A mini-review of research with Puerto Ricans displaced by Hurricane Maria: insights from the Adelante Boricua study

Introduction

Hurricane Maria in 2017 and the subsequent large-scale relocation of Puerto Ricans to the United States (US) mainland serve as a stark example of how severe weather events and population displacement impact the health of storm survivors and the nation in general. Nearly a decade after Hurricane Maria, roughly 130,000 displaced Puerto Ricans still reside on the mainland as long-term relocated Maria survivors. Our team has led multiple studies with this population, including the Adelante Boricua study, a longitudinal cohort study funded by the National Institutes of Health examining the complex interplay among severe weather events, displacement, resettlement, and mental health.

This article provides an overview of what we have learned from studying relocated Maria survivors. We begin by providing a concise outline of Adelante Boricua and related research projects we have conducted, along with the conceptual framework that guides our ongoing research with populations displaced by severe weather events. We then share major findings from our research and consider the implications. In doing so, we highlight valuable insights into the dynamics of severe weather events and of displacement more broadly.

Adelante Boricua and related projects

Context for research

In September 2017, Hurricane Maria made landfall in Puerto Rico as the most powerful hurricane to hit the island territory in nearly a century, and the fourth costliest storm in US history (Mora et al., 2021; NOAA, 2025). Given sustained winds of 155 miles per hour and torrential rains, vast numbers of Puerto Ricans saw their homes destroyed, and many were left without food, water, electricity, and cell or internet service (Deibert, 2019). For months, thousands remained without power, and many struggled to obtain basic necessities for more than a year.

In the aftermath, many Puerto Ricans relocated to the US mainland. Estimates of the number of people who left the island—temporarily or permanently—in the first 6 months after Hurricane Maria range from ~200,000–400,000 individuals, with conservative estimates indicating that, while many returned after the situation in Puerto Rico stabilized, around 130,000 Puerto Ricans have remained on the mainland for the long term (Acosta et al., 2020; Alexander et al., 2019; Martín et al., 2020). Our primary objective has been to understand how experiences during the hurricane and relocation to the mainland unfold over time, with an emphasis on the roles of hurricane trauma, resettlement stressors, close relationships, and mental health. Below, we describe the Adelante Boricua study and outline the conceptual framework underlying this work.

The Adelante Boricua sample

With approval from the institutional review boards at the authors’ home institutions, the original Adelante Boricua sample of 319 adults (93 male, 226 female; M_age = 38.5, SD = 12.0, range = 18–77) was recruited, consented, and assessed at baseline between August 2020 and October 2021. We utilized a respondent-driven sampling approach, where seed participants were recruited through community organizations, and these seed participants (and subsequently referred participants) were offered additional incentives to refer other eligible individuals. Seed participants were recruited in South and Central Florida via our community partners and through members of our Community Advisory Board. We collected all survey data remotely via the Qualtrics online survey tool and conducted all qualitative interviews via Zoom.

Most participants relocated to the U. S. mainland in 2017 (59%) or 2018 (29%). Approximately 75% of Adelante Boricua participants resided in the Orlando/Kissimmee area. At baseline, the sample was largely low-income, with 81% reporting annual incomes below $35,000, and Spanish-dominant, with 61% of participants reporting that they speak English “poorly.” Retention was 83% across six assessment waves conducted over 4 years. This retention rate is quite strong—particularly given the challenges of conducting data collection with a mobile population.

Conceptual framework

The Adelante Boricua study is grounded in what we have termed the Theory of Resettlement Stress (see Figure 1). In our prior work, we have provided extensive overviews of cultural stress theory (Salas-Wright and Schwartz, 2019; Salas-Wright et al., 2021) and crisis migration (Salas-Wright et al., 2025; Vos et al., 2021).

Both the cultural stress and crisis migration frameworks inform the underlying logic of the Theory of Resettlement Stress. The theory of resettlement stress focuses on how the myriad pressures that accompany the resettlement process are related to close relationship dynamics and, in turn, to mental health. In particular, we are interested in stressful experiences, such as mistreatment by individuals and the perception of being unwelcome in the new receiving community. The sources of mistreatment can include people with whom one is in a close relationship, as well as more distal relationships, such as acquaintances or strangers. In prior work, we have examined how such dynamics unfold in the context of international migration (Schwartz et al., 2025a); however, as others (Mooney, 2005) have argued, we posit that similar processes are likely to be observed among populations displaced within a single country. Stress may be experienced as difficulty adjusting to new social norms, differences in the built environment, or a different climate.

The theory of resettlement stress posits that exposure to such stressors during and after resettlement can compromise key aspects of close relationships with family members (e.g., closeness, cohesion), including parents, siblings, spouses, extended family, and even close friends. This hypothesis is consistent with several theoretical frameworks (Agnew, 2017; Goode, 1960; McCubbin et al., 1980), which postulate that exposure to stress can precipitate frustration and emotional strain, resulting in increased irritability, poor communication, and withdrawal—all of which can impair close relationships. In turn, disrupted close relationships increase risk for mental health symptoms. The basic structure of these pathways is similar to cultural stress theory; however, the emphasis shifts from mistreatment and unwelcomeness based exclusively on a “foreign” national identity to encompass negative experiences stemming from being part of a displaced or culturally distinct group, as well as other sociocultural stressors.

The theory of resettlement stress also integrates the trauma of exposure to and displacement by a severe weather event with the relocation process. Specifically, traumatic exposure is conceptualized as negatively impacting mental health both directly and through impaired close relationships. Importantly, we also postulate that traumatic exposure to severe weather events is linked with resettlement stress in several ways. One is that trauma can interact with resettlement stress, such that individuals exposed to higher levels of both trauma from a severe weather event and resettlement stress may be especially likely to experience compromised close relationships and mental health problems. We have also hypothesized that traumatic exposure can directly influence resettlement stress by destabilizing one’s emotional well-being and, in turn, leading individuals to be more sensitive to external threats. The key insight here is that a comprehensive understanding of severe weather events, displacement, and resettlement requires attention to experiences in one’s home community before, during, and immediately after the event, as well as during resettlement.

Major findings

In this section, we summarize a decade of research into three major findings and consider the policy and practice implications of each. For more details on our first 25 scholarly articles in this area, please consult Table 1 to see “what we did” and “what we learned” in each of our published papers focused on Puerto Ricans displaced in the aftermath of Hurricane Maria.

Table 1. Publications from the Adelante Boricua study and associated projects with individuals displaced by hurricane Maria.

Major finding #1

Posttraumatic stress is a persistent, long-term challenge

The first major finding is that, for many Puerto Ricans, posttraumatic stress represents a persistent, long-term challenge. As part of our initial pilot study in the aftermath of Hurricane Maria, we conducted surveys of 213 survivors in Puerto Rico and Florida in March and April 2018, approximately 6 months after the storm. In that project, we found that most respondents screened positive for posttraumatic stress disorder, and that rates were especially high among those who had relocated to the mainland (66% among relocated Maria survivors versus 44% of those who remained in Puerto Rico; Scaramutti et al., 2019).

Beyond the initial levels of post-traumatic stress disorder (PTSD), what has been surprising is the degree to which PTSD has remained a significant challenge among many relocated Maria survivors years after the storm. When we surveyed a new sample of 319 relocated Maria survivors between August 2020 and October 2021 as part of the Adelante Boricua project, we expected that a substantial proportion of respondents would report that posttraumatic stress was no longer a pressing challenge, given that 3–4 years had passed. However, Duque et al. found that more than half (52%) of our sample screened positive for posttraumatic stress disorder in 2020–2021 using the same measure our team used in our pilot work in early 2018 (Duque et al., 2025a). When we concluded data collection for Adelante Boricua between January and June 2024, 6½ years after Hurricane Maria—more than one third (34%) of our sample still screened positive for posttraumatic stress disorder. Although longer-term research with individuals displaced by severe weather events is scarce, studies conducted with similar populations, such as survivors of Hurricanes Katrina and Sandy (LaJoie et al., 2010; Raker et al., 2019; McLaughlin et al., 2011; Schwartz et al., 2017), tell a similar story of the long-term mental health sequelae of living through severe weather events.

A related sub-finding is worth noting here. Specifically, not all hurricane survivors were equally likely to develop posttraumatic stress disorder, nor is everyone who develops it equally likely to remit from it. Duque et al. (2026) found that specific constellations of experiences during the hurricane, such as loss of property and physical injury, served as stronger predictors of posttraumatic stress disorder than did geographic proximity to the hurricane’s landfall. As is often the case in weather-related disasters, much of one’s experience depends on infrastructure and materials, since very strong winds and heavy rain can destroy a home’s roof but leave the roof next door intact (Amini and Memari, 2020). Duque et al. (2025a) also found that the severity of traumatic experiences during Hurricane Maria predicted not only posttraumatic stress disorder at baseline but also the likelihood of remission several years later.

This first major finding has several important implications. For one, it is critical that mental health professionals provide psychological support to individuals in the immediate aftermath of severe weather events—and solid research suggests that early intervention amid disasters and other emergencies can mitigate the risk of longer-term psychological challenges (Kip et al., 2024; North and Pfefferbaum, 2013; Saeed and Gargano, 2022). Our research suggests that such efforts should focus not only on those who remain in the epicenter of a disaster but also on individuals displaced by severe weather events (Lee et al., 2009; Mills et al., 2007; Picou and Hudson, 2010).

Another implication of our findings is that policymakers should be aware that, for some individuals displaced by severe weather events, posttraumatic stress disorder and other related mental health challenges likely require attention for years. Simply, severe weather events capture our attention in the short term, but the mental health needs of survivors, perhaps especially those who relocated in the aftermath, require our long-term concern and attention.

Major finding #2

We must consider both hurricane trauma and resettlement stress

The second major finding is that, in terms of mental health, we must consider both the trauma of severe weather events and the stress that many experience when resettling in a new community. Many of our published studies touch on this core insight, but we will focus here on findings from two studies on how acute trauma and chronic resettlement stress interact to influence mental health.

Montero-Zamora et al. (2023) used a person-centered approach to model self-reported experiences of trauma during the hurricane and key indicators of resettlement stress on the US mainland. That study found that individuals who reported elevated levels of both hurricane trauma and resettlement stress were—by far—most likely to endorse elevated levels of depression, anxiety, and PTSD. In a separate study, Hodges et al. (2025) used a multivariate approach to examine how hurricane trauma and resettlement stress relate to PTSD symptoms. They found that, even accounting for hurricane trauma, resettlement stressors, such as mistreatment by individuals and feeling unwelcome in one’s new community, were strongly linked with the likelihood of developing PTSD symptoms and receiving PTSD screening diagnoses. These findings provide strong support for the idea that, for displaced individuals, mental health is a function both of experiencing a severe weather event and of feeling comfortable after resettlement.

In Hodges et al. (2025), an unexpected finding emerged, adding another layer of nuance to our understanding. Namely, when we looked at the interaction between hurricane trauma and resettlement stress, resettlement stress predicted PTSD symptoms, but only when hurricane trauma levels were low to moderate. Our interpretation is that this reflects a “ceiling effect,” in which individuals exposed to high levels of hurricane trauma are so adversely affected by the hurricane that additional adverse exposures after resettlement—although painful and insidious—do not measurably worsen mental distress. Maria survivors reporting high levels of hurricane trauma are likely to have seen others injured (or been injured themselves) during the hurricane, been separated from family, gone without food and water, and thought they might die during the storm. It seems plausible that exposure to these traumatic and stressful experiences might “max out” their psychological distress.

This second major finding has implications for practice and policy. At a basic level, it makes clear the importance of considering the full range of experiences among individuals who live through severe weather events and then relocate to new communities. Mental health professionals often practice psychological first aid and other approaches in the aftermath of disasters. However, they should not overlook the manifold challenges that displaced individuals and families face, which may be even greater than those faced by families who remain near the disaster’s epicenter. Similarly, although those exposed to the highest levels of trauma may immediately present with mental health needs, we should not overlook the possibility that displaced individuals who are exposed to more modest levels of trauma may still experience substantial stress as they resettle—and that such stress can have mental health consequences.

Major finding #3

Many who relocated had seriously considered leaving long before the hurricane

The third major finding we present in this article is that many participants in the Adelante Boricua study—people who left Puerto Rico after Hurricane Maria and remained on the U. S. mainland for the long term—had often thought seriously about leaving their home communities well before the disaster struck.

Garcia et al. (2026) asked parent–child dyads who relocated to Florida after Hurricane Maria to describe, in their own words, why they left Puerto Rico. We assumed that everyone in our sample would describe how Hurricane Maria had created conditions that made remaining in Puerto Rico untenable—homes destroyed, lack of access to food and water, et cetera. However, the most common reason listed was not the hurricane. Instead, it was employment that was noted by 47% of participants, with comments such as “I did not have work” or “Lack of employment.” The other two major drivers of resettlement—each noted by roughly one-third of those interviewed—were “consequences of Hurricane Maria” and a desire for a “better quality of life” in terms of safety, stability, and opportunity. That is, although the hurricane was explicitly identified as a significant reason for leaving, most participants unexpectedly cited reasons other than Hurricane Maria as the primary reason for their departure.

Without a doubt, many people lost their jobs as a consequence of the hurricane, as businesses were destroyed and multiple sectors of the economy came to a standstill (Kenner et al., 2023). Similarly, public safety concerns intensified, and opportunities for personal advancement disappeared as a function of Maria (Garcia et al., 2024, 2026). Thus, the push factors of “employment” and “quality of life” are by no means completely unrelated to the hurricane. However, these data seem to speak to longer-standing concerns in Puerto Rico that predate the hurricane. Hurricane Maria occurred during a specific historical moment—one in which socioeconomic conditions on the island were rapidly deteriorating after several decades of job losses, falling wages, and overall decline (Caraballo-Cueto, 2021). Many Puerto Ricans were leaving the island each year before the hurricane, due primarily to widespread economic concerns (Acosta et al., 2020).

This general pattern aligns with our findings from in-depth qualitative interview data (Garcia et al., 2025b). Indeed, we found that leaving Puerto Rico had long been on many people’s minds. However, they were reluctant to separate from family and friends and to leave behind the properties they owned (typically modest homes) or their small businesses. Then, the destruction caused by the hurricane, along with a likely very slow recovery, set in motion processes that people had long contemplated amid challenging economic conditions. As we heard from participants in Florida shortly after the hurricane, “The hurricane gave the final push” to leave (Clark-Ginsberg et al., 2024). Relocating was not a new idea, but rather evolved from a possibility into a reality as the disaster unfolded.

This third major finding has several important implications. First, it serves as a reminder that community and societal factors play an important role in shaping decision-making amid severe weather events. People are less likely to leave following a disaster if they see a clear pathway to recovery in their home community. In keeping with crisis migration theorizing, large-scale population movements often occur when macro-level conditions are weak or unstable, and then a crisis event takes place (McAdam, 2014; Schwartz et al., 2025b). Second, mental health clinicians working with displaced or resettled populations should not assume that the crisis event itself is the “whole story.” Instead, long-term displacement often occurs when people who are already struggling to meet their expenses and manage their lives experience a large-scale crisis, such as a major hurricane.

Limitations

Findings from the Adelante Boricua study should be interpreted in light of several limitations. First, the study population was geographically concentrated in Central Florida. Although this was the epicenter of relocation for most Hurricane Maria survivors, findings here may not generalize to other receiving communities. Second, recruiting displaced disaster survivors did not allow us to use random sampling measures, which further limits generalizability. Relatedly, our sample is predominantly female and low-income, which may not generalize to the broader population in Puerto Rico. Third, the study relied entirely on self-reported screening measures, including for outcomes such as PTSD and depression, which would ideally be measured with clinical diagnostic confirmation. Finally, selection effects may have contributed to Major Finding #3, given that individuals who had already considered leaving before the hurricane may differ systematically from those who remained.

The road ahead

At present, many important questions remain.

One straightforward question is simply, what happens next? Although many displaced people remain in their new receiving contexts, research on the long-term trajectories of individuals displaced by severe weather events remains relatively scarce. We have compelling evidence that a subset of our sample has improved in mental health and overall functioning as they have become more settled. How does this continue to unfold over the years, in terms of recovery, thriving in the face of adversity, and overall flourishing? Such questions have yet to be explored in sufficient depth among displaced populations.

Two other major sets of questions exist. The first relates to how the decision to relocate permanently (or for many years) relates to mental health in comparison with the other two main options people have in the aftermath of a severe weather event, namely, to stay in the affected community or to temporarily evacuate the affected area and then return several weeks or months later when conditions have improved. Was one of these “strategies” better than the others in terms of mental health? Is staying or leaving, on average, better for certain groups, such as young people versus older adults, or single persons versus parents with young children? Answers to such questions could inform decision-making among those affected by severe weather events.

The final set of questions concerns the extent to which the experiences of those displaced by Hurricane Maria are unique. Certainly, multiple factors make the situation of Puerto Ricans unique, including language, culture, politics, and geography. However, we suspect that many of the dynamics we have observed may not be unique to Puerto Ricans or Hurricane Maria, and we encourage others to join us in examining the complex dynamics of traumatic exposure, displacement, resettlement, and adaptation across multiple populations and contexts.

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Footnotes

Edited by: Sarah Rosengaertner, Global Centre for Climate Mobility, United States

Reviewed by: Yaritza Inostroza-Nieves, San Juan Bautista School of Medicine, Puerto Rico