CUADERNOS DE INVESTIGACIÓN

INSTITUTO DE INVESTIGACIONES INTERDISCIPLINARIAS

UNIVERSIDAD DE PUERTO RICO EN CAYEY

TRAMIL Ethno-pharmacological Survey in the

Southeast Region of Puerto Rico
José A. Alvarado-Guzmán
Jannette Gavillán-Suárez
Lionel Germosén-Robineau

Cuaderno 5
Año 2008
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© JGS
Preliminary manuscript
If cited, please contact the corresponding author at jgavillan@cayey.upr.edu

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

José A. Alvarado-Guzmána, Jannette Gavillán-Suárez,a,b,* Lionel Germosén-Robineauc

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

Barceló Ave., Cayey, PR 00736

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

Ave., Cayey, PR 00736

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

UFR SEN BP 592, 97159 Pointe à 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

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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 Panamá 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

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commonly use as medicinal plants and 170 less known for their therapeutic value (Nuñez,

1989; Martínez, 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), Institute of

Interdisciplinary Research. 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

island’s 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.

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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)

2 2
where, n = minimum simple size; N = total population size (123,855); Zα = 1.645 (α =.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, Rincón and Toíta) 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

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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

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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 women’s 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-

6
Guzmán) reviewed the questionnaires and received the vouchers. Field work was supervised

by the second author (J. Gavillán-Suárez).

2.5 Survey instrument

The questionnaire used was approved by the Internal Review Board at the UPR-Cayey, field-

tested 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 family’s or neighbors’

backyards. Classification of the botanical species was performed by José Sustache, Botanist

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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, 2-

year 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

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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

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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

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(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.

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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,

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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, Panamá, 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

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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 (Chávez, 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 antigen-

induced 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,

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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 (Hernández, 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; Nuñez 1989). Hernández 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 TRAMIL’s definition of significant use, reflecting

TRAMIL’s 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).

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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 UPR-

Cayey students who conducted the interviews: Carlos Marzant, José I. López, Melissa

Guzmán, Melissa Olivieri, Mercedes López, Orly Santos, Rosángela Rosario, Yahaira Rosario

and Yasmín Pérez; and to the students who completed the data entry: Dalixis Rivera and María

del C. Rodríguez. Thanks to Mr. José 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-

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

P2MD001112-0.

6. References

Aday, Lu Ann; Llewellyn J. Cornelius; 3rd ed., 2006. Designing and Conducting Health

Surveys: A Comprehensive Guide,Jossye-Bass,154-194.

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sanación espiritual en Puerto Rico, Verde Luz 23643, Road 743, Cayey, PR, 00736-9496.

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Cayey, PR, 00736-9496.

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75.

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Costa, M. And Carvalho-Freitas, M. I. R., 2002. Anxiolytic and sedative effects of extracts and

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19
Nahir, R. L., Dahlhamer, J. M., Taylor, B. L., Barnes, P. M., Stussman, B. J., Simile, C. M.,

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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.

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Económicas y de Vivienda, Appendix B, 17 – 18, (a) Family’s Households: Habitual residence

of two or more persons who are related through blood (birth), marriage or adoption; Appendix

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vivienda, 127 – 145.

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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?
______________________________________

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Table 2: Descriptive characteristics of the families (n=118) that reported the use of herbal
remedies

Women in Percentage
Variables families using within herbal χ2 p- OR 95% CI
herbal remedies use value
remedies
(n=118)
Age Groups
<=50 67 58.6 .522 1.19 .758 – 1.87
>50 48 41.4
Marital Statusa
single 62 46.6 .002 2.09 1.37 – 3.31
married 54 53.4
Employment Status
employed 56 49.6 .061 1.59 1.01 – 2.50
unemployed 57 50.4
Level of Education
college degree 65 57.0 .036 1.67 1.1 – 2.62
< college degree 49 43.0

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 Number of times the Percent Number of IAR-valuec
(Description of symptons in spanish) ailment was cited Medicinal plants
(n = 118)b cited for the ailment
Gastritis (ICD – K29) 42 19.7 22 0.49
dolor/ardor en el estómago, dolor/ardor en la boca del estómago,
acidez, vómitos
Nervousness (ICD – R45) 29 13.6 14 0.54
susto, ansiedad, asfixia, calores repentinos, temblor, intranquilidad, coraje
Migraine (ICD – G43) 26 12.2 16 0.40
presión en la cabeza, dolor de cabeza bien fuerte, latidos en la cabeza,
punzadas en los ojos, pesadez y presión en la cabeza
Asthma (ICD – J45) 24 11.3 24 0.0
fatiga, presión en el pecho, asfixia, pito en el pecho
Rhinopharyngitis (ICD – J31) 20 9.4 9 0.58
sangrado nasal, gotereo, secreción, ardor y congestión nasal, inflamación,
picor y ardor de garganta, estornudo, flema, tos, ronquera, dolor en la cara
Gastroesophagus reflux disease (ICD – K21) 18 8.5 15 0.18
calentón en el esófago, saliva agria, acidez, suben jugos gástricos,
ardor que sube y baja en la garganta
Allergic Rhinitis (ICD – J30) 17 8.0 14 0.19
Gotereo nasal, picor en ojos y nariz
Chronic Sinusitis (ICD – J32) 16 7.5 10 0.40
dolor de cabeza, hinchazón en cavidad nasal, calambres, corriente en la
nariz
Depression (ICD – F32) 11 5.2 6 0.50
ansiedad, nerviosismo, asfixia, dificultad respiratoria, ganas de irse del
mundo, hablar
Arthritis (ICD – M05) 10 4.7 10 0.0
dolor en coyunturas, huesos, articulaciones, inflamación coyunturas,
hinchazón

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 Local name Parts used/ Administration Diseases treated Frequencya
(voucher specimen) Preparation (%)
Annonaceae guanábano Fresh leaves/ Decoction Oral Gastritis 14
Annona muricata L.
(GAV- )
Asteraceae salvia Fresh leaves/ Topical Migraine 27
Pluchea carolinensis (Jacq.) Cataplasm
G. Don in Sweet
(GAV- )
Laminaceae menta Fresh leaves/ Decoction Oral Sinusitis 25
Mentha piperita L.
(GAV- )
Laminaceae yerbabuena Fresh leaves/ Decoction Oral Gastritis 14
Mentha nemorosa Willd. Ex L.
(GAV- )
Rutaceae naranja Fresh leaves/ Decoction Oral Depression 33
Citrus aurantium L. Fresh or Nervousness 20
(GAV-506) dry leaves/ Decoction Oral
Rutaceae limón Fresh pulp/Juice Oral Rhinopharyngitis 40
Citrus aurantifolia (Christm.) Swingle
(GAV-606)
Verbenaceae poleo Fresh leaves/ Decoction Oral Gastritis 10
Lippia stoechadifolia (L.) Kunth
(GAV-
a
Percentage of the families using this plant for this health problem

29