De La Salle Health Sciences Institute- College of Medicine Department of Family and Community Medicine

Comparison of Malnutrition among Institutionalized and Non-Institutionalized Children in Paco, Manila as determined by Body Mass Index

Research Protocol 2nd year, Sec. B, Group 15

Matel, Ma. Carolina Nazareno, Christine Panghulan, Aldee Ray Parao, Angelo Reyes, Kevin Sampelo, Ma. Carmela Tee, Jan Raemon

Preceptor: Josephine M. Carnate M.D., MPH November 8, 2011 1

INTRODUCTION

Research Question Is the prevalence of malnutrition generally higher in institutionalized children in orphanages compared to non-institutionalized children in Paco, Manila during the year 2011

Research Hypothesis The prevalence of malnutrition is generally higher in institutionalized children compared to non-institutionalized children. There is a direct relationship between the childrens environment (socio-economic and demographic factors such as location and condition of household, presence or absence of biological parents) and their nutrition status.

Background of the Study Malnutrition has long been recognized as a consequence of poverty. It is widely accepted that higher rates of malnutrition will be found in areas with chronic widespread poverty [1]. Malnutrition is believed to be caused by marginal dietary intake, combined with infection. In turn, malnutrition is an interplay of household food insecurity, lack of clean water, lack of knowledge on good sanitation, and lack of alternative sources of income. It is also compounded by inadequate care, gender inequality, poor health services, and poor environment. Measures of child nutritional status can help capture certain aspects of welfare, such as distribution within the household which are not adequately reflected in other indicators. Child malnutrition standards are applicable

across cultures and ethnicities. Studies have proven that the relationship between child nutritional status and poverty is more evident at the lower bracket of the income range [2]. Based on the study of the International Food Policy Research Institute, there are exactly fours strong determinants to malnutrition in 63 developing countries. The four, ranked by their strength of impact, are women's education, national food availability, womens status relative to men's, and health environment quality [3]. Recent studies have also pointed out those women who were malnourished as children are more likely to give birth to low birth-weight children and thus there is an intergenerational effect of child malnutrition.

RESEARCH OBJECTIVES
General Objective To be able to compare the prevalence of malnutrition among institutionalized children in orphanages and non-institutionalized children located in Paco, Manila during the year 2011. Specific Objectives To determine the body mass index (BMI) of institutionalized children in orphanages and non-institutionalized children. To compare the Body Mass Index (BMI) of institutionalized children in orphanages and non-institutionalized children. To correlate the absence or presence of biological parents to the frequency of malnutrition among institutionalized children in orphanages and noninstitutionalized children.

REVIEW OF RELATED LITERATURE

Epidemiology of Disease Interest It was estimated that nearly 30% of infants, children, adolescents, adults and elderly in the developing world are suffering from one or more of the multiple forms of malnutrition[4]. About 20 million children under five years old worldwide are severely malnourished, which leaves them more vulnerable to illness and early death. Nearly 10 million children under the age of five die every year, more than 1,000 every hour[5]. Almost all of these children could survive and thrive with access to simple, affordable interventions. These children could survive and escape death if they are given access even to the simplest and most affordable interventions. Our country today is suffering from poverty, and thus children belonging to the lower class are the ones who are severely affected. Malnourished Filipino Children Underweight and under height are two of the parameters that are considered in malnutrition. A number of Filipino children who were underweight and under height or stunted increased from the year 2005 to 2008. The prevalence of underweight children aged 0-5 years increased from 24.6% to 26.2%, about 3.35 million children. The rate of children who are under height increased from 26.3% to 27.9%, representing 3.57 million children. There was also a significant increase in the prevalence of underweight children aged 6-10 years from 22.8% in 2005 to 25.6% in 2008, which is equivalent to 2.6 million. The number of under height children in this age group likewise increased from 32% to 33.1%. A very high level of acute malnutrition among preschoolers (aged 0-5) was noted in six regions, namely Mimaropa, Bicol, Western Visayas, Eastern Visayas, Zamboanga Peninsula and Soccsksargen where the underweight-for-age prevalence was at least 30%. Chronic malnutrition affected a very high percentage of preschoolers in the provinces of

Masbate, Biliran, Northern Samar, Western Samar, ZamboangaSibugay, Sarangani, Abra and Mountain Province. About 30% of Manila's 50,000-75,000 street children are estimated to be moderately or severely malnourished. According to international standards, both male and female were seriously underweight (lowest 8%) and underheight (lowest 2.5%). Malnourished Institutionalized Children 49% of the 10.4 million deaths occurring in children below 5 years of age in developing countries are linked with protein-energy malnutrition[5]. Although this kind of malnutrition occurs more frequently in low-income countries, several children from higher-income countries (Children from large urban areas and low socio-economic status, children with chronic disease, and children who are institutionalized) are also affected. Orphans represent an important sector in any society, because they are mostly children in crucial phases of physical and mental growth, so they need special nutritional and health care with guidance. Another study reported that the nutritional status of orphans in Sana'a was miserable, especially when it was compared with that of orphans in different countries[6]. 75% of the children were found to be underweight, and 37 % severely so. The prevalence of wasting, which indicates acute or current malnutrition was 27%. 12% of children suffered from moderate or severe wasting. Some 74% of children suffered from stunted growth, and 40% were moderately or severely stunted. All of these percents were mainly higher in the Al-Aitam orphanage, and boys were particularly affected. The study also found that 12% of orphans were anemic. The percentage was higher in boys, at 13%, whereas only 8% of girls were anemic. Also, AlAitam Orphanage had the highest percentage of anemics, at 14%, compared with just 8% in the Al-Rahmaa Orphanage.

In another study comparing institutionalized children and children living in a permanent household, institutionalized children have significantly lower height & weight percentiles[7]. Institutionalized children have significantly lower weight for age and height for age measurements (P 0.05). Using the CPC RCMAS and the DAPT, the scores of institutionalized children were inferior to those of the domiciled children (P 0.05). Epidemiology of exposure/ factor of interest Risk Factors of the Disease (Possible Confounding Variables) In the Philippines poverty and pervasive malnutrition are not limited to families of deprived seasonal workers. Undernourishment is endemic and increasing throughout most of this archipelago of some 7,107 islands, and is compounded by the prevalence of intestinal parasites and gastrointestinal diseases which health workers estimate deprive youngsters of at least 5-10% of the nutritional value in food they do consume. This problem is particularly prevalent in rural villages and city slums where many people eat with their fingers. Philippine National Nutrition Survey provides benchmarks to gauge the countrys progress toward achieving the Millennium Development Goals, including the eradication of hunger, reduction of child mortality and improvement of maternal health. Infectious diseases, especially the intestinal parasites, affect a high rate of children in orphanages in 3rd world countries. Entamoebahistolytica was the most common intestinal parasite affecting orphans, especially boys[7]. Such habits facilitate more infections that lead to nutritional problems. Crowded orphanages facilitate transmission of those infections. Lack of frequent health assessments and programs that can discover and track the orphans nutritional and infectious problems in early stages make them more exposed to disease. The inability of orphanages to cover the expenses of proper food and medical treatments also makes children vulnerable.

SUMMARY OF RELATED/SIMILAR STUDIES

Factors of malnutrition among institutionalized and non-institutionalized Filipino children Comparison of malnutrition among institutionalized and non-institutionalized children may be based on the following dimensions: deprivation of food, proper shelter, sanitation facilities, water, electricity, information, education, and health. The prevalence of malnutrition among Filipino children aged 05 has been continuously declining, though very modestly, since 1998. However, still a quarter of all children in this age cohort are considered underweight for their age, thus, considered suffering from less severe deprivation of food, according to the 2005 estimates of the Food and Nutrition Research Institute (FNRI). Concerning the prevalence of underweight preschoolers, the National Nutrition Survey (NNS) conducted by the Food and Nutrition Research Institute (FNRI) showed a decline from 30.6% in 2001 to 26.9% in 2003. This declined further to 24.6% in 2005. The target of the Millennium Development Goal by the year 2015 is 17.25%, which requires an annual decline of 0.74%.

Malnutrition among children is associated with nutrition status of mothers

According to the 2003 Situation Analysis of Children and Women in the Philippines, malnutrition among infants and young children was found to be associated with the mothers level of education, health, and nutrition status. Older children and adolescents are not spared from malnutrition as reports showed that 3 of 10 children have

stunted growth due to malnutrition, and 33 of 100 among the age group 1119 are underweight. Having established that the nutritional status of children depends on the kind of care they receive (from the kind of care mothers receive while pregnantmaternal care programsto vitamin supplementation, information sharing, and others), this should be continuously pursued. Since breastfeeding is vital to infant nutrition, massive information campaign on its benefits and proper practice should be continued. Incentives for

breastfeeding may likewise be offered to ensure that conducive and safe breastfeeding places, for both mother and infant, are available in areas they frequent such as hospitals and malls. Since mothers are crucial in effective infant-feeding practices, vital information should be made available to them. A widespread program providing better access to water and sanitary facilities should be launched as these have a major effect on malnutrition. In the Philippines, DOHs FHSIS reports that in 2007, 85.7% of households have access to safe water, and 77.5% of households have sanitary toilet facilities.

NUTRITIONAL STATUS OF FILIPINO SCHOOL-AGE CHILDREN AMONG DIFFERENT INCOME GROUPS

There are disparities in the nutritional status of our school-age children across income groups there are more underweight, stunted, anemic, and iodine deficient in the lower income groups, and more overweight in the higher/highest income groups

Majority have normal nutritional status, at least 6 out of 10 children have either normal weight-for-age, height-for-age, or weight-for-height, or not anemic; and 9 out of 10 are not iodine deficient. But at least 3 out of 10 children have poor nutritional status (either low weight-for-age, low height-for-age or are anemic, compromising these childrens development potential).

Are orphans at increased risk of malnutrition in Malawi? The nutritional statuses and health problems of village orphans, non-orphans, and orphanage children were compared by a cross-sectional study conducted in three orphanages and two villages near Blantyre, Malawi. Seventy-six orphanage children, 137 village orphans and 80 village non-orphans were recruited. It was reported that children below 5 years of age manifested the prevalence of undernutrition, with 54.8% compated to village orphans and non-orphans with 33.3% and 30%, respectively. Another

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significant finding was that 64% of young orphanage children experienced stunted growth compared with 50% of village orphans and 46.4% non-orphans. Conversely, older

orphanage children (age equivalent to 5 years old and above) were less stundted and wasted than orphans and non-orphans in villages. Illness of children in the last month was reported to be higher in the non-orphan group, especially diarrhoeal disease, which occurred in 30% compared with 10.8% of village orphans and 6.6% of orphanage children. More than three children in a family being cared for by guardians was significantly associated with undernutrition. Children who had been admitted to an orphanage for more than a year were less malnourished. In village orphans, there was no association between undernutrition and duration of stay in extended families. Age and education of guardians were not associated with the nutritional status of children. Young orphanage children are more likely to be undernourished and more stunted than village children and older orphanage children seem to have better nutrition than village orphans [12]. There was no significant difference in nutritional status between village orphans and non-orphans.

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CONCEPTUAL FRAMEWORK

Non-institutionalized children

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METHODOLOGY Research Design Operational definition of variables:

Dependent variable In this study, the prevalence of malnutrition would be the dependent variable. This variable would be determined using BMI. Values less than 18.5 is regarded as underweight while a BMI value greater than 25 is considered overweight and above 30 is considered obese.as set by WHO.

Independent variables The independent variables in this particular study would be either being an institutionalized child or being a non-institutionalized child. Institutionalized children for this matter will be defined as those living in the orphanages for at least 6 months. Non-institutionalized children are those who are living in a permanent residence with either or both biological parents.

Confounding variables

Confounding variables include age, sex, lifestyle,diet, environment and physical activity.

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Research Design:

Type of study to be employed

A cross-sectional type of study will be utilized to identify the relationship between being in an orphanage and/or being in a non-institutionalized child and the prevalence of malnutrition.

Definition of study population/study groups and source of subjects

Children, both male and female, ages 6 to 10 would be the target subjects of this study. They will be randomly selected from a study population which will come from an orphanage in Paco, Manila (for the representatives of the Institutionalized children). To represent non-institutionalized children, the areas within the vicinity of the orphanage will be surveyed to build the sample population. This is done to eliminate any factors and variables which may affect the outcome of the study like the availability of certain food groups, environmental hazards, degree of pollution et cetera.

Steps to be undertaken/ Procedure to be followed The samples from the aforementioned locations would be randomly numbered and selected using a randomizer (table of random numbers or automated random number generator) to eliminate selection bias. The heights and weights would be determined using a standard balance and height meter respectively. Survey 14

questionnaires would also be given out to the parents and care takers of the orphanages. The data gathered from the questionnaires would be sorted, analyzed and by statistics association of the risk factors involved in acquiring malnutrition for the institutionalized and non-institutionalized children would be done.

Schematic Diagram of the Research Design

Non-institutionalized Street Child (+) Child (+) malnutrition malnutrition Non-institutionalized Street Child (-) Child (-) malnutrition malnutrition

Institutionalized Children and Noninstitutionalized Children

Randomly selected children ages 6-10

Institutionalized Child (+) malnutrition Institutionalized Child (-) malnutrition

Biases/Limitations Much consideration had been given to the selection of the ages from 6 to 10 primarily which is the facilitation of the measuring of the heights and weights to determine accurate Body-mass indices. This range has also the advantage of being able to confirm and validate certain information from the survey questionnaires which in most cases will be answered by the parents or care takers of the orphanage. Likewise, the degree of cooperation tends to increase from ages 6 and up. Therefore the study was decided to be limited to this age range. Another limitation to this study is the inability of the researchers to determine and eliminate confounders like inherent defects in metabolism which may significantly affect the outcome of the study. Likewise, the difficulty of defining and determining factors such as crowding limits 15

the study to some extent. Other quantitative determinants of malnutrition will also not be included in this study which will solely rely on BMI data to report malnutrition. The extent of association between the availability of some food groups, presence of pollution and other variables would not be discussed intensively but their individual possible contribution to malnutrition would be thoroughly discussed. Selection bias may follow the tendency of the researchers to opt for malnourish-looking individuals in hopes of generating a large sample population with a very high percentage of positive malnutrition. This will be circumvented by using random selection of samples from the representative population.

Study Population The focus of this study is the population of Non-institutionalized children and Institutionalized children in Paco, Manila.

Sample population An orphanage is chosen by location as approved by Esperanza C. Gutierrez, the president of the Associacion de Damas Filipinas, Inc. Settlement Homes in Paco, Manila. Through simple random sampling 50 children (the sample population) will be selectedusing the inclusion criteria: (1) is a Filipino citizen; (2) ages between 6-10 years old; (3) has stayed in the orphanage for at least 6 months. For the sampling of
non-institutionalized children, selection will be based following these criteria: (1) a

child whom either parents has a source of income; (2) reside within 5 km radius of the named orphanage; (3) ages between 6-10 years old. Exclusion criteria for both samples include; the child has pre-existing and/or an illness during selection; has no 16

consent from the parents or guardian as well as the childs consent if he/she is 7-10 years of age.

Sampling frame A list of all the names of the orphans in Associacion de Damas Filipinas, Inc. Settlement Homes in Paco, Manila staying, at the least, since March 2011 as certified by the administration of the aforementioned orphanage. For the noninstitutionalized children, a list will be generated through the local barangay registry.

Sampling Unit This will be taken from the study population, Filipino orphans, ages 6-10, from AssociaciondeDamas Filipinas, Inc. Settlement Homes, who stayed for at least 6 months(Institutionalized children). For non-institutionalized children, Filipinos ages 6-10 living within a 5 km radius from the orphanage will be selected.

Elementary Unit Filipino orphans, ages 6-10, from Associacion de Damas Filipinas, Inc. Settlement Homes, who stayed for at least 6 months(Institutionalized children). For non-institutionalized children, Filipinos ages 6-10 living within a 3 km radius.

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Selections Subjects The target population of the study is the institutionalized and noninstitutionalized children in Paco, Manila. Since the population is relatively

homogenous for the orphanage, simple random sampling will be used and randomization will be achieved via computer generated random numbers. This will be done to avoid selection bias which may arise. For the non-institutionalized children population, which is heterogenous, stratified random sampling will be conducted.

Sampling Design The study that will be done is a cross-sectional type. The population is relatively homogenous for the orphanage therefore, simple random sampling will be used and randomization will be achieved via computer generated random numbers. This will be done to avoid selection bias which may arise. For the
non-institutionalized children population, which is heterogenous, stratified random

sampling will be conducted.

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Definition of the Variables used in Data Collection p1 The p1 variable is the estimate of the sample population for orphans located within the vicinity of the subject orphanage who are malnourished. The value that will be used for this study is 54.8% as taken from the literature reviewed. The value for p1 was obtained from the journal article Are Orphans At Increased Risk of Malnutrition in Malawi? by Annals of Tropical Paediatrics: International Child Health, Volume 19, Number 3, 1 September 1999, pp. 279-285(7), in which the statistical value is 54.8% in favour of institutionalized children.

p2 The p2 variable is the estimate for the sample population of non-institutionalized

children located within the vicinity of the subject orphanage who are malnourished.

The value that would be used is 24.6 which was taken from the study conducted by the Philippines Food and Nutrition Research Institute (FNRI) as published in the Philippines Midterm Progress Report on the Millennium Development Goals.

Alpha Alpha () is the probability of committing Type I error in which the null hypothesis is rejected when it is true. In this study, is the probability of rejecting the claim stating that the percentage of malnutrition among the non-

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institutionalized children and institutionalized children is the same, when in fact, it is

true. A 90% confidence interval will be used, hence is 0.1. Beta Beta () is the probability of committing Type II error or failing to reject the null hypothesis. In this study, is the probability of failing to reject the claim that the percentage of malnutrition among non-institutionalized children is the same among institutionalized children. The power of the study is 80%, therefore is 0.20.

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Direction of the test The study is a two-tailed test. The critical region is split into two parts. The null hypothesis states that there is no association between being a noninstitutionalized children and malnutrition if the value that will be obtained is greater

or lesser than that of the alternative hypothesis. The alternative hypothesis states that there is an association between being a non-institutionalized children and malnutrition. VALUES OF THE VARIABLES FOR CALCULATIONS Variables p1 p2 Alpha Beta Values 54.8% 24.6% 0.10 0.20

SAMPLE SIZE COMPUTATION A cross-sectional analytic study regarding the relationship of malnutrition between institutionalized and non-institutionalized children in Paco, Manila will be conducted. The percent of malnutrition of unexposed with outcome, which are the non-institutionalized children is 24.6%, while the percent of exposed with outcome, which are the institutionalized children is 54.8%. At a confidence level of 90% and a power of 80%, 38 institutionalized children and 38 non-institutionalized children will be selected randomly to obtain a sample size of 76 Filipino children, ages 6-10.

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VARIABLES AND DATA TO BE COLLECTED

Weight Values One(1) Platform type weighing scale will be used to obtain the weight of each subject. Only one researcher will be allowed to measure the weight of the subject at the same time of the day for accurate and precise data collection. Each subject will be asked to remove his or her footwear and make sure there is nothing on his or her pocket. Have the child or teen remove shoes and heavy clothing, such as sweaters.Have the subject stand with both feet in the center of the scale. Record the weight to the nearest decimal fraction. The set of data will be obtained using a will be recorded with the KILOGRAM unit.

Height Values Same platform type of weighing scale with height rod will be used. Only one researcher will be allowed to measure the height of the each subject. The subject will be asked to remove his footwear, bulky clothing, and hair ornaments, and to unbraid hair that interferes with the measurement. Have the subject stand with feet flat, together, and against height rod. Make sure legs are straight, arms are at sides, and shoulders are level. Make sure the child is looking straight ahead and that the line of sight is parallel with the floor. Use a flat headpiece to form a right angle with the height rod and lower the headpiece until it firmly touches the crown of the head. Lightly mark where the bottom of the headpiece meets the height rod. Accurately record the height to the nearest 1/8th inch or 0.1 centimeter.

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BMI Values This set of data will be obtained by dividing the weight values obtained (in kg) over the square of the height values obtained (m2) and will have a final unit of kg/m2. Values less than 18.5 and greater than 25 will be considered as positive disease cases (malnutrition).

Method for elimination of confounding variables The frequency of malnutrition may be influenced by several factors other than the childrens environment, which pertains to having a proper shelter and guidance from their biological parents. These other factors, which we call confounding variables, include the childrens age, sex, and their physical activity. In order to eliminate these confounding variables, an interview with the help of a standardized questionnaire will be carried out prior to collection of height and weight. This will elicit information regarding these variables and will determine if the participant is qualified to participate in this study. Since the participants are not of the legal age, their guardian will be the representative or informant for the interview. There will be separate questionnaires for the institutionalized children and
non-institutionalized children. The initial questions in the said interview will comprise

of the childrens general data such as their name, age, sex, address or location of the childrens shelter, name of guardian or family members present in the household and their salary per day to obtain their socio-economic status. Then, the representative of the participants will be asked several questions regarding their lifestyle and daily activities from the time they wake up in the morning until the time they go to bed.

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Further on, they will be asked about their daily diet, which pertains to the quality and quantity of food they usually consume and the frequency of food consumption per day, if it is once, twice, or thrice a day. If the children do not qualify the aforementioned criteria, with the age range of 6- 10 years old, residing within the 5 km radius of the chosen orphanage for noninstitutionalized children, duration of stay of 6 or more months inside the orphanage,

then the particular participant will not qualify as one of the participants in the study.

Method for data collection For the purpose of this study, Observation by making use of equipment and tools is the preferred method for data collection. Specifically, the use of standardized and calibrated platform type of weighing scale with height rod will be used for taking weight and height measurements respectively. This method was chosen over other data collection methods primarily because the key element in this study is the determination of BODY MASS INDEX to determine the nutritional status of the subjects. This data is quantifiable and measurable by using the height and weight measurements of the subjects. While it can be argued that observing the physical appearance, behaviour and characteristics of the subject may be used as a method for nutritional status determination, it is very much prone to subjective bias from the observers and will not give accurate results unlike the proposed method of data collection. The same reason holds true in justifying observation using equipment and tools as choice for data collection over Focus Group Discussion and Questionnaires/interview which will not give appropriate and quantified results. 25

Data Collection Tool 1. Letter of Consent for the Participation of Institutionalized Children

De LaSalle Health Sciences Institute College of Medicine

Mrs. Esperanza C. Gutierrez President Associacion de Damas Filipinas, Inc. Settlement Homes Paco, Manila Maam Good day! We are second year medical students from De La Salle Health Sciences Institute, Dasmarinas City, Cavite. As part of our course requirement in Community Medicine 2, we are conducting a comparative study on the nutritional status among institutionalized and non-institutionalized children. For the former category, we will specifically be assessing those children living in the orphanages. In light of this, we would like to ask permission from your good office to allow us to conduct our study in your institution. Aside from the assessment of nutritional status, our study will also include analysis on the factors which affect the nutrition and health status of street and institutionalized children. We believe that this study would be able to provide you with valuable input during your general improvement planning for the institution and we would be very glad to share the results of our study with you. We also assure you that we will only use information necessary for the study and any sensitive and other data concerning the children and the institution will not be published. All information obtained shall be limited for the purpose of the study ONLY and access to the files shall be restricted to the research team. Documents will be stored in a concealed envelope which is only accessible to the research team. Once the research process is completed all files will be destroyed. Do understand that this is a nonprofit study and that no monetary compensation would be handed out. You will also be asked to sign a consent form, which contains the details of the data collection method, for each of the participants (76 in total, 38 of which will be coming from your institution). Likewise, we are very much open to discussing these important terms with you if you deem it necessary to do so. Should you agree to the terms discussed above, kindly affix your signature at the bottom of this page. We are looking forward to meeting and working with you regarding this study and it is hoped and prayed for that you would grant us permission to do so. Thank you and may our good Lord bless you more. Thank you for your kind consideration.

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Conformed :

___________________________________ Mrs. Esperanza C. Gutierrez

Sincerely yours, __________________ Angelo Parao Noted by: ___________________________ Josephine M. Carnate, MD, MPH

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2. Consent Form (for Parents/Guardians institutionalized children) Magandang araw!

of

Institutionalized

and

Non-

Kami ay mga estudyante ng medisina sa De La Salle Health Sciences Institute at kasalukuyang nagsasagawa ng pag-aaral ukol sa pagkokompara ng malnutrisyon sa mga batang nakatira kasama ang kanilang mga magulang at mga batang nasa bahayampunan sa Paco, Manila para sa taong kasalukuyan. Layunin ng pagaaral na ito na malaman ang body-mass index (relasyon ng timbang sa taas ng isang indibidwal) ng mga batang mga batang nakatira kasama ang kanilang mga magulang at mga batang nasa bahay ampunan. Titingnan din ng pagaaral na ito ang ilang salik sa kadalasan ng pagkakaroon ng malnutrisyon katulad ng pagkakaroon ng magulang o guardian. Random sampling ang gagamitin sa pagkuha ng mga partisipante. Sa kabuuan, 76 na kalahok ang kakailanganin sa pag-aaral na ito : 38 na bata mula sa ampunan at 38 na nakatira kasama ang kanilang magulang. Bagaman walang tulong na pinansyal ang pagsusuring ito, makakadagdag naman ito sa mga panibagong impormasyon at kaalaman ng buong lipunan. Sa kadahalinanang ito, nais naming hingin ang inyong tulong sa pagsagot ng ilang mga simpleng katanungan. Bibigyan naming kayo ng 5 hanggang 10 minuto upang sagutan ang mga tanong na ito. Kung mayroon kayong hindi maintindihan maaari lamang na pakilapitan ang mga researchers na nagbihay sa inyo ng papel na naglalaman ng mga tanong. Nais ng mga researchers linawin na maaring tumanggi na sumailalim sa pagsali sa pagaaral o pagsusuri ng nasabing paksa. Sa pagsagot ng mga tanong dito, inyo pong kinukumpirma na maliwanag at nauunawaan ninyo na: Boluntaryo ang inyong pagsagot sa mga katanungan at sumasangayon kayo na sumali sa pagaaral na ito ng walang kapalit na tulong pinansyal. Na nauunawaan nyo na mananatiling lihim ang mga maseselang impormasyon na hindi naman kailangan sa pagaaral na ito. At ang anumang ibinahagi nyo ay para lamang sa kaalaman ng mga researchers at para sa pagaaral na ito at hindi isasapubliko

Sa pagkuha ng timbang, isang uri ng Platform Weighing Scale ang gagamitin upang makuha ang bigat ng bawat bata. Isang researcher lamang ang pinapayagan upang masukat ang timbang ng bawat bata sa parehong oras ng araw para sa wasto at tumpak na pangongolekta ng datos. Ang bawat bata ay pakikiusapan na alisin ang kanyang tsinelas o sapatos at siguraduhin na walang laman ang kanyang bulsa. Dagdag pa dito, pakikiusapan din na alisin ang mga mabibigat na damit tulad ng jacket, sweaters, atbp. Sa pagsusukat ng timbang, ang bata ay patatayuin sa parehong mga paa sa gitna ng timbangan saka irerekord ang bigat ng bawat bata. Sa pagkuha ng taas o tangkad ng bawat bata, parehong uri ng Platform Weighing Scal ang gagamitin. Ang bata ay muling pakikiusapan na alisin ang kanyang tsinelas, malalaking damit, mga ipit o burloloy sa buhok nito na makakasagabal sa pagsusukat. Ang bata ay patatayuin sa nasabing platform at titiyaking ang binti ay tuwid, braso ay

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nasa gilid at balikat ay pantay. Sa pagrerekord ng datos, mamarkahan kung saan ang pinakamlapit na sukat. Sumasang ayon din kayo bilang magulang o guardian ng isa sa mga batang kukuhanin naming ng timbang na ipagamit ang datos ukol sa timbang, bigat at iba pang kailangang impormasyon. Kayo din ay nagbibigay pahintulot sa mga researchers na gawin ang mga kailangang pamamaraan upang makuha ang sukat ng mga ito .

________________________ Lagda Maraming salamat sa inyong pagtulong at pakikibahagi sa pagaaral na ito!

Sumasainyo, __________________________________ Angelo E. Parao, Researcher Contact number : (0926)680-8970

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3. Questionnaire De La Salle Health Scineces Institute- College of Medicine- Community Medicine 2 MGA KATANUNGAN Pangalan ng Anak/ Inaalagaan : _________________ Edad ng bata:_____ Kasarian ng bata : ______________

Pakilagyan ng tsek ang item/mga item na sa tingin nyo ay pinakamahusay na sumasagot sa katanungan 1. Ano po ang malimit nyong kainin sa pang araw-araw? (Maaaring lagyan ng tsek ang ISA HANGGANG TATLONG pagpipilian sa baba) [ ] Manok [ ] Baboy [ ] Isda [ ] Gulay [ ] Kanin [ ] Noodles [ ] Prutas [ ] De Lata [ ] Tinapay [ ] Pampalasa (Asin,toyo, ketchup) [ ] Sabaw [ ] Iba pa : _____________________ (pakisulat)

2. Ano ang nagdedetermina ng pagpili nyo ng ihahanda bilang pagkain ? ( Pumili lamang ng dalawa) [ ] Kung ano ang kaya ng pera [ ] Kung ano ang mura pero masustansya para sa bata [ ] Kahit mahal ang presyo basta masustansya para sa bata [ ] Kung ano ang malapit bilihin [ ] Kung ano ang mas nakakabusog (mabigat sa tyan ) [ ] Kung ano ang masarap. [ ] Iba pa _________________________ (pakisulat)

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4. Assent Form ( for Children seven years old and above )

PAHINTULOT Ako si _________________, ____ taong gulang ay nagbibigay pahintulot na gamitin ang mga impormasyon ukol sa aking timbang, taas at ilan pang bagay na kakailanganin sa pag-aaral na ito. Naunawaan ko ang kahalagahan at naisin ng pag-aaral na ito at ako ay sumasang-ayon na maging kabahagi ng pagsasaliksik na ito. Ako ay hindi pinilit na maging kalahok nito at ako ay nagbibigay ng pahintulot na gawin nila ang kinakailangan (katulad ng pagtanggal ng damit pang-itaas) upang makakuha ng wastong sukat ng timbang at taas. Nauunawaan ko din na ang pagtanggi ko dito ay hindi makakaapekto sa akin o sa aking pamilya at wala itong maidudulot na anumang kapahamakan. Bagaman walang tulong na pinansyal ang pagsusuring ito, makakadagdag naman ito sa mga panibagong impormasyon at kaalaman ng buong lipunan. Sa kadahalinanang ito, nais naming hingin ang inyong tulong sa pagsagot ng ilang mga simpleng katanungan. Bibigyan naming kayo ng 5 hanggang 10 minuto upang sagutan ang mga tanong na ito. Kung mayroon kayong hindi maintindihan maaari lamang na pakilapitan ang mga researchers na nagbihay sa inyo ng papel na naglalaman ng mga tanong. Nais ng mga researchers linawin na maaring tumanggi na sumailalim sa pagsali sa pagaaral o pagsusuri ng nasabing paksa. Sa pagsagot ng mga tanong dito, inyo pong kinukumpirma na maliwanag at nauunawaan ninyo na: Boluntaryo ang inyong pagsagot sa mga katanungan at sumasangayon kayo na sumali sa pagaaral na ito ng walang kapalit na tulong pinansyal. Na nauunawaan nyo na mananatiling lihim ang mga maseselang impormasyon na hindi naman kailangan sa pagaaral na ito. At ang anumang ibinahagi nyo ay para lamang sa kaalaman ng mga researchers at para sa pagaaral na ito at hindi isasapubliko Sa pagkuha ng timbang, isang uri ng Platform Weighing Scale ang gagamitin upang makuha ang bigat ng bawat bata. Isang researcher lamang ang pinapayagan upang masukat ang timbang ng bawat bata sa parehong oras ng araw para sa wasto at tumpak na pangongolekta ng datos. Ang bawat bata ay pakikiusapan na alisin ang kanyang tsinelas o sapatos at siguraduhin na walang laman ang kanyang bulsa. Dagdag pa dito, pakikiusapan din na alisin ang mga mabibigat na damit tulad ng jacket, sweaters, atbp. Sa pagsusukat ng timbang, ang bata ay patatayuin sa parehong mga paa sa gitna ng timbangan saka irerekord ang bigat ng bawat bata. Sa pagkuha ng taas o tangkad ng bawat bata, parehong uri ng Platform Weighing Scal ang gagamitin. Ang bata ay muling pakikiusapan na alisin ang kanyang tsinelas, malalaking damit, mga ipit o burloloy sa buhok nito na makakasagabal sa pagsusukat. Ang bata ay patatayuin sa nasabing platform at titiyaking ang binti ay tuwid, braso ay nasa gilid at balikat ay pantay. Sa pagrerekord ng datos, mamarkahan kung saan ang pinakamlapit na sukat. Sumasang ayon din ako na kukuhanin ang aking ng timbang at taas bilang datos ukol sa kailangang impormasyon. Ako din ay nagbibigay pahintulot sa mga researchers na gawin ang mga kailangang pamamaraan upang makuha ang sukat ng mga ito .

________________________ Lagada ng kalahok

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5. Mass Index Determination Sheet

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