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

Assessing the impact of health sector reform in Costa Rica through a quasi-experimental study

OBJECTIVE: To assess the impact of health sector reform in Costa Rica on that country's child and adult mortality rates and on the people's access to primary health care.
METHODS: Health sector reform was initiated in Costa Rica in 1995 in some districts, but in others reforms were adopted later. This made it possible to perform a time series analysis, using a quasi-experimental study design, in which observations were made annually from 1985 through 2001 for each of the 420 districts that existed in Costa Rica in 1984. The time series were divided into three periods that allowed all districts to be grouped into three categories (pioneer, intermediate, and late) according to the year when they first implemented health sector reform: 1995-1996; 1997- 2000; and 2001 or after, respectively. For each of these periods, mortality rates were broken down by cause (communicable, socially-determined, or chronic disease), sex, and age group. The status of the reform process in a particular district was described by two indicators: (1) the presence or absence of health sector reform during a given period and, wherever such reforms had been adopted, (2) the number of years that had transpired since their adoption. Eight variables were used to control for confounders. Vital statistics and demographic data were obtained from the National Institute for Statistics and Census' [Centro Nacional de Estadística y Censos] electronic database.
Poisson multiple regression analysis with fixed effects was used to estimate the impact of reform on child and adult mortality from different causes. Assessment of the population's access to primary care before and after the reform was based on the percentage of people who lived within a 4 km radius of a health facility that offered patient visiting hours two or more days a week. This information came from a previous study that used census data from 2000 and geographic information systems to map health care facilities throughout the country.
RESULTS: Multiple regression showed that the reform was associated with an overall 8% reduction in deaths among children and with a 2% reduction in deaths among adults, both statistically significant. Also noted were a 14% reduction in deaths from communicable diseases or from conditions brought on by the presence of infectious processes, a 0% reduction in deaths from socially-determined causes, and a 2% reduction in deaths from chronic diseases. An estimated 120 child lives and 350 adult lives were saved by the reform in 2001 alone. Also, the percentage of people without equitable access to primary health services dropped by 15% between 1994 and 2000 in areas where health sector reform was implemented in 1995-1996, whereas areas that had not yet initiated health sector reform in 2000 experienced only a 3% reduction.
CONCLUSION: Health sector reform significantly reduced mortality in Costa Rica and put an end to a decade of stagnation, as shown by certain health indicators, such as life expectancy. Equity in access to primary care improved considerably, perhaps because the first reforms were implemented in less developed areas of the country.

OBJETIVO: Valorar el impacto de la reforma del sector de la salud iniciada en Costa Rica en 1995 sobre la mortalidad de niños y adultos y la equidad en el acceso a los servicios de salud.
MÉTODOS: La reforma del sector de la salud se inició en Costa Rica en 1995 en algunos distritos, pero en otros su adopción fue posterior. Esto permitió efectuar un análisis de series temporales, usando un diseño cuasiexperimental con observaciones anuales de 1985 a 2001 en cada uno de los 420 distritos que tenía Costa Rica en 1984. Las series temporales se dividieron en tres períodos que permitieron agrupar a los distritos en tres categorías (grupo pionero, intermedio y tardío) según el momento en que iniciaron el proceso de reforma: 1995-1996; 1997-2000; 2001 o después, respectivamente. Las series incluyeron datos de defunción desagregadas por sexo, grupos de edad y tres grandes grupos de causas de muerte (enfermedades transmisibles, de origen social, o crónicas); estimaciones de población por edad y sexo; dos variables que miden la intervención (si el distrito ha adoptado o no la reforma y, en caso de que sí, el número de años desde que adoptó la reforma); y ocho variables para controlar efectos de confusión. Los datos se obtuvieron de los registros de defunciones y nacimientos, censos de población y estimaciones demográficas. Se usaron modelos de regresión múltiple de Poisson con efectos fijos para estimar el impacto de la reforma en la mortalidad. También se valoró el acceso de la población a los servicios de salud en el primer nivel de atención antes y después de la reforma. El indicador de acceso utilizado fue el porcentaje de personas que vivían a menos de 4 km de distancia de un servicio que ofreciera consultas médicas.
RESULTADOS: Según lo estimado por los modelos de regresión, la adopción de la reforma redujo significativamente la mortalidad de los niños en 8% y la de los adultos en 2%. El efecto fue de 14% en la mortalidad de adultos debida a enfermedades transmisibles o desencadenadas por procesos infecciosos, nulo en la debida a causas sociales y similar al total (2%) en la mortalidad debida a enfermedades crónicas. Se estima que la reforma salvó aproximadamente 120 vidas de niños y 350 vidas de adultos en el año 2001 únicamente. La reforma se puso en marcha primero en las zonas menos densamente pobladas y de menor desarrollo socioeconómico. Como resultado, la brecha en la equidad del acceso a los servicios de salud en el primer nivel de atención se redujo significativamente. El porcentaje de personas sin acceso equitativo a los servicios de salud del primer nivel de atención se redujo en 15% entre 1994 y 2000 en las áreas que adoptaron la reforma en 1995-1996, mientras que en las áreas que no habían adoptado la reforma en 2000, la reducción fue solo de 3%.
CONCLUSIÓN: La reforma redujo significativamente la mortalidad en Costa Rica y puso fin a una década de estancamiento en algunos indicadores, como la esperanza de vida. El efecto de la reforma se produjo probablemente gracias a su focalización en las regiones menos desarrolladas del país, lo cual dio lugar a un mejoramiento en la equidad de acceso al primer nivel de atención médica.

Risk perception and strategies for mass communication on dengue in the Americas

Dengue is clearly a very serious public health problem. In the Americas the number of dengue cases has been increasing since the 1960s, and outbreaks of the disease have been occurring more frequently. Furthermore, the density of infestation with the disease vector, the Aedes aegypti mosquito, is high in the Americas. The general strategy for preventing and controlling dengue and dengue hemorrhagic fever is based on promoting behavior changes that lead to incorporating the community in controlling the disease, particularly the vector. In order to achieve this, mass communication programs on dengue should have two primary aims: converting information into practice and encouraging the community to take over prevention and control measures. The new generation of programs should be designed based on the local sanitation structure (water distribution and waste disposal) as well as information on community organizations and the roles of different family members. Furthermore, the new programs should incorporate all the following ten components: epidemiological surveillance, intersectoral actions, community participation, managing the environment and basic services, patient care, case reporting, education, using insecticides and vector control, training, and preparing for emergencies. Communication should be aimed at modifying the behavior of individuals and the community by empowering them to carry out prevention and control measures.

Challenges facing Caribbean countries 10 years after the International Conference on Population and Development in Cairo, Egypt

At the International Conference on Population and Development (ICPD) that was held in Cairo, Egypt, in 1994, participants acknowledged that population, economic growth, and sustainable development are concepts that are closely linked, and important strides were made in terms of increased recognition of sexual and reproductive rights. The Programme of Action ratified at that Conference was adopted as a platform for designing national and international policies in the areas of population and development for a period of twenty years. However, in Latin America and the Caribbean all types of obstacles–financial, institutional, and human–still stand in the way of attaining the goals of the Programme of Action, and some governments have established measures that undermine their people's exercise of sexual and reproductive rights. The Caribbean Subregional Meeting to Assess the Implementation of the Programme of Action of the International Conference on Population and Development 10 Years after its Adoption was held in Port of Spain, Trinidad and Tobago, in November of 2003. At the meeting, which was attended by representatives from 20 Caribbean countries and territories, a call was made for more rational use of available resources and for mobilization of additional funds for developing and implementing population and development programs and policies in the Caribbean. The meeting also saw the approval of the Caribbean Declaration, which lays out the challenges that should serve as the roadmap for taking actions to consolidate the progress achieved so far and come closer to attaining the goals established by the ICPD. In the Declaration, the countries and territories of the Caribbean asserted their commitment to continue legislative reforms at the national level while seeking to enforce these reforms in an effort to ensure implementation of the ICPD's Programme of Action and of the Caribbean Plan of Action for Population and Development that was adopted in 1996 by the Economic Community for Latin America and the Caribbean.

The treatment received by public health services users in Mexico

Objective. To document the fact that differences in the treatment received by health services users in Mexico are mainly dependent on the type of provider, regardless of the users' socioeconomic status.
Methods. The data were obtained by means of a survey of 18 018 users who visited 73 health services in 13 states within Mexico. They were asked to grade the way the institution had performed in seven of the eight domains that define appropriate user treatment (autonomy, confidentiality, communication, respectful manner, condition of basic facilities, access to social assistance networks, and free user choice). The questionnaire included some vignettes to help determine user expectations. A composite ordinal probit model was applied; the perception of quality in connection with each of the appropriate treatment domains was the independent variable, whereas gender, educational level, age, type of provider, and user expectations were used as control variables.
Results. The type of provider was the main factor that determined users' perceptions regarding the treatment they received when visiting health services in Mexico. Institutions belonging to the social security system performed the worst, while the services provided under the program targeting the rural population (IMSS Oportunidades) received the highest scores. Overall, the domain that was most highly ranked was respectful manner, whereas the lowest score was given to the ability to choose the provider. Men felt they had been able to communicate better than women, while respectful manner, communication, and social support showed a significant negative association with educational level (P < 0.05).
Conclusions. Differences were noted in the way different public health service providers in Mexico treat their users, regardless of the latter's socioeconomic status. Social security system providers showed the greatest deficiencies in this respect. Respectful manner was the domain that received the highest scores in the case of all providers. Organizational changes need to be made, since the shortcomings detected are not solely determined by factors related to health personnel, but also by certain aspects of the way the health system is structured in Mexico.

Objetivo. Documentar que las diferencias en el trato recibido por los usuarios de los servicios de salud en México dependen principalmente del proveedor, independientemente de las condiciones socioeconómicas de los usuarios.
Métodos. Los datos se obtuvieron mediante una encuesta aplicada a 18 018 usuarios que asistieron a 73 servicios de salud de 13 estados de México. Los usuarios debían calificar la forma en que la institución se había desempeñado en siete de los ocho dominios del trato adecuado de los usuarios (autonomía, confidencialidad, comunicación, trato respetuoso, condiciones de las instalaciones básicas, acceso a redes de apoyo social y capacidad de elección). En el cuestionario se presentaron viñetas para valorar las expectativas de los usuarios. Se aplicó un modelo probit ordinal compuesto con la percepción sobre la calidad de cada uno de los dominios del trato adecuado como variable dependiente y el sexo, la escolaridad, la edad, el tipo de proveedor y las expectativas de los usuarios como variables de control.
Resultados. El principal factor que determinó la percepción de los usuarios sobre el trato que recibieron en los servicios de salud en México fue el proveedor. Las instituciones de seguridad social mostraron el peor desempeño, mientras que los servicios del programa destinado a la población rural (IMSS Oportunidades) recibieron las mejores calificaciones. En general, el dominio mejor calificado fue el trato respetuoso, mientras que la menor calificación se asignó a la capacidad de elección del proveedor. Los hombres consideraron haber tenido mejor comunicación que las mujeres, mientras que el trato respetuoso, la comunicación y el apoyo social tuvieron una asociación significativa inversa con respecto al nivel educacional (P <0,05).
Conclusiones. Se encontraron diferencias en la forma en que los diferentes proveedores públicos de servicios de salud de México tratan a sus usuarios, independientemente de las características socioeconómicas de estos. Los proveedores de las instituciones de seguridad social mostraron más deficiencias en este sentido. El trato respetuoso fue un dominio que presentó calificaciones altas en todos los proveedores. Se deben realizar modificaciones organizativas, ya que las deficiencias encontradas no están únicamente determinadas por el perfil del personal de salud, sino también por aspectos relacionados con la forma en que está estructurado el sistema de salud en México.

This paper considers the implications that distinct organizing principles for health systems have for the control of infectious diseases. The paper takes the health systems in Mexico and Cuba as examples of neighboring but widely divergent systems, producing different pubic health outcomes. The paper will look at the dissimilar organizing principles of these two systems, along with their programs and outcomes in relation to five of the most important and dangerous infectious diseases. The paper will then consider what broader lessons might be drawn from the experiences in Cuba and Mexico.

Mexico has pursued a federal and neoliberal system, based on tripartite social insurance (State, employer, and employee contributions), private "partnerships" (private-for-profit investment in public services), and competitive service provision (competitive rather than coordinated services). On the other hand, Cuba has maintained a public system, with guaranteed free and universal access, universal patient registration, assignment of all persons to a family doctor, and centralized public coordination of services. How have these two health systems approached tuberculosis, HIV/AIDS, diarrhea, measles, and malaria?

In recent decades both countries have made substantial progress in dealing with these five diseases, but Cuba has maintained a superior performance, despite having a lower income per capita and less total Government funding available. This at first seems to contradict the broad international correlation between income levels and health outcomes. It also poses questions for the "pro-poor" policies that the Organization for Economic Cooperation and Development (OECD) (the wealthy countries' club) suggests for developing countries. Those policies emphasize "scaling up resources and private investment," including with competitive service provision and expanded "choice" in health services (1, 2).

Important research (3) has demonstrated that general income growth has less correlation with reductions in major categories of mortality and with other major advances in public health than do the education of women and the implementation of appropriate technology. The question of the contribution of other social and organizational factors in reducing mortality and morbidity levels is left open. However, it is well established, for example, that major reductions in maternal mortality are much more strongly linked to the presence of a skilled birth assistant than to expensive facilities or high technology (4).

What then of infectious disease? In most poor and developing countries, epidemics of tuberculosis, HIV/AIDS, diarrhea, measles, and malaria are major killers. While highly controlled in most wealthy or "low-mortality" countries, these five diseases each kill many hundreds of thousands of people worldwide every year, as do poor maternal-infant health conditions and nutritional disorders. In 2002, for example, HIV/AIDS killed 2.8 million persons worldwide, tuberculosis 1.6 million, diarrheal diseases 1.8 million, malaria 1.2 million, and measles 760 000 (5). Beyond the bland demands for "broad-based economic growth" (6), how might the organization of health policy be linked to substantial advances in combating these diseases?

Most of the serious infectious diseases that affect developing countries are no longer the primary health problems of the more wealthy countries. Nor are infectious diseases the main problems of Mexico and Cuba. In recent years, these two countries have been wrestling with these "preventable" diseases and, to varying degrees, have overcome them. Because of their divergent systems and their differing outcomes with infectious diseases, it seems that a comparative study of Mexico and Cuba might be enlightening.

La estructuración de los sistemas de salud y el control de las enfermedades infecciosas: un vistazo a México y a Cuba

En este trabajo se examinan las consecuencias que tienen para el control de las enfermedades infecciosas diferentes maneras de concebir la organización de los sistemas de salud. En particular se examinan las bases teóricas de la organización de los sistemas de salud de México y de Cuba, junto con sus programas y resultados, en conexión con cinco de las principales y más peligrosas enfermedades infecciosas: la tuberculosis, la infección por VIH y el sida, la diarrea, el sarampión y el paludismo. México ha tenido un sistema federal y neoliberal basado en un programa de seguridad social tripartito (el Estado, el empleador, y aportaciones del empleado), en consorcios del sector privado (inversiones en servicios públicos por parte de entidades privadas con fines de lucro) y en la provisión competitiva de servicios (servicios competitivos en lugar de coordinados). En cambio, Cuba ha tenido un sistema público con acceso libre garantizado para toda la población, una coordinación pública centralizada, y la inscripción de todos los pacientes sin excepción (todo miembro de la población tiene un registro médico y un médico asignado). ¿Cómo se han lidiado con las enfermedades infecciosas más peligrosas de la humanidad dos sistemas de salud con estas características? La superioridad casi invariable que ha mostrado Cuba en el control de las enfermedades parece depender del acceso garantizado que tiene todo habitante a los servicios de salud, a la coordinación centralizada del sistema sanitario y a una abundancia de trabajadores de salud bien capacitados. Por otro lado, en México la provisión desigual de servicios asistenciales no ha logrado satisfacer las necesidades de todos los mexicanos y la expansión de los servicios privados difícilmente podrá compensar las carencias observadas en las zonas más pobres del país. Las deficiencias de infraestructura y de otros recursos imponen límites sobre lo que Cuba puede alcanzar, pero son peores los resultados de salud que se obtienen con la distribución desigual de recursos en México. Comparar a México con Cuba nos permite reflexionar en torno a la importancia de las bases organizativas de un sistema de salud, impidiéndonos optar por una mayor infusión de capital sin más. Estos resultados refuerzan ciertas inquietudes que han surgido en el pasado acerca de los vínculos existentes entre la desigualdad social, el acceso desigual a los servicios, y la obtención de resultados de salud inferiores.

The Pan American Health Organization traces its origin back to the First General International Sanitary Convention of the American Republics, which was held in Washington, D. C., in December 1902. At the top of the agenda of the meeting were the complex public health issues involved in fighting yellow fever and other epidemic infectious diseases. The final resolution of the first convention stated, “It shall be the duty of the International Sanitary Bureau to lend its best aid and experience toward the widest possible protection of the public health of each of the said Republics, in order that disease may be eliminated and that commerce between said Republics may be facilitated.” In the 19th century, efforts at inter-American cooperation had been limited almost exclusively to assisting commerce, and had had almost nothing to do with health. In 1923 the International Sanitary Bureau changed its name to the Pan American Sanitary Bureau, which would eventually become known as the Pan American Health Organization (PAHO) (1).

Pan-Americanism is the guiding principle upon which PAHO was founded. That principle is expressed in the PAHO Member States’ commitment to working together to improve the health of their citizens and to support the countries facing the greatest need. This principle recognizes that many health problems require a collective effort. The PAHO Member States acknowledge that the health and public health of one’s neighbors is a shared responsibility of all. Pan-Americanism is grounded in values aimed at breaking down the barriers of health inequities. This principle is perhaps even more relevant today in a world of free trade and vast movements of people.

In the 20th century, Pan-Americanism spawned several disease control initiatives that strengthened the collective efforts for improving technical cooperation among PAHO Member States, and that enhanced the strategy of “regional programs.” These initiatives included yellow fever eradication and malaria eradication. The targets were not achieved with these two initiatives, mostly because the strategies were not technically feasible. Experience has subsequently demonstrated that it is virtually impossible to eradicate diseases that have mosquito vectors. However, the use of immunization and vaccine technologies enabled Member States and PAHO to establish the program to eradicate smallpox in the Western Hemisphere, a target achieved in the Region of the Americas well in advance of other regions of the world. While the program for smallpox eradication in the Americas relied on many of the elements of Pan-Americanism, the initiative to eradicate smallpox did not realize its full potential for Regional cooperation. For example, some countries in the Americas acted independently of the policies of PAHO and the World Health Organization (WHO) and stopped vaccinating with smallpox vaccine, leaving those nations at enormous risk for importations of virus and for ensuing outbreaks.

The subsequent global achievement of smallpox eradication spearheaded the development of the Expanded Program on Immunization in PAHO and WHO. Unlike the rest of the world, EPI in the Americas was accentuated with the development of PAHO’s Revolving Fund for the procurement of vaccines and syringes for Member States. PAHO’s management of the Revolving Fund has helped ensure an adequate and safe supply of vaccines at affordable prices in the Americas, which in turn optimizes the likelihood that targets will not be jeopardized by insufficient supplies of vaccine. In the Americas the establishment of EPI and the Revolving Fund paved the way for the Region of the Americas to be the first region in the world to eradicate polio, as well as to achieve remarkable progress towards measles elimination. This paper will study the experience of the Regional program on immunization in the Americas in order to identify the lessons learned. It also examines PAHO’s original Expanded Program on Immunization, the PAHO Revolving Fund for procurement of vaccines and syringes for national immunization programs, and polio eradication in the Americas. These lessons are intended to assist policymakers at the global, regional, and subregional levels in ensuring the highly effective coordination of health interventions among groups of countries.

Dos funciones esenciales de los programas de vacunación regionales aplicados en varios países simultáneamente consisten en controlar en todo un territorio, franqueando fronteras, las enfermedades que se pueden prevenir mediante la vacunación y en reducir las faltas de equidad en materia de salud. Los buenos resultados de los programas de vacunación regionales dependen del esfuerzo coordinado que hagan los países y sus socios por alcanzar una meta regional en común. Con el fin de explorar las lecciones derivadas de la experiencia, en este artículo se echa un vistazo al Programa Ampliado de Inmunización original de la Organización Pan americana de la Salud (OPS), al Fondo Rotatorio de la OPS para la adquisición de vacunas y jeringas para los programas nacionales de vacunación, y a la erradicación de la poliomielitis del territorio americano. Se resaltan estas lecciones para ayudar a los formuladores de políticas en los niveles mundial, regional y subregional a coordinar eficazmente las intervenciones de salud realizadas por varios países en conjunto. Para ser provechosos, los programas de salud regionales tienen que verse respaldados por un genuino compromiso con la cooperación entre países como valor fundamental; la capacidad para averiguar qué problemas existen e idear buenas soluciones; la capacidad para llevar a cabo intervenciones de manera sustentable; el firme compromiso de los ministros de salud y otros jefes de gobierno; la gestión eficaz de los programas; los planes de salud nacionales; la buena supervisión técnica y la coordinación de alianzas; una cooperación técnica más intensa con los países más pobres, donde hay que redoblar los esfuerzos por conseguir más recursos y apoyo; la cooperación entre países; y la capacidad para responder a circunstancias insólitas.

Women’s empowerment and life expectancy at birth in Mexico

Objectives. To assess the effect of women’s empowerment (WE) on life expectancy at birth (LEB) in the federative states of Mexico and to compare the results of measuring WE with various compound indicators that reflect, to a greater or lesser degree, an individual or population focus.
Methods. This was an ecological study conducted in Mexico’s 32 federative states. We estimated the correlations between overall and sex-specific LEB on the one hand, and a measure of gender empowerment (MGE), the index of women’s ability to make decisions within the household (WADH), the index of women’s autonomy (IWA), income inequality, certain aspects of the physical environment, the proportion of the population who spoke an indigenous language, and the net migratory rate on the other. By using robust regressions, we studied the effect on LEB of MGE, IWA, and WADH, after mutually adjusting for other independent variables.
Results. A very strong inverse correlation (–0.93) was found between overall LEB and factors of the physical environment linked to population vulnerability and biodiversity. Significant direct and inverse correlations were also found between LEB on the one hand and WADH, IWA, net migratory rate, the percentage of the population that spoke an indigenous language, and the Gini coefficient on the other. Multiple robust regressions showed inverse associations between MGE and LEB in women (b: –1.44; 95% confidence interval [95% CI]: –2.71 to –0.17). WAI was positively associated with LEB in men (b: 0.88; 95% CI: 0.01 to 1.75) and women (b: 0.66; 95% CI: 0.03 to 1.30).
Conclusion. The use of MGE as a surrogate for WE failed to reveal a positive effect of WE on LEB in Mexico. It is necessary to review the components that make up MGE and the relevance of using such a measure in different contexts. WAI showed a greater association with LEB and its effect was greater among men. This indicator made it possible to measure WE in Mexico and its use is recommended, as long as there are no other indicators available for capturing more effectively all the components that affect WE.

Objetivos. Evaluar el efecto del empoderamiento de las mujeres (EM) sobre la esperanza de vida al nacer (EVN) en los estados federativos de México y comparar los resultados de medir el EM con diferentes indicadores compuestos que privilegian en mayor o menor medida un enfoque individual o poblacional.
Métodos. Estudio ecológico con datos de los 32 estados federativos mexicanos. Se estimaron las correlaciones entre la EVN total y por sexo y la medida de empoderamiento de género (MEG), el índice de poder de decisión de la mujer en el hogar (IPDH), el índice de autonomía de la mujer (IAM), la desigualdad en el ingreso, algunos factores del ambiente físico, la proporción de la población que hablaba lengua indígena y la tasa migratoria neta. Mediante regresiones robustas se exploró el efecto de la MEG y los índices de autonomía y de poder de decisión de la mujer en el hogar sobre la EVN, ajustado por las demás variables independientes.
Resultados. Se encontró una correlación inversa muy fuerte (–0,93) entre la EVN total y el factor del ambiente físico que caracteriza la vulnerabilidad poblacional y la biodiversidad. También se encontraron correlaciones significativas, tanto directas como inversas, entre la EVN por una parte y el IPDH, el IAM, la tasa migratoria neta, el porcentaje de la población que hablaba lengua indígena y el coeficiente de Gini por la otra. Las regresiones robustas múltiples mostraron asociaciones inversas entre la MEG y la EVN en mujeres (β: –1,44; intervalo de confianza de 95% [IC95%]: –2,71 a –0,17). El IAM se asoció de manera directa con la EVN en hombres (β: 0,88; IC95%: 0,01 a 1,75) y mujeres (β: 0,66; IC95%: 0,03 a 1,30). Conclusión. El uso de la MEG como aproximación al EM no puso de manifiesto efectos positivos del EM sobre la EVN en México. Se deben revisar los elementos que integran la MEG y la pertinencia de su uso en diversos contextos. El IAM mostró una mayor asociación con la EVN y su efecto fue de mayor magnitud en los hombres. Este indicador permitió medir la EM en México y se recomienda usarlo mientras no se tenga otro que permita captar más eficazmente todos los elementos que inciden en el EM.

Changes in the prevalence of dental caries in schoolchildren in three regions of Mexico: surveys from 1987–1988 and 1997–1998

OBJECTIVE: To compare the prevalence and severity of dental caries found in epidemiological surveillance studies conducted in three areas of Mexico in two different periods, 1987–1988 and 1997–1998.
METHODS: The 1987–1988 survey was done with representative samples of schoolchildren 6 to 10 years old in two states, Nuevo León and Tabasco, as well as in the country's Federal District (which includes Mexico City). The Federal District's 1987– 1988 sample also included schoolchildren who were 12 years old. The total number of students examined in the 1987–1988 period was 7 590. The 1997–1998 survey included schoolchildren who were 6–10 years old and 12 years old, in all three of the areas. The total number of students included in the 1997–1998 survey was 8164. To compare the prevalence and severity of dental caries in the two periods, the average value for the index of decayed, missing, and filled teeth (DMFT) was used with all of the age groups.
RESULTS: The values of the DMFT indices were significantly lower in the 1997–1998 period for all of the age groups studied (P < 0.05 for all the age groups). In the 1997– 1998 period both Tabasco and Nuevo León achieved the goal recommended by the World Health Organization of an average of no more than three decayed, missing, and filled teeth among the 12-year-olds, with DMFT indices of 2.67 and 1.72, respectively. However, in the Federal District in that 1997–1998 period the DMFT index exceeded the recommended level, with a value of 3.11.
CONCLUSIONS: The reduction seen in the DMFT indices could be due to several factors, including the consumption of fluoridated salt, the use of dentifrices and fluoride rinses, and broader access to dental services.

OBJETIVO: Comparar la prevalencia y la gravedad de la caries dental en dos estudios de vigilancia epidemiológica realizados en tres regiones de México en los años 1987–1988 y en 1997–1998.
MÉTODOS: La encuesta de 1987–1988 se aplicó a una muestra representativa de escolares de 6 a 10 años de edad de los estados de Nuevo León, Tabasco y el Distrito Federal (D.F.); adicionalmente se incluyeron escolares de 12 años del D.F. El total de alumnos examinados en 1987–1988 fue de 7590. En la encuesta de 1997–1998 se incluyó a escolares de 6 a 10 y 12 años de edad de las tres regiones estudiadas. El total de alumnos incluidos en 1997–1998 fue de 8164. Se compararon las medias del índice de dientes cariados, perdidos u obturados (CPOD) de cada grupo de edad en ambos períodos.
RESULTADOS: Los resultados mostraron una disminución de la prevalencia y de la gravedad de la caries dental en los grupos de edad examinados (P < 0,05). En 1997–1998, tanto en el estado de Tabasco como en el de Nuevo León se logró la meta propuesta por la Organización Mundial de la Salud de reducir a no más de tres los dientes cariados, perdidos u obturados a los 12 años de edad, con índices de CPOD de 2,67 y 1,72, respectivamente, aunque el D.F. sobrepasó esa cifra tope (CPOD = 3,11).
CONCLUSIÓN: La disminución observada en los índices CPOD podría deberse a varios factores, tales como el consumo de sal fluorada, el uso de dentífricos y enjuagues fluorados, y un mayor acceso a los servicios odontológicos.

Metabolic syndrome and risk factors associated with life style among adolescents in a city in Argentina, 2005

Objectives. To determine the prevalence of metabolic syndrome among adolescents in a city in Argentina and to establish its association with certain risk factors linked to life style.
Methods. Cross-sectional study of a representative sample of 532 middle and high school students from 11.20 years of age (mean: 15.3 years; females: 60%) in the city of Posadas, province of Misiones, Argentina, from July.October 2005. Surveys were conducted of individualsf dietary habits, anthropometric measurements, sedentary levels, blood pressure readings, and laboratory results. Metabolic syndrome was diagnosed if three or more of the following conditions were present: fasting glucose . 110 mg/dL; triglycerides . 110 mg/dL; HDL cholesterol . 40 mg/dL; arterial systolic or diastolic pressure > 90th percentile; and waist circumference > 90th percentile.
Results. The prevalence of metabolic syndrome was 4.5%; significantly higher among males than among females (7.5% vs. 2.5%; P = 0.006) and among the 15.20 year old age group than among the 11.14 year old group (6.3% vs. 2.5%; P = 0.037). Of the adolescents, 44.7% had one or more components of metabolic syndrome. The risk of metabolic syndrome among obese adolescents was elevated (odds ratio = 119.73; 95% confidence interval: 27.6.519.41). Dietary habits and frequency of food consumption were similar among students with and without metabolic syndrome; however, the first group consumed fattening foods more frequently. Of all the adolescents in the sample, 84.8% were sedentary (100% of those with metabolic syndrome).
Conclusions. In the city of Posadas, some 1 400 students suffer from metabolic syndrome and about 13 000 have at least one metabolic syndrome component. Joint efforts by the state government and the community are needed to change dietary habits and increase physical activity, mainly among boys, those 15.20 years of age, and the obese, to reverse the situation and reduce the morbidity/mortality that results from metabolic syndrome.

Objetivos. Determinar la prevalencia de sindrome metabolico (SM) en adolescentes de una ciudad argentina y establecer su asociacion con algunos factores de riesgo vinculados con el estilo de vida.
Metodos. Estudio descriptivo transversal en una muestra representativa de 532 estudiantes de ensenanza secundaria de 11 a 20 anos (promedio: 15,3 anos; mujeres: 60,0%) de la ciudad de Posadas, Misiones, Argentina, entre julio y octubre de 2005. Se realizaron encuestas personales y sobre habitos alimentarios, mediciones antropometricas, pruebas de sedentarismo, mediciones de la tension arterial y pruebas de laboratorio. Se diagnostico SM si se presentaban tres o mas de las siguientes condiciones: glucemia . 110 mg/dL, trigliceridos . 110 mg/dL, colesterol de HDL . 40 mg/dL, tension arterial sistolica o diastolica > percentil 90 y circunferencia de la cintura > percentil 90.
Resultados. La prevalencia de SM fue de 4,5%; significativamente mayor en varones que en mujeres (7,5% frente a 2,5%; P = 0,006) y en el grupo de 15 a 20 anos que en el de 11 a 14 anos (6,3% frente a 2,5%; P = 0,037). De los adolescentes, 44,7% tenia uno o mas componentes del SM. El riesgo de los adolescentes con obesidad de padecer SM fue elevado (OR = 119,73; IC95%: 27,6 a 519,41). Los habitos alimentarios y la frecuencia de consumo de alimentos fueron similares en los estudiantes con SM y sin SM, pero los primeros consumian alimentos obesogenicos con mayor frecuencia. Del total de adolescentes de la muestra, 84,8% eran sedentarios (100% de los que tenian SM).
Conclusiones. En Posadas, unos 1 400 estudiantes padecerian de SM y alrededor de 13 000 tendrian al menos un componente del SM. Se necesitan programas conjuntos del Estado y la comunidad para modificar los habitos alimentarios y aumentar la actividad fisica, principalmente en varones, el grupo de 15.20 anos y los obesos, para revertir esta situacion y reducir la morbimortalidad derivada del SM.