mes y Ao: __________ Por qu motivo o motivos se vino para Monteverde? a. Trabajo: _____ b. Reunificacin Familiar: _____ c. Otro: ___________________________________________________________ La primera vez que vino a Monteverde, lo hizo: (solo, con familia) ________________________________ ______________________________________________________________________________________ En que trabaj cuando lleg a Monteverde por primera vez? ____________________________________ ______________________________________________________________________________________ Estaba asegurado? Yes: _____ No: _____ Estructura Familiar y Remesas: Detalle cules familiares dependen econmicamente de usted. Incluya tanto a quienes residen en Costa Rica como a quienes viven en Nicaragua u orto pas. Cdigo Pas de residencia Si reside en CR Naci en CR Ao de ingreso Enva usted o su familia ayudas econmic as (remesas) a familiares en Nicaragua? a. S: _____ b. No: _____ ---pase a la pregunta Cul fue el monto (en dlares) de la ltima ayuda en dinero enviada? ____________ Cul es el monto promedio enviada por mes? __________ Cada cunto tiempo enva dinero a Nicaragua (del ltimo ao)? __________________________________

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281 Appendix D (Continued) Nicaraguan Household Demogr aphic Interview (Spanish) Cul es el principal uso que tiene esa ayuda econmica para sus familiares? ________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Cul es la forma “principal” que utiliza para enviar dinero? (Empresa remesadora, personal): __________ ______________________________________________________________________________________ ______________________________________________________________________________________ Ha enviado otro tipo de ayuda que no sea dinero? -Si -No -Que cosa: ___________________ ______________________________________________________________________________________ Percepciones del Estatus Social: Si usted compara su situacin actual con la que tena en Nicaragua anteriormente, piensa que: __________ ______________________________________________________________________________________ Ha sentido usted un trato diferente a los costarricenses en el mbito del: Trabajo: _______________________________________________________________________________ ______________________________________________________________________________________ Salarios: ______________________________________________________________________________ ______________________________________________________________________________________ Servicios: _____________________________________________________________________________ ______________________________________________________________________________________ Siente usted que la sociedad tica respeta las tradic iones, costumbres y prcticas culturales del pueblo Nicaragense? -S -No: por qu? _________________________________________________ Piensa permanecer en Costa Rica? S: ____ No: _____

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282 Appendix E: Household Water Man agement Interview (Spanish) Cdigo del Hogar: _____________ Comunidad: ______________________________ Nombre de Persona a Cargo: ______________________________________________ Nombre del Entrevistado: _________________________________________________ Fecha: __________ Hora Em pezado: __________ Hora Terminado: __________ Servicio de Agua: Cul es la fuente de su agua?: Manantial [1] Ro [2] No s [3] Otro [0] _________________________________________________________ Qu tipo de sistema de agua tiene?: Acueducto (pblico) [1] Sistema privada (grupo) [2] Sistema privada (individual) [3] No se [4] Otro [0] __________________________________________________________ Cmo clasificara Ud. su suministro de agua?: Malo [1] Satisfactorio [2] Excelente [3] Quin es responsable por la reserva de agua y su mantenimiento en su comunidad? __________________ Cunto paga por promedio por mes para el agua que consuma su familia? __________________________ En su opinin el monto mensual que paga para agua es: Poco [1] Razonable [2] Mucho [3] No hay costo (privado) [4] Calidad del Agua: Cmo es el agua que Ud. usa/o de su casa? Descrbala. _________________________________________ Qu es agua potable? ___________________________________________________________________ Cree que el agua de esta comunidad es buena y segura para consumirla? ___________________________ ______________________________________________________________________________________ Hay veces cuando recibe agua de mala calidad?: Nunca [1] A veces [2] Frecuentemente [3] Explique.______________________________________________ b) Si recibe agua de mala calidad, la trata con cloro o la hierve en la casa? Qu Hace?: Nunca [1] A veces [2] Frecuentemente [3] Explique. ______________________________________________ Ud. toma el agua de la llave?: Si [1] No [2] No s [3] En su opinin, cul es la diferencia entre agua de buena calidad y agua de mala calidad? Agua de buena calidad: _______________________________________________________________

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283 Appendix E (Continued) Household Water Management Interview (Spanish) Agua de mala calidad: ________________________________________________________________ ______________________________________________________________________________________ Qu hace al agua insegura para….? Beber: ____________________________________________________________________________ Cocinar: __________________________________________________________________________ Lavar: ____________________________________________________________________________ Mencione algunas cosas que pueden afectar la calidad de su agua potable.___________________________ ______________________________________________________________________________________ En el futuro, Piensa que habrn riesgos potenciales para la reserva de agua de la comunidad? Enumere – Explique. ______________________________________________________________________________ ______________________________________________________________________________________ Se ha contaminado la reserva de agua de la comunidad alguna vez? Pregnteles cundo, cmo, qu ocurri y qu se hizo al respecto? ___________________________________________________________ ______________________________________________________________________________________ Cantidad de Agua: Ha tenido escasez de agua o le han cortado el agua? a. Cuando: ______________________________________________________________________ b. Por cunto tiempo: _____________________________________________________________ c. Qu pas, cmo y porqu ocurri: _________________________________________________ d. Cree que puede pasar de nuevo: ___________________________________________________ Ud. guarda agua en su casa?: S [1] No [2] Cuales son algunas razones de que pasa la escasez o que hay cortes de agua? Avisan? ______________________________________________________________________________________ ______________________________________________________________________________________ Cules factores contribuyen a la escasez o cortes de agua? (Como malas tuberas, conexiones). ______________________________________________________________________________________ Hay algunas personas en la comunidad qu e tienen mejor acceso al agua que otras? Hay algunas personas en la co munidad que usan demasiada agua? a) Quines? b) Por qu? Cules son las consecuencias de esto? Caractersticas del Manejo de Aguas Grises: Adnde van sus aguas grises?: al desage [1] la calle [2] la quebrada [3] al suelo [4] No s [5]

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284 Appendix E (Continued) Household Water Management Interview (Spanish) A veces tiene problemas con su sistema de aguas grises?: Nunca [1] A veces [2] No s [3] Frecuentemente [4] Explique. ______________________________________________ Cree usted que es necesario que haya un servicio de aguas residuales?: S [1] No [2] No s [3] Causan las aguas grises problemas para la comunidad? (En trminos de salud o medio ambiente). ______________________________________________________________________________________ ______________________________________________________________________________________ Pida a la persona que le muestre cmo funciona el sistema de aguas grises. a. Cmo funciona: _______________________________________________________________________ b. Tiene que hacerle mantenimiento: _______________ _______________ _______________ ___________ c. Cmo le hace. ________________________________________________________________________ d. Quin le hace: ________________________________________________________________________ f. Pregunta de qu cosas van o que son eliminadas en las aguas grises: _____________________________ Caractersticas del manejo del tanque sptico: Tiene tanque sptico? Si No Otro: _____________________________________________ Qu hace cuando su tanque sptico est lleno?: Lo vacan con bomba [1] Lo vaciamos nosotros mismos [2] Instalamos otro tanque[3] No s [4] Otro [0] ___________________________________________________________ a. Si es as, con que regularidad: ____________________________________________________________ b. Quin lo hace: ________________________________________________________________________ c. Cunto cuesta hacerlo: _________________________________________________________________ Cuntos servicios sanitarios hay en la casa/edificio?: 1 [1] 2 [2] 3 [3] ms [4] Qu tipo de servicio sanitario tiene?: Inodoro con agua [1] Letrina [2] De compost [3] Mezclado [4] _____ _______________ ____________ ____________ __________ Qu hace con su papel higinico? __________________________________________________________ Qu si los tanques spticos son mejores con lo que tenan antes? (bao de hueco, madera) ______________________________________________________________________________________ ______________________________________________________________________________________ Ud. tiene preocupaciones sobre la salud de su familia relacionada a su suministro de agua o sus sistemas de saneamiento?: ______________________________________________________________________________________

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285 Appendix F: Semi-Structured Intervie w Guide Parasite Perceptions and Knowledge (Spanish) Cdigo #____________________ Comunidad: _______________________________ Entrevistador:________________________ Entrevistado/a: ______________________ Persona a Cargo:_________________________________________________________ Fecha y Hora de la Entrevista:_______________________________________________ PREGUNTAS BASICAS SOBR E LOS PARASITOS – TRAN SMISION Y PREVENCION Hbleme de lo que sabe sobre los parsitos. Qu son? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________ De dnde vienen? O Qu causa tener parsitos? Por qu uno se tiene parsitos? Si sabe si vienen del agua, comida, animales, la tierra, o la suciedad? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________ Cmo se agarran los parsitos? Cmo nos dan parsitos? ______________________________________________________________________________________ __________________________________________________________ Cmo se sabe si uno tiene parsitos? ______________________________________________________________________________________ __________________________________________________________ A Quines tienen/o les dan ms parsitos? (nios, adolescentes, adultos, o ancianos) ______________________________________________________________________________________ __________________________________________________________ Las personas tienen ms parsitos en cier tas pocas del ao? ______________________________________________________________________________________ __________________________________________________________ Qu hara o que podra hacer para sacarse/qui tar los parsitos del cuerpo? Incluye remedios caseros, clnica, medicinas. ______________________________________________________________________________________ ______________________________________________________________________________________ ____________________________________________ Qu se puede hacer para prevenir/e vitar las infecciones con parsitos? ______________________________________________________________________________________ ______________________________________________________________________________________ ____________________________________________ Sabe qu son las Amebas o los Lombrices?_________________________________________________

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286 Appendix F (Continued) Semi-Structured Interview Guide: Parasi te Perceptions and Knowledge (Spanish) Cules enfermedades/o males son causad os/o le dan uno por parsitos? a. ______________________________________________________________________ b. ______________________________________________________________________ c. ______________________________________________________________________ Sntomas conocidas: Qu la da a una persona cuando tiene parsitos? a. ______________________________________________________________________ b. ______________________________________________________________________ c. ______________________________________________________________________ Es una enfermedad seria? Cmo lo sabe? a. ______________________________________________________________________ b. ______________________________________________________________________ c. ______________________________________________________________________ Qu hara o que podra hacer para tratarla/Curar se? Incluye remedios caseros, clnica, medicinas. a. ______________________________________________________________________ b. ______________________________________________________________________ c. ______________________________________________________________________ PREGUNTAS ACERCA DE LOS PARSITOS EN LA COMUNIDAD: Son los parsitos comunes en esta comunidad? Es comn tener parsitos por ac? _____ Si _____ No _____ N/S Otro _______________________________ Cules son los ms comunes? ________________________________________________________________________ En cul temporada? ________________________________________________________________________ A Quines las da ms parsitos? ________________________________________________________________________ Cmo se curan las personas de los parsitos? Cmo se los sacan? ________________________________________________________________________ Qu hacen para evitar los parsitos? Qu hacen la Clnica o las Escuelas? ________________________________________________________________________

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287 Appendix F (Continued) Semi-Structured Interview Guide: Parasi te Perceptions and Knowledge (Spanish) PREGUNTAS DE LA HISTORIA FAMILIAR SOBRE LA MORBIDIDAD CON PARASITOS: Historia de Morbilidad de Infeccion es con Parsitos dentro del Hogar. En los ltimos 6 meses (o si no, cuando sea) quien/quienes han tenido problemas del estomago, diarrea, o parsitos. Quien Enfer medad Causa Sntomas Duracin Tratamiento Quien decidi como tratarla Prevencin PREGUNTAS PARA VERIFICAR EL CONOCIMEINTO: Podemos agarrar parsitos por el agua? _____ Si _____ No _____ N/S Explique: _________________________________________________ Podemos agarrar parsito s cuando hay poco agua o cuando la corten? _____ Si _____ No _____ N/S Explique: _________________________________________________ Se puede agarrar parsito s por los alimentos? _____ Si _____ No _____ N/S Explique: _________________________________________________ Se puede agarrar parsitos por los animales o por tocarlos? _____ Si _____ No _____ N/S Explique: ________________________________________________ Se puede agarrar parsitos por la suciedad o la mala higiene? _____ Si _____ No _____ N/S Explique: ________________________________________________ Se puede agarrar parsitos por las heces o caca de otra persona? _____ Si _____ No _____ N/S Explique: _________________________________________________ Se puede agarrar parsi tos por los insectos? _____ Si _____ No _____ N/S Explique: _________________________________________________

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288 Appendix F (Continued) Semi-Structured Interview Guide: Parasi te Perceptions and Knowledge (Spanish) PREGUNTAS SOBRE EL USO DE MEDICAMIENTOS CONTRA LOS PARASITOS: Hay alguien que est toma ndo medicina o remedios contra parsitos en este hogar? Quin? ________________________________________________________________ Cul Medicina Tom? ____________________________________________________ Dnde lo Consigui? _____________________________________________________ Cunto Cost? __________________________________________________________ Resultados? ____________________________________________________________ Hay alguien que est tomando un purgante o anticido en este hogar? Quin? ________________________________________________________________ Cul Medicina Tom? ____________________________________________________ Dnde lo Consigui? _____________________________________________________ Cunto Cost? __________________________________________________________ Resultados? ____________________________________________________________ Hay alguien que haya tomado algo contra los parsitos durante los ltimas dos meses en este hogar? Quin? ________________________________________________________________ Entre Cules Fechas? _____________________________________________________ Cul Medicina Tom? ____________________________________________________ Dnde lo Consigui? _____________________________________________________ Cunto Cost? __________________________________________________________ Resultados? ____________________________________________________________ Cundo fue la ltima vez que alguien tom algo contra los parsitos en este hogar? Quin? ________________________________________________________________ Entre Cules Fechas? _____________________________________________________ Cul Medicina Tom? ____________________________________________________ Dnde lo Consigui? _____________________________________________________ Cunto Cost? __________________________________________________________ Resultados? ____________________________________________________________

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A P P J a U F I n Q C Q C 1 4 7 9 Appen d A CERCA DE L OR UNA VI D RACTIQUE L a son Lind U niversidad d e acultad de Sa n vesti g acin d Q UE SON L O C OMO ING R Q UE DAO S C UALES SO N Estma g o in f Falta de ape t Sueo. Comezn en d ix G: Para s L OS PARAS I D A SALUDA B L A BUENA H e l Sur de la Fl o lud Pblica d e Enfermeda d O S PARASIT O So n viv e hu m inf e po r pre R ESAN A NU E 1. L a b c 2. T pis a 3. C fec a ali m S PRODUCE N 1. P 2. I co n 3. 4. I N LOS SINT O f lado. t ito. el ano. s ite Educat i I TOS B LE PARA U S H IGIENE Y P o rida d es Parasitar i O S? n or g anismos m e n en los intes m ano. Vienen e ctadas. Estas r razones de f a vencin; E STRO CUE R L os parsitos a Al tocar ali m b Al comer a e c Al tomar a gu T ambin in g r e a mos heces h u C uando las m o a l humana o a m entos que to N LOS PARA S P ueden prod u I mpiden que n n sumimos lo q Retardo en el I ncapacidad p O MAS DEL C 2. Mare o 5. Dolo r 8. Cans a 10. Dia r 289 i on Handou S TED Y PA R P REVENGA L i as Intestinale m icroscpico s tinos donde s e de las heces d heces puede n a lta de hi g ien e R PO? entran por n u m entos para c e lementos co m u a contamin a e san a nuestr o u manas o de a o scas, cucara c a nimal y la tr a quen. S ITOS? u cir enfermed a n uestro cuerp o q ue conlleva a crecimiento y p ara aprende r C ONTAGIO C o s. r de estma g o a ncio y falta d r rea. t for Stud y R A SUS HIJO S L OS PARASI T s s al g unos no s e aprovechan d e personas o a n contaminar a e Ten g a en c u u estra boca: omer o cocin a m o las verdur a a da. d. Al com o cuerpo cua n a nimales. c has, ratones u a en en sus pa t a des g raves c o o aproveche b desnutricin. y desarrollo. r C ON PARAS I 3. Nuse a 6. Dolor d d e fuerzas. Participan t S T OS s e pueden ver de los nutrie n a nimales que ag ua, tierra, o u enta lo si g uie n a r con las ma n a s y frutas m a er carnes cru d n do caminam o u otros anim a t as a las casas o mo la anemi a b ien los alime n I TOS? a y vmito. d e cabeza. t s (Spanish ) a simple vist a n tes del cuerp o estn y a o b j etos y alim e n te para su n os y uas su c a l lavados o s u d as o mal coc i o s descalzos y a les pisan mat e contaminan d a n tos que ) a que o e ntos c ias u cios i das. e ria d o los

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290 Appendix G (Continued) Parasite Education Handout for Study Participants (Spanish) COMO PODEMOS EVITAR LOS PARASITOS? PRACTIQUE LA HIGIENE PERSONAL La 1. Lvese las manos con agua y jabn: a. Antes y despus de preparar la comida. b. Antes de comer. c. Despus de usar el servicio sanitario o la letrina y despus de lavar o cambiar un paal. d. Despus del trabajo en el campo en la tierra o con los animales. e. Crtese las uas cada semana. f. Bese todos los das. g. Ande calzado, con chanclet as o zapatos todo el tiempo. h. Use siempre la letrina o el servicio sanitario. i. No haga deposicin al aire libre. j. La letrina o servicio debe estar siempre limpia y tapada. Los papeles se deben tirar en un basurero. Nunca se de ben tirar en el rea del agua del consumo del hogar. j. Limpiarse bien con papel higinico. k. Tenga mucho cuidado cuando recoja el papel higinico para botarlo. Para lavarse las manos: a. Use jabn y agua. b. Frtese las manos tantas veces como sea posible. c. Abra la llave de la pila con la mano que no haya empleado para limpiarse, para que los microbios de la mano sucia no contaminen la llave y se propaguen los parsitos a otras personas. d. Use un trapo limpio despus de lava das o dejarlas secar al aire (no use su ropa para secarlas). AGUA SEGURA Es importante proteger el ag ua de la contaminacin: 1. Utilice agua segura, del tubo, clorada o potable 2. Hierva el agua para beber, cocinar y lavar los alimentos, si no es potable porque aunque se vea limpia y clara puede tener microbios. 3. Mantenga la limpieza del agua. 4. Si recoge y guarda ag ua, hgalo en recipientes limpios y bien tapados 5. Si sospecha que no es segura, la puede purificar hirvindola por dos minutos o agregndole una cantidad muy pequea de cloro. Por cada litro de agua agregue dos gotas de cloro. Utilice esta agua para beber o lavar las frutas y verduras que se van a comer crudos. *Recuerde tambin que el cloro NO mata toda clase de parsitos. *Deje correr el agua por unos minutos antes de usarla despus de que la hayan cortado.

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H Q C S i m P H IGIENE CO N Q UE HACE R C onsulte a su m i y a sabe que t m edicamento a P arasite Ed u N LOS ALIM a. L b. S en u mo s est c. S st e ant e d. C R SI SOSPEC H m dico de in m t iene parsito a decuado. App e u cation Ha n ENTOS: L ave bien los a S i los aliment o u n lu g ar fres c s cas u otros i n n contamina d S i un alimento e y a contiene m e s de comerlo C omer carne b H A QUE TIE N m ediato para q s consulte co n 291 e ndix G (C o n dout for S t a limentos, las o s no se van a c o y ventilado. n sectos se par e d as con micro se g uarda po r m icrobios; po r especialmen t b ien cocida. N E PARASI T q ue le ha g an u n su mdico o f o ntinued) t ud y Partic i frutas y las v e comer inmed i Si tapamos l o e n en ellos y a bios. r ms de cuat r r lo tanto, el a t e si se le va a T OS? n examen de m f armaceuta p a i pants (Spa n e rduras con a g i atamente, t p o s alimentos, e que las patas r o horas desp a limento debe dar a un ni o m ateria fecal. a ra que le re c n ish) g ua se g ura. p elos y mant n e vitaremos q u de los insecto s us de prepa r hervirse de n u o menor de 2 a c eten el ng alos u e las s r ado, u evo a os.

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About the Author Jason D. Lind grew up in Little Falls, Minnesota and attend ed Minnesota State University – Mankato where he earned a Bachelor’s Degree in Spanish and Latin American Studies in 1996. After graduati on, Mr. Lind traveled extensively throughout Latin America and later worked as a fiel d anthropologist for a CDC funded program aimed at reducing childhood diarrhea through the implementation of a community-based clean water project in Eastern Bolivia. Upon returning to the U.S., Mr. Lind completed a Master’s Degree in Anthropology from Minneso ta State University – Mankato in 2000. While in the Ph.D. program in Applied Anthropology and the M.P.H. program in Global Communicable Diseases at the University of South Florida, Mr. Lind worked as a Graduate Research Assistant for the U SF-Globalization Research Center. After completing his dissertation research in M onteverde, Costa Rica, Mr. Lind moved to Bucaramanga, Colombia, South America, where he collaborated on several communitybased health projects and worked as an Assi stant Professor at the Universidad Industrial de Santander teaching classe s in educational research. Upon returning to the U.S., Mr. Lind wa s a Research Associate at the Florida Prevention Research Center at University of South Florida where he collaborated on the Partnership for Citrus Worker Health; a comm unity based social marketing project that focused on reducing eye injuries among Mexican citrus pickers in Fl orida. Currently, Mr. Lind is employed at the James A. Haley VA Medical Center, HSR& D/RR&D Center of Excellence in Tampa, FL where he work s as a qualitative health researcher.


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The political ecology of intestinal parasites among Nicaraguan immigrants in Monteverde, Costa Rica
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ABSTRACT: Over the past 15 years Monteverde, Costa Rica has undergone rapid economic, social, political, and environmental change due to a flourishing ecotourism economy. While the effects of ecotourism development in Monteverde are many, two important consequences have been: 1) the immigration of Nicaraguan nationals to the area seeking low-skilled wage labor; and 2) compromised water resources management due to pollution and rapid population growth. The objective of this research is to investigate and identify the inter-relationships between ecotourism development in Monteverde and its affect on infectious diseases outcomes within the context of immigration and water resources management. Specifically, this dissertation uses both anthropological and public health methods within a political ecology of health framework to compare prevalence rates of intestinal parasites between Nicaraguan immigrants and Costa Rican residents living in Monteverde. Results indicate that Nicaraguan immigrants suffer disproportionately from infections with intestinal parasites compared to Costa Rican residents. The results further indicate that community based water resources are not a significant source of infection. Instead, the prevalence of intestinal parasites is most likely the result of fecal-oral transmission at the household level and is related to indicators such as access to health care, underemployment, home ownership, and household sanitation infrastructure.
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Advisor: Linda M. Whiteford, Ph.D.
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