Gendered and Layered Vulnerability: Cumulative Risk and Psychological Distress Among Older Adults In Puerto Rico during COVID-19

Background
Older adults in Puerto Rico faced significant disruptions during the COVID-19 pandemic, including healthcare delays, economic instability, and increased social isolation. These challenges occurred within a broader context of long-standing structural inequalities related to high poverty rates, strained healthcare systems, and repeated disaster exposures following Hurricane María and subsequent crises. Older women may be particularly vulnerable in this context because the likelihood of gendered socioeconomic disadvantage, longer life expectancy, and greater likelihood of living alone converge in later life. Despite these conditions, most research examines individual risk factors rather than how multiple vulnerabilities accumulate. Guided by the multidimensional vulnerability framework and the stress process model, this study examines how layered risks across structural, health, and social domains contribute to psychological distress among older women in Puerto Rico during the pandemic.

Methods
Data are from a cross-sectional survey of community-dwelling older adults in Puerto Rico conducted between January and December 2021 (N = 213). Participants aged 60 and older were recruited through community centers, social service agencies, and public spaces using purposive sampling, and they completed structured interviews by telephone or in person. The mean age was 71.90 years, with 56% women. Psychological distress was measured using the Self-Reporting Questionnaire (SRQ-20) (M=5.63, range = 0-20). A multidimensional vulnerability index was constructed to capture layered risks across multiple domains, including economic disruption (income loss), institutional barriers (delayed healthcare), physical vulnerability (poor self-rated health), and social disconnection (loneliness and social isolation) during the pandemic. Covariates included gender, age, marital status, and income. We used regression analyses to assess the association between cumulative vulnerability and psychological distress and to test gender moderation.

Results
There was no significant gender difference in cumulative vulnerability (female: M = 0.79; male: M = 0.71; p = .482). However, women had significantly higher SRQ scores than men (female: M = 6.28; male: M = 4.82; p = .033). Cumulative vulnerability was significantly associated with higher psychological distress (β = 2.17, p < .001). Women reported higher levels of psychological distress than men (β = 2.56, p = .007). The interaction between cumulative vulnerability and gender was not statistically significant (β = −0.65, p = .498). Also, marital status was associated with higher psychological distress (β = 2.49, p = .014).

Implications
This study contributes to theoretical and empirical research on aging and disaster by demonstrating that vulnerability is a multidimensional and cumulative process. Understanding how overlapping structural, health, and social risks shape mental health outcomes can guide integrated social work and public health interventions during crises. Given that women had higher levels of mental distress regardless of the layered vulnerability, the intervention should prioritize recruiting and supporting older women. Findings may also inform policies and services that aim to support older adults who experience multiple, intersecting vulnerabilities during public health emergencies.