Association between adverse experiences during Hurricane María and mental and emotional distress among adults in Puerto Rico.

OBJECTIVES: To evaluate the association between adverse experiences during Hurricane María and mental and emotional distress in Puerto Rico. METHODS: This cross-sectional study used baseline data from adult (30-75 years) participants of the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT). Enrolled individuals prior to COVID-19 who completed a 33-item questionnaire on Hurricane María-related experiences (sub-categorized as personal, service, or property losses), depression symptomatology, post-traumatic stress disorder (PTSD), and anxiety were included for analysis (n = 456). RESULTS: Most participants experienced fear for their family's safety, damage to their home and personal items, communication outages, and water shortages. Each additional stressor was significantly associated with higher odds of depression symptoms, PTSD, and anxiety. Personal losses were significantly associated with higher likelihood of all outcomes, while services losses were associated with depression symptoms and anxiety; property loss was not significantly associated with any outcome. CONCLUSIONS: Adverse experiences during a major natural disaster are associated with mental and emotional distress. Strategies to minimize hardships during natural disasters, especially personal and service losses, are essential to preserve mental health. Post-disaster psychological support to individuals is crucial.

Design and Implementation of the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT).

The Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT) is a prospective cohort study in Puerto Rico (PR) aiming to identify trends and longitudinal associations in risk factors for cardiovascular disease (CVD). In 2019, PROSPECT investigators started recruiting a sample of 2,000 adults aged 30-75 years in PR using multistage probabilistic sampling of households and community approaches. Culturally sensitive trained research assistants assess participants, at baseline and at 2-year follow-up, in private rooms at a network of partner clinics. The study collects comprehensive data on demographic factors, socioeconomic and environmental factors, medical history, health conditions, lifestyle behaviors, psychosocial status, and biomarkers of CVD and stress. PROSPECT will estimate the prevalence and incidence of psychosocial, lifestyle, and biological CVD risk factors, describe variations in risk factors by urbanicity (urban areas vs. rural areas) and exposure (before and after) to natural disasters, and determine predictors of longitudinal changes in CVD risk factors. The study has 4 coordinated operational strategies: 1) research productivity (including synergy with existing epidemiologic cohorts of Hispanics/Latinos for comparison); 2) research infrastructure (biorepository, ancillary studies, and clinical research network); 3) capacity-building, education, and training; and 4) community outreach, dissemination, and policy. PROSPECT will inform public health priorities to help reduce CVD in PR.

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.

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.

Lessons learned by adapting and implementing LUCHA: a deep-structure culturally tailored healthy eating randomized pilot intervention for ethnic-diverse Latinos.

Objectives: To report the adaptation and implementation of LUCHA (Latinos United for a Culturally Healthy Alimentation), a pilot intervention to improve dietary quality and behaviors (primary outcomes) of Latinos in Massachusetts, US, and the lessons learned during the process, including disruptions during the COVID-19 pandemic, to help shape future programs. Methods: The cultural adaptation process was pre-planned using a framework, grounded in the Theory of Reasoned Action/Planned Behavior, and informed by formative mixed-methods research. A projected 75 self-identifying Latino adults (25-65y) were recruited with community-wide strategies and randomized to receive, in parallel, daily healthy eating text messages for 2 months, reinforced for 2 subsequent months, to either control (i.e., surface-level messages based on USDA MyPlate in Spanish), or intervention (i.e., deep-structure messages). The intervention messages were ethnically tailored to Caribbean or non-Caribbean heritages specifically, grounded in entrenched cultural attitudes, norms, and preferences. Trained research assistants administered questionnaires and clinical measurements at baseline, 2-months, and 4-months, in person (pre-pandemic) or via online video calls (at-pandemic). Clinicaltrials.gov registration #NCT04724382. Results: LUCHA faced challenges and opportunities that conveyed lessons for future cultural adaptation and implementation of healthy eating programs. Recommendations are provided to improve digital programs for diverse ethnicities, such as widening language capabilities in texting services, using familiar video call applications, and instructing participants to measure their own clinical metrics at home using guided standardized protocols. Conclusion: Tailoring nutrition programs with deep-structure cultural messages is essential when promoting healthy eating in diverse Latino heritages. LUCHA can inform programs for similar ethnic groups.

Self-Rated Health and Medically Diagnosed Chronic Disease Association among Adults in Puerto Rico.

Introduction: Latinos report lower self-rated health (SRH) than non-Hispanic White persons. However, the association between SRH and medically diagnosed chronic diseases (MDCDs) remains understudied in Latino populations. This study assessed the relationship between a single-item SRH indicator and MDCD status among predominantly Latino adults in Puerto Rico. Methods: Participants (30-75 years; n=965) of the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT) reported SRH (excellent/very good, good, or fair/poor) and MDCD (ever vs never). We performed multivariate logistic regressions to evaluate the association between SRH and MDCD, which adjusted for key socioeconomic, demographic, and behavioral confounders. Results: Twenty-seven percent of participants reported excellent/very good SRH, 39% good, and 34% fair/poor. Participants with fair/poor SRH (vs excellent/very good) were more likely to report MDCD for painful inflammation (odds ratio [OR]=4.95 [95% CI, 3.27-7.48]), kidney disease (4.64 [2.16-9.97]), sleep disorder (4.47 [2.83-7.05]), migraine headaches (4.07 [2.52-6.58]), overweight/obesity (3.84 [2.51-5.88]), depression (3.61 [2.28-5.74]), hypertension (3.59 [2.43-5.32]), high blood sugar (3.43 [2.00-5.89]), cardiovascular disease (3.13 [2.01-4.87]), anxiety (2.87 [1.85-4.44]), arthritis (2.80 [1.83-4.30]), diabetes (2.46 [1.57-3.83]), respiratory problems (2.45 [1.59-3.79]), stomach problems (2.44 [1.57-3.81]), eye disease (2.42 [1.44-4.06]), gallbladder disease (2.34 [1.35-4.05]), liver disease (2.26 [1.38-3.70]), heartburn (2.25 [1.55-3.26]), hyperlipidemia (2.10 [1.44-3.06]), and thyroid conditions (2.04 [1.30-3.21]). Conclusions: SRH may reflect MDCD burden and serve as a valid screener to efficiently identify Latino individuals in high need of clinical services. This is relevant in Puerto Rico, where chronic disease rates remain high amid limited, disparate access to health care.

Design and Implementation of a Culturally-Tailored Randomized Pilot Trial: Puerto Rican Optimized Mediterranean-Like Diet.

Background: Adhering to a Mediterranean Diet (MedDiet) is associated with a healthier cardiometabolic profile. However, there are limited studies on the MedDiet benefits for non-Mediterranean racial/ethnic minorities, for whom this diet may be unfamiliar and inaccessible and who have a high risk of chronic diseases. Objectives: To describe the study design of a pilot trial testing the efficacy of a MedDiet-like tailored to adults in Puerto Rico (PR). Methods: The Puerto Rican Optimized Mediterranean-like Diet (PROMED) was a single-site 4-mo parallel two-arm randomized pilot trial among a projected 50 free-living adults (25-65 y) living in PR with at least two cardiometabolic risk factors (clinicaltrials.gov registration #NCT03975556). The intervention group received 1 individual nutritional counseling session on a portion-control culturally-tailored MedDiet. Daily text messages reinforced the counseling content for 2 mo, and we supplied legumes and vegetable oils. Participants in the control group received cooking utensils and one standard portion-control nutritional counseling session that was reinforced with daily texts for 2 mo. Text messages for each group were repeated for two more months. Outcome measures were assessed at baseline, 2 and 4 m. The primary outcome was a composite cardiometabolic improvement score; secondary outcomes included individual cardiometabolic factors; dietary intake, behaviors, and satisfaction; psychosocial factors; and the gut microbiome. Results: PROMED was designed to be culturally appropriate, acceptable, accessible, and feasible for adults in PR. Strengths of the study include applying deep-structure cultural components, easing structural barriers, and representing a real-life setting. Limitations include difficulty with blinding and with monitoring adherence, and reduced timing and sample size. The COVID-19 pandemic influenced implementation, warranting replication. Conclusions: If PROMED is proven efficacious in improving cardiometabolic health and diet quality, the findings would strengthen the evidence on the healthfulness of a culturally-appropriate MedDiet and support its wider implementation in clinical and population-wide disease-prevention programs.

Lifestyle Behavioral Factors and Integrative Successful Aging Among Puerto Ricans Living in the Mainland United States.

BACKGROUND: Few studies have assessed multidimensional models for predicting successful aging that incorporate both physical and cognitive-psychosocial elements among minority populations. This study aimed to establish a comprehensive lifestyle behavioral factors (cLBF) score and an integrative successful aging (ISA) score and explore their associations among older Puerto Rican adults. METHODS: Data were assessed from 889 adults (45-75 years) participating in the longitudinal (baseline and 2-year follow-up) Boston Puerto Rican Health Study. Higher cLBF score (range 0-10) indicates healthier behaviors (nonsmoking, lack of sedentarism, physical activity, high diet quality, and adequate sleep). The physical domain score of ISA included 8 components (functional impairment, hypertension, diabetes, cancer, cardiovascular disease, respiratory disease, arthritis, osteoporosis) and ranged 0-11. The cognitive-psychosocial domain of ISA included 5 components (cognitive impairment, depressive symptoms, social support, perceived stress, and self-rated health) and ranged 0-10. The sum of both domains comprised the ISA score, ranging 0-21. Higher scores of ISA and its domains indicate more successful aging. RESULTS: At 2 years, the mean ± SD of cLBF score was 4.9 ± 1.8, and ISA was 10.1 ± 3.3. In multivariable-adjusted models, cLBF score was significantly and positively associated with 2-year change in overall ISA (ß [95% CI]: 0.15 [0.07, 0.24] points), in physical domain (0.09 [0.04, 0.13] points), and in cognitive-psychosocial domain (0.08 [0.02, 0.14] points). CONCLUSIONS: Maintaining healthier lifestyle behaviors may contribute to successful aging through both physical and cognitive-psychosocial domains. The results support using a multidimensional definition of successful aging in Puerto Ricans and evaluating it in other populations.

Implementing a state-based stroke quality improvement collaborative: the Massachusetts experience.

BACKGROUND: The Stroke Collaborative Reaching for Excellence is a voluntary stroke quality improvement (QI) collaborative led by a partnership between the Massachusetts Department of Public Health and the American Heart Association/American Stroke Association. Since 2005, the collaborative has assisted Massachusetts Primary Stroke Service hospitals in improving the quality of acute stroke care based on national clinical guidelines. We provide a general overview for states seeking to establish a public-private partnership to promote hospital stroke QI. METHODS: Based on the Institute for Healthcare Improvement's Collaborative model, the program enrolled hospitals, trained staff in data collection, and provided expertise on clinical QI. To assess the success of the model at engaging hospitals, rates of change in participation and case entry were calculated with descriptive statistics. RESULTS: From 2005 to 2010, 58 of 70 (83%) Primary Stroke Service hospitals participated in the collaborative, accounting for over 85% of the statewide annual stroke discharges. On average, 74% of hospital representatives attended learning sessions, 55% participated in data quality conference calls, and 54% attended regional meetings. Over 39,000 cases were entered into the registry from 2007 to 2010, with a 15% increase from 2007 (mean, 171 ± 136; n = 9425) to 2010 (mean, 197 ± 143; n = 10,809). CONCLUSION: Consistent participation and case entry confirm that a voluntary state-based hospital QI collaborative is feasible and sustainable. This occurred in the absence of continued hospital funding. Further research is needed to identify the relationship between program participation and improved patient care and the generalizability of the model.