Table 1.

National Institute of Minority Health and Health Disparities (NIMHD) Research Framework adapted to reflect historic and socio-cultural influences of the Puerto Rican population.

Domains of Influence	Levels of Influence
	Individual	Interpersonal	Community	Societal
Biological	Biological Vulnerability and Mechanisms	Caregiver-Child Interaction Family Microbiome	Community Illness Exposure U.S. Navy presence in Vieques and Culebra Ashes from AES Power Plant Hazardous waste sites Herd Immunity	Sanitation Water quality Immunization 85% in 35 mo in 2014 Pathogen Exposure Dengue, Chikungunya, Zika, Leptospirosis, STI
Behavioral	Health Behaviors Coping Strategies Resilience Religion/Spirituality Communal bonds	Family Functioning Extended family Women heads of household School/Work Functioning	Community Functioning Solidarity Community Councils	Policies and Laws Puerto Rico Oversight, Management, and Economic Stability Act (PROMESA) Law Jones Act Civil Code
Physical/Built Environment	Personal Environment	Household Environment Deficient infrastructure Public housing Closed neighborhoods School/Work Environment School closures Deficient infrastructure	Community Environment Natural resources Social capital Community Resources Tourism Local businesses Local non-governmental organitzations	Societal Structure Almost 50% live in poverty Diaspora in U.S.
Socio-Cultural Environment	Socio-demographics 20% less than 18 years 20% 65 years or more 60% 18–64 years old Limited English English taught as a second language Cultural Identity Boricua/American citizens Response to Discrimination Historical trauma Colonized mindset	Social Networks Extended family Organized Communities Family/Peer Norms Interpersonal Discrimination	Community Norms Local Structural Discrimination	Societal Norms Societal Structural Discrimination Racism Classism Sexism Homophobia/Transphobia
Health Care System	Insurance Coverage Mi Salud program Private insurance Medicare/Medicaid Health Literacy Treatment Preferences Focus on remedial instead of prevention medicine	Patient-Clinical Relationship Medical Decision Making	Availability of Services Migration of physicians Private practices Difficultly receiving referrals Community health centers Safety Net Services Community Health Centers	Quality of Care Health professional shortage Poorly coordinated care Long wait times Health Care Policies Department of Health Law (1912)
Health Outcomes	Individual Health	Family/Organizational Health	Community Health	Population Health