About the Assessment

Each community health needs assessment commissioned by The Health Collaborative evolves

in some way from the last assessment, aiming to challenge how we think about and work to

improve our community’s health and well-being. The 2016 Bexar County Community Health

Needs Assessment sought to support Bexar County partners in moving from knowledge about

local health conditions to improvement of those conditions, using an equity lens and publishing data online for the first time. This 2019 Atascosa and Bexar County Community Health Needs Assessment represents another step forward in this continuing evolution.

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• Continued Support of interactive online data portal. To address the varying issues that different people face and improve our county’s health overall, we must “drill down” to a greater level of detail than a report can give. The Health Collaborative will continue to make publicly available a larger collection of data for exploration and download through an interactive online data portal.

• Continued integration with the Community Health Improvement Plan (CHIP). Last updated in 2017, the CHIP is the community-wide action plan to improve health and well-being in five priority areas: Healthy Eating and Active Living, Healthy Child and Family Development, Safe Communities, Behavioral and Mental Well-Being, and Sexual Health. The 2019 Assessment will inform the review and revision, if necessary, of these five focus areas and of the associated objectives and performance measures.

• Looking at health with an equity lens. It is now widely accepted that the relative contribution of medical care to health and well-being is small – an estimated 10% to 20%. That means that the greater share of disparities in health and life expectancy for different populations can be traced not so much to differences in access to and use of medical care, but to stark differences in the conditions in which people are born, grow up and grow old, work and play. Improving health and well-being will mean both improving those conditions and explicitly addressing the effects those conditions have already had on so many members of our community.

What's new for this assessment

One major shift from prior assessments is the movement toward a regional community health

needs assessment via the addition of Atascosa County to the geographic scope. Adjoining Bexar County immediately to the south, Atascosa differs markedly from Bexar in a number of social determinants, health-related behaviors and risks, and health outcomes. More than anything, though, it differs in the availability of data for many of the indicators traditionally measured in Bexar. Because Atascosa’s population is about 2.5% the size of Bexar’s, the available data is based on fewer of everything: people surveyed, births, illnesses and injuries, deaths, cars on the road, students in high school, and on and on. Some of the major consequences of these small numbers are that trends often rise and fall like extreme rollercoasters, margins of error and confidence intervals are often so wide as to be nearly meaningless, and disaggregated figures (e.g., the rate for each race/ethnicity group) are missing from charts because the numbers were suppressed by the data owner to protect privacy.  

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Each and every instance of these challenges presents a judgment call: is this data actually better than nothing? Is it actually worse than nothing because it’s confusing or misleading?

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Wherever possible, the same or similar indicators are presented for both counties, each time

accompanied by narrative and callout boxes explaining where and why the data may not be

trustworthy. That approach often means compromises in how an indicator is calculated. For

example, three-year averages – or in one case, a 19-year average – make trend lines and bar

charts easier to make sense of but sacrifice some of the recency of the data. The Behavioral Risk Factor Surveillance System (BRFSS) data for Atascosa was usable only with seven survey years of data and included both Medina and Wilson County responses in the dataset. These choices have been noted in the narrative and footnotes to help the reader decide how to interpret the data. 

Another change is much more extensive disaggregation of the data, breaking it out by race/ethnicity group, age group, sex, and smaller-than-county geography. This assessment includes close to four times as many maps and more than twice as many charts and tables as did the 2016 assessment. The purpose of disaggregation is to shine a bright light on differences, disparities, and inequities so that they can be identified, understood, and addressed. Unfortunately, breaking the data down into many categories results in the same problems described above for Atascosa data: volatile or unreliable rates, wide margins of error, and suppressed data. Suppressed data especially hurts disaggregation by race/ethnicity group. Data are consistently available only for Hispanics and non-Hispanic whites, resulting in the loss of so much important information about other members of our community.

Finally, to help assemble a more complete picture of an issue, “Related data” text boxes direct the reader to relevant information covered in a different section of the assessment. As one example, liquor store density might be covered in one section, alcohol-involved motor vehicle crashes in another, and alcohol-induced deaths in yet another.

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What continues with this Assessment

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As in 2016, this assessment focuses on equity and organizes the content largely consistent with the health equity framework developed by the Bay Area Regional Health Inequities Initiative (BARHII). That framework explicitly recognizes the social and economic determinants that are the primary drivers of health, as the relative contribution of medical care to health and well-being is only 10% to 20%1 and emphasizes the living conditions that are upstream of – and entirely surrounding – personal behaviors, disease, and death.

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Once again, benchmarking against other geographies – other counties, Texas, or the United

States – was beyond the scope of this assessment, although a few comparisons are embedded

in the narrative. Geographic comparisons for a number of key indicators are available through

Community Information Now’s Viz-a-lyzer online data tool, the Robert Wood Johnson Foundation’s County Health Rankings & Roadmaps, and most state and national data query tools. Content gathered though community focus groups and interview participants is integrated into each report section to which it relates. These quotes reflect the opinion of one or more community members and not necessarily that of The Health Collaborative. Narrative summaries of all qualitative information provided through the interviews and discussion groups are included in the Appendices.

Figure 1.1 -- Click to Enlarge.