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

Objective. Only one previous study had examined the epidemiology of mental health in Guatemalan refugees. The objective of this new study was to estimate the prevalence of mental illness and to assess factors associated with poor mental health among Guatemalan Mayan refugees who had been repatriated to Guatemala after spending 12–18 years in refugee camps in Mexico, and to compare the results for the repatriated Guatemalans with those for Guatemalan refugees who were continuing to live in Mexico.
Methods. In 2001 a cross-sectional survey of adults (≥ 16 years) was conducted with random household sampling proportional to the population size in each of the five repatriation villages surveyed. Posttraumatic stress disorder (PTSD), anxiety, and depression were measured by the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25.
Results. Together, the five repatriation villages had 565 households. Of the 565 households, 203 of them were approached to solicit study participation. A total of 179 households (one adult per household) agreed to participate, representing an overall participation rate of 88%, and one-third of all the households in the five communities. The respondents had personally experienced a mean of 5.5 trauma events and had witnessed a mean of 7.3 other trauma events. Of the respondents, 8.9% met the symptom criteria for PTSD, 17.3% for anxiety, and 47.8% for depression. PTSD was associated with being seriously wounded and with having relatives or friends mutilated. Logistic regression analyses indicated that anxiety was associated with being sexually assaulted, being female, having friends or family mutilated, being seriously wounded, and having 6–12 children (vs. having 1–5 children). Depression was associated with having 6–12 children. Anxiety was significantly more prevalent among the refugees remaining in Mexico (54.4%) than it was among the repatriated refugees (17.3%). The difference in the prevalence rates was not significant for PTSD (11.8% for refugees remaining in Mexico vs. 8.9% for those repatriated) or for depression (38.8% for refugees remaining in Mexico vs. 47.8% for those repatriated).
Conclusions. Psychiatric morbidity was common among the repatriated Mayans. The repatriation of refugees involves moving an already vulnerable, often traumatized population back to a place of distressing memories and still-unsettled conditions. There is a need to consider and plan for adequate mental health services for repatriating refugees.

La salud mental de refugiados mayas después de su repatriación a Guatemala

Objetivo. Existe un solo estudio en el que se hayan examinado las tendencias epidemiológicas observadas en el ámbito de la salud mental en refugiados guatemaltecos. El objetivo de este nuevo estudio radica en calcular la prevalencia de enfermedades mentales y evaluar los factores asociados con el menoscabo de la salud mental en refugiados guatemaltecos de ascendencia maya que fueron repatriados a Guatemala después de pasar de 12 a 18 años en campamentos para refugiados en México, así como comparar los resultados observados en los guatemaltecos repatriados con los observados en refugiados guatemaltecos que siguieron viviendo en México.
Métodos. En 2001 se llevó a cabo una encuesta transversal de adultos (≥16 años de edad) con muestras aleatorias de un tamaño que guardaba proporción con el de la población de cada una de las cinco aldeas de repatriados que se estudiaron. Se determinó la prevalencia del síndrome de estrés postraumático (SEP), de estados de ansiedad y de depresión mediante el Cuestionario de trauma de Harvard (Harvard Trauma Questionnaire) y la Lista 25 de verificación de síntomas de Hopkins (Hopkins Symptom Checklist-25).
Resultados. En las cinco aldeas de repatriados había en conjunto 565 hogares, de los cuales 203 fueron abordados para solicitar su participación en el estudio. Aceptó participar un total de 179 hogares (un adulto en cada hogar), equivalente a 88% de la muestra y a una tercera parte de todos los hogares en las cinco comunidades. Las personas que respondieron a la encuesta habían tenido individualmente un promedio de 5,5 experiencias traumáticas personales y habían presenciado un promedio de 7,3 episodios ajenos de carácter traumático. De las personas que participaron en la encuesta, 8,9% satisfacían los criterios diagnósticos de SEP, 17,3% los de ansiedad y 47,8% los de depresión. El SEP mostró una asociación con haber sufrido heridas graves y con tener parientes que habían sido mutilados. Los análisis de regresión logística revelaron una asociación entre la presencia de estados de ansiedad y el haber sufrido agresión sexual, ser mujer, haber tenido amigos o parientes mutilados, haber sufrido heridas graves y tener de 6 a 12 hijos (frente a tener de 1 a 5). La depresión mostró una asociación con tener de 6 a 12 hijos. Los estados de ansiedad mostraron una prevalencia significativamente mayor entre los refugiados que se quedaron en México (54,4%) que entre los que fueron repatriados (17,3%). En cambio, no se observaron diferencias significativas entre los refugiados que permanecieron en México y los que fueron repatriados en cuanto a las tasas de prevalencia de SEP (11,8% frente a 8,9%, respectivamente) y de depresión (38,8% frente a 47,8%, respectivamente).
Conclusiones. Se observaron problemas psiquiátricos frecuentes en los mayas repatriados. La repatriación de refugiados entraña movilizar a una población que de por sí es vulnerable y que ha sido víctima de muchos traumas a un lugar cargado de recuerdos dolorosos y donde siguen imperando condiciones muy precarias. Es preciso, por ende, contemplar la necesidad de planificar servicios de salud mental para refugiados repatriados.

WHO guidelines for governments and consumers regarding the use of alternative therapies

Herbal remedies and other alternative treatments, such as acupuncture and homeopathy, are widely used in traditional societies and are becoming immensely popular in developed countries as well. Most are cheap, readily available, easy to use, and are perceived to be "healthier" than pharmaceutical substances. However, users need to be better informed as to the actual benefits and properties of these forms of therapy and their potential hazards. Improper use puts consumers at risk for potentially serious side effects as a result of allergy, drug interactions, contamination of the products with pesticides, heavy metals, and other substances, or trauma inflicted by inexperienced or poorly trained practitioners. Some traditional remedies can cause undesirable effects, such as excessive bleeding. Thus, it is essential that users have access to information that is reliable, clear, and easily available.

In June of this year the World Health Organization released a new set of guidelines to help national health authorities develop and distribute this type of information. The Guidelines on Developing Consumer Information on Proper Use of Traditional, Complementary and Alternative Medicine,which were developed with the financial and technical support of the Government of Lombardy, Italy, and the Government of Sweden, are part of a collaborative project that seeks to promote the proper use of traditional, complementary, and alternative therapies by consumers. In addition to offering advice for government officials on how to prepare reliable consumer information, the guidelines contain a series of simple questions that can guide users through the process of deciding on the use of such therapies. The guidelines are published in English at the World Health Organization's website: http://www.who.int/en/

Objective. To describe the prevalence of drug use disorders, the correlates of drug use, and the utilization of specialized treatment services for drug users among the Mexican urban population 18–65 years old.
Methods. The data were collected in 2001 and 2002 in the Mexican National Comorbidity Survey. The sample design was stratified probabilistically for six geographical areas of the country in a multistage process for census count areas, city blocks, groups of households, and individuals. The data were weighted, taking into account the probability of selection and the response rate. The information was collected using a computerized version of the World Mental Health Survey edition of the Composite International Diagnostic Interview. The weighted response rate for individuals was 76.6%.
Results. Overall, 2.3% of the population reported any illicit use of drugs in the preceding 12 months; marijuana and cocaine were the substances most often used. Low levels of education were significantly associated with use, abuse, and dependence. Use of any drug was significantly more common among those who were in the youngest age group (18–29 years), were male, or were living in the Northwest region of the country. Overall, 1.4% had a lifetime history of drug abuse or dependence, with this being much more common for men (2.9%) than for women (0.2%). The 12-month prevalence of drug abuse or dependence was 0.4% overall (0.9% for men, and 0.0% for women). The rate of treatment during the preceding 12 months for those with the 12-month criteria for abuse or dependence was 17.1%; 14.8% were seen in specialized treatment centers; 2.8% reported having attended self-help groups.
Conclusions. A noticeable number of Mexicans have a drug use disorder, but demand for treatment is limited, in part due to stigma. Our results indicate that there is an urgent need to organize the specialized services for persons with a substance abuse disorder according to the prevalence of dependence on different substances and the variation in prevalence in the different regions of the country.

Prevalencia de trastornos vinculados con el consumo de drogas y factores relacionados con ellos en Mexico

Objetivo.Describir la prevalencia de tastornos relacionados con el consumo de drogas, sus factores asociados, y la utilización de servicios terapéuticos especializados por usuarios de drogas en la población urbana de México entre los 18 y 65 años de edad. Métodos. Los datos se reunieron en 2001 y 2002 mediante la Encuesta Nacional de Epidemiologia Psiquiátrica de México. El muestreo se llevó a cabo por estratificación probabilística de seis regiones geográficas del país en un proceso polietápico que comprendió, en orden sucesivo, áreas censuales, manzanas urbanas, grupos de domicilios, e individuos. Los datos se ponderaron teniendo en cuenta la probabilidad de selección y el porcentaje de respuesta. La información se recogió mediante una versión computadorizada de la edición de la Entrevista Diagnóstica Internacional Compuesta usada para la Encuesta Mundial de Salud Mental. El porcentaje de respuesta ponderado para individuos fue de 76,6.
Resultados. En general, 2,3% de la población declaró haber incurrido en el consumo ilícito de drogas durante los 12 meses anteriores a la encuesta; la marijuana y la cocaína fueron las sustancias consumidas con mayor frecuencia. La baja escolaridad mostró una asociación significativa con el consumo, el abuso y la dependencia de drogas. El consumo de cualquier tipo de droga tuvo una frecuencia significativamente mayor en personas pertenecientes al grupo de edad más joven (18–29 años), en varones, o en habitantes de la parte noroccidental del país. De la muestra en general, 1,4% había abusado o dependido de las drogas en algún momento de la vida, y ello ocurrió con mucha más frecuencia en varones (2,9%) que en mujeres (0,2%). La prevalencia del abuso o de la dependencia de drogas en el transcurso de los 12 meses anteriores a la encuesta fue de 0,4% en general (0,9% en varones y 0,0% en mujeres). La tasa de tratamiento durante los 12 meses anteriores a la encuesta entre quienes cumplían los criterios de abuso o dependencia durante ese período fue de 17,1%; 14,8% fueron atendidos en centros de tratamiento especializados, y 2,8% dijeron haber asistido a grupos de autoayuda.
Conclusiones. Un número apreciable de mexicanos tienen un trastorno relacionado con el consumo de drogas, pero la demanda de un tratamiento es poca, en parte debido a temor al estigma. Según nuestros resultados, urge organizar los servicios especializados para personas con trastornos vinculados al abuso de sustancias en función de la prevalencia de la dependencia de las diversas sustancias y de la variación que muestra esta prevalencia en las distintas regiones del país.

The effect of structural adjustment on health conditions in Latin America and the Caribbean, 1980�2000

Objective. To assess the impact of structural adjustment on health indicators in Latin America and the Caribbean during 1980-2000.
Methods. This was an ecological study. Public spending and per capita gross domestic product (pcGDP) figures were obtained from the World Bank, and life expectancy (LE) and infant mortality (IM) figures were obtained from the World Health Organization. Structural adjustment (government downsizing) was assessed by looking at the change in the amount of spending taken up by the government (or the reduction in public spending) in Latin American and Caribbean countries during 1980-1990. Changes in health indicators were measured in terms of the percentage variation in LE and IM. The variations found in Latin America and the Caribbean were compared to those seen in different groups of countries in other parts of the world during 1980-2000. Pearson's chi squared test was used to explore the associations between the decrease in public spending and health indicators. In order to estimate the health effects of such changes, a multivariate linear regression model was created, with adjustments for pcGDP.
Results. A deceleration in the rise of LE and in the decline of IM in Latin America and the Caribbean was noted, especially over the period from 1980 through 1990. Significant associations were observed between health indicators and the change in public spending in all groups of countries included in the study. When adjustments were introduced into the multiple regression model, the only associations that remained were seen in Latin America and the Caribbean.
Conclusions. In the decade of 1980, adjustments in macroeconomic policies had a negative effect on social indicators, specifically those that had to do with health conditions in Latin America and the Caribbean. Such an effect lasted throughout the following decade. State reform, reduction in public spending, impact in the health condition, Latin America, Caribbean region.

Objetivo. Evaluar el impacto del ajuste estructural sobre los indicadores de salud en América Latina y el Caribe durante el período de 1980-2000.
Métodos. Se trata de un estudio ecológico. Los datos del gasto público y del producto interno bruto per cápita (PIBpc) se tomaron del Banco Mundial y los de la esperanza de vida (EV) y mortalidad infantil (MI), de la Organización Mundial de la Salud. El ajuste estructural(adelgazamiento del Estado) se evaluó mediante el cambio en el consumo de gobierno (la reducción del gasto público) en los países de América Latina y el Caribe en la década de 1980-1990. El cambio en los indicadores de salud se midió por la variación porcentual de la EV y la MI. Se compararon estas variaciones en América Latina y el Caribe con las observadas en diferentes grupos de países de otras regiones del mundo durante el período de 1980-2000. Se determinaron las asociaciones entre la reducción del gasto público y los indicadores de salud mediante la prueba de Pearson. Para estimar el efecto de los cambios sobre la salud se construyó un modelo de regresión lineal multifactorial ajustado según el PIBpc.
Resultados. Se observó una ralentización del incremento de la EV y del descenso de la MI en América Latina y el Caribe, especialmente en la década de 1980-1990. Se encontraron asociaciones significativas entre la variación de los indicadores de salud y el cambio del gasto público en todos los grupos de países analizados. Al ajustar el modelo de regresión múltiple, las asociaciones solo se mantuvieron en América Latina y el Caribe.
Conclusiones. En la década de 1980, el ajuste de las políticas macroeconómicas tuvo un efecto negativo sobre los indicadores sociales, específicamente sobre los relacionados con la situación de salud en América Latina y el Caribe. Estos efectos se siguieron observando durante la década siguiente.

Objectives. We assessed self-reported frequency of purchase of medications and medical care services in Mexico by southern New Mexico (United States, [U.S.]) residents in relation to their medical insurance coverage.
Methods. We analyzed data obtained in 1998 and 1999 from a health interview survey of residents in a six-county region of southern New Mexico, using prevalence and logistic regression methods for complex survey data.
Results. About 22% of southern New Mexico residents had purchased medications and 11% had sought medical care in Mexico at least once during the year preceding the survey. When we adjusted for the effects of other variables, persons able to pay for services out of pocket and those who were uninsured were more likely than persons who were fully covered to purchase medications or medical care in Mexico.
Conclusions. Large numbers of people residing near the border in New Mexico traveled south to Mexico to purchase medications and medical care. Lack of medical insurance was associated with higher frequencies of these purchases. There seems to be a need to establish relationships between U.S. private and public care plans and Mexican medical care providers to identify appropriate mechanisms for U.S. residents to purchase medical care in Mexico.

Utilización y compra de servicios médicos en México por personas que viven en los Estados Unidos de América, 1998-1999.

Objetivos. Evaluamos la frecuencia con que habitantes del sur del estado de Nuevo México, Estados Unidos, autoinformaron de la frecuencia con que compraban medicamentos y servicios médicos en México y examinamos dicha frecuencia a la luz de su cobertura con un seguro médico.
Métodos. Analizamos los datos obtenidos en 1998 y 1999 mediante una entrevista de salud de residentes de una región de seis condados en Nuevo México, usando métodos de prevalencia y regresión logística para datos de encuesta complejos.
Resultados. Cerca de 22% de los residentes de la parte sur del estado de Nuevo México habían comprado medicinas y 11% habían buscado atención médica en México por lo menos una vez en el transcurso del año que precedió a la encuesta. Cuando se hicieron ajustes en función de los efectos de otras variables, las personas que podían pagar los servicios de su propio bolsillo y las que no tenían seguro eran más propensas a comprar medicinas o atención médica en México que las que tenían cobertura médica completa.
Conclusiones. Muchas personas que habitan cerca de la frontera en el estado de Nuevo México viajaban hacia el sur hasta México para comprar medicinas y atención médica. La falta de seguro médico estuvo asociada con una compra más frecuente de ambas cosas. Parece haber una necesidad de establecer relaciones entre los planes de seguro médico estadounidenses privados y públicos y los proveedores de servicios médicos mexicanos con el fin de identificar mecanismos apropiados para que los residentes de Estados Unidos puedan comprar atención médica en México.

Health, equity, and the Millennium Development Goals

In September 2000 representatives of 189 countries met for the Millennium Summit, which the United Nations convened in New York City, and adopted the declaration that provided the basis for formulating the Millennium Development Goals (MDGs). The eight goals are part of a long series of initiatives that governments, the United Nations system, and international financial institutions have undertaken to reduce world poverty. Three of the eight goals deal with health, so the health sector will be responsible for implementing, monitoring, and evaluating measures proposed to meet targets that have been formulated: to reduce by two-thirds the mortality rate in children under 5 years of age between 1990 and 2015; to reduce by three-quarters the maternal mortality rate between 1990 and 2015; and to halt and begin to reverse the spread of HIV/AIDS by the year 2015, as well as to halt and begin to reverse the incidence of malaria, tuberculosis, and other major diseases. The health sector must also work with other parties to achieve targets connected with two other of the goals: to improve access to affordable essential drugs, and to reduce the proportion of persons who do not have safe drinking water. Adopting a strategy focused on the most vulnerable groups—ones concentrated in locations and populations with the greatest social exclusion—would make possible the largest total reduction in deaths among children, thus reaching the proposed target as well as producing greater equity. In the Region of the Americas the principal challenges in meeting the MDGs are: improving and harmonizing health information systems; designing health programs related to the MDGs that bring together the set of services and interventions that have the greatest impact, according to the special characteristics of the populations who are intended to be the beneficiaries; strengthening the political will to support the MDGs; and guaranteeing funding for the measures undertaken to attain the MDGs.

The reduction in maternal mortality in Chile, 1990–2000

OBJECTIVE: To determine if Chile achieved the objective of reducing maternal mortality by 50% between 1990 and 2000, in line with the provisions of the Regional Plan of Action for the Reduction of Maternal Mortality in the Americas, which the governments of the Americas approved in 1990 at the 23rd Pan American Sanitary Conference.
METHODS: A descriptive, observational study was designed, making it possible to analyze the trend in maternal mortality in Chile from 1990 through 2000. The variables that were evaluated were the maternal mortality ratio, the causes of death, and the age of the mothers who died. The causes of death were classified according to the ninth revision of the International Classification of Diseases (ICD-9), and the raw data were obtained from the yearbooks of the National Institute of Statistics of Chile. The changes in the variables were estimated according to the percentage of cumulative change, and trends were analyzed with the Pearson correlation coefficient.
RESULTS: The study found a 60.3% reduction in maternal mortality from 1990 to 2000. The lowest maternal mortality ratio, 18.7 per 100 000 live births, occurred in the year 2000. The five leading causes of maternal mortality were hypertension, miscarriage, other current conditions in the mother, puerperal sepsis, and postpartum hemorrhage. There was a significant downward trend in maternal mortality due to hypertension (r = –0.712; P = 0.014), abortion (r = –0.810; P = 0.003), and puerperal sepsis (r = –0.718; P = 0.013), but there were no statistically significant changes in mortality from other current conditions in the mother or from postpartum hemorrhage. The highest level of maternal mortality was found in women who were 40 years of age or older (100.2/100 000 live births), and the lowest level was in adolescents 15 to 19 years old (18.7/100 000 live births).
CONCLUSIONS: Chile achieved the objective of the Regional Plan of Action for the Reduction of Maternal Mortality in the Americas, with a decrease of more than 50% in maternal mortality in the 1990–2000 period. That reduction is due mainly to the decline in maternal mortality from hypertension, abortion, and puerperal sepsis.

OBJETIVO: Determinar si Chile alcanzó el objetivo de reducir en 50% la mortalidad materna entre 1990 y 2000, conforme a lo establecido en el Plan de Acción Regional para la Reducción de la Mortalidad Materna en las Américas.
MÉTODOS: Se diseñó un estudio observacional y descriptivo que permitiera analizar la tendencia de la mortalidad materna en el país durante 1990–2000. Las variables evaluadas fueron la razón de mortalidad materna, las causas de muerte y la edad de las madres fallecidas. Las causas se clasificaron de acuerdo con la novena revisión de la Clasificación internacional de enfermedades,traumatismos y causas de defunción (CIE-9), y los datos brutos se obtuvieron de los anuarios del Instituto Nacional de Estadísticas de Chile. La fluctuación de las variables se estimó según el porcentaje de cambio acumulado, y la tendencia, mediante análisis de correlación de Pearson.
RESULTADOS: El estudio demostró una reducción de la mortalidad materna de 60,3% de 1990 a 2000; la razón de mortalidad materna más baja, de 18,7/100 000 nacidos vivos, se registró en el año 2000. El análisis indica que las cinco causas más importantes de muerte materna fueron: hipertensión arterial, aborto, enfermedades maternas concurrentes (pregestacionales), sepsis puerperal y hemorragia posparto. Se observó una tendencia descendente significativa de la mortalidad materna por hipertensión arterial (r= –0,712; P= 0,014), aborto (r= –0,810; P = 0,003) y sepsis puerperal (r= –0,718; P= 0,013), pero no se encontraron cambios estadísticamente significativos en la mortalidad por enfermedades maternas concurrentes ni por hemorragia posparto. La cifra más alta de mortalidad materna correspondió a las mujeres de 40 años de edad y mayores (100,2/100 000 nacidos vivos), y la más baja a las adolescentes de 15 a 19 años (18,7/100 000 nacidos vivos).
CONCLUSIONES: Chile cumplió el objetivo del Plan de Acción Regional para la Reducción de la Mortalidad Materna en las Américas, habiendo logrado un descenso de más de 50% de dicha mortalidad en el período 1990–2000. Tal reducción se debe principalmente al descenso de la mortalidad materna por hipertensión arterial, aborto y sepsis puerperal.

Objective. To detect health disparities among three populations—Puerto Ricans living in Puerto Rico as well as Puerto Ricans and non-Hispanic whites living on the United States (U.S.) mainland.
Methods. Data from two similarly designed surveys conducted in 1999–2000 were analyzed. The Behavioral Risk Factor Surveillance System (BRFSS) provided data on Puerto Ricans living on the island and on non-Hispanic whites in the U.S. Another survey of Puerto Ricans living in New York City provided data on mainland Puerto Ricans. The age- and sex-standardized weighted prevalences of various health parameters (e.g., obesity, diabetes, smoking, and physical illness) and indicators of access to health care (e.g., frequencies of routine checkups and diabetes care) were compared between populations by means of standardized rate ratios (SRR).
Results. Puerto Ricans living on the mainland and those living on the island had a similar prevalence of obesity (21% to 22%). Compared with islanders, mainland Puerto Ricans had a higher prevalence of diabetes (SRR = 1.4; 95% confidence interval [95% CI] = 1.01 to 2.0); those with diabetes also showed higher prevalences of smoking (SRR = 4.2; 95% CI = 2.3 to 7.7) and physical illness (SRR = 1.5; 95% CI = 1.1 to 2.0) than Puerto Ricans living on the island. While mainland Puerto Ricans were similar to non-Hispanic whites in terms of their utilization of primary prevention and diabetes care, island Puerto Ricans trailed behind significantly.
Conclusions. Puerto Ricans living on the U.S. mainland and those living in Puerto Rico both need to target lowering their prevalence of obesity and diabetes. For island Puerto Ricans, improved education about the significance of primary prevention and diabetes care is needed. For mainland Puerto Ricans, the accessibility of the primary health care system renders it a potentially effective venue for interventions, particularly for smoking cessation. More studies are warranted to identify factors associated with the poor health status observed in mainland Puerto Ricans.

Disparidades de salud entre puertorriqueños que viven en la isla de Puerto Rico y en tierra firme estadounidense

Objetivo. Detectar disparidades de salud entre tres poblaciones: puertorriqueños que viven en Puerto Rico, así como puertorriqueños y personas no hispanas de raza blanca que viven en tierra firme estadounidense.
Métodos. Se analizaron los datos obtenidos mediante dos encuestas de similar diseño que se realizaron en 1999–2000. El Sistema de Vigilancia de Factores de Riesgo Conductuales proporcionó datos acerca de los puertorriqueños radicados en la isla y de residentes de Estados Unidos de raza blanca que no son hispanos. Otra encuesta de puertorriqueños radicados en la Ciudad de Nueva York aportó datos acerca de los puertorriqueños que residían en tierra firme estadounidense. Se usaron las razones de las tasas estandarizadas (standardized rate ratios, SRR) para hacer las comparaciones interpoblacionales de las prevalencias ponderadas, estandarizadas por edad y sexo, de varios parámetros (obesidad, diabetes, tabaquismo y dolencias físicas) y de indicadores de acceso a la atención sanitaria (frecuencia de los exámenes de rutina y de la atención de la diabetes).
Resultados. Los puertorriqueños que vivían en tierra firme estadounidense y los que vivían en la isla tuvieron una prevalencia de obesidad parecida (21% a 22%). Comparados con los habitantes de la isla, los puertorriqueños radicados en tierra firme tuvieron una prevalencia de diabetes más alta (SRR = 1,4; intervalo de confianza de 95% [IC95%]: 1,01 a 2,0); los que tenían diabetes también mostraron una mayor prevalencia de tabaquismo (SRR = 4,2; IC 95%: 2,3 a 7,7) y de dolencias físicas (SRR = 1,5%; IC95%: 1,1 a 2,0) que los puertorriqueños que vivían en la isla. Mientras que los puertorriqueños en tierra firme se asemejaron a los blancos que no eran hispanos en cuanto a la utilización de servicios de prevención primaria y de atención de la diabetes, los puertorriqueños en la isla tenían cifras de utilización mucho más bajas.
Conclusiones. Tanto los puertorriqueños radicados en tierra firme estadounidense como los que viven en Puerto Rico tienen que ponerse como meta reducir su prevalencia de obesidad y diabetes. En el caso de los puertorriqueños en la isla, hace falta una mejor educación en torno a la importancia de la prevención primaria y de la atención de la diabetes. En el caso de los puertorriqueños en tierra firme, la accesibilidad del sistema de atención primaria hace que este sea idóneo para llevar a cabo diversas intervenciones, particularmente contra el hábito de fumar. Se necesitan más estudios para determinar qué factores se asocian con el mal estado de salud observado en puertorriqueños radicados en tierra firme.

Fluoride mouth-rinsing to prevent dental caries in a Brazilian municipality with fluoridated drinking water

OBJECTIVE: To compare the prevalence of dental caries in two groups of schoolchildren: (1) schoolchildren participating in a weekly 0.2% sodium fluoride mouth-rinsing program and (2) schoolchildren not participating in the program.
METHODS: This cross-sectional study was conducted in the city (municipality) of Londrina, in the state of Paraná, Brazil; the city has fluoridated drinking water. We examined 367 12-year-old children: 190 participants in the weekly mouth-rinsing program (51.8%) and 177 nonparticipants (48.2%). The prevalence of caries was determined based on the scores for decayed, missing, and filled teeth and for decayed, missing, and filled surfaces. The examinations were performed by three examiners, with nearly perfect agreement in their diagnosis of caries (kappa = 0.90). The dependent variable was dental caries. The independent variables were: participation or nonparticipation in the mouth-rinsing program, attending a private school or a public school, frequency of tooth-brushing, amount of toothpaste used, consumption of sweets between meals, and visits to the dentist.
RESULTS: The decayed, missing, and filled teeth score (mean and standard deviation) at 12 years of age was 0.85 ± 0.059 overall, 1.0 ± 0.058 for program participants, and 0.70 ± 0.060 for nonparticipants. The decayed, missing, and filled surfaces score (mean and standard deviation) was 1.16 ± 0.017, with it ranging from a low of 0.34 in one private school to a high of 1.66 in one public school. Bivariate analysis showed an association between caries (P < 0.05) and the following variables: attending a public school, participating in the mouth-rinsing program, and consuming sweets between meals more than once a day. In the multivariate analysis, attending a public school (P = 0.0004) and consuming sweets (P = 0.001) remained associated with the presence of caries.
CONCLUSIONS: The weekly mouth-rinsing program was not associated with a decreased prevalence of caries, in either the public schools or the private schools. However, additional research is needed to assess the cost-effectiveness of fluoride mouth-rinsing programs in populations with a higher prevalence of caries. Given the caries prevalence that we found in the schoolchildren whom we studied, the resources allocated to the fluoride mouth-rinsing program for them should probably be used to pay for other health-promotion activities with them.

OBJETIVO: Comparar a prevalência de cárie dentária em escolares que participaram de um programa semanal de bochecho com fluoreto de sódio a 0,2% com a prevalência de cárie em escolares que não participaram do programa.
MÉTODOS: Estudo transversal na Cidade de Londrina, Estado do Paraná, Brasil, cuja população consome água fluoretada. Foram examinados 367 escolares de 12 anos: 190 participantes (51,8%) e 177 não participantes (48,2%) do programa semanal de bochecho. Os índices utilizados foram o de dentes cariados, perdidos e obturados e o de superfícies cariadas, perdidas e obturadas. Os exames foram conduzidos por três examinadores e a concordância no diagnóstico de cárie foi quase perfeita (K = 0,90). A cárie dentária foi considerada variável dependente. As variáveis independentes foram: a participação ou não no programa, estudar em escola pública ou privada, escovação dentária, quantidade de dentifrício utilizada, ingestão de doces e consulta ao dentista.
RESULTADOS: O índice de dentes cariados, perdidos e obturados aos 12 anos foi 0,85 ± 0,059 (0,70 ±0,060 para não participantes e 1,0 ±0,058 para participantes). O índice de superfícies cariadas, perdidas e obturadas foi 1,16 ±0,017, variando de 0,34 a 1,66. Na análise bivariada, estiveram estatisticamente associados (P <0,05) com a presença de cárie: estudar em escola pública, participar no programa de bochecho e ingerir doces entre as refeições mais de uma vez por dia. Na análise de regressão logística multivariada, mantiveram-se associados com a presença de cárie estudar em escola pública (P = 0,0004) e ingerir doces (P = 0,0010).
CONCLUSÕES: O programa de bochecho com flúor não esteve associado a menor prevalência de cárie, seja em escolas públicas ou privadas. Entretanto, outros estudos são necessários para análise de custo-efetividade do programa em populações com maior prevalência da doença. No nível de prevalência de cárie observado, o recurso destinado ao programa de bochecho com flúor poderia financiar outras ações de promoção de saúde.