The Puerto Rico Department of Health (PRDOH) administers the Title V Block Grant that consists of the Maternal, Child and Adolescent Health Program or MCAHP housed in the Maternal, Child and Adolescent Division (MCAHD) and the Children with Special Heath Care Needs Program or CSHCNP located in the Children with Special Medical Needs Division (CSMND).
To place Title V efforts in context one must first understand the general conditions of Puerto Rican society that play a crucial role in the health and wellbeing of populations.
Puerto Rico (PR), a territory of the US, is divided into 78 jurisdictions known as municipalities, each headed by a mayor. Vieques and Culebra are offshore municipalities whose residents travel to the Great Island (PR) in ferry for secondary and tertiary health care and other services.
Every four years, a governor, 28 senators, and 51 House members are elected to serve in the PR government. A non-voting delegate to the US House of Representatives is also elected. Puerto Ricans are US citizens, serve in the US military, and contribute to Social Security and Medicare but are not eligible to receive the Earned Income Tax Credit that gives refunds to low-income workers. From 2021, PR residents qualify for the Child Tax Credit if they have one or more children.
The governmental structure has three major branches: the executive (called Central government), the legislative and the judicial. Each major state agency is divided into a Central office and Region offices distributed across PR.
Population
Puerto Rico is an area of about 3,500 square miles and a population of 3,263,584 persons (ACS 2021) that tend to cluster in urban areas.
Puerto Rico is mainly a Spanish speaking country where most of its residents are Puerto Ricans followed by other foreign Hispanic ethnic groups like Dominicans and Cubans. Regarding racial composition, there have been drastic changes in race identification when one compares the 2010 and 2020 Decennial Census. The number of people that identified themselves as only white decreased from 75.8% in 2010 to 17.1% in 2020 but increased to 28.1% in 2021. Meanwhile, the number of persons that selected more than one race increased significantly from 3% in 2010 to 50% in 2020 but decreased in 2021 to 35.8 %. According to race experts in PR, increased awareness of the African heritage and stronger identification as a Black Puerto Rican may have contributed to changes in people’s racial identification.
In the 2010 Census, people in PR may have opted to report their race as white (despite skin tone) due to an unstated contempt for everything associated with being dark or black skinned. For example, in PR people make a distinction between “bad hair’’ (kinky hair linked to being black) and “good hair’’ (straight hair linked to white and Indio). Although new generations identify themselves as black, the euphemism “de color’’ (literally of color) is commonly used as the word black is seldom used as a direct term of reference. There is also a generalized denial of racial prejudice and discrimination on the island. While it is not possible to explain in depth the manifestation of racism in PR, suffice is to say that it takes a covert form exemplified by sly comments and racial jokes (often seen as harmless) in day-to- day interactions. On an institutional level, dark/black skinned people are underrepresented in the main media outlets and high-status positions in both the corporate world and government, according to the PR Civil Rights Commission.
It must be noted that race is a culturally grounded concept that varies from one society to another. Race taxonomies in PR are based on phenotype traits such as texture of hair, skin tone, and lip and mouth shape and intermediate categories exist between white and black not represented in the US Census. Some examples are: “indio’’ (literally Indian, light brown and brown skinned with straight hair), “jabao’’ (fair skinned with kinky hair), and “trigueño’’ (light to dark-brown skinned). Besides Census and federal race categories, experts on the race in PR propose the use of local-specific racial categories for gathering data to better determine racial disparities. Indeed, research (Institute for Interdisciplinary Research at the University of Puerto Rico) reveals the association of skin color or tone with health disparities.
PR has been experiencing population loss in the last decades. The population decreased by 462,205 (12.4%) from 3,725,789 000 in 2010 to 3,263,584 in 2021. Two main factors are linked with population decline. First, the natural population growth continues to decrease due to declining natality and fecundity rates. Second, the migration of people to the US mainland in search of better job opportunities and living conditions that intensified after Hurricane María in 2017.
The MCA population constituted 38.7% of the total 3.2 million population in 2021. The MCA population composition was as follows: 0.6% infants; 7.1% children 1-9 years of age; 11.5% adolescents aged 10-19 (5.8% males and 5.6% females) and; 19.5 % reproductive age women between the ages 20-49.
Education
The 2021 PRCS (1YR estimate) reports that people 25 years and over with less than 9th grade was 12.9% and those with a high school diploma was 28.0%. Of those 25 years and over with post-secondary education, 11.7% had an associate degree; 20.5% a bachelor’s degree and; 7.9% a graduate or professional degree.
This school year (2022-2023) school year, public schools faced difficulties as the PR Department of Education have over 2000 fewer teachers. This is due to the massive retirement of teachers as those retiring in incoming years will receive a lower amount in pensions as stipulated by the PR Debt Adjustment Plan (DAP).
Health Care System
In the 1990’s public healthcare was transferred from the government to contracted private insurers to provide health care services on a capitated payment plan. The PR Health Insurance Administration (PRHIA or ASES, Spanish acronym) oversees and negotiates contracts with private insurers.
The Government Health Plan (GHP) integrates physical and mental health in one facility, expands preventive medicine and screening, and provides direct access to specialists without need for referral within a Preferred Provider Network. The GHP is financed by a combination of state, municipal and federal funds (Medicaid and SCHIP). Medicaid funding to PR is limited to a fixed amount regardless of the eligible population medical needs, unlike the states that are set based on per capita income. ACA funds (non-recurrent) were added to the GHP for Medicaid assigned funds and several benefits such as family planning and contraception methods services were added to GHP’s coverage. Medicaid assigned additional funds to cover GHP’s expenses on health services, especially during the pandemic crisis.
The GHP has a Special Coverage Registry (SCR) for CSHCN. Enrollees have the option to choose the providers for services within the Preferred Provider Network of their PMG or their Health Plan’s General Network. Medications, laboratory tests, diagnostic tests and other related procedures specified are part of this coverage. The PR-Medicaid Information Management System shows 60,149 children 0 to 17 enrolled in the SCR in 2022. The GHP also has an SCR for ASD. When ASD is suspected, children are enrolled in temporary coverage for up to 6 months for diagnostic interventions. If the diagnosis of ASD is certified by one of the following GHP providers: neurologist, psychiatrist, developmental pediatrician, or clinical psychologist the child is included in the ASD Special Coverage Registry. PRHIA 2022 database shows 3,091 children enrolled in the ASD-SCR.
In 2021, most MCA populations were insured mainly through the GHP. The combined insured percentage (private and public) and GHP specific are as follows: 91 % of women of reproductive age (48.9 % GHP); 93.1 % infants (61.5 % GHP); 97% children (64.8 % GHP); 94.5% adolescents (53 % GHP).
Puerto Rico passed Act No. 14- 2017 - “Incentives Act for the Retention and Return of Medical Professionals”- to provide income tax incentives (4% fixed rate) to retain practicing physicians and to attract those who migrated to the US.
To address the use of opioids, the Prescription Monitoring Program for Controlled Substances (under Law 70- 2017, Monitoring the Prescription of Controlled Substances) was implemented in 2018, to maintain a system of electronic prescription monitoring of controlled substances dispensed in PR.
Social and Economic Conditions
In the last decades PR has been experiencing adverse socioeconomic conditions. Between 2006 and 2019 employment fell by 22% according to the Bureau of Labor Statistics (BLS). Concomitantly, the labor force participation rate declined from 49% in 2006 to 43.6 % in 2022. There was also a reduction of 78,000 persons or 4.8% who were neither working nor looking for work in 2022 compared to 2021.
Lack of employment is accompanied by income levels that in PR are still far behind those of the states. The per capita income for PR in the 1YR 2021 PRCS was $14,468 compared with the US $38,332. The 1YR 2021 PRCS median household income was $22,237, less than half of Mississippi ($48,716), the state with the lowest US median household income in 2021.
Poverty is a significant problem in PR affecting women, children, and families. In 2021, the poverty rate in PR (40.5%) was higher than in the US (11.6%) and higher than Mississippi (18.1%). Children under 18 years of age living in poverty in PR were 50.1% in 2021. Family structure influences poverty rates as single female-headed families tend to be poorer than married-couple families. While the percent below poverty level in the 2021 PRCS in married-couple families with children was 24.8%, the percent of families with children headed by a female with no husband present was 69.6%. Residents of rural areas in PR have higher poverty rates than those living in urban areas. High poverty rates and low-income levels lead families to rely on public assistance programs for survival. The 1YR 2021 PRCS reports that 49.5% of households in PR received nutritional assistance benefits compared to 12% in the US.
In many municipalities, mass transportation is unavailable, and people rely on private transportation services (12 passenger vehicles) called “carros públicos’’ (public cars) that may not be available after 2 PM or even earlier. Those who have their own private cars may have to drive a long distance from and to their homes to work, study and receive services. To cover gaps in transport, there are municipalities that provide transportation mainly to the Greater Metropolitan Area to people in need of specialized health services. While mass transportation in San Juan municipality, - capital of PR - is available, there are limitations as the waiting time in some routes can be anywhere between one to two hours. The Urban Train only covers San Juan and Bayamón municipalities and lacks sufficient connecting buses to and from its 16 stations.
Like families, the PR government has been experiencing severe economic difficulties for almost a decade: a public debt of more than $70 billion, revenue loss, high GHP expenditure, depletion of pension funds, and insufficient liquidity to operate and meets its obligations. To face the crisis, the PR government has taken measures to reduce costs and increase revenues over the past years. Some of the measures are budget cuts to state agencies, school closings, reduction in subsidies to municipalities and NGOs, and tax increases. Measures related to government employees include lay-off of public workers (Law 7, 2009), increases in employees’ contributions and retirement age (Law 2013) and fringe benefit reductions and mobilization across agencies (Fiscal Compliance Act of 2017).
In 2016 the US Congress enacted the PR Oversight, Management and Economic Stability Act (PROMESA), installing the Financial Management and Oversight Board (FMOB) with decision-making power on all fiscal matters. In May 2017, the Oversight Board filed in the federal district court for debt relief under Title III of PROMESA, a form of bankruptcy to restructure PR fiscal liabilities. The court proceedings lasted five years and ended with the approval of the Debt Adjustment Plan (DAP) that became effective on March 15, 2022.
The high cost of living, low wages, and proposed changes to the formula for determining pensions caused indignation among public workers. From November 2021 through February 2022, public workers from the Central Government and Public Corporations carried out a series of actions claiming what they called “dignified retirement” and “wage salary justice”. “Dignified retirement” meant zero pension cuts and no changes to the formula determining the amount an employee would receive upon retirement. “Wage justice” claims aimed at wage increases in the context of rising cost of living. The main course of action was absenteeism from work, thus there was a “blue flu” (police officers), “orange flu” (medical emergencies), “red flu” (firefighters), “white flu” (hospital health workers/nurses), and “teacher flu” (teachers at the public school system), among others. This strategy was accompanied by protests by each group and one collective manifestation. The governor offered each group a salary hike ranging from $500 dollars to $1,000 dollars per month.
Amid the fiscal crisis, Hurricane Maria, with 155 mph winds struck PR on September 20, 2017. The hurricane caused billions of dollars in damage leaving behind widespread destruction of homes, businesses, roads, highways, and public and private institutional facilities. The wind force destroyed Puerto Rico’s energy grid causing the longest blackout in US history. Research on the deaths related to the hurricane place the death toll at approximately 3,000 people. Nearly three years (2020) after the hurricane, there were still thousands of houses with blue tarps, damaged roads in rural and urban areas, a considerable number of damaged traffic lights in the Metro Area, and many closed small businesses all over the island. Yet, it was not until 2020 that FEMA disbursed the funds for home repairs. However, there have been problems with home repairs and about 6,000 homes still have roofs covered with tarps in early 2023. The hurricane’s devastation also pushed people out of Puerto Rico to the US mainland.
A sociohistorical event known as “the Puerto Rican Summer of 2019” occurred during the month of July 2019. For 12 days, massive protests of people from all walks of life, ages, and different parts of the island took place clamoring for the resignation of Governor Ricardo (Ricky). The protests arose in response to the leak of chat messages between governor Roselló and 11 all-male top aides and associates that provoked people’s anger and indignation as these included insults, mockery, and contempt for victims of Hurricane María, LGBT community, people with obesity, women, political opponents, and celebrities. Roselló resigned on August 2, 2019, becoming the first governor of PR to ever resign.
While still struggling to recover from the devastation caused by Hurricane María, in early January 2020 PR was hit by two major earthquakes. On January 6, the day of the three kings’ day celebration, an earthquake of 5.6 magnitude struck the southwestern region. Ironically, this is one of the most important celebrations in the island in which children receive gifts from the wise men but this time - for many children and families - it became a sad day hardly ever to be forgotten. The day after, on January 7, an earthquake with a magnitude of 6.4, the most powerful earthquake in 102 years, hit Puerto Rico with its epicenter located once again in the south/southwestern regions. Hours later, it was followed by an aftershock of 6.0 magnitude. The most affected areas in the south/southwest were the Guánica, Ponce, Peñuelas, Guayanilla, and Yauco municipalities which are in the PR DOH Ponce Health Region.
The southwest is one of the poorest areas in Puerto Rico. The poverty rates for the five municipalities hardest hit by the quakes were higher than that of PR (43.1%) back in 2020: Guánica (63.8%), Ponce (50.9%), Peñuelas (56.5%), Guayanilla (55.6%), and Yauco (48.4%). Child poverty in some of these municipalities was higher than that of PR (57%). For example, child poverty in Guánica stood at 83% while Ponce and Guayanilla had 69% rates.
The quakes damaged more than 8,000 houses of which about 2,500 became uninhabitable, according to the PR Department of Housing, thus leaving thousands of people homeless. Nearly half of the businesses were forced to close - some temporarily while others permanently. There were losses to the infrastructure such as roads, bridges, government buildings and dams. Besides damage to homes and buildings, there were mud slides and an iconic tourist attraction in the Guayanilla municipality simply disappeared.
Immediately after the quakes, families, and individuals across the south/southwest set up camps along roadsides, home front yards, private farms, town squares, parking lots, and basketball courts. People also moved to official shelters and/or government tent camps once opened. People camped out for two main reasons. On the one hand, their homes suffered extensive structural damage (collapsed, about to collapse or had severe fissures). On the other hand, many people, despite having no major home structural damage or no damage at all, slept outside because of fear to sleep in their homes due to the constant tremors.
Puerto Rico’s main power plant (Costa Sur) that supplies energy to the northern regions was severely damaged and was out of operation. Economists in Puerto Rico estimated that the economic losses totaled more than one billion dollars.
Schools in the affected area suffered extensive damage, some of which were at risk of collapse or collapsed as was the case of the Agripina Middle School in the Guánica Municipality, a participating school of Title V school-based Youth Promoters Program. The collapse of this school had an impact on students and their families that woke up the morning of January 7, to see their school in crumbles.
Classes in the public school and the private system across PR were suspended so the buildings could be inspected. In Puerto Rico, many schools have what structural engineers call a “short-column design” which buckles instead of swaying in an earthquake. Over 90% of all public schools were built before the 1970’s and 1980s and do not comply with current seismic safety standards. The re-opening of public schools was a slow process that took several weeks and even months. Parents and teachers alike did not trust the school inspections as these were walk-in to assess visible signs of damage from the earthquakes but did not certify that a school could withstand a future earthquake magnitude 6.5 or higher.
Beyond economic costs and home displacement, the earthquakes caused sadness, distress, anguish, and uncertainty as people’s lives in the municipalities hit hardest were completely disrupted. For many people in these municipalities, it was like setting the clock back right after hurricane María, but this time the event did not stop as the southwest continued shaking throughout 2020 with tremors ranging from 2.3 to 5.4 magnitude or higher.
Amid earth tremors, the COVID-19 pandemic reached Puerto Rico in March 2020. Initially, the PRDOH Secretary and the Chief Epidemiologist mishandled and downplayed the risk to the island’s residents which led to their resignation in mid-March. PR was one of the first US jurisdictions to order (EO 2020-20) a strict lockdown to protect the health system and halt the spread of the virus. The lockdown- effective March 15 - involved shutting down non-essential services including public mass transportation, a night curfew (9 pm to 5 am) and school closings. Essential services included: grocery stores, pharmacies, gas stations, convenience stores, banks, health care, and restaurants/eateries (could only operate for take-out orders and deliveries). During the day, people could leave their homes only to work in essential services; buy food, hygiene products and medicines; get gasoline; or go to the bank or laboratory and/or physician’s office. Central government public workers would remain home with full pay and benefits until further notice. Some employees, consultants and professional services could work remotely if necessary.
Subsequently, the PR government issued a pandemic-related executive order every 15 days modifying some of the restrictions and curfew hours while requiring the use of masks in businesses, offices, and all public places. The re-opening of activities was done in three phases. Phase one (May 1, 2020) involved opening of outdoor activities, and certain economic sectors while maintaining the 7 pm- 5 am curfew. New commercial permitted activities included: barbershops, beauty salons, automotive sales, and extended the operating hours of auto repair shops, tire centers, and hardware stores. Parks, athletic tracks, beaches, gyms remained closed. All businesses were ordered to remain closed to the public on Sundays. Phase two (May 25, 2020) extended the operating hours of businesses already opened and the re-opening of the ones that were closed. The permitted activities included: restaurant dining rooms (at 25% capacity), barbershops/beauty salons by appointment and malls and retail stores at 50% capacity. It also included the utilization of recreational boats, public use of beaches, natural reserves, and golf courts. Phase three (June 16, 2020) re-activated most of the economic sectors and allowed to open gyms, movie theaters, bars, spas, museums, and casinos. The order allowed restaurant dining rooms to operate at 50% capacity. Public transportation also re-opened, and people could once again ride in buses and the urban train. The curfew remained in place being in effect from 10 pm to 5 am. Elective surgeries banned previously were permitted.
Thereafter, the government modified pandemic restrictions according to the positivity rate and all were lifted in 2022 including the use of face masks except in schools, public offices, and health facilities.
Today (2023) businesses in PR continue to grapple with a shortage of workers that began back in 2020 during the second and third reopening phases. It is very common to see signs in supermarkets, restaurants, and other businesses advertising job openings and higher wages. According to experts, the pandemic brought about changes in workers’ views on quality of life and they are exerting some power to bargain for better working conditions and wages.
School closures and distant learning during the pandemic posed big challenges for many families with children. Distance schooling posed a problem for many children, adolescents, and families as only 54% of households in PR have access to the internet and 62% have a computer at home, according to the PRCS 2013-2017. Consequently, public school students from the poorest sectors were unable to engage in distance learning because they were not provided with computers as planned by the Department of Education or because of connectivity issues (no access to internet or poor unstable service). Students unable to engage in distance learning were provided with printed learning modules.
In addition, many working parents, especially those with low-income, were unable to work from home as they have jobs that require their presence in the workplace. How working parents - regardless of their income level - coped with childcare is yet to be known as there is no research in Puerto Rico that assessed this issue during the pandemic. Given that many grandparents in Puerto Rico provide childcare (all day or after school hours) how being at high risk affected their role in childcare deserves attention.
Another effect was food insecurity among students in the public-school system that depend solely on the school breakfast and lunch program to consume a healthy meal. Due to school closures this service was not available in Puerto Rico during 2020.
Registering newborns in the Demographic Registry was also a difficulty faced by families as the service went online, and many had problems understanding the instructions on how to use the platform, unstable internet, or no internet. The process itself was hard to follow. First, families had to access Online Renovations, then go to the Demographic Registry site to fill out a virtual form to solicit registration of an infant. Afterwards, they would receive an appointment at their local Registry Office to go in person to register the baby. Generally, it took more than 5 months to be able to register the babies. This caused much trouble and anxiety among families as the birth certificate is required by the WIC and Medicaid to receive service.
Hospitals experienced reductions in room occupancy and emergency visits due to people’s fears of becoming infected and the ban on elective surgeries. For example, in early April 2020 room occupancy was 38% according to the Association of Hospitals, which led to the reduction of working hours and temporary layoffs of hospital workers including nurses and physicians. The PR government provided aid to hospitals to offset this situation. Over time, hospital use by non-COVID-19-patients increased as more people trusted the preventive measures taken and the restart of elective surgeries and other procedures. The pandemic also affected medical offices whose operational costs increased by 20% or more, according to the President of the College of Surgeons.
From March 2020 to April 26, 2023, PR had a total of 448, 572 confirmed COVID-19 positive cases and 667,151 probable cases, according to PRDOH data. Massive and local-specific vaccinations (stadiums. churches, community centers, supermarkets, pharmacies, town squares, hospitals, shopping malls) were held across PR. By May 26, 2022, 87.4% of the population 5 years and over had completed the COVID-19 vaccines while 61.1% of those 12 years and over had the booster shot, as reported by the PRDOH.
While recovering from the pandemic, Hurricane Fiona (category 1) struck PR on September 18, 2022. The strong winds and heavy rain (6 to 30 inches) caused mudslides, flooding, a general blackout, damage to homes and about 1,000 people trapped across PR. Fiona’s effects brought memories of what people went through in the aftermath of Hurricane María, five years ago – hardships, losses, despair, and sadness.
PR Society Strengths
The people of PR despite economic hardships do have cultural strengths like a sense of humor (helps to cope with stressful conditions), reciprocity and generosity. Kinship ties provide emotional and financial support (may include housing) to women and children as resources are pooled, borrowed, and shared. Grandparents (as well as other kin) are very influential in parents’ and children’s lives. It is common for grandparents to provide unpaid childcare to working mothers and/or at times of need. They also enjoy taking their grandchildren out and having them stay in their homes overnight.
There is a wide variety of informal and formal organizations geared to improve life through cultural promotion (arts, music, dance), neighborhood revitalization, environmental protection, youth development, and community development (may include micro enterprises, health promotion and community/home vegetable gardens) and alternative education to school dropouts. Other important assets are a strong cooperative movement, ecological movement, and the resurgence of agricultural work among young generations (under 40 years of age). A skilled and semi-skilled labor force that has been and still is sought after in the US is also an asset.
The strengths and resiliency in PR become most evident during critical events. In the aftermath of Hurricane María in 2017, the non-governmental agencies (NGO’s) were highly instrumental in helping people as they distributed food, water, water filters, solar lights and other supplies in shelters and communities. Very importantly, people themselves displayed generosity and resourcefulness as neighbors shared food, water, ice and even power from generators through extension cords. In some communities, neighbors shared their own money to pay private electricians to restore energy. All over the island, people turned to cultural practices like music, songs, phrases (like “Puerto Rico se Levanta” - Puerto Rico Rises) and the Puerto Rican flag as symbols of strength and resolve to help overcome the pain and desolation caused by the storm.
When the earthquakes hit PR the NGOs, professional associations, foundations, faith organizations, public school teachers, and the academia played a key role in the provision of assistance – medical, psychological, educational, temporary housing - to the families and individuals affected. Very importantly, citizens and groups across PR collected supplies and foodstuffs which they delivered to families and individuals in the affected areas.
During the COVID-19 pandemic individual citizens, NGOs, health professional associations, and faith organizations once again became key players. Some groups distributed prepared meals and/or bags of foodstuffs to people in need like the homeless, the elderly, and the extremely poor including children and families. Technological groups developed and distributed face shields among health professionals. NGOs continued providing interventions and support to programs’ participants through emergency lines and social networks. Health organizations held virtual conferences on COVID-19 signs and symptoms, how it is spread, and what to do to decrease the risk of contagion.
PR Title V Roles, Challenges and Strengths
The issues highlighted in this overview illustrate that the greatest challenge in PR is the overall societal context that impacts the health trajectories of the populations served. The strengths and capacities of the PR Title V have made possible the promotion of health and wellbeing despite adverse social and economic conditions.
The Life Course (LC) approach that interconnects time, context, and process has been useful in addressing population health and wellbeing. Under this perspective health is considered a life-long process that starts in the fetal stage and ends in death. Trajectory, transition and turning point are central concepts within this framework. A trajectory refers to sequences or long-term patterns in life and a transition refers to any change or changes in state within trajectories. A turning point is an event that results in a change of direction in people’s life trajectories. Trajectories in different domains of life (e.g., family, education, work, health) are interconnected and reciprocally affect one another within changing socio-historical contexts.
In 2013, the PR Title V developed its own Life Course Scheme aligned to: a) some of the principles of the Life Course (agency, linked lives, context, and timing); b) health trajectories processes (cumulative effects); and c) MCHB goal of eliminating health disparities and achieving equity.
The PR Title V LC Scheme is composed of six interrelated elements: 1) Human Agency – populations have strengths and are active participants of their life course through their choices and actions within the opportunities and constraints of society; 2) Context – people’s lives and health are shaped by historical events, physical environment, social conditions known as social determinants of health (SDH), and cultural norms/values both at the macro level – of the larger society and micro level of neighborhoods/communities; 3) Linked Lives - people’s lives are linked within familial and community settings across different life stages; 4) Cumulative Effects -individuals and groups accumulate advantages or disadvantages over time; 5) Timing- events and transitions are likely to be experienced in different ways depending on the life stage at which they occur; 6) Equity - strategies and actions are geared toward empowering populations through health literacy as well as enhancing their opportunities by means of advocacy and networking.
PR Title V has played a lead role in several important health related initiatives and public policies propounded by the DOH.
PUBLIC POLICY EXAMPLES
Law 186 (2016): PR Maternal Mortality Epidemiologic Surveillance System
Administrative Order 336 (2015): Compels hospitals to establish a Breastfeeding Support Program as requirement for hospital operation licensed by SARAFS.
Administrative Order 357 (2016): Requires hospitals to change their measurements for pediatric patients to the metric system and to change their weighing equipment so to only measure grams and kilograms.
Administrative Order 359 (2016): Creates the Youth Advisory Council (YAC).
Administrative Order 369 (2017): Policy for testing symptomatic and asymptomatic pregnant women for Zika.
Administrative Order 388 (2018): Guidelines for the Evaluation and Management of Infants Born to Mothers with Laboratory Evidence of Possible Zika virus infection during pregnancy.
Regulation 9184 (2020): Licensing regulations require birthing hospitals operating in PR to implement a Hard Stop Policy to reduce non-medically labor inductions before 39 weeks gestation in accordance with the recommendations of the American College of Obstetricians and Gynecologists (ACOG). The written Hard Stop Policy must be visible and accessible in the hospital areas that provide services to pregnant women. The hospital must offer information to pregnant women through printed materials. The hospital must also design and implement continuous evaluation processes as well as submitting an annual report to the Auxiliary Secretariat for Regulation and Accreditation of Health Facilities (SARAFS, Spanish acronym) evidencing compliance with the Hard Stop Policy.
An important asset of PR Title V is leadership through committees and coalitions including the Regional Boards (RBs). The RBs - composed of representatives from government and non-government entities, and community – are located in each of the 7 DOH Health Regions.
Having a broad and strong network of partners within and outside the health field (NGOs, medical associations, health organizations, parents’ organizations, among others) is also an asset. The PR Title V supports the efforts of partners through staff participation in task forces, committees, and alliances.
The PR Title V has a well-established health promotion component that includes massive media campaigns, community education, parenting and prenatal courses, and professional training. It also involves the creation of educational materials. An example is the Passport to Health, a booklet for families about children’s growth, development, and signs of developmental delays through which to document the child’s health and services. Another example is My Health Planner, a WRA care pocket guide (based on the WRA Preventive Health Services Guidelines) for women to document and track their preventive health care.
The greatest strength of PR Title V is a highly committed workforce and capacity to respond speedily to critical events Puerto Rico has experienced in the last five years that impinged on the health of populations. A summary of these events and the way PR Title V grappled these crises is presented below.
Zika Epidemic (2016): Implementation of two CDC funded projects: a) The Zika Active Pregnancy Surveillance System (ZAPSS) monitored pregnant women with laboratory evidence of Zika infection and prenatally or perinatally exposed infants born to these women.; b) the Zika Postpartum Emergency Response Survey in Puerto Rico (PRZPER I and II) conducted a rapid population- based assessment of maternal behaviors, experiences and attitudes related to Zika virus exposure among recently pregnant women in PR.
PR Title V staff received training on the Zika virus and disease, transmission, and prevention enabling them to provide accurate Zika information to women, families, and communities. They also promoted early prenatal care and testing for Zika in pregnancy as well as referrals to the CSHCN program for developmental surveillance and coordination of specialized services.
Hurricane Maria (2017): The PR Title V staff- even those who suffered personal losses- worked tirelessly to help MCA/CSHN populations and families across Puerto Rico in the aftermath of the catastrophe. The staff played a key role in identifying the emergent storm-related needs of MCA/CSHCN populations in shelters, households, and communities. The Register for Technology-Dependent Children was developed and implemented (2017) to register and follow-up families with a technology-dependent child. Due to their knowledge and community networks, the HVNs played a leading role in the municipalities they serve by becoming the main liaison for the mitigation and recovery efforts directed to families.
Educational materials were developed on emergent public health threats and their prevention (e.g., leptospirosis, safe food storage, personal hygiene, hand washing, and breastfeeding during emergencies). The staff also collaborated with partners in developing protocols and offering trainings to community leaders, teachers, and health professionals on the identification and management of common health conditions and the prevention of unintentional injuries after a disaster. The “HOPE after Hurricane” session of the Alliance for Climate’s Education was translated and adapted to allow youth in PR to better understand and respond to their own emotions during and after a hurricane.
Earthquakes (2020): The PR Title V collaborated with the PRDOH Office of Public Health Preparedness and Response in the revision of guidelines. Tittle V staff tended to the needs MCA/CSCHN populations and families in shelters and communities, coordinated services and helped them face the disaster and its effects including constant fear, insecurity, and sense of loss. They also collaborated and shared resources with partners to offer urgent medical care, basic hygiene materials, psychological aid, stress management, breastfeeding practices, safe infant feeding practices, children’s safety, and health education in general. They also used and disseminated educational materials on how to cope with stress and secondary trauma. The staff adapted the Hope after Hurricane to the seismic events for use with youth and provided education on emergency backpack and earthquakes.
The HVN’s (live in the same municipalities they serve) in the affected areas despite experiencing personal losses and difficulties, assessed the basic and housing needs of program participants and continued providing education and support including psychological first aid techniques. They also assured those pregnant women participants keep up their prenatal care, detect any signs of complications, and those infants and children receive adequate care.
The Ponce Pediatric Center (Ponce Health Region) continued providing services to CSCHN children/youth and families once it assessed the damage to the physical facility. To ensure safety they developed an evacuation plan for staff and center’s services recipients. It also held special meetings with staff to allow them to vent feelings, emotions, and concerns.
COVID-19 Pandemic (2020): The PR Title V adjusted strategies, activities, and timelines across all domains to handle the pandemic. Most importantly, immediate steps were taken to face a situation that posed a different challenge than previous critical events due to the high risk of infection.
The PR Title V developed recommendations for staff protection including instructions to maintain physical distance in the community or if the staff presented any symptoms. To assure understanding and compliance, the PR DOH protocol for on-site office work was presented to all staff through virtual conference. All staff teams held virtual meetings to discuss plans, interventions, assessments, protocols, and concerns.
Services were provided remotely. For example, the PR Title V Home Visiting Program (HVP) provided case management, education, needs identification, emotional help through telephone calls and other technologies. The clinical services provided by the Pediatric Centers and Autism Center to the CSCHN populations and families were done through tele-health activities.
The staff, in collaboration with partners, developed virtual conferences and webinars such as the virtual conference on COVID-19 and pediatric care that was attended by pediatricians from PR and abroad.
Videos on a variety of health topics were also produced to promote health during the pandemic. Most noticeable was the creation of a 24-minute digital prenatal course. Prior to the pandemic, the staff had been offering a 4-session Prenatal Course “A Baby on its Way”, targeted at pregnant women and their companions to build knowledge and provide tools to maintain a healthy pregnancy, prevent risk behaviors, increase the chances for a healthy delivery and appropriate baby care. The in-person course was suspended in March 2020 to comply with COVID-19 measures. The virtual prenatal course covers all the topics in an abbreviated fashion.
The health educational materials created by the PR Title V are available online at the PRDOH website, Google Drive, You Tube, and the websites of health partners.
Presently, PR Title V is back to normal operations involving both virtual and in-person health promotion that allow reaching out to people and families that may not be able to attend educational activities.
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