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Dietary patterns and risk of nonfatal acute myocardial infarction in Costa Rican adults
(European Journal of Clinical Nutrition, Vol. 60, no. 6, 2006) Martínez Ortiz, J. A.; Fung, T. T.; Baylin, Ana; Hu, F. B.; Campos, Hannia
Cardiovascular disease (CVD) has become an important public health problem in transition countries in Latin America (Medina and Kaempffer, 2000; Cubillos-Garzón et al., 2004; Ventura and Mehra, 2004; World HealthOrganization, 2004). Because changes in dietary intake are, in part, likely responsible for the increase in CVD during the past 20–30 years (Popkin, 2001), it is essential to identify foods that could play a role on CVD in developing countries. Food pattern analysis has become a valuable tool to examine the effects of diet on chronic disease (Jacques and Tucker, 2001; Hu, 2002). A major advantage of this procedure is that it takes into account multiple dietary factors, including nutrient and non-nutrient components, which could have complex effects on disease risk (Hu, 2002). In the context of Western countries, two main patterns that relate to CVD have been identified. In one study in men (Hu, 2002), a Western dietary pattern consisting primarily of red and processed meat, refined grains, sweets and desserts, French fries, and high-fat dairy products was associated with increased risk of coronary heart disease. In Denmark, a prudent dietary pattern consisting of whole meal bread, fruit, and vegetables was protective against all cause and cardiovascular mortality (Osler et al ., 2001). In the same study, no association with mortality was found for a Western pattern characterized by high intake of meat products, potatoes, white bread, butter, and lard. Consistently, a Mediterranean style diet which includes olive oil, fiber, fruits, vegetables, fish and alcohol, and reduced in meat and meat products was also protective against myocardial infarction (MI) (Martinez-Gonzalez et al ., 2002). The purpose of our study is to identify dietary patterns that are associated with risk of incident MI in Costa Rica, a Latin American country in transition (Reddy, 2004).
Abdominal obesity and hyperglycemia mask the effect of a common APOC3 haplotype on the risk of myocardial infarction
(Am J Clin Nutr., no. 87, 2008) Ruiz Narváez, Edward A.; Sacks, Frank M; Campos, Hannia
The plasma concentration of apolipoprotein (apo) C-III is a strong predictor of the risk of coronary heart disease (CHD) (1, 2). Apo C-III impairs the clearance of apo B lipoproteins from plasma, which results in an increase in plasma triacylglycerol concentrations (3–7) and directly activates atherosclerotic and inflammatory pathways in vascular cells (8, 9). Therefore, genetic variation affecting the expression of the APOC3 gene may alter apo C-III metabolism and influence CHD. Minor alleles of the 3238C - G (SstI site), -482C-T, and -455T-C polymorphisms are associated with higher plasma triacylglycerol (10–13) and apo C-III (14) concentrations and with an increased risk of CHD (13, 15–17).
Effect of apolipoprotein E genotype and saturated fat intake on plasma lipids and myocardial infarction in the Central Valley of Costa Rica
(Human Biology, Vol. 79, no. 6, 2007) Yang, Yadong; Ruiz Narváez, Edward A.; Kraft, Peter; Campos, Hannia
Apolipoprotein E (apoE) is a ligand for the low-density lipoprotein (LDL) receptor and the LDL receptor-related protein (LRP) (Mahley and Rall 2000). Through these receptors apoE mediates the uptake of chylomicron remnants into the liver and the uptake of circulating very low density lipoprotein (VLDL) and intermediate-density lipoprotein (IDL) particles into peripheral tissues and cells (Mahley and Rall 2000).
Triggers of nonfatal myocardial infarction in Costa Rica : heavy physical exertion, sexual activity, and infection
(Annals of epidemiology, Vol. 17, no. 2, 2007) Baylin, Ana; Hernández Díaz, Sonia; Siles, Xinia; Kabagambe, Edmond K.; Campos, Hannia
The incidence of coronary heart disease is increasing in developing countries undergoing socioeconomic transition(1). Lifestyles in many of these countries are dramatically different from those in Europe and the United States. For ex-ample, vigorous physical activity is more likely to be related to work than to recreational activities(2). The pattern of acute infections also is distinct, with a greater incidence than in developed countries. In addition, because transition countries are characterized by the presence of both infectious and chronic disease (3), the study of gastroenteritis episodes as a trigger of myocardial infarction (MI) is of particular interest in these countries. Cardiovascular disease (CVD) as a major health problem was established only recently in transition societies, and very few studies examined factors affecting CVD in the context of these different lifestyles(4).
Adipose tissue arachidonic acid and the metabolic syndrome in Costa Rican adults
(Clinical Nutrition, no. 26, 2007) Williams, Eric S.; Baylin, Ana; Campos, Hannia
Arachidonic acid, an n-6 polyunsaturated fatty acid (PUFA), is a major component of mammalian cell membranes and may account for up to 25% of all phospholipid fatty acids. Although it is consumed in the diet in meats, eggs, and some fish, it is also synthesized in the liver from linoleic acid, the most abundant dietary PUFA, and transported to other cell types via serum albumin or lipoproteins. A major function of arachidonic acid is to serve as a precursor to the eicosanoid family of autocrine and paracrine hormones that modulates immune and inflammatory responses in the body. Additionally, there is evidence that arachidonic acid may act as a transcriptional regulator by modulating signal transduction at the cell surface, by altering membrane fluidity, or cell surface interactions by acylating membrane proteins.
Transient exposure to coffee as a trigger of a first nonfatal myocardial infarction
(Epidemiology, Vol. 17, No.5, 2006) Baylin, Ana; Hernández Díaz, Sonia; Kabagambe, Edmond K.; Siles, Xinia; Campos, Hannia
Coffee is one of the most popular beverages worldwide, with an average consumption of 6.7 million tons per year. Prepared from the seed of the coffee plant Coffea arabica originated in Ethiopia and domesticated in Yemen, this beverage has been part of the diet for the past 5 centuries. Coffee contains many biologically active compounds, including caffeine, diterpenes, and polyphenols, with numerous metabolic properties and diverse health effects. Because of the potential adverse effects of coffee on blood cholesterol, homocysteine, and hypertension, the effects of coffee intake on heart disease have been extensively studied for decades. Findings are still controversial, with most case–control studies showing increased heart disease risk for heavy drinkers and cohort studies showing both negative and positive results. Some authors have suggested that this discrepancy is the result of a more acute effect of coffee on the risk of myocardial infarction that could be better assessed using a case–control design. More recent studies have observed a J-shaped association between coffee drinking and heart disease, which suggests that people with light or occasional intake could be at higher myocardial infarction risk because coffee may act as a trigger of myocardial infarction. The transient effects of coffee intake on increased blood pressure and sympathetic tone support this hypothesis. It has also been suggested that the disruption of a vulnerable atherosclerotic plaque in response to hemodynamic stress could trigger a myocardial infarction.
Adipose tissue biomakers of fatty acid intake
(American Journal of Clinical Nutrition, No.76, 2002) Baylin, Ana; Kabagambe, Edmond K.; Siles, Xinia; Campos, Hannia
The use of biomarkers to assess dietary intake has increased dramatically in the past few years (1-7). Biomarkers may provide a more accurate and objective measure of long-term intake than dietary questionnaires provide because biomarkers do not rely on memory, self-reported information, or interviewer bias. However, nutrient concentrations in tissue or blood do not always reflect dietary intake because they can be affected by genetic factors, smoking, obesity, physical activity, and metabolism.
Decreased consumption of dried mature beans is positively associated with urbanization and nonfatal acute myocardial infarction
(The Journal of Nutrition, vol 35, no. 7, 2005) Kabagambe, Edmond K.; Baylin, Ana; Ruiz Narváez, Edward A.; Siles, Xinia; Campos, Hannia
Beans, Phaseolus vulgaris, are legumes that are thought to have originated from southern Mexico and Central America over 7000 y ago (1); they still form an important part of the staple diet in those regions. For many centuries, beans have remained part of the human diet in several countries on all continents. Black beans or black Spanish beans are the commonest variety in Latin America; they are usually consumed as dried mature beans together with rice. The combination of rice and dried mature black beans (later referred to as beans) supplies various nutrients including essential amino acids, folate, soluble fiber, copper, magnesium, iron, potassium, calcium, zinc, and _-linolenic acid (2–10). Although there are several varieties of beans that occur in different sizes, shapes, and colors, their nutrient composition is quite similar to that of black beans (Table 1). Legumes including beans may protect against cardiovascular disease (CVD)3 through various mechanisms (2,5,10,11). However, epidemiologic data on the association between individual legumes such as beans and peas and CVD are lacking. Beans form the core of the Latin American staple diet and contribute significantly to energy and micronutrient intakes (5–7,12). Despite the recommendation to increase the intake of beans by health organizations (8), their consumption, as well as that of other legumes, has decreased with urbanization (13). This is probably because of the increased availability and advertising of relatively cheap simple carbohydrate diets such as pasta and white bread (7,13). As expected, these trends are likely to be responsible for the increased obesity and the slow emergence of cardiovascular and other chronic diseases in many Latin American countries, including Costa Rica, where myocardial infarction (MI) accounts for 47.2% of CVD (14,15). Some of the few studies that have investigated the nutrients in beans [e.g., fiber (16 –18), folate (19), magnesium (20,21), and copper (22)], suggest inverse associations with CVD. Unlike soybeans and peanuts, the role of other legumes (e.g., beans) in CVD has not been reported. We therefore investigated, in a large incident case-control study in Costa Rica, whether eating beans is associated with risk of MI and explored potential mechanisms for such an association.
Some dietary and adipose tissue carotenoids are associated with the risk of nonfatal acute myocardial infarction in Costa Rica
(The Journal of Nutrition, Volumen 135, no. 7, 2005) Kabagambe, Edmond Kato; Furtado, Jeremy; Baylin, Ana; Campos, Hannia
Antioxidants, particularly carotenoids and tocopherols, may protect against cardiovascular disease. The objective of this study was to determine whether dietary and adipose tissue carotenoids and tocopherols are associated with the risk of myocardial infarction (MI). Cases (n 1456) of a first acute MI were identified and matched by age, sex, and residence to randomly selected population controls (n 1456) living in Costa Rica. Carotenoids and tocopherols were measured in adipose tissue using HPLC. Dietary intake was assessed using a validated FFQ. Anthropometrical and lifestyle data were collected using an interviewer-administered questionnaire. Subjects were distributed into quintiles of intake or adipose tissue concentration of carotenoids or tocopherols. The lowest quintile was used as the referent in conditional logistic regression analyses. Adipose tissue-carotene showed a significant inverse relation with MI risk; the odds ratio (OR) comparing the highest to the lowest quintile was 0.70 (95% CI: 0.51– 0.96, P for trend 0.02). Intake of fruits and vegetables that are rich in-carotene was also inversely associated with the risk of MI (OR 0.74; CI: 0.54 –1.01, P for trend 0.09). In contrast, lutein zeaxanthin in adipose tissue (OR 1.46; CI: 1.05–2.05, P for trend 0.02) and diet (OR 1.18; CI: 0.88 –1.57, P for trend 0.02) was positively associated with MI risk. MI risk was not associated with any of the other carotenoids or tocopherols in the diet or adipose tissue. Thus, the inverse association between -carotene and MI risk suggests that -carotene protects against MI or it is a marker of some protective factor in foods containing -carotene. The mechanism underlying the positive association between lutein zeaxanthin and the risk of MI warrants investigation.
APOC3/A5 haplotypes, lipid levels, and risk of myocardial infarction in the Central Valley of Costa Rica
(Journal of Lipid Research, vol. 46, no. 12, 2005) Ruiz Narváez, Edward A.; Yang, Yadong; Nakanishi, Yukiko; Kirchdorfer, Jill; Campos, Hannia
Apolipoprotein C-III (apoC-III) and A-V (apoA-V) regulate triglyceride metabolism in opposite ways (1–3). In mice, the overexpression of the human APOC3 transgene (1) leads to severe hypertriglyceridemia, whereas knockout mice lacking the endogenous Apoc3 gene have hypotriglyceriemia (2). In contrast, overexpression of the human APOA5 transgene and the lack of the endogenous Apoa5 gene show opposite triglyceride effects (3). Several studies indicate that naturally occurring sequence variation in the APOC3 and APOA5 genes affects plasma triglyceride concentrations in humans (4–7). People with the G allele of the 3238C>G polymorphism (SstI site) in the 3 untranslated region (3 UTR) of APOC3 tend to have higher plasma triglyceride concentrations (4, 5), as do individuals with two minor alleles, 482C>T and 455T>C (8–10), found in the insulin response element (IRE) of the APOC3 promoter. Several minor alleles of APOA5, the 1131T>C (upstream of the proximal promoter) (3, 6, 7), c. 3A>G (in a putative Kozak sequence) (11), c.56C>G (amino acid change p.Ser19Trp in the signal peptide) (7, 11), IVS3 476G>A (3, 11), c.553G>T (amino acid change p.Gly185Cys in exon 3) (12), and c.1259T>C (located in the 3 UTR) (3, 11), are also associated with increased plasma triglyceride concentrations.
Alcohol intake, drinking patterns and risk of nonfatal acute myocardial infarction in Costa Rica
(The American Journal of Clinical Nutrition, vol. 82, no. 6, 2005) Kabagambe, Edmond K.; Baylin, Ana; Rimm, Eric B.; Campos, Hannia
Moderate consumption of alcohol in developed countries has been associated with a reduced risk of myocardial infarction (MI) (1–3). This evident protection is thought to be due to improved plasma lipid profiles, particularly an increase in HDL cholesterol (4–6), increased adiponectin (7), reduced plasma fibrinogen (8), viscosity (9), platelet activity (10, 11), C-reactive protein (8, 12), and improved insulin sensitivity (13). However, the protective effect of alcohol is not uniform across sex and populations or socioeconomic classes (14, 15), which raises doubts as to whether alcohol per se is truly protective or instead is a marker for another protective factor associated with alcohol consumption (4). Others have suggested that certain types of alcohol, eg, wine, may be more protective than others (16 –18). Growing evidence (2, 6, 14) suggests that the amount and pattern of intake, rather than the type of alcohol (19, 20), are more important in explaining the effects of alcohol in populations. Other studies suggest that sex (14) and genetic diversity of alcohol users (6, 21) may also play an important role in explaining the observed protection and differences across studies. For instance, in a recent prospective study, alcohol was inversely related to MI in white Americans but was hazardous for hypertension and MI in African Americans (14, 22). These disparities could be due to differences in alcohol intake patterns or the prevalence of functional genetic polymorphisms in genes encoding alcoholmetabolizing enzymes that have been reported across races (23–26). Polymorphisms in the alcohol dehydrogenase gene have been associated with changes in bothHDLcholesterol and risk of MI in moderate drinkers (6). Apart from one multicountry study (3) in which consumption of alcohol was marginally associated with a reduced risk of MI, to date, no large case-control studies have investigated the association between alcohol intake, patterns, and risk of MI in developing countries where diet and lifestyles differ from those in Western cultures. We conducted a large (n = 4548), matched, incident casecontrol study of residents of the Central Valley of Costa Rica, a country with low wine intake, to determine whether alcohol users, compared with self-reported lifelong abstainers, are less likely to have an MI. We also determined whether the pattern of alcohol drinking is associated with the risk of MI or intermediate phenotypes such as plasma lipid concentrations.
Arachidonic acid in adipose tissue is associated with nonfatal acute myocardial infarction in the Central Valley of Costa Rica
(The Journal of Nutrition, vol. 135, no. 12, 2004) Baylin, Ana; Campos, Hannia
Arachidonic acid (AA), a precursor of prothrombotic eicosanoids, is potentially atherogenic, but epidemiologic data are scarce. We evaluated the hypothesis that increased AA in adipose tissue is associated with increased risk of nonfatal acute myocardial infarction (MI), and if so, whether this association is related to dietary or adipose tissue linoleic acid. We studied the association between AA and MI in 466 cases of a first nonfatal acute MI, matched on age, gender, and residence to 466 population controls. Fatty acids (FA) were assessed by GC in adipose tissue samples collected from all subjects. Odds ratios (OR) and 95% CI were calculated from multivariate conditional logistic regression models. Subjects in the highest quintile of adipose tissue AA (0.64% of total FA) had a higher risk of nonfatal acute MI than those in the lowest quintile (0.29% of total FA), after adjusting for potential confounders including (n-3) and trans FAs (OR=1.94, 95% CI: 1.07, 3.53, P for trend = 0.026). Adipose tissue AA was not correlated with dietary AA (r 0.07), linoleic acid (r 0.04), or other dietary (n-6) FAs, or with adipose tissue linoleic acid (r = -0.07). These data suggest that the association between MI and adipose tissue AA is not related to dietary intake of (n-6) FAs including linoleic acid. Better understanding of the metabolic factors that increase AA in adipose tissue is urgently needed.
Susceptibilidad al tetanos y rubeola en las mujeres de Costa Rica, 1984-85
(Revista Costarricense de Ciencias Médicas, vol. 9, no. 4, 1987) Ramírez, Jorge A.; Rosero Bixby, Luis; Oberle, Mark W.
Se documenta por primera vez en Costa Rica, el nivel de susceptibilidad al tétanos y la rubéola en la población femenina costarricense entre los 25 y 29 años. Se encuestó a 805 de las mujeres (93%) que conformaban la muestra, de ellas el 88 por ciento (762) dio su consentimiento para la obtención de muestras de sangre para el análisis serológico. El nivel de susceptibilidad encontrado para la rubéola y el tétanos fue de 10.9 y 7.9 por ciento, respectivamente. Las mujeres susceptibles al tétanos presentaron una asociación estadísticamente significativa (p<0.05) con la edad, la educación y el estrato socioeconómico. En contraste, las susceptibles a la rubéola no presentaron ninguna asociación estadística. La entrevista oral para determinar susceptibilidad a la rubéola mostró una sensibilidad sólo del 26 por ciento, en contraposición a la del tétanos que fue de un 40 por ciento. Se discuten las medidas complementarias a los programas de vacunación ya existentes, necesarias para disminuir o eliminar los acúmulos de susceptibles en la población de mujeres costarricenses.
A population-based serosurveillance of syphilis in Costa Rica
(Sexually Transmitted Diseases, vol. 18, no. 2, 1991) Larsen, Sandra; Oberle, Mark W.; Sánchez Braverman, Juana M.; Rosero Bixby, Luis; Vetter, Kathleen M.
As part of a case-control study to investigate the high incidence of cervical cancer in Costa Rican women, the seroprevalence of the treponematoses, in particular, syphilis was determined. In each age group, women with a history of two or more sex partners were two to four times more likely to be seroreactive in tests for syphilis than women with zero or one sex partner. The highest percentage of reactive results in the microhemagglutination assay for antibodies to Treponema pallidum (MHATP) was seen in samples from women aged 50-59 who had had two or more lifetime partners (23.8%). Three observations from our study support reactivity due to syphilis rather than yaws or pinta: ( /) a similar percent of reactive rapid plasma reagin (RPR) card test results among MHA-TP reactors in the two age groups of women who were surveyed (42 vs. 49%) was observed; (2) women who were seroreactive in the MHA-TP had multiple risk factors for STD (low socioeconomic status (9.4%), urban residence (22.8%), first intercourse under 16 years of age (14.1%), and multiple sex partners (26.3%)|, and (j) only sexually experienced women had reactive results in the MHA-TP test.
Herpes simplex virux type 2 antibodies : high prevalence in monogamous women in Costa Rica
(The American Journal of Tropical Medicine and Hygiene, volumen 41, no. 2, 1989) Oberle, Mark W.; Rosero-Bixby, Luis; Lee, Francis K.; Sánchez Braverman, María; Nahmias, Andre J.; Guinan, Mary E.
We studied the prevalence o f antibody to Herpes simplex virus types 1 and 2 (HSV-J and HSV-2) in 766 randomly selected Costa Rican women 25-59 years of age in a national household survey in 1984-1985. Overall, 97.1% were seropositive for HSV-1 and 39.4% for HSV-2. Only 1.1% o f HSV-2 seropositive women gave a history o f symptomatic genital herpes. HSV-2 virus antibody increased with age and with the number of lifetime sexual partners. HSV-2 seroprevalence among women who reported only 1 lifetime sexual partner was almost twice as high as the prevalence among women who denied sexual experience (30.5% vs. 17.7%) and reached 79.2% among women with > 4 partners. HSV-2 seroprevalence was lower among women whose partners used condoms: 28.9% for those who had used condoms for at least 2 years vs. 44.3% for those who never used condoms.
Monitoring a primary health care programme with lot quality assurance sampling : Costa Rica, 1Monitoring a primary health care programme with lot quality assurance sampling : Costa Rica, 1987987
(Health Policy and Planning, volumen 5, no. 1, 1990) Rosero Bixby, Luis; Grimaldo, Carmen; Raabe, Carlos
The Lot Quality Assurance Sampling (LOAS) method was developed in industry to determine at reasonable cost whether each lot of a shipment is acceptable, based on samples of a few elements from the lot. Acting as inspectors of quality control, the field supervisors of the Costa Rican primary health care programme used the LOAS technique to assess performance in all of the programme's 758 delivery points (lots). They selected probability samples of 20 households and classified the lot as unacceptable when the sample contained more than four unserved households. This 20-4 LOAS rule was aimed to identify lots with less than 70% coverage. Forty-three percent of lots were found unacceptable in their home visit schedule, and 25% unacceptable in vaccination coverage. The probability of accepting defective lots, or consumer risk, was estimated at 4%, and the probability of rejecting acceptable lots, or provider rik, was at 17%. As side results, it was found that 84% of children aged 1–2 years were fully vaccinated, and an estimated 58% of households had been visited in the last six months. A household survey showed that clinic records, which serve as both a sampling frame and source of information for the LOAS assessment, produce accurate estimates of vaccination coverage but contain biased information about home visit dates. Given the chronic lack of timely and accurate information from service statistics, and the high costs of conventional sampling surveys, the LOAS technique appears to be a cost-efficient alternative for monitoring delivery points of primary health care in some circumstances.
Prevalencia de enfermedades de transmisión sexual en las mujeres de Costa Rica
(Revista Costarricense de Ciencias Médicas, volumen 11, no. 2, 1990) Oberle, Mark W.; Rosero-Bixby, Luis; Larsen, Sandra
Pocos estudios han descrito la epidemiología de las infecciones por enfermedades de transmisión sexual (ETS) basándose en muestras serológicas representativas de la población en general y no solo en grupos selectos de pacientes. Ello se debe a la dificultad para obtener serologías en muestras representativas de la población y a la falta de información sobre el historial médico y sexual de los pacientes para quienes existen estudios serológicos. Por otra parte, es solo en años recientes que se ha desarrollado una prueba serológica lo suficientemente especifica par diferenciar los anticuerpos a los tipos 1 y 2 del virus del Herpes simplex (VHS) (1) lo que ha hecho posible estimar con precisión la prevalencia de la infección con el VHS de tipo 2 (VHS-2): una de lá& más importantes ETS. El presente artículo se basa en las pruebas serológicas y la información de una muestra nacionalmente representativa de las mujeres de Costa Rica. Describe la prevalencia de anticuerpos al virus del Herpes simplex tipos 1 y 2, sífilis, chlamydia, virus de inmunodeficiencia humana (HlV-1) y virus linfotrópico de células humanas-T (HTLV-1) según características demográficas, médicas y sexuales. El artículo también muestra la distribución regional de la prevalencia de anticuerpos a estos agentes.
La actividad sexual en Costa Rica: una medición estadística
(Asociación Demográfica Costarricense, 1985) Rosero-Bixby, Luis; Sosa Jara, Doris; Grimaldo Vásquez, Carmen
Con el objeto de medir la frecuencia de relaciones sexuales entre las parejas costarricenses, se entrevistó. en 1982 a una muestra de más de 800 mujeres que utilizan los servicios públicos de planificación familiar. Se obtuvo un promedio de 1.7 relaciones sexuales para la semana anterior a la entrevista. Sin embargo, las entrevistadas declararon que “generalmente” tienen un número mayor (2.5 en promedio). La actividad sexual resultó más intensa el fin de semana, especialmente el día sábado. En este día resultó un 50 por ciento mayor que de lunes a jueves. Se estimó que la actividad sexual es bastante menor —pero no es nula- durante los días de la menstruación. En el resto del ciclo menstrual ésta no es homogénea. Se estimó que la fecundabilidad, o probabilidad de concebir en un ciclo menstrual, será de entre 20 y 23 por ciento si el grupo estudiado no utilizara, anticonceptivos. Las mujeres recién casadas mostraron una frecuencia mayor de relaciones sexuales. En función de la edad o la educación de la mujer no se observaron diferencias.
The children of Santa María Cauqué : a prospective field study of health and growth
(Cambridge, Mass, 1978) Mata, Leonardo J.
This study of the natural history of health and growth of children was conceived in Boston, was born and grew in Guatemala, and matured in Seattle. In Boston the concept of a study in a developing rural region and the plans to carry it out were developed and fertilized by discussions with teacherd and friends. The choice of Guatemala for the field work was logical in view of my own origin in Central America and a personal familiarity with the area.
Porcentaje de cobertura del seguro social, 1984
(INISA, 2000) Guell, Douglas; Rosero Bixby, Luis

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