In Puerto Rico, the COVID-19 burden in the elderly population is significant as 23% of the confirmed COVID-19 cases and
75% of the deaths have been reported in this group with a low testing rate (3.4 per 100,000) in those > 65 years. The
knowledge, beliefs, attitudes, and practices about the risk of infection from COVID-19, symptoms, testing and
vaccination, remain a public health concern in Puerto Rico. In 2019, 21.3% of the population living in PR were elderly (>
65 years) with 43.3% living in poverty, were isolated, and medically vulnerable due to their chronic diseases. Isolation for
elders has been exacerbated due to the high rate of migration of their family members that culturally cared and lookout
for them. The Puerto Rico Community Action Research and Engagement (PR-CARE) initiative aims to focus on the
elderly communities in PR who are disadvantaged by geography, sexual and/or gender identification, homelessness
and/or income to identify how multiple factors serve to disadvantage this at-risk population in COVID-19 testing and
vaccine uptake. Our well-established community partner network, using a mixed methods research strategy, has the
goal of examining how social determinants of health, in addition to critical policy and environmental factors, address
testing and vaccine access and uptake in elderly (> 65 years old) populations in Puerto Rico who suffer from high levels
of social vulnerability (i.e., homeless), who are geographically isolated (i.e., living in isolated or rural areas), living in
poverty, and gender or sexual diverse (i.e., L.G.B.T.T.Q.I.A.+). Our strategies are guided by four theoretical frameworks:
Community Engagement Continuum, Intersectionality-Informed Approach, Anderson’s Behavioral Model of Health, and
Historical Trauma. These models will enable us to portray a critical array of multi-domain determinants of health to
understand health disparities and healthcare utilization, specifically COVID-19 testing, and vaccinations, in vulnerable
elderly communities. Our aims are to: 1) assess federal and Puerto Rico Commonwealth policy implications on COVID-19
testing in low-resourced and socially vulnerable elderly in Puerto Rico; 2) examine individual and social determinants of
health that influence the uptake of the COVID-19 diagnostics among low-resourced and socially vulnerable elderly in
Puerto Rico and 3) combine results from the systematic policy review and key informants (Aim 1: qualitative) and elderly
individuals (Aim 2: quantitative and qualitative) to identify challenges, barriers and effective strategies and language to
support and improve COVID-19 testing and other related health outcomes in this vulnerable population. The community
engagement research that comprises PR-CARE will work to expand the scope, reach, access to and uptake of COVID-19
testing for vulnerable elderly populations in Puerto Rico. Concurrently, it will identify and create permanent pathways in
health policy that increase the availability of health services for vulnerable populations, promoting health equity using
the lens of social, ethical, and behavioral implications.
