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

Comparison of Malnutrition among Institutionalized and Street 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 October 13, 2011 1

INTRODUCTION

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

Research Hypothesis The prevalence of malnutrition is generally higher in street children compared to 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 street children and institutionalized children in orphanages located in Paco, Manila during the year 2011.

Specific Objectives To determine the body mass index (BMI) of street children and institutionalized children living in orphanages. To compare the Body Mass Index (BMI) of street children and institutionalized children living in orphanages. To correlate the absence or presence of biological parents to the frequency of malnutrition among street children and institutionalized children in orphanages.

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, Zamboanga Sibugay, 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 Filipino Street Children In the Philippines, there are three types of children roaming in the streets. Children on the Streetsdescribed as children working on the streets but have homes to return to. Children of the Streetsdescribed as children living on the street and Completely Abandoned Childrenwho are entirely responsible for their own physical and psychological survival[8]. Children on the Streets make up approximately 75% of the street children in the Philippines, while Children of the Street and Completely Abandoned Children make up 25-30% and 5-10%, respectively, of the approximate total of street children, which was estimated to be 1.5 million as of 1998. Around 70% of these street children are boys[9]. 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. Entamoeba histolytica 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. A survey of street children from Manila, the Philippines, identified two factors that are strongly correlated with malnutrition in this population: drug use and nonattendance at school. Children who were in school and did not use drugs showed the highest mean weight, while those who were out of school and using drugs had the lowest mean weight; children with one of these risks factors occupied an intermediate position. About half the street children reported regular drug use, primarily glue sniffing. It is recommended that programs currently serving Filipino street children assess the barriers to participation (e.g., policies against drug use) by high-risk children and pilot projects to train social workers and street educators in substance abuse counseling. The effectiveness of such interventions would be enhanced by a detailed study of the various gangs and syndicates of children in Manila. SUMMARY OF RELATED/SIMILAR STUDIES Social correlates of malnutrition among Filipino street children A similar study conducted by the University Of Connecticut School Of Medicine, researched on social correlates of malnutrition among Filipino street children. The study

was published by Hixon A.L. on year 1993. He sought to identify subgroups of street children at high risk for nutritional deficiency in metropolitan Manila in the Philippines. He had a sample of 150 street children ages six through 18 that were weighed, measured, and interviewed to establish nutritional parameters. The interrelationships of nutritional status with social conditions were explored. Children using drugs and children not in school were the two variables listed showing the highest association with low weight for age. These variables should be seen as indicative of a range of variation among Filipino street children, in whom those on drugs and not in school represent the sector at greatest risk and one to which nutritional programs should be targeted. The following are the results of the survey conducted on street children from Manila, Philippines by Hixon[10]. He identified two factors that are strongly correlated with malnutrition in the population: drug use and non-attendance at school. About 30% of Manila's 50,000-75,000 street children are estimated to be moderately or severely malnourished. In the study, he recruited a sample of 150 male and female children ages 618 years was recruited, with the help of social workers, from a neighborhood estimated to have 500 street children. According to international standards, both male and female respondents were seriously underweight (lowest 8%) and underheight (lowest 2.5%). Results showed that children who were in school and did not use drugs has the highest mean weight, while those who were out of school and using drugs had the lowest mean weight; children with one of these risks factors occupied an intermediate position. About half the street children reported regular drug use, primarily glue sniffing. Among his recommendations for the study, were to establish programs currently serving Filipino street children assess the barriers to participation like policies against drug use by high-risk children. Another is to pilot projects to train social workers and street educators in substance abuse counseling. He also pointed out to conduct detailed

studies of the various gangs and syndicates of children in Manila for better understanding of life of street children and for the effectiveness of such interventions. On another similar study, a descriptive cross-sectional study was constructed with all the streets of Lilongwe serving as potential recruitment areas. However, for practical purposes it was decided that the study should consider recruiting children from highdensity areas such as the streets that are in close proximity to the main market since in the Lusaka study. Since street children are highly mobile, a purposive sampling method was used to recruit children who suited characteristics of being street children. The characteristics included begging, appearing to be seeking social favours such as piece work, looking generally disadvantaged, scavenging, and without guidance of an older responsible person The inclusion criteria were: That the subject be identified as a street child based on the descriptions mentioned above as well as self testimony; That the subject be adequately briefed about the study and give verbal assent to participate in the study; and, that the subject was not already interviewed. 3/4 of the children indicated that most of the times they eat three main meals each day, one fifth (19.4%) eat two main meals each day, while 5.6% indicated eating only one meal a day. When the children were asked to state their impression about the adequacy of the food they ate in the 24 hours preceding the survey, 75% perceived it to be adequate. Notably, foods that were mostly consumed on a daily basis include nsima (100%), rice (50%), confectionery (44.4%), and mangoes (41.7%). On the other hand, foods that were consumed three times a week included fish (80.6%), chicken (58.3%), potatoes (36.1%), cookies (19.4%), pumpkin leaves (19.4%), and bananas (13.9%). For the majority of the children, vegetables were mostly consumed once a week. Legumes and nuts were vividly not reported, with only 11% indicating that they consume legumes (beans only) on a daily basis. Results of nutritional status assessment showed that 8.4% of the children were wasted (WHZ <-2), with 5.6% being severely wasted (WHZ <-3)[11].

One particular bias occurs in the study mentioned and that is in terms of age, gender and time that the child has been living on the streets. Children living on the streets longer are more prone to wasting because of the less food and nutritional intake that they get. Boys are also more prone to wasting because than are more active than the girls their age. Its is also necessary to control the age group of the subjects because children at different age groups have different nutritional requirements from one another. No such study is conducted in the Philippines. This one should be taken into consideration. Much research that has addressed the nutritional status of street children has only touched on the kind of food that they are taking in. One of the primary goals of research on street children should capture the overall health and wellbeing of the children. Future research should also examine the variation between street children from different regions and racial/ethnic backgrounds. 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 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

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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.

CONCEPTUAL FRAMEWORK

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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 street child. Institutionalized children for this matter will be defined as those living in the orphanages for at least 6 months. Street children are further classified as Children on the Streets described as children working on the streets but have homes to return to and Children of the Streets described as children living on the street.

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 the street 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 street 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 questionnaires would also be given out to the parents and care takers of the 13

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 street children would be done.

Schematic Diagram of the Research Design

Street Child (+) malnutrition Street Child (-) malnutrition

Institutionalized Children and Street 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 the study to some extent. Other quantitative determinants of malnutrition will also not 14

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 Street 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 atleast 6 months. For the sampling of street children, selection will be based following these criteria: (1) works on the street with a shelter to go to at the end of the day (Children on the Street) and/or works on the street without a shelter to go to at the end of the day(Children of the Street); (2) within 3 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 15

illness during selection; has no 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 street children, whenever applicable (Children on the Street), the names will be verified through the local barangay unit, otherwise the list of names will be generated through personal interviews.

Sampling Unit This will be taken from the study population, Filipino orphans, ages 6-10, from Associacionde Damas Filipinas, Inc. Settlement Homes, who stayed for at least 6 months(Institutionalized children). For street children, Filipinos ages 610 living within a 3 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 street 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 street 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 street 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 street children population, which is heterogenous, stratified random sampling will be conducted. Definition of the Variables used in Data Collection p1 The p1 variable is the estimate of the sample population for street children located within the vicinity of the subject orphanage who are malnourished. The value for p1 was taken from International Centre for Diarrhoeal Disease Research, Bangladesh: Dissemination Seminar on: Health Needs and Health

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Seeking Behaviours of Street Dwellers in Dhaka City, wherein 73% of street children are found to be malnourished. p2 The p2 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 p2 was obtained from the journal 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. 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 street children and orphans 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 street children is the same among orphans. 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 street 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 street children and malnutrition. VALUES OF THE VARIABLES FOR CALCULATIONS Variables p1 p2 Alpha Beta Values 73% 54.8% 0.10 0.20

Sample Size Computation

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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 the street 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 street 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. 22

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

DeLaSalle 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 street 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. Likewise, we are very much open to discussing these important terms with you if you deem it necessary to do so.

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Should you agree on 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.

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 of Street Children ) Magandang araw! 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 lansangan at mga nasa ampunan 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 lansangan at mga 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. 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 meron kayong hindi maintindihan maaari lamang na pakilapitan ang mga researchers na nagbihay sa inyo ng papel na naglalaman ng mga tanong. 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 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

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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 (pakisulat) [ ] Kanin [ ] Noodles [ ] Prutas [ ] De Lata [ ] Tinapay [ ] Pampalasa (Asin,toyo, ketchup) [ ] Sabaw [ ] Iba pa : _____________________

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. Consent 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. ________________________ Lagada ng kalahok

5. Body-Mass Index Determination Sheet

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