Health Disparities Research Framework Adaptation to Reflect Puerto Rico's Socio-Cultural Context

Psychological resilience, resilient coping, and health behaviors among adults in Puerto Rico after multiple adverse events

Objective: Residents of Puerto Rico have recently experienced multiple adverse events, including hurricanes, earthquakes, and political unrest. Such adversity is associated with worse mental and physical health. Psychological resilience and effective coping may mitigate these relations by fostering positive health behaviors, like consuming a high-quality diet and being physically active. However, empirical evidence for these relationships is limited. Methods: We assessed psychological resilience, resilient coping, and health behaviors among two groups of adults in Puerto Rico, before and during the pandemic, in 2019-2023 (total N = 1,342). Resilience and resilient coping were assessed using the Brief Resilience Scale and Brief Resilient Coping Scale. Diet quality was defined by the Alternate Healthy Eating Index from a food frequency questionnaire. We collected data on sleep, physical activity, alcohol intake, and tobacco use using validated questionnaires. Results: Adjusting for confounders, higher resilience z-scores were associated with being in the highest category of diet quality [OR: 1.25, 95 % CI: 1.04, 1.50]; getting 7-8 h of sleep per night [OR: 1.15, 95 % CI: 1.02,1.30]; and reporting moderate or heavy physical activity (vs. light or sedentary) [OR: 1.17, 95 % CI: 1.02,1.34]. The same patterns were observed for higher resilient coping z-scores, and for categorical measures of resilience and resilient coping. These relationships were stronger among participants interviewed during (vs. before) the COVID-19 pandemic, suggesting that resilience and resilient coping may be particularly relevant during an ongoing stressor. Conclusion: Identifying supportive strategies to cultivate resilience and effective coping mechanisms may contribute to healthier behaviors, particularly in a vulnerable population.

Empowering Underserved Communities in Southern Puerto Rico: A Formal Training Program in Community Health Promotion

Community health promotion offers a potential solution to persistent healthcare challenges, with community health workers playing a pivotal role. The Community Training Institute for Health Disparities (CTIHD) implemented a problem-solving curriculum in Community Health Promotion, integrating a competency-based learning model through two courses: Introduction to Community Health Promotion and Design of an Action Plan for the Promotion of Community Health. Each course comprised ten three-hour sessions, featuring pre/post-tests, evaluations, and a cognitive debriefing. Knowledge change was assessed using pre/post-test scores among 27 community leaders from southern Puerto Rico. Cohort 1 and Cohort 2 demonstrated an overall retention rate of 62.6% and 96.7%, respectively. Although differences in knowledge gained between cohorts and courses weren't statistically significant, a trend toward increased knowledge was noted. Cohort 1 experienced a 22% knowledge increase in Course 1 and a 24% increase in Course 2. Cohort 2 demonstrated a 41% knowledge increase in Course 1 and a 25% increase in Course 2. The CTIHD's Community Health Promotion Program has made significant strides in elevating awareness and knowledge, marking a positive step toward reducing health disparities and fostering healthier, empowered communities in southern Puerto Rico.

Colonialism as a Social Determinant of Health in Puerto Rico: Using the Socioecological Model to Examine How the Jones Act Impacted Health After Hurricane María

INTRODUCTION

Puerto Rico is a territory of the United States, making Puerto Ricans vulnerable to damaging colonial policy. The purpose of this article is to utilize the socioecological model (SEM) to evaluate how the Jones Act impacted Puerto Rico after Hurricane María, examining colonialist policy as a social determinant of health (SDOH) in Puerto Rico.

METHODS

Levels of the SEM used in this examination included: individual, institutional, community, policy, and context.

RESULTS

Evaluation of the Jones Act using the model demonstrated relationships between all socioecological levels. The Jones Act caused delays and increased prices for goods needed to rebuild community utility infrastructure, which led to extended closures of institutions like workplaces, schools, and hospitals, and ultimately contributed to increased acute and chronic physical and mental illness among Puerto Ricans.

DISCUSSION

This evaluation establishes that colonialist policy negatively impacts the health of Puerto Ricans, positioning colonialism as an SDOH.

The Puerto Rico community engagement alliance (PR-CEAL) against COVID-19 disparities: outreach and research engagement efforts in disproportionately affected communities

In September 2020, the National Institutes of Health acted in response to the COVID-19 pandemic, recognizing the critical need to combat misinformation, particularly in communities disproportionately affected by the crisis. The Community Engagement Alliance (CEAL) emerged as an initiative dedicated to fostering reliable, science-based information, diversity, and inclusion; aiming to implement effective strategies to mitigate the spread of COVID-19 nationwide. One of the teams participating in this initiative is Puerto Rico-CEAL (PR-CEAL). Our whose goal was to raise awareness about the coronavirus disease and advance research, mainly focusing on vulnerable and underserved populations. This concept paper seeks to outline PR-CEAL's infrastructure during its initial two cycles, providing insights into the research and community engagement activities designed to enhance prevention, counter misinformation, and foster awareness and uptake of COVID-19 vaccines. Ultimately, our objective is to reflect on the strengths and challenges encountered thus far as we endeavor to sustain this robust infrastructure, addressing ongoing public health issues with a forward-looking approach.

Self-reported neighborhood stressors and sleep quality among Puerto Rican young adults

OBJECTIVE

To examine the association between changes in self-reported neighborhood stressors and sleep quality and determine whether this varied by sociocultural context among Puerto Rican young adults.

METHODS

Data come from the Boricua Youth Study Health Assessment, a sample of Puerto Rican young adults from San Juan, Puerto Rico, and South Bronx, New York (n = 818; mean age=22.9years). Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Neighborhood social stressors (disorder, social cohesion, and safety) were parent-reported in childhood and self-reported in young adulthood and categorized into: low in childhood/young adulthood (reference group), high in childhood/low in young adulthood, low in childhood/high in young adulthood, and high in childhood/young adulthood. Sociocultural context was based on participant residence during childhood (San Juan vs. South Bronx).

RESULTS

Adjusting for sociodemographic factors, living with high neighborhood stressors in both childhood and young adulthood (prevalence ratios=1.30, 95% CI: 1.01, 1.66) was associated with overall poor sleep (PSQI score >5). Among PSQI components, living with high neighborhood stressors in young adulthood only or in both time periods was associated with worse subjective sleep quality and daytime dysfunction. Additionally, there were various associations between the neighborhood stressor measures and PSQI components. Results did not differ by sociocultural context.

CONCLUSION

Findings suggest that living with high levels of neighborhood stressors during childhood and young adulthood may have a cumulative adverse impact on sleep quality in young adulthood.

Prevalence of cardiometabolic risk and health factors among Puerto Rican young adults in the Boricua Youth Study - Health Assessment

We describe and compare the prevalence of cardiometabolic risk factors and ideal cardiovascular health (CVH) among Puerto Rican young adults in the San Juan metro area in Puerto Rico and the South Bronx, NY. As part of the Boricua Youth Study - Health Assessment, (mean age 23 ± 0.1 years) objective anthropometric, blood pressure and blood samples were collected. Information on diet, physical activity and sleep were collected via surveys. Life's Essential 8 metrics were characterized as continuous with higher scores indicating more optimal CVH and categorically (80-100 scores for ideal CVH). Mean CVH score among NY participants was lower (61.9) than in PR (68.9). No participant had all ideal health metrics, 36% of participants in PR had 5 or more ideal CVH; while only 16% in NY met this criterion. The prevalence of cardiometabolic risk factors was high for obesity (35% in NY, 19% in PR) and diabetes (17% NY, 20% PR). In this ethnically homogenous population, we found low levels of ideal CVH that varied across study site, suggesting differences by sociocultural context. Interventions to maintain and improve CVH across the life course, tailored to sociocultural environments, are necessary for the prevention of cardiovascular disease.

Ethno-racial variation in psychotic experiences in the United States: Findings from the National Latino and Asian American Survey and the National Survey of American Life

BACKGROUND

Ethno-racial differences in psychosis risk are documented; however, there is less research on whether these differences extend to sub-threshold psychotic experiences, and whether there is significant variation within ethno-racial categories.

METHODS

We analyzed data from the National Latino and Asian American Survey (NLAAS) and the National Survey of American Life (NSAL). Using multivariable logistic regression, we examined the association between race/ethnicity and lifetime psychotic experiences among Latino, Asian, and Black adults in the general population, adjusting for gender, age, nativity, education level, income level, employment status, and everyday discrimination.

RESULTS

Puerto Ricans, Cubans, and other Hispanics had greater odds of lifetime psychotic experiences when compared with Mexicans, though differences diminished when adjusting for covariates. Filipino and other Asians had greater odds of lifetime psychotic experiences when compared with Chinese, though again, differences diminished when adjusting for covariates. Among Black Americans, there were no significant ethnic subgroup differences.

CONCLUSION

Ethno-racial differences extend across the psychosis continuum. There are nuanced health profiles across and within ethno-racial categories. Differences may be attributable to differences in experiences living in the US, underscoring the need for community-specific interventions.

Sociodemographic and health risk factors associated with health-related quality of life among adults living in Puerto Rico in 2019: a cross-sectional study

BACKGROUND

Puerto Rico, a US territory, faces numerous challenges adversely affecting public health, including poverty, a fragile healthcare system, inadequate infrastructure, a debt crisis, and vulnerability to climate change-related natural disasters. The impact of these factors on the Health-Related Quality of Life (HRQoL) measure has not been comprehensively evaluated. Only two studies have assessed HRQoL, with the latest conducted in 2011, prior to recent events that could affect public health. This study aimed to assess the HRQoL and associated sociodemographic and health risk factors among adults living in Puerto Rico in 2019.

METHODS

Prevalence and 95% confidence intervals were used to describe HRQoL and its associations with sociodemographic and health-related variables among adults living in Puerto Rico who answered the Behavioral Risk Factor Surveillance System (BRFSS) survey (n = 4,944) in 2019. Multivariable logistic regression models were developed to identify which of these variables were more likely to be associated with each of the four core HRQoL questions (HRQoL-4), expressed as prevalence odds ratios with 95% confidence intervals adjusted for potential confounders.

RESULTS

Through a comprehensive multivariable analysis, we uncovered significant risk factors - increasing number of chronic conditions, advanced age, and low income - associated with poor HRQoL among adults living in Puerto Rico. Specifically, our findings suggest that individuals with an increasing number of chronic conditions were more likely to report poor HRQoL across all 4 domains. As the number of reported chronic conditions increases by one, the odds of reporting having: fair/poor general health increased by a factor of 2.24 (POR: 2.24, 95% CI: 2.08-2.41), physical health impairment increased by a factor of 1.93 (POR: 1.93, 95% CI: 1.78-2.08), mental health impairment increased by a factor of 1.90 (POR: 1.90, 95% CI: 1.78-2.02) and activity limitation increased by a factor of 1.27 ( POR: 1.27, 95% CI: 1.13-1.42). Advancing age was associated with all domains of poor HRQoL, except for the mental health domain for which we observed higher rates of poor HRQoL among the younger population (POR: 4.76, 95% CI: 2.4-9.1).

CONCLUSION

This paper shows that the prevalence of poor HRQoL has not improved compared to the only previous study of HRQoL of Puerto Rico in the last decade. We also found that poor HRQoL is associated with having multiple chronic conditions in adults living in Puerto Rico. This may be a consequence of a decline in health services after natural disasters and socioeconomic downturns on the island. The study emphasizes the need for targeted interventions and ongoing monitoring of the population's HRQoL over time to reach vulnerable subgroups, especially those with chronic conditions, advanced age, and low income, in order to reduce health disparities in Puerto Rico.

Food Insecurity Is Associated With Dysfunctional Eating Behaviors Among Adults in Puerto Rico

OBJECTIVE

To examine the association between food insecurity and dysfunctional eating behaviors among adults in Puerto Rico.

METHODS

Data from 865 participants were obtained from baseline interviews from the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT) cohort. The association between food insecurity and emotional eating (EE) and uncontrolled eating (UE) (categorized as no/moderate/high) was examined using multinomial logistic models. Potential mediation by perceived stress was explored.

RESULTS

The prevalence of food insecurity was 20.3%. Compared with adults with food security, adults with food insecurity had higher odds of both moderate EE (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.18-3.09) and high EE (OR, 2.85; 95% CI, 1.75-4.64), and both moderate UE (OR, 1.78; 95% CI, 0.91-3.50) and high UE (OR, 3.28; 95% CI, 1.70-6.33). Perceived stress slightly attenuated these associations.

CONCLUSIONS AND IMPLICATIONS

Food insecurity was associated with a higher likelihood of engaging in dysfunctional eating behaviors. Interventions alleviating food insecurity or stress might help adults sustain healthy eating behaviors.

A Qualitative Approach to Explore Perceptions, Opinions and Beliefs of Communities who Experienced Health Disparities towards Chronic Health Conditions

The prevalence of chronic medical conditions is associated with biological, behavioral, and social factors. In Puerto Rico (PR), events such as budget cuts to essential services in recent years have contributed to deepening health disparities. This study aimed to explore community perceptions, opinions, and beliefs about chronic health conditions in the southern region of Puerto Rico. Framed by a Community-Based Participatory Research (CBPR) approach, this qualitative study developed eight focus groups (n = 59) with adults (age of 21 or older) from southern Puerto Rico, in person and remotely, during 2020 and 2021. Eight open-ended questions were used for discussions, which were recorded, transcribed, and analyzed via computer analysis. Content analysis revealed four main dimensions: knowledge, vulnerabilities, barriers, and identified resources. Relevant topics included: concerns about mental health-depression, anxiety, substance use, and suicide; individual vulnerabilities-risk behaviors, and unhealthy habits; economic factors-health access and commercialization of health. Resource identification was also explored, and participants discussed the importance of alliances between public and private sectors. These topics were addressed across all focus groups, with various recommendations. The results highlight the importance of prioritizing identified community needs, evaluating available resources, and promoting tailored-made interventions to reduce risk factors for chronic health conditions.

The neighborhood context and all-cause mortality among older adults in Puerto Rico

Background

Recent efforts have been made to collect data on neighborhood-level attributes and link them to longitudinal population-based surveys. These linked data have allowed researchers to assess the influence of neighborhood characteristics on the health of older adults in the US. However, these data exclude Puerto Rico. Because of significantly differing historical and political contexts, and widely ranging structural factors between the island and the mainland, it may not be appropriate to apply current knowledge on neighborhood health effects based on studies conducted in the US to Puerto Rico. Thus, we aim to (1) examine the types of neighborhood environments older Puerto Rican adults reside in and (2) explore the association between neighborhood environments and all-cause mortality.

Methods

We linked data from the 2000 US Census to the longitudinal Puerto Rican Elderly Health Conditions Project (PREHCO) with mortality follow-up through 2021 to examine the effects of the baseline neighborhood environment on all-cause mortality among 3,469 participants. Latent profile analysis, a model-based clustering technique, classified Puerto Rican neighborhoods based on 19 census block group indicators related to the neighborhood constructs of socioeconomic status, household composition, minority status, and housing and transportation. The associations between the latent classes and all-cause mortality were assessed using multilevel mixed-effects parametric survival models with a Weibull distribution.

Results

A five-class model was fit on 2,477 census block groups in Puerto Rico with varying patterns of social (dis)advantage. Our results show that older adults residing in neighborhoods classified as Urban High Deprivation and Urban High-Moderate Deprivation in Puerto Rico were at higher risk of death over the 19-year study period relative to the Urban Low Deprivation cluster, controlling for individual-level covariates.

Conclusions

Considering Puerto Rico's socio-structural reality, we recommend that policymakers, healthcare providers, and leaders across industries to (1) understand how individual health and mortality is embedded within larger social, cultural, structural, and historical contexts, and (2) make concerted efforts to reach out to residents living in disadvantaged community contexts to understand better what they need to successfully age in place in Puerto Rico.

Applying a socioecological framework to chronic disease management: implications for social informatics interventions in safety-net healthcare settings

Objective

Vulnerable populations face numerous barriers in managing chronic disease(s). As healthcare systems work toward integrating social risk factors into electronic health records and healthcare delivery, we need better understanding of the interrelated nature of social needs within patients' everyday lives to inform effective informatics interventions to advance health equity.

Materials and Methods

We conducted in-depth interviews, participant-led neighborhood tours, and clinic visit observations involving 10 patients with diabetes in underserved San Francisco neighborhoods and 10 community leaders serving those neighborhoods. We coded health barriers and facilitators using a socioecological framework. We also linked these qualitative data with early persona development, focusing on patients' experiences in these communities and within the healthcare system, as a starting place for our future informatics design.

Results

We identified social risk and protective factors across almost every socioecological domain and level-from physical disability to household context to neighborhood environment. We then detailed the complex interplay across domains and levels within two critical aspects of patients' lives: housing and food. Finally, from these data we generated 3 personas that capture the intersectional nature of these determinants.

Conclusion

Drawing from different disciplines, our study provides a socioecological approach to understanding health promotion for patients with chronic disease in a safety-net healthcare system, using multiple methodologies. Future digital health research should center the lived experiences of marginalized patients to effectively design and implement informatics solutions for this audience.