By Marianne Cruz-Carrión, MS and Norma Boujouen Ramírez, PhD, Puerto Rico Department of Health

Introduction

The Puerto Rico Title V program’s interdisciplinary team has members from the health, social sciences, and behavioral health fields. The team took a comprehensive approach to assessing the health needs of maternal, child, and adolescent populations, representing 40 percent of the 3 million people living in the jurisdiction. This three-tiered approach is interconnected. It  involves:

• collecting and analyzing quantitative and qualitative data of the population’s needs;
• assessing system capacity to meet the needs of the maternal, child, and adolescent population, as well as assessing the Puerto Rico Title V program strengths and challenges; and
• setting potential needs priorities by matching needs to capacity, setting targets, identifying activities and/or actions to meet these needs, and allocating resources.

Stakeholder engagement is crucial in the health needs assessment processes so partners can share their knowledge and experiences, actively participate in the prioritization process, and provide input into the state action plan.

History

The current comprehensive health needs assessment resulted from a collaboration of Puerto Rico Title V stakeholders invested in identifying gaps and meeting the challenges represented in each tier. Below, we describe how our health needs assessment evolved and what was done to fill in gaps, enhance the needs assessment processes, and address other barriers and challenges.

Addressing a Critical Data Collection Gap

In 2009, the Puerto Rico Title V program’s cultural anthropologist identified a critical gap in the data collection efforts for the health needs assessments. The program had not gathered qualitative information from Puerto Rican populations and providers about their concerns, experiences, and views related to health. To address this issue, beginning in 2010, Puerto Rico’s Title V program began gathering qualitative data via focus groups; health dialogues; key informant interviews; and individual interviews with staff, families, youth, and providers. Qualitative information is equally important to the health needs assessment process as quantitative information. Qualitative data gathering by asking open-ended questions allows people to respond in their own words about experiences, perceptions, and knowledge related to their own health, health information, use of services, and interactions with providers.

The Puerto Rico Title V program also performs qualitative analysis of responses to survey open-ended questions, evaluation commentaries, and the Centers for Disease Control and Prevention’s (CDC’s) Puerto Rico Pregnancy Risk Assessment Monitoring System (PRAMS) back-page comments. This extensive qualitative gathering and analysis provides insights into needs not reflected in quantitative data.

Addressing Language Barriers to Increase Public Input into Health Needs Assessment Updates

For many years, Puerto Rico received little or no public input into the health needs assessment annual updates: only one or two people would show up to read the report written in English. To make the health needs assessment annual updates more accessible, since 2018 the program has distributed via email and social media a Spanish version of the state snapshot and the revised state action plan. The program has also been distributing a digital form to our stakeholders so they can provide input on how well we are addressing needs and share recommendations about other strategies and activities that could be included in the state action plan. In addition to feedback received as part of qualitative data gathering, public input is an important way to keep our stakeholders engaged with the Title V program every year.

Establishing a Three-Step Process to Set Priorities with Stakeholders 

For many years, we gathered stakeholders to help us set priorities based on the health needs assessment results. However, this process was burdensome because we held only one meeting with stakeholders. In 2019, we established the following three-step prioritization process that works well for our program:

Although the health needs assessment is conducted every five years, annual updates to monitor the progress of the state action plan are required. This was a challenge because we lacked a tool to adequately assess the effectiveness of the strategies and activities proposed in the state action plan. In 2020, we began using the Plan–Do–Study–Act (PDSA) Cycle, an iterative, four-stage problem-solving model for testing change implementation. Following the prescribed steps allows us to evaluate the outcome, improve upon it, and test it again. In other words, the PDSA allows us to examine the impact of the strategies that must be improved or replaced with ones that more effectively address the priorities.

Meeting Additional Challenges in Obtaining Data

As a territory, Puerto Rico has struggled to obtain trustworthy and comparable data such as that obtained from national surveys. Although the Puerto Rico Title V program obtains data from Vital Statistics, the Youth Risk Behavioral Surveillance System, and the Behavioral Risk Factor Surveillance System (BRFSS), limitations have occurred in monitoring the progress of health indicators to meet our population’s needs. Over time, we have taken steps, such as the following, to meet this challenge.

• From 2002 to 2016, postpartum women, before hospital discharge, completed the Puerto Rico Maternal and Infant Health Survey, a survey equivalent to the CDC PRAMS. Although the people surveyed represented only a convenience sample, the data was very useful up until 2017, when CDC PRAMS was implemented in Puerto Rico.
• Since 2017, the Title V program health needs assessment has included PRAMS data, allowing comparison with other states.
• For the 2020 five-year health needs assessment, we developed a survey targeted at community and health care providers at federally qualified health centers. The survey was designed to obtain data on socioeconomic situations, healthy lifestyles, health prevention, health conditions, and health care access, and the major barriers providers face in providing services. These needs are supported with statistical data for the last available years.
• Since 2019, we have been using the Health Resources and Services Administration Maternal and Child Health Jurisdictional Survey to supplement Puerto Rico data collection efforts, although trend analysis is not yet feasible with the two rounds of data gathering finished.
• Furthermore, the Title V health needs assessment identified needs that resulted in additional questions to the BRFSS, improving our understanding of the scope of the needs.

Conclusion

Our interdisciplinary team representing the health, social sciences, and behavioral health fields took a comprehensive approach that made it possible to identify gaps and take the necessary corrective actions to improve the Puerto Rico Title V health needs assessment process. In so doing, we have been able to better meet the needs of maternal, child, and adolescent populations: women of reproductive age, pregnant women, infants, children, adolescents, and children and youth with special health care needs.