Puerto Rico Health Services Research Institute

Research Projects

Health Seeking Behavior and Complementary and Alternative Medicine (CAM) Utilization Patterns in Puerto Rico: Implications for Health Policy and Administration (Roberto E. Torres-Zeno, PI)


The proposed pilot study will provide preliminary data to support future research on CAM utilization seeking behavior patterns, user demographics, insurance coverage, and expenditures in Puerto Rico. The project will provide the first data set ever on CAM utilization patterns in the island, generating critical information to better understand important CAM issues regarding conventional health care services in Puerto Rico.

The purpose of this proposal is to conduct a pilot research project to determine CAM prevalence, utilization and seeking behavior patterns, demographic factors, insurance coverage and expenses in Puerto Rico. CAM modalities refer to a wide range of unconventional health care modalities, including relaxation techniques, herbal medicine, massage, chiropractic, megavitamins, homeopathy, hypnosis, acupuncture, folk medicines, imagery, commercial diet and spiritual healing, among others. Complementary and alternative medicine (CAM) is a term used to refer to interventions neither taught widely in medical schools nor generally available in U.S. hospitals (Eisenberg et al., 1993). It has also been defined as diagnosis, treatment and/or prevention which complement mainstream medicine by contributing to a common whole, satisfying a demand not met by orthodoxy, or diversifying the conceptual frameworks of medicine (Ernest, 1995). Studies indicate that the use of CAM by health care consumers is widespread and increasingly common. This has been documented by several studies conducted in the United States, as well as in other countries throughout the world (Eisenberg, 1993; Fisher and Ward, 1994;MacLennan et al., 1996; Yamauchi, 1996:Millar, 1997;Eisenberg et al., 1998;Ernest and White, 2000). In Western European countries as well as in Far East countries, alternative methods have been used for centuries by traditional health care providers to treat health problems.

The specific aims of the proposal are to:

  1. develop and validate a CAM survey instrument to be used in a population-based pilot study in Puerto Rico;

  2. based on the survey instrument, develop a profile of CAM utilization and health seeking behavior patterns, including use rates, reasons for CAM use, health status perceptions, consumer characteristics, and costs and health insurance coverage for CAM services in Puerto Rico;

  3. formulate a new research proposal for a more comprehensive and ambitious CAM study comparing CAM use of Puerto Ricans in the island and Puerto Ricans living in the U.S.

Development of a Spanish Version of the Primary Care Assessment Tool (PCAT)


This pilot study will provide preliminary data to support future research addressing the outcomes of primary care services in Puerto Rico. It is expected that the proposed study will contribute to build capacity for conducting research that focuses on the primary care services evaluation and assessment of organizational resources and processes that can be improved to ultimately positively influence outcomes of health care delivery. This project will be the first to develop and use validated and reliable measures to collect and analyze information about a sample of settings from the primary care delivery system in Puerto Rico. This pilot project offers the opportunity to the faculty to obtain further experience and skills in the health service research field that may be applied to their current academic responsibilities and may lead to the development of upcoming research projects.

A strong primary care system has been recognized as a requirement for the achievement of effectiveness and equity in a health service system (Cassady, Starfield, Hurtado, Berk, Nanda and Friedenberg, 2000; Institute of Medicine, 1996; Shi, Starfield, Kennedy and Kawachi, 1999; Shi, 2000; Starfield, 1994). Primary care has been defined as that level of a health service system that provides entry into the system for all new needs and problems, provides person-focused rather than disease-oriented care over time, provides care for the most common problems in the community by providing preventive, curative, and rehabilitative services to maximize health and well-being, and coordinates or integrates care provided elsewhere or by others (Starfield, 1998). The Primary Care Assessment Tools (PCAT) has been widely used as a measure to assess the health services delivery system according to the characteristics of their approach to providing primary care. We propose to translate into Spanish these instruments using the methods developed by Matías-Carrello and colleagues (2003) that aim to achieve a valid and generalizable instrument. The Spanish-translation, cultural adaptation and test of the PCAT will make available a valid and reliable method of assessing the quality of a primary care system analogous to the US health system and with an ethnic group that represents a rising segment of the diverse US Latino population.

We specifically aim to:

  1. To translate and culturally adapt the Primary Care Assessment Tools (PCAT) to Spanish for use with Latino-American populations, specifically, Puerto Ricans.

  2. To assess the construct validity and internal consistency of the Primary Care Assessment Tools (PCAT)-Consumer surveys Spanish version as reported by a sample of adults/children's parents that receive services in four primary care settings in Puerto Rico.

  3. To assess the feasibility and adequacy of the Primary Care Assessment Tools-)-Consumer surveys detecting differences in the quality of the primary care delivered in four primary care settings in Puerto Rico.

Social Environment and Family Factors Associated with Childhood Obesity Among Elementary School Students (First to Sixth Grade) from Public and Private Schools in Puerto Rico.


The purpose of this pilot project is to develop preliminary data on obesity prevalence and social environment factors associated to obesity in Puerto Rico that will lead to more comprehensive studies in the future. Childhood obesity is a significant and growing health problem in the US and other parts of the world. The high prevalence of overweight and obesity in the USA and elsewhere is the result of a combination of factors including nutritional and physical activity practices, in addition to genetic, behavioral, environmental, and socioeconomic characteristics. However, among those factors, education and income levels have been identified as the strongest predictors of health (1). There is mounting evidence that the widening gap between the rich and the poor contributes to health disparities. Consequently, Healthy People 2010 emphasizes that special attention should be given to minority groups, particularly low-income populations. There is the need to develop new interventions to address this epidemic. The first step must be to determine the magnitude of the problem. In Puerto Rico, data on food behavior practices is scarce, particularly among children. This study proposes to examine determinant factors that may influence food behavior, physical activity practices, and prevalence of overweight and obesity in a sample of children from elementary schools in Puerto Rico. Special attention will be given to the examination of health disparities in nutrition and health care services. We propose to survey children and parents from Cayey, Puerto Rico. This will be the initial effort to develop an intervention aiming to reduce the prevalence of overweight and obesity in this population.

We specifically aim to:

  1. Compare prevalence of obesity among elementary school students (first to sixth grade) from private and public schools in Puerto Rico, and their access to preventive nutrition and health education programs.

  2. Examine the association of social environment factors, such as access to health and nutrition services, with child's weight status among elementary school students (first to sixth grade) from private and public schools in Puerto Rico.

  3. Examine the association of family factors, such as parents' perceptions of children's weight status and family lifestyles, with child's weight status among elementary school students (first to sixth grade) from private and public schools in Puerto Rico.

  4. Examine behavioral factors, such as dietary and physical activity practices, with weight status among elementary school students (first to sixth grade) from private and public schools in Puerto Rico.

This website is supported by the Agency of Healthcare Research and Quality, Grant No. 1 R24 HS1 4060-02 and by a Research Centers in Minority Institutions Award, G12RR-03051, from the National Center for Research Resources, National Institutes of Health

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