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AMERICAN JOURNAL OF HUMAN BIOLOGY 00:0000 (2015)

Original Research Article

Intergenerational Changes in Knee Height Among Maya Mothers and Their


Adult Daughters from Merida, Mexico
^ VARELA-SILVA,3 SUDIP DATTA BANIK,1 AND FEDERICO DICKINSON1
HUGO AZCORRA,1* LUIS RODRIGUEZ,2 MARIA INES
Department of Human Ecology, Centro de Investigaci
on y de Estudios Avanzados del Instituto Politecnico Nacional (Cinvestav)-Unidad
Merida, 97310 Merida, Yucatan, Mexico
2
Facultad de Matem
aticas, Universidad Aut
onoma de Yucat
an, Merida, Yucat
an, Mexico
3
Centre for Global Health and Human Development, School of Sports, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU United Kingdom

Objectives: To analyze differences in knee height (KH) between adult Maya mothers and daughters in Merida City,
Mexico, and determine if these differences are associated with their childhood socioeconomic conditions.
Methods: From September 2011 to January 2014, we measured KH and collected data on childhood conditions (place
of birth, type of drinking water, family size, and fathers occupation) from a sample of 180 Maya mother-daughter
dyads. Mean KH intergenerational difference was calculated and compared for each category of socioeconomic variables and a multiple regression model was used to assess the association between childhood conditions and KH
difference.
Results: A relative increase of 1.05 cm (SD 5 2.3 cm) or 0.45 standard deviations (effect size of difference) was
observed in KH between generations. Place of birth was significantly associated with KH. With three other variables
statistically adjusted for, the intergenerational KH difference was 1.5 cm greater when mothers born outside Merida
but daughters born in the city. Piped water consumption by mother-daughter dyads was associated with 1.5 cm of
increase in KH difference compared with dyads who consumed well water (P 5 0.058).
Conclusions: The relative increase in KH between mothers and daughters represents a portion of the expected
change in growth in a group that has experienced few substantial improvements in their living conditions. Some
improvements in childhood living conditions resulting from the intergenerational transition from rural to urban environments seem to be linked to a modest, but statistically significant intergenerational increase in KH among Maya
C 2015 Wiley Periodicals, Inc.
V
women in Merida. Am. J. Hum. Biol. 00:000000, 2015.
INTRODUCTION
Intergenerational changes in human growth are usually assessed using changes in the mean heights of a
population at different points of time; however, some
studies suggest that positive changes in adult stature
between populations are mainly explained by increases
in lower body segments (Bogin et al., 2002, Cole, 2003;
Bogin, 2013; Garn, 1987, Hauspie et al., 1997; Himes,
1979; Moore, 1970; Tanner et al., 1982). Specifically,
lower limb distal segments may be more sensitive than
lower limb upper segments during prepubertal growth
periods (Bailey et al., 2007; Lampl et al., 2003; Pomeroy et al., 2012). In addition, distal limb segments,
especially the tibia, tend to exhibit more variation than
the proximal segments (femur) within and between
populations (Auerbach and Sylvester, 2011; Holliday
and Ruff, 2001). Tibia length is a notoriously difficult
parameter to measure in living people, but knee height
(KH) can be used as a proxy for this segment (Bogin
et al., 2014).
Knee height is particularly useful in the evaluation of
intergenerational (i.e., parents-offspring) differences in
growth attained as adults. It has been estimated that the
cumulative height reduction from 30 to 70 years of age
is, on average, 3 cm for men and 5 cm for women, and
further accelerates afterward (Sorkin et al., 1999). However, loss in adult height is less pronounced in lower
body segments than in trunk (Chumlea et al., 1985). The
KH tends to be relatively stable from early adulthood to
senescence and some studies report that this segment is
the most closely associated with total height in adults
C 2015 Wiley Periodicals, Inc.
V

from different populations (Bermudez et al., 1999; Duyar


and Pelin, 2003; Palloni and Guend, 2005; Prothro and
Rosenbloom, 1993).
Intergenerational studies show that infancy and childhood are the stages of life when the largest proportion of
increase in linear growth occurs (Bogin, 2013; Cole, 2003;
Hauspie et al., 1997). This suggests that nutrition and
other environmental factors experienced during the first
years of life may partially explain intergenerational differences in lower body segments such as KH.
Intergenerational changes in the length of body segments, such as KH, can be positive or negative in response
to the changes in environmental conditions experienced
by each generation during sensitive growth periods. Socioeconomic factors involved in the changes of patterns of
growth between generations are specific for each population and depend on changes in socioeconomic and sociopolitical circumstances among people of the studied region
or nation. We suggest that intergenerational differences
between parent and offspring (i.e., mothers and daughters) can be explained by differences in socioeconomic

Contract grant sponsor: National Council of Science and Technology of


Mexico; Contract grant number: 168047.
*Correspondence to: Hugo Azcorra, Departamento de Ecologa Humana,
Centro de Investigaci
on y de Estudios Avanzados del Instituto Polit
ecnico
Nacional, M
erida, Yucat
an, M
exico. E-mail: hugoazpe@hotmail.com
Received 20 November 2014; Revision received 11 May 2015; Accepted
16 May 2015
DOI: 10.1002/ajhb.22752
Published online 00 Month 2015 in Wiley Online Library
(wileyonlinelibrary.com).

H. AZCORRA ET AL.

circumstances experienced by both generations during


childhood.
PARTICIPANTS AND METHODS
The Maya people constitute the largest indigenous
group in Mexico. The State of Yucatan in the southern
part of Mexico has historically been the home of a great
number of Maya people. Since the 1970s, Merida, the capital city of Yucatan, has attracted many Maya peasants
who have moved from the rural areas. Since the first
European contacts nearly 5 centuries ago, the Maya people have experienced adverse living conditions. Even,
nowadays, as a group, the Maya are still involved in
social, economic, and cultural transitions resulting from
the imposition of government policies related to the
national and global economy (Bracamonte, 2007). These
adverse environmental conditions have been probably
expressed in the poor biological status of the Maya. Previously published studies involving living populations suggest that mean height among Maya women in Yucatan
has remained historically very low (<148 cm). Early studies done in Yucatan between 1895 and 1941 found that
mean height in Maya women ranged from 141.5 cm to
142.7 cm (Starr, 1902; Steggerda, 1932, 1941; Williams,
1931). More recent studies have reported average mean
height in adult Maya women residing in Merida of
147.2 cm (SD 5 5.4) (Varela-Silva et al., 2009), 147.9 cm
(SD 5 4.8) (Azcorra et al., 2013), and 146.8 cm (SD 5 4.6)
(Wilson et al., 2014). The objectives of this study are: (i) to
analyze differences in KH between Maya mothers and
their adult daughters in the city of Merida, Mexico, and
(ii) determine if these differences are associated with socioeconomic circumstances experienced by the mothers and
daughters during their childhood.
Ethical clearance
The research design was approved by the Bioethics
Committee for the Study of Human Beings of the Center
for Research and Advanced Studies of the National Polytechnic Institute (Cinvestav-IPN), Mexico, and by the
Ethical Advisory Committee of Loughborough University,
UK. Mothers and daughters were informed in details
about the purpose of the study and their rights as participants. Written informed consent was obtained from literate participants and thumb impressions were asked from
illiterate women as proof of their consent.
Sample size
The sample included 180 dyads of Maya mothers and
their adult biological daughters residing in Merida city.
The sample did not include daughters who were siblings.
Maya ethnicity was identified by the presence of both
paternal and maternal Maya surnames in mothers and
daughters. Fathers were not included in this study
because they were almost always unavailable, spending
most of the days, including weekends, at work outside
home. While we acknowledge that paternal genetic influences contribute to individual mother-daughter differences in KH, average contributions by fathers are assumed
to be similar.
Data collection
A cross-sectional and intergenerational study was
undertaken from September 2011 to January 2014 in the
American Journal of Human Biology

neighborhoods from south, west, and east of Merida. Left


KH was measured in mothers and daughters with participants seated, barefoot, and with the lower leg positioned
at a 90-degree angle to the thigh. KH was measured as
the distance between the proximal border of the patella
and the floor, as suggested by Bogin (2012). Anthropometric measurements were done during home visits by
trained female research assistants.
A socioeconomic questionnaire was applied to mothers
and daughters addressing childhood living conditions.
The questionnaire design was based on similar instruments developed and applied over the last years by two of
the coauthors (FD and MIVS) and their research assistants and postgraduate students. Since the questionnaire
was designed to obtain retrospective information, based
on peoples memory, we gave special care to include in several parts of the questionnaire questions that allowed us
to confirm responses given by the participants. Research
assistants who applied the questionnaire were attentive
to identify inconsistencies in responses obtained from the
participants and, if necessary, clarified the situation or
made observations to allow subsequent interpretations.
In addition, questionnaires were applied during home visits and mothers and grandmothers helped each other to
answer questions related to their childhood. In this study,
we are focusing on four socioeconomic variables collected
from both generations: (1) place of birth, (2) family size
(FS), (3) type of drinking water, and (4) fathers occupation. The rationale for the selection of these variables was
based on our knowledge about social and economic
changes that occurred in Yucatan in recent decades. We
selected parameters that represent plausible links to
intergenerational differences in growth and were sufficiently variable among the participating mother-daughter
dyads.
With reference to the socioeconomic parameters, three
categorical and one numeric variable were taken into
account to describe the conditions of both generations.
Three levels of place of birth were defined: (1) mother and
daughter born out of Merida, (2) mother born out of Merida and daughter born in Merida, and (3) mother and
daughter born in Merida. Categories of type of drinking
water were: (1) mother and daughter drinking well water,
(2) mother drinking well water and daughter drinking
piped water, and (3) both mother and daughter drinking
piped water. Categories of fathers occupation were: (1)
mother and daughter with a peasant father, (2) mother
with a peasant father and daughter with a nonpeasant
father, and (3) mother and daughter with a nonpeasant
father. The quantitative variable FS was computed with
the difference between the number of family members of
both generations (daughters FS mothers FS).
Statistical analysis
Preliminary analyses used paired Students t-test to
compare differences in KH and FS between motherdaughter dyads. Chi-square tests were used to compare
the categories of place of birth, type of water to drink, and
fathers occupation between mothers and daughters. Oneway ANOVA were used to compare the intergenerational
differences in KH (KH differences 5 daughters KH
mothers KH) among categories of place of birth, type of
water to drink, and fathers occupation. A multiple regression model was used to assess the association between

INTERGENERATIONAL CHANGES IN KNEE HEIGHT IN MOTHER-DAUGHTER DYADS

socioeconomic variables and intergenerational differences


in KH with other variables adjusted for. Except by FS,
each predictor was introduced into the model as two
dummy variables with a third as the reference, having
the smallest mean value. The next categories of predictors
were used as the references in the model: mother and
daughter born out of Merida, mother and daughter drinking well water, and mother and daughter with a peasant
father. The difference in FS between generations was
introduced into the model as a numerical variable. All
possible interactions between predictors were generated
and regressed on the outcome to check their effects. Several diagnostic tests were used to assess the validity of
models. Normality of residuals and outcome variable was
verified using Shapiro-Wilk test. Noncollinearity between
predictors was confirmed by the calculation of variance
inflation factor values. Statistical analyses were done
using the Stata/IC 11.1 for Windows statistics package
(StataCorp LP, 2010). Significance level in all analyses
was a 5 0.05.
RESULTS
Mothers (mean age 5 60.16 years, Standard Deviation
or SD 5 8.93) were on average 27.05 (SD 5 7.18) years
older than their daughters (mean age 5 33.11 years,
SD 5 5.63), and daughters showed higher mean values of
KH than their mothers (45.53 cm [SD 5 2.03] vs. 44.48 cm
[SD 5 1.90], P < 0.001; mean difference 5 1.05 cm
[SD 5 2.33]; t 5 6.05, df 5 179).
Differences in socioeconomic conditions experienced in
childhood between mothers and daughters are presented
in Table 1. Only 7.2% (13/180) of mothers were born in
Merida, compared with 41.1% (74/180) of their daughters.
As a group, daughters grew up in families slightly smaller
than their mothers and the proportion of women that consumed well water during childhood was greater in mothers than in daughters (93.9% vs. 28.3%). Compared with
their daughters, most of mothers reported that their
father was peasant (78.9% vs. 22.6%).
Table 2 shows the mean intergenerational differences
in KH for each category of socioeconomic variables. Place
of birth was the only unadjusted variable that was significantly associated with KH differences; the greatest mean
difference was between mothers born outside Merida and
daughters born in Merida. A Bonferroni multiple comparison tests revealed that KH differences among motherdaughter dyads just noted were significantly greater than
among dyads where both mother and daughter were born
outside Merida (1.98 cm vs. 0.53 cm). As indicated in
Table 2, unadjusted differences of other variables considered were not statistically significant, though the smallest
mean differences were found in mother-daughter dyads
that plausibly experienced the smallest changes in childhood environments. Unadjusted association (simple
regression) between the difference in FS and the outcome
variable was not significant. The mean value of the intergenerational difference in FS was 20.97 (SD 5 3.86).
Multiple regression model for intergenerational differences in KH is presented in Table 3. Place of birth was significantly related to the outcome variable (KH). With
other variables statistically adjusted for, compared with
the reference category (mother and daughter born outside
Merida), the differences in circumstances of mother born
outside Merida as compared with their daughters born in

TABLE 1. Differences in socioeconomic indicators between daughters

and mothers by childhood living conditions variables


Variables
Place of birth
Born in Merida
Born outside Merida
Family size
Drinking water access
Well
Piped
Fathers occupation
Peasant
Nonpeasant

Daughters

Mothers

P-value

41.1%
58.9%
7.2 (SD 5 2.4)

7.2%
92.8%
8.2 (SD 5 3.2)

P < 0.001

28.3%
71.7%

93.9%
6.1%

P < 0.001

22.6%
77.4%

78.9%
21.1%

P < 0.001

P < 0.001

the city were significantly associated with an increases of


1.5 cm KH difference. Consumption of piped water during
childhood by both mothers and daughters was associated
with an increase in KH difference (1.5 cm) compared with
those mothers and daughters who consumed well water
(P 5 0.058). The intergenerational differences in FS and
paternal occupation were not significantly associated with
intergenerational differences of KH. None of the interactions between predictors showed a significant association
with intergenerational differences in KH.
DISCUSSION
Our results suggest that the Maya daughters of our
sample experienced slightly better childhood living conditions than their mothers, which is consistent with their
mean increase of 1.05 cm in KH. Given the variation of
mean intergenerational difference in KH (SD 5 2.3 cm),
this difference represents an estimated effect size of difference around 0.45 standard deviations. This positive
change may be associated with investment made by the
Mexican government during the last 34 decades to
reduce poverty levels in the region. Government investment has been focused on improvements in basic household infrastructure and the health care system (Levy,
2006; OECD, 2007). Poor families have been supplied
with better access to piped drinking water, concrete floors,
and toilets in the house. Improvements in the health care
system have included the increase in the number of
health care units in urban and rural areas and an expansion in the immunization and coverage of vitamin doses to
infants. However, we suggest that the conditions experienced by previous generations of the Maya in Yucatan
were so precarious that these material improvements
observed in the last years have not been sufficient to
make more than fairly modest increases in measures of
growth such as KH.
The study of Maya migrants in the United States of
America by Bogin et al. (2002) provides a useful initial
point of comparison for our results. In their study, Bogin
and his coworkers found that Guatemalan Maya children
aged 5 to 12 years living in a poor setting in the United
States were 11.54 cm taller than their peers living in Guatemala and that 60% of the mean height increase was
explained by the differences in leg length (leg length5 height sitting height). Differences between groups
were attributed to remarkable improvements in sanitary
conditions and food support programs of schools in the
United States. Compared with these findings, we may
suggest that the 1.05 cm increase as identified in this
study between mothers and daughters who had completed
American Journal of Human Biology

H. AZCORRA ET AL.

growth in KH, represent only a portion of the potential


increase in growth between generations we might anticipate if Maya people living in and around Merida experience more substantive positive changes in future.
Both the unadjusted (see Table 2) and adjusted results
(Table 3) indicate that the single greatest influence on
mother-daughter differences in KH reflected where the
individuals were born. A brief review of the history of the
area helps explain why. Almost all of the mothers in this
study were born in the former sisal (Agave sisalana sp.)
cultivation zone of Yucatan between 1949 and 1960. During this period, this zone was subject to an economic system derived from the agrarian reform of the 1930s and
1940s. In this system, the elite social group (rich families
who had substantial political influence within the government) controlled the processing of sisal fiber even when
the agricultural laborers were working under the figure of
the ejido, a kind of collective ownership (Bracamonte,
2007). Many Mayan men, the family heads, were
employed in the sisal agro-industry under very disadvantaged socioeconomic conditions.
TABLE 2. Mean and standard deviations of intergenerational differ-

ences of KH according to socioeconomic conditions


KH
difference
Socioeconomic parameter
Place of birth
Mother and daughter out of
Merida, n 5 106
Mother out of Merida/daughter
in Merida, n 5 61
Mother and daughter in
Merida, n 5 13
Type of water to drink
Mother and daughter well, n 5 51
Mother well/daughter piped, n 5 118
Mother and daughter piped, n 5 11
Fathers occupation
Mother and daughter peasant, n 5 36
Mother peasant/daughter
nonpeasant, n 5 95
Mother and daughter nonpeasant, n 5 34
Family size (FS)
Daughters FS Mothers FS

Mean
(cm)

SD

Test
and P-value

0.53

2.00

F 5 8.16

1.98

2.44

P < 0.001

0.88

2.13

0.81
1.03
2.36

2.30
2.33
2.29

F 5 2.05
P 5 0.132

0.57
1.04

2.00
2.29

F 5 1.69
P 5 0.170

1.63

2.78

B 5 20.03
P 5 0.558

The families of many mother participants in our study


experienced the crisis of sisal agro-industry, characterized
by low wages, unemployment, and migration. Between
1940 and 1960, most the inhabitants of Yucatan sisal zone
belonged to large families in which the fathers, with little
or no formal education, worked in the plantations or sisal
shredders for very low wages. Mothers often contributed
through household work (including fuel wood collection)
and weaving hammocks and clothes to sell to the intermediate traders at very low prices. These families usually
lived in a house with one bedroom, had only well water to
drink, cooked with firewood, and had no electricity and
drainage system. These living conditions generated
health problems as most people had no toilet in their
households (Ba~
nos, 1996; Bentez, 1962; Katz, 1980; Lugo
Perez, 1996; Nickel, 1997).
With the crisis of the sisal industry since the late sixties, but mainly after its total collapse, a great number of
Mayan people started moving to the growing urban centers such as Merida, Yucatan, and Cancun, in the state of
Quintana Roo, in search of better job opportunities (Lizama Quijano, 2012). Merida city became an important
destination for rural-to-urban Mayan migrants; from
1970 to 2000 its population increased from 212,097 to
777,615 inhabitants, which corresponded to an increase of
351% in 30 years, largely due to migration (INEGI, 1971,
2001). The immigrants (most from sisal zone) had very
low education and poor job training so they were typically
employed as masons in construction works, unskilled
laborers, and multiple informal activities such as sale of
goods along downtown street corners. These immigrants
settled in the south of the city of Merida, an area with precarious urbanization, limited access to electricity, sanitation, drinking water, transport, schools, and public
markets (Dickinson et al., 1999; Fuentes, 2005; Perez
Medina, 2010). Our results suggest that migration to Merida city produced some improvements in the living conditions of daughters families. We think it is important to
emphasize, however, that these improvements were relatively small and the absolute increase in KH of daughters
reflects more profoundly the impoverished conditions
their mothers experienced as children.
Changes in FS were not associated with intergenerational differences in KH. On average, daughters families
reported one family member less than their mothers

TABLE 3. Multiple regression model of socioeconomic parameters experienced by mothers and daughters in childhood for intergenerational dif-

ferences in KH
Variable
Place of birth
Ref 5 Mother and daughter out of Merida
Mother out of Merida/Daughter in Merida
Mother and daughter in Merida
Type of water to drink
Ref 5 Mother and daughter well
Mother well/daughter piped
Mother and daughter piped
Fathers occupation
Ref 5 Mother and daughter peasant
Mother peasant and daughter nonpeasant
Mother and daughter nonpeasant
Family size (Daughters FS Mothers FS)
Constant

Coefficient

S. E.

CI 95%

1.48
20.03

0.42
0.78

3.56
20.04

<0.001
0.966

0.66
21.57

2.30
1.50

0.12
1.54

0.41
0.81

0.29
1.91

0.774
0.058

20.70
20.05

0.94
3.13

20.02
0.38
20.05
0.31

0.48
0.61
0.05
0.43

20.04
0.63
21.03
0.72

0.970
0.532
0.303
0.474

20.98
20.82
20.14
20.54

0.94
1.59
0.04
1.15

S.E.: standard error; R2 5 0.16, Shapiro-Wilk residual normality test P 5 0.888; Breusch-Pagan/Cook-Weisberg homoscedasticity test P 5 0.180; mean variance inflation factor 5 1.39.

American Journal of Human Biology

INTERGENERATIONAL CHANGES IN KNEE HEIGHT IN MOTHER-DAUGHTER DYADS

families
[mean
mothers 5 8.2,
(SD 5 3.2);
mean
daughters 5 7.2, (SD 5 2.4)]. Decreases in FS between two
generations in our study may be associated with more
individual resources for feeding, better access to high
quality health services, and decreased crowding in the
household and better growth status among offspring could
be expected. However, it is possible that FS do not have
the same implications for growth in such generations.
Our analysis shows that paternal occupation was not
significantly associated with the differences in KH. However, the greatest difference in KH (mean 5 1.63 cm
[SD 5 2.8]) was observed when both mothers and their
daughters reported having a nonpeasant father and least
(mean 5 0.57 cm, SD 5 2) when both generations had a
peasant father during their childhood. Most of nonpeasant men were employed in Merida and outside the city as
salaried workers such as masons, laborers, and poorly
qualified employees. It is possible that the relatively better income of nonpeasant fathers the daughters generation allowed better average conditions in those
participant families and thus the expression of larger differences in KH.
As far as we know, very few studies have investigated
changes in lower body segments between parents and offspring and their associations to childhood conditions
(Bogin et al., 2014; Sohn, in press; Floyd, 2007; Himes,
1979). In their study among Taiwanese families living in
Auckland, New Zealand, and Taipei, Taiwan, during
2003, Floyd (2007) found that parent-offspring differences
in subischial leg length tended to be less when both generations experienced disadvantaged living conditions in
early years of development; more noticeable changes were
observed when conditions experienced by parents were
relatively more unprivileged than their offspring and differences were less evident when parents and offspring
experienced relatively well-off circumstances in childhood. Our results are consistent with findings reported by
Floyd (2007) in the sense that greater differences in KH
were observed when daughters experienced better conditions than their mothers, as is the case of place of birth.
In their study with Bangladeshi mothers and daughters
living in Bangladesh and in the UK, Bogin et al. (2014)
found that daughters born and living in the UK were
3.8 cm taller than daughters living in the UK but born in
Bangladesh, with KH values accounting for 53% (2 cm) of
the total difference in height. The authors suggest that
these differences are due to that (1) living conditions experienced by women in Bangladesh were worse than in the
UK during childhood, and (2) the daughters born in Bangladesh experienced more emotional stress due to the
migration, including the fact that fathers usually
migrated first, leaving mothers and children behind for
some months or years. In our study, Mayan daughters
born in Merida were around 1.5 cm taller than daughters
born outside of Merida; the differences in KH being about
0.6 cm. The magnitude of the differences compared with
the differences reported by Bogin and collaborators with
Bangladeshi women are consistent with differences in the
amounts of change in developmental settings. We suggest
that living conditions in the UK of Bangladeshi women
after migration were substantially better than circumstances experienced by Maya women in the city of
Merida.
In summary, childhood living conditions experienced by
Mayan daughters were somewhat better than that their

mothers experienced, which is consistent with their positive difference in KH (mean 5 1.05 cm [SD 5 2.33]). Our
analysis suggests that differences are associated with
rural-to-urban migration experienced by mothers as a
result of the sisal agro-industry crisis and its collapse in
Yucatan from the 1960s to the 1980s and by the differences in FS between generations influenced by official policies toward birth control. Our results suggest that present
living conditions of Mayan women remain generally
unfavorable, constituting a continuation of those experienced by their ancestors since, at least, the 19th Century
in the sisal zone, a period of time known locally as The
Slavery Time, as one informant reported to one of us (FD)
in 1978.
ACKNOWLEDGMENTS
The authors thank two anonymous reviewers for their
criticism and suggestions. The authors also thank Ms.
Graciela Valentn and Ms. Adriana V
azquez-V
azquez for
assisting with somatic measurements, questionnaire
application and field work organization, and Ms. Frida
Gutierrez, Ms. Paulina Cauich, and Ms. Samantha
S
anchez for collaborating in the field work. Ms. Ina Susan-Lopez and Ms. Adriana V
azquez-V
azquez
ana Falf
developed the dataset and took part in participant recruitment design. The authors also thank the mothers and
daughters who agreed to participate in the study. Mr.
John Lindsay improved our written English.
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