Revista Panamericana de Salud Pública/Pan American Journal of Public Health

Structural equation model for predicting well-being and functional dependency of the elderly in the Dominican Republic

Objective. To produce a multivariate structural model that explains functional dependence and well-being in terms of certain related sociodemographic factors among elderly adults in the Dominican Republic.
Methods. A cross-sectional study that surveyed a sample of 1 397 individuals 65 or more years of age, representing the Dominican Republic’s elderly population. Those surveyed were asked for sociodemographic information (sex, age, level of education, employment status, and income level), data needed to determine their Barthel Index, and responses to questions from Ryff’s Scale of Psychological Well-being. Three structural equation models were used to identify relationships among the key variables.
Results. The most fitting structural adjustment model linked sociodemographics to the ability to perform basic activities of daily living (BADL) and the Ryff’s Scale of Psychological Well-being, without suggesting latent factors. With regard to endogenous variables, the model’s predictive power was weak. Age was negatively associated with some areas of well-being and with the ability to perform BADL; sex was related to the area of positive relationships with others; and educational level positively influenced environment, personal growth, and having a sense of purpose, as well as the ability to perform BADL.
Conclusions. The proven models provide information necessary for developing policies aimed at two levels of coordinated action: promoting autonomy among elderly adults and expanding enrollment in formal education programs. These results support efforts to increase investment in social policies.

Objetivo. Generar un modelo estructural multifactorial que explique la dependencia funcional y el bienestar a partir de algunas características sociodemográficas asociadas con esos dominios, en adultos mayores de la República Dominicana.
Métodos. Estudio transversal mediante encuesta en una muestra de 1 397 personas de 65 años o más representativa de la población de adultos mayores de la República Dominicana. Se recabó información sociodemográfica de los entrevistados (sexo, edad, nivel de estudios, si realizaba alguna actividad remunerada y nivel de ingresos) y los datos necesarios para calcular el índice de Barthel y las respuestas a las preguntas de las escalas del bienestar psicológico de Ryff. Para identificar las relaciones entre las variables de interés se probaron tres modelos de ecuaciones estructurales.
Resultados. El modelo estructural de ajuste más satisfactorio relacionó las características sociodemográficas con la capacidad para realizar las actividades básicas de la vida diaria (ABVD) y las dimensiones del bienestar psicológico de las escalas de Ryff sin proponer factores latentes. La capacidad predictiva del modelo para las variables endógenas fue débil. La edad se relacionó negativamente con algunas dimensiones del bienestar y con la capacidad para realizar las ABVD; el sexo se relacionó con la dimensión de relaciones positivas con otros; y el nivel de estudios influyó positivamente sobre el dominio del ambiente, el crecimiento personal y el propósito en la vida, así como en la capacidad para realizar las ABVD.
Conclusiones. Los modelos validados brindan información necesaria para desarrollar políticas orientadas a dos niveles de acción complementarios: la promoción de la autonomía de los adultos mayores y el aumento de la cobertura de los sistemas de enseñanza formal. Estos resultados respaldan la conveniencia de aumentar las inversiones en políticas sociales.

Sociodemographic factors associated with symptoms of depression in a sample of women held at two prisons in Mexico

Objectives. To determine the prevalence of depressive symptoms among a sample of women held in two Mexican prisons and to identify the sociodemographic factors associated with these symptoms.
Methods. An exploratory, descriptive study was conducted of women 18–50 years of age in two prisons in the state of Veracruz, Mexico: the Pacho Viejo (PV) facility and Fortaleza San Carlos (FSC) facility. The Hamilton scale for depressive illness was applied and relationships were found between the participants’ scores and their sociodemographic traits (age, marital status, number of children, jail work assignment, and number/frequency of visitors), legal status, type of crime committed, and length of sentence. The analysis employed Student’s T test, Chi-squared test, and Student- Newman-Keuls’ post hoc test, depending on the variable.
Results. All of the women studied at both facilities presented with symptoms of depression. Women at the PV facility had a lower score for depressive symptoms than those at FSC (20.8 ± 0.8 versus 25.2 ± 0.9; P < 0.001). A higher score was found among women with children than among those without children (25.3 ± 0.9 versus 21.8 ± 1.3; P < 0.05); the group of women receiving weekly visits scored (15.0 ± 1.3) significantly lower than the other groups (F[4.46] = 30.7; P < 0.0001). No significant differences were found to be related to marital status, work assignment, age, type of crime, or the length of sentence.
Conclusions. Symptoms of depression were prevalent among the study sample, and were most powerfully related to having children and infrequent visits. Social adaptation programs should encourage continuous contact between women and their children, family, and friends.

Objectives. To determine the prevalence of depressive symptoms among a sample of women held in two Mexican prisons and to identify the sociodemographic factors associated with these symptoms.
Methods. An exploratory, descriptive study was conducted of women 18–50 years of age in two prisons in the state of Veracruz, Mexico: the Pacho Viejo (PV) facility and Fortaleza San Carlos (FSC) facility. The Hamilton scale for depressive illness was applied and relationships were found between the participants’ scores and their sociodemographic traits (age, marital status, number of children, jail work assignment, and number/frequency of visitors), legal status, type of crime committed, and length of sentence. The analysis employed Student’s T test, Chi-squared test, and Student- Newman-Keuls’ post hoc test, depending on the variable.
Results. All of the women studied at both facilities presented with symptoms of depression. Women at the PV facility had a lower score for depressive symptoms than those at FSC (20.8 ± 0.8 versus 25.2 ± 0.9; P < 0.001). A higher score was found among women with children than among those without children (25.3 ± 0.9 versus 21.8 ± 1.3; P < 0.05); the group of women receiving weekly visits scored (15.0 ± 1.3) significantly lower than the other groups (F[4.46] = 30.7; P < 0.0001). No significant differences were found to be related to marital status, work assignment, age, type of crime, or the length of sentence.
Conclusions. Symptoms of depression were prevalent among the study sample, and were most powerfully related to having children and infrequent visits. Social adaptation programs should encourage continuous contact between women and their children, family, and friends.

Reasons for and barriers to exercising and sports participation in Madrid

Objectives. To analyze the motivators and barriers to physical activity and sports among the population of metropolitan Madrid, as well as any correlations with gender, age, and social status.
Methods. A cross-sectional study of a sample of 625 individuals whose data were representative of the whole population, with a + 4% margin of error and a 95.5% confidence interval (95%CI). The sampling type selected was multistage, utilizing an ad hoc questionnaire.
Results. The most frequently cited motivations for exercising were: for fun (29.9%), to stay in shape (26.4%), and health (16.1%), differing according to gender (÷2(8) = 19.635; P = 0.009; 95%CI: 0.007–0.011) and age (÷2(32) = 55.671; P = 0.006; 95%CI: 0.005–0.0080). With regard to activity cessation, the demands of work and family (24.1%) and lack of time (22.2%) were the most common reasons, correlating with age (÷2(24) = 36.955; P = 0.041; 95%CI: 0.037–0.044) and slightly with gender (÷2(6) = 11.753; P = 0.069; 95%CI: 0.063–0.074). The reasons most often cited for never exercising were lack of time (24.4%) and not enjoying it (24.4%), uncorrelated with any of the study variables.
Conclusions. Among the study sample, the purpose of sports and exercise was for fun and recreation, aimed at maintaining and improving health and acquiring an attractive figure. Motivators driving activity and discontinuation were correlated with age and gender. Conversely, the reasons for never exercising were independent of the study variables.

Objetivos. Analizar los motivos y barreras de la poblacion metropolitana de Madrid para realizar actividad fisica y/o deporte, asi como sus relaciones con el genero, la edad y la posicion social.
Metodos. Estudio transversal realizado con una muestra de 625 personas, con datos representativos a nivel global, con un margen de error del + 4% y un intervalo de confianza del 95,5%. El tipo de muestreo fue polietapico, utilizandose un cuestionario ad hoc.
Resultados. Diversion (29,9%), mantenimiento de la forma (26,4%) y salud (16,1%), fueron los motivos de practica mas frecuentes, mostrando diferencias segun genero [ƒÔ2(8) = 19,635; p = 0,009; IC95%: 0,007.0,011] y edad [ƒÔ2(32) = 55,671; p = 0,006; IC95%: 0,005.0,008]. Respecto al abandono de la practica, las exigencias laborales y familiares (24,1%) y la falta de tiempo (22,2%), fueron las causas mas habituales, relacionandose con la edad [ƒÔ2(24) = 36,955; p = 0,041; IC95%: 0,037.0,044] y marginalmente con el genero [ƒÔ2(6) = 11,753; p = 0,069; IC95%: 0,063.0,074]. Los motivos mas frecuentes para no haber practicado nunca fueron la falta de tiempo (24,4%) y el hecho de no gustarles (24,4%), no existiendo relaciones con las variables analizadas.
Conclusiones. La practica fisico-deportiva en la muestra estudiada tiene un caracter ludico y recreativo y esta dirigida al mantenimiento y mejora de la salud y a la adquisicion de un buen aspecto fisico. Los motivos que conducen a la practica y a su abandono estan relacionados con la edad y el genero. En cambio, las razones para no haber practicado nunca son independientes de las variables analizadas.

Objective. This report aims to 1) explain and illustrate the use of the subjective well-being (SWB) approach as an alternative health-valuation methodology by estimating the monetary value of five general categories of illness in Costa Rica, and 2) foster comparative research on the advantages and limitations of alternative approaches to health valuation.
Method. Use of the SWB valuation approach to measure the monetary value of illness (MVI), based on empirical data from a representative survey in Costa Rica carried out in 2004. The MVI is defined as the estimated percentage of monthly income that would be required to compensate for the loss in life satisfaction (LS)—a primary SWB conception—that is expected to occur with the onset of illness. The five general categories of illnesses studied were cancer, cardiovascular disease, thyroid disease, arthritis, and infectious disease.
Results. There was wide disparity in the monetary values of the different illnesses. Some illnesses had relatively high monetary value compared to persons’ mean income, indicating the high value of good health and of programs that aim to prevent the emergence of illnesses or abate their negative impact on people’s well-being.
Conclusions. The SWB valuation approach can be used to estimate illnesses’ monetary value and thus can contribute to the design of health policies related to resource allocation and compensation, and revenue-generating schemes.

Estimación del valor monetario de las enfermedades en Costa Rica: enfoque del bienestar subjetivo

Objetivos. Explicar e ilustrar el uso del enfoque del bienestar subjetivo (BS) como metodología alternativa para evaluar la salud mediante la estimación del valor monetario de cinco categorías de enfermedades en Costa Rica y promover investigaciones comparativas sobre las ventajas y las limitaciones de enfoques alternativos para la valoración de la salud.
Métodos. Se utilizó el enfoque de valoración del BS para calcular el valor monetario de la enfermedad a partir de los datos empíricos de una encuesta representativa de Costa Rica realizada en 2004. El valor monetario se definió como el porcentaje estimado de los ingresos mensuales requeridos para compensar las pérdidas en satisfacción de vida —una noción primaria del BS— que ocurrirían una vez que comienza una enfermedad. Las cinco categorías generales de enfermedades estudiadas fueron: cáncer, enfermedad cardiovascular, enfermedad tiroidea, artritis y enfermedad infecciosa.
Resultados. Se observó una amplia heterogeneidad en los valores monetarios de las diferentes enfermedades. Algunas enfermedades presentaron un valor monetario relativamente alto en relación con el ingreso medio de las personas, lo que indica el elevado valor de la buena salud y de los programas dirigidos a prevenir la emergencia de enfermedades o reducir su impacto negativo sobre el bienestar de las personas.
Conclusiones. El enfoque de valoración del BS puede emplearse para estimar el valor monetario de las enfermedades y contribuir así al diseño de políticas de salud relacionadas con la asignación y la compensación de recursos y esquemas generadores de utilidades.

Human resources for health in Chile: the reform’s pending challenge

Omission of human resources from health policy development has been identified as a barrier in the health sector reform’s adoption phase. Since 2002, Chile’s health care system has been undergoing a transformation based on the principles of health as a human right, equity, solidarity, efficiency, and social participation. While the reform has set forth the redefinition of the medical professions, continuing education, scheduled accreditation, and the introduction of career development incentives, it has not considered management options tailored to the new setting, a human resources strategy that has the consensus of key players and sector policy, or a process for understanding the needs of health care staff and professionals. However, there is still time to undo the shortcomings, in large part because the reform’s implementation phase only recently has begun. Overcoming this challenge is in the hands of the experts charged with designing public health strategies and policies.

Algunos autores han destacado la dificultad de posicionar a los recursos humanos en salud como un aspecto substancial de los procesos de reforma de la salud (1). Tal afirmación se da precisamente en un escenario de crisis global del capital humano, producto de décadas de fallas en la formación de profesionales sanitarios, condiciones laborales y salarios deficientes, con la consecuente emigración de recursos humanos, y en general una mala gestión de este componente crítico para el buen funcionamiento de los sistemas de salud. En este contexto, al que hay que sumarle la insuficiencia de conocimientos acerca de los procesos de planificación y desarrollo de políticas y programas, no se puede desconocer la urgencia de que los sistemas de salud trabajen conjuntamente para dar prioridad al problema de los recursos humanos en los procesos de reforma actuales y futuros.

Peru has a large indigenous population (40% of the total), made of 72 distinct groups. These peoples are at a great disadvantage compared to the mestizos and other groups that are more closely connected with the dominant culture. The political and economic inequality and inequities are particularly stark with regard to health conditions. National policy and plans have not considered the indigenous peoples’ values and identity, nor their right to self-determination and control of their land and resources, and even less so, their health knowledge and practices, inasmuch western “modern medicine” has been imposed upon them by the dominant culture.

Since 1992, as a result of international forums and academia, as well as a growing movement in Peru to acknowledge the value of cultural diversity and the rights of indigenous peoples, Government proposals, initiatives, and programs were undertaken to incorporate and empower cultural contributions and traditional practices in a way that would not only benefit the indigenous, but also enrich, through various intercultural venues, the stock of cultural traditions and ethnic roots of the greater Peruvian society.

This article explores specifically how these intercultural strategies have been rolled out in health care to institutionalize the vertical birth method in rural, predominantly indigenous, communities, and endeavors to assess the decrease in maternal mortality, as well as the difficulties encountered, and mostly overcome, by expressing multiculturalism in the health field.

El Perú alberga muchas culturas que guardan entre sí relaciones muy diversas, a menudo conflictivas, pero que en ocasiones también revelan puntos de convergencia y aprendizajes recíprocos. El Estado nacional se define a sí mismo como democrático y representativo de esa pluralidad de culturas, pero con un sello propio que expresa pautas y valores hegemónicos sobre otras culturas escasamente reconocidas en él. Estas tensiones responden a relaciones de poder y asimetrías sociales y económicas. Es así como los grupos mejor posicionados respecto del aparato estatal logran propagar sus valores y modos de vida a la sociedad en su conjunto, en particular, a la forma de gobierno, el sistema educativo, la lengua, la administración de justicia, y las prácticas médicas. Puede ocurrir, sin embargo, que algunos elementos de las culturas no hegemónicas lleguen a formar parte de la comunidad nacional más amplia, que ciertos sectores sociales incorporen recursos culturales de otros, o que haya grupos que se resistan a adoptar nuevas ideas o prácticas.

The long-standing inequity and inefficiencies of Latin American health systems have been well established. They were worsened by the economic crisis of the 1980s and the reforms that followed. Today, many health systems in Latin America are characterized by gross inequalities, stagnant public expenditure on health as a share of gross domestic product, and high out-of-pocket expenditures (1, 2). Access to and utilization of health care services have also been reduced with a marked deterioration in public health facilities throughout the region, coupled with an increase in the precariousness of working conditions of health personnel (3). Fragmentation and segmentation have typified Latin American health care systems and have been a key concern of the Pan American Health Organization and ministries of health of the region (4). However, despite the improvement in some regional health indicators, inequalities in health status and in access to and utilization of health services remain (5–7).

Redes integradas de atención sanitaria en América Latina: hacia un marco conceptual para el análisis

Las inequidades e ineficiencias de los sistemas de salud de América Latina motivaron algunas reformas, concentradas en las últimas dos décadas, particularmente en el financiamiento y el suministro de la atención sanitaria. Este trabajo se enfoca en la introducción de redes integradas de atención sanitaria (RIAS) en varios países de América Latina y los ubica en el contexto internacional. La descripción y el análisis de las RIAS, ya fueran regionales o de afiliación, resaltan el debate actual sobre sus posibles beneficios y riesgos. El impacto de las RIAS —en términos del mejoramiento del acceso a la atención sanitaria o de la promoción de la eficiencia y la equidad en los sistemas de salud— se ha evaluado en muy pocas oportunidades. Para contribuir al tema, se propone un marco conceptual abarcador para el análisis del desempeño de las RIAS, que trata el proceso interno y los factores externos considerados críticos para alcanzar sus objetivos intermedios y finales.

New questionnaire to assess self-efficacy toward physical activity in children

Objectives. To design a questionnaire for assessment of self-efficacy toward physical activity in school children, as well as to measure its construct validity, test-retest reliability, and internal consistency.
Methods. A four-stage multimethod approach was used: (1) bibliographic research followed by exploratory study and the formulation of questions and responses based on a dichotomous scale of 14 items; (2) validation of the content by a panel of experts; (3) application of the preliminary version of the questionnaire to a sample of 900 school-aged children in Mexico City; and (4) determination of the construct validity, test-retest reliability, and internal consistency (Cronbach’s alpha).
Results. Three factors were identified that explain 64.15% of the variance: the search for positive alternatives to physical activity, ability to deal with possible barriers to exercising, and expectations of skill or competence. The model was validated using the goodness of fit, and the result of 65% less than 0.05 indicated that the estimated factor model fit the data. Cronbach’s consistency alpha was 0.733; test-retest reliability was 0.867.
Conclusions. The scale designed has adequate reliability and validity. These results are a good indicator of self-efficacy toward physical activity in school children, which is important when developing programs intended to promote such behavior in this age group.

Objetivos. Desarrollar un cuestionario para evaluar autoeficacia hacia la actividad física en niños de edad escolar, así como medir su validez de constructo, confiabilidad test-retest y consistencia interna.
Método. Se utilizó un multimétodo en cuatro etapas: 1) Investigación bibliográfica y consecutivamente un estudio exploratorio. Construcción de los reactivos del cuestionario utilizando una escala dicotómica de 14 ítems. 2) Evaluación de la validez de contenido a través de un panel de expertos. 3) Aplicación de la primera versión del cuestionario final a una muestra de 900 niños de edad escolar de la ciudad de México. 4) Determinación de la validez de constructo, la confiabilidad test-retest y la consistencia interna (Alfa de Cronbach).
Resultados. Se obtuvieron tres factores que explican el 64,15% de la varianza: búsqueda de alternativas positivas hacia la actividad física, capacidad para enfrentar posibles barreras para llevarla a cabo y expectativas de habilidad o competencia. Se validó el modelo por medio de la bondad del ajuste, obteniéndose un 65% de residuos inferiores a 0,05, resultado indicativo de que el modelo factorial estimado se ajusta a los datos. La consistencia alfa de Cronbach fue de 0,733, la confiabilidad test-retest fue de 0,867.
Conclusiones. Se desarrolló una escala con validez y confiabilidad adecuadas. Estos resultados permiten utilizarla como un buen indicador de la autoeficacia hacia la actividad física en niños de edad escolar, lo cual es importante en el desarrollo de programas cuyo objetivo sea fomentar dicha conducta en este grupo de edad.

A framework for evaluating primary health care in Latin America

Objectives. To determine the relevancy of applying the Canadian primary health care (PHC) assessment strategy to Latin America and to propose any modifications that might be needed for reaching a consensus in Latin America.
Methods. The Delphi method was used to reach a consensus among 29 experts engaged in PHC development or evaluation in Latin America. Four virtual sessions and a face-to-face meeting were held to discuss the PHC evaluation logic model and the seven goals and six conditioning factors that make up the Canadian strategy, as well as any questions regarding the evaluation and indicators. The relevance of each concept was ranked according to the perspective of the Latin American countries.
Results. The experts considered the Canadian strategy’s objectives and conditioning factors to be highly relevant to assessing PHC in Latin America, though they acknowledged that additional modification would increase relevance. The chief suggestions were to create a PHC vision and mission, to include additional objectives and conditioning factors, and to rework the original set. The objectives that concerned coordination and integrated comprehensive care did not achieve a high degree of consensus because of ambiguities in the original text and multiple interpretations of statements regarding certain aspects of the evaluation.
Conclusions. Considerable progress was made on the road to building a PHC evaluation framework for the Region of the Americas. Indicators and informationgathering tools, which can be appropriately and practically applied in diverse contexts, need to be developed.

Objetivos. Determinar la pertinencia de aplicar la estrategia canadiense de evaluación de la atención primaria de salud (APS) en América Latina y proponer las modificaciones necesarias para llegar a un consenso latinoamericano.
Métodos. Se utilizó el método Delphi para llegar a un consenso entre 29 expertos comprometidos con el desarrollo o la evaluación de la APS en América Latina. Se realizaron cuatro rondas virtuales y un encuentro presencial para discutir el modelo lógico de evaluación de la APS, los siete objetivos y los seis factores condicionantes que forman parte de la estrategia canadiense, con sus interrogantes de evaluación e indicadores. Se calificaron la relevancia y la pertinencia de cada concepto desde el punto de vista de los países de América Latina.
Resultados. Los expertos consideraron los objetivos y los factores condicionantes de la estrategia canadiense altamente pertinentes para evaluar la APS en América Latina, aunque reconocieron la necesidad de modificarlos para aumentar su pertinencia. Los principales cambios fueron la formulación de una visión y una misión de la APS, la inclusión de nuevos objetivos y factores condicionantes y la reformulación de los originales. Los objetivos de coordinación y atención integral e integrada no lograron un alto nivel de consenso debido a ambigüedades en los enunciados originales y la coexistencia de distintas interpretaciones sobre el significado de ciertas dimensiones de evaluación referidas en los enunciados.
Conclusiones. Se lograron avances significativos en el camino hacia la construcción de un marco de evaluación para la APS en la Región de las Américas. Es necesario desarrollar indicadores e instrumentos de recolección de información adecuados y factibles de ser aplicados en distintos contextos.

Design and comparative analysis of an inventory of avoidable mortality indicators specific to health conditions in Colombia

Objectives. To develop a list of indicators of avoidable mortality (LIAM) in order to analyze failed efforts to control the mortality risks prevalent in Colombia, and to compare its results to those of two widely-used approaches.
Methods. The official mortality records of Colombia for 1985–2001 were reviewed; the basic causes of death were classified according to the ICD-9. Indicators of avoidable mortality (AM) were selected using an algorithm that combined the lists of Holland and Taucher, the definition of Rutstein and colleagues, and the principle of Uemura. The proportions of avoidable deaths that resulted from applying the LIAM and the two AM lists were compared to a database containing Colombia’s official death records from 1993–1996.
Results. Of the 680 617 deaths registered during the study period, 18.2% were classified as avoidable according to Holland’s list, and 51.3%, by Taucher’s list. According to the LIAM, avoidable mortality rose to 76.7%. This pattern remained relatively stable in 1993–1996. The differences observed between the proportions of avoidable deaths according to the LIAM and that of the two other lists were related to the local epidemiological profile and the conceptual approach of each list.
Conclusions. The differences between the LIAM and the AM lists of Taucher and of Holland attest to the consequences of using one or another classification in the Colombian context. The LIAM can be a valuable resource for undergirding and evaluating health policies, but must be adjusted to the specific situation in which it is applied.

Objetivos. Elaborar un inventario de indicadores de mortalidad evitable (INIME) que permita analizar las fallas en el control de los riesgos de mortalidad predominantes en Colombia y comparar los resultados de su aplicación con los obtenidos mediante dos enfoques ampliamente utilizados.
Métodos. Se revisaron los registros oficiales de mortalidad de Colombia de 1985 a 2001; las causas básicas de muerte se clasificaron según la CIE-9. Se seleccionaron los indicadores de mortalidad evitable (ME) mediante un algoritmo que combinó las listas de Holland y de Taucher, la definición de Rutstein y colaboradores y el principio de Uemura. Se compararon las proporciones de muertes evitables resultantes de aplicar el INIME y las dos listas de ME a una base de datos con los registros oficiales de defunciones de Colombia de 1993 a 1996.
Resultados. De las 680 617 defunciones registradas en el período de estudio, se clasificaron como evitables 18,2% según la lista de Holland y 51,3% según la lista de Taucher. La ME según el INIME ascendió a 76,7%. Este patrón se mantuvo relativamente estable entre 1993 y 1996.
Las diferencias observadas en la proporción de muertes evitables según el INIME y las dos listas de ME se relacionaron con el perfil epidemiológico local y el enfoque conceptual de cada lista. Conclusiones. Las diferencias entre el INIME y las listas de ME de Holland y de Taucher muestran las consecuencias de usar una u otra clasificación en el contexto colombiano. El INIME puede constituir un recurso valioso para fundamentar y evaluar políticas sanitarias, pero debe ajustarse a la situación específica en que se aplique.