CUADERNOS DE INVESTIGACIN

INSTITUTO DE INVESTIGACIONES INTERDISCIPLINARIAS UNIVERSIDAD DE PUERTO RICO EN CAYEY

TRAMIL Ethno-pharmacological Survey in the Southeast Region of Puerto Rico

Jos A. Alvarado-Guzmn Jannette Gavilln-Surez Lionel Germosn-Robineau

Cuaderno 5 Ao 2008

En la serie Cuadernos de Investigacin del Instituto de Investigaciones Interdisciplinarias de la Universidad de Puerto Rico en Cayey se presentarn resultados parciales y preliminares de algunas de las investigaciones auspiciadas por el Instituto, versiones preliminares de artculos, informes tcnicos emitidos por nuestras(os) investigadoras(es) as como versiones finales de publicaciones que, por su naturaleza, sean de difcil publicacin por otros medios. Los(as) autores(as) son responsables por el contenido y retienen los derechos de publicacin sobre el material contenido en estos Cuadernos. Copias de los Cuadernos se pueden obtener solicitndolos por telfono, por correo regular o por correo electrnico al Instituto. Tambin se pueden descargar de nuestra pgina electrnica en formato pdf. Instituto de Investigaciones Interdisciplinarias Universidad de Puerto Rico en Cayey 205 Ave. Antonio R. Barcel Cayey, PR 00736 Tel. 787-738-2161, exts. 2615, 2616 Fax 787-263-1625 Correo electrnico: instituto.investigacion@upr.edu Pgina web: http://webs.oss.cayey.upr.edu/iii/

Diseo de Portada: Prof. Harry Hernndez Encargado de la serie de cuadernos: Dr. Errol L. Montes Pizarro Directora del Instituto: Dra. Isar P. Godreau Directora Auxiliar: Sra. Vionex M. Marti

JGS

Preliminary manuscript If cited, please contact the corresponding author at jannette.gavillan@upr.edu TRAMIL Ethno-pharmacological Survey in the Southeast Region of Puerto Rico Jos A. Alvarado-Guzmna, Jannette Gavilln-Surez,a,b,* Lionel Germosn-Robineauc
a

Institute of Interdisciplinary Research, University of Puerto Rico at Cayey, #205 Antonio R.

Barcel Ave., Cayey, PR 00736

b

Department of Chemistry, University of Puerto Rico at Cayey, #205 Antonio R. Barcel

Ave., Cayey, PR 00736

c

Department of Biology, Faculty of Science, University of French Antilles and Guyana, UAG

UFR SEN BP 592, 97159 Pointe Pitre, Guadeloupe (FWI) Guadeloupe

Abstract An ethno-pharmacological survey based on TRAMIL methodology was conducted in the southeast region of Puerto Rico to record medicinal plants commonly or frequently used to treat ten common health conditions of prevalence in the region and the trends in medicinal plant use among the study population. The results were analyzed using univariate and multivariate statistical analysis. One hundred and eighteen herbal remedies were recorded for the treatment of depression, nervousness, chronic sinusitis, gastritis, gastroesophagus reflux disease, allergic rhinitis, rhinofaryngitis, asthma, arthritis and migraine. Among the most frequently used plants were Citrus aurantium L. (depression and nervousness), Citrus aurantifolia (Christm.) Swingle (rhinopharyngitis), Pluchea odorata (L.) Cass (migraine), and Mentha piperita L. (sinusitis). The use of medicinal plants was more frequent among single women with high education level. The use of medicinal plants is decreasing due to an increase

in the use of conventional medical care and to self medication with over-the-counter pharmaceutical products. Keywords: Puerto Rico; TRAMIL; ethno-pharmacological survey; urban medicinal plants use

1. Introduction

TRAMIL network (Traditional Medicines in the Islands) was founded in 1982 in order to understand, validate and expand health practices based on the use of medicinal plants in the Caribbean. At present, 48 TRAMIL ethno-pharmacological surveys have been completed in 27 territories in the Caribbean region. TRAMIL also organizes outreach activities (TRADIF) aimed at disseminating the results obtained from scientific validation (based on efficacy and toxicity studies) on the use of medicinal plants reported during the surveys. TRADIF

workshops have been offered at community, primary health care (providers and promoters) and governmental levels. At present, over 90 medicinal plants evaluated by TRAMIL are recognized in Cuba, Dominican Republic, Honduras, Nicaragua and Panam as effective mechanisms in devising primary health care programs (DaSilva, 1999). The TRAMIL

Program also leads to the protection and conservation of traditional knowledge that is now endangered by: the lack of verbal transfer to new generations, irrational use of some species and degradation of natural resources (Longuefosse, 1996; Katewa, 2004). Puerto Rico joined TRAMIL in 1994 by conducting a field survey in the southwest region of the Island. Seven medicinal plants were identified as plants of significant use (reported in at least 20 % of the interviews for the same health condition) for common health problems (TRAMIL, 2005). In Puerto Rico, approximately 2,900 plant species have been identified, 236 endemic, 135 are

commonly use as medicinal plants and 170 less known for their therapeutic value (Nuez, 1989; Martnez, 2002). Since the 1994 survey, additional activities designed to continue the field work in other islands of the Puerto Rican archipelago and in the US Virgin Islands, or to join the TRAMIL network in the validation of plants with (medicinal) significant use have not been undertaken. From December 2006 to January 2007, a TRAMIL-based survey was

conducted in the southeast region of the Island. The region includes eleven municipalities in the service area of the University of Puerto Rico at Cayey (UPR-Cayey), Interdisciplinary Research. Institute of

An important demographic characteristic of this region is its

transformation during the last two decades from a rural to an urban area (US Census Bureau, 2000). This report describes the herbal remedies with significant use and examines the trends in medicinal plant use in the region.

2. Methodology 2.1 Geographic coverage Puerto Rico has three main physiographic regions: the mountainous interior, the coastal lowlands, and the karst area in the North. The mountainous interior (covering 60% of the islands territory) is formed by a central mountain range that transects the island from East to West. The second main physiographic feature are the coastal lowlands, which extend 13 to 19 Km inward to the North and 3 to 13 Km to the South. This study was conducted in the southeast region of Puerto Rico, including eleven municipalities located in mountainous and coastal lands, Figure 1.

2.2 Study population The US Bureau of Census definition for families was used to identify the number of family households in each town/municipality. The Decennial Census of Puerto Rico (2000) was used to determine the number of family households in each town (US Census Bureau, 2002). The total number of family households (sample unit) in the 11 municipalities was 123,855. Based on the total family households in the region, a study population of 270 households was calculated using equation 1:

(Equation 1)

where, n = minimum simple size; N = total population size (123,855); Z = 1.645 ( =.10); p = expected proportion (50%); q = 1- p = 1 0.5 = 0.5 and d = precision (5%). To adjust for the design effect of the sample methodology, the size of the sample was increased by 30% (Cornelius, 2006). Cluster, stratified and systematic sampling techniques were

combined to select the family households (sample unit) in the survey. The cluster technique allowed to select the barrios (town subdivisions) that included 10% or more of the family households in the town. For example, in Cayey, three town subdivisions were selected

(Pueblo, Rincn and Tota) since they have 34%, 12.3% and 13.5% (more than 50% of the households), of the 12,735 family households in the town. The town subdivisions selected in the region are shown in Figure 2a. The town subdivisions were stratified by block groups contained in the geographical limits of the town subdivision, to determine which sector of the

town subdivision was going to be surveyed, (US Bureau of Census, 2000b).

Figure 2b

illustrates an example of the selected block groups in Barrio Pueblo, Cayey. The block groups were also stratified by family income. Each interval had an amplitude of ten thousand (US$). From each income strata the block group with the most family households was selected to conduct the survey. Finally, since the rate of occupied house units to family households was 2 to1, the sample units included in the survey were those that were identified as multiples of three. Figure 2c illustrates this mapping. Maps were created using Maptitude Geographic Information System for Windows (version 4.8, Caliper Corp., Newton, Massachusetts, USA). Protocols that established the working definition of family and the condition that at least one family member had suffered from one or more of the ten ailments included in this study, were developed to guide the interviewers during the selection of the sample unit.

2.3 Prevalence of diseases surveyed The Puerto Rico Continuous Health Study which provides disease prevalence data for each of the seventy eight municipalities of Puerto Rico was used to identify the specific health conditions surveyed (Ramos, 2003). Only self-limiting conditions that might be treated with medicinal plants were considered (TRAMIL). From the data for each town, the 10 ailments (excluding diabetes and hypertension) that were prevalent in at least 5 towns were selected for the study. These conditions were asthma, arthritis, chronic sinusitis, allergic rhinitis,

depression, rhinopharyngitis, gastritis, nervousness, migraine and gastroesophagus reflux disease. The International Classification of Diseases (ICD-10; WHO 2007) provided the diagnostic codes for the health conditions that were discussed with the medical director of the Cayey Municipality Hospital. Information on the nosologic entity, symptoms description and

clinical presentation of the ailments selected for the survey were obtained and used in the survey questionnaire to describe some of the ailments. For example, rhinopharyngitis was described as nasal secretion with sore throat and hoarseness, chronic sinusitis as nasal congestion and inflammation, allergic rhinitis as nasal allergy with frequent sneeze, gastroesophagus reflux disease as reflux and nervousness as nerves.

2.4 Interviewing methods TRAMIL methodology aims to reach the knowledge shared among all members of a community about the use of medicinal plants to treat simple ailments and to document the perceptions of these ailments by the study population. Following TRAMIL methodology, the mother or woman in the family was interviewed with preference to other members of the family after seeking prior informed consent. Studies about gender roles in relation to the knowledge about medicinal plants use support the notion that the utilization and responsibility of transferring this knowledge is traditionally womens domain (Singhal, 2005; Arango Caro, 2004; Quinlan and Quinlan, 2007). To be eligible for participation in the study, participants had to be at least 18 years of age. Prior to the field work, an interdisciplinary team of undergraduate research assistants at the UPR-Cayey majoring in general science, biology, English and business administration, were offered workshops in ethno-botany, voucher preparation and how to conduct interviews. The research assistants approached potential participants in their homes, determined their willingness to participate in the study and administered the survey. The study was divided in three phases to monitor the quality and consistency of the interviews. During each phase the assistants submitted the study

instruments (questionnaires, informed consent forms, maps) and the first author (J. Alvarado-

Guzmn) reviewed the questionnaires and received the vouchers. Field work was supervised by the second author (J. Gavilln-Surez).

2.5 Survey instrument The questionnaire used was approved by the Internal Review Board at the UPR-Cayey, fieldtested in a pilot study in a nonparticipating block group and individual items were refined as needed. The questionnaire was adapted from the one published by TRAMIL (www.tramil.net) which has two sections: the first section collects specific demographic and socio-economic information from a given community, and in the second, following a structured interview participants were asked to provide information about the medicinal plants used by the family as the first treatment for the ailments included in the survey (see Table 1). When the participant stated the use of a medicinal plant as the first treatment, open-ended questions were used to obtain a detailed description of the treatment, the form of preparation and application, including combinations with other plants, dosage and contraindications or side effects for adults and children. The place where the plant was collected or obtained was also identified. The data collected in this section allowed researchers to compare the use of medicinal plants reported in the study with the use in other Caribbean locations as reported in the Caribbean Herbal Pharmacopoeia (2005).

2.6 Collection of plants Appropriate vouchers were collected and numbered during the interviews, and photographs were taken when the medicinal plants were obtained from the familys or neighbors backyards. Classification of the botanical species was performed by Jos Sustache, Botanist

and Head of the PR Department of Natural and Environmental Resources Herbarium. The vouchers were deposited at the George Proctor Herbarium (SJ) in Puerto Rico.

2.7 Statistical analysis Data from the questionnaires were entered into Access (Microsoft Office 2003 Suite) database and imported into SPSS 13.0 (SPSS Inc. Chicago, Ill.) for Windows. Frequencies and cross tabulation tables were used to describe the socio-demographic characteristics of the study participants interviewed in the family households. Family income was excluded from the analysis since one third of the families refused to offer this information. The Continuity Correction of the Chi Square Test was applied to evaluate associations with medicinal plant use (1 if the family use medicinal plants for at least one of the conditions and 2 if not) and the independent variables: age (less or equal to 50 years and more than 50 years), marital status (single, which includes divorced and widowed; and married, which includes living in common-law marital union), education (below college degree which includes 6th to 12th grades and technical degrees; and college degree which includes, 2year college, baccalaureate and higher degrees), and employment status (unemployed; and employed, a category that includes part time and full time employment). To measure the strength of the statistically significant associations, odd ratios (OR) and 95% confidence intervals (95% CI) were estimated from the corresponding 2 x 2 tables. Based on previous studies (Kuo, 2004; Nahim 2007) that showed significant relations between medicinal plants use and age or employment status, an analysis of these variables as confounding variables of the significant associations was performed according to the Mantel-Haenszel Method, (Szklo, 2000). A multivariable logistic regression analysis was conducted using the reference

variables: age less or equal to 50 years, below college degree, married, and unemployed. The Backward Stepwise method was use to eliminate non-significant factors from the model. The Index of Agreement on Remedies (IAR) was calculated for the 10 health conditions surveyed in this study based on the following equation: IAR = (na nr)/ (na 1), where na is the citation frequency of the health condition and nr is the number of different plant remedies cited to treat that health condition (Vanderbroek, et. al., 2007). The IAR values offer a consensus index by participants about the use of remedies cited for a given health condition.

3. Results 3.1 Description of the study population Three hundred and fifty one families were surveyed. The woman in charge of the household was interviewed in all families except in one family where a male was interviewed. Median age was 47 years old ( 1.4 years). Approximately half of the study population interviewed (51.5%) had less than a college education and 64.8% were married. Approximately 42% of the participants had full or part-time jobs, while 58% were either unemployed or studying. Consulting a physician (48%), self medication with pharmaceutical products (32%) and use of medicinal plants (14%) were described as the first treatments used by the study population for the health conditions surveyed.

3.1 Description of the population using medicinal plants One hundred and eighteen families (33.6%) use medicinal plants as the first treatment for at least one of the health problems surveyed. The characteristics of the study sample that use

medicinal plants are summarized in Table 2. Participants in the age group <= 50 years used more medicinal plants than older participants ( > 50 years) with 67.0% and 48.0% usage, respectively. The majority of the participants reported to having a college degree and being single (65.0 and 62.0 percent, respectively). Almost an equal number of the sample population that uses medicinal plants reported to be either employed or unemployed. Thus, women in the family households that reported use of medicinal plants in the region are mostly single, aged under 50 years, have college education and are either employed or unemployed.

3.2 Factors associated with medicinal plants use In this study socio-demographic variables demonstrating a significant univariate association (p < 0.05) with medicinal plant use were education (p = .036) and marital status (p = .002) (seeTable 2). Significant relations were not found between medicinal plant use and age or employment status. Based on the OR values, the percentage of families who treated a disease with medicinal plants if the woman holds a college degree is 66.5% (OR = 1.67, 95%CI, 1.10 2.62) higher than the odd for families where the women have not completed a college degree. The odd of families that use medicinal plants when the woman is single is twice the OR of families where the woman is married (OR 2.09, 95% CI, 1.37 3.31). Families where the woman is single and holds a college degree are three times more likely to use medicinal plants. A stratified analysis was conducted to measure the association and estimate the OR in each category by age and employment status. Statistical analysis showed that there is no difference in the odd ratios between stratas of the two variables (age and employment status), although employment status weakens the association between education and the use of medicinal plants (Crude OR = 1.67, Adjusted OR = 1.57). In the multivariate logistic regression analysis

10

(results not shown), education (OR = 1.61, S.E. = 0.27) and marital status (OR = 2.22, S.E. = 0.24) remained significant predictors of medicinal plants use (p < 0.05). The effect of

education on medicinal plant use is weakened by inclusion of the variable employment status in the model, while marital status was not affected when the variable was discarded from the model.

3.3 Medicinal Plant Use Two hundred and thirteen plant remedies were used the last time one of the health problems surveyed was suffered. The number of ailments treated with medicinal plants varied from one to seven in a given family, with an average of two medicinal plants per family. Table 3 lists the citation frequency of plant remedies, IAR-values for the health conditions surveyed, and the number of different (medicinal) plants that were reported for the treatment of a given health condition. The ailments most frequently cited affect the respiratory (36% used for asthma, rhinopharyngitis, allergic rhinitis and sinusitis) and gastrointestinal (28% used for gastritis and reflux) systems. Plant remedies were also use for nerves (13.6%), migraine (12.2%),

depression (5.2%) and arthritis (4.7%). Fifty eight medicinal plants were used for the preparation of herbal remedies. Average consensus in the use of medicinal plants were

obtained for rhinopharyngitis (0.58), nervousness (0.54), depression (0.50), gastritis (0.49), sinusitis (0.40) and migraine (0.40). Most of the treatments (78 %) were reported just once for a given health problem and are therefore not described in this report. Most of the plants were obtained at a store or market (53.8%). Nine medicinal plants species belonging to 5 genera and 5 families were identified as important herbal treatments in the region. None of the species were indigenous to Puerto Rico.

11

The families best represented were Lamiaceae and Rutaceae with 2 species each. For each species, the common name, parts of the plant used for a given disease, form of preparation and administration and frequency of use are presented in Table 4. The preparation methods included decoction in water of fresh or dried leaves, poultice or juice. Dosages are variable with most of the families reporting to use 1 cup of tea prepared as a decoction from one to three times a day during several days. Plants were used without restrictions, especially for

children except for the use of the fresh juice of Citrus aurantifolia (Christm.) Swingle) where the dosage is half of that used by adults to treat the symptoms of rhinofaryngitis.

4. Discussion 4.1 Relative importance of the species with significant use TRAMIL defines a remedy with significant use as that combination of plant species, plant part and form of preparation that is identified by 20% or more of the participants that use that treatment as the primary resource to treat a given disease the last time it was presented in a family member. Based on TRAMIL methodology, only six medicinal plant species (9.0% of the total medicinal plants recorded) resulted to have significant use for the treatment of the symptoms of depression, nervousness, rhinofaryngitis, migraine and sinusitis (Table 4). The decreasing order of significant use was Citrus aurantifolia (Christm.) Swingle (40.0%), Citrus aurantium L. (33.0%), Pluchea carolinensis (Jacq.) (30.0%) and Mentha piperita L. (25.0%). Two species with significant use for depression (36%) and nervousness (21%) were obtained in the market as tea bags and vouchers were not collected. Their common names are tilo and manzanilla (chamomile), respectively. The large number of records obtained for these species suggest a high degree of popular belief in their therapeutics properties, (Carrillo Rosario,

12

2006). C. aurantifolia (Christm.) Swingle for rhinopharyngitis, C. aurantium L. leaves have significant use for depression and nervousness, M. piperita L. for sinusitis and P. carolinensis (Jacq.) for migraine. The use of the juice of C. aurantifolia (Christm.) Swingle for cold, flu and cough have been reported in TRAMIL surveys at Colombia, Honduras, Panam, Guyana, Dominica and Puerto Rico (TRAMIL). The essential oil obtained from the leaf, flower, fruit and bark of C. aurantifolia (Christm.) Swingle is rich in monoterpenoid derivatives limonene, linalool or nerol. The fresh juice of C. aurantifolia (Christm.) Swingle exhibited antimicrobial activity against Staphylococcus aureus and Candida albicans, and caused stimulation of gastric secretion (TRAMIL). The natural occurring (-)-linaool induced a reduction of carrageenin-

induced edema in rats at 25 mg/Kg suggesting its potential anti-inflammatory activity (Peana, et. al., 2002). These biological activities have been associated to the antiseptic, antitusive and expectorant action of essential oil-rich herbs and their efficacy in clinical phytotherapy to treat respiratory ailments (CONAPLAMED, 2000). Citrus auratium L. leaves contain linalool and flavonoids. The fruit contains triterpenes and the isoquinoline alkaloid synephrine, an adrenergic agonist related to ephedrine (TRAMIL). Activities upon the central nervous system (CNS) attributed to Citrus auratium L. include its usage to treat anxiety and hysteria, and cases of depression. Sedative effects include hypnotic, anticonvulsant and hypothermic properties (Costa, 2002; Emamghoreishi, 2006). The sedative activity (sleeping time induced by sodium pentobarbital; SPB: 40 mg/Kg i.p.) have been reported for extracts and essential oil from Citrus auratium L. (Costa). The hexane and dichloromethane fractions of the hydroethanolic extract from the leaves, and the essential oil from the peel enhanced the sleeping time induced by barbiturics at a dose of 1.0g/Kg. In this study, the route of administration (i.p.) and the form of preparation were different from the traditional oral route in human. Therefore, the extent of

13

the effects reported cannot be extrapolated to validate the traditional use since the pharmacokinetics of the active components and the therapeutic doses may be affected (Emamghoreishi). TRAMIL applied research addresses the need to validate the biological activity according to the traditional use of the (medicinal) plants with significant use in order to determine their use in primary medical care. Isolation and concentration of the synephrine content in the pulp of whole fruit of Citrus auratium L. from 0.33 mg/g to 20 mg/g in some dietary supplements and to 35 mg/g in extracts, poses potential cardiovascular effects and shows a misuse of this otherwise safely food plant for weight loss. Weight loss have been documented in rodent, but is weakly supported in humans (Chvez, 2008 ). Linalool, found in the leaves of Citrus auratium L. has shown to have sedative and anticonvulsant activity in animal studies, and anxiolitic and sedative activity in human studies. Linalool slows and inhibits the release of acetylcholine, reducing the length of time that the channels are open in the mouse neuromuscular junction (Perry, et. al., 2003). These findings could provide

evidence to confirm the traditional use of linalool-producing medicinal plants. Sedative effects of flavonoids, quercetin, chriyn and apigenin, and flavonoid glycoside isoquercitrin have also been reported (Emamghoreishi). The internal use of M. piperita L. oil for catarrhs of the respiratory tract and inflammation of the oral mucosa and cough have been reported previously (Blumenthal, 2000; ESCOP, 1997). A flavonoid glycoside, luteolin-7-O-

rutinoside, isolated from the aereal parts of M. piperita L. has shown to be effective inhibiting histamine release from rat peritoneal mast cells and a dose-related inhibition of the antigeninduced nasal response at doses of 100 and 300 mg/kg (Blumenthal, 2000; ESCOP, 1997). The significant uses found in our study region for the decoction of the fresh or dry leaves of Citrus aurantium L. and Mentha piperita L. to treat depression and nervousness and sinusitis,

14

expands the uses reported by TRAMIL for this plants. C. aurantium L., C. aurantifolia (Christm.) Swingle and M. piperita L. are plants of a cosmopolitan nature that can be found in use in the United States, Europe and Mexico and have been extensively studied for therapeutic, pharmacologic and toxicologic effects (Hernndez, et. al., 1984). Ethnobotanical accounts in Puerto Rico for C. aurantifolia (Christm.) Swingle and C. aurantium L. to treat hoarseness and restlessness, symptoms used to describe rhinofaryngitis and nervousness have been documented previously, (Benedetti, 2001; Benedetti, 2004; Nuez 1989). Hernndez et. al. (1984) reported C. aurantium L. as the most frequently used plant as sedative and for gastrointestinal disorders, among the patients visiting out patient clinics on the Island. Contrary to mainstream beliefs that herbal remedies are often harmful or toxic, the medicinal plants with higher frequency in this report are common, edible food plants. These plants are designated by the US Food and Drug Administration (FDA) as generally recognized as safe (GRAS) (FDA). A second group of plants with less than 20% in the frequency of use (Annona muricata L., Mentha nemorosa Willd. Ex L. and Lippia stoechadifolia (L.) Kunth) was reported for the treatment of gastritis, the ailment where the use of medicinal plants was most cited (42 citations; IAR 0.49). Although we expected to find a decrease in the number of useful plants cited due to cultural erosion, the ethno-pharmacological use of these plants at the population level poses one of the constraints of TRAMILs definition of significant use, reflecting

TRAMILs aim to address specifically-applied primary health care objectives. Nevertheless, the decoction of leaves of Mentha sp. (yerbabuena) to treat some of the symptoms described for gastritis has been validated by TRAMIL (2005).

15

4.2 Trends in medicinal plant use Our data show that the traditional knowledge on the use of medicinal plants is decreasing due to an increase in the use of conventional medical care. Overall, about 14% of the families in the southeast region of Puerto Rico used at least one herbal remedy the first time one of the 10 ailments surveyed was suffered. This report is consistent with the reports in the use of herbal medicine (9.6%; Hanyu, 2002) or natural products that include herbal medicine and functional food supplements (18.9%; Nahir, 2004) among US adults according to data from the complementary and alternative medicine (CAM) section of the National Health Interview Survey. The reports based on NHIS data, describe the use of CAM as most prevalent among women, persons with education of >= 16 years and persons aged 35 to 54. Unlike other reports, we did not find a significant relationship between age and medicinal plant use. Positive and negative associations between education as predictor of medicinal plant use have been reported. In our study employment status tended to reduce this interaction. A similar effect on medicinal plant knowledge was reported in rural Dominica where education was marginally significant only when related to parenthood (Quinlan and Quinlan, 2007) and participants with commercial occupations (e.g. wage salary) that could be related with employment status knew fewer plants for each additional year of education. One limitation of our study is that participants were not asked the reasons for using a specific herbal remedy nor if they use herbal remedies concomitantly with prescription medications.

5. Conclusion Popular knowledge on the use and the diversity of medicinal plants to treat health problems of higher prevalence in the southeastern region of Puerto Rico is decreasing due to an increase in

16

the use of conventional medical care practices and self medication.

However, ethno-

pharmacological knowledge and use of herbal treatments is higher among single women with college degrees. This suggests an emerging health care paradigm that blends conventional medicine with alternative remedies concordant with personal values and cultural beliefs about health care. Six botanical species with significant uses, not previously recorded in the

Caribbean Herbal Pharmacopoeia have been identified. This report will be followed by the scientific validation and toxicity studies by the academic research laboratories that collaborate with TRAMIL. The survey will be expanded to include Vieques (one of the islands of the archipelago of Puerto Rico) and the US Virgin Islands. In future studies, economic and cultural reasons will be examined to understand the prevailing use of medicinal plants in the region of study and to better tailor TRADIF activities to our communities.

5. Acknowledgments The authors wish to thank all the families who participated in this survey from the eleven municipalities served by the University of Puerto Rico at Cayey. Special thanks to the UPRCayey students who conducted the interviews: Carlos Marzant, Jos I. Lpez, Melissa Guzmn, Melissa Olivieri, Mercedes Lpez, Orly Santos, Rosngela Rosario, Yahaira Rosario and Yasmn Prez; and to the students who completed the data entry: Dalixis Rivera and Mara del C. Rodrguez. Thanks to Mr. Jos Sustache, botanist and Director of the Puerto Rico Department of Natural and Environmental Resources, who helped in the identification of the plants collected and provided the herbarium facilities to maintain the vouchers. Jolene Yurkes for reviewing this manuscript. This work was conducted with partial support from the UPR-

17

Cayey Institutional Research Fund and the National Institutes of Health RIMI Program #1P2MD001112-0.

6. References Aday, Lu Ann; Llewellyn J. Cornelius; 3rd ed., 2006. Designing and Conducting Health Surveys: A Comprehensive Guide,Jossye-Bass,154-194. Arango Caro, S., 2004. Ethnobotanical studies in the Central Andes (Colombia): Knowledge distribution of plant use according to informants characteristics, Lyonia 7, 89 104. Benedetti, M.D., 2001. Hasta los baos te curan! Plantas Medicinales, remedios caseros y sanacin espiritual en Puerto Rico, Verde Luz 23643, Road 743, Cayey, PR, 00736-9496. Benedetti, M.D., 1996. Sembrando y sanando en Puerto Rico, Verde Luz 23643, Carr. 743, Cayey, PR, 00736-9496. Blumenthal, M., Goldberg, A., Brinckmann, J., eds., 2000. Herbal Medicine, expanded Commission E Monographs. Newton, Integrative Medicine Communications. Byg, A., H. Balslev. 2001. Diversity and use of palms in Zahamena, Eastern Madagascar. Biodiversity Conserv., 10, 951-970. Carrillo Rosario, T., Moreno, G., 2006. Importancia de las plantas medicinales en el autocuidado de la salud en tres caserios de Santa Ana Trujillo, Venezuela. Revista de la Facultad de Farmacia 48, 21 28. Comisin Nacional para el Aprovechamiento de Plantas Medicinales (CONAPLAMED) 2000. Cuaderno de Fitoterapia Clnica I: Afecciones respiratorias y digestivas. Delens, M., ed., 11 75.

18

Costa, M. And Carvalho-Freitas, M. I. R., 2002. Anxiolytic and sedative effects of extracts and essential oils of Citrus aurantium L. Biol. Pharm. Bull. 25, 1629-1633. DaSilva, E.J., Hoareau, L., 1999. Medicinal plants: a re-emerging health aid. Electronic Journal of Biotechnology, 2, 56 70. Emamghoreishi, M. and Heidari-Hamedani, G., 2006. Sedative-hypnotic activity of extracts and essential oil of coriander seeds. Iran J Med Sci [Online], 31, 22-27. Farnsworth, N.R., Akerele, O., Bingle, E.S., Soejarto, D.D., Guo, Z., 1985. Medicinal plant in therapy. Bulletin of the World Health Organization. 63, 965 - 981. FDA Code of Federal Regulations (CFR) GRAS parameters Title 21 Parts 172, 182, 184 and 186. Hernndez, L., Muoz, R.A., Mir, G., Marnez, M., Silva-Parra, J., Chvez, P. I., 1984. Use of medicinal plants by ambulatory patients in Puerto Rico. American Journal of Hospital Pharmacy, 41, 2060 2064. Katewa, S.S., Chaudhry, B. L., Jain, A., 2004. Folk herbal medicines from tribal area of Rajasthan, India, Journal of Ethnopharmacology, 92, 41 46. Kuo, G. M., Hawley, S. T., Weiss, L. T., Balkrishnan, B., Volk, R. J. 2004. Factors associated with herbal use among urban multiethnic primary care patients: a cross-sectional survey. BMC Complementary and Alternative Medicine [Online], 4, 18 26. Longuefosse, J-L., Nossin, E., 1996. Medical ethnobotany survey in Martinique. Journal of Ethnopharmacology, 53, 117 142. Martnez, T.T., Martnez, R.R., 2002. Medicinal Herbs from the Caribbean National Forest (El Yunque), Puerto Rico, Proc. West. Pharmacol. Soc. 45, 20 22.

19

Nahir, R. L., Dahlhamer, J. M., Taylor, B. L., Barnes, P. M., Stussman, B. J., Simile, C. M., Blackman, M. R., Chesney, M. A., Jackson, M., Miller, H., McFann, K. K., 2007. Health behaviors and risk factors in those who use complementary and alternative medicine. BMC Complementary and Alternative Medicine [Online], 7, 217 225. Nolan, J.M., 1998. The Roots of Tradition: Social Ecology, Cultural Geography, and Medicinal Plants Knowledge in the Ozark Ouachita Highlands. Journal of Ethnobiology, 18, Nuez, E., 1989. Plantas Medicinales de Puerto Rico. Editorial de la Universidad de Puerto Rico, Pagano, M., Gauvreau K., 2000. Principles of Biostatistics (2nd ed.), Duxbury, (a) 196 213, (b) 470 487. Peana, A.T., DAquila, P.S., Panin, F., Serra, G., Pippia, P. and Moretti, M.D.L., 2002. Antiinflammatory activity of linalool and linalyl acetate constituents of essential oils. Phytomedicine, 8, 721-726. Perry, N.S.L., Bollen, C., Perry, E. K. and Ballard, C., 2003. Salvia for dementia therapy: review of pharmacological activity and pilot tolerability clinical trial, Pharmacology Biochemistry and Behavior [Online], 75, 651-659. Singhal, R., 2005. Medicinal plants and primary health care. Journal of Health Management 7, 277 - 293. Szklo, M., Nieto, J.F., 2000. Epidemiology: Beyond the Basics, Aspen, 190 109. TRAMIL, 2005. Caribbean Herbal Pharmacopoeia, www.tramil.net. US Census Bureau, 2001. Puerto Rico 2000 - Resumen de caractersticas Sociales, Econmicas y de Vivienda, Appendix A, 13. In 1980, 56.2% of the study region population lived in rural

20

areas. This number decreased to only 7.3% in 2000. Urban area is define as a densely populated territory with 2,500 to 50,000 habitants or more. US Census Bureau, 2001. Puerto Rico 2000 Resumen de caractersticas Sociales, Econmicas y de Vivienda, Appendix B, 17 18, (a) Familys Households: Habitual residence of two or more persons who are related through blood (birth), marriage or adoption; Appendix A, 13 14, (b) Block Group is define as an area with a population between 600 and 3,000 inhabitants, with an optimum population of 1,500 inhabitants. US Census Bureau, 2002. Puerto Rico 2000 Resumen de caractersticas de la poblacin y vivienda, 127 145. Vandebroek, I., Balick, M.J., Yukes, J., Durn, L., Kronenberg, F., Wade, C., Ososki, A., Cushman, L., Lantigua, R., Meja, M., Robineau, L., 2007. Use of Medicinal Plants by Dominican Inmigrants in New York City for Treatment of Common Health Problems A Comparative Analysis with Literature Data from the Dominican Republic. In: Traveling Cultures and Plants. The Ethnobiology and Ethnopharmacy of Human Migrations (Eds. A. Pieroni and I. Vandebroek). Volume 7. Studies in Environmental Anthropology and Ethnobiology. Oxford, UK: Berghahn Books.

21

Figure 1: Eleven municipalities surveyed in the Southeast region of Puerto Rico: Aguas Buenas, Aibonito, Arroyo, Barranquitas, Caguas, Cayey, Cidra, Coamo, Guayama, Patillas and Salinas; Estimated total population: 467,339 (US Bureau of Census).

22

(a)

(b)

(c)

23

Figure 2: (a) Selected town subdivisions (barrios) in the region; (b) Selected block groups in Barrio Pueblo, Cayey and (c) House units that could be surveyed in a block group with id 720352608002 at Barrio Pueblo, Cayey. Maps were created using

Maptitude Geographic Information System for Windows (version 4.8, Caliper Corp., Newton, Massachusetts, USA).

24

Table 1: Ethnopharmacological survey questionnaire _________________________________ Part I. Socioeconomic Information 1. Age 2. Gender a. female b. male 3. Marital status: a. single b. married c. divorce d. widow e. living with a partner 4. Education: a. first to six grade b. seventh to nine grade c. tenth to twelve grade (High School diploma) d. technical degree (specify): e. college/university degree f. None 5. Monthly Family Income 6. Laboral Status a. housewife b. student c. full time employee d. part time employee Part II. Ethnopharmacological Survey 1. You or anyone in your family has suffered from one of the following health problems? a. asthma b. migraine c. nasal allergy with frequent sneeze d. gastritis e. depression f. reflux g. nasal secretion with sore throat and hoarseness h. nasal congestion and inflammation (sinusitis) i. nerves j. arthritis 2. Give a brief description of the problem 3. What was the first treatment you use the last time that you or a member in your family suffered the health problem? a. medicinal plant or home remedies b. physician consultation c. botanical supplements d. selfmedication with pharmaceutical drugs (If the participant answered b d the interview is completed for that particular condition.

25

4. What plants or combination of plants you used the last time that you suffered the condition? If several plants are mentioned complete Part II for each plant. 5. What part(s) of the plant you use to prepare the remedy? a. leaves b. bark c. root d. pulp e. flower f. fruit g. seed 6. Describe how you prepare the treatment? a. decoction b. infusion c. aqueous steeping d. juice e. raw 7. Describe the administration of the treatment: a. oral b. bath c. inhalation d. poultice, compress 8. In what quantity or dosage you use the treatment? 9. For how long? 10. Where do you get the plant(s)? a. garden around the house b. in the market c. forest d. other (specify): Take photographs and request a botanical sample if the plant is obtained in the garden. Prepare voucher on site. 11. Have you used this treatment? a. Yes b. No 12. What results did you obtained? 13. Are there any precautions/ contraindications when using this remedy? 14. Do you use this remedy for children? What is the dosage? Are there any precautions/contraindications? ______________________________________

26

Table 2: Descriptive characteristics of the families (n=118) that reported the use of herbal remedies Women in families using herbal remedies (n=118) 67 48 62 54 56 57 65 49 Percentage within herbal remedies use

Variables

2 pvalue

OR

95% CI

Age Groups <=50 >50 Marital Statusa single married Employment Status employed unemployed Level of Education college degree < college degree

58.6 41.4 46.6 53.4 49.6 50.4 57.0 43.0

.522 .002 .061 .036

1.19 2.09 1.59 1.67

.758 1.87 1.37 3.31 1.01 2.50 1.1 2.62

a) Single includes women that are single, divorced or widow; Married includes women living with a partner or married. The distinction between married and living with a partner was made by the respondent.

27

Table 3: Index of Agreement on Remedies (IAR) Values for Common Health Conditions
Health Condition (ICD-10 Code)a (Description of symptons in spanish) Number of times the Percent ailment was cited (n = 118)b 42 19.7 29 26 24 20 18 17 16 11 10 13.6 12.2 11.3 9.4 8.5 8.0 7.5 5.2 4.7 Number of Medicinal plants cited for the ailment 22 14 16 24 9 15 14 10 6 10

IAR-valuec 0.49 0.54 0.40 0.0 0.58 0.18 0.19 0.40 0.50 0.0

Gastritis (ICD K29) dolor/ardor en el estmago, dolor/ardor en la boca del estmago, acidez, vmitos Nervousness (ICD R45) susto, ansiedad, asfixia, calores repentinos, temblor, intranquilidad, coraje Migraine (ICD G43) presin en la cabeza, dolor de cabeza bien fuerte, latidos en la cabeza, punzadas en los ojos, pesadez y presin en la cabeza Asthma (ICD J45) fatiga, presin en el pecho, asfixia, pito en el pecho Rhinopharyngitis (ICD J31) sangrado nasal, gotereo, secrecin, ardor y congestin nasal, inflamacin, picor y ardor de garganta, estornudo, flema, tos, ronquera, dolor en la cara Gastroesophagus reflux disease (ICD K21) calentn en el esfago, saliva agria, acidez, suben jugos gstricos, ardor que sube y baja en la garganta Allergic Rhinitis (ICD J30) Gotereo nasal, picor en ojos y nariz Chronic Sinusitis (ICD J32) dolor de cabeza, hinchazn en cavidad nasal, calambres, corriente en la nariz Depression (ICD F32) ansiedad, nerviosismo, asfixia, dificultad respiratoria, ganas de irse del mundo, hablar Arthritis (ICD M05) dolor en coyunturas, huesos, articulaciones, inflamacin coyunturas, hinchazn

a) International Classification of Diseases (ICD-10) classifies diseases and other health problems recorded on health and vital records including hospital records. Source http://www.who.int/classifications/apps/icd/icd10online/ b) Out of 351 interviews, 118 mentioned the use of medicinal plants as the first treatment. c) IAR values range from 0 to 1, with 0 representing no consensus, 0.5 average consensus and 1 total consensus.

28

Table 4: Plant with medicinal use in the Southeast Region of Puerto Rico Scientific Name (voucher specimen) Annonaceae Annona muricata L. (GAV- ) Asteraceae Pluchea carolinensis (Jacq.) G. Don in Sweet (GAV- ) Laminaceae Mentha piperita L. (GAV- ) Laminaceae Mentha nemorosa Willd. Ex L. (GAV- ) Rutaceae Citrus aurantium L. (GAV-506) Rutaceae Citrus aurantifolia (Christm.) Swingle (GAV-606) Verbenaceae Lippia stoechadifolia (L.) Kunth (GAVa

Local name guanbano salvia

Parts used/ Preparation Fresh leaves/ Decoction Fresh leaves/ Cataplasm Fresh leaves/ Decoction Fresh leaves/ Decoction Fresh leaves/ Decoction Fresh or dry leaves/ Decoction Fresh pulp/Juice Fresh leaves/ Decoction

Administration Diseases treated Oral Topical Gastritis Migraine

Frequencya (%) 14

27

menta yerbabuena naranja

Oral Oral Oral Oral Oral Oral

Sinusitis Gastritis Depression Nervousness

25 14

33 20

limn poleo

Rhinopharyngitis 40 Gastritis 10

Percentage of the families using this plant for this health problem

29