The Boston Puerto Rican Health Study, a longitudinal cohort study on health disparities in Puerto Rican adults: Challenges and opportunities

USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts, USA.
BMC Public Health (Impact Factor: 2.26). 03/2010; 10(1):107. DOI: 10.1186/1471-2458-10-107
Source: PubMed


The Boston Puerto Rican Health Study is an ongoing longitudinal cohort study designed to examine the role of psychosocial stress on presence and development of allostatic load and health outcomes in Puerto Ricans, and potential modification by nutritional status, genetic variation, and social support.
Self-identified Puerto Ricans, aged 45-75 years and residing in the Boston, MA metro area, were recruited through door-to-door enumeration and community approaches. Participants completed a comprehensive set of questionnaires and tests. Blood, urine and salivary samples were extracted for biomarker and genetic analysis. Measurements are repeated at a two-year follow-up.
A total of 1500 eligible participants completed baseline measurements, with nearly 80% two-year follow-up retention. The majority of the cohort is female (70%), and many have less than 8th grade education (48%), and fall below the poverty level (59%). Baseline prevalence of health conditions is high for this age range: considerable physical (26%) and cognitive (7%) impairment, obesity (57%), type 2 diabetes (40%), hypertension (69%), arthritis (50%) and depressive symptomatology (60%).
The enrollment of minority groups presents unique challenges. This report highlights approaches to working with difficult to reach populations, and describes some of the health issues and needs of Puerto Rican older adults. These results may inform future studies and interventions aiming to improve the health of this and similar communities.


Available from: Katherine L Tucker
The Boston Puerto Rican Health Study, a
longitudinal cohort study on health disparities in
Puerto Rican adults: challenges and opportunities
Katherine L Tucker
, Josiemer Mattei
, Sabrina E Noel
, Bridgette M Collado
, Jackie Mendez
, Jason Nelson
John Griffith
, Jose M Ordovas
, Luis M Falcon
Background: The Boston Puerto Rican Health Study is an ongoing longitudinal cohort study designed to examine
the role of psychosocial stress on presence and development of allostatic load and health outcomes in Puerto
Ricans, and potential modification by nutritional status, genetic variation, and social support.
Methods: Self-identified Puerto Ricans, aged 45- 75 years and residing in the Boston, MA metro area, were recruited
through door-to-door enumeration and community approaches. Participants completed a comprehensive set of
questionnaires and tests. Blood, urine and salivary samples were extracted for biomarker and genetic analysis.
Measurements are repeated at a two-year follow-up.
Results: A total of 1500 eligible participants completed baseline measurements, with nearly 80% two-year follow-
up retention. The majority of the cohort is female (70%), and many have less than 8
grade education (48%), and
fall below the poverty level (59%). Baseline prevalence of health conditions is high for this age range: considerable
physical (26%) and cognitive (7%) impairment, obesity (57%), type 2 diabetes (40%), hypertension (69%), arthritis
(50%) and depressive symptomatology (60%).
Conclusions: The enrollment of minority groups presents unique challenges. This report highlights approaches to
working with difficult to reach populations, and describes some of the health issues and needs of Puerto Rican
older adults. These results may inform future studies and interventions aiming to improve the health of this and
similar communities.
Racial and ethnic disparities in prevalence and incidence
of chronic conditions are an important problem in the
United States (US). Their investigation can contribute to
progress toward their elimination and improved under-
standing of the etiology of diseases [1-5]. Reduction of
existing racial and ethnic health disparities is a primary
concern for ethical and economic reasons. Without
improvements, as minority populatio ns grow and age so
will the burden on the health care system. Hispanics
currently represent 14.8% of the US population and are
projected to increase to almost 25% by the year 2050
Most epidemiologic research on Hispanics has focused
on Mexican Americans, due to their majority as a sub-
group. However, evidence suggests that health outcomes
vary significantly by Hispanic ethnic subgroup; geogra-
phical and ethnic variation have been reported for the
prevalence of type 2 diabetes among elderly participants
in the US, South Ameri ca and the Caribbean [ 7]. Ther e
is evidence of variation in management of diabetes
among Latino subgroups, which suggests that grouping
Hispanics into one category may obscure important dif-
ferences [8].
Puerto Ricans are the second largest Hispanic sub-
group in the US [9]. They report the worst health status
and highest prevalence of several acute and chronic
medical conditions, when compared with non-Hispanic
whites (NHW) and other Hispanic subgroups [10].
* Correspondence:
USDA Human Nutrition Research Center on Aging, Tufts University, Boston,
Massachusetts, USA
Tucker et al. BMC Public Health 2010, 10:107
© 2010 Tucker et al; licensee BioM ed Central Ltd. This is an Open Access article distributed under t he terms of the Creative Commons
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Page 1
National data show that 21% of older Puerto Ricans
reported having an activity limitation, compared with
15% of Cuban and Mexican Americans [11]. Pu erto
Rican elders living in Massachusetts show significantly
greater prevalence of physical disability, type 2 diabetes,
depression and other chronic conditions than NHW liv-
ing in the same neighborhoods [12-18].
There is a paucity of knowledge regarding the health
status and behaviors of Puerto Rican adults living in the
US. Moreover, little is known about strategies for
recruitment and retention when conducting research
with this population. Therefore, the goal for this report
is to describe the challenges and opportunities for
recruitment and a ssessment of a cohort of Puerto Rican
adults living in the Boston, MA area, as well as their
baseline characteristics. The Boston Puerto Rican Health
Study (BPRHS) is funded as part of the Centers for
Population Health and Health Disparities, a special
initiative of the National Institutes of Health to foster
trans-disciplinary and multilevel research to improve
understanding of health disparities in the US [19].
Study design
The BPRHS is an ongoing longitudinal study that aims
to examine the role of psychosoc ial stress on the pre-
sence and development of allostatic lo ad (physiological
dysregulation) and health outcomes such as depressive
symptomatology, cognitive impairment, functional lim-
itations, and metabolic conditions in Puerto Ricans.
Further i nvestigation inc ludes the potential modification
of these associations by nutritional status, especially for
dietary fat, B vitamins and antioxidants, by genetic varia-
tion, and by sources and type of social and community
support. The study was approved by the Institutional
Review Board at Tufts Medical Center and Northeastern
University. All participants provided written informed
Participants are recruited from t he Greater Boston area
using door-to-door enumeration and community
approaches. Data from the 2000 Censu s was used to
identify census tracks with at least 25 Puerto Rican
adults, ages 45-75 years. Within these, randomly selected
census blocks with 10 or more Hispanics, ages 45-75
years, were enumerated door-to-door. Blocks were visited
at least threeand u p to sixtimes, on different days of
the week, including weekends, and at varying times of
day, incl uding evenings. Households with at least one eli-
gible adult were identified. One participant per qualified
household was randomly invited to participate.
Similar t o other studies [20-22], multiple recruitment
strategies were used. In additio n to the door to door
enumeration, participan ts were identified by random
approach during community festivals/fairs and events
sponsored by local community organizations, through
referrals, and through calls to the study office from
flyers distributed at community locations, or from radio
or television spots a bout the study. The community
partner, La Alianza Hispana, is a non-profit organization
serving Latinos in the Boston area. They provided advice
and assistance with the recruitment and retention
efforts, and continue to serve as a liaison with the
Eligible participants must be of self-identified Puerto
Rican descent, able to answer questions in English or
Spanish, ages 45-75 years, a nd living in the Boston, MA
metropolitan area at the time of the study. Individuals
who were u nable to answer questions due to serious
health conditions, planned to move away from the area
within two years, or who ha d a low Mini Mental State
Examination (MMSE) score ( 10) were excluded. Inter-
views were scheduled after the initial screening contact.
Participants were provided with a written reminder of
the interview date, and were called 1-2 days pri or to the
interview to remind them. For those who cancel, resche-
duling was attempted at least five times, after which par-
ticipants were considered de-facto refusals.
Data collection
Baseline questionnaires and tests were administered by
trained, bilingual interviewers in the participantshome.
After obtai ning informed consent, neuropsychological
tests were conducted to identify participants that may
need assistance from a proxy, or be excluded due to low
MMSE score. Those who qualified completed the rest of
the interview. Participants were given a 12-hour urine
collection cup and two saliva tubes, wit h procedures for
collection and instructions on fasting for the next days
blood d raw. A certified phlebot omist returned to collect
the samples and draw blood in the home.
All interviewers were thoroughly trained by experi-
enced staff to administer the questionnaires and t o per-
form meas urement s following procedures fr om National
Health and Nutrition Examinati on Survey (NHANES) II
[23] and the MacArthur Studies of Successful Aging
[24]. Retraining and review sessions, including checks
on scoring of tests and scales, were conducted periodi-
cally. Each new interviewer was required to observe sev-
eral interviews by experienced interviewers and to
practice repeatedly before collecting data. Completed
interviews were self- and peer-reviewed prior to data-
base entry.
General background characteristics
Participants provided information on age, education
level, household income, migration, acculturation,
employment history, family size and food security.
Tucker et al. BMC Public Health 2010, 10:107
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These questionnaires were designed based on NHANES
III [25,26], the Hispanic Health and Nutrition Examina-
tion Survey [27,28] and the National Health Interview
Survey S upplement on A ging [29 ]. Pov erty sta tus wa s
computed using the poverty thresholds released each
year by the US Census Bureau [30]. Each participants
total annual household income was compared to the
threshold based on the age of the head of household,
participants family size, and year of interview. If total
household income was less than this threshold, the par-
ticipant was considered to live in poverty.
Acculturation was captured by a set of questions on
language use in a number of everyday activities [31,32].
This language-based questionnaire was adapted from
the Bi-dimensional Acculturation Scale for Hispanics
(BAS), which focuses on language preference in various
settings [33]. This allows for the possibility that accul-
turation ent ails the acquisition of American cultural
traits without displ acing Hispanic ones. The scale yields
two scores wh ich rank participants acculturation in the
Hispanic domai n and the non-Hispanic domai n; a value
of 100% represents a fully acculturated participant in
the non-Hispanic domain who speaks fluent English. A
psychological acculturation scale that focuses on psycho-
logical attachment to either culture was also admin is-
tered. The scale was validated with three different
samples of Puerto R icans from the greater Boston area
Health and health behaviors
Partic ipants were asked to self-report whether they have
been diagnosed with a specific list of chronic conditions.
Detailed information on prescription and over-the-coun-
ter medications was collected by asking participants to
show t he bot tles fo r medi cations they currently take.
Participants prov ided health insurance information and
self-r ated their health st atus and satisfaction with health
care practice s. Frequency, history, and type of alcohol
consumption and smoking were assessed. Current physi-
cal activity was captured using a modified Paffenbarger
questionnaire of the Harvard Alumni Activity Survey
[35,36], which was effectively tested in an elderly Puerto
Rica n population [14]. A physical a ctivity score was cal-
culated as the sum of hours spent on typical 24-hour
activities (heavy, moderate, light, or sedentary activity,
and sleeping) multiplied by weighing factors that parallel
the rate of oxygen consumption associated with each
Anthropometric and blood pressure measurements
Standing height, knee height, weight, and waist and hip
circumferences were measured in duplicate [23,37].
Body mass index (BMI) was calculated using weight
(Kg) divided by height (m) squared. Systolic and diasto-
lic blood pressures were measured in duplicate, at three
time points during the interview. The second and third
readings were averaged. Detailed methodology is
included in Additional File 1.
Physical disability
Participants were asked to report d ifficulty performing
daily activities, with modified Katz Activities of Daily
Living (ADL) and Instrumental Activities of Daily Living
(IADL) scales [38]. The twelve ADL and six IADL items
have been used effectively in a previous cohort of elderly
Puerto Ricans [12]. Additional physical performance
tests, which measure balance, gait, chair stands, f oot
taps and manual ability, were completed, following tests
used in the MacArthur Studies of Successful Aging [39].
Cognitive function
A comprehensive neuropsychological examination
assessed specific impairments in cognitive function ing.
Tests were selecte d base d on evidenc e of val idity in
Spanish-speaking populations, and to evaluate higher
cognitive functioning to minimize floor effects. They
include the MMSE for general function [40], the word
list learning test [41] for verbal memory, the Stroop [41]
for mental processing s peed, di git span [41] for working
memory, verbal fluency [41] for executive function with
language, and clock drawing [42] and figure copying
[43] for visuospatial function. Cognitive impairment
categories, as defined by MMSE scores, were adjusted
for education al level, as this correction optimizes the
test [44]. For all levels, considerable impairment w as
defined as a score of 11 through 17; mild impairment
includes score of 18 through 21 for participants with
middle school, 18-23 for t hose who completed high
school, and 18-24 for those with college or graduate
education. Higher scores than those cutoff values by
educational attainment were deemed as having no
Depressive symptomatology, stress and support scales
Depressive and anxiety symptoms were ass essed using
the Center for Epidemiology Studies Depression (CESD)
Scale [45-47]. The CESD has shown consistency and
validity in older adults [48]. It has also been used with
Hispanics [47], inclu ding Puerto Ricans [12], with good
reliability. The Spanish versions of the Life Events Ques-
tionnaire [49,50] and the Norbeck Social Support Ques-
tionnaire [51] were u sed to assess life an d psychos ocial
stress. The Perc eived Stre ss Scale mea sures the deg ree
to which oneslifeisviewedasstressful[52],with
higher values representing higher perceived stress. The
scale has been satisfactori ly tested in other Spanish-
speaking groups [53,54]. A second stress scale, devel-
oped through qualitative interviews with a subset of par-
ticipants, was also administered in the s econd wave of
Dietary assessment
Dietary intake was assesse d using a semi-quantitative
food-frequency questionnaire (FFQ) with 126 items,
Tucker et al. BMC Public Health 2010, 10:107
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Page 3
adapted and validated for this population [55]. The FFQ,
based on the National Cancer Institute-Block FFQ for-
mat, was revised to include appropriate foods and por-
tion sizes, and was shown to capture intakes reported in
24-hour recalls more accurately than the original ques-
tionnaire, both in total nutrient estimates and in ranking
of individuals [55]. This FFQ has been validated against
plasma carotenoids [56], vitamin E [57] and vitamin B12
[58] in Hispanics aged 60 years. Those with energy
intakes < 600 or > 4800 kilocalories and/or > 10 ques-
tions blank on the FFQ were excluded from dietary
Biological measures
Detailed methodology is included in Additional File 1.
Blood samples were analyzed for complete blood counts,
creatinine, albumin, plasma lipids, total carotenoids,
vitamin C, folate, vitamin B12, pyridoxal-5-phosphate,
homocysteine, methylmalonic acid, C-reactive protein,
glucose, insulin, glycosylated hemoglobin, bloo d urea
nitrogen, and dehydroepiandrostero ne sulfate. A 12-
hour urine sample was analyzed for cortisol, creatinine,
epinephrine and norepinephrine. Saliva samples were
used for measurement of salivary cortisol.
Definition of medical conditions
Diabetes status was defined as fasting plasma glucose
126 mg/dL or use of medication [59]. Hypertension was
defined a s blood pressure 140/90 mmHg or use of
medication [60]. BMI was used to classify wei ght status,
with BMI 25-29. 9 as overweight, 30-39.9 as obese class I
and II, and 40 as extremely obese [61]. Waist circum-
ference > 102 cm in men or > 88 cm in women was
defined as high [61]. Depressive symptomatology was
defined as CESD score 16 [62].
DNA isolation and genotyping
DNA extraction and genotyping methods have been pre-
viously described [63]. Briefly, genomic DNA w as iso-
lated from blood using QIAamp DNA Blood mini kit
(Qiagen, Hilden, G ermany). Genetic polymorphisms
were genotyped with Applied Biosystems TaqMan SNP
genotyping system [64]. Genotyping error rate was <
1%, as estimated by internal quality control and inde-
pendent, external laboratories. Genes and poly morph-
isms were selected by bioinformatics assessment, based
on previously reported associations or knowledge of
their function in known biological mechanisms. Over
140 autoso mal, diallelic polymorphisms, from 35 differ-
ent genes have been genotyped.
Two-year follow-up
Two-year follo w-up is ongoing at time of writing. All
subjects are contacted and asked to participate in a fol-
low-up visit after two years, to repeat all questionnaires
and measurements. Participants are called every six
months to update contact information (at which point
they update a life events inventory questionnaire), and
receive holiday and birthday cards and occasional news-
letters with updates on the study. At baseline, partici-
pants were asked to provide the names of two contacts
who could locate them if they moved. These persons are
contacted if the participant cannot be reached directly
after several attempts. When participants cannot be con-
tacted by phone, letters are sent requesting that they call
the study. When there is no response, a staff member
visits the home. Awareness of the study in the ge neral
community is fostered by participating in community
events, attending meetings of community agencies to
present information on the study, encouraging articles
in both Spanish and main newspapers, and participating
in media appearances.
Statistical analysis
Statistical analyses for this report were completed using
the SAS System for Windows (version 9.1, SAS Institute,
Inc, Cary , NC). Descriptive analyses to examine differ-
ences between sex and age groups (45-59 and 60-75
years) were performed using chi-square analyses for
categorical variabl es and t-tests for continuous variables
with normal distributions. Fishersexacttestswereused
for vari ables wi th an expected cell count of less than
five. P values were calculated and a significance level of
< 0.05 was used. All tests were two-sided.
Participant recruitment
door-to-door enumeration (77.4%), with the r est
recruited through community events (9.8%), referrals
(7.2%), and calls to the study office (5.6%) (Figure 1).
From June 2004 to October 2009, a total of 2,170 Puerto
Ric an age-quali fying adults were identified. Of these, 77
met t he exclusion criteria, and 2,093 were invited to
participate. From those invited, 1,811 (86.5%) agreed to
be interviewed. Primary reasons for declining included
not being interested in the study, too b usy, and refusal
of blood draw. Those who declined were more likely to
be older (58.4 versus 56.7 years, data not shown) and
had lived on the US for more years (32.9 versus 28.8
years, data not shown). No significant differences in sex,
language spoken or birthplace were observed between
those participating and thos e declining. Among those
agreeing to participate, nine participants were excluded
due to low MMSE score (0.5%), 15 (0.8%) dropped out,
36 (2.0%) were lost before interview, and 2 51 (13.9%)
were never intervi ewed due to persistent unavai lability.
Therefore, 1,500 of 1,802 eligible participants who initi-
ally agreed to participate (83.2%), or of 2,084 eligib le
participants who were initially invited (72.0%), com-
pleted the baseline interviews. Results presented in this
Tucker et al. BMC Public Health 2010, 10:107
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report include 1,357 participants with completed and
cleaned baseline interviews at the time of writing.
Those recruited through door-to-door enumeration,
relative to co mmunity events or calls in response to
advertising the study, were significantly older, more
likely to be women, have lower education, less accultu-
rated, and less likely to be employed than those
recruited by community approaches (data not shown).
They did not differ by poverty status, BMI, or preva-
lence of type 2 diabetes. Based on year 2000 Census
tract data, these recruitment strategies included access
to 78% of the Puerto Ricans, aged 45-75 years, living in
the Boston area towns with participants in the study.
When limited to towns with 5 or more participants,
coverage was close to 96% for the do or-to-door enu-
meration approach.
Once re cruited, completi on of interviews was time-
consuming and expensive. Appointments needed to be
rescheduled approximately 40% of the time, usually
time, or cancelled at t he last minute. Among the most
common reasons for cancellations were participant s
failure to remember the interview appointment, a
conflicting medical appointment, illness or death of a
family member, and reported illness by the participant.
Characteristics of baseline participants
The majority o f the sample was female (70%). Mean
ages were 57.2 years for men and 57.9 years for women.
Older Puerto Rican adults (60-75 years) reported fewer
years of education than younger adults (45-59 y ears);
over 60% of older adults had < 8
grade education
(Table 1). Approximately 50% of adults in all age cate-
gories fell below the poverty level, with older women
more likely to be living in poverty. Only one-third of
men and one-quarter of w omen in the younger group,
and even fewer older adults, were employed at the time
of the study. Residential stability was 50% or more for
all groups except for younger men (35.1%).
The particip ants in th is Puerto Rican cohort had lived
in the US for over three decades, o n average; of those
aged 60-75 years, men had lived in the US longer than
women (42.2 versus 36.0 years). Language-based accul-
turation scores were significantly lower in the older than
younger age group for bo th men and women. In the
younger age group, men were significantly mor e
Figure 1 Flow chart of study participant recruitment for the Boston Pue rto Rican Health Study. * Various r easons including: not Puerto
Rican; spouse in study. ** Various reasons including: currently busy, upcoming vacation or surgery, and houseguests, health problems or illness.
Tucker et al. BMC Public Health 2010, 10:107
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Page 5
acculturated than women. Psychological a cculturation
scale by age, but men and women had comparable
To evaluate life events and social support, participants
were asked to identify important persons in their life
and to indicate their perception of how these important
persons could support them emotionally or assist them
in time of nee d. Significant differences by sex were
social networks and in the perception of availability of
emotional and functional support (Table 2). Younger
women reported larger networks, but also a lower per-
ception of existing emotional and functional support
from these networks than did men in the same age cate-
gory. These differences were not found among the older
cohort, suggesting that some o f the earlier differences
may be related to life cycle events like marriage, work,
and the availability of kin. Womenssocialnetworks
included a larger number of blood relatives than the
social networks of men (3.7 versus 3.2, respectively). Dif-
ferences between men and women in the presence of
friends, other type of relatives, and others in their net-
works were not significant (data not shown). Reported
sources of social support in this population were limited
to close family and friends, with few social contacts, on
average, beyond the latter two categories.
Health, health behaviors and chronic conditions
Significantly more men than women in both age groups
were overweight, while a greater percent of all women
fell into the extreme obesity category (Table 3). Close to
80% of women, in both age groups, had abdominal obe-
sity. Overall, participants we re relatively inactive; fewer
than 12% of men and 4% of women participated in
moderate or vigorous activity. Men were more likely to
smoke cigarettes or be heavy drinkers than women.
About o ne in five participants used multivitamins, with
no significant differences in use b y sex or age group.
fiber, but less carbohydrate, vitamin B6 and potassium
than women across both age groups (Ta ble 4). Partici-
pants in the older age category had lower energy intake,
and consumed less fat but more carbohydrate than
younger participants.
A quarter of women aged 45-59 years and over a third
age d 60-75 years reported consid erable physical impair-
ment (Table 5). Cognitive impairment was significantly
Table 1 Selected baseline characteristics for participants of the Boston Puerto Rican Health Study.
Men (N = 401) Women (N = 956)
Ages 45-59 (N = 253) Ages 60-75 (N = 148) Ages 45-59 (N = 587) Ages 60-75 (N = 369)
Age (% within sex) 63.1 36.9 61.4 38.6
Education ( 8th grade) 34.8** 61.0 39.3** 65.5
Below the poverty level 49.6* 52.5* 58.2** 68.1
Currently working
32.3** 15.1* 22.6** 7.4
Residential stability
** 62.6 51.5** 58.9
Living alone 36.3* 41.5 26.6** 48.6
Length of residence in US 32.3 (11.1)** 42.2 (10.8)* 32.1 (11.7)** 36.0 (12.9)
Language-based acculturation
** 24.1 (21.2)* 26.7 (22.7)** 14.4 (17.6)
Psychological acculturation
19.2 (7.4)** 17.3 (6.2) 19.0 (6.8)** 16.8 (6.1)
*P < 0.05, between sex, within age category
**P < 0.05, between age categories, within sex
Reported as percent or mean (SD), except when noted
Response limited to participants who have held a paid job for more than 3 months
Defined as percent of participants with a length of residence 5 years in the same residence
Percent of English language use (0-100%)
Scale of 10-50, ranging from less acculturated to more acculturated
Table 2 Characteristics of social networks in the Boston Puerto Rican Health Study.
Characteristic (Mean) Men Women
Ages 45-59 Ages 60-75 Ages 45-59 Ages 60-75
Size of social network 5.1* 5.5 5.7 5.8
Average emotional support from social network 14.3* 13.9 13.7 14.1
Average assistance from social network 6.3*
** 5.7 5.7 5.7
*P < 0.05; between sex, within age category
**P < 0.05; between age categories, within sex
Tucker et al. BMC Public Health 2010, 10:107
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higher in women than in men in the older age category;
considerable impairment was more prevalent in the
older than the y ounger group. The majority of partici-
pants self-reported their healt h status as fair, but more
women reported poor health status. Fi fty-one percent of
women and 45% of men aged 60-75 years had type 2
diabetes (Table 6). More than three-quarters of all older
participants had hypertension. A higher proportion of
younger than older participants had depressive sympto-
matology, but prevalence was high f or all groups. Self-
report of cardiovascular disease was significantly higher
for the older group of Puerto Ricans; there were no sig-
nificant differences by sex. Approximately 70% of older
women self-reported diagnosis of arthritis.
At the p oint of this writing, 951 (78.7%) two-year fol-
low-up visits have been completed, from the 1,209 parti-
cipants who have reached their follow-up scheduling
time point (data not shown). Of non-completing partici-
pants (258), 85 (7.0%) dropped out, 52 (4.3%) were lost
to follow-up, and 17 (1.4) were deceased. The remaining
104 participants are being actively rescheduled due to
frequent change of residence within the city, circular
migration to and from Puerto Rico, and disconnected
telephones. Although exact two-year timing of follow-up
is difficult, participants are continuously being con-
tacted. Increase d participation a nd retention h as been
attained throughout the course of the study, as it
becomes better known in the community. The
remaining 291 baseline participants will b e scheduled at
their appropriate follow-up time. Assuming the same
participation rate as baseline, a final two-year follow-up
of at least 1,200 participants is expected.
The experience of the BPRHS illustrates the c hallenges
and demonstrates the disparities faced by this commu-
nity. The study has recruited 1,500 older adult Puerto
Ricans, but considerable effort to obtain completed
interviews has been required. Several studies have
reported difficulties in recruiting minority re search par-
ticipants [65-68], especially Latino men [20]. It is possi-
ble that with door-to-door enumeration, women are
more likely to be at home and therefore more frequently
approached. They also appear to be more willing to par-
ticipate than men, although this was not statist ically sig-
nificant in this study.
After enumeration, re-contacting individuals posed
significant challenges. A key factor in the eventual s uc-
cess in locating individuals was recording information of
close contacts. However, in many cases, field staff
needed to return to the neighborhood to locate the indi-
vidual. Recruitment completion was further delayed by
frequent cancellations of appointments. These chal-
lenges led to loss of staff time and effort, and greatly
increased the study cost over that originally estimated.
Similarly, Eakin et al. reported the need to hire extra
phone staff in order to increase retention of Latino s
Table 3 Health behaviors and anthropometric characteristics for participants of the Boston Puerto Rican Health Study.
Characteristic (%) Men Women
Ages 45-59 Ages 60-75 Ages 45-59 Ages 60-75
Abdominal obesity
43.0* 45.6* 79.7 84.1
Overweight 46.6* 47.5* 30.4*** 30.4
Obesity (Class I and II) 49.5 49.2 51.2 57.1
Extreme Obesity (Class III) 3.9 3.4 18.5 12.6
Physical activity Sedentary 36.7* 46.9* 39.8*** 61.4
Light activity 52.2 44.9 56.3 37.8
Moderate & vigorous activity 11.2 8.2 3.9 0.8
Current smoker
** 27.6* 25.7** 12.8
Non-drinker 48.2* 52.5* 59.0*** 75.9
Current moderate drinker
35.5 36.4 36.7 22.2
Current heavy drinker
16.3 11.2 4.3 1.9
Multivitamin use 18.5 21.2 18.2 20.4
*P < 0.05; between sex, within age category
**P < 0.05; between age categories, within sex
***P < 0.05; overall between age categories, within sex
Waist circumference > 102 cm in men; > 88 cm in women
Defined as weight (kg)/height (m)
; overweight = 25-29.9, obesity class I and II = 30-39.9, and extreme obesity (class III) 40.
Significant differences determined for current versus past and never
Moderate drinker defined as 1 drink/day in females or 2 drinks/day in males. Heavy drinker defined as > 6 drinks during one day of drinking, or > 1 drink/
day in females or > 2 drinks/day in males.
Tucker et al. BMC Public Health 2010, 10:107
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[21]. Interestingly, m ain reasons for cancellation
included medical appointments and illness of the parti-
cipant or a relative, which is consistent with the
observed high preval ence of disease, and the shari ng of
burden among socially connected individuals.
Mistrust of scientific investigations is frequently
reported as a major barrier to recruitment in mino rity
participants [65]. Several strategies were used to f acili-
tate recruitment, including employing a bilingual and
ethnically diverse staff, and partnering with a local com-
munity organization. Recruitment at community e vents
increased the study s visibility a nd involvement in the
community, and enabled staff to obtain updated contact
information for enrolled participants. Use of the media
also reinforced the legitimacy of the study. Because the
total community is relatively small, receptivity increased
over time.
Efforts to keep the participants trust and engage-
ment in the study have helped sustain a high retention
during two-year follow-up. As the study moves for-
ward, questions on progression and mechanisms of
diseases may be a nswered more accurately. Little is
known about the environmental influences and life
events of elderly Puerto Ricans li ving in the US; thus,
possible cohort effects require further consideration.
The wide age range of this group, constant migration
patterns to/from Puerto Rico, limited social networks,
and low residential stability may limit assumptions
about cohort effects.
As with most epidemiological studies, selection bias
could be operating in this study. For example, as those
declining participation in the study were living in the
US longer that those participating, possible selection
bias by acculturation, which is highly correlated to years
living in the US, may occur. Still, there was low accul-
turation in this sample, suggesting that such bias may
not exist. The door-to-door recruitment method may
have introduced selection bias, as participants recruited
with this method, who comprised the majority of this
cohort, had somewhat differing chara cteristics than
those recruited t hrough community events. The study
followed exhaustive protocols to identify participants at
home, making a great effort to expand recruitment with
various strategies; the addition of participants from
community approaches likely improved the representa-
tiveness for the study, as individuals who may have been
seldom at home were inclu ded. Notably, the majority of
Puerto Ricans aged 45-75 years identified by Census
tracts, lived in neighborhoods and communities from
which the study recruited.
Data from the 2000 Census show that, of Puerto
Ricans aged 45-75 years living in high-density Hispanic
Table 4 Dietary profile of participants of the Boston Puerto Rican Health Study.
Men Women
Ages 45-59 Ages 60-75 Ages 45-59 Ages 60-75
Energy intake (kcal) 2541 (899)*
** 2264 (842)* 2125 (896)** 1880 (825)
Total fat 33.7 (5.6)*
** 31.2 (5.9) 32.3 (5.4)** 30.6 (5.8)
Saturated fat 10.0 (2.5)*
** 9.2 (2.4) 9.7 (2.2)** 9.2 (2.4)
Monounsaturated fat 11.7 (2.1)*
** 10.7 (2.0) 11.2 (2.1)** 10.5 (2.2)
Polyunsaturated fat 9.0 (2.1) 8.7 (2.0) 8.7 (2.1)** 8.3 (2.1)
Protein 16.6 (2.6) 16.6 (3.2) 17.0 (3.4) 17.1 (3.1)
Carbohydrates 48.6 (7.4)*
** 51.2 (7.6)* 51.3 (7.3)** 53.5 (8.0)
Fiber (g/day) 22.9 (8.7)* 23.1 (9.4)* 20.0 (8.8) 19.7 (8.5)
Vitamin B12 (μg) 9.8 (0.4) 8.1 (0.5) 8.9 (0.3) 8.1 (0.3)
Vitamin B6 (mg) 2.2 (0.04)* 2.1 (0.04)* 2.4 (0.02) 2.2 (0.02)
Vitamin D (μg) 5.4 (0.2) 4.9 (0.2) 5.2 (0.1) 5.2 (0.1)
Vitamin E (IU) 15.5 (0.8) 12.2 (0.3)* 15.8 (0.4) 13.3 (0.2)
Folate (μg) 495.5 (9.2) 482.3 (11.2) 505.8 (5.7) 475.6 (6.8)
Calcium (mg) 905.5 (23.9) 810.9 (31.3)* 930.2 (14.9) 925.2 (18.9)
Magnesium (mg) 325.5 (5.1) 307.3 (5.5) 337.2 (3.2) 317.6 (3.3)
Potassium (mg) 3111.8 (44.3)* 3010.2 (56.6)* 3288.7 (27.7) 3159.4 (34.3)
*P < 0.05, between sex, within age category
**P < 0.05, between age categories, within sex
Reported as mean (SD), unless otherwise noted, of food intake, not including supplements
Reported as percent of energy unless otherwise noted
Reported as mean (SE) per day and adjusted for energy intake
Tucker et al. BMC Public Health 2010, 10:107
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blocks in Boston, 75% were 45-59 years, and 25% were
60-75 years [69]. Overall, the sample of this study was
somewhat older, with about two-thirds in the younger
and one-third in the older age range. When stratified by
recruitment method, the age distribution more closely
resembled that of the Census findings for those
approached through flyers, community events or refer-
rals (70% aged 45-59 years), whereas door-to-door
recruitment yielded 60% in the younger category. Educa-
tion levels for study participants were similar t o those
identified for Census data for Puerto Ricans in Boston;
yet the study had fewer women in the older group that
held a current job relative to 2000 Census data, while a
greater number of men in the older age category
reported workin g in this sample. This difference may be
partly due to economic cha nges that have occurred
since t he year 2000 . This sample of 1,500 i ndividuals
represents a fairly large proportion (15%) of the 10,241
Puerto Ricans in this age range living in the tow ns that
we recruited from, as of 2000. Although this may sug-
gest that a representative sample for this population was
likely ca ptured, the limited areas and approaches for
recruitment may have reduced representativeness. Still,
the results should be reasonably generalizable to similar
communities of Puerto Rican adults living in high den-
sity urban areas in the US.
Hispanic su bgroups are of ten com bined toge ther in
health research; however, this practice may obfuscate
important differences in subgroups. Though limited,
accumulating studies provide evidence that health dispa-
rities differ considerably by subgroup [7,8,12-18,70]. The
results of this study su pport observations that Puerto
Ricans on the US experience considerable health dispa-
rities which exceed those reported for NHW or other
Hispanic subgroups, including the more commonly stu-
died Mexican Ame ricans. The prevalence of physical
and cognitive disability, type 2 diabetes, obesity, depres-
sive symptomatology, hypertension, and self reported
heart disease were h igher in t his sample, in relation to
published reports for similarly-aged Mexican Americans
[3,71-73]. Notably, the high prevalence of these con di-
tions was observed even for those in the younger age
category. For example, the prevalence of obesity in this
sample of Puerto Rican men and women, aged 45-59
years, (43% and 60.5%, respectively) was higher than
that reported by NHANES 2001-2004 for Mexican
Americans in the same age range (36.3% and 52.2%,
respectively) [74]. One caveat of this type of compari-
sons is that differences in survey methodology and year
of data collection may affect the interpretation of the
In conclusion, the BPRHS is the largest and most com-
prehensive study conducted to date on older adult
Puerto Ricans living in the US, exclusively. It adds con-
siderably to the efforts of other studies conducted in
Hispanic elde rs, including the Health and Retirement
Study, the Hispanic Established Populations for Epide-
miologic Studies of the Elderly, and the Hispanic Com-
munity Health Study/Study of Latinos. This group
experiences chronic health conditions at higher preva-
lence than those reported nationally for Mexican Ameri-
cans or for NHW. The reasons for these health
Table 6 Chronic health conditions for participants of the
Boston Puerto Rican Health Study.
Health Outcomes (%) Men Women
37.2 45.0 33.9* 50.7
64.2* 76.6 58.7* 83.7
Depressive symptomatology
50.0** 43.8** 68.1* 58.6
Cardiovascular disease
17.1* 27.2 15.6* 25.1
** 46.3 48.6*
** 69.2
*P < 0.05, between age categories, within sex
**P < 0.05 between sex, within age category
Defined as fasting plasma glucose 126 mg/ dl or medication use
Defined as 140/90 mmHg or medication use
Defined as a CESD score 16
Cardiovascular disease (heart disease and heart attack) and arthritis are self-
Table 5 Physical and cognitive function and self-rated
health in the Boston Puerto Rican Health Study.
Characteristic (%) Men Women
Physical impairment
No impairment 45.0* 38.8* 27.3** 19.6
Some impairment 37.1 46.3 48.1 43.2
Considerable impairment 17.9 15.0 24.6 37.2
Cognitive impairment
No impairment 78.5** 74.0* 73.4** 61.4
Mild impairment 17.5 15.1 23.2 26.6
Considerable impairment 4.0 11.0 3.4 12.0
Self-reported health status
Very good or excellent 14.7* 15.7* 11.1** 5.7
Good 27.9 24.5 18.6 11.7
Fair 49.0 49.7 56.3 66.0
Poor 8.4 10.2 13.8 16.6
*P < 0.05, overall between sex, within age category
**P < 0.05 overall between age categories, within sex
Defined as Activities of Daily Living score of zero (none), 1-5 (some) or 6
Defined based on MMSE score and educational level. Considerable
impairment = 11-17 for all levels; mild impairment = 18 through 21 for
middle school, 23 for high school, and 24 for college or graduate school;
scores above those cutoff values by educational level are considered no
Tucker et al. BMC Public Health 2010, 10:107
Page 9 of 12
Page 9
disparities remain largely unexplained, but illustrate the
critical need for more research on the dynamics
involved in these poor health outcomes. They also
underscore the need t o investigate Hispanic subgroups
as unique cohorts, and to be careful when using the
encompassing terms Hispanic or Latino when pre-
senting health issues. The recruitment process portrays
the challenges and opportunities involved in the enroll-
ment of minority groups in epidemiological and clinical
research, and may help strengthen future efforts for
other studies. Understanding the unique needs of Puerto
Rica ns will inform interven tions and public health prac-
tice, s o tha t reso urces may be used prudently , a nd
health disparities may be reduced. Improved scientific
understanding of the etiology and progression of chronic
conditions may also be attained.
Additional file 1: Detailed Methodology for the Boston Puerto
RicanHealth Study. A full description of the protocols used to obtain
anthropometric and biochemical (blood, urine, saliva) measures.
Click here for file
107-S1.DOC ]
ADL: Activities of Daily Living; BMI: Body mass index; BPRHS: Boston Puerto
Rican Health Study; CESD: Center for Epidemiology Studies Depression scale;
FFQ: Food frequency questionnaire; IADL: Instrumental Activities of Daily
Living; MMSE: Mini mental state examination; NHANES: National Health and
Nutrition Examination Survey; NHW: Non-Hispanic white; US: United States.
This study is supported by the National Institutes of Health-National Institute
on Aging grant number P01-AG023394, and by the United States
Department of Agriculture, Agriculture Research Institute agreement number
Author details
USDA Human Nutrition Research Center on Aging, Tufts University, Boston,
Massachusetts, USA.
Northeastern University, Boston, Massachusetts, USA.
Friedman School of Nutrition Science and Policy, Tufts University, Boston,
Massachusetts, USA.
Tufts Medical Center, Boston, Massachusetts, USA.
Authors contributions
KLT, the principal investigator, designed the study, directed its
implementation, and supervised data analysis and interpretation; JMattei and
SEN analyzed the data, interpreted the results, and contributed to writing
the manuscript; BMC assisted with data analysis and the manuscript draft;
JMendez coordinated the field activities and provided portions for the
manuscript text; JN and JG collaborated with data analysis, interpretation of
results, and portions of the text; JMO and LMF, co-principal investigators,
helped design the study, conduct portions of its implementation, and
interpret results. All authors reviewed the manuscript and approved the final
Competing interests
The authors declare that they have no competing interests.
Received: 28 July 2009 Accepted: 1 March 2010
Published: 1 March 2010
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Cite this article as: Tucker et al.: The Boston Puerto Rican Health Study,
a longitudinal cohort study on health disparities in Puerto Rican adults:
challenges and opportunities. BMC Public Health 2010 10:107.
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    • "All participants provided written informed consent. The design of the Boston Puerto Rican Health Study has been described elsewhere [23]. Briefly, at the baseline (June 2004 to October 2009 ) and at 2-year follow-up , bilingual interviewers visited the participants' homes and administered questionnaires to collect information on socioeconomic status, health and health behaviors, acculturation, depressive symptoms, stress, social support, usual diet, and cognitive function. "
    [Show abstract] [Hide abstract] ABSTRACT: To examine the association between sleep patterns (sleep duration and insomnia symptoms) and total and regional bone mineral density (BMD) among older Boston Puerto Rican adults. We conducted a cross-sectional study including 750 Puerto Rican adults, aged 47-79 y living in Massachusetts. BMD at 3 hip sites and the lumbar spine were measured using dual-energy X-ray absorptiometry. Sleep duration (≤5 h, 6 h, 7 h, 8 h, or ≥9 h/d) and insomnia symptoms (difficulty initiating sleep, difficulty maintaining sleep, early-morning awaking, and non-restorative sleep) were assessed by a questionnaire. Multivariable regression was used to examine sex-specific associations between sleep duration, insomnia symptoms and BMD adjusting for standard confounders and covariates. Men who slept ≥9h/d had significantly lower femoral neck BMD, relative to those reporting 8 h/d sleep, after adjusting for age, education level, smoking, physical activity, depressive symptomatology, comorbidity and serum vitamin D concentration. This association was attenuated and lost significance after further adjustment for urinary cortisol and serum inflammation biomarkers. In contrast, the association between sleep duration and BMD was not significant in women. Further, we did not find any significant associations between insomnia symptoms and BMD in men or women. Our study does not support the hypothesis that shorter sleep duration and insomnia symptoms are associated with lower BMD levels in older adults. However, our results should be interpreted with caution. Future studies with larger sample size, objective assessment of sleep pattern, and prospective design are needed before a conclusion regarding sleep and BMD can be reached.
    Full-text · Article · Jul 2015 · PLoS ONE
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    • "Inclusion criteria/eligibility included selfidentified Puerto Rican ethnicity, aged 45–75 years, and being able to answer questions in English or Spanish. Individuals who were unable to answer questions due to serious health conditions or who had a low Mini Mental State Examination (MMSE) score (r10) were excluded (Tucker et al., 2010 ). Participants completed a comprehensive set of survey questionnaires and a neuropsychological test, via in person interviewing. "
    [Show abstract] [Hide abstract] ABSTRACT: Neighborhood context may influence health and health disparities. However, most studies have been constrained by cross-sectional designs that limit causal inference due to failing to establish temporal order of exposure and disease. We tested the impact of baseline neighborhood context (neighborhood socioeconomic status factor at the block-group level, and relative income of individuals compared to their neighbors) on allostatic load two years later. We leveraged data from the Boston Puerto Rican Health Study, a prospective cohort of aging Puerto Rican adults (aged 45-75 at baseline), with change in AL modeled between baseline and the 2nd wave of follow-up using two-level hierarchical linear regression models. Puerto Rican adults with higher income, relative to their neighbors, exhibited lower AL after two years, after adjusting for NSES, age, gender, individual-level SES, length of residence, and city. After additional control for baseline AL, this association was attenuated to marginal significance. We found no significant association of NSES with AL. Longitudinal designs are an important tool to understand how neighborhood contexts influence health and health disparities. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · May 2015 · Health & Place
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    • "Baseline recruitment occurred between 2004 and 2009. Specifics of the study and recruitment are described in detail elsewhere (Tucker et al., 2010). The initial data collection yielded a baseline cohort of 1504 participants. "
    [Show abstract] [Hide abstract] ABSTRACT: Pre-migration and post-migration factors may influence the health of immigrants. Using a cross-national framework that considers the effects of the sending and receiving social contexts, we examined the extent to which pre-migration and post-migration factors, including individual and neighborhood level factors, influence depressive symptoms at a 2-year follow-up time point. Data come from the Boston Puerto Rican Health Study, a population-based prospective cohort of Puerto Ricans between the ages of 45 and 75 y. The association of neighborhood ethnic density with depressive symptomatology at follow-up was significantly modified by sex and level of language acculturation. Men, but not women, experienced protective effects of ethnic density. The interaction of neighborhood ethnic density with language acculturation had a non-linear effect on depressive symptomatology, with lowest depressive symptomatology in the second highest quartile of language acculturation, relative to the lowest and top two quartiles among residents of high ethnic density neighborhoods. Results from this study highlight the complexity, and interplay, of a number of factors that influence the health of immigrants, and emphasize the significance of moving beyond cultural variables to better understand why the health of some immigrant groups deteriorates at faster rates overtime. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · May 2015 · Social Science & Medicine
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