Community-Based Organizations in Public Housing Resident Recovery in Puerto Rico

Publication Date: 2022

Executive Summary

Overview

Community-based organizations (CBOs) are critical institutions in the post-disaster recovery process, especially in helping marginalized populations to recover. They provide direct service and grassroots advocacy, enabling socially vulnerable populations to return to normalcy. However, limited capacity—including limited funding and staffing—affects the services they can offer. To fill their own service gaps, CBOs engage with other stakeholders. This situation can be complicated in concurrent disasters, impacting both public housing residents and CBO capacity and services. Using the case of the 2020 Southwest Earthquake Sequence and COVID-19 pandemic in Ponce, Puerto Rico, this study investigated the services and assistance that CBOs provide to public housing residents in disasters. The earthquake sequence resulted in $150 million in total damages in Ponce. As we describe in the report, the earthquakes caused extensive damage to public housing units which resulted in 5,000 residents camping outside their homes for months. The earthquakes added to the unsettling elements generated by the longstanding economic issues on the island and the destruction caused by Hurricane Maria in 2017.

Research Questions

This study investigated the impact of concurrent disasters on public housing residents in Ponce and the actions that have been taken to promote the recovery of public housing residents. We studied the types of health services CBOs provide to public housing residents after disasters and how concurrent disasters, including the earthquake sequence and the pandemic, affect organizational capacity to provide these services. We also examined other institutions, such as government agencies and other nonprofits, that engage in the recovery of public housing residents and the determinants of this engagement. Moreover, we looked for ways of engaging and facilitating CBOs within formal public housing residents’ recovery planning efforts.

Research Design

Using the case of the 2020 Southwest Earthquake Sequence and COVID-19 pandemic in Ponce, Puerto Rico, this study investigated the services and assistance that CBOs provide to public housing residents in disasters. We conducted semi-structured, open-ended interviews with 39 key informants who were housing and health advocates, public housing administrators, civic associations, and other CBOs. The interviews were coded thematically for the analysis.

Findings

Our key informant interviews showed that the residents of public housing units faced mental health issues following the series of earthquakes and the pandemic. The fear of tremors and anxiety caused by the pandemic impacted many residents. Some residents with superficial damages refused to return to their units after the earthquake.

Public housing administrative offices, CBOs, private entities, and governmental organizations worked together to help the residents and their staff recover from these concurrent disasters. This collaboration focused on overcoming the anxiety and stresses experienced by residents. We also found that organizations formed these alliances to address the needs of the residents. In addition, alliance partner organizations including public housing administrative offices, CBOs, and governmental partners considered the strengths and types of services that these entities provided for their clients to fill their gaps.

Public Health Implications

This study helps guide mitigation, preparedness, response, and recovery strategies that can promote population health in future disasters. It Identifies critical services and best practices for ensuring at-risk populations are integrated into community recovery planning efforts. Findings from this study can help healthcare providers and public housing administrators better engage with CBOs in providing recovery and health services to at-risk public housing residents, specifically in the face of concurrent disasters. The study showed (a) the diversity of institutions engaged in post-disaster public health recovery planning for public housing residents and (b) the need to train the organizations’ staff to better prepare for similar emergencies and provide services during concurrent disasters. These findings also call for more detailed planning in which public health agencies, healthcare providers, and policymakers involve CBOs in recovery efforts and thereby improve public health outcomes of disaster-affected public housing residents. For example, they could map all CBOs in their local jurisdiction, encourage networking between CBOs and community members, train CBOs to provide health care or coordinate with health agencies after a disaster and help build pre-and post-disaster recovery capacity by educating CBOs on disaster recovery resources, including those that can reduce workforce stress.

Introduction

Public housing residents in the United States are often low income, racial minorities, seniors, and people with chronic stress and disabilities that depend on governmental resources. These residents often struggle to access resources even in non-disaster contexts, and disasters only put extra pressure on them to find resources to meet their recovery needs. The recovery of public housing residents and their access to essential socioeconomic and health services is a necessary part of the post-disaster recovery process of public housing. However, research shows that public housing and its associated services are some of the slowest aspects of community recovery, which only further marginalizes these at-risk populations. To better serve these populations requires a nuanced understanding of the various institutions involved in their recovery and ways to engage these institutions in the formal recovery processes.

Community-based organizations (CBOs) are critical institutions in this process. They play a significant role in helping marginalized populations to recover, especially when post-disaster governmental assistance is delayed. They do this through direct service provision, grassroots advocacy, and representation of community interests in larger decision forums. CBO operations are, however, limited by their capacity to provide such services and engage with other stakeholders. This situation is even further complicated in concurrent disasters, which may compound a CBO’s organizational capacity.

Using the case of the 2020 Southwest Earthquake Sequence and COVID-19 pandemic in Ponce, Puerto Rico, this study investigated (a) the services and assistance that CBOs provide to public housing residents in the event of disasters, (b) the challenges and opportunities of engaging with these critical recovery agents through formal public health and recovery efforts and, (c) the extent to which concurrent disasters complicate these efforts. The study employs a qualitative approach, using key informant interviews with CBOs serving public housing residents, housing and health advocates, and public housing and public health administrators currently involved in post-earthquake and pandemic response and recovery in Ponce, Puerto Rico.

Literature Review

Public Housing Residents

Despite the benefits public housing provides in terms of access to social support, employment, and health services for poor populations (Fertig & Reingold, 2007¹), it has also been shown to affect the community negatively. Public housing can be an unsafe and unhealthy environment in which to live; however, the subsidized rent may free up resources for nutritious food and health care. On the other hand, public housing developments are often located in distressed neighborhoods with a high concentration of poverty and natural hazards risk (Carter et al., 1998²). This combination of increasing urbanization, social inequities, and higher disaster risk has made public housing residents more susceptible to adverse impacts of disasters (Vlahov & Galea, 2002³; Cutter et al., 2003⁴; Van Zandt et al., 2012⁵). This impact is compounded by the effect of other health risks public housing residents already face. In addition to typically being older, low-income, and racial and ethnic minorities, public housing residents are more likely to have chronic health conditions, chronic stress, disabilities, and limited access to health resources (Baum et al., 1999⁶; Gallo & Matthew, 2003⁷; U.S. Department of Housing and Urban Development [HUD], 2017⁸; Hernández et al., 2018⁹). This puts public housing residents at very high health risk in general, a risk that is compounded by the loss of housing after disasters.

The Housing Act of 1937 provides publicly funded houses (termed “public housing”) to households that cannot afford market-based rent (Fertig & Reingold, 2007). Public housing programs refer to state-led programmatic actions that provide housing for low-income families, older adults, and persons with disabilities at a subsidized rent of no more than 30% of a household income (HUD, 2017). While the program mainly deals with housing specifically, it is often accompanied by case management services that aim to help families establish the socioeconomic and health support required to maintain their well-being (HUD, 2017). The Council of Large Public Housing Authorities, for example, recognizes the importance of partnering with public housing agencies and governmental and nonprofit public health providers (Council of Large Public Housing Authorities [CLPHA], 2018¹⁰).

While public housing agencies commonly provide post-disaster shelter and affiliated case management services (such as reestablishing healthcare access), three issues complicate this. First, public housing authorities appear to be ill-prepared, underfunded, and understaffed to provide these services in the short- and long-term (Khajehei & Chandrasekhar, 2021¹¹). Second, providing such services in the face of concurrent disasters (i.e., two major catastrophes co-occurring) is tricky when a typical response to one of the disasters directly conflicts with the required response to another. For example, an earthquake response involves placing affected populations in centralized locations (Federal Emergency Management Agency [FEMA], 2015¹²), while pandemics require adequate social distancing and quarantining (Holloway et al., 2014¹³). On the other hand, rooflessness is not an option since exposure to various weather and infectious conditions can negatively affect health and prolong recovery from preexisting health issues (Shaw, 2004¹⁴). The problem is further compounded by the fact that response planning to natural hazards is typically led by emergency management agencies. In contrast, response planning for pandemics is led by public health agencies, which raises questions about coordination during concurrent but significant disaster events. In addition, the National Response Framework, which lays out such coordination structures, does not mention how concurrent events of such magnitude can be managed.

This study aims to fill these gaps by increasing the focus on public housing residents by public health planners and policymakers in the aftermath of disasters. Especially the study is interested in concurrent disasters, how public housing recovery and post-disaster public health planning are coordinated on the ground and the various institutions involved in these processes.

Community-Based Organizations as Mediators of Public Housing Residents’ Post-Disaster Health Outcomes

While it might be assumed that recovery is a governmental action and that governments are better positioned to act for the public good, research shows that governmental arrangements cannot always meet the dynamic post-disaster conditions of recovery (Olshansky et al., 2012¹⁵). Instead, CBOs—including community-, faith-, and nonprofit organizations—have emerged as critical actors in addressing community needs after disasters (Mlcek & Ismay, 2015¹⁶). In contrast to the federal technocratic post-disaster assistance, CBOs showed more flexibility and sensitivity to the communities’ needs because of their local knowledge and capabilities. This flexibility manifests in two forms: either in the form of expansion of regular disaster services in new locations or through extension, that is, increasing types of services but keeping existing organizational structures (Dynes, 1970¹⁷; Phillips, 2014¹⁸; Donnelly-Cox et al., 2020¹⁹). Such organizational flexibility allows CBOs to help a more diverse set of community cohorts, especially marginalized ones like public housing residents with need-based assistance, regardless of their original mission (Bolin & Stanford, 1998²⁰; Rivera & Nickels, 2014²¹; Stys, 2011²²). In addition to this, CBOs have been shown to act as a mediator and engage marginalized communities like public housing residents in recovery activities and, through this, improve the quality of life for these residents and build grassroots resiliency (Drennan & Morrissey, 2019²³; Tierney, 2013²⁴; Saadian et al., 2020²⁵).

However, the literature on the CBOs role in the post-disaster recovery of public housing residents is mixed and highlights, to some extent, the importance of differentiating between those with greater and lesser local connections. For example, research in New Orleans after Hurricane Katrina has shown that smaller, local-level CBOs were involved in advocating for the public housing recovery. CBOs also provided essential social services to public housing residents, while larger nonprofits were, directly and indirectly demolishing public housing units (Graham, 2012²⁶; Arena, 2013²⁷). This highlights the importance of public health planners and policymakers ensuring that the nonprofits they engage with understand and closely work with the community residents they wish to help, such as public housing residents.

One way to distinguish this is to focus on CBOs with more significant ties to the localities in which they operate and have a better sense of local community interests and aspirations (Boraine, 2014²⁸). CBOs come in various forms, such as housing organizations, sporting groups, or faith-based organizations, and have been long-established as essential stakeholders in community development, public health efforts, and disaster recovery at the grassroots level (Boraine, 2014; Wilson, et al., 2012²⁹; Drennan & Morrissey, 2019). In Puerto Rico, research shows that the organizational capacity of small nonprofits and CBOs in Puerto Rico has decreased in the face of recent concurrent disasters (García & Chandrasekhar, 2020³⁰; Chandrasekhar, et al., 2021³¹). As a result, CBOs have increased social entrepreneurship efforts to obtain public, private, market, and philanthropic resources to fund the projects and maintain financial sustainability (Borges-Mendez, 2020³²). Importantly, research in Puerto Rico also shows that more CBOs are involved in public health activities in the face of concurrent disasters than just the “health sector” organizations. This indicates the need for public health agencies to broaden their efforts to engage with more CBOs (García, et al., 2021³³).

This research suggests that CBOs are essential intermediaries between public health agencies and public housing residents after concurrent disasters and that there is a need to engage CBOs in formal public health efforts. Yet, while both the National Health Security Strategy and the National Disaster Recovery Framework emphasize the importance of CBOs’ role in disasters, they do not offer any framework or guidance on how to facilitate this exactly or in the face of such decreasing capacity (FEMA, 2016³⁴; U.S. Department of Health and Human Services, 2009³⁵). This study addresses this gap by examining how CBOs that serve public housing residents are engaged in public health and disaster planning efforts after concurrent disasters. We used the case of post-disaster recovery in Ponce, Puerto Rico, after the concurrent 2020 Southwest Earthquakes Sequence and the COVID-19 pandemic. We chose the Ponce earthquakes since they added to the unsettling elements caused by the longstanding economic issues on the island and the destruction caused by Hurricane Maria in 2017. The shakes left thousands of people in temporary shelters, vehicles, and tents for months. In addition, the pandemic resulted in another setback. Roofless families worried about the health consequences of the pandemic and faced the dilemma of being told to stay at home because COVID-19 and leave the house because of the earthquake (Corujo et al., 2020³⁶).

Moreover, Puerto Rico's governance has been in jeopardy for a while, and CBOs play a significant role in development activity, including public health and recovery. Therefore, what CBOs do on the mainland is only a fraction of what they do on the island. This makes this study relevant to places where governmental capacity is generally weak (e.g., communities lacking trust in government, colonies of the south, informal communities, refugee areas, etc.). Study findings will identify pathways to involve the civic institutions within public health planning efforts and, in turn, improve health and recovery outcomes for public housing residents.

Research Design

Research Questions

This study identified ways in which public health planners and policymakers can better engage and collaborate with CBOs that provide housing and health services to public housing residents after concurrent disasters, including a series of earthquakes and the pandemic. The specific research questions are:

• What was the impact of concurrent disasters on public housing in Ponce? What actions were taken to promote the recovery of public housing residents?
• What health and housing services did CBOs provide to public housing residents after disasters? How do the impact of earthquakes and the pandemic (such as impacts on operation, employee/volunteer morale, and funding) affect the capacity of organizations to provide these services?
• To what extent do CBOs engage with other institutions, such as government agencies and other CBOs, during their recovery work? To what extent does the compounded impact of earthquakes and the pandemic affect this level of engagement?
• What are the challenges and opportunities of engaging CBOs within formal public housing recovery planning efforts? How can this engagement be more effectively facilitated?

Study Site Description

Puerto Rico Public Housing Administration is one of the largest public housing agencies in the country, with 53,922 units around the island (CLPHA, 2020³⁷). Located in the southwest of Puerto Rico, Ponce has 5,305 public housing units. As depicted in Figure 1, an earthquake series struck the city from December 2019 to January 2020. The largest and the most damaging earthquake of this sequence was on January 7, 2020, with 6.4 magnitudes, according to the U.S. Geological Survey (2020)³⁸. The earthquake sequence resulted in $150 million in total damages in Ponce. In addition, the earthquake caused extensive damage to residential units and led to 5,000 residents camping outside their homes for months (Hauck, 2020³⁹)

Figure 1. Regions Affected by the 2020 Earthquake Series in Puerto Rico

While the island’s housing stock was shrinking due to the consecutive disasters, the shakes left thousands of people in temporary shelters, vehicles, and tents for months. Public housing residents tend to be low-income families, older adults, persons with disabilities, persons who experienced domestic violence, and persons with chronic stresses. They tend to be among one of the most socially vulnerable cohorts of the community and struggle with housing challenges and maintaining their health during the concurrent disasters in Puerto Rico.

With the help of collaboration, commitment, and community-driven efforts in Puerto Rico, homeless service providers, philanthropic activists, and other providers with the support of nonprofits such as PATH, Continuum of Care (CoC), and the University of Puerto Rico provided shelter, psychological aid, and healthcare services during the pandemic to the displaced population (HUD, 2020⁴⁰). Some CBOs, including study partner Ponce Neighborhood Housing Services (hereafter, “Ponce NHS”), were funded through the Social Interest Housing Programs to help displaced people. They also helped them with psychological aid and healthcare services during the pandemic (HUD, 2020). The Puerto Rico Disaster Recovery Action Plan also provided grant funds under the Social Interest Housing Program to nonprofit and non-governmental organizations, including Ponce NHS, to serve highly vulnerable populations such as public housing residents to address their needs (Government of Puerto Rico Department of Housing, 2021⁴¹).

Since Hurricane Maria, CBOs have been actively involved in disaster response and recovery on the island because of their extensive contacts and networks. For example, Ponce NHS was one of the first responders to the 2020 Southwest Earthquake Sequence, providing emergency supplies and health services to hundreds of communities and thousands of families. Study partner Ponce NHS reports that such actions have significantly extended their outreach to populations such as public housing residents and have also created new partnerships with healthcare providers. For example, Ponce NHS has partnerships with more than nine healthcare providers, medical clinics, community pharmacies, mental health clinics, and other public health collaborators such as MedCentro, Ponce Health Science University, Walgreens, Violence Prevention Association, Administración de Servicios de Salud Mental y Contra la Adicción (ASSMCA), Triple S, Naturopatía sin Fronteras, National Guard, among others. These collaborators now provide basic health, medical, and mental health services through health and services fairs, ambulatory health clinics, mobile clinics, health education workshops, and vaccination campaigns and rallies, among other activities.

Methods

This study used a qualitative approach to investigate the institutions involved in public housing resident recovery during earthquakes and the pandemic and their role in improving public housing residents’ health and recovery outcomes as socially vulnerable populations. We conducted key informant interviews with public health and housing institutions involved in public housing resident recovery.

Sampling and Participants

We conducted in-depth interviews with 39 housing and health advocates, healthcare providers, officials who work in public housing authorities, public health administrators, Ponce NHS, local church groups, civic associations, and other CBOs involved in providing services to the public housing recovery residents. These interviewees were purposively identified with the help of Ponce NHS, as well as throughout the interview process using snowball sampling. Participation in this study was voluntary, and the interviews were conducted with the full informed consent of participants.

Procedure

We explored the organizations and institutions during December 2021 and January 2022 to identify key informants for the interviews. Ponce NHS staff conducted semi-structured, open-ended interviews with 39 key informants. The interviewees were recruited via phone calls and emails, and Ponce NHS provided seven interviewees with gift cards at their discretion. Interview meetings were set through Zoom video calls, in-person, and via phone. In the recruiting emails, the participants were provided with a consent form in which the project goals were discussed. The voluntary interviews were between 10 and 45 minutes long and audio-recorded.

The interviews were focused on the organization's characteristics; their role in public housing recovery and/or public health planning; helping public housing residents in general and in the aftermath of disasters; the challenges of assisting public housing residents; resources their organization has to help public housing residents with housing and/or health needs; engagement with other organizations (both government and CBOs), and determinants of this engagement; the challenges of engaging with other CBOs; the impact of concurrent disasters on their assistance quality; the challenges of helping public housing residents during their housing recovery; and ways to better prepare for assisting public housing residents in future disasters.

Interviews were conducted in Spanish, audio-recorded, and transcribed and translated to English. Two professional companies translated the Spanish transcriptions. All transcriptions were uploaded into NVivo 12 pro for qualitative analyses. The English transcriptions were coded thematically for the analysis. We used open coding and wrote analytical memos to get nuanced insights and understanding of the role of CBOs in the recovery of public housing residents. This step was done between February and April 2022.

Ethical Considerations, Researcher Positionality, Reciprocity, and Other Considerations

This study was approved as non-human subjects research based on federal regulations by the University of Utah’s Institutional Review Board on December 9, 2021, before the start of the project. However, all interviews were conducted with informed consent, and participation was voluntary. All participant identities were kept confidential during analysis and reporting.

Results

We read through all transcriptions initially and then began the coding process. Coding allowed for nuanced insights and an understanding of our research questions. We used open coding techniques in the first coding round, coding all transcripts and writing analytical memos to draw out themes. For this, we developed categories and subcategories for coding moving forward. Codes were categorized into five significant groups based on the research questions, including the impact of concurrent disasters on public housing residents; services offered by CBOs during concurrent disasters; CBO engagement with institutions; the impact of earthquakes and the pandemic on the capacity of organizations; and the challenges of and opportunities for engaging CBOs in recovery. This set of codes examined connections and patterns in the data and allowed us to understand the role of CBOs in public housing residents’ recovery.

Impact of Concurrent Disasters on Public Housing Residents

Our key informant interviews showed that in addition to typically being older, low-income, and victims of domestic violence, public housing residents have chronic health conditions, chronic stress, disabilities, and limited access to health resources. Our interviews also found that the residents of public housing units faced mental health impacts during the concurrent disasters. In addition, the fear of tremors and anxiety caused by the pandemic impacted many residents. These residents refused to return to their units for a long time in the aftermath of the earthquake, while the damages to their units were superficial.

Services Offered by Community-Based Organizations During Concurrent Disasters

The Mental Health Program from the Health Department and ASSMCA in the area and some external resources from psychologists and clinical social workers from various CBOs and residential and administrative offices helped residents obtain mental health services. Specifically, they helped the residents by hosting workshops on overcoming stress or referring them to psychologists. For example, one of the interviewees stated that:

Because after the earthquakes, the pandemic, and everything, it was like it all fell on top of us, to put it that way. With us being a resource for the residents, it was even more difficult for us. We would make referrals, ‘Look, I wanna refer you to a psychologist.’ We set it up for the resident to have a little more in-depth and consistent care. Even when we were in the middle of the pandemic, when all this happened, they gave us a workshop on how to deal with our emotions. It was provided by the coordinators, and it was excellent.

The group workshops focused on managing emotions and group therapy. There were also public housing, residential, and administrative offices that gave individual and family therapy. In addition, they had support from the School of Behavioral Health at Catholic University, which came to provide individual, family, and group therapy. If the workshops didn’t address resident needs, the public housing residence administrators referred residents to long-term services. For example, one of the office administrators stated that they referred them to the “School of Medicine or Metro Pavia Behavioral Health which are close to their residential complexes.”

It is typically believed that public housing administrators only provide their residents with a roof over their heads. However, the administrative offices in Ponce, in collaboration with other CBOs, provided this cohort of communities with various services such as recreational, educational, and employment areas to support residents in their educational, personal, and professional aspects of life. For example, one of the social workers said:

Well, besides me, there’s the recreational area, which is very important. Also, recreation for children and older adults to be able to leave that social area. The social worker can help fill some of the deficiencies and issues of a sick person. Sometimes, our elderly are alone. They can contact their family. ‘Look, this elderly man is alone. He needs medicine. He needs more help.’ All these services can be provided to the residents. It all runs together because everything has to go hand in hand. The educational or economic, plus my social area. Also, the recreational aspect by the leaders.

Earthquakes and the Pandemic Affect the Capacity of Organizations

The pandemic and the earthquakes impacted the services provided by CBOs. Some of the interviewees expressed that their organization was severely impacted. For example, some of their facilities were damaged by the earthquakes, and employees were not allowed to return even two years later. Moreover, most of their services were limited by COVID-19 protocols and were no longer offered in person.

These new policies made it hard for both service providers and public housing residents. In-person services were changed to phone, video calls, social media, or other digital platforms. However, not all residents could attend these virtual meetings and workshops. In addition, attending these workshops was hard for those with either limited access to electric devices or less knowledge of using technologies, such as older adults, a considerable population among the residents of public housing units. For example, one of the social workers at one of the CBOs stated that:

There are a lot of elderly people who don’t have that ability or knowledge, and it was complicated. When they closed during the pandemic, we gave services over the phone. That was the way that we were able to serve the residents, but it was very difficult because not everyone was able to use a computer and get connected to receive a workshop or orientation. We did the work, but it was very difficult.

While some service providers reported difficulties with these new approaches, some interviewees believed new methods were more helpful. For example, one of the key informants said:

I think that the staff now, well, on the one hand, um of the networks and the technology that we are using has helped us to impact more people, perhaps to reach a little further and impact families all over the island. But on the other hand, it has been a process of transition and adaptation.

Community-Based Organizations Engaging With Other Institutions and Public Housing Administrative Offices

The administrative offices in Ponce, with their partner CBOs, established alliances and collaborative agreements with municipalities, other CBOs, governmental agencies, and private entities during concurrent disasters to assist families better. They believed that these collaborations with other institutions and organizations made them stronger. The partnerships were determined based on the needs of the residents and organizations. CBOs and their partners provided the community with workshops as well as working in the area. The partnered public and private organizations helped CBOs and public housing administrators to better provide services to the community and meet their needs including hygiene, health, food, clothes, transportation, emotional, and educational needs. For example, they helped CBOs to provide the public housing residents with masks and COVID-19 tests, medications, extra meals, as well as outdoor group counselling, and electronic devices for their education workshops. These collaborations and alliances provided the residents with more resources and helped the organizations to reach out to a broader community. One of the interviewees revealed that “establishing alliances has helped us a lot to reach other communities or expand our service area, actually.”

The Challenges and Opportunities of Engaging Community-Based Organizations in Recovery

The interviewees believed that providing services to the community was challenging during concurrent disasters since the requests were increased, while the number of volunteers and employees, and their in-person services were limited. People needed more emotional counselling and services because of the fear of tremors and the pandemic, while the employees and volunteers, themselves were affected by the disasters. For example, the employees had to help their family members, or they could not go to the affected regions to help the community because of the road collapse or structures failure. In addition, based on the new protocols, the number of people in a roofed place were limited and thereby providing services were slower. The interviewees also mentioned that their alliances and cooperation with other organizations needed to be managed and thereby reevaluate contingency plans. This procedure will help them to have better work plan in the future and cover the needs of community with realistic agreements among CBOs. Considering these challenges and opportunities of virtual and multi-organizational assistance, the interviewees believed that it would be helpful for the CBOs to be trained by the municipalities or governmental organizations annually on any changes and updates to any protocols. This would help them be better prepared for future possible disasters. For example, one of the interviewees believed that:

Well, uh, it would be pertinent, uh, the type of training that helps us in how to act when an emergency occurs, an earthquake, floods, this is if there is a fire, uh, crisis management, because if all the people who are here working, what are we working here, we have the preparation by profession. But if we understand that it is pertinent that agencies come to train us in all these types of issues that arise on a recurring basis and all that need arises on a recurring basis, so basically that is what I understand that, that we would need, organizations that approach us and they can give us that training in that type of subject.

Conclusions

Due to the various challenges experienced by the Puerto Rican government over the last several years, CBOs play a significant role in both public health and recovery. Our findings show that public housing residential and administrative offices, CBOs, private entities, and governmental organizations are working together in Ponce to help public housing residents recover from concurrent disasters. Together they have provided public housing residents—a population that typically experiences high health risks and is more disadvantaged in terms of recovery resources—with various services to help them return to normalcy and improve their health. The focus on collaboration allowed these organizations to enhance their reach among public housing residents. Agreements and alliances facilitate these collaborations and ensure they are based on resident needs.

These organizations offer various services to assist public housing residents in overcoming the psychological impacts of concurrent disasters and improving the individual and social aspects of their lives. These services are offered in workshops and referrals to the related service providers. The pandemic impacted these collaborations and services and made both organizations and residents adapt to the new conditions and protocols. This makes this study relevant to places where governmental capacity is generally weak (e.g., communities lacking trust in government, colonies of the south, informal communities, refugee areas, etc.). Our findings call for better pre-disaster planning to engage various CBOs and the public and private sectors in recovery efforts among public housing residents.

Public Health Implications

This study helps guide mitigation, preparedness, response, and recovery strategies that can promote population health in future disasters. It Identifies critical services and best practices for ensuring at-risk populations are integrated into community recovery planning efforts. CBOs are very important to public health because they not only provide direct health services but focus comprehensively on the Social Determinants of Health framework (Economic Stability, Food Insecurity, Social Context, Environment, Education, and Healthcare Systems). Promoting formal alliances between CBOs and healthcare providers, public housing administrators, private entities, and governmental organizations can increase the resources available to public housing residents for recovery, including mental health services.

As demonstrated by our research, CBO engagement with various formal recovery initiatives in Ponce is an effective way to address the needs of public housing residents during concurrent disasters. We identified specific resources that could improve this engagement, such as annual public health agency trainings to prepare CBOs for future disasters. In addition to training, public health agencies could facilitate CBO engagement in recovery efforts. For example, they could identify and map all CBOs in their local jurisdiction, encourage networking between CBOs and with community members, train CBOs to provide health care or coordinate with health agencies after a disaster, and help build pre-and post-disaster recovery capacity by educating CBOs on disaster recovery resources, including those that can reduce workforce stress. This, in turn, could improve the impact of post-disaster public health initiatives on public housing residents.

Limitations and Strengths

This study has three main strengths. First, we used qualitative inquiry methods, which allowed us to gather nuanced perspectives on the importance of the role of various organizations in the recovery of public housing residents and their health outcomes. Second, the exceptional context—a community that experienced multiple disasters, from pandemics to earthquakes and hurricanes—has given us insight into institutional learning stemming from different disaster types and various organizations involved in the recovery of public housing residents. Third, the key informant interviews were done by one of the CBOs in the community, which provided the interviewees with a context to share their experiences better.

This study also has some limitations. Data collection was challenged by translation from Spanish to English because the principal investigator is not a Spanish speaker. Interviews were also challenging due to the inability of the principal investigator to do the fieldwork and do some parts of the interviews.

Future Research Directions

Future studies will focus on better coordinating recovery efforts of public health and public housing authorities by examining the linkages between various CBOs involved in the recovery of public housing residents in the aftermath of disasters. This focus will help improve partnerships between public health, housing authorities, and CBOs in ways that provide optimal post-disaster health and housing services to these vulnerable populations. This partnership can be formalized in the recovery policies for similar at-risk communities.

References