Perceptions of dengue risk and acceptability of a dengue vaccine in residents of Puerto Rico

Dengvaxia is the first dengue vaccine recommended in the United States (U.S.). It is recommended for children aged 9-16 y with laboratory-confirmed previous dengue infection and living in areas where dengue is endemic. We conducted focus groups with parents and in-depth interviews with key informants (i.e. practicing pediatricians, physicians from immunization clinics, university researchers, and school officials) in Puerto Rico (P.R.) to examine acceptability, barriers, and motivators to vaccinate with Dengvaxia. We also carried out informal meetings and semi-structured interviews to evaluate key messages and educational materials with pediatricians and parents. Barriers to vaccination included lack of information, distrust toward new vaccines, vaccine side effects and risks, and high cost of/lack of insurance coverage for laboratory tests and vaccines. Motivators included clear information about the vaccine, a desire to prevent future dengue infections, the experience of a previous dengue infection or awareness of dengue fatality, vaccine and laboratory tests covered by health insurance, availability of rapid test results and vaccine appointments. School officials and parents agreed parents would pay a deductible of $5-20 for Dengvaxia. For vaccine information dissemination, parents preferred an educational campaign through traditional media and social media, and one-on-one counseling of parents by healthcare providers. Education about this vaccine to healthcare providers will help them answer parents' questions. Dengvaxia acceptability in P.R. will increase by addressing motivators and barriers to vaccination and by disseminating vaccine information in plain language through spokespersons from health institutions in P.R.

Prevalence and correlates of alcohol use among the elderly in the Eastern Caribbean Health Outcomes Research Network (ECHORN) cohort study

BACKGROUND

Alcohol use is pervasive in the Caribbean; however, the prevalence and correlates of alcohol use and drinking problems in the elderly have not been extensively studied.

METHODS

Data were obtained from the Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study, a cohort study of Caribbean people from Puerto Rico, Barbados, Trinidad, and Tobago, and the U.S. Virgin Islands, collected between 2013 and 2018 (baseline study sample, ages 60+, n = 811). Descriptive statistics were used to compare the differences in drinking status (current vs. former vs. never), alcohol problems (Cut-down, Annoyed, Guilty, and Eye-opener (CAGE) scale score ≥2 vs. <2), and binge drinking days (0 days vs. 1-2 days vs. ≥3 days) across sample characteristics. Logistic regression analyses estimated the association of these alcohol measures with sociodemographic (e.g., sex), psychological (depression), and cultural (e.g., religion) correlates.

RESULTS

Thirty-six percent were 70 + years of age, 64 % were female, and 41 % had less than a high school education. Alcohol problems (≥2 CAGE score) was 21 %. Binge drinking ≥3 days was 30.6 %. Never attending religious services (vs. attending once a week or more) was associated with almost three times higher odds of alcohol problems (adjusted Odds Ratio: OR = 2.88, 95 % CI = 1.02, 8.15) four times higher odds of increasing binge drinking days (aOR = 4.04, 95 % CI = 1.11, 14.96). College education was protective against both the outcomes.

CONCLUSION

We provide current estimates of alcohol problems among elderly Eastern Caribbean people. Among the sociodemographic, psychological, and cultural correlates examined, religious attendance was significant. Replicate longitudinal studies using DSM-5 alcohol dependence are recommended.

Urinary phenol and paraben concentrations in association with markers of inflammation during pregnancy in Puerto Rico

Exposure to phenols and parabens may contribute to increased maternal inflammation and adverse birth outcomes, but these effects are not well-studied in humans. This study aimed to investigate relationships between concentrations of 8 phenols and 4 parabens with 6 inflammatory biomarkers (C-reactive protein (CRP); matrix metalloproteinases (MMP) 1, 2, and 9; intercellular adhesion molecule-1 (ICAM-1); and vascular cell adhesion molecule-1 (VCAM-1)) measured at two time points in pregnancy in the PROTECT birth cohort in Puerto Rico. Linear mixed models were used, adjusting for covariates of interest. Results are expressed as the percent change in outcome per interquartile range (IQR) increase in exposure. Particularly among phenols, numerous significant negative associations were found, for example, between benzophenone-3 and CRP (-11.21 %, 95 % CI: -17.82, -4.07) and triclocarban and MMP2 (-9.87 %, 95 % CI: -14.05, -5.5). However, significant positive associations were also detected, for instance, between bisphenol-A (BPA) and CRP (9.77 %, 95 % CI: 0.67, 19.68) and methyl-paraben and MMP1 (10.78 %, 95 % CI: 2.17, 20.11). Significant interactions with female fetal sex and the later study visit (at 24-28 weeks gestation) showed more positive associations compared to male fetal sex and the earlier study visit (16-20 weeks gestation). Our results suggest that phenols and parabens may disrupt inflammatory processes pertaining to uterine remodeling and endothelial function, with important implications for pregnancy outcomes. More research is needed to further understand maternal inflammatory status in an effort to improve reproductive and developmental outcomes.

Historical Hot Spots of Dengue and Zika Viruses to Guide Targeted Vector Control in San Juan, Puerto Rico (2010-2022)

Dengue viruses (DENV) continue to cause large outbreaks in tropical countries, while chikungunya and Zika (ZIKV) viruses have added complexity to Aedes-borne disease prevention and control efforts. Because these viruses are transmitted by the same vectors in urban areas, it is useful to understand if sequential outbreaks caused by these viruses have commonalities, such as similar seasonal and spatial patterns, that would help anticipate and perhaps prevent future outbreaks. We explored and analyzed the heterogeneity of confirmed cases of DENV (2010-2014 and 2015-2022) and ZIKV (2016-2017) during outbreaks in the San Juan metropolitan area of Puerto Rico to explore their degree of overlap and prioritize areas for Aedes aegypti control. Deidentified, georeferenced case data were aggregated into grid cells (500 × 500 m) within a geographical information system of the study area and analyzed to calculate the degree of overlap between outbreaks. Spatial autocorrelations using local indicators of spatial associations were conducted to identify significant disease case hot spots and correlations between outbreaks. We found that 75% of cases during the three transmission periods were concentrated in 25% of the total number of grid cells covering the study area. We also found significant clustering of cases during each outbreak, enabling identification of consistent disease hot spots. Our results showed 85% spatial overlap between cases of ZIKV in 2015-2017 and DENV in 2010-2014 and 97% overlap between DENV cases in 2010-2014 and 2015-2022. These results reveal urban areas at greater risk of future arbovirus outbreaks that should be prioritized for vector control.

Multiple myeloma incidence, mortality, and survival differences at the intersection of sex, age, and race/ethnicity: A comparison between Puerto Rico and the United States SEER population

BACKGROUND

Multiple myeloma (MM) survival has increased during the last decades due to the introduction of new therapies. We investigated the intersectionality among age, sex, and race/ethnicity to better understand the pattern of MM incidence, mortality, and survival.

METHODS

Puerto Rico (PR) Central Cancer Registry and the United States of America (US) Surveillance, Epidemiology, and End Results (SEER) Program databases were used. We analyzed MM incidence and mortality trends from 2001 to 2019 using Joinpoint regression models to calculate annual percent change (APC). Age-standardized rate ratios (SRR) for incidence and mortality were used to compare PR with US SEER racial/ethnic groups during 2015-2019. Five-year survival analyses were also performed stratified by age and sex.

RESULTS

Regardless of age and race/ethnicity, males had higher MM incidence and mortality rates than females. PR had a higher increase in incidence rates of MM than other ethnic groups, regardless of sex and age (PR APC = 4.3 among males <65, 3.1 among males ≥65, 6.3 among females <65, and 2.6 among females ≥65 years old). No significant change in mortality APCs (p > 0.05) was observed in PR when stratified by age or sex while other groups showed a decrease. Among males < 65 years, PR had significantly higher incidence rates than non-Hispanic Whites (NHW), and US Hispanics (USH). However, among both males and females ≥ 65 years, PR had significantly lower MM mortality rates than NHW, non-Hispanic Blacks (NHB), USH, and US Overall. In terms of survival, PR showed the lowest 5-year overall survival among males < 65 years (54.6%, 95% CI: 47.2-61.5) and males ≥ 65 years (34.5%, 95% CI: 29.2-39.9) but not among females.

CONCLUSION

The incidence of MM in PR increased significantly over the study period, particularly among younger women. Despite the introduction of new therapies, mortality rates in PR have remained stable while other ethnic groups show significant decreases among all intersections of sex and age.

Preferences and Demand for Mosquito Control among Dengue-Endemic Communities in Peñuelas, Puerto Rico: An Application of the Best-Worst Choice Model

Aedes aegypti is the primary vector of dengue virus and threatens 3.9 billion people living in many tropical and subtropical countries. Prevention and reduction of dengue and other Aedes-borne viruses, including Zika and chikungunya, requires control of mosquito populations. Community mobilization and input are essential components of vector control efforts. Many vector control campaigns do not engage communities prior to implementation, leading to program failure. Those that do often conduct basic knowledge, attitude, and practice surveys that are not designed to explicitly elicit preferences. Here, we applied a novel stated preference elicitation tool, best-worst choice, to understand preferences, willingness to participate, and willingness to pay for mosquito control in dengue-endemic communities of Peñuelas, Puerto Rico. Findings revealed that the community preferred mosquito control programs that are 1) applied at the neighborhood level, 2) implemented by the local government, and 3) focused specifically on reducing disease transmission (e.g., dengue) instead of mosquito nuisance. Programs targeting the reduction of disease transmission and higher educational level of participants increased willingness to participate. Participants were willing to pay an average of $72 annually to have a program targeting the reduction of diseases such as dengue. This study serves as a model to engage communities in the design of mosquito control programs and improve stakeholders' decision-making.

Neonatal Abstinence Syndrome and Corresponding Pharmacotherapy Approaches from 2 University-affiliated Neonatal Intensive Care Units in Puerto Rico (2018-2020)

OBJECTIVE

Neonatal abstinence syndrome (NAS) is a set of drug withdrawal symptoms suffered by neonates exposed to drugs in utero. Several studies have widely described NAS incidence and treatment approach; however, little is known regarding the incidence and manifestations of this disease in Puerto Rico (PR). The principal aim of this study was to describe NAS incidence in the neonatal units of hospitals affiliated with the University of PR in terms of occurrence, clinical manifestations, and treatment approaches.

METHODS

Our study evaluated the medical records of NAS babies diagnosed from 2018 through 2020 at 2 hospitals affiliated with the University of PR Medical Sciences Campus. Descriptive and inferential statistics were employed to analyze trends.

RESULTS

We identified 12 neonates diagnosed with NAS, 5 with low birthweights (<2500 g); for a NAS incidence of 2 cases per 1000 admitted for the 3 years of recollected data. The urine toxicology results revealed that 9 had experienced intrauterine polydrug exposure. Phenobarbital loading dose were determined on the day of diagnosis (indicated by Finnegan score). The first manifestation of NAS symptoms varied: 8 neonates showed symptoms within 48 hours after birth, whereas 4 had withdrawal symptoms within 72-120 hours of their births. Differences between dosing practices and guidelines were observed, ranging from a 0.69% to a 25% difference during treatment initiation.

CONCLUSION

Further research on the incidence of NAS in PR (national level) is needed for a deeper understanding that we hope will lead to the development of enhanced treatment protocols in PR.

Age-specific case data reveal varying dengue transmission intensity in US states and territories

Dengue viruses (DENV) are endemic in the US territories of Puerto Rico, American Samoa, and the US Virgin Islands, with focal outbreaks also reported in the states of Florida and Hawaii. However, little is known about the intensity of dengue virus transmission over time and how dengue viruses have shaped the level of immunity in these populations, despite the importance of understanding how and why levels of immunity against dengue may change over time. These changes need to be considered when responding to future outbreaks and enacting dengue management strategies, such as guiding vaccine deployment. We used catalytic models fitted to case surveillance data stratified by age from the ArboNET national arboviral surveillance system to reconstruct the history of recent dengue virus transmission in Puerto Rico, American Samoa, US Virgin Islands, Florida, Hawaii, and Guam. We estimated average annual transmission intensity (i.e., force of infection) of DENV between 2010 and 2019 and the level of seroprevalence by age group in each population. We compared models and found that assuming all reported cases are secondary infections generally fit the surveillance data better than assuming all cases are primary infections. Using the secondary case model, we found that force of infection was highly heterogeneous between jurisdictions and over time within jurisdictions, ranging from 0.00008 (95% CrI: 0.00002-0.0004) in Florida to 0.08 (95% CrI: 0.044-0.14) in American Samoa during the 2010-2019 period. For early 2020, we estimated that seropositivity in 10 year-olds ranged from 0.09% (0.02%-0.54%) in Florida to 56.3% (43.7%-69.3%) in American Samoa. In the absence of serological data, age-specific case notification data collected through routine surveillance combined with mathematical modeling are powerful tools to monitor arbovirus circulation, estimate the level of population immunity, and design dengue management strategies.

Exploring U.S. Hispanic origin groups diagnosed with uterine cancer - Are there disparities?

OBJECTIVE

To evaluate patterns and trends of uterine cancer among Hispanic subgroups.

METHODS

The United States Cancer Statistics (USCS), National Cancer Database (NCDB), and World Population Review were used to obtain data on incidence, demographic characteristics, and cancer histology. Joinpoint regression program was used for statistical analysis.

RESULTS

Based on 2001-2017 USCS data, the overall incidence of uterine cancer was 27.46 vs. 23.29/100,000 in Hispanics vs. non-Hispanic Whites. There was an over 2-fold higher annual increase in the incidence in Hispanics (1.94%; p < 0.001) vs. Whites (0.85%; p < 0.001), particularly in local stage disease. There was an increase in grade 1 endometrioid carcinoma (1.48%; p < 0.001 vs. -0.52%; p = 0.1) and aggressive histologic subtypes (4.04% p = 0.000 vs. 2.53% p = 0.000) in Hispanics vs. Whites. Using the NCDB (2004-2015), we analyzed 17,351 Hispanics by subgroup (Mexican, South/Central American, Puerto Rican, Cuban, and Dominican). Over the 12 years, there was an increase in the proportion of uterine cancer diagnoses in all Hispanics (5.2% to 11.0%; p < 0.0001). Dominican patients experienced the largest increase in diagnosis (2.6% to 14.9%; p < 0.0001), the highest proportion of advanced disease at 28.0% (p < 0.0001), and the highest incidence of non-endometrioid histologies at 37.1% (p < 0.0001). World Population Review 2023 revealed the highest female obesity rates in Puerto Rico (51.4%), the Dominican Republic (34.1%), and Mexico (32.8%).

CONCLUSION

Uterine cancer incidence is increased in Hispanics, with the largest increase in Dominican women with more advanced stages and high-risk histologic subtypes. The impact of obesity on cancer risk, especially in Puerto Ricans, Dominicans, and Mexicans, warrants further investigation.

Ensuring Community Engagement in Disease Surveillance: The Municipal Case Investigation and Contact Tracing System for COVID-19 in Puerto Rico

Objectives. To describe the implementation of a novel disease surveillance model in Puerto Rico, the Municipal Case Investigation and Contact Tracing System for COVID-19, established during the pandemic as the primary response. Methods. We analyzed data from July 2020 to June 2021, including all COVID-19 cases reported by public and private laboratories in Puerto Rico to describe the accomplishments and limitations of the surveillance. Results. During the first year, the system was successfully implemented in all Puerto Rican municipalities, collecting data on more than 132 000 confirmed COVID-19 cases. It improved case investigation coverage, reduced laboratory reporting times, and facilitated community engagement for ongoing response enhancements. Conclusions. Surveillance systems of this scale were new to Puerto Rico's Health System, and there was a steep learning and improvement curve. This approach enabled tailored health education, equitable distribution of testing and treatments, and surveillance by educational institutions. Public Health Implications. Near-real-time epidemiological data publication promoted trust, education, and evidence-based policymaking. (Am J Public Health. 2024;114(S1):S96-S102. https://doi.org/10.2105/AJPH.2023.307493).

The Role of Place of Birth and Residence in Puerto Rican Health Disparities: Evidence From Disability Prevalence Among Archipelago- Vs. Mainland-Born Puerto Ricans

Objectives: This paper provides new estimates of disability prevalence for the archipelago and mainland-residing Puerto Rican populations ages 40 and above and compares disability by place of birth and place of residence to investigate drivers of middle and older age health. Methods: Large nationally representative samples from 2013 to 2017 American Community Survey and Puerto Rico Community Survey data are used to estimate age-specific disability prevalence for archipelago-born/archipelago-residing, archipelago-born/mainland-residing, mainland-born/mainland-residing Puerto Ricans. Results: Mainland-born/mainland-residing Puerto Ricans have the lowest age-adjusted disability rates and archipelago-born/archipelago-residing Puerto Ricans have the highest rates. Differences in education explain part of this disparity. Discussion: Similarities in disability prevalence are strongest based on where one was born as opposed to current residence, pointing to early life as a critical period in the disablement process for later-life health. Early life socio-economic disadvantage on the archipelago may have an enduring impact on later-life disability prevalence for archipelago-born Puerto Ricans.

Trends in Cesarean Delivery in Puerto Rico, 2018-2022

Cesarean delivery is major surgery associated with higher costs and adverse outcomes, such as surgical complications, compared with vaginal delivery (1-3). The cesarean delivery rate in Puerto Rico rose from just over 30% in the early to mid-1990s to over 40% by the early 2000s (4,5). During this time, cesarean delivery rates in Puerto Rico were 40%-70% higher than rates in the U.S. mainland and up to 78% higher than rates for Hispanic women in the U.S. mainland (4,5). This report describes trends in Puerto Rico's cesarean delivery rate from 2010 to 2022 and explores changes by maternal age, gestational age, and municipality from 2018 to 2022.

Degenerative Cervical Disc Herniation: Prevalence of Affected Cervical Level in a Hispanic Population in Puerto Rico

BACKGROUND

In the literature, degenerative cervical disc herniation is considered to occur more frequently at the C5-C6 and C6-C7 levels. This study aimed to evaluate the operated cervical level prevalence among patients with degenerative cervical disc herniation in a Hispanic Puerto Rico population.

METHODS

The University of Puerto Rico Neurosurgery database was used to identify patients who underwent anterior cervical discectomy for degenerative cervical disc herniation during a 15-year period from January 1, 2006 until December 31, 2020. Operated cervical levels for each patient were analyzed.

RESULTS

During the study period, 409 patients were operated on for degenerative cervical disc herniation. Two hundred-eight patients (50.8%) had disc herniations at more than 1 cervical level for 663 treated levels. The most prevalent cervical levels in this Hispanic population were C5-C6 (34.8%) and C4-C5 (28.1%). The C6-C7 level was involved in 18.9% of the operated levels, and the C3-C4 level in 17.3%. The C7-T1 level was involved in only 0.6% of the operated levels, and the C2-3 level in 0.3%. The cohort included 51.3% of men and 48.7% of women, with a men-to-women ratio of 1.05:1. The median age of females was 56.5 (range 26-82) and 59.0 (range 31-85) for males. Operated cervical discs were most common between the ages of 48 and 66 years for either sex.

CONCLUSIONS

In a Hispanic Puerto Rico population, the most prevalent operated degenerative cervical disc levels were C5-C6 and C4-C5.

Home range overlap between small Indian mongooses and free roaming domestic dogs in Puerto Rico: implications for rabies management

The small Indian mongoose (Urva auropunctata) is the primary terrestrial wildlife rabies reservoir on at least four Caribbean islands, including Puerto Rico. In Puerto Rico, mongooses represent a risk to public health, based on direct human exposure and indirectly through the transmission of rabies virus to domestic animals. To date, the fundamental ecological relationships of space use among mongooses and between mongooses and domestic animals remain poorly understood. This study is the first to report mongoose home range estimates based on GPS telemetry, as well as concurrent space use among mongooses and free roaming domestic dogs (FRDD; Canis lupus familiaris). Mean (± SE) home range estimates from 19 mongooses in this study (145 ± 21 ha and 60 ± 14 ha for males and females, respectively) were greater than those reported in prior radiotelemetry studies in Puerto Rico. At the scale of their home range, mongooses preferentially used dry forest and shrubland areas, but tended to avoid brackish water vegetation, salt marshes, barren lands and developed areas. Home ranges from five FRDDs were highly variable in size (range 13-285 ha) and may be influenced by availability of reliable anthropogenic resources. Mongooses displayed high home range overlap (general overlap index, GOI = 82%). Home range overlap among mongooses and FRDDs was intermediate (GOI = 50%) and greater than home range overlap by FRDDs (GOI = 10%). Our results provide evidence that space use by both species presents opportunities for interspecific interaction and contact and suggests that human provisioning of dogs may play a role in limiting interactions between stray dogs and mongooses.

Uneven demographic consequences of the 2022 disease outbreak for the sea urchin Diadema antillarum in Puerto Rico

Pervasive epizootic events have had a significant impact on marine invertebrates throughout the Caribbean, leading to severe population declines and consequential ecological implications. One such event was the regional collapse of herbivory, partly caused by the Diadema antillarum mortality event in 1983-84, resulting in a trophic cascade and altering the structure of reef communities. Consequently, there was a notable decrease in coral recruitment and an increase in the coverage of macroalgae. Nearly four decades later, in early 2022, the Caribbean basin experienced another widespread mass mortality event, further reducing the populations of D. antillarum. To assess the effects of this recent mortality event on the current demographics of D. antillarum, we surveyed eight populations along the eastern, northeastern, northern, and northwestern coast of Puerto Rico from May to July 2022, estimating their population density, size distribution, and disease prevalence. Additionally, the study compared these population parameters with data from four sites previously surveyed in 2012 and 2017 to understand the impact of the recent mortality event. The survey conducted in 2022 showed varying population densities at the surveyed reefs. Some populations exhibited mean densities of nearly one individual per square meter, while others had extremely low or no living individuals per square meter. The four populations with the highest density showed no evidence of disease, whereas the four populations with the lowest D. antillarum densities exhibited moderate to high disease prevalence. However, when considering all sites, the estimated disease prevalence remained below 5%. Nevertheless, the comparison with data from 2012 and 2017 indicated that the recent mortality event had a negative impact on D. antillarum demographics at multiple sites, as the densities in 2022 were reduced by 60.19% compared to those from the previous years. However, it is still too early to determine the severity of this new mortality event compared to the 1983-84 mortality event. Therefore, it is imperative to continue monitoring these populations.

Knowledge of Obesity's Health Related Outcomes among Hispanic Women living in Puerto Rico

OBJECTIVE

The primary aim of this cross-sectional study was to assess, according to previous cancer diagnosis, the knowledge Puerto Rican women have on the link between obesity-endometrial, -breast, and colon cancer, and determine women's most common source for medical information.

METHODS

In this cross-sectional study, eligible female patients (n=234) from the Gynecology and Gynecology-Oncology Clinics completed a self-administered survey from October 2014 to March 2016. Participants were evaluated on sociodemographic, body mass index, knowledge of the obesity-cancer link, and source of medical information.

RESULTS

About 49% and 31% of women in the study were obese and overweight, respectively. Less than 52% of the women knew about the link between obesity-breast,-colon, and/or -endometrial cancers. Women with previous cancer diagnoses were more likely aware of the association between obesity-colon cancer than women without previous cancer diagnoses (58% vs. 44%, p0.05). Higher incomes showed increased odds for the knowledge obesity-cancer link among women with a cancer history, but the odds decreased for women without previous cancer diagnoses (p>0.05). Higher education showed a trend towards a better knowledge of the obesity-cancer association. The most common sources of information were the primary doctor (80%) and the internet (54%).

CONCLUSION

Counseling about preventable cancer risk factors through primary care to all women must be encouraged especially in young healthy females. Further studies should address qualitative aspects of the odds differences in the obesity-cancer link knowledge observed between income categories for women with/without previous cancer diagnoses.

Puerto Rican Students Rising in STEM: Findings from a Multicampus Collaborative CURE Program to Promote Student Success

Although Hispanic population is growing rapidly, Latino students earn fewer STEM degrees than their peers. Therefore, it is mandatory to implement strategies that improve STEM retention and graduation rates for Hispanic students. There is little research about the ways in which multicampus collaborative CUREs combined with additional academic support, affect low-income, Hispanic students and none that focus solely on Puerto Rican students in STEM. Puerto Rico (PR) has a 99% Hispanic population; thus, it is imperative to include PR in education research literature. This study sought to examine the impacts of the Research for Improved Student Experiences (RISE) in STEM program at two campuses of the Inter American University of Puerto Rico. The program included multicampus collaborative CUREs, academic advising, and peer mentoring using quasi-experimental design. Impact assessment included psychosocial metrics such as self-efficacy, science identity and sense of belonging in a pre/posttest design. These findings were triangulated with the differences between treatment and control for retention, pass rate, and course grades. The findings revealed statistically significant improvements on all metrics. This study's findings support multicampus collaborative CUREs, academic advising, and peer mentoring as useful and effective strategies for improving outcomes for low-income Hispanic students in Puerto Rico.

Tobacco Use and Depression: A Hidden Epidemic among Smokers 18 Years and Older, Puerto Rico, 2018-2020

OBJECTIVE

According to the literature, depression and tobacco use are closely linked. This study's main objectives were to provide the first population-based epidemiological profile of smokers with depression (SWD) who were 18 years and older and living in Puerto Rico (PR) from 2018 to 2020 and identify any statistically significant differences between SWD and smokers without depression (SWOD).

METHODS

A descriptive cross-sectional study was carried out using PR Behavioral Risk Factor Surveillance System (PRBRFSS) data (2018-2020). Univariate analysis was performed to obtain an epidemiological profile of smokers who had depression. Likewise, using bivariate analysis, SWD and SWOD were compared to identify statistically significant differences in terms of chronic conditions, risk factors, and quit attempts.

RESULTS

Depression prevalence among smokers 18 years and over in PR from 2018-2020 was 23.7%. Smokers with depression were more likely to be physically inactive (P < .001), overweight or obese (P < .001), have arthritis (P < .001), chronic obstructive pulmonary disease (P < .001), asthma (P < .001), high cholesterol (P < .001), hypertension (P < .001), coronary heart disease (P < .001), diabetes (P < .001), stroke (P < .001), and heart attack (P < .001) compared with SWOD. Likewise, SWD made more quitting attempts in the past year than did SWOD (P < .001).

CONCLUSION

Our results indicate that SWD should be targeted in any health-based tobacco-control efforts to develop evidence-based strategies to reduce or eliminate tobacco use in this same population.

Quantifying the relationship between arboviral infection prevalence and human mobility patterns among participants of the Communities Organized to Prevent Arboviruses cohort (COPA) in southern Puerto Rico

Human movement is increasingly being recognized as a major driver of arbovirus risk and dissemination. The Communities Organized to Prevent Arboviruses (COPA) study is a cohort in southern Puerto Rico to measure arboviral prevalence, evaluate interventions, and collect mobility data. To quantify the relationship between arboviral prevalence and human mobility patterns, we fit multilevel logistic regression models to estimate odds ratios for mobility-related predictors of positive chikungunya IgG or Zika IgM test results collected from COPA, assuming mobility data does not change substantially from year to year. From May 8, 2018-June 8, 2019, 39% of the 1,845 active participants during the study period had a positive arboviral seroprevalence result. Most (74%) participants reported spending five or more weekly hours outside of their home. A 1% increase in weekly hours spent outside the home was associated with a 4% (95% confidence interval (CI): 2-7%) decrease in the odds of testing positive for arbovirus. After adjusting for age and whether a person had air conditioning (AC) at home, any time spent in a work location was protective against arbovirus infection (32% decrease, CI: 9-49%). In fact, there was a general decreased prevalence for individuals who visited locations that were inside and had AC or screens, regardless of the type of location (32% decrease, CI: 12-47%). In this population, the protective characteristics of locations visited appear to be the most important driver of the relationship between mobility and arboviral prevalence. This relationship indicates that not all mobility is the same, with elements like screens and AC providing protection in some locations. These findings highlight the general importance of AC and screens, which are known to be protective against mosquitoes and mosquito-transmitted diseases.

Risk factors for household food insecurity in the Eastern Caribbean Health Outcomes Research Network cohort study

Background

Globally, 1.3 billion people were considered food insecure as of 2022. In the Caribbean region, the prevalence of moderate or severe food insecurity was 71.3% as of 2020, the highest of all subregions in Latin America. Experienced based measurement scales, like the Latin American and Caribbean Food Security Scale, are efficient measurement tools of food insecurity used globally. The Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study is a population-based longitudinal cohort study in the two Caribbean U.S. territories of Puerto Rico and the U.S. Virgin Islands, as well as in Barbados and Trinidad & Tobago. The purpose of this research was to examine the demographic, psychosocial, behavioral, and environmental risk factors associated with household food insecurity (HFI) among adults ≥40 years of age in the ECHORN cohort.

Methods

A cross-sectional analysis of baseline ECHORN cohort study data was conducted. The primary outcome was household food insecurity (none, mild, moderate/severe). A total of 16 known and potential risk factors were examined for their association with HFI. The ANOVA and chi-square statistics were used in bivariate analysis. Ordinal logistic regression was used for the multivariable and sex stratified analyses.

Results

More than one-quarter of the sample (27.3%) experienced HFI. In bivariate analyses, all risk factors examined except for sex, were significantly associated with HFI status. In the multivariable analysis, all variables except sex, education, marital status, smoking status, and residing in Puerto Rico were significant predictors of HFI in the adjusted model. In sex stratified analysis, depression, food availability, self-rated physical health, and island site were significantly associated with increased odds of worsening HFI for women, but not for men. Source of potable water was an important risk factor for both men and women.

Discussion

The prevalence of HFI in the ECHORN cohort study is comparable to other studies conducted in the region. While women did not have an increased risk of HFI compared to men, a different set of risk factors affected their vulnerability to HFI. More research is needed to understand how water and food security are interrelated in the ECHORN cohort.

A Closer Look at Indirect Causes of Death After Hurricane Maria Using a Semiparametric Model

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic as well as other recent natural emergencies have put the spotlight on emergency planning. One important aspect is that natural disasters or emergencies often lead to indirect deaths, and studying the behavior of indirect deaths during emergencies can guide emergency planning. While many studies have suggested many indirect deaths in Puerto Rico due to Hurricane Maria; the specific causes of these deaths have not been carefully studied.

METHODS

In this study, we use a semiparametric model and mortality data to evaluate cause of death trends. Our model adjusts for cause of death effect potentially varying over time while also inferring on how long excess deaths occurred.

RESULTS

From September 2017 to March 2018, after adjusting for intra-annual variability and population displacement, we find evidence of significant excess deaths due to Alzheimer's/Parkinson, heart disease, sepsis, diabetes, renal failure, and pneumonia and influenza.

CONCLUSIONS

In contrast, for the same time period we find no evidence of significant excess deaths due to cancer, hypertension, respiratory diseases, cerebrovascular disease, suicide, homicide, falling accidents, and traffic accidents.

Skin cancer prevention behaviors, beliefs, distress, and worry among hispanics in Florida and Puerto Rico

BACKGROUND

Incidence of skin cancer has been increasing among U.S. Hispanics, who often are diagnosed with larger lesions and at later stage disease. Behaviors to decrease exposure to ultraviolet radiation can reduce risk of skin cancer. We describe skin cancer prevention behaviors and psychosocial variables among Hispanic participants recruited into a skin cancer prevention trial.

METHODS

Self-reported Hispanic participants from eight primary care clinics in Tampa, Florida and Ponce, Puerto Rico were recruited into a randomized controlled prevention trial. Information on demographics, sun-related behaviors, and psychosocial variables were collected before intervention materials were provided. Multivariable regression models were used to compare baseline sun-related behaviors and psychosocial variables across groups defined by geographic location and language preference.

RESULTS

Participants reported low levels of intentional outdoor tanning, weekday and weekend sun exposure, and very low levels of indoor tanning. However, only a minority of participants practiced sun-protective behaviors often or always, and about 30% experienced a sunburn in the past year. Participants had low levels of recent worry and concern about skin cancer, modest levels of perceived risk and severity, and high levels of response efficacy and self-efficacy. When comparing across groups defined by geographic location and language preference, English-preferring Tampa residents (hereafter referred to as Tampeños) had the highest proportion who were sunburned (35.9%) and tended toward more risky behavior but also had higher protective behavior than did Spanish-preferring Tampeños or Puerto Ricans. Spanish-preferring Puerto Ricans had higher recent concern about skin cancer, comparative chance of getting skin cancer, and response efficacy compared to either English- or Spanish-preferring Tampeños. Spanish-preferring Tampeños had the highest levels of familism and recent distress about skin cancer.

CONCLUSIONS

Our results mirror previous observations of low levels of sun-protective behavior among U.S. Hispanics compelling the need for culturally appropriate and translated awareness campaigns targeted to this population. Because Hispanics in Tampa and Puerto Rico reported modest levels of perceived risk and severity, and high levels of response efficacy and self-efficacy, interventions aiming to improve skin cancer prevention activities that are anchored in Protection Motivation Theory may be particularly effective in this population subgroup.

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.

Pregnant Women's Experiences During and After Hurricanes Irma and Maria, Pregnancy Risk Assessment Monitoring System, Puerto Rico, 2018

OBJECTIVE

Exposure to natural disasters during and after pregnancy may increase adverse mental health outcomes. Hurricanes Irma and Maria struck Puerto Rico in September 2017. Our objectives were to understand hurricane-related experiences, maternal health concerns, and the impact of hurricane experiences on postpartum depressive symptoms (PDS).

METHODS

We used data from the 2018 Pregnancy Risk Assessment Monitoring System to describe differences in maternal hurricane experiences among women who were pregnant during and after the 2017 hurricanes. We assessed maternal concerns and PDS. We estimated adjusted prevalence ratios (aPRs) and 95% CIs for the associations between hurricane experiences and PDS.

RESULTS

The most frequently reported hurricane experiences were losing power for ≥1 week (97%) and feeling unsafe due to lack of order/security (70%). Almost 30% of women who were pregnant during the hurricanes reported missing prenatal care. PDS were reported by 13% of women. Most hurricane experiences were associated with an increased prevalence of PDS. Feeling unsafe (aPR = 2.4; 95% CI, 1.2-4.9) and having difficulty getting food (aPR = 2.1; 95% CI, 1.1-4.1) had the strongest associations.

CONCLUSIONS

Most women who were pregnant during or after hurricanes Irma and Maria struck Puerto Rico reported negative hurricane experiences, and most experiences were associated with an increased prevalence of PDS. Understanding the experiences of pregnant women during and after disasters and identifying risks for adverse mental health outcomes after pregnancy are important to inform emergency preparedness and prenatal and postpartum care.

H - 12 Bienestar Psicológico Y Aflicción en Cuidadores Informales de Adultos Mayores Con Demencia en Puerto Rico, Durante Tiempos de Pandemia

OBJETIVO

Los objetivos del estudio fueron describir los niveles de aflicción y bienestar psicológico en cuidadores informales (CI) de personas diagnosticadas con demencia en Puerto Rico, así como determinar la relación entre estos, durante el periodo de pandemia por COVID-19.

MÉTODO

En este estudio descriptivo y correlacional participaron 84 adultos puertorriqueños entre las edades de 21 y 65 años. El 92.9% se identificó con el género femenino. Se administró un cuestionario sociodemográfico, la Escala de Bienestar Psicológico de Ryff (EBPR) y el Inventario de Aflicción del Cuidador Marwit y Meuser (IACMM), formulario corto, a través de Psychdata.

RESULTADOS

Un 70.0% de la muestra (n = 59) reportó presentar niveles de aflicción promedio, un 19.0% (n = 16) bajos, y 11.0% (n = 9) altos. El promedio de aflicción reportada en la IACMM fue de 63.89 (DE = 13.31). Un 61.0% (n = 51) de los participantes reportó niveles bajos de bienestar psicológico. La EBPR reflejó un promedio de 70.39 (DE = 13.09). Se llevó a cabo un análisis de correlación Pearson para evaluar la relación entre puntuaciones en la IACMM y la EBPR. Los resultados reflejaron una correlación negativa, moderada baja y estadísticamente significativa, r = -0.374 (p < 0.01).

CONCLUSIÓN

La muestra reportó niveles de aflicción comparables con los reportados por muestras de CI en tiempos pre-pandemia. También reportaron niveles de bienestar psicológico por debajo de lo esperado para la población puertorriqueña en general. Los resultados apoyaron la correlación inversa entre aflicción y bienestar psicológico documentada previamente en la literatura. Se discutirán implicaciones de estos hallazgos para la población puertorriqueña de CI.

Impact of Hurricanes Irma and Maria on Asthma, Hypertension, and Depression in a Sample of the Puerto Rico Population

OBJECTIVE

To evaluate the impact of Hurricanes Irma and Maria on 3 major chronic diseases in Puerto Rico.

METHODS

San Juan Overweight Adults Longitudinal study participants were re-evaluated after Hurricanes Irma and Maria (May 2019-July 2020) for the Preparedness to Reduce Exposures and Diseases Post-hurricanes and Augment Resilience study. This study compared the prevalence and incidence of asthma, depression, and hypertension within the same 364 individuals over time.

RESULTS

Asthma and depression prevalence and incidence did not change significantly after the hurricanes. The prevalence of hypertension increased significantly after the hurricanes (OR = 2.2, 95% CI: 1.2, 3.9). The incidence of hypertension after the hurricanes (IR = 9.0, 95% CI: 6.5, 12.4) increased significantly compared to before the hurricanes (IR = 6.1, 95% CI: 4.5, 8.0) (age-adjusted incidence rate ratio [aIRR] = 1.4, 95% CI: 4.5, 8.0) for similar time periods.

CONCLUSION

Hurricanes Irma and Maria were associated with a significant increase in the prevalence and incidence of hypertension in this study population. Contrary to expectations, no significant increases were observed in depression and asthma prevalence after the hurricanes. Results from this study can inform better strategies to prevent and manage hypertension in the population affected by a hurricane.

Barriers and facilitators to anal cancer screening among people living with HIV in Puerto Rico

BACKGROUND

Anal cancer (AC) disproportionally affects people living with HIV (PLWH). Although there are no consensus-based AC screening guidelines, experts recommend anal pap as a primary screening tool in settings where high-resolution anoscopy (HRA) is available. We aimed to assess barriers and facilitators to anal cancer screening in a sample of Hispanic PLWH in Puerto Rico.

METHODS

To assess their knowledge and attitudes, we conducted a cross-sectional survey from 2020-2021 among PLWH in Puerto Rico (n = 212). Data was collected through a telephone interview that assessed information on sociodemographics, knowledge, and attitudes about AC, and the history of AC screening. The chi-square test, Fisher exact test, and logistic regression models were used to assess factors associated with screening uptake.

RESULTS

Anal Pap and HRA awareness were 60.4% and 30.7%, respectively. Anal Pap and HRA uptake was 51.5% and 19.3%, respectively. The most common barriers for anal Pap and HRA were lack of knowledge about the test and lack of physician recommendation. MSM were more likely to have heard of anal Pap (OR: 2.15, 95% CI:1.30-3.54) than MSW. MSM (OR: 3.04, 95% CI: 1.79-5.19) and women (OR: 3.00, 95% CI: 1.72-5.20) were also more likely to have undergone anal Pap. Similarly, individuals with a history of genital warts were more likely to have heard of anal Pap and HRA and have undergone anal Pap and HRA. Awareness of where to go for concerns about anal health was positively associated with having received anal Pap and HRA.

CONCLUSIONS

With emerging evidence on the effectiveness of screening and treatment for anal cancer, several organizations are steering toward generating consensus-based anal cancer screening recommendations. Our study provides foundational data on barriers and facilitators to anal cancer screening in Puerto Rico that will be critical to informing screening implementation in this US territory.

Breast and Colorectal Cancer Screening Utilization after Hurricane María and the COVID-19 Pandemic in Puerto Rico

Puerto Rico (PR) has faced environmental and public health challenges that could have significantly affected cancer screening access. Using administrative claims data from PR's Medicaid population, this study assessed trends in colorectal and breast cancer screening from 2016 to 2021, the impact of disasters in screening, and the absolute deficit in screening due to the pandemic. The monthly rates of claims were analyzed using Poisson regression. Significant reductions in breast and colorectal cancer screening utilization were observed. The colorectal cancer screening rate in 2017 was 77% lower a month after Hurricanes Irma and María [RRadj: 0.23; 95% CI: 0.20, 0.25] compared to the same time period in 2016. Breast cancer screening dropped 50% in November 2017 compared to November 2016 [RRadj: 0.50; 95% CI: 0.47, 0.54]. Prospectively, a recovery in utilization has been observed only for breast cancer screening. The results revealed that cancer screening utilization substantially declined after environmental disasters and the pandemic. These findings have potentially severe long-term implications for cancer health disparities and mortality in PR.

RABIES VIRUS SEROSURVEY OF THE SMALL INDIAN MONGOOSE (URVA AUROPUNCTATA) ACROSS MULTIPLE HABITATS IN PUERTO RICO, 2014-21

The small Indian mongoose (Urva auropuncata) is a rabies reservoir in Puerto Rico and accounts for over 70% of reported animal rabies cases annually. The presence of rabies virus-neutralizing antibodies (RVNA) is often used as a tool to measure exposure to rabies virus in wildlife populations. We conducted a serosurvey of mongooses at 11 sites representing six habitat types across Puerto Rico. We collected a serum sample from 464 individual mongooses during 2014-21. Overall, 80/464 (17.0%; 95% confidence interval, 14.1-20.9%; 55 male, 23 female, and two sexes not recorded) of individual mongooses sampled across all habitats were RVNA positive. The geometric mean (SD) RVNA titer for 80 unique seropositive animals was 0.58 (2.92) IU/mL. Our models indicated that the probability of mongooses being RVNA seropositive mostly varied by habitat, with some influence of sex in the individual-level analyses. Population-level RVNA seroprevalence is dynamic in mongoose populations, but these data may shed light on rabies virus transmission across regions to help inform rabies management activities in Puerto Rico.

Evaluating the performance of anal cytology and high-risk HPV genotyping for detecting anal HSIL in a clinic-based sample of people living with and without HIV in Puerto Rico

BACKGROUND

Given the disproportionately elevated anal cancer risk in high-risk populations, it is important to assess the performance of commonly used anal cancer screening tools to improve the effectiveness of detection and treatment methods. This study evaluates 1) the concordance between anal cytology and histology results and 2) the performance of cytology and high-risk human papillomavirus (HR-HPV) genotyping as screening tools for detecting histologically confirmed anal high-grade squamous intraepithelial lesions (HSIL).

METHODS

Data from the Anal Neoplasia Clinic in Puerto Rico (2014-2021; n = 466) was used. The clinical performance of anal cytology and HR-HPV genotyping to detect HSIL was compared to the gold standard: high-resolution anoscopy-guided biopsy. Sensitivity, specificity, positive predictive value, negative predictive value, and κ coefficients were calculated.

RESULTS

A total of 66.95% of the patients were men, 74.0% were people living with HIV, 76.2% had anal HR-HPV infection, and 40.34% had histologically confirmed anal HSIL. The weighted κ statistic between the tests (cytology and histology) was 0.25 (p < .001). The sensitivity and specificity of cytology alone to detect anal HSIL were 84.3% (95% confidence interval [CI], 78.3%-89.1%) and 36.0% (95% CI, 30.3%-42.0%), respectively. Anal HR-HPV genotyping had higher sensitivity (92.2%; 95% CI, 87.4%-95.6%) and similar specificity (34.8%; 95% CI, 29.2%-40.7%) compared to cytology. The two tests combined (positive results following cytology or HR-HPV test) improved sensitivity to detect anal HSIL (97.9%; 95% CI, 94.8%-99.4%), but specificity was compromised (19.2%; 95% CI, 14.7%-24.4%).

CONCLUSION

Although HR-HPV genotyping improved the detection of anal HSIL, HR-HPV testing had lower specificity than anal cytology alone.

The associations of income and Black-White racial segregation with HIV outcomes among adults aged ≥18 years-United States and Puerto Rico, 2019

OBJECTIVE(S)

To examine associations between Index of Concentration at the Extremes (ICE) measures for economic and racial segregation and HIV outcomes in the United States (U.S.) and Puerto Rico.

METHODS

County-level HIV testing data from CDC's National HIV Prevention Program Monitoring and Evaluation and census tract-level HIV diagnoses, linkage to HIV medical care, and viral suppression data from the National HIV Surveillance System were used. Three ICE measures of spatial polarization were obtained from the U.S. Census Bureau's American Community Survey: ICEincome (income segregation), ICErace (Black-White racial segregation), and ICEincome+race (Black-White racialized economic segregation). Rate ratios (RRs) for HIV diagnoses and prevalence ratios (PRs) for HIV testing, linkage to care within 1 month of diagnosis, and viral suppression within 6 months of diagnosis were estimated with 95% confidence intervals (CIs) to examine changes across ICE quintiles using the most privileged communities (Quintile 5, Q5) as the reference group.

RESULTS

PRs and RRs showed a higher likelihood of testing and adverse HIV outcomes among persons residing in Q1 (least privileged) communities compared with Q5 (most privileged) across ICE measures. For HIV testing percentages and diagnosis rates, across quintiles, PRs and RRs were consistently greatest for ICErace. For linkage to care and viral suppression, PRs were consistently lower for ICEincome+race.

CONCLUSIONS

We found that poor HIV outcomes and disparities were associated with income, racial, and economic segregation as measured by ICE. These ICE measures contribute to poor HIV outcomes and disparities by unfairly concentrating certain groups (i.e., Black persons) in highly segregated and deprived communities that experience a lack of access to quality, affordable health care. Expanded efforts are needed to address the social/economic barriers that impede access to HIV care among Black persons. Increased partnerships between government agencies and the private sector are needed to change policies that promote and sustain racial and income segregation.

Association Between Concurrent Use of Benzodiazepines and Opioids and Health Care Utilization Among Patients With Cancer in Puerto Rico

PURPOSE

To evaluate the association between concurrent use of opioids and benzodiazepines (BZDs) and emergency room (ER) visits and hospital admissions in patients with cancer.

METHODS

Data were obtained from the Puerto Rico Central Cancer Registry-Health Insurance Linkage. Odds ratios (ORs) with 95% CIs and incidence rate ratio (IRR) were estimated using logistic and negative binomial regression analyses to assess the association between concurrent use of opioids and BZDs (overlap of at least 7 days) and ER visits and hospital admissions.

RESULTS

A total of 9,259 patients were included in the main analysis. The logistic regression results showed a significant association between concurrent use of opioids and BZDs and at least one ER visit (OR, 1.28 [95% CI, 1.07 to 1.54]) or hospital admission (OR, 1.42 [95% CI, 1.18 to 1.71]) compared with individuals with BZDs alone, after adjusting for age, sex, comorbidity index, cancer stage, health insurance, and health region. Compared with individuals with opioid use alone, the association did not reach significance. In the negative binomial regression, a significant association was observed for ER visits (IRR, 1.52 [95% CI, 1.31 to 1.76]) and hospitalizations (IRR, 1.34 [95% CI, 1.20 to 1.50]) when compared with individuals with BZDs alone. Compared with individuals with opioids alone, it only reached significance for ER visits (IRR, 1.39 [95% CI, 1.20 to 1.61]).

CONCLUSION

Careful evaluation must be done before prescribing concurrent opioids and BZDs in patients with cancer, as the results suggest that coprescribing may increase the odds of ER visits and hospitalizations.

Adverse birth outcomes are associated with circulating matrix metalloproteinases among pregnant women in Puerto Rico

Matrix metalloproteinases (MMPs) are major extracellular matrix (ECM) remodeling proteinases and regulate uterine remodeling, which is a critical process for healthy pregnancies. The goal of this study was to investigate associations between maternal blood MMPs during pregnancy and birth outcomes among 898 pregnant women in the Puerto Rico PROTECT birth cohort. MMPs (MMP1, MMP2, and MMP9) were quantified using a customized Luminex assay in blood samples collected at two gestational study visits (around 18 and 26 weeks gestation). Linear and logistic regression models were used to regress continuous and binary birth outcomes, respectively, on MMPs at each study visit separately. Sensitivity analyses were conducted to test for effect modification by fetal sex on associations between MMPs and birth outcomes. We observed significant associations between MMP2 at visit 1 and newborn length that were in the opposite direction from the associations between MMP9 at visit 3 and newborn length. MMPs were associated with increased odds of preeclampsia and gestational diabetes mellitus, though case numbers were low. We also observed significant inverse associations with gestational age for MMP9 and MMP2 at visit 1 and visit 3, respectively, and these associations were observed only in mothers carrying male fetuses. Further, MMP2 was associated with heavier female fetuses, whereas MMP9 was associated with lighter female fetuses. We observed significant associations between birth outcomes and MMPs, and the majority of these associations differed by fetal sex. This study highlighted significant MMPs-birth outcomes associations that may provide a basis to explore the impact of MMPs on endometrium health and physiology.

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.

Refractive Error Changes Due to COVID-19 Pandemic Confinement in Children from Puerto Rico: A Retrospective Study

SIGNIFICANCE

The progression of myopia increased in children after the pandemic confinement. A myopic shift in the refractive error of the Hispanic population was found regardless of the refractive status of the school-aged children studied.

PURPOSE

This study aimed to evaluate the refractive error in Puerto Rican children before and after the COVID-19 pandemic. We were interested in whether there was a significant change in refractive error attributed to online learning during the pandemic lockdown.

METHODS

A retrospective record review of children aged 7 to 18 years who underwent a comprehensive visual evaluation between 2018 and 2021 at the Inter American Eye Institute in Puerto Rico was performed. The spherical equivalent pre- and post-lockdown was compared. The study excluded the best-corrected visual acuities worse than 20/40, any corneal or retinal disease, and amblyopia.

RESULTS

In total, 801 records were included in this study. The mean age was 12.7 ± 3.2 years, with 50.3% male and 49.7% female children. The mean spherical equivalent for the right and left eyes was similar ( r = 0.93, P ≤ .001). A significant difference in the mean spherical equivalent was found pre- and post- lockdown (0.22 ± 0.59 D, t800 = 10.44, P ≤ .001). A myopic shift post-lockdown was significant for all ages except those in the 7- (0.13 ± 0.79 D, t28 = 0.84, P = .40) and 8-year-old range (0.12 ± 0.65 D, t40 = 1.22, P = .23), respectively. No significant change was found between sexes before (0.16 ± 0.12 D; t799 = 1.38, P = .16) and after (0.15 ± 0.13 D; t799 = 1.19, P = .23) confinement.

CONCLUSIONS

The current study revealed a significant myopic shift in Hispanic school-aged children as a result of the pandemic confinement.

Leprosy Reactions: Experience in the Puerto Rico Hansen's Disease Population

OBJECTIVE

Hansen's disease (HD) is a chronic granulomatous infection endemic in the tropics. Its main clinical manifestations involve the cutaneous, nervous, and musculoskeletal systems. Leprosy reactions (LR) are systemic inflammatory and immune-mediated complications of HD. These include reversal reactions (RR), erythema nodosum leprosum (ENL), and Lucio phenomenon. These reactions significantly increase disease-related morbidity and disability. We aimed to determine the number and type of LR, their association to hosts' immune responses (Ridley Jopling classification), timing of development, and treatment of HD patients in Puerto Rico.

METHODS

A retrospective medical record review was performed on 291 HD patients containing LR status data available from the Dermatology Service at the Hispanic Alliance for Clinical & Translational Research.

RESULTS

Our data revealed that 83 (29%) patients developed LR, of which 31% had RR and 69% had ENL. Most LR were observed in patients in the lepromatous border (97%): Borderline lepromatous leprosy (BL) and Lepromatous Leprosy (LL). Most patients with RR and ENL had a single episode (83% and 62%, respectively), and those that received multi-drug therapy (MDT) had a reaction onset occurring most frequently within the first year of MDT and after the first year of MDT, respectively. Prednisone was the first line treatment used to manage both types of LR.

CONCLUSION

Most lepromatous reactions occur within the lepromatous border. ENL was the most common LR. Prompt recognition and management of these immunologic reactions is essential to prevent long term nerve function impairment.

The cervical microbiota of Hispanics living in Puerto Rico is nonoptimal regardless of HPV status

The cervicovaginal microbiota is influenced by host physiology, immunology, lifestyle, and ethnicity. We hypothesized that there would be differences in the cervicovaginal microbiota among pregnant, nonpregnant, and menopausal women living in Puerto Rico (PR) with and without human papillomavirus (HPV) infection and cervical cancer. We specifically wanted to determine if the microbiota is associated with variations in cervical cytology. A total of 294 women, including reproductive-age nonpregnant (N = 196), pregnant (N = 37), and menopausal (N = 61) women, were enrolled. The cervicovaginal bacteria were characterized by 16S rRNA amplicon sequencing, the HPV was genotyped with SPF10-LiPA, and cervical cytology was quantified. High-risk HPV (HR-HPV, 67.3%) was prevalent, including genotypes not covered by the 9vt HPV vaccine. Cervical lesions (34%) were also common. The cervical microbiota was dominated by Lactobacillus iners. Pregnant women in the second and third trimesters exhibited a decrease in diversity and abundance of microbes associated with bacterial vaginosis. Women in menopause had greater alpha diversity, a greater proportion of facultative and strictly anaerobic bacteria, and higher cervicovaginal pH than premenopausal women. Cervical lesions were associated with greater alpha diversity. However, no significant associations between the microbiota and HPV infection (HR or LR-HPV types) were found. The cervicovaginal microbiota of women living in Puerto Rican were either dominated by L. iners or diverse microbial communities regardless of a woman's physiological stage. We postulate that the microbiota and the high prevalence of HR-HPV increase the risk of cervical lesions among women living in PR. IMPORTANCE In the enclosed manuscript, we provide the first in-depth characterization of the cervicovaginal microbiota of Hispanic women living in Puerto Rico (PR), using a 16S rRNA approach, and include women of different physiological stages. Surprisingly we found that high-risk HPV was ubiquitous with a prevalence of 67.3%, including types not covered by the 9vt HPV vaccine. We also found highly diverse microbial communities across women groups-with a reduction in pregnant women, but dominated by nonoptimal Lactobacillus iners. Additionally, we found vaginosis-associated bacteria as Dialister spp., Gardnerella spp., Clostridium, or Prevotella among most women. We believe this is a relevant and timely article expanding knowledge on the cervicovaginal microbiome of PR women, where we postulate that these highly diverse communities are conducive to cervical disease.

Previous Dengue Infection among Children in Puerto Rico and Implications for Dengue Vaccine Implementation

Limited dengue virus (DENV) seroprevalence estimates are available for Puerto Rico, which are needed to inform the potential use and cost-effectiveness of DENV vaccines. The Communities Organized to Prevent Arboviruses (COPA) is a cohort study initiated in 2018 in Ponce, Puerto Rico, to assess arboviral disease risk and provide a platform to evaluate interventions. We recruited participants from households in 38 study clusters, who were interviewed and provided a serum specimen. Specimens from 713 children aged 1 to 16 years during the first year of COPA were tested for the four DENV serotypes and ZIKV using a focus reduction neutralization assay. We assessed the seroprevalence of DENV and ZIKV by age and developed a catalytic model from seroprevalence and dengue surveillance data to estimate the force of infection for DENV during 2003-2018. Overall, 37% (n = 267) were seropositive for DENV; seroprevalence was 9% (11/128) among children aged 1 to 8 years and 44% (256/585) among children aged 9 to 16 years, exceeding the threshold over which DENV vaccination is deemed cost-effective. A total of 33% were seropositive for ZIKV, including 15% among children aged 0 to 8 years and 37% among children aged 9 to 16 years. The highest force of infection occurred in 2007, 2010, and 2012-2013, with low levels of transmission from 2016 to 2018. A higher proportion of children had evidence of multitypic DENV infection than expected, suggesting high heterogeneity in DENV risk in this setting.

Incidence and Mortality Rates for Childhood Acute Lymphoblastic Leukemia in Puerto Rican Hispanics, 2012-2016

BACKGROUND

Acute lymphoblastic leukemia (ALL) accounts for 80% of all leukemias diagnosed in children. Although ALL age patterns are consistent across racial/ethnic groups, their incidence and mortality rates are highly variable. We assessed the age-standardized ALL incidence and mortality rates of Puerto Rican Hispanic (PRH) children and compared them with those of US mainland Hispanics (USH), non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), and Non-Hispanic Asian or Pacific Islanders (NHAPI).

METHODS

Differences between racial/ethnic groups were assessed by estimating the standardized rate ratio (SRR) for 2010 to 2014. Secondary data analyses of the Puerto Rico Central Cancer Registry and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) databases were performed for the 2001 to 2016 period.

RESULTS

PRH children had 31% lower incidence rates than USH, but 86% higher incidence rates than NHB. In addition, the incidence trends of ALL increased significantly from 2001 to 2016 among PRH and USH, with 5% and 0.9% per year, respectively. Moreover, PRH have a lower 5-year overall survival (81.7%) when compared with other racial/ethnic groups.

CONCLUSIONS

PRH children were found to have disparities in ALL incidence and mortality rates compared with other racial/ethnic groups in the US. Additional research is warranted to identify the genetic and environmental risk factors that may be associated with the disparities observed.

IMPACT

This is the first study reporting the incidence and mortality rates of childhood ALL for PRH and making comparisons with other racial/ethnic groups in the US. See related commentary by Mejía-Aranguré and Núñez-Enríquez, p. 999.

Exposure to violence and asthma in Puerto Rican youth with high Th2 immunity

BACKGROUND

Little is known about the determinants of asthma among youth with high T helper 2 (Th2) immunity. We hypothesized that exposure to violence (ETV) and violence-related distress are associated with asthma in children and adolescents with high Th2 immunity.

METHODS

We analyzed data from Puerto Ricans with high Th2 immunity aged 9-20 years in the Puerto Rico Genetics of Asthma and Lifestyle (PR-GOAL) and the Epigenetic Variation of Childhood Asthma in Puerto Ricans (EVA-PR) studies, and in a prospective study (PROPRA). High Th2-immunity was defined as ≥1 positive allergen-specific IgE and/or a total IgE ≥ 100 IU/mL and/or an eosinophil count ≥ 150 cells/μL. Asthma was defined as physician-diagnosed asthma and current wheeze. ETV and violence-related distress were assessed with the validated ETV Scale and Checklist of Children's Distress Symptoms (CCDS) questionnaires, respectively.

RESULTS

In multivariable analyses, each 1-point increment in ETV score was significantly associated with 1.13-1.17 times increased odds of asthma in PR-GOAL and in EVA-PR (both at p ≤ 0.01), and each 1-point increment in CCDS score was significantly associated with 1.53-1.54 increased odds of asthma in PR-GOAL and in EVA-PR (both at p ≤ 0.03). Further, a persistently high ETV score was significantly associated with asthma in PROPRA (odds ratio [OR] = 2.83, 95% confidence interval [CI] = 1.10-7.29). Similar results were obtained in a sensitivity analysis using an eosinophil count ≥ 300 cells/μL instead of ≥150 cells/μL to define high Th2 immunity.

CONCLUSIONS

ETV during childhood is associated with increased risk of persistent or new-onset asthma in youth with high Th2 immunity.

Comparative analysis of onychomycosis in Puerto Rico using molecular and conventional approaches

Onychomycosis is the most prevalent nail ailment in adults, accounting for 50% of all nail infections. Dermatophyte fungi are the primary cause, but non-dermatophyte molds (NDM) and yeasts can also cause onychomycosis. It remains important to precisely determine the fungal cause of onychomycosis since the response to current treatments may vary between fungal classes. Real-time polymerase chain reaction (qPCR) has become a widespread tool for detecting fungal organisms for diagnosis due to its sensitivity and ability to detect down to the species level. This retrospective study aims to evaluate the qPCR Onycho+ test for dermatophyte detection using remnants of toenails from a cohort of patients from Puerto Rico.  Two hundred forty-two toenail samples submitted for histological examination via Periodic acid Schiff (PAS) staining for suspected onychomycosis were analyzed by the Onycho+ test and Sanger sequencing of the internal transcribed spacer (ITS-2). Compared to the gold standard Sanger sequencing method, the Onycho+ test reported an agreement of 91.39%, a sensitivity of 100% and a specificity of 84.5% in detecting dermatophytes, superior to the histology method which had a 69.53% agreement, 85.1% sensitivity and 57.1% specificity. The distribution of fungal organisms detected in this cohort shows a dermatophyte majority but a higher-than-expected proportion of NDMs. Nails negative for the Onycho+ test and positive for histology were mostly NDMs. This study demonstrates that the clinical performance of the Onycho+ test is superior to histology in detecting dermatophytes and that a combination of Onycho+ and histology can result in a higher clinical accuracy.

El Niño Southern Oscillation (ENSO) effects on local weather, arboviral diseases, and dynamics of managed and unmanaged populations of Aedes aegypti (Diptera: Culicidae) in Puerto Rico

We investigated the effects of interannual El Niño Southern Oscillation (ENSO) events on local weather, Aedes aegypti populations, and combined cases of dengue (DENV), chikungunya (CHIKV), and Zika (ZIKV) viruses in 2 communities with mass mosquito trapping and 2 communities without mosquito control in southern Puerto Rico (2013-2019). Gravid adult Ae. aegypti populations were monitored weekly using Autocidal Gravid Ovitraps (AGO traps). Managing Ae. aegypti populations was done using 3 AGO traps per home in most homes. There were drought conditions in 2014-2015 concurrent with the emergence of a strong El Niño (2014-2016), wetter conditions during La Niña (2016-2018), a major hurricane (2017), and a weaker El Niño (2018-2019). The main factor explaining differences in Ae. aegypti abundance across sites was mass trapping. Populations of Ae. aegypti reached maximum seasonal values during the wetter and warmer months of the year when arbovirus epidemics occurred. El Niño was significantly associated with severe droughts that did not impact the populations of Ae. aegypti. Arbovirus cases at the municipality level were positively correlated with lagged values (5-12 mo.) of the Oceanic El Niño Index (ONI), droughts, and abundance of Ae. aegypti. The onset of strong El Niño conditions in Puerto Rico may be useful as an early warning signal for arboviral epidemics in areas where the abundance of Ae. aegypti exceeds the mosquito density threshold value.

Community Forums as Amplifiers of Communities' Voices: Isolated Communities in Puerto Rico

Social determinants of health contribute to health disparities and inequities. We conducted a community forum on the topic of isolation with the objectives of (1) identifying and prioritizing key health-related issues needing attention in isolated communities in Puerto Rico; (2) developing strategies in terms of Policies, Programs, and Practices to address the community priorities we identified. We used the triangulation method for qualitative data, integrating the Colorado State University's Tri-ethnic Center Model and the Delphi Technique for a better understanding of community health needs and priorities. The five community health-related priorities identified in the community forum were: (1) access to health services (physical and mental); (2) older adults; (3) access to basic services; (4) preparedness for future disasters/emergencies; and (5) COVID-19 and access to vaccination. The Alliance Leaders and Advisory Boards understand that we will work with the priorities of preparedness for future natural disasters/emergencies and COVID-19 and access to vaccination. Fifteen strategies were developed for these priorities and were grouped into five areas that require more attention in order to reduce health disparities. Isolated communities in Puerto Rico present an intersectionality of factors that affect a wide range of health-related risks and outcomes.

Consumption of sugar-sweetened beverages and T2D diabetes in the Eastern Caribbean

OBJECTIVE

Sugar-sweetened beverages (SSB) are implicated in the increasing risk of diabetes in the Caribbean. Few studies have examined associations between SSB consumption and diabetes in the Caribbean.

DESIGN

SSB was measured as teaspoon/d using questions from the National Cancer Institute Dietary Screener Questionnaire about intake of soda, juice and coffee/tea during the past month. Diabetes was measured using self-report, HbA1C and use of medication. Logistic regression was used to examine associations.

SETTING

Baseline data from the Eastern Caribbean Health Outcomes Research Network Cohort Study (ECS), collected in Barbados, Puerto Rico, Trinidad and Tobago and US Virgin Islands, were used for analysis.

PARTICIPANTS

Participants (n 1701) enrolled in the ECS.

RESULTS

Thirty-six percentage of participants were unaware of their diabetes, 33% aware and 31% normoglycaemic. Total mean intake of added sugar from SSB was higher among persons 40-49 (9·4 tsp/d), men (9·2 tsp/d) and persons with low education (7·0 tsp/d). Participants who were unaware (7·4 tsp/d) or did not have diabetes (7·6 tsp/d) had higher mean SSB intake compared to those with known diabetes (5·6 tsp/d). In multivariate analysis, total added sugar from beverages was not significantly associated with diabetes status. Results by beverage type showed consumption of added sugar from soda was associated with greater odds of known (OR = 1·37, 95 % CI (1·03, 1·82)) and unknown diabetes (OR = 1·54, 95 % CI (1·12, 2·13)).

CONCLUSIONS

Findings indicate the need for continued implementation and evaluation of policies and interventions to reduce SSB consumption in the Caribbean.

Breast, cervical, and colorectal cancer screening test use in the US territories of Guam, Puerto Rico, and the US Virgin Islands

BACKGROUND

The United States Preventive Services Task Force (USPSTF) recommends breast, cervical, and colorectal cancer screening among eligible adults, but information on screening use in the US territories is limited.

METHODS

To estimate the proportion of adults up-to-date with breast, cervical, and colorectal cancer screening based on USPSTF recommendations, we analyzed Behavioral Risk Factor Surveillance System data from 2016, 2018, and 2020 for the 50 US states and DC (US) and US territories of Guam and Puerto Rico and from 2016 for the US Virgin Islands. Age-standardized weighted proportions for up-to-date cancer screening were examined overall and by select characteristics for each jurisdiction.

RESULTS

Overall, 67.2% (95% CI: 60.6-73.3) of women aged 50-74 years in the US Virgin Islands, 74.8% (70.9-78.3) in Guam, 83.4% (81.7-84.9) in Puerto Rico, and 78.3% (77.9-78.6) in the US were up-to-date with breast cancer screening. For cervical cancer screening, 71.1% (67.6-74.3) of women aged 21-65 years in Guam, 81.3% (74.6-86.5) in the US Virgin Islands, 83.0% (81.7-84.3) in Puerto Rico, and 84.5% (84.3-84.8) in the US were up-to-date. For colorectal cancer screening, 45.2% (40.0-50.5) of adults aged 50-75 years in the US Virgin Islands, 47.3% (43.6-51.0) in Guam, 61.2% (59.5-62.8) in Puerto Rico, and 69.0% (68.7-69.3) in the US were up-to-date. Adults without health care coverage reported low test use for all three cancers in all jurisdictions. In most jurisdictions, test use was lower among adults with less than a high school degree and an annual household income of < $25,000.

CONCLUSION

Cancer screening test use varied between the US territories, highlighting the importance of understanding and addressing territory-specific barriers. Test use was lower among groups without health care coverage and with lower income and education levels, suggesting the need for targeted evidence-based interventions.

Age-Related Differences in Anxiety and Depression Diagnosis among Adults in Puerto Rico during the COVID-19 Pandemic

Residents of Puerto Rico bear a significant burden of mental health disorders, which the COVID-19 pandemic may have exacerbated. However, age-specific data on these disorders during the pandemic in Puerto Rico are scarce. This study evaluated age-related differences in the self-reported diagnosis of depression and anxiety among adults ≥18 years residing in Puerto Rico during the pandemic. An anonymous online survey was administered from December 2020 to February 2021 via Google Forms to measure self-reported sociodemographic and behavioral characteristics and physician-diagnosed mental health disorders. Multivariable logistic regression models were conducted for each self-reported mental health diagnosis after adjusting for sex, education, income, marital status, chronic diseases, and smoking. Out of 1945 adults, 50% were aged 40 years and over. Nearly 24% of responders self-reported an anxiety diagnosis, whereas 15.9% reported depression. Compared to individuals 50 years and over, those 18-29 y, 30-39 y, and 40-49 y had significantly higher odds of an anxiety diagnosis (OR = 1.84, 95% CI = 1.34-2.55; OR = 1.50, 95% CI = 1.09-2.07; and OR = 1.37, 95% CI = 1.01-1.87, respectively). However, no association between age and depression diagnosis was found. Despite anxiety and depression being frequent disorders during the pandemic in this sample, younger adults bear a higher burden of anxiety. Further research is needed to allocate appropriate mental health resources during emergencies according to population subgroups.

Preexisting Depression and Ambulatory Status After Stroke: Florida-Puerto Rico Collaboration to Reduce Stroke Disparities

OBJECTIVE

Stroke is a global public health burden, and therefore it is critical to identify modifiable risk factors to reduce stroke incidence and improve outcomes. Depression is such a risk factor; however, the association between preexisting depression and stroke outcomes, such as independent ambulation, is not well studied, especially among racial-ethnic minority groups. To address this gap in the literature, effects of preexisting depression on ambulatory status at hospital discharge after stroke were evaluated among individuals participating in the racially and ethnically diverse Florida-Puerto Rico Collaboration to Reduce Stroke Disparities project.

METHODS

Data were analyzed from a total of 42,031 ischemic stroke patients, who were independently ambulatory prior to their stroke, after discharge from 84 hospitals between 2014 and 2017. Preexisting depression was confirmed by medical history or antidepressant medication use. Multilevel multivariate logistic regression analyses were used to assess the association of preexisting depression with independent ambulation at hospital discharge. Effects of sex and race-ethnicity on this association were examined.

RESULTS

Of 42,031 participants (mean±SD age=70.4±14.2 years; 48% were female; race-ethnicity: 16% Black, 12% Hispanic living in Florida, and 7% Hispanic living in Puerto Rico), 6,379 (15%) had preexisting depression. Compared with participants without depression, those with preexisting depression were older, were more likely to be female and non-Hispanic White, and had a greater burden of vascular risk factors or comorbid conditions. Independent ambulation at hospital discharge was less frequent among women, Black participants, and individuals with vascular risk factors or comorbid conditions. In multivariate models, preexisting depression decreased the likelihood of independent ambulation at discharge (odds ratio=0.88, 95% CI=0.81, 0.97). No interactions were found between preexisting depression and race-ethnicity or sex.

CONCLUSIONS

Preexisting depression was independently associated with dependent ambulation at hospital discharge after stroke, regardless of sex and race-ethnicity. Treating depression may contribute to primary stroke prevention and could improve ambulatory status at discharge.

Psychological sense of community, self-rated health and quality of life among older adults in Puerto Rico two years after Hurricane María

Older adults who experience natural disasters are at risk for immediate and longer-term negative health outcomes and diminished quality of life (QOL), in part due to disruptions to social relationships and protections. We use a risk and resilience framework to examine the protective effects of psychological sense of community (PSOC) on self-rated health (SRH) and QOL for older adults in Puerto Rico 2 years after the devastation of Hurricane María in 2017. Between September 2019 and January 2020, we conducted face-to-face interviews with a nonprobability sample of 154 community-dwelling adults aged 60+ in Puerto Rico. Controlling for covariates, we used multivariate regression to examine the association of PSOC and key social risk factors (mental health, social isolation, and loneliness) with SRH and QOL. Higher levels of PSOC were significantly associated with better SRH and QOL. Regarding risks, worse mental health was significantly associated with lower QOL and SRH, loneliness was significantly related to worse QOL, and social isolation was significantly associated with better SRH and better QOL. PSOC was a protective factor for older adults, suggesting that prevention and intervention efforts should focus on building and sustaining older adults' sense of community in the longer-term wake of natural disasters.

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.