Mental Health Among Puerto Rican Adolescents Living in the United States During the COVID-19 Pandemic

ABSTRACT

Objectives

The present study examined how different family level (family financial stress, family violence) and individual (food insecurity, gender, race) determinants of health were associated with mental health among Puerto Rican adolescents living in the U.S. during the COVID-19 pandemic.

Method

A sample consisting of 119 Puerto Rican adolescents, aged 13 to 17, was collected via Qualtrics Panels between November 2020 and January 2021. We examined the association between family financial stress experienced during the pandemic and psychological distress. We also evaluated whether the association between family financial stress and psychological distress was moderated by family violence, food insecurity, and the participant’s gender and race.

Results

Findings showed that food insecurity positively predicted psychological distress. Results also showed that participants’ race moderated the association between family financial stress and psychological distress. Specifically, we found that while there was a significant positive association between family financial stress and psychological distress among Puerto Rican adolescents who identified as a racial minority, this association was nonsignificant among White Puerto Rican adolescents.

Conclusion

Our research highlights the significant role of COVID-19 related family financial stress and food insecurity on Puerto Rican adolescents’ poor mental health during the COVID-19 pandemic.

Resumen

Objetivos: El presente estudio examinó cómo diferentes determinantes de la salud a nivel familiar (estrés financiero familiar, violencia familiar) e individual (inseguridad alimentaria, género, raza) se asociaron con la salud mental de les adolescentes puertorriqueñes que vivieron en los EE. UU. durante la pandemia de COVID-19.

Método: Se recolectó una muestra compuesta por 119 adolescentes puertorriqueñes, de 13 a 17 años, a través de paneles Qualtrics entre noviembre de 2020 y enero de 2021. Examinamos la asociación entre el estrés financiero familiar experimentado durante la pandemia y la angustia psicológica. También evaluamos si la asociación entre el estrés financiero familiar y la angustia psicológica fue moderada por la violencia familiar, la inseguridad alimentaria, el género y la raza de los participantes.

Resultados: Los hallazgos mostraron que la inseguridad alimentaria predijo positivamente la angustia psicológica. Los resultados también mostraron que la raza de les participantes moderó la asociación entre el estrés financiero familiar y la angustia psicológica. Específicamente, encontramos que si bien hubo una asociación positiva significativa entre el estrés financiero familiar y la angustia psicológica entre les adolescentes puertorriqueñes que se identificaron como una minoría racial, esta asociación fue estadísticamente no significativa entre les adolescentes puertorriqueñes blancos.

Conclusión: Nuestra investigación destaca el papel importante del estrés financiero familiar y la inseguridad alimentaria relacionados con el COVID-19 en la salud mental de les adolescentes puertorriqueñes durante la pandemia de COVID-19.

Latinxs¹ make up about 18.5% of the U.S. population yet they account for 24.8% of COVID-19 infections and 33.3% of COVID-19 deaths (Centers for Disease Control and Prevention [CDC], 2022). Additionally, about 45% of COVID-19 deaths in children and young adults happened among Latinxs (Rodriguez et al., 2021). Indeed, the COVID-19 pandemic has significantly harmed the wellbeing of Latinx communities in the United States (U.S.). Beyond COVID-19 infection and deaths, the pandemic effects have also manifested in worsened economic, food insecurity, family violence, and mental health inequities among the Latinx community during the pandemic (Krogstad et al., 2020; Noe-Bustamante et al., 2021; Suro, 2021).

During the pandemic, close to 50% of Latinx adults reported job losses or pay cuts compared to 43% of all U.S. adults who reported job or income losses (Pew Research Center, 2021). Food insecurity (i.e., inability to adequately obtain food due to limited money and other financial resources; Coleman-Jensen et al., 2021) also hit astronomical levels with 46% of Latinx households reporting food insecurity (Wolfson et al., 2020) compared to 17% of Latinx households in 2019 (Coleman-Jensen et al., 2021). Family violence (e.g., verbal and physical abuse perpetrated by a member of a family on other members of the family; Livingstong & Livingston-Dole, 2022) has also increased among Latinx families during the COVID-19 pandemic. In their study with Latinx communities in Texas, Garcini et al. (2022) found that almost half of the participants (49%) reported domestic violence wherein family stressors were worse in households with a prior history of domestic violence and limited resources. Latinxs have also experienced worsened mental health inequities during the pandemic. For example, from 2019 to 2020, psychological distress increased significantly among Latinx adults compared to other groups (Breslau et al., 2021). Particularly, McGinty et al. (2022) found that Latinx adults were more likely to experience severe psychological distress during the pandemic compared to non-Latinx Black and non-Latinx White Americans. Similarly, Czeisler et al. (2020), documented heightened depression and anxiety among Latinx adults during the COVID-19 pandemic.

The stressors Latinx adults and families have faced during the COVID-19 pandemic have in turn been associated with significant effects on the mental health of Latinx adolescents. For example, in their study with 547 Latinx adolescents living in the state of Georgia, Roche et al. (2022) showed that COVID-19 related household hospitalization, loss of job or income, and increased home responsibilities were associated with worse academic performance and increased depression and isolation among Latinx adolescents. Carlos Chavez et al. (2023) found that household economic and academic stress were associated with psychological distress among 398 Mexican American adolescents. Meanwhile, in a sample of 322 adolescents (10–14 years of age, 71% Latinx adolescents), Penner et al. (2021) showed that family support, less family conflict, and lower financial stress were associated with lower internalizing symptoms among adolescents during the COVID-19 pandemic.

The growing scholarship on the impact of the COVID-19 pandemic on Latinx adolescents living in the U.S. provides important information mental health professionals and policymakers can use to mitigate the negative psychological impact the pandemic has had on this population. However, effective psychological interventions with Latinx adolescents in the aftermath of the pandemic must be informed by population-specific research. Therefore, to gain a nuanced understanding of the psychological health of Latinx adolescents during the COVID-19 pandemic, the present study focused on Puerto Rican adolescents exclusively. Specifically, the present study examined how different family and individual determinants of mental health were associated with psychological distress experienced by Puerto Rican adolescents living in the U.S. during the third wave of the COVID-19 pandemic.

Puerto Rican Adolescents Mental Health Before the Pandemic

The focus on examining determinants of Puerto Rican adolescent mental health is primarily informed by the fact that Puerto Ricans living in the U.S. persistently have higher rates of mental health disorders than other Latinx groups living in the U.S (Alegría et al., 2007; Lee & Held, 2015). Before the COVID-19 pandemic, Puerto Ricans were already burdened by disproportionate rates of serious psychological symptoms and disorders. A robust body of empirical research persistently shows that Puerto Rican adults report higher rates of serious psychological distress and poorer mental health (e.g., major depressive disorder) than Latinx adults of Mexican, Central, and South American descent (e.g., Jetelina et al., 2016).

Researchers have also documented significantly higher rates of mental health disorders among Puerto Rican parents living in the U.S. than Mexican and Salvadoran parents living in the U.S (Ramos-Olazagasti & Conway, 2022). Moreover, several studies with Puerto Rican parents/caregivers and their adolescent children living in the U.S. have shown the significant effect of parental/caregiver mental health on the mental health of their adolescent children (e.g., Alegría et al., 2019; Duarte et al., 2008). Although there is less information about how Puerto Rican adolescents’ mental health fares in comparison to other Latinx adolescent groups, previous research has shown that Puerto Rican adolescents living in the U.S. report more psychological distress than Puerto Rican adolescents living in Puerto Rico (e.g., Alegría et al., 2019; Ramos-Olazagasti et al., 2013). Given pre-pandemic mental health disparities in Puerto Rican parents/caregivers and their effect on the mental health of their adolescent children, Puerto Rican adolescents may have also been at a greater risk for psychological distress during the COVID-19 pandemic compared to adolescents from other Latinx communities in the U.S.

Theoretical Framework

Adolescence is a critical time of development and transition between childhood and adulthood (Sawyer et al., 2012). How well adolescents do during this development and transition can be significantly influenced by several social and economic determinants. For example, Viner et al. (2012) note that adolescents with greater access to economic and educational resources do better than those with less access. These structural factors in combination with determinants at the family (e.g., family financial stress, family conflict) and community (e.g., neighborhood poverty, decayed infrastructure) levels can exert great influence on the mental health of adolescents (Bennet & Blankenship, 2020; Viner et al., 2012).

Informed by decades of research on social and economic determinants of children and adolescent psychological health, Manseau (2014) proposed the Economic Social Determinants of Mental Health model. This framework argues that social and economic factors such as poverty and neighborhood economic deprivation are key determinants of mental health among children and adolescents. Additionally, this model suggests that the link between social and economic determinants and mental health is influenced by different factors across community, neighborhood, family, and individual levels (Manseau, 2014). At the community and neighborhood levels, determinants like poverty, decayed infrastructure, and exposure to violence are theorized to moderate the effect of social and economic inequality on mental health outcomes. In turn, Manseau (2014) argues that community factors can affect children’s and adolescents’ mental health by disrupting family functioning. That is, issues at the family level such as family stress, family violence, family conflict, financial stress, child abuse and neglect, and poor parenting can worsen the effect of community factors on the psychological wellbeing of children and adolescents (Manseau, 2014). Finally, individual characteristics such as gender and race, as well as individual vulnerabilities such as food insecurity and preexisting neurobiological issues can further moderate the association between family health determinants and mental health among children and adolescent populations (Manseau, 2014).

Drawing on the Economic Social Determinants of Mental Health framework, our study examined a moderated regression model that focused on family and individual-level correlates of psychological distress reported by Puerto Rican adolescents, aged 13 to 17 years during the COVID-19 pandemic. Guided by Manseau’s work (2014), our model examined the ability of family violence and food insecurity to moderate the relationship between family financial stress and psychological distress. We also examined whether the association between family financial stress and psychological distress would be moderated by the participants’ gender and race.

Family Financial Stress and Puerto Rican Adolescent Mental Health

Researchers have persistently found how mental health disparities documented in Puerto Rican communities in the U.S. are associated with the racialized social and economic inequities Puerto Rican communities of all ages experience because of their status as colonized people (e.g., Capielo Rosario et al., 2021; Carlos Chavez et al., 2023; Ramos-Olazagasti et al., 2013). To illustrate, the percentage of Puerto Rican families in the U.S. that live in poverty (17%) is almost double the poverty rate of all U.S. families (9%; U.S. Census, 2019). Additionally, while the median U.S. family income is about $80,000, Puerto Rican families make only about $58,741 annually. The overrepresentation of Puerto Rican workers in low-wage service jobs in the U.S. (Visser & Meléndez, 2011) is another example of the disproportionate economic burden that many Puerto Rican households face in the U.S. These economic conditions, in turn, put Puerto Ricans at a significantly increased risk of experiencing poor mental health outcomes (Burgos et al., 2017).

The extant literature on Puerto Rican adolescent mental health provides support for the role family financial stress (e.g., job losses, pay cuts) has on the mental health of Puerto Rican adolescents. A study by Felix et al. (2011) with Puerto Rican adolescents living in Puerto Rico found that higher perceptions of family poverty (an indicator of family financial stress) were positively associated with externalizing and internalizing symptoms among adolescents ages 11 to 17. Also using a Puerto Rican sample (ages 4 to 17), Canino et al. (2004) found that low family income was significantly associated with externalizing symptoms such as defiance and impulsivity. While providing important insights into the effects of family financial stress on Puerto Rican adolescents’ mental health, these studies have focused on Puerto Rican adolescent populations living in Puerto Rico. Therefore, very little is known about the role family financial stress plays on the mental health of Puerto Rican adolescents living in the U.S., particularly during the COVID-19 pandemic. This is concerning because of the persistent and intergenerational economic disparities faced by Puerto Ricans in the U.S. and because a majority of Puerto Ricans live in the U.S., not Puerto Rico (Noe-Bustamante et al., 2019). In light of the economic disparities Puerto Ricans were facing before the pandemic in combination with the impact the COVID-19 pandemic has had on Latinx households, it is urgent to examine the effect of COVID-19 related family financial stress on Puerto Rican adolescents’ mental health during the pandemic.

Family Violence, Food Insecurity, and Puerto Rican Adolescents’ Mental Health

Exposure to family violence, defined as incidents of physical, psychological, economic, and verbal abuse perpetrated by a member of a family on other family members (Piquero et al., 2021), is another important factor to consider when examining determinants of mental health among Puerto Rican adolescents. To illustrate, multiple studies have shown that the perception of family conflict and violence by Puerto Rican children and adolescents is associated with depression and anxiety symptomatology (e.g., Sáez Santiago & Rosselló, 2001). More recently, a study with Puerto Rican adolescents living in the U.S. and Puerto Rico found that those with greater exposure to adversities like family violence were also more likely to report early alcohol use (Ramos-Olazagasti et al., 2017). Furthermore, incidents of family violence can be exacerbated during times of financial hardship. To illustrate, among Latinx households, a review of the literature by Cummings et al. (2013) revealed that unemployment and lack of economic resources were consistent predictors of family violence. Therefore in the present study, we argue that the association between family financial stress on Puerto Rican adolescents’ reported psychological distress would be moderated by family violence.

Food insecurity also requires attention as a moderator between the association of family financial stress and psychological distress. A review of the literature on food insecurity among Latinx households living in the U.S., including Puerto Rican households, reveals that food insecurity is associated with financial hardship (Varela et al., 2023). That is, households where parents experienced unemployment were also more likely to report food insecurity (Bermúdez-Millán et al., 2011). In a separate study with 200 female Puerto Rican caregivers living in Connecticut, Dhokarh et al. (2011) noted that lack of financial resources was associated with food insecurity among caregivers and their children. Food insecurity in turn has been associated with worse health outcomes in Puerto Rican families. For example, Sostre (2022) found that food insecurity was positively linked to psychological distress among Puerto Rican households in Puerto Rico. Although less information is available about how food insecurity is associated with psychological outcomes among Puerto Rican adolescents living in the U.S., previous research has demonstrated the association between food insecurity and poor mental health among U.S. Latinx adolescents (e.g., Hall et al., 2018; Potochnick & Perreira, 2010).

The effect of family financial stress on the mental health of Latinx adolescents may also be moderated by gender and race. Research suggests that adolescent boys and girls respond differently to family financial stress, with boys having significantly more negative reactions than girls (e.g., externalizing behaviors) (e.g., Conger et al., 1993; Elder & Caspi, 1988). Specific to Latinx adolescents, Coltrane et al. (2008) found that compared to Latina girls, Latino boys reported more negative reactions (e.g., risk behaviors, psychological maladjustment) to their family’s financial problems. This may be because traditional Latinx gender roles place financial responsibility on Latino men, and thus Latino boys may feel a greater obligation to know about their family’s financial status than Latina girls (Arredondo et al., 2014; Delgado et al., 2013). On the other hand, a longitudinal study by Delgado et al. (2013) with Mexican families showed that perceptions of family financial stress affected boys and girls equally. Delgado et al. (2013) attributed this finding to values and expectations of family obligation and care that are characteristic of many Latinx families.

Although race has not received as much attention as gender has as a moderator of the association between family financial stress and mental health among Latinx adolescents, research with Latinx adults shows that Black Latinxs have worse economic (e.g., unemployment), psychological (e.g., depressive symptoms), and physical health (e.g., cardiovascular disease) outcomes as a result of race-based discrimination (Borrell, 2005). A recent study by Capielo Rosario et al. (2021) showed that Puerto Rican adults with darker skin color reported more psychological distress and racial discrimination than Puerto Rican adults with lighter skin color. Thus, it is reasonable to expect that race also plays an important role in the mental health of Puerto Rican adolescents.

Study Objectives and Hypotheses

The primary objective of the present study was to examine the association between family financial stress and psychological distress reported by Puerto Rican adolescents during the COVID-19 pandemic, and the moderating effects of family violence and food insecurity in the association between family financial stress and psychological distress. Based on Manseau’s (2014) framework, our second aim focused on examining the moderating effect of gender and race on the association between family financial stress and psychological distress. Accordingly, we hypothesize that:

H1:

Family financial stress will positively predict psychological distress scores.

H2:

The positive association between family financial stress and psychological distress will be stronger among Puerto Rican adolescents who report more food insecurity.

H3:

The positive association between family financial stress and psychological distress will be stronger among Puerto Rican adolescents who report family violence.

H4:

The positive association between family financial stress and psychological distress will be stronger among Puerto Rican adolescents who identify as a racial minority.

Although we examine gender as a moderator, given the conflicting nature of this association in the literature, we do not offer a hypothesis as to whether the association between family financial stress and psychological distress will be stronger among boys or girls.

Method

This research is part of a larger national study conducted by the National Alliance of Psychological Associations for the Advancement of Racial and Ethnic Equity to assess the needs of Communities of Color (CoC) during the pandemic. This larger study received approval from the Institutional Review Board (IRB) at Arizona State University. The survey consisted of measures that assessed several factors related to wellbeing and health during the COVID-19 pandemic. Data were collected online using Qualtrics Panels between November 2020 and January 2021 (i.e., the third wave of the pandemic in the U.S.). Qualtrics panel relies on recruiting the guardians of potential minor participants from various sources, including website intercept recruitment, member referrals, targeted e-mail lists, gaming sites, customer loyalty web portals, permission-based networks, and social media. To invite participants, Qualtrics sent an e-mail invitation to guardians of potential minor participants that included a description of the study and a link to the study. All study forms, including the consent form, were made available in English.

Procedures

After obtaining consent from parents/guardians, the parents/guardians were asked to pass the survey to the minor. Participants were asked to assent to the survey. Adolescents’ participation in this study was voluntary. Parents could choose not to have their child participate or withdraw from the study at any time, without any penalty. Likewise, the adolescent participants could choose not to participate or to withdraw from the study at any time with no penalty to them. Each adolescent received $1.50 worth of market research points for completing the survey. Four validity checks were placed throughout the survey to ensure accurate responses. Participants who failed any of the validity checks were removed from the data. Additionally, completed surveys in extremely short amounts of time were also deleted from the data. The final sample consisted of 119 Puerto Rican adolescents, ages 13–17 years old.

Sample Characteristics

Adolescents in the sample had a mean age of 15.08 (SD = 1.26). The majority of the sample were girls (52.1%) and 55.5% indicated they were either in 9th or 10th grade at the time of the survey. A little over half of the sample racially identified as White (50.4%), followed by 19.3% identifying as Black, 14.6% as Biracial, 9.2% as Multiracial, and 6.7% as Indigenous. A majority of adolescents lived in a two-parent household (29.4%) or a single-parent household (25.2%), and 88.2% described themselves as being financially dependent on their family. In terms of U.S. regional location, 49% of participants lived in the southeast, 25% lived in the northeast, 14% lived in the midwest, .09% lived in the west, and .03% lived in the southwest. This is consistent with the regional distribution of Puerto Ricans in the U.S..

Instruments

Family Financial Stress

To measure family financial stress experienced by Puerto Rican adolescents during the COVID-19 pandemic, participants answered five questions from the Epidemic-Pandemic Impacts Inventory (EPII; Grasso et al., 2021). Because the EPII was created for adults, we modified the five items so that we could assess the impact of the pandemic on adolescents. For example, instead of asking whether the participant had personally experienced financial problems (e.g., layoff, job loss), we asked whether the adolescent’s family experienced problems related to an inability to meet financial obligations (e.g., How likely is it that your family will run out of money because of the coronavirus within the next 3 months?; How likely is it that your family will not be able to pay rent/mortgage because of the coronavirus within the next 3 months?”). Participants responded to these questions along a 6-point Likert scale (1 = Not likely to happen, 6 = Very likely to happen/it already happened), with higher total scores indicating a higher likelihood of family financial stress. Cronbach’s alpha was .71, indicating adequate internal consistency.

Family Violence

To assess family violence experienced during the pandemic, participants were asked to answer a single item created by the researcher to assess current and potential problems related to domestic violence in the home. Participants were asked, “How likely will your family experience violence (e.g., verbal abuse, physical abuse, emotional abuse) because of the coronavirus in the next 3 months?” Participants responded to these questions along a 6-point Likert scale (1 = Not likely to happen, 6 = Very likely to happen/it already happened), with higher scores indicating a higher likelihood of family violence.

Food Insecurity

Adolescents answered a total of nine questions about food security based on the Self-Administered Food Security Module for Youth Ages 12 and older (CFSSM; Connell et al., 2004). This survey assesses a child’s experiences with anxiety related to having less access to food, having less access to nutritious foods, and experiencing hunger. Sample items included; “Did you worry that food at home would run out before your family got money to buy more?” and “Were you hungry but didn’t eat because your family didn’t have enough food?” With each statement, adolescents indicated how often they experienced food insecurity in the past 12 months by selecting one of the following choices: “Yes,” “No,” or “I don’t know.” Positive responses received a score of 1. A raw food insecurity score was calculated for each participant, with higher scores indicating more food insecurity. The Cronbach’s alpha for this scale was .93.

Psychological Distress

The 5-item Mental Health Inventory (MHI-5; Rumpf et al., 2001) was used to assess psychological distress, specifically, depression (3 items; e.g., “in the last month, how often have you felt down and blue?”) and anxiety (2 items; e.g., “in the last month, how often have you felt tense or high-strung?”) symptoms. Participants responded to each item on a 6-point Likert scale (1 = all of the time to 6 = none of the time) to indicate how much they have experienced the symptoms indicated in the last 30 days. After reverse coding two of the items (items 1 and 3 from the inventory), a standard linear transformation is done to create a score that can range from 0 to 100 (Kelly et al., 2008), with higher scores indicating greater distress. Moderate to strong internal consistency for the MHI-5 was demonstrated in prior research (α = .84; Rumpf et al., 2001).   Cronbach’s alpha for the MHI-5 in the current study was .85.

Demographics

Adolescents also answered questions about their age, gender, sexual orientation, education, racial identification, Latinx ethnicity, nativity, and parental/caregiver’s essential worker status.

Analytical Plan

Our preliminary analyses focused on: (a) assessing data distribution and analytical assumptions, (b) evaluating data descriptives and frequencies, (c) conducting a bivariate correlation analysis between the study’s independent variables and dependent variables, and (d) conducting a power analysis. Our main analysis consisted of a hierarchical regression. All analyses were performed using SPSS, Version 28. To examine the moderating effect of race, we re-coded participants’ race into a binary categorical variable because of the small sample size in four of our five race categories. Specifically, White racial identity was coded as 1, and Black, Indigenous, Biracial, and Multiracial (BIPOC) racial identities were dummy-coded as 0. To test the moderating effect of gender, we dummy-coded girls as 1 and boys as 0.

Results

Preliminary Results

No multicollinearity was detected between the predictors. All variance inflation factor values fell below 1.5. The sample size of 117 used in the regression achieved an 80% power to detect an ∆R² of .06 associated with a given focal predictor or two-way interaction, given an alpha of .05.

Bivariate correlation analysis between the variables showed that psychological distress was significantly and positively associated with family financial stress, family violence, food insecurity, and gender (see Table 1). However, race was not significantly associated with psychological distress. Table 1 also shows the means and standard deviations for our variables.

Table 1. Bivariate correlations, means, and standard deviations.

Measure	1	2	3	4	5	6
1. Psychological distress	−	−	−	−	−	−
2. Family financial stress	.27**	−	−	−	−	−
3. Family violence	.31**	.27**	−	−	−	−
4. Food insecurity	.43**	.44**	.34**	−	−	−
5. Race	−.12	.06	−.03	−.01	−	−
6. Gender	.21*	.22*	.09	.12	−.17	−
M (SD)	47.80 (25.44)	7.86 (4.99)	1.42 (1.00)	3.45 (3.38)	−	−

Note: **p < .01, *p < .05. Gender (boys = 0, girls = 1); Race (BIPOC = 0, White = 1).

Hierarchical Regression

All variables were centered before proceeding with our regression analysis. Results from the hierarchical regression analysis showed that the first step, which included gender and race was significant F(2,114) = 3.12, p = .04, R²=.05. However, only gender was significantly associated with family financial stress (b = 9.45, t = 2.00, p = .04). The second step which included family financial stress, family violence, and food insecurity showed significant improvement from the first model, ∆F(3,111) = 9.25, p < .001, ∆R² = .19. In the second step, only food insecurity significantly predicted psychological distress (b = 2.48, t = 3.46, p < .001). As shown in Table 2, gender was no longer significant after introducing family financial stress, family violence, and food insecurity.

Table 2. Hierarchical regression analysis of predictors of psychological distress.

Predictor	R^2	∆R^2	F	∆F	t	b	β
Step 1	.05*		3.12*
Gender					2.00*	9.45*	.19*
Race					−1.11	−5.22	−.10
Step 2	.24***	.19***	7.06***	9.25***
Gender					1.40	6.15	.12
Race					−1.13	−4.87	−.10
FFS					.52	.25	.05
FV					1.91	4.73	.17
FI					3.46***	2.48***	.33***
Step 3	.25***	.01	5.20***	.64
Gender					1.46	6.47	.13
Race					−1.12	−4.86	−.10
FFS					.79	.40	.08
FV					1.94	4.96	.18
FI					3.17*	2.37*	.32*
FFS x FV					−.86	−.46	−.09
FFS x FI					−.22	−.04	−.02
Step 4	.29*	.04	4.89***	3.13*
Gender					1.56	6.78	.13
Race					−1.12	−4.77	−.09
FFS					.74	.37	.07
FV					1.95	4.93	.18
FI					3.37**	2.48**	.33**
FFS x FV					−1.27	−.68	−.13
FFS x FI					−.33	−.05	−.03
FFS x Gender					−.08	−.07	−.01
FFS x Race					−2.49*	−2.16*	−.21*

Note: Gender (boys = 0, girls = 1); Race (BIPOC = 0, White = 1); FFS = Family financial stress; FV = Family violence; FI = Food insecurity. ***p < .001, **p < .01, *p < 05.

The last two steps of our regression analysis included our interaction terms. In the third step, we included the family financial stress by family violence interaction and the family financial stress by food insecurity interaction. This step did not improve the model significantly, ∆F(2,109) = .62, p = .53, ∆R² = .01; neither of the interactions were significant (see Table 2). However, food insecurity remained a significant predictor of psychological distress. In the final step of the regression, we included the family financial stress by gender interaction and the family financial stress by race interaction. This improved the model significantly, ∆F(2,107) = 3.13, p = .04, ∆R² = .04, but only the family financial stress by race interaction was significant (b = −2.16, t = −2.49, p = .01). Simple slopes analysis showed (see Figure 1) that while family financial stress was positively related to psychological distress among BIPOC Puerto Rican adolescents (b = 2.04, p = .001), the association was nonsignificant for White Puerto Rican adolescents (b = 0.65, p = .32).

Figure 1. Family financial stress by race interaction plot.

Discussion

Findings from our study suggest that family financial stress and food insecurity may place Puerto Rican adolescents at risk of experiencing psychological distress. The positive and significant link between psychological distress and food insecurity is consistent with previous work (Althoff et al., 2016; Shankar et al., 2017). Our results are also supported by Manseau’s framework (2014), which argues that food insecurity puts adolescents at risk of experiencing psychological distress. According to researchers, food insecurity places children and adolescents at risk of experiencing mental health problems by affecting areas of the brain in charge of emotional regulation and stress response (Benton, 2008; Georgieff, 2007).

Also in support of Manseau’s framework (2014), we observed that the effect of family financial stress on psychological distress was moderated by the participants’ race. The positive association observed between family financial problems and psychological issues among Puerto Rican adolescents who identified as a racial minority is also supported by previous studies with Puerto Rican adult samples (e.g., Capielo Rosario et al., 2021). Although it is important to recognize that financial stress is both a cause and a consequence of mental health problems in childhood and adolescence (Knifton & Inglis, 2020), the lack of an association between family financial stress and psychological distress among White Puerto Rican adolescents could suggest that financial hardship at the family level in combination with longstanding unequal access to resources documented among BIPOC Latinxs may further erode resources that the family may have to deal with life stressors, and thus mental health issues follow (Borrell, 2005). This study represents a needed expansion of the extant literature on mental health disparities among Puerto Rican racial minorities because most of the available research either focuses on Puerto Rican adults or does not consider the role race may play in the mental health of Puerto Rican adolescents.

Although family violence was positively correlated with psychological distress, family violence did not explain enough variability in psychological distress, suggesting that in the current sample, food insecurity and family financial stress (among BIPOC Puerto Rican adolescents) were more relevant to the mental health of Puerto Rican adolescents. Additionally, while boys and girls in our sample initially differed in their psychological distress scores, this difference was no longer significant in the presence of other indicators of mental health. Consistent with Delgado et al. (2013), which examined the role of gender in the association between family financial stress and psychological distress, gender did not influence this association in our study. However, it is important to note our sample’s age (13–17) is representative of adolescents in middle and late adolescence and that research suggests that perceptions of stress significantly decrease during these stages of adolescence (Seiffge-Krenke et al., 2009). Hence, our results may look different had we included more participants in the stage of early adolescence (10–13 year olds).

Implications for Practice and Advocacy

Although the present study was unable to examine how community-level economic deprivation and violence might have affected Puerto Rican adolescents during the pandemic, it is important to contextualize study findings within the context Puerto Rican adolescents and their families experience in the U.S (Friedline et al., 2020). That is, the disproportionate family and individual hardships Puerto Rican adolescents and families may have experienced during the pandemic are the result of a century’s worth of policies that have engendered intergenerational poverty and racialized segregation among Puerto Rican communities in the U.S. (Capielo Rosario et al., 2023). For example, The Racialized Place Inequality framework by Burgos et al. (2017) shows that physical and mental health disparities among Puerto Rican individuals in the U.S. can result from macro (e.g., country, state) and meso (e.g., community, neighborhood) factors such as poverty and violence. Therefore, we focus on the implications of individual-level interventions, and advocacy and policy interventions.

Because family financial stress was associated with psychological distress among BIPOC Puerto Rican adolescents, it is critical to integrate issues related to financial hardship into individual and family therapeutic work with this community. For example, clinicians should receive training on how to assess socioeconomic status in clinical practice. Practitioners and practitioners-in-training should be encouraged to facilitate an in-depth assessment that can help provide an understanding of the family’s financial situation and their experiences with financial hardship, such as asking the client’s family about their ability to recover from unexpected situations or emergencies (e.g., sudden job loss; Kim & Cardemil, 2012). Practitioners and practitioners-in-training should also formulate case conceptualizations that take into account the client’s household financial situation and experiences with financial hardship and how financial stress can help explain clinical concerns. Moreover, clinicians are encouraged to explore how financial hardship may be related to race-based discrimination and how this may rob BIPOC Puerto Rican families and adolescents of the resources necessary to deal with or recover from financial hardship, thus increasing the risk for psychological distress. Additionally, it is critical to integrate issues related to food insecurity into individual and family therapeutic work. For example, clinicians should receive training on how to assess issues related to nutrition in clinical practice. The integration of USDA food security modules like the assessment of food insecurity used in this study could help assess food insecurity among adolescent clients as well as other family members in the same household. Moreover, given prior research on the association between negative mood, food insecurity, worry about parents/caregivers’ ability to eat healthy foods, anger and embarrassment about the family’s situation, and strained family relationships (Leung et al., 2020), assessing psychological distress stress associated with food insecurity for Puerto Rican adolescents is critical.

Effective psychological interventions with Puerto Rican adolescents also necessitate going beyond one-on-one interventions to help clients experiencing stress related to economic hardship and food insecurity. Specifically, therapeutic work ought to incorporate interventions and services that help clients’ families access financial (e.g., assisting families to apply for TANF funds) and nutrition resources (e.g., assisting families to apply for SNPA benefits). For example, a review by De Marchis et al. (2019) of food insecurity interventions in healthcare settings showed that the provision of food vouchers effectively increased the consumption of vegetables and fruits among participants with food insecurity. Interventions that provided food to food-insecure participants saw significant decreases in food insecurity (De Marchis et al., 2019).

Finally, our findings also underline the importance of advocacy efforts that can help build and expand infrastructure support for Puerto Rican adolescents and families. First, it is critical for clinicians working with BIPOC Puerto Rican adolescents who may be experiencing psychological problems and financial hardship related to race-based discrimination to take a therapeutic stance that integrates anti-racist individual interventions (e.g., assessing the role racism plays in the lives of BIPOC Puerto Rican adolescents) with actions that confront systemic racism (e.g., advocate for anti-racist and anti-poverty policies). The significant association between food insecurity and psychological distress among Puerto Rican adolescents warrants an increase in funds and programs that can support healthy eating. Aligned with values of advocacy within the counseling and psychology profession (Ratts et al., 2016), practitioners should advocate for increased support for Puerto Rican adolescents and families through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). This program provides increased availability of fresh fruits and vegetables that can be purchased, and an expansion of the list of foods (including fresh produce) that can be purchased with SNAP benefits could also greatly benefit this community. Increases in SNAP benefits can lead to significant decreases in food insecurity and psychological distress (Myers, 2020). It is also imperative to establish healthy eating initiatives in places easily accessible to children and adolescents such as schools. Although school-based prevention programs such as Backpack Buddies and Food for Kids provide healthy and nutritious balanced meals (including snacks) to children to take home for the weekend during the school year (Byker & Smith, 2015; Rodgers & Milewska, 2007), we suggest that schools in partnership with state and federal agencies should establish the provision of dinner boxes programs to help children and adolescents supplement potentially missed meals throughout the day during the school year and to promote the provision of lunch and dinner boxes program (including weekends) during the summer when school is not in session to potentially complement the lack of nutritious foods at home. Mental health practitioners must also take an active role in advocating for policies that can help end or ameliorate financial hardship among racial minority Puerto Rican adolescents. For example, a 2019 report by The Academies of Science, Engineering, and Medicine (2019) lays out different policy changes that can help significantly reduce childhood poverty in the U.S. According to this report, expansions of the Child and Dependent Care Tax Credit and the Earned Income Tax Credit can help significantly reduce poverty and financial hardship among U.S. households. Other programs like modifying the minimum wage and housing vouchers should also be advanced.

Limitations and Future Directions

The study findings should be interpreted in light of some limitations. First, while our results offer important information about important correlates of mental health among Puerto Rican adolescents during the pandemic, we are unable to provide conclusions about causation. Therefore, a longitudinal examination of how family and individual determinants of health persisted throughout later waves of the pandemic and how they continue to affect the mental health of Puerto Rican adolescents should follow. It is important to note that our findings should not be generalized to Puerto Rican adolescents living in Puerto Rico. Follow-up studies could replicate our study using a Spanish-speaking Puerto Rican adolescent sample. It is also important to note that we did not consider how social processes such as discrimination, which are related to the group’s racial heterogeneity, may also influence the psychological wellbeing of Puerto Rican adolescents. Studies have shown that the physical and psychological health of Puerto Ricans is affected by racial and ethnic discrimination (Capielo Rosario et al., 2021). Researchers have also documented that discrimination experienced by AfroLatinxs (Masked) is associated with higher levels of pandemic psychological distress and increased alcohol use. Accordingly, future studies should also consider how factors like racial and ethnic discrimination could have further exacerbated psychological distress among Puerto Rican adolescents during the COVID-19 pandemic and impede efforts to mitigate the impact of the pandemic on their mental health. Additionally, we did not assess Puerto Rican parents’ reports of household food security (or the lack thereof) in our study. Given that previous dyadic studies have shown that 51% of Latinx households have “discordant” reports of household food security wherein the parent and the adolescent living in the same household were unaware of each other’s food insecurity realities (Carlos Chavez et al., 2017), future studies need to include dyadic data sets that examine the concordance or discordance reports of household food security among Latinx adolescent and their respective effects on Latinxs’ mental health. Lastly, although we examined the role of financial stress, we did not gather data on the sample’s socioeconomic status. Follow-up studies should consider how socioeconomic status may serve a protective or exacerbating role in the associations between family financial stress, food insecurity, and psychological distress.

Conclusion

The present study provides important insights into the correlates of mental health among Puerto Rican adolescents who were living in the U.S. during the third wave of the COVID-19 pandemic. Findings indicated that food insecurity was positively and significantly associated with psychological distress in our sample. Additionally, we observed that compared to White Puerto Rican adolescents, family financial stress was significantly associated with psychological distress among BIPOC Puerto Rican adolescents. This study contributes to a limited body of work that addresses the mental health needs of Puerto Rican adolescents living in the U.S.

Acknowledgments

We acknowledge the support of NLPA and organizational partners in The Alliance of National Psychological Associations for Racial and Ethnic Equity.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was funded by a research grant from the Ford Foundation, JPB Foundation, WK Kellogg Foundation, National Urban League, California Endowment, Weingart Foundation, and the California Wellness Foundation. This paper is part of a larger study supported by the National Urban League.

Notes

¹ The term Latinx was used in this manuscript to be inclusive of all forms of gender and racial identity.

This article is part of the special issue “Understanding the Impact of the COVID-19 Pandemic on the Mental Health of Latinx Children, Youth, and Families: Clinical Challenges and Opportunities” edited by José M. Causadias and Enrique W. Neblett, Jr.