US Mainland Research Articles

A Non-nuclear US Ally’s Nuclear Option: South Korea’s Case

North Korea’s nuclear armament has placed South Korea in a dilemma, as it can neither rely entirely on the United States’ nuclear extended deterrence (NED) nor pursue its own nuclear weapons development (the nuclear option). The reliability of the US NED has diminished, given North Korea’s ability to deploy intercontinental ballistic missiles capable of striking the US mainland. However, pursuing the nuclear option is fraught with difficulties due to the stringent restrictions imposed by the international non-proliferation regime. This article evaluates the feasibility of South Korea’s nuclear option using three factors: opportunity, willingness and the availability of special nuclear materials. The findings suggest that the feasibility of South Korea’s nuclear option is very low. Consequently, the article advises the South Korean public to acknowledge this reality rather than making emotional demands for the nuclear option. Furthermore, it calls upon the international community to engage in discussions and address the dilemma faced by non-nuclear US allies, such as South Korea, in light of the growing threat of nuclear attacks from nuclear-armed states like Russia and North Korea.

Where should the cancer control interventions target: A geospatial hotspot analysis for major cancer mortality 2018-2022 in the U.S.

Identifying changes in geographical disparities of cancer mortality reveals locations where cancer prevention and control efforts should be focused/targeted. We use recent cancer surveillance data to demonstrate the geographical disparity of major cancer mortality rates in the US and its shift compared to previous data. This cross-sectional study used the 2018-2022 county-level mortality rates of colorectal, lung, breast and prostate cancer from the CDC mortality data. Counties with suppressed death counts were imputed by spatial regression models. Getis-Ord Gi* statistics were used to evaluate spatial clustering of county mortality. Identified hotspot counties were visualized and compared with literature for hotspot pattern change. A total of 3108 US mainland counties were included. Cancer mortality rates were significantly higher in 244 counties for colorectal, 456 for lung, 147 for breast and 180 for prostate. Hotspot areas were central Appalachia (for colorectal and lung), Lower Mississippi Delta (colorectal, breast and prostate), Midwest (colorectal and lung), north Michigan/Wisconsin (lung and prostate), north Florida (lung), and the West (prostate). West central Appalachia and Lower Mississippi Delta continue to be hotspots for major cancer types, while previously identified eastern North Carolina/Virginia hotspots shrunk, east Oklahoma and north Florida emerged as the new hotspot for lung cancer, and several hotspots emerged in the West for prostate cancer. This study updated the analyses for geospatial disparity in major cancers' mortality since 2018-illustrating recent changes in the disparity pattern and pinpointing areas that cancer prevention and control efforts should target.

Tracking sero-molecular trends of swine brucellosis in Hawai'i and the central Pacific.

Brucellosis is a zoonotic disease of mammals caused by bacterial species of the Brucella genus. The reservoir for disease is typically mammals, with species of Brucella found infecting amphibians, bats, and marine mammals. Brucella spp. can pass directly to humans through contact with infected animals or their products. Brucella spp. can cause chronic debilitating infections in mammals, including humans, and is associated with spontaneous abortions in infected animals, causing reduced fecundity. In Hawai'i, terrestrial species that could harbor Brucella spp. include swine, cattle, horses, and axis deer among others. The numerous feral swine in Hawai'i are known to carry Brucella suis, with evidence supporting infections in cattle. Brucella suis also poses infection risk to humans, dogs, and potentially horses across the state. In this study, 3,274 feral swine serum samples collected from 5 of the 8 main islands over a 15-year span were analyzed for exposure to B. suis. Of the 558 watersheds in the state, 77 were sampled as part of this effort. Spatial analysis was used to identify watersheds of concern. MLVA and whole genome SNP analysis was used for molecular epidemiological analysis. Statewide seropositivity rates were triple that of feral swine found in the conterminous United States. Smoothed positivity rates were highest on Maui, followed by O'ahu, and the island of Hawai'i. Island-by-island analysis found high brucellosis positivity levels associated with specific watersheds and agricultural areas. Local spatial autocorrelation identified hot spots on O'ahu and Hawai'i. MLVA analysis of available B. suis from Hawai'i found molecular epidemiological connections with B. suis found in French Polynesia and the mainland US while differing from those in Tonga, Western Polynesia. Strains from Hawai'i are phylogenetically closest to strains from the United States. MLVA and SNP analysis found B. suis strains from Hawai'i fell into the genetic group that contains biovar 1 B. suis. This work identified islands and watersheds of high brucellosis seropositivity in feral swine of Hawai'i, highlighting the magnitude of the zoonotic risk. Introduction of strains in recent history is unlikely due to modern animal trade and disease control practices. Genomic analysis of strains in Hawai'i and the Pacific area can provide hidden historical and local clues to brucellosis epidemiology in the state.

Acylcarnitines are associated with lower depressive symptomatology in a mainland puerto rican cohort.

Recent studies have implicated acetyl-L-carnitine as well as other acylcarnitines in depression. To our knowledge, no untargeted metabolomics studies have been conducted among US mainland Puerto Ricans. We conducted untargeted metabolomic profiling on plasma from 736 participants of the Boston Puerto Rican Health Study. Using Weighted Gene Co-expression Network Analysis, we identified metabolite modules associated with depressive symptomatology, assessed via the Center for Epidemiologic Studies Depression scale. We identified metabolites contributing to these modules and assessed the relationship between these metabolites and depressive symptomatology. 621 annotated metabolites clustered into eight metabolite modules, of which one, the acylcarnitine module, was significantly inversely associated with depressive symptomatology (β = -27.7 (95% CI (-54.5-0.8); p = 0.043). Several metabolite hub features in the acylcarnitine module were significantly associated with depressive symptomatology, after correction for multiple comparisons. In this untargeted plasma metabolomics study among mainland Puerto Rican older adults, acylcarnitines, as a metabolite module were inversely associated with depressive symptomatology.

Abstract PO5-09-10: Inflammatory Breast Cancer Patient Profile in a Population of Puerto Rican Women

Abstract Background: Breast cancer (BC) is the most frequently diagnosed cancer type, as well as the leading cause of cancer death among women in Puerto Rico (PR). Moreover, inflammatory breast cancer (IBC) is a highly aggressive BC subtype. The current study aimed to describe the patient profile and the clinicopathological characteristics of IBC tumors in Hispanic women living in Puerto Rico. Methods: This is a retrospective, population-based study using the Puerto Rico Central Cancer Registry (PRCCR) database and the Health Insurance Linkage Database (PRCCR-HILD) to identify and describe the patient profile of Puerto Rican women diagnosed with IBC from 2008 to 2018. Variables such as age at diagnosis, staging variables, tumor receptor subtypes, treatment received, and overall survival (OS) were studied. Statistical analysis methods were employed to describe the population, estimate survival curves and examine the risk of dying. Results: We identified a total of 51 patients. The mean age at diagnosis of IBC in the current study was 59 years old, which is older than the mean age at diagnosis of IBC for women in the mainland US, but younger than the mean age of women that are diagnosed with BC in PR (63 years old). A total of 62.8% of patients had no metastases at diagnosis and 64.7% were diagnosed with stage III disease. Most tumors presented with ER+/PR+/Her2- (21.6%), or a triple-negative (ER-/PR-/Her2-, 15.7%) tumor concordance. The OS during the 12 months post-diagnosis was 66%, whereas at 36 months, OS decreased to 39%. The triple-negative subtype had the worst survival at 36 months (36%). Women with stage IV disease and those with ER-/PR- tumor subtype had a higher risk of dying. Conclusions: This is the first research to describe the patient profile and characteristics of women diagnosed with IBC in Puerto Rico. Our results suggest that the Puerto Rican IBC patient population presents unique characteristics. This research increases awareness about this lethal disease in PR. Citation Format: Luz Arroyo-Cruz, Michelle Martinez-Montemayor. Inflammatory Breast Cancer Patient Profile in a Population of Puerto Rican Women [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-09-10.

68 Visiting endowed chair: a new model to support Hispanics junior investigators

OBJECTIVES/GOALS: Analyze how the Endowment HIREC ‘s Mentoring and Career Coach Model A productive mentoring relationship is essential to advance researchers into being independent and bring extramural funds. METHODS/STUDY POPULATION: Provide Hispanic researchers mentoring and career coaching to strengthen their pathway as researcher. The HiREC’s Career Coach and Mentoring Component (CCMC) is an innovated approach to support long-lasting research mentoring relationships in our institution. This approach was developed to advance research to eliminate health disparities, promote multidisciplinary translational research in a Minority Institution and sustain research infrastructure and services, career, and workforce development initiatives. Promising Faculty are target and early and mid-career investigators interested in pursuing a research career. To implement the CCMC with the Visiting Endowed Chair a HiREC Advisory Leadership Group in Mentoring will be established, with researchers from Puerto Rico, and US mainland. RESULTS/ANTICIPATED RESULTS: Three Hispanic mid-career women from the School of Medicine and one from the School of Health Professions from the University of Puerto Rico received a HiREC Advanced Research Award of $50,000. The awardees achieved their goals; completed their research plan, research infrastructure needs, peer-reviewed publications, and submission of a competitive grant. They also provided successful perspectives on mentoring relationships in a Minority institution. Each one showed the mentor’s and mentee’s experiences as fundamental for their research advancements, productivity, leadership, and successful results. HiIREC’s mentoring component with the Visiting Endowed Chairs improves a healthy work environment and expands the research agenda for each awardee sustaining the institutional research culture. DISCUSSION/SIGNIFICANCE: A productive mentoring relationship is essential to advance researchers into being independent and bring extramural funds. Four mentees received formal, long-term guidance and endowment funds for their research infrastructure requirements with successful outcomes. HiREC contributes to building up an institutional mentoring program.

The Spanish translation, adaptation, and validation of a Community-Engaged Research survey and a pragmatic short version: Encuesta Comunitaria and FUERTES.

Community-Engaged Research (CEnR) and Community-Based Participatory Research (CBPR) require validated measures and metrics for evaluating research partnerships and outcomes. There is a need to adapt and translate existing measures for practical use with diverse and non-English-speaking communities. This paper describes the Spanish translation and adaptation of Engage for Equity's Community Engagement Survey (E2 CES), a nationally validated and empirically-supported CEnR evaluation tool, into the full-length "Encuesta Comunitaria," and a pragmatic shorter version "Fortaleciendo y Uniendo EsfueRzos Transdisciplinarios para Equidad de Salud" (FUERTES). Community and academic partners from the mainland US, Puerto Rico, and Nicaragua participated in translating and adapting E2 CES, preserving content validity, psychometric properties, and importance to stakeholders of items, scales, and CBPR constructs (contexts, partnership processes, intervention and research actions, and outcomes). Internal consistency was assessed using Cronbach's alpha and convergent validity was assessed via a correlation matrix among scales. Encuesta Comunitaria respondents (N = 57) self-identified as primarily Latinos/as/x (97%), female (74%), and academics (61%). Cronbach's alpha values ranged from 0.72 to 0.88 for items in the context domain to 0.90-0.92 for items in the intervention/research domain. Correlations were found as expected among subscales, with the strongest relationships found for subscales within the same CBPR domain. Results informed the creation of FUERTES. Encuenta Comunitaria and FUERTES offer CEnR/CBPR practitioners two validated instruments for assessing their research partnering practices, and outcomes. Moreover, FUERTES meets the need for shorter pragmatic tools. These measures can further strengthen CEnR/CBPR involving Latino/a/x communities within the US, Latin America, and globally.

OLDER MEDICARE BENEFICIARIES WITH KIDNEY FAILURE FROM PUERTO RICO MIGRATED AFTER HURRICANE MARIA

Abstract The vast majority of the literature regarding migration often focuses on younger and healthy migrants. However, recent studies have shown that older adults with complex chronic conditions are migrating to receive services and supports from family members, especially after natural disasters. After Hurricane Maria landed in Puerto Rico in 2017, health care facilities struggled to provide care. Patients with complex chronic conditions faced significant challenges to receive care. The objective of this study is to characterize migration rates among older Medicare beneficiaries with kidney failure after Hurricane Maria. We conducted a cross-sectional analysis of older Medicare beneficiaries (65 and over) with kidney failure from Puerto Rico from 2010 to 2020. We used data from the Master Beneficiary Summary File and the Chronic Conditions Data Warehouse (CCW) Chronic Conditions Segment. Beneficiaries with kidney failure were identified using the End-Stage Renal Disease Indicator from the CCW. Outmigration was defined as changing the state of residence the following year. There were 9450 which contributed 28445 person-years of information. About 537 (1.9%) older adults with kidney failure migrated to the US mainland during the study period. Migration rates before Maria were 1.5 (95% CI, 1.3 – 1.7), which increased by 3.6 percentage points (95% CI, 2.8 – 4.4). However, migration rates dropped to pre-Maria levels after 2017. Older migrants were more likely to be females, fee-for-service beneficiaries and younger compared to non-migrants. These findings suggest that older adults with kidney failure migrated to the US mainland to access care immediately after Hurricane Maria.

LONELINESS IN OLDER ADULTS LIVING IN PUERTO RICO DURING THE COVID-19 PANDEMIC: AN UNDEREXAMINED PUBLIC HEALTH CONCERN

Abstract Loneliness is a critical public health problem, yet it is under-examined among older adults in Puerto Rico. We explored sociodemographic and health-related risks for loneliness using data from a Knowledge, Attitudes and Practices COVID-19 study of Older Adults in Puerto Rico study. We conducted telephone and face-to-face interviews (January - December 2021) with a nonprobability sample of adults aged 60+ in Puerto Rico (n= 213). Data collection included measures of objective and subjective physical and mental health. We used generalized linear regression analyses to explore main effects of salient demographic and health factors on loneliness. Missing data were treated with Multiple Imputation. Prevalence of loneliness (3-item TILS) was 36.3% . Widowhood (β=.832, SE=.38, p=.029), low household income (<$12,500; β=.691, SE=.23, p=.003), psychological distress (β=.141, SE=.03, p<.001) were positively associated with greater loneliness. Living alone (β=-.664, SE=.27, p=.015) and higher sense of community (β=-.067, SE=.01, p<.001) were negatively associated with loneliness. Pandemic specific challenges (e.g., someone close diagnosed or hospitalized with COVID-19) and other common predictors (e.g., age, female, self-rated health) were not significant. We consider that contextual (e.g., outmigration, under-resourced aging and healthcare infrastructure) and cultural factors (e.g., familism) may help shape predictors and their effects on loneliness. Mainland US and Puerto Rican researchers and practitioners should collaborate on examining loneliness narratives, their impact on health, and implementation of culturally appropriate and contextually feasible interventions in Puerto Rico.

Abstract C007: Disparities in occurrence and outcome of male reproductive cancers in the United States Pacific Islander community

Abstract Data from the National Cancer Database indicates prostate cancer (CPa) prevalence in the Pacific Islander (PI) community to be nearly 1.6 times higher than the national standard. Recent data suggests that prostate cancer rates seen in United States PI men are comparable to that of African American men, the community with the longstanding recognition as having the highest rates of the disease in the US. PIs are defined as those originating from or being indigenous to the islands of Polynesia, Melanesia, and Micronesia including the US governed Hawaiian islands, Guam, Northern Marianas Islands, and American Samoa. PIs make up a grossly underrepresented minority group, often being overshadowed by their mainland Asian counterparts when aggregated together as a group defined as “AANHPI” in sociological and epidemiological data sets and studies. In addition, Pacific Islanders, at least in the mainland US, are considered a “new” minority population, and with the exception of those indigenous to US territories, the vast majority of the population are post 1970 first or second generation immigrants. Research into health disparities in the PI community is thus unsurprisingly sparse, and there is great work to be done to explore these alarming trends. The purposes of this study are threefold: further explore the data pertaining to prostate cancer prevalence in the pacific islander community; disaggregate the data between ethnic lines; and provide a foundation for future research that can further elucidate the causes and outcomes of this disease in the Pacific Islander community. Data was taken from the 2014 Native Hawaiian and Pacific Islander National Health Interview Survey (NHPI NHIS). The NHPI NHIS is a national survey administered by the CDC-NCHS to collect disease data including health condition and characteristics, health care access and service utilization but specific to the national NHPI population. Among 2588 participants, 4% indicated ever having been diagnosed with cancer among which prostate cancer was the second most commonly diagnosed. This study relies heavily on large-scale national questionnaires, thus future research should incorporate additional qualitative exploratory research, including targeted and ethnicity-specific canvassing and interviews in order to better understand the real life manifestations of the disease. The preliminary findings highlight an ever growing concern for the health outcomes of this community, and provide compelling evidence in support for both disaggregation of the community from Asian Americans, as well as interethnic disaggregation in data sets. A common thread of distancing between PI communities and the healthcare system was particularly evident, raising the concern that PIs are not being screened early enough and are not seeking life saving medical attention until advanced disease progression. A hopeful outcome of this study is a recognition that more outreach and community work must be done to bridge the gap between PIs and the Western healthcare system in order to mitigate the observed disparities. Citation Format: Nicholas A. Sowizral. Disparities in occurrence and outcome of male reproductive cancers in the United States Pacific Islander community [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C007.

Exploring the Role of Phonological Environment in Evaluating Social Meaning: The Case of /s/ Aspiration in Puerto Rican Spanish

Research in sociophonetic perception has suggested that linguistic factors influence the social meaning of a particular variant, such that the strength of social meaning appears to be mediated by factors like grammatical category or phonological environment. Here, we further investigate the impact of linguistic factors on the perception of sociolinguistic variables by examining evaluations of /s/ aspiration in the speech of four male Puerto Rican Spanish speakers. We look at how evaluations of this variable pattern based on the phonological context (preconsonantal vs. prevocalic), the proportion of a given variant ([s] or [h]) in the stimuli, and the listener residence (Puerto Rico vs. mainland US). Our results replicate earlier work showing that /s/ realization contributes to status and masculinity ratings. However, we do not find evidence of an effect of incremental changes in the proportions of [s]:[h] variants in an utterance or an effect of listener residence. Critically, we do find that phonological context influences the evaluations of listeners: [s] is rated as less masculine than [h] in preconsonantal environments, but in prevocalic environments, there is no effect of variant. Given that [s] is rarely found in preconsonantal contexts in Puerto Rican Spanish, and even less so in male speech, this result is consistent with studies arguing that social meaning is stronger in marked contexts. Expected patterns for gender, phonological context, and dialect interact to make an [s] realization of preconsonantal /s/ particularly rare in male speech of this variety, which opens the door for more robust socioindexical meaning.

Development of an HIV/STI and partner violence health promotion intervention for abused US Virgin Islands women.

Women in the US Virgin Islands (USVI) experience intimate partner violence (IPV) and human immunodeficiency virus (HIV) at disproportionate rates compared to women on the US mainland. Women in violent relationships report experiencing controlling behaviours that decrease their ability to negotiate for sex using condoms or to prevent unwanted pregnancies. Though several evidence-based interventions exist to prevent either IPV or HIV, few address them through an integrated health promotion approach or attend to particular USVI cultural mores. This article describes the systematic development of a theory based, culturally tailored, integrated health promotion intervention that addresses IPV and HIV among USVI women experiencing abuse. The process included: (i) identifying and integrating evidence-based health promotion interventions, (ii) conducting formative research using focus groups, (iii) synthesizing focus group data to inform intervention development and (iv) developing a culturally and linguistically appropriate intervention specific to the needs and concerns of USVI women. The Empowered Sisters Project: Making Choices Reducing Risks (ESP) was developed through this research. ESP is a three-session health promotion curriculum focussed on enhancing sexual health and safety among women experiencing abuse. The ESP intervention components included promoting condom use, increasing IPV and HIV knowledge and developing a personalized safety plan. Health professionals facilitated individual intervention sessions using culturally tailored visual media and scripts. This program focussed on experiences of women living in the USVI and has implications for utility across the Caribbean diaspora.

Disparities in African American oncology care in the US: A socioeconomic and geographic outlook.

e18590 Background: Mortality from cancer has been decreasing for all races and ethnicities. However, African Americans (AA) continue to have the highest mortality. Healthcare disparity contributes to poor outcomes. Here, we evaluate the differences in access to health care and socioeconomic status between different races and ethnicities in the US. Methods: We extracted data on demographic and healthcare coverage variables of patients diagnosed with cancer from the 2021 Behavioural Risk Factor Surveillance System (BRFSS), a national health-related telephone survey. We analyzed the effect of racial disparities in relation to socioeconomic factors and Census Bureau regions. R version 2.2.2 was used for all data extraction and analysis. Results: Out of 4,31,639 responders of BRFSS from the mainland US territory, 41,933 (9.71%) had been diagnosed with cancer other than skin cancer. Of these, 9,746 (9.74%) were from North East, 8,827 (9.11%) were from West, 10,806 (9.98%) were from South, and 12,554 (9.92%) were from Mid-West. In our sample, 35,137 (83.8%) were White, 2,356 (5.6%) were AA, 1,383 (3.3%) were Hispanic, and 3,047 (7.3%) were from others (Asian, American Indian/Alaskan Native, other race). More than 95% of oncology patients had health care coverage. However, the proportion of AA without healthcare coverage was higher than the White population (2.1% vs 1.2%, p < 0.005). 5.3% of cancer patients did not see physicians due to cost. This percentage was significantly higher among AA compared to White (8.2% vs 4.3%, p < 0.001). The rates of health care coverage and being unable to see a physician due to cost between AA and White were also statistically significant in each census region (not shown in table). Compared to White, AA patients with cancer were found to have statistically significantly lower education and income levels. This difference was present in all census regions of the US (not shown in table). Conclusions: Among cancer patients, AA are more likely not to have health care coverage, unable to see a physician due to cost, and have lower education and income level than White. These disparities impacting care of cancer patients exists in all major US regions, which likely promotes poor health outcomes. In addition, AA patients are underrepresented in this survey. [Table: see text]

The impact of social risk factors on the presentation, treatment and survival of patients with hepatocellular carcinoma at an urban, academic safety-net hospital

BackgroundVulnerable populations have worse hepatocellular carcinoma (HCC) outcomes. We sought to understand if this could be mitigated at a safety-net hospital. MethodsA retrospective chart review of HCC patients was conducted (2007–2018). Stage at presentation, intervention and systemic therapy were analyzed (Chi-square for categorical variables and Wilcoxon tests for continuous variables) and median survival calculated by Kaplan-Meier method. Results388 HCC patients were identified. Sociodemographic factors were similar for stage at presentation, except insurance status (diagnosis at earlier stages for commercial insurance and later stages for safety-net/no insurance). Higher education level and origin of mainland US increased intervention rates for all stages. Early-stage disease patients had no differences in receipt of intervention or therapy. Late-stage disease patients with higher education level had increased intervention rates. Median survival was not impacted by any sociodemographic factor. ConclusionUrban safety-net hospitals with a focus on vulnerable patient populations provide equitable outcomes and can serve as a model to address inequities in HCC management.

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

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). 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. 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. 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. 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.

On leaving: Coloniality and physician migration in Puerto Rico

Puerto Rico (PR) has a growing physician migration problem. As of 2009, the medical workforce was composed of 14,500 physicians and by 2020 the number had been reduced to 9,000. If this migration pattern continues, the Island will not be able to meet the recommended physicians per capita ratio proposed by the World Health Organization (WHO). Existing research has focused on the personal motivations for movement to, or permanence in, a particular setting, and social variables that encourage physicians to migrate (e.g., economic conditions). Few studies have addressed the role of coloniality in fostering physician migration. In this article we examine the role of coloniality and its impact on PR's physician migration problem. The data presented in this paper stem from an NIH-funded study (1R01MD014188) that aimed to document the factors associated with physician migration from PR to the US mainland and its impact on the Island's healthcare system. The research team used qualitative interviews, surveys, and ethnographic observations. This paper focuses on the data from the qualitative interviews with 26 physicians who had migrated to the USA and ethnographic observations, which were collected and analyzed between September 2020 and December 2022. The results evidence that participants understand physician migration as a consequence of three factors: 1) the historical and multidimensional deterioration of PR, 2) the idea that the current healthcare system is rigged by politicians and insurance companies, and 3) the specific challenges faced by physicians in training on the Island. We discuss the role of coloniality in fostering these factors and how it serves as the backdrop for the problem faced by the Island.

The importance of acculturation orientation in understanding the impact of pre- and post-migration stressors on behavioral health: Evidence from a crisis migrant sample.

We examine the interplay of acculturation orientation, cultural stress, and hurricane trauma exposure with behavioral health among Puerto Rican crisis migrants who relocated to the US mainland after Hurricane Maria. Participants were 319 adult (Mage = 39 years; 71% female; 90% arriving in 2017-2018) Hurricane Maria survivors surveyed on the US mainland. Latent profile analysis was used to model acculturation subtypes. In turn, ordinary least squaresregression was executed to examine the associations of cultural stress and hurricane trauma exposure with behavioral health while stratifying by acculturation subtype. Five acculturation orientation subtypes were modeled, three of which-Separated (24%), Marginalized (13%), and Full Bicultural (14%)-align closely with prior theorizing. We also identified Partially Bicultural (21%) and Moderate (28%) subtypes. Stratifying by acculturation subtype, with behavioral health (depression/anxiety symptoms) specified as the dependent variable, hurricane trauma and cultural stress accounted for only 4% of explained variance in the Moderate class, a somewhat greater percentage in the Partial Bicultural (12%) and Separated (15%) classes, and substantially greater amounts of variance in the Marginalized (25%) and Full Bicultural (56%) classes. Findings underscore the importance of accounting for acculturation in understanding the relationship between stress and behavioral health among climate migrants.

Abstract P638: Sex Differences in Cardiovascular Health Among Young Adults in Puerto Rico

Background: Emerging evidence supports significant variations in cardiovascular health (CVH), as defined by the American Heart Association (AHA) using “Life’s Simple 7” metrics, among Hispanics in the mainland US by sex and heritage group. Of these, Hispanic men and those of Puerto Rican background are less likely to meet favorable CVH criteria. Yet data on young men and women residing in Puerto Rico, an understudied population with a unique sociocultural context, are scarce. We assessed sex differences in CVH among young adults living in Puerto Rico. Measures: We used PR-OUTLOOK baseline data, collected between September 2020 and September 2022, for this analysis. Participants were between the ages of 18-29 years. CVH was measured using the AHA Life’s Essential 8 (LE8) score, a revised composite metric of physical activity, smoking, diet, sleep, body mass index (BMI), blood pressure, blood glucose, and non-HDL cholesterol. The total score ranges from 0-100, with higher scores indicating better CVH. For this analysis, the measure was modified to exclude diet given the lack of dietary data. Multivariable linear regression models were used to assess sex differences in the overall CVH score and its components. Analyses were adjusted for age, sex, marital status, and childhood material deprivation. Results: The sample included 964 adults - 619 women and 345 men. In adjusted analysis, women had a higher overall CVH score compared to men (β=2.77, 95% CI: 1.10, 4.44). Women also had higher scores for nicotine exposure (β=9.24, 95% CI: 5.18, 13.29), non-HDL cholesterol (β=4.31, 95% CI: 1.11, 7.51), and blood pressure (β=13.22, 95% CI: 10.39, 16.05) but lower for physical activity (β=-9.55, 95% CI: -15.18, -3.91). There were no significant sex differences in scores for sleep health, BMI, and blood glucose. Conclusion: There are sex differences in CVH among young adults in Puerto Rico, with women having overall better CVH. Interventions to improve nicotine exposure, non-HDL cholesterol, and blood pressure in men and participation in physical activity in women are needed to enhance and preserve overall CVH.

MIGRATION ACROSS THE LIFE COURSE AMONG OLDER ADULTS FROM PUERTO RICO

Abstract The prior literature regarding migration among Hispanics to US states has largely focused on younger migrants and often excluded people from Puerto Rico (e.g., Hispanic Paradox; Bostean, 2013). However, older Puerto Ricans appear to be moving to the US mainland (US Census Bureau, 2020, 2021). Therefore, the primary objective of this research was to examine migration among Medicare beneficiaries from Puerto Rico. Using data from Medicare, our results showed that migration trends among Medicare beneficiaries from Puerto Rico have increased over the past decade, including those with special needs. There were 5,593 (1%) Medicare beneficiaries who migrated in 2009 compared to 12,382 (~2%) beneficiaries who migrated in 2018. Among those who migrated, 3,679 were 65 and older in 2009 compared to 8,805 in 2018. The majority of older adults who moved to US states were female (59%), about 75 years old and were enrolled in Medicare Advantage. Destination states among Medicare beneficiaries from Puerto Rico included Florida, New York and New Jersey (comparable to those reported for the general population of Puerto Rico in the US Census). This research has policy implications. Although people from Puerto Rico have different reasons for migrating, those with long term care needs may have multiple varying reasons to move to the mainland. However, migration to the US may have additional challenges for people with high needs (Mellgard et al., 2019). For instance, Medicare coverage/network may not transfer to the US and plan switching/disenrolling may not be a straightforward process for people leaving Puerto Rico.

COVID-19 impact on the psychological health of Latinx transgender and non-binary individuals in mainland United States and Puerto Rico: a mixed-methods study

BackgroundThe COVID-19 pandemic continues to generate an unprecedented impact on all aspects of everyday life across the world. However, those with historically and currently marginalized identities (i.e., gender or ethnicity) who already experience a wide range of structural inequities have been disproportionally impacted. LTNB are a particularly at-risk population as they lie at the intersection of race/ethnicity, gender identity, language, migration status, geographical location, among others, which could further increase their COVID-19 and other health-related risks and disparities. The objective of this study was to examine the impact of key social determinants of health (i.e., gender identity, country, health insurance, employment) among a sample of LTNB individuals.MethodsThe team implemented a cross-sectional exploratory design with an online survey technique using the secure web platforms REDcap and SurveyMonkey. A total of 133 participants completed the online survey. Most of the sample self-identified as transwomen (38.8%), transmen (26.3%), and non-binary (21.8%) between the ages of 21 to 72. All participants were Latinx living in either Puerto Rico (47.7%) or mainland United States (52.3%). Descriptive statistics, reliability tests, Mann-Whitney and rapid thematic analysis test were conducted.ResultsFindings show that most participants were always (38.1%) or almost always (33.3%) worried about contracting COVID-19. Individuals living in Puerto Rico reported more difficulties than those residing in the mainland US regarding COVID-19 impact on psychosocial, emotional, and COVID-related thinking. Most participants’ answers for the COVID-19 open-ended questions focused on three main domains: income, access to trans-affirmative health care, and coping strategies.DiscussionFindings evidence that although most of LTNB participants were negatively impacted by the COVID-19 pandemic in multiple aspects of their lives, those living in Puerto Rico experienced these differently when compared to those in mainland US. More research is needed to understand better the mechanisms and pathways through which this context specifically impacts LTNB health and wellbeing, particularly in Puerto Rico. This study could help shape the public health response taking into account the geographical location and other intersectional identities that play critical roles in the production and reproduction of inequities.