Abstract Community readiness involves the perspective of leadership on the need for changes within the territory, combined with the local capacity to promote them. "Communities That Care" is a prevention system being adapted in Brazil. This study aimed to assess community readiness with 34 community leaders from São Paulo and 36 from Florianópolis. The study employed a quantitative, descriptive, and cross-sectional methodology. Results indicated difficulties in driving change and structural differences between the communities; however, there was cohesion in leaders’ opinions. It was unanimously recognized that drug use is a risk behavior, but that drugs are easily accessible in these communities. There is a perceived urgency to implement preventive programs, although such programs are not well-known. The study concludes that investing in readiness assessment can be crucial to supporting community interventions.

This study examined how cultural stress mediates the relationship between ethnic identity and mental health distress among Puerto Rican parent-youth dyads who migrated to the mainland United States after Hurricane Maria. We used a longitudinal actor-partner interdependence mediation model to test direct and indirect effects between ethnic identity (Wave 1), cultural stress (Wave 2), and mental health (Wave 3). Given our small sample, we used factor scores instead of latent variables to summarize observed constructs, reducing model complexity and conserving statistical power. Factor scores were derived using factor analysis on depressive symptoms, anxiety, and posttraumatic stress disorder to represent the latent mental health construct. These scores served as input in our actor-partner interdependence mediation model. Results showed significant actor effects: Youth ethnic identity predicted their own cultural stress, and cultural stress predicted mental health distress for both youth and parents. Partner effects revealed that youth cultural stress was associated with parents' mental health. Mediation analyses revealed two significant indirect effects: (a) Youth ethnic identity was associated with parent mental health through youth cultural stress, and (b) youth ethnic identity was associated with their own mental health through youth cultural stress. Findings underscore the importance of youth experiences in shaping family mental health outcomes in the context of cultural stress and postdisaster migration.

The rising prevalence of illicit drug use among Romanian youth underscores the need for effective prevention service delivery systems, particularly in European contexts characterized by high social transition, severe resource constraints, and limited prevention service infrastructure. This study explored international expert and local Romanian stakeholder perspectives regarding factors contributing to the contextual adaptation and potential implementation of the Communities That Care (CTC) prevention system in Romania. Through qualitative interviews with experts in CTC (n = 15) and validation of findings with Romanian community stakeholders (n = 9), this study examined potential challenges in implementing CTC in Romania, such as lack of evidence-based interventions, resource scarcity, cultural differences, and resistance to change. Key factors identified by CTC experts as needed for successful implementation include community improved readiness, continuous adaptation, favorable facilitator and champion characteristics, and community engagement. Romanian stakeholder perspectives further suggested that rural communities may offer particularly favorable conditions for CTC implementation. Stakeholders emphasized the need for partnerships that reflect the needs of local groups and for attention to Romanian values (e.g., including strong family ties, religious traditions, and respect for authority), which should be considered alongside broader societal experiences (e.g., migration, funding limitations, and long-standing institutional distrust). By situating Romania within a broader European context, these findings provide valuable insights for stakeholders seeking to adapt and implement CTC in countries new to the prevention science movement and highlight the relevance of the Romanian case for the Balkan region and similar European settings.

Background:Motivational interviewing (MI) is widely used in preventive interventions, yet coding MI techniques and monitoring intervention adherence remain resource-intensive due to the reliance on manual transcription and expert review. Large language models (LLMs) offer a promising approach to automate these tasks, but their agreement with human coders in the context of prevention interventions has not been established. Objective:This study evaluated the agreement between an AI-based coder (OpenAI's GPT 4.1) and trained human coders on two tasks: (1) identification of MI techniques (eg, open questions, affirmations, giving information) at the facilitator-message level and (2) completing a 21-item checklist of implementation adherence for a brief MI-based preventive intervention for adolescent substance use. Methods:Two certified MI facilitators independently coded 72 facilitator messages from 2 standardized Spanish-language Brief Intervention Based on Motivational Interviewing program (Intervención Breve Basada en Entrevista Motivacional [IBEM]) practice sessions with chatbot-simulated adolescent responses. The facilitators classified MI techniques using the OARS (open questions, affirmations, reflections, and summaries) framework and completed a 21-item implementation-adherence checklist. An AI-based coder (OpenAI's GPT-4.1, accessed through the API) classified the same facilitator messages and checklist items using a structured prompt derived from the MI coding manual. MI techniques were compared at the facilitator-message level and implementation adherence at the session level. Intercoder agreement in use of MI techniques and implementation adherence was assessed using Cohen κ, Fleiss κ, and Cochran Q tests. Results:For use of MI techniques, the AI coder demonstrated moderate-to-substantial agreement with human coders across most techniques, including open questions (κ=0.66-0.69), affirmations (κ=0.66-0.77), and giving information (κ=0.91). No statistically significant differences in percentages of MI technique use were observed among the 3 coders, although agreement was the weakest for higher-inference categories such as complex reflections (κ=0.00). For MI implementation adherence, overall agreement was moderate (Fleiss κ=0.487), and pairwise agreement between the AI coder and 1 human coder was substantial (κ=0.67), exceeding the agreement observed between the 2 human coders (κ=0.53). Conclusions:These findings provide support for the feasibility of using LLMs to recognize MI techniques and assess implementation adherence. The results support a human-AI collaborative model in which the AI coder "precodes" facilitator messages and flags sessions for expert review, while human coders retain responsibility for higher-inference judgments and shift their effort from routine coding toward contextual review and coaching feedback. Because the analyses are based on only 2 sessions, these results should be interpreted as early-stage, proof-of-concept evidence rather than a basis for large-scale deployment. Future research should compare different LLMs and evaluate whether AI-assisted coding improves the scalability of routine implementation monitoring.

This study evaluated the psychometric properties of the adapted Spanish version of the Hurricane-Related Traumatic Experiences (HURTE) scale among Puerto Rican adults (N = 312) who relocated to the U.S. mainland after Hurricane Maria. Using Exploratory Factor Analysis (EFA) and Item Response Theory (IRT), the study assessed the scale's reliability, validity, factor structure, and item characteristics. EFA revealed a two-factor structure aligning with the original HURTE scale but with variations in item-factor constellations. Factors reflected the physical impact of the hurricane and emotional/interpersonal impacts of hurricane-related experiences. IRT analyses showed the scale includes items of varying difficulty, allowing for a nuanced assessment of trauma severity. Differential item functioning (DIF) analyses across age and education found no significant DIF, but three items showed DIF by gender. This preliminary validation of the Spanish-language HURTE scale is essential for assessing hurricane-related traumatic experiences among Spanish-speaking adults, particularly in the context of increasing natural disasters. The findings contribute to understanding the scale's psychometric properties, paving the way for future research and applications in disaster-related contexts involving non-English-speaking populations, especially in hurricane-prone regions. The study emphasizes the importance of validating measures tailored to diverse linguistic and cultural groups to improve assessment accuracy after natural disasters.

The present study provides preliminary evidence for validity of the Multidimensional Inventory of Cultural Stress (MICS), a measure of cultural stress developed to expand existing conceptualizations of cultural stress. The participants were 309 Hispanic/Latine adolescents (60.2% female; Mage= 15.30 years). Exploratory structural equation modeling (ESEM) revealed a four-factor solution: exclusionary political climate (i.e., perception of anti-immigrant and xenophobic rhetoric), Spanish criticism (i.e., experiences of being criticized for Spanish proficiency), within-group discrimination (i.e., experiences of being bullied/discriminated against for being too enculturated), and language brokering (i.e., experiences with having to translate for parents). Moreover, whereas exclusionary political climate was positively associated with alcohol use and symptoms of anxiety, Spanish criticism was negatively associated with self-esteem and positively associated with symptoms of depression and anxiety. These findings expand our current conceptualization of cultural stress and provide further guidance regarding how cultural stress impacts adjustment.

Haitians have a high incidence of sickle cell disease. The Comparative Study of Children in Haiti and Miami with Sickle Cell Disease (CSHSCD) assessed clinical and social characteristics of children of Haitian immigrants and African American controls comparing them with Haitian children living in Haiti with the purpose of overcoming differences during follow-up. We hypothesized that at baseline there would be significant differences and that time since migration may correlate with improved access to medical care. Baseline clinical characteristics and parental self-reported barriers to care were compared. Acculturation measured as English proficiency was assessed among Haitian American parents. Two hundred fifty-five children (mean age 38 months) were recruited: 204 Haitians, 32 Haitian Americans and 19 African Americans. African American and Haitian American children with hemoglobin SS were more likely receiving hydroxyurea (p < 0.001) and were less likely to have experienced a vaso-occlusive crisis than children in Haiti (p < 0.001). Being in the United States over 10 years was associated with better English proficiency. Children in Haiti were more anemic, more likely to be malnourished and to lack pneumococcal conjugate vaccinations. Haitian families could not afford treatment. Longer length of stay in the United States was associated with appropriate pneumococcal vaccination, higher parental education, and better English competency. Haitians living in Haiti were at a significant disadvantage in every aspect of care, requiring ongoing assistance with community resources, medications and vaccines. We encourage global partnerships to decrease barriers to care in disadvantaged populations.

OBJECTIVES:This study aimed to examine the relationship between marijuana use and aggression and victimization among Colombian adolescents. We aimed to clarify marijuana's distinct role by comparing different categories of drug use and by considering the order of drug initiation. METHODS:We conducted a secondary analysis of nationally representative cross-sectional data collected from Colombian adolescents in 2016. The original sample included 80,018 students in Grades 7 to 11. Participants were categorized into marijuana-use groups - EXCLUSIVE (marijuana only), INITIAL (marijuana use before other drugs), and SUBSEQUENT (marijuana use following other drugs) - and non-marijuana-use groups - NON-DRUG (no use), ONE-DRUG (one other drug only), and MULTIPLE-DRUG (two or more other drugs).Aggressive behaviors (individual aggression, group aggression, harassment) and victimization were assessed based on self-reported involvement in the past 12 months. Logistic regression models examined associations between marijuana use patterns and these outcomes, controlling for sex, age, parental education, and grade repetition. For the SUBSEQUENT group, the total number of other drugs used was also controlled. RESULTS:Adolescents with no drug use had the lowest rates of all aggressive behaviors and victimization. As drug use increased, so did the prevalence of these outcomes, with MULTIPLE-DRUG users exhibiting the highest levels. Compared to NON-DRUG adolescents, each marijuana-use group (EXCLUSIVE, INITIAL, SUBSEQUENT) showed increased odds of some forms of aggression and victimization. For example, EXCLUSIVE users had higher odds of aggression compared to NON-DRUG users. However, the magnitude of these associations differed when comparing marijuana-use groups against each other and against ONE-DRUG and MULTIPLE-DRUG groups. INITIAL and SUBSEQUENT users often demonstrated greater odds of aggression than EXCLUSIVE users, suggesting that polydrug involvement and the sequence of drug initiation matter. CONCLUSIONS:These findings underscore the importance of moving beyond binary classifications of marijuana use when examining aggression and victimization among adolescents. Marijuana use is associated with an increased risk of aggression and victimization, but other substance use patterns and the temporal order of drug initiation influence this relationship. Policymakers, educators, and clinicians should consider these when designing preventive interventions. Future research should employ longitudinal designs and incorporate additional contextual variables to further clarify the mechanisms linking marijuana use to aggression and victimization.

Since 2015, over seven million Venezuelans have left their home country, with significant numbers resettling in the United States and Colombia. The aim of the present study was to examine the primary motivations for migration among Venezuelans relocating to these two countries, and to assess whether these motivations were associated with their destination choice. Additionally, we explored how migration motivations were linked to mental health outcomes (i.e., symptoms of depression, anxiety, and PTSD symptom count) within this population. We conducted an online survey with 647 Venezuelan participants to assess mental health outcomes and explored their primary reasons for leaving Venezuela through open-ended questions. Responses were analyzed using sequential exploratory content analysis and latent class analysis. Eight thematic categories of reason to migrate were identified, and three distinct latent classes emerged: Political Threats, Economic Insecurity, and Shortages and Street Violence. Reasons to migrate differed significantly between destination countries, with more wealthy individuals relocating to the United States. We also found that PTSD symptom count was significantly different among migrants in the Political Threats class residing in the United States, compared to those in the other two classes. No class differences for anxiety or depressive symptoms were observed. A better understanding of how varying motivations for migration may influence migrants’ destination choices and their mental health can help inform more effective clinical interventions, and guide policymakers in planning and responding to future migration movements.

Employee behaviors that strategically support implementation (i.e., implementation citizenship behavior [ICB]) theoretically promote the adoption and high-fidelity use of evidence-based practices (EBPs). ICB (e.g., helping colleagues overcome implementation barriers) may vary across contexts, including schools where children are most likely to access and receive mental and behavioral health services. Pragmatic measures are needed to advance nascent research on school-based ICB and inform how these behaviors can be used to support successful implementation. The current study expanded the Implementation Citizenship Behavior Scale (ICBS) to create and validate the School Implementation Citizenship Behavior Scale (SICBS) in a sample of elementary school teachers implementing evidence-based prevention programs to support children’s mental and behavioral health. Based on subject matter expert feedback, items were refined from the original ICBS and items for two new subscales (taking initiative, advocacy) were created for the SICBS. A sample of 441 public school teachers from 52 elementary schools in the Midwest and Western United States of America completed a survey that included the SICBS and additional measures to assess convergent and divergent validity. SICBS was refined and validated via examination of item characteristics curves to reduce items and develop a pragmatic instrument, confirmatory factor analyses to evaluate the hypothesized measurement structure, and assessment of convergent and divergent validity. The original two ICBS subscales (helping others, keeping informed) were retained, and two new three-item subscales resulted from item reduction analyses (taking initiative, advocacy). The hypothesized second-order factor model was generally well fit to the data (CFI = .99, TLI = .99, RMSEA = .09), all first- (λs = .85-.96) and second-order factor loadings (λs = .93-.95) were high. All SICBS subscales demonstrated acceptable reliability (αs = .88-.92). Convergent validity was evidenced by moderate correlations with organizational citizenship behavior items (rs = .42-.49). Divergent validity was demonstrated by weak correlations with teachers’ beliefs about teaching (rs = .31-.38) and null correlations with most school demographics. Results support the structural, convergent, and divergent validity of the 12-item, 4-factor SICBS. The SICBS provides a deeper understanding of individual implementer actions that may serve as implementation mechanisms or outcomes.

This study explores how ethnic identity, national identity, and cultural stress interact to impact mental health among Latino youth and their parents, using the Actor–Partner Interdependence Mediation Model (APIMeM). By analyzing survey data from Latino parent–youth dyads, we assessed both individual (actor) and cross-dyadic (partner) effects of identity and cultural stress on mental health outcomes. The APIMeM framework allowed us to examine whether cultural stress mediates the relationship between identity factors and mental health. Results revealed significant actor effects, with higher levels of cultural stress associated with increased mental health distress in both parents (β = 0.65, p < 0.001) and youth (β = 0.32, p < 0.001). Ethnic identity did not demonstrate significant actor or partner effects on either cultural stress or mental health. In contrast, stronger national identity was inversely related to youth mental health distress (β = −0.11, p = 0.01) and had a significant protective partner effect on parental mental health (β = −0.16, p = 0.02). However, cultural stress did not mediate the relationship between ethnic identity and mental health. These findings underscore the importance of national identity and interdependent family dynamics in shaping mental health outcomes within Latino families experiencing cultural stress.

Healthcare access in Latin America is highly unequal, with rural and peri-urban populations disproportionately excluded from essential and specialized services. To address the persistent gaps often obscured by conventional urban–rural classifications, this study developed a machine learning framework integrating the Functional Urban Area (FUA) model with Density-Based Spatial Clustering of Applications with Noise (DBSCAN) and Shannon entropy optimization to refine urbanization gradients and quantify inequities across 11 countries. High-resolution population density data from the Meta High Resolution Settlement Layer (HRSL, 2020) and CIESIN’s Gridded Population of the World (GPWv4, rev. 11), combined with healthcare facility locations from Healthsites.io, were processed in R to generate population-facility networks. Entropy optimization dynamically determined country-specific DBSCAN distance thresholds, ensuring representative clustering of functional urban and rural areas. Facilities were categorized by care level, and per-capita densities were compared across clusters. Results showed that entropy-optimized DBSCAN improved spatial precision over traditional approaches and revealed systemic urban bias: Peru, Chile, and Venezuela had the lowest hospital densities, while Ecuador, Bolivia, and Paraguay displayed the strongest rural deficits in primary care. Specialized services were overwhelmingly concentrated in urban clusters. This reproducible framework establishes a quantitative baseline for healthcare inequities, providing data-driven insights to inform the design of decentralized strategies to improve equitable access to care across Latin America.

After Hurricane Maria made landfall in Puerto Rico, thousands of Puerto Ricans left the archipelago and resettled permanently on the U.S. Our objective in the present study was to examine pre- and post-migration religiosity among Maria migrant adults in the U.S., and to determine how religiosity relates to mental health and migration-related cultural stress. Participants in the present study were 319 adult Hurricane Maria survivors residing on the U.S. mainland. We used ordinary least squares regression and structural equation modeling to examine the relationship between religiosity, mental health, and cultural stress. We found a modest increase in mean levels of intrinsic religiosity pre- to post-migration contexts. We also observed noteworthy declines in the frequency of public religious participation in the transition from Puerto Rico to the U.S. Furthermore, we found that higher levels of post-migration religiosity, and an increase in religiosity from before and after migration, were associated with lower symptoms of depression and anxiety. Finally, we found that the relationship between intrinsic religiosity and mental health was mediated by cultural stress experiences. Findings from this study highlight the importance of integrating discussions about religiosity and spirituality before and after migration in therapeutic mental health settings.

In the aftermath of Hurricane Mar & iacute;a's devastating impact on Puerto Rico in September 2017, a wave of migration to the continental United States followed. Despite Puerto Rico's territorial association with the United States, its distinct culture and language often render its migrants as cultural minorities who are often treated as foreigners. Prior research has indicated that natural disasters can have a profound effect on the family unit, so examining the experiences of displacement and resettlement of Puerto Rican parents can shed light on the challenges faced by these families. Using cultural stress theory and psychological sense of community as guiding frameworks, this qualitative study aimed to explore the experience of Puerto Rican parents displaced to the United States following Hurricane Mar & iacute;a. A total of 42 Puerto Rican Hurricane Mar & iacute;a migrant parents agreed to participate in semistructured interviews. Our findings illuminate a trade-off in the lives of Puerto Rican migrants: As they departed their homeland, they exchanged social connections, support networks, and the vibrant social fabric of Puerto Rico for the promise of economic stability, reduced crime, and enhanced prospects for themselves and their children in the United States. This study represents a crucial contribution to the understanding of Puerto Ricans who have embarked on the challenging journey of relocating in the aftermath of Hurricane Mar & iacute;a. It underscores how they grapple with the multifaceted challenges and benefits inherent in their roles as cross-cultural climate migrants, transitioning from the predominantly Spanish-speaking, Latin American context of Puerto Rico to the diverse landscape of the United States.

Background: Ventilator associated pneumonia (VAP) occurring in the intensive care unit (ICU) are common, costly, and potentially lethal. Methods: We implemented a multidimensional approach and an 8-component bundle in 374 ICUs across 35 low and middle-income countries (LMICs) from Latin-America, Asia, Eastern-Europe, and the Middle-East, to reduce VAP rates in ICUs. The VAP rate per 1000 mechanical ventilator (MV)-days was measured at baseline and during intervention at the 2nd month, 3rd month, 4-15 month, 16-27 month, and 28-39 month periods. Results: 174,987 patients, during 1,201,592 patient-days, used 463,592 MV-days. VAP per 1000 MV-days rates decreased from 28.46 at baseline to 17.58 at the 2nd month (RR = 0.61; 95% CI = 0.58-0.65; P < 0.001); 13.97 at the 3rd month (RR = 0.49; 95% CI = 0.46-0.52; P < 0.001); 14.44 at the 4-15 month (RR = 0.51; 95% CI = 0.48-0.53; P < 0.001); 11.40 at the 16-27 month (RR = 0.41; 95% CI = 0.38-0.42; P < 0.001), and to 9.68 at the 28-39 month (RR = 0.34; 95% CI = 0.32-0.36; P < 0.001). The multilevel Poisson regression model showed a continuous significant decrease in incidence rate ratios, reaching 0.39 (p < 0.0001) during the 28th to 39th months after implementation of the intervention. Conclusions: This intervention resulted in a significant VAP rate reduction by 66% that was maintained throughout the 39-month period.

Purpose: We examined the extent to which depressive symptomatology measures operate across different Latino subgroups as there is inconsistency regarding its performance across Latinos, a large and rapidly growing cultural group in the United States. Methods: We evaluated the reliability and structural validity of the scores generated by the Center for Epidemiologic Studies Depression Boston Form (CES-D-B) using four distinct Latino samples residing in US: Mexicans, Venezuelans, Cubans, and “other Latinos” (total N =1033). To further explore structural validity of CES-D-B scores, we conducted measurement invariance analyses across different countries of origin, gender groups, educational levels, and languages of assessment (English, Spanish). Results: For all four samples, CES-D-B scores were highly reliable, and the factor structure had a good to excellent fit to the data. While measurement invariance analyses for different educational levels indicated scalar invariance across all samples, the same level of measurement equivalency was achieved only for Mexicans and Venezuelans with varying gender and languages of assessment. Conclusions: The findings indicated that CES-D-B scores are internally consistent, possess a strong four-factor structure, and have somewhat equivalent psychometric properties across diverse Latino groups. Findings from this study highlight the importance of considering gender and languages of assessment when assessing depressive symptoms of various Latino subgroups.

Objective: To identify urinary catheter (UC)-associated urinary tract infection (CAUTI) incidence and risk factors. Design: A prospective cohort study. Setting: The study was conducted across 623 ICUs of 224 hospitals in 114 cities in 37 African, Asian, Eastern European, Latin American, and Middle Eastern countries. Participants: The study included 169,036 patients, hospitalized for 1,166,593 patient days. Methods: Data collection took place from January 1, 2014, to February 12, 2022. We identified CAUTI rates per 1,000 UC days and UC device utilization (DU) ratios stratified by country, by ICU type, by facility ownership type, by World Bank country classification by income level, and by UC type. To estimate CAUTI risk factors, we analyzed 11 variables using multiple logistic regression. Results: Participant patients acquired 2,010 CAUTIs. The pooled CAUTI rate was 2.83 per 1,000 UC days. The highest CAUTI rate was associated with the use of suprapubic catheters (3.93 CAUTIs per 1,000 UC days); with patients hospitalized in Eastern Europe (14.03) and in Asia (6.28); with patients hospitalized in trauma (7.97), neurologic (6.28), and neurosurgical ICUs (4.95); with patients hospitalized in lower-middle-income countries (3.05); and with patients in public hospitals (5.89).The following variables were independently associated with CAUTI: Age (adjusted odds ratio [aOR], 1.01; P < .0001), female sex (aOR, 1.39; P < .0001), length of stay (LOS) before CAUTI-acquisition (aOR, 1.05; P < .0001), UC DU ratio (aOR, 1.09; P < .0001), public facilities (aOR, 2.24; P < .0001), and neurologic ICUs (aOR, 11.49; P < .0001). Conclusions: CAUTI rates are higher in patients with suprapubic catheters, in middle-income countries, in public hospitals, in trauma and neurologic ICUs, and in Eastern European and Asian facilities. Based on findings regarding risk factors for CAUTI, focus on reducing LOS and UC utilization is warranted, as well as implementing evidence-based CAUTI-prevention recommendations.

Background: Catheter-Associated Urinary Tract Infections (CAUTIs) frequently occur in the intensive care unit (ICU) and are correlated with a significant burden. Methods: We implemented a strategy involving a 9-element bundle, education, surveillance of CAUTI rates and clinical outcomes, monitoring compliance with bundle components, feedback of CAUTI rates and performance feedback. This was executed in 299 ICUs across 32 low- and middle-income countries. The dependent variable was CAUTI per 1,000 UC days, assessed at baseline and throughout the intervention, in the second month, third month, 4 to 15 months, 16 to 27 months, and 28 to 39 months. Comparisons were made using a 2-sample t test, and the exposure-outcome relationship was explored using a generalized linear mixed model with a Poisson distribution. Results: Over the course of 978,364 patient days, 150,258 patients utilized 652,053 UC-days. The rates of CAUTI per 1,000 UC days were measured. The rates decreased from 14.89 during the baseline period to 5.51 in the second month (risk ratio [RR] = 0.37; 95% confidence interval [CI] = 0.34-0.39; P < .001), 3.79 in the third month (RR = 0.25; 95% CI = 0.23-0.28; P < .001), 2.98 in the 4 to 15 months (RR = 0.21; 95% CI = 0.180.22; P < .001), 1.86 in the 16 to 27 months (RR = 0.12; 95% CI = 0.11-0.14; P < .001), and 1.71 in the 28 to 39 months (RR = 0.11; 95% CI = 0.09-0.13; P < .001). Conclusions: Our intervention, without substantial costs or additional staffing, achieved an 89% reduction in CAUTI incidence in ICUs across 32 countries, demonstrating feasibility in ICUs of low- and middle-income countries.

Hurricane María caused significant devastation on the island of Puerto Rico, impacting thousands of lives. Puerto Rican crisis migrant families faced stress related to displacement and relocation (cultural stress), often exhibited mental health symptoms, and experienced distress at the family level. Although cultural stress has been examined as an individual experience, little work has focused on the experience as a family. To address this gap, we conducted a mixed-methods study designed to examine the predictive effects of cultural stress on family conflict and its mental health implications among Puerto Rican Hurricane María parent and child dyads living on the U.S. mainland. In the quantitative phase of the study, 110 parent-child dyads completed an online survey assessing cultural stress, family dynamics, and mental health. As part of our primary analysis, we estimated a structural equation path model. Findings from the quantitative phase showed a significant positive relationship between family cultural stress and family conflict, as well as individual parent and child mental health symptoms. In the qualitative phase of the study, 35 parent-child dyads participated in individual interviews. Findings from the interviews revealed variations in difficulties related to language, discrimination, and financial burdens, with some participants adapting more quickly and experiencing fewer stressors. Findings also highlight the impact on mental health for both parents and youth, emphasizing the family-level nature of cultural stress, while noting a potential discrepancy between qualitative and quantitative findings in the discussion of family conflict.