Hurricane María in PR

As an archipelago located in the Caribbean, PR is highly prone to natural hazards, particularly hurricanes. Hurricane María was a category 4 hurricane that landed on September 20^th, 2017, and became one of the most catastrophic hurricanes to hit PR and the United States, resulting in 2,975 estimated deaths [23,24]. Some authors have estimated a total of 1,205 excess deaths, of which 1,038 were among people aged 60 years or older [25]. PR had already experienced another hurricane just two weeks before María, Hurricane Irma, and together they caused severe damage to the power grid, roads, communication networks, food, and health services [26]. It has been estimated that Hurricane María caused up to $90 billion in damages, making it one of the costliest storms in the US since 1900 [27]. The damages caused frequent power outages and the overall recovery lasted up to six months, although it took much longer in some areas of the island, namely rural communities [28].

These events drew attention to PR’s long history of environmental injustice and degradation, community disparities, slow response and inadequate preparedness, and the archipelago’s high susceptibility to cyclones due to a combination of geographic, economic, and political problems [15,29,30]. However, little is known about the experiences and perspectives of older adults living in rural communities after the hurricane, and their needs and actions have remained largely invisible. Two areas in PR located right in the heart of PR’s rural area are Adjuntas and Castañer. These communities are recognized for their high number of older adults living in poverty but also their unique and well-established history of social and community work [31–34].

Context and study objective

This research was conducted in the rural and centermost region of PR, in the municipality of Adjuntas and Castañer (See Fig 1). Adjuntas is a town in PR with a population of approximately 18,100 inhabitants [33]. It is estimated that almost 67.1% of the population lives below the US federal poverty line. Furthermore, out of the total population, 21% are older adults (65 and over) [33]. On the other hand, Castañer is known as a poblado (smaller town or village-like, without an official designation). It borders Adjuntas and other municipalities with the highest levels of poverty and older adults in PR (i.e., Lares: 24% 65 or older, 51% below poverty line; Maricao: 30% 65 or older, 45% below poverty line; and Yauco: 21% 65 or older; 42% below poverty line) [35–37]. This predominantly coffee growing region has recently gained increased recognition worldwide for its unique community organizing approaches and services [32,34], As a result, older adults in Adjuntas and Castañer often turn to community organizations and service providers for support after natural hazards [31].

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Fig 1. Map of Adjuntas and Castañer.

https://doi.org/10.1371/journal.pone.0316156.g001

On the other hand, previous post-hazard literature in PR has focused on the quality of life and natural hazard preparedness of older adults, and political planning forth wellbeing and management of chronic diseases of older individuals after a natural hazard [38,39]. Nonetheless, little research has explored the mental health needs of older adults in PR in the aftermath of a disaster, and much less in rural regions [40]. This is of vital importance in the context of post-disaster research in PR as data has evidenced a sharp increase in mental illnesses in the aftermath of Hurricane María [40]. Therefore, given their unique history and needs, the main objective of this study is to examine the experiences and perceptions of older adults, as well as community leaders and caregivers who provide care to the elderly, about the challenges and needs that older adults have had after Hurricane María in the rural towns of Adjuntas and Castañer, PR.

Study design

Given the exploratory nature of this study, we implemented a qualitative research design [41]. We conducted this study by following the Consolidated Criteria for Reporting Qualitative Research (COREQ), a checklist developed to improve transparency and reliability in qualitative research [42] (See S1 Text). Recruitment was then completed using purposive sampling. We conducted individual in-depth semi-structured interviews among two main groups who experienced Hurricane María in the municipality of Adjuntas and Castañer: 1) older adults (aged >60 years or older) and 2) community leaders and caregivers engaged in any type of care (i.e., social support, healthcare, etc.) for the older adult population, in order to gain a deeper understanding of the experiences of older adults during and after Hurricane María.

Additionally, this work was informed by the principles of Liming methodology, a culturally affirming research approach that draws from the cultural practice of liming (an event common in the Caribbean in which people come together to relax, share food or music and talk, but also for communicating and sense-making) [43]. This Caribbean-centric methodology is used to affirm the ways of knowing and the worldviews of communities and to enable both researchers and participants to be active agents of knowledge construction [44]. It is important to mention that, even though we did not consider this methodology a priori, we implemented key elements pertaining to it as the study moved along. For example, although initially designed to implement semi-structured individual interviews lasting no more than 60-minutes, we immediately noticed this approach was limiting for this context and population. When participants invited us to their homes to share their experiences after Hurricane María, a common element across most interviews was the offering of coffee to begin the conversations. The sharing of this beverage immediately turned the conversation into a more familiar one in which interviewees and interviewers were able to communicate and make sense of the Hurricane María event. This led interviews to last longer than initially proposed. Guided by Liming methodology, interviewers engaged in humor, mutual storytelling about personal experiences with Hurricane María, extended interview times, and food consumption as practices to facilitate the interview process with older adults [43]. We believe this flexible approach allowed us to better connect, share experiences and co-construct meaning with participants in this context.

Reflexivity statement

Our research team was composed of young adult men and women (less than 35 years old) all of which lived in PR during Hurricane María. Members of our team were students in a PhD program in Clinical Psychology at the time of the study, supervised by a faculty member (ER-S). All authors have old adult family members (i.e., grandmothers, grandfathers, mothers, fathers, etc.) that lived through Hurricane María and are currently living in PR. Furthermore, two of the authors are from Adjuntas (ER-S) and Castañer (AJS-S), and one continues to live in Castañer to this date (AJS-S). Having lived in the region, the first and third authors were acquainted with key community-based organizations (i.e., Casa Pueblo and Hospital General Castañer), and some participants recognized them (ER-S) or their family members as members of the Adjuntas and Castañer communities. Therefore, authors conveniently identified community leaders who then became community partners supporting our study. This project is the result of our individual and family experiences as well as our contextual firsthand knowledge and agency as researchers living in PR. Our position as researchers studying the communities we come from and still live in, shapes our engagement, understanding and interpretation of finding in several ways. One example is when a small pilot funding opportunity became available, the author’s (ER-S) lived experiences in this context before and after the event played a key role in the selection of the topic, population and study location. Additionally, the completion of the project was determined by the first author (AJS-S) and supported by the second author (JR-S). Finally, although these experiences and positionality shape our engagement in this study, we want to highlight that we do not aim to speak for or in the name of older adults in PR.

Participants

A total of 25 participants engaged in our interview process including older adults (n = 15) and caregivers and community leaders that provide formal and informal care services to older adults (n = 10). The inclusion criteria applied to the first group were: 1) being older than 60 years of age; and 2) having experienced Hurricane Irma and María in Adjuntas and/or Castañer. For the service providers group, the inclusion criteria consisted of 1) being older than 21 years of age, 2) engaged in any type of care (i.e., social support, healthcare, etc.) for the older adult population, 3) having experienced Hurricane Irma and María in Adjuntas and/or Castañer. Participants varied in their marital status, achieved academic degree and income, although most older adults described themselves below the poverty line. Refer to Tables 1 and 2 for a detailed summary of the participants’ socio-demographic information.

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Table 1. Socio-demographic data of older adults.

https://doi.org/10.1371/journal.pone.0316156.t001

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Table 2. Socio-demographic data of community leaders and caregivers.

https://doi.org/10.1371/journal.pone.0316156.t002

Procedure

The research protocol for this study was approved by the Ponce Health Sciences University Institutional Review Board (IRB-Protocol 1903007163). Following IRB approval and using a snowball sampling procedure, we began the recruitment process. We first contacted our previously identified community partners (i.e., community leaders from Casa Pueblo and Hospital General Castañer) who supported outreach efforts by the team (i.e., using promotional flyers and word of mouth). To facilitate recruitment, our community partners recommended potential participants based on eligibility criteria. Furthermore, individuals who were interested in the study such as older adults, family members of older adults, community and organizational leaders and caregivers, among others, also approached the research team to participate. This process was seamlessly reproduced by study participants who also identified potential candidates and provided them with the team’s contact information. After explaining the research study, additional questions were clarified, and the individual interview was coordinated at the participant’s preferred date and location.

The semi-structured interview guide consisted of the following themes: 1) sociodemographic information, 2) general information regarding personal experiences after Hurricane María, 3) perceived emotional and social wellbeing before and after Hurricane María, and 4) perceived impact of physical and social environment changes after Hurricane María (See S2 Text). All participants gave written informed consent to take part in our study. No potential participant refused to participate in the study and no participant dropped out of the study. Most older adult participants requested that interviews be conducted in their own homes. Most community and organizational members preferred their respective work offices. However, despite the selected interview spaces, the team ensured that no one else was present during the interviews, although some occasional interruptions during the interviews did occur (i.e., phone ringing and knocking on doors). All interviews were conducted in Spanish. Participants in this study received a $25 compensation. Although all participants were provided a stipend, it is important to highlight that at the end of the interviews, some participants initially mentioned that the stipend was not necessary and emphasized their ethical responsibility to share what they know even without compensation. Interviews were audio-recorded and conducted face-to-face during the period of March 29, 2019, to October 30, 2019, by the second (JR-S) and last (ER-S) authors. Interviews generally lasted between an hour and a half to two hours. However, interviews with older adults frequently lasted more, usually about two and a half hours and in some instances more.

To maintain rigor and validity, the last author (ER-S) met with the interviewer (JR-S) for a debriefing after each individual interview to address issues such as: underemphasized areas, specific techniques to manage the interviewer’s emotions, among others. After debriefings, the interviewer proceeded to conduct the next scheduled interview. This process continued until we achieved data saturation [45]. Transcripts were not returned to participants for comments or corrections.

Data analysis

All audio-recorded interviews were transcribed verbatim in word processors and analyzed. We used thematic analysis to approach participant data and further organize it, which allowed us to interrogate and interpret patterns found in the dataset [46]. No qualitative data analysis software was used in this study. Rather, the team conducted an open coding process directly on the transcripts in the word processor. Furthermore, based on inductive analysis [47], the team developed a codebook that captured older adults’ disaster experiences after Hurricane María (e.g., solidarity, mental health). As such, we carried out an inductive analysis process by extrapolating the codes and themes based on participants’ quotes. First, the first and second author (AJS-S, JR-S) read the dataset repeatedly to familiarize themselves with the data and develop a list of preliminary codes. These two authors then took on the role of coders and independently assigned preliminary codes to all the interviews. During initial coding, memos and comments were also written in the transcripts to reflect and improve themes, to distinguish between the perception of the research team and that of the participants, and to minimize bias in the interpretation of meaning. After preliminary coding, both coders met with the third author (ER-S) who served as a mediator to integrate different perspectives and ensured agreement regarding the codes that were used.

Based on the most salient patterns identified, coders made a second review of the codes to develop the initial themes and select the representing quotations. These were brought back to the entire team (AJS-S, JR-S, ER-S) for discussion, to engage in a reflective process, and to ensure consensus. During the first review, emerging themes were related to challenges faced by older adults after Hurricane María, as well as their use of general resources as coping strategies. During the second review, the team identified more specific themes about relational solidarity and la brega among older adults. After reaching consensus, the final themes and their respective quotations were determined. These are presented in the results section below. The authors translated all quotes to English for publication purposes. Original Spanish quotes are included as supplementary material. We attempted to maintain the original meaning of the quotations and included some words in Spanish that we considered had no literal equivalent in English.

“Many old people taking care of old people”—Challenges to wellbeing after a natural hazard among older adults in Adjuntas and Castañer, PR

For participants [15/15], the hurricane brought many demands and lack of resources that became challenges for their psychological health and emotional functioning. Due to the broad demographic of older adults in Adjuntas and Castañer, having to care for other older adults in their communities had become a common reality for the elderly. However, caring for other elderly became much harder after the hurricane as the few young relatives they had left migrated away in search of work and safety, and would rarely visit. As such, multiple participants [12/15] lacked the means and access to care and had to rely on neighbors and older relatives to care for each other. This challenge became so common that providers [10/10] who serve the elderly in the region consider it a public health problem. When we asked about his professional experience with the topic, one of the interviewees told us:

“There are many old people taking care of old people, I mean… there are many, when they do not have adequate resources, an old person taking care of another old person is not the best thing…” (Professional Administrator of local hospice program).

While living in fragile and lonely environments, participants [10/15] had to care for others while juggling their own chronic and comorbid health conditions, such as Alzheimer’s, diabetes, and dementia, to name a few. Some [3/15] even said they had to care for bedridden relatives and neighbors while lacking the strength to lift them or help them move. An elderly caregiver we interviewed was a vivid example of this experience. In a mountain residence up winding roads and far from urban centers and medical services, this caregiver’s home awaited. From her empty house, she had to care for her bedridden husband, alone and without access to utilities. When we asked her to describe her experience, she said:

“This is very difficult, well… and then just being alone here, well, with… Not entirely alone because my brother is here, but he tends to go out and so on. But this, to live such a situation alone. Washing clothes by hand, with a bedridden person, you know, that’s been very difficult.” (Female denizen, 71 years old; wife and caretaker).

Due to the infrequency of family visits, participants [12/15] felt significant loneliness following Hurricane María. Older participants supported their children and grandchildren in their search for more favorable living opportunities, but still felt forgotten and neglected. Providers [10/10] realized their older clients felt alone but noticed their loneliness had worsened after the hurricane. Providers even noticed that older adults were coming to appointments looking for company and conversation, rather than for their own health needs. One of the providers we interviewed, who was also an older adult from Adjuntas, indicated that she saw this loneliness among her clients often. In her interview, she told us:

“… they live alone (Older adults), you know, the children, the family, they forgot, they left, and these people live alone.” (Female denizen, 60 years old, Alzheimer’s patient caretaker)

On top of this loneliness, hurricane-force winds and heavy rains had led the homes of the elderly to suffer severe structural damage. Some participants [14/15] tried to fix their homes but struggled to recover due to financial insecurity and lack of resources, leaving them with the emotional strain and powerlessness of a frustrated desire. A recently widowed, elderly participant was one such case. Sitting in his rocking chair on his balcony, he welcomed us into his newly built wooden home and explained why Hurricane Maria was so difficult for his family:

“[B]ecause we lost practically everything we had. The roof and everything flew out, everything went flying and that’s traumatizing. So, since you are not wealthy, you do not have money, you have to wait for donations…” (Male denizen, 68 years old).

Recognizing the loneliness and the risks of their damaged homes, younger relatives tried to get their elderly out to have them close and support them. However, many participants [7/15] were reluctant to leave and preferred to stay despite the challenges they faced. For them, there was no other option than to stay. In general, the interviewed older adults experienced constant grief and loneliness after the hurricane because of their pervasive challenges. So much so that when we asked one of the providers about the sadness he saw among his older patients, he said:

“I can tell you that most of who lived through that experience are no longer here. They already died in the program. And many of those were because of sadness, they were very sad.” (Social Worker for local hospice).

“In this community each one was working together”—relational solidarity among older adults in Adjuntas and Castañer

To cope with these challenges, many participants [10/15] turned to their neighbors for support and exchanged resources reciprocally. From the first day after the hurricane, participants saw that their neighbors were experiencing similar needs and decided to share their supplies despite having their own shortcomings. With the little they had, older adults gave resources (e.g., water, food, shared their power generators) to their neighbors without expecting anything in return. Soon after, older adults in the region joined together as a community to assist each other through manual labor. The elderly came together to clean roads and remove debris on their own with old tools they found in their sheds. They even went to stores on foot to get supplies for their communities whenever a neighbor could not go out. Beyond attending to their material needs, the elderly neighbors kept each other company and nourished each other with conversation, which helped them feel less alone. Taken together, these acts were living examples of relational solidarity, a concept of community respect and support to reach greater collective wellbeing [48]. For instance, when we asked one of the older participants about her relationship with her community, she said:

“… the commitment that we had as citizens of here of Castañer. The union, the commitment…the familiarity because everyone here practically, although we were not family, since we were all always familiar with what do you need, if I go someplace to buy something its “what do I bring to you”, “what do I give to you”. That. Mainly among everything was the union we had, but the commitment. To be aware of everyone…” (Female Caregiver feminine, 61 years old)

These acts of solidarity evoked strong feelings of belonginess in their communities [8/15], which became a source of strength for older adults in Adjuntas and Castañer. This feeling for their communities soon turned into pride in themselves since the older adults felt they were working hard despite the challenges they faced. One older participant felt honored to be part of a small neighborhood in Adjuntas who organized itself to attend community needs without help from the local government. She said:

“…I’m proud to belong to Portillo, right, to Tanamá…” (female denizen, 60 years old, caregiver of Alzheimer patients).

Although she lived alone, participants like her found comfort in the people around her and their willingness to share. These reciprocal aids became a symbol of belonging and companionship that allowed older adults to cope with their loneliness and sparse family support. One occasion, lacking help even motivated them to act. For example, when asked about help from the local government, an older participant told us:

“…[m]ovement from the government was very slow and that forced people to come together to work, everyone in their respective area.” (Male denizen, 68 years old).

The participants suffered due to the lack of solidarity from the local government, especially from the mayors of Adjuntas and Lares. The government was offering aid at the time; however, help was concentrated far from these mountain communities. Most older adults [13/15] felt forgotten when they heard that the government was sending essentials to certain regions, but nothing was reaching them. One of the older participants said:

“It took about four months after Hurricane María, if not more, for a mayor to come here. No one from the government showed up here. Nothing.” (Female caregiver, 61 years, old)

Nevertheless, the elderly were not the only ones who showed relational solidarity in Adjuntas and Castañer. Community-based and service-providing institutions [7/10] mobilized support to remote regions with elderly in need. In the absence of government assistance, local organizations such as Castañer General Hospital and Casa Pueblo became pillars of support for older adults in the region. To help hard-to-reach communities, an interviewed provider said:

“We formed a team of doctors, mental health, and nursing staff, and we began to visit shelters. It could be said that we had the tools to know what was going to be done there, because there was no plan.” (Castañer male clinical psychologist)

Similarly, non-profit organizations, local churches of different denominations, and different institutions strengthened these efforts to bring food and support to the elderly. When we asked one of the participants what kind of help she had received, she said:

“The Red Cross, the National Guard did come a lot, many people came here personally and one of these came from institutions, they also came. And many people here still bring things to this date.” (Female denizen, 71 years old)

According to this interviewee, aid continued to benefit older adults in the region even a year and a half after Hurricane María, which is when we conducted the interviews. In other words, relational solidarity continued to be a source of support even long after the hurricane. However, some participants [5/15] saw neglect where others saw solidarity. A few interviewees indicated that no one from their communities helped them or checked on them, not even their closest neighbors. These participants reported that their neighbors were apathetic and individualistic during the recovery process. For example, one participant stated:

“It was difficult… But the indifference here in Adjuntas is also difficult… Nobody, nobody here…I’ve been here for about 39 years more or less and my neighbors, some came later, but there were some who had been here for a long time… [and were] quite indifferent…” (Female denizen, 80 years old)

In summary, although a few older adults had to address their challenges alone, most participants benefited from a sense of solidarity and belonging that allowed them to nurture their emotional wellbeing. As one interviewee succinctly summarized:

“…in this community, they were well united. In this community, each one was working together.” (Female denizen, 78 years old).

To cope with the challenges, this sense of solidarity amidst disaster recovery also came with a sense of hard work which we will elaborate in the next section.

“If I decay, I am not going to solve anything…”—La brega among older adults in Adjuntas and Castañer

Despite the solidarity that benefited participants, many older adults still struggled to manage their challenges. Although support was helpful, some benefited more than others. As a result, many older adults [12/15] organically engaged in la brega (i.e., a Puerto Rican term loosely similar to “the hustle”). La brega refers to a practice of radically accepting precarious conditions in a given situation and working through despite the limitations. For example, many participants had to work with the fewest resources available, such as their small homes made of wood and metal panels. From the perspective of la brega, the suboptimal conditions of the house mattered little. The house was still useful if it was standing. Despite living in vulnerable spaces, participants prioritized making makeshift fixes to their homes and moving on to the next achievable goal. When talking about the support he received from his wife, one of the older participants said:

“The whole house [was] destroyed, and… she told me; ‘We are alive, we have to push forward’. And my wife, who is strong, gave me her support. She would always tell me; ‘we are going to get through it [bregar], forget about it, little by little’. And my roof had plastic coverings for more than a year…” (Male denizen, 68 years old)

For this participant, being reminded that there were things more important than material losses offered the support he needed after the hurricane. Similarly, other participants [13/15] made the most of the few materials they could find by bartering with their neighbors, which helped them adapt to scarcity and loneliness. According to participants, the goal of la brega seemed to be resourcefulness. When we asked one of the interviewees what materials she used to cope with the shortages, she said:

“…I would look for a candle, lit it, and with that we would light up around. And to cook, since we couldn’t, well we would go downstairs too. If we ran out of gas, we would go down there to the kitchen, turn on a little fire over there and yes, [I] worked through [bregaba] downstairs, cooking and everything.” (Female denizen, 80 years old)

Despite the emotional decline brought on by their limited conditions, older adults empowered and motivated themselves to get back up. This self-motivation allowed them to maintain their daily functioning and move their recovery along. Participants [13/15] felt they had to drive themselves and drew strength from any possible source to avoid stagnating. For instance, one participant said:

“So, well, how do I put it, I am human, like, I do not give up, I am not insensitive, but I remain firm, but always seeing and visualizing that if I decay, I’m not going to solve anything, that I need to draw strength from myself, strength from wherever I have to look for it, to face whatever comes and contribute what I can.” (Female denizen, 78 years old).

Interviewed providers [5/10] also used la brega in their organizations to offer support services to older adults in the region. As such, providers felt they had a shared responsibility to their communities. Speaking about how they engaged with community work, one provider said:

“…Well, because you have the people, because you have the infrastructure, because you have the relationships, because you have, in the case of Casa Pueblo it has credibility and a history. When we face problems, we face them [with our] heads up high and we solve them with what’s within our reach, with the limitations that one might have." (Casa Pueblo-Community-based organization from Adjuntas)

Similarly, another provider shared this feeling of responsibility towards her community members. When asked how she felt about her work after María, one provider said:

“Since I quickly got involved in working, maybe I didn’t have a lot of time to regret and not because I wasn’t emotionally upset, it was just time to get involved, to do what I had to do.” (Female psychologist)

Overall, older adults in Adjuntas and Castañer used la brega to encourage themselves, face adversity, and exercise their social responsibility as community members. At the same time, providers served older adults using la brega to support them despite having their own limitations. Similar to relational solidarity, la brega was another meaningful strategy that older adults used to confront their challenges and nurture their emotional wellbeing following Hurricane María. In Table 4, we present a data table with the specific number of older adult participants and community leaders and providers that endorsed each narrative and examples.

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Table 4. Number of older adult participants and community providers who endorsed theme narrative and examples.

https://doi.org/10.1371/journal.pone.0316156.t004

Strengths and limitations

One of the strengths of our study is the expansion of knowledge of the remote and isolated geographical regions of Adjuntas and Castañer. This study focused on increasing the visibility of the experiences of underserved populations (i.e., older adults living in poor conditions) in particularly hard to access places. Furthermore, because Castañer has no specific designation, being a Poblado surrounded by four towns, its older adult population could be considered even more underserved and invisible. Additionally, some of our team members grew up in Adjuntas and Castañer, and had firsthand experience navigating these community spaces. This representation by the team facilitated access to the sample and, in turn, served to better contextualize the experiences of the participants.

On the other hand, our study has some limitations worth mentioning. Firstly, we began data collection one year after the impact of Hurricane María. As such, the study’s timing represents a limitation since the passage of time could lead to recall bias. Additionally, all participants from Castañer were from central areas of the Poblado and the experiences of older adults and caregivers from lesser-known areas of Castañer were excluded. Future studies on Castañer should include participants from lesser-known areas to account for their specific experiences.