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Like many under resourced, island communities, most of the municipalities in Puerto Rico are medically underserved. However, there is limited information about changes in hospital capacity and any regional disparities in availability of hospital services in Puerto Rico, especially given the multiple public health emergencies the island has faced in recent years (e.g. hurricanes, earthquakes, and COVID-19). This study described the trends in hospital capacity and utilization for the Island of Puerto Rico and by health regions from 2010 to 2020. We analyzed the 2021-22 Area Health Resource File (AHRF) and aggregated the data by seven health regions, which are groupings of municipalities defined by the Puerto Rico Department of Health. Ten-year estimates for hospital utilization were adjusted for population size by health region. During the more recent five-year period, there were decreases in hospitals, hospital beds, and surgeries, which represent a shift from the earlier five-year period. Over the 10 years of the study period, there was an overall decrease in population-adjusted measures of hospital utilization on the island of Puerto Rico-despite multiple disasters that would, theoretically, increase need for health care services. We also found variation in hospital capacity and utilization by health regions indicating the rate of change was not uniform across Puerto Rico. The capacity of Puerto Rico's hospital system has shrunk over the past decade which may pose a challenge when responding to recurrent major public health emergencies, especially within specific health regions.

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BACKGROUND: The Latino health paradox is the phenomenon whereby recent Latino immigrants have, on average, better health outcomes on some indicators than Latino immigrants who have lived in the United States longer and US-born Latinos and non-Latino Whites. This study examined whether the paradox holds after accounting for health care access and utilization. METHODS: The 2019-2020 National Health Interview Survey data were used. The main predictors included population groups of foreign-born and US-born Latinos (Mexican or non-Mexican) versus US-born non-Latino Whites. Predicted probabilities of health outcomes (self-reported poor/fair health, overweight/obesity, hypertension, coronary heart disease, diabetes, cancer, and depression) were calculated and stratified by length of residence in the United States (<15 or ≥15 years) among foreign-born Latinos and sex (female or male). Multivariable analyses adjusted for having a usual source of care other than the emergency department, health insurance, a doctor visit in the past 12 months, predisposing and enabling factors, and survey year. RESULTS: After adjusting for health care access, utilization, and predisposing and enabling factors, foreign-born Latinos, including those living in the United States ≥15 years, had lower predicted probabilities for most health outcomes than US-born non-Latino Whites, except overweight/obesity and diabetes. US-born Latinos had higher predicted probabilities of overweight/obesity and diabetes and a lower predicted probability of depression than US-born non-Latino Whites. CONCLUSIONS: In this national survey, the Latino health paradox was observed after adjusting for health care access and utilization and predisposing and enabling factors, suggesting that, although these are important factors for good health, they do not necessarily explain the paradox.

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Although numerous studies have found that Latine immigrants to the United States (US) have better health outcomes on average than persons born in the US, studies of persons living in Mexico have found that undocumented immigrants have worse health, especially those that were deported, compared to Mexican citizens that never migrated or migrated with authorization. However, the health outcomes of Mexican migrants using a smuggler to cross the US-Mexico border is a gap in the literature. We hypothesized that undocumented immigrant adults who used a smuggler to cross the US-Mexico border would be more likely to report mental health problems upon return to Mexico compared with undocumented immigrant adults that did not use a smuggler. We analyzed nationally representative, cross-sectional survey data of 1,563 undocumented immigrants currently living in Mexico. Most undocumented immigrants in the sample (87%) used a smuggler. Use of a smuggler by undocumented immigrant adults was associated with a 4.7% higher prevalence of emotional or psychiatric problems compared to undocumented immigrant adults that did not use a smuggler. We conclude that modality of ingress into the US is a risk factor for poorer mental health among undocumented immigrant adults.

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The goal of this nationally representative, cross-sectional study is to evaluate the trends in routine checkup within the last year associated with exposure to a hurricane. We compared Puerto Rico (2017 Hurricane Irma, Hurricane Maria), Texas (2017 Hurricane Harvey), and Florida (2017 Hurricane Irma, Hurricane 2018 Michael) with states that had a category 1-2 hurricane make landfall from 2014 to 2019: Georgia, Louisiana, Mississippi, North Carolina, and South Carolina. We found that states impacted by a major hurricane in 2017 had a drop in routine checkup while the states that experienced a category 1-2 landfall did have a change in that year. By the following year, all states reported an increase in routine checkup suggesting that the disruption in routine care was temporary.

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OBJECTIVE: To study the impact of Medicaid funding structures before and after the implementation of the Affordable Care Act (ACA) on health care access for Latinos in New York (Medicaid expansion), Florida (Medicaid non-expansion), and Puerto Rico (Medicaid block grant). DATA SOURCES: Pooled state-level data for New York, Florida, and Puerto Rico from the 2011-2019 Behavioral Risk Factor Surveillance System and data from the 2011-2019 American Community Survey and Puerto Rico Community Survey. STUDY DESIGN: Cross-sectional study using probit with predicted margins to separately compare four health care access measures among Latinos in New York, Florida, and Puerto Rico (having health insurance coverage, having a personal doctor, delayed care due to cost, and having a routine checkup). We also used difference-in-differences to measure the probability percent change of having any health insurance and any public health insurance before (2011-2013) and after (2014-2019) the ACA implementation among citizen Latinos in low-income households. DATA COLLECTION: The sample consisted of Latinos aged 18-64 residing in New York, Florida, and Puerto Rico from 2011 to 2019. PRINCIPAL FINDINGS: Latinos in Florida had the lowest probability of having health care access across all four measures and all time periods compared with those in New York and Puerto Rico. While Latinos in Puerto Rico had greater overall health care access compared with Latinos in both states, health care access in Puerto Rico did not change over time. Among citizen Latinos in low-income households, New York had the greatest post-ACA probability of having any health insurance and any public health insurance, with a growing disparity with Puerto Rico (9.7% any [1.6 SE], 5.2% public [1.8 SE]). CONCLUSIONS: Limited Medicaid eligibility (non-expansion of Florida's Medicaid program) and capped Medicaid funds (Puerto Rico's Medicaid block grant) contributed to reduced health care access over time, particularly for citizen Latinos in low-income households.

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Puerto Rico is a US territory and a popular destination for Latino immigrants in the Caribbean. Even with few language and cultural barriers, however, many Latino immigrants in Puerto Rico are uninsured. Using data from the 2014-19 Puerto Rico Community Survey, we examined inequities in health insurance coverage for non-Puerto Rican Latinos ages 18-64 living in Puerto Rico according to citizenship status and Latino subgroup (Dominican, Cuban, Mexican, and other Latino). After controlling for potential confounders, we found that noncitizen Dominicans had a significantly lower probability of having any health insurance (57.2 percent) and having any private insurance (31.5 percent). Regardless of similarities in culture and language, Latino immigrants on the island, particularly Dominicans, experience major health insurance coverage inequities. Considering that Puerto Rico's immigration system is regulated by US federal statute, both federal and local policy makers should acknowledge and focus on reducing these immigrant disparities in health insurance coverage.

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OBJECTIVES: We examined changes in health care access and utilization associated with the Patient Protection and Affordable Care Act (ACA) for different Asian American subgroups relative to non-Latino whites (whites). RESEARCH DESIGN: Using 2003-2017 California Health Interview Survey data, we examined changes in 4 health care access measures and 2 utilization measures among whites and 7 Asian American subgroups. We estimated the unadjusted and adjusted percentage point changes on the absolute scale from the pre-ACA to post-ACA periods. Adjusted estimates were obtained from multivariable logistic regression models that controlled for predisposing, enabling, and need factors. We also estimated the pre-ACA to post-ACA changes between whites and Asian American subgroups using a difference-in-difference approach. RESULTS: After the ACA was implemented, uninsurance decreased among all Asian American subgroups, but improvements in disparities relative to whites in these measures were limited. In particular, Koreans had the largest absolute reduction in uninsurance (-16.8 percentage points) and were the only subgroup with a significant reduction in terms of disparities relative to whites (-10.1 percentage points). However, little or no improvement was observed in the other 3 access measures (having a usual source of care, delayed medical care in past year, or delayed prescription drug use in past year) and 2 utilization measures (having a physician visit or emergency department visit in past year). CONCLUSIONS: Despite coverage gains among Asian American subgroups, especially Koreans, disparities in access and utilization persisted across all Asian American subgroups.

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To explore the association between past sexual abuse and depression in elders living in Bogotá, Colombia, we used data from the SABE (Salud, Bienestar y Envejecimiento [Health, Well-being, and Aging]) Bogotá Study. Participants were 2000 community-dwelling adults aged 60 years and older in 2012. Sexual abuse was assessed by self-report. Depression was measured by the Geriatric Depression Scale. The weighted prevalence estimate was 2.6% for past sexual abuse and 23.4% for depression. Multivariate data analyses showed significantly higher odds of depression for past sexual abuse (odds ratio [OR] = 3.91, 95% confidence interval [CI]: 2.13-7.16). Other characteristics associated with depression were history of being displaced by violence (OR = 1.77, 95% CI: 1.30-2.40), low socioeconomic status, low education, poor self-rated health status, and poor self-rated memory. Thus, past sexual abuse and history of being displaced by violence were strongly associated with depression among Colombian elderly individuals.

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Using data from the 2008 Cross-Border Utilization of Health Care Survey, we examined the relationship between United States (US) health insurance coverage plans and the use of health care services in Mexico by US residents of the US-Mexico border region. We found immigrants were far more likely to be uninsured than their native-born counterparts (63 vs. 27.8 %). Adults without health insurance coverage were more likely to purchase medications or visit physicians in Mexico compared to insured adults. However, adults with Medicaid coverage were more likely to visit dentists in Mexico compared to uninsured adults. Improving health care access for US residents in the southwestern border region of the country will require initiatives that target not only providing coverage to the large uninsured population but also improving access to health care services for the large underinsured population.

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OBJECTIVE: The purpose of this study is to compare sample attrition between foreign born and US born older Mexican Americans. METHODS: Prospective cohort data over five waves (Hispanic established population for the epidemiological study of the elderly) of 3,050 older Mexican Americans were used to estimate the number and proportion of drop outs. Multivariate logistic regression of predictors of attrition included nativity, age, gender, race/ethnicity, marital status, financial strain, employment status, education, chronic conditions, cognitive function, disability, and depressive symptoms. RESULTS: Over 11 years of follow-up, 62% of the respondents dropped out of the study, but the difference between respondents born in the US and Mexico differed by only 2% points. Multivariate analyses of correlates for attrition related to death, refusal, and lost to follow-up revealed that older respondents in poor health were more likely to die and be lost to follow up. CONCLUSION: Over 11 years of follow-up, immigrants were no more likely to drop out than US born respondents.

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PURPOSE: To examine the risk and correlates of mortality after death of a spouse and whether mortality risk varies by sex. METHODS: Prospective cohort study (1993 to 2000) of 1693 Mexican Americans ages 65 years and older who were married at baseline. Mortality was confirmed by matching records with the National Death Index or through proxy report. Risk of death related to incidence of widowhood was estimated by using proportional hazard regression and adjusted for age, education, US nativity, financial strain, social support, health behaviors, medical conditions, disability, and depressive symptoms. RESULTS: In the unadjusted Cox hazard analysis, widowed men are significantly more likely to die (HR=2.32, CI=1.48 to 3.61), but loss of spouse has no significant effect on the subsequent risk of death for widowed women (HR=1.50, CI=0.90 to 2.49). After adjustment for covariates known to influence survival, the association between widowhood and mortality in men remained significant, but the magnitude of the association decreased by 26%, which suggests a partial mediation effect of these factors on survival. The trajectory of the survival curve shows that the risk of death associated with widowhood is highest within the first 2 years. CONCLUSIONS: Widowhood in older Mexican American men is a risk factor for mortality.

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OBJECTIVE: To assess the association of health behaviors among husbands and wives. METHODS: Cohort study of 553 Mexican American couples aged 65 years or older from the Hispanic Established Populations for the Epidemiologic Studies of the Elderly (H-EPESE). Multivariate regression analyses test the association of body mass index, smoking, and alcohol consumption among husbands and wives. RESULTS: Body mass index is positively associated among couples. Risk of smoking or drinking was higher if the partner had ever smoked or drank alcohol. CONCLUSION: Health behaviors are associated among older Mexican American couples. Intervention efforts should be directed at both spouses.

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PURPOSE: There is a strong connection between marriage and well-being, with evidence suggesting that the well-being of one spouse is closely correlated with that of the other. However, among older Mexican Americans, there is little information about this phenomenon. To address this, we explore two research questions: Does one spouse's well-being predict the other spouse's well-being? Are there gender differences in these effects? DESIGN AND METHODS: We assess information from 553 couples who participated in Wave 1 (1993-1994) of the Hispanic Established Populations for the Epidemiologic Studies of the Elderly. Using structural equation models, we examined three aspects of well-being among older Mexican American couples: depressive symptoms, life satisfaction, and self-rated health. RESULTS: The findings revealed evidence of an association between the well-being of one spouse and that of the other. Specifically, the self-rated health of husbands and wives predicts that of their partners. However, there is evidence that husbands' depressive symptoms and life satisfaction influence wives' well-being, but not the reverse. IMPLICATIONS: The findings from this study are important because they add to the literature on the connection of well-being among spouses, point to important gender differences, focus on an understudied minority group with unique cultural characteristics, and have implications for the examination of well-being within a marriage framework.

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INTRODUCTION: There is substantial evidence that marriage is beneficial to health, but evidence on whether the health status of one spouse is similar, or concordant, with the other spouse is limited. This study assessed whether a chronic condition of one spouse is a risk factor for the same chronic condition in the other spouse. METHODS: The study used baseline data from the Hispanic Established Populations for the Epidemiologic Studies of the Elderly on 553 couples (1106 individuals) who are representative of approximately 500,000 older (> or =65 years) Mexican Americans living in the southwestern United States. Logistic regression was used to predict six chronic conditions among couples: heart condition, stroke, hypertension, diabetes, arthritis, and cancer. Analyses were adjusted for age, education, U.S. nativity, blood pressure, body mass index, smoking, and alcohol consumption. RESULTS: The wife's history of hypertension, diabetes, arthritis, and cancer was associated with higher odds that the husband would have these conditions. A history of hypertension, arthritis, and cancer in the husband was associated with higher odds that the wife would have these conditions. CONCLUSION: These results provide preliminary evidence that chronic conditions in one spouse are associated with an increased risk of developing like conditions in the other spouse among older Mexican American couples. We propose that the reciprocal influence that marital partners have on each other may be caused by shared living arrangements and shared health risks. Health promotion activities should target family systems. In particular, health providers should gather health histories not only from patients and their genetic family members but also from spouses.

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