The 2016 Community Health Needs Assessment Report for Bexar County
About the Assessment
The Health Collaborative is pleased to present the 2016 Bexar County Community Health Assessment. The 2016 Assessment seeks to support Bexar County partners in moving from knowing about local conditions and health outcomes to changing those conditions and outcomes. This emphasis resulted in three key changes.
Creation of an 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 for the first time this year will make publicly available a larger collection of data for exploration and download through an interactive online data portal.
Stronger integration with the Community Health Improvement Plan (CHIP). Last updated in 2014, 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 2016 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%[i]. 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 Makes Us Healthy?
Healthy People 2020 defines health equity as the “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”[ii] The Bay Area Regional Health Inequities Initiative (BARHII) created a framework (Figure 1.1) to show the links between disparities in conditions and disparities in health.
As shown in the figure, “upstream” factors and conditions lead to “downstream” factors and conditions, and public health and healthcare alike are recognizing the need to intervene further “upstream” than people’s risk behaviors. The lower section of the figure shows that the types of action that are effective upstream are very different from those that are effective downstream, and policy is key at every point. Data on both health-affecting conditions and health outcomes will be anchored to this framework throughout the assessment.
Notable Trends and Patterns
The 2016 Assessment contains quantitative data on approximately 150 indicators for Bexar County. Many indicators are broken out by demographic characteristic or geography, typically zip code or sub-county sector. These eight sectors were developed for the 2013 assessment in response to the problem of small sample sizes, particularly with regard to the BRFSS dataset.
Following are a few especially noteworthy trends, patterns, and driving forces. Please refer to the full document for data points and sources.
People & Place
A major driving force of change in Bexar County is population growth, with the 2050 population projected to be half again the 2010 total, and disproportionate growth in certain subpopulations. The growth rate is by far the steepest among Hispanics, mirroring state and national trends. Given racial/ethnic disparities in educational attainment, income, and health outcomes, that growth has major implications for the county as a whole. The population is also aging, with the senior population 65 and older – another vulnerable population subgroup – projected to exceed half a million by 2050, nearly triple the 2010 total. Population density in the county is growing despite sprawl, and population growth is steepest in the central city, the northside, and the northwest side.
Environment & Living Conditions
Two key themes emerge from a close look at environment and living conditions. First, fundamental social determinants of health like poverty and educational attainment remain stubbornly unchanged. Some, like income inequality and segregation, are getting worse, and Bexar County’s income inequality now resembles that of China and the Dominican Republic.
Second, these social determinants vary by race/ethnicity, and even more strikingly by neighborhood. Median household and family incomes have risen slightly overall, but low income and poverty are overwhelmingly concentrated in westside, eastside, and southside neighborhoods. Four in 10 renter-occupied households overall are housing cost-burdened, paying 35% or more of household income to cover housing costs, but the proportion is as high as six in 10 on the eastside and southside. Unemployment has dropped overall, but the highest unemployment rates in central-city neighborhoods are eight times those on the far northside. Uninsured rates are declining, but the eastside and westside are more likely than other areas of the county to have a high rate of uninsured.
Health-Related Behaviors & Early Outcomes
Our understanding of health-related behavior trends and patterns in Bexar County is stymied by heavy reliance on population surveys. Wide confidence intervals for estimates generated from the BRFSS dataset make it almost impossible to have certainty about either county trends over time or about current demographic and geographic differences. New YRBS data for youth is not available at all for this assessment.
For those trends we can consider trustworthy, the news is mixed. No improvement in fruit or vegetable consumption, physical activity, or smoking is apparent. But the percent of adults reporting that they never drink sugar-sweetened beverages has increased, possibly to a substantial degree.
Healthy behaviors like vaccination, routine screening and testing, safer sex and drug injection behaviors, and early and adequate prenatal care all play a role in reducing the incidence of communicable disease. The past few years have seen continuing declines in the incidence of some reportable communicable diseases, namely Hepatitis B, chlamydia, and gonorrhea, and a reversal of recent spikes in congenital syphilis and HIV incidence. Pertussis or whooping cough incidence has declined but remains higher than 2010.
The overall teen birthrate continues to decline dramatically, driven by reduced birthrates among Hispanic and black or African-American girls. There appears to be a decline in the proportion of total births that followed early and adequate prenatal care, though, and possibly an accompanying increase in hospitalizations for pregnancy-related complications.
Health & Well-Being
As with social determinants and health-related behaviors, many health outcomes have seen no clear progress in recent years, including percent of adults who report good or excellent health, report being diagnosed with diabetes, or are overweight or obese. The high degree of year-to-year overlap in BRFSS confidence intervals means that although the point estimate has declined slightly from 2010, there is no evidence of true decrease in the percent of adults who are overweight or obese.
Some indicators vary quite a big by age group. The asthma hospitalization rate has declined significantly for seniors, but not for children and teens. Of all principal diagnoses examined, the only hospitalization rate that has increased dramatically from 2010 is for mental illness, primarily among youth and to a lesser degree among adults. Whether this increase is real or reflects substantive change in diagnosis coding practice is not clear.
But the single most striking theme in health outcomes is inequity. Again, disparities are often evident when comparing racial/ethnic subgroups. Self-reported health status and overweight/ obesity are much worse among Hispanics versus non-Hispanic whites.
When comparing neighborhoods, though, the disparity is especially dramatic, with clear differences in self-reported health status. And the difference in life expectancy between prosperous and poor neighborhoods is a staggering 20 years.
Priority Issues and Implications for Action
Taking all of the quantitative and qualitative data and information together, a number of common themes and high-priority issues emerge.
Issues with Technical Fixes. These are issues that can be addressed by relatively straightforward policy or practice changes supported by a strong evidence base.
Vaccination against communicable disease, most notably HPV vaccination of both girls and boys and vaccination of seniors against influenza and pneumonia.
Trauma-informed care. At its most basic, a trauma-informed approach changes the question from "What's wrong with you?" to "What’s happened to you?"[iii]
Policy for a healthy food environment. Tax abatements to retailers of healthy food can support a healthy food environment as well.[iv]
Complex Problems Requiring Complex Solutions. These issues call for long-term, complex, multi-sector interventions.
Mental illness and substance use. This set of interrelated issues includes mild to severe mental illness including depression and post-traumatic stress disorder (PTSD), problem drinking, and problem drug use, including prescribed medications.
Physical inactivity. Physical activity is a lever of some kind – a contributor to or an effective intervention for – a number of other important health issues like depression, overweight and obesity, and chronic physical illness and disability.
Unhealthy eating and hunger. Unhealthy eating contributes in different ways to a number of health issues, notably overweight and obesity, diabetes, and heart disease and stroke. Hunger is one of the single greatest threats to the well-being of low-income seniors and remains a serious problem for children as well.
Senior whole-life well-being. Rapid growth in the senior population will place increasingly significant demands on local health care and social service systems. A completely different approach to senior well-being is needed if this large segment of the county population is to thrive with a high quality of life, not simply survive until an advanced age.
Unplanned pregnancy. Reducing unplanned pregnancy can only yield improvements in birth outcomes, maternal health and well-being, the prevalence of adverse childhood experiences, and a host of other issues.
Interpersonal violence. Child abuse, family violence, and street violence are common in Bexar County and do serious harm to health and well-being.
Premature mortality among people of color and low-income people. Particularly for lower-income males [MLC1] of color, Bexar County’s premature mortality is striking. Premature death is an inarguable metric and the inevitable conclusion of years or decades of health inequity.
Root Causes. Four key root causes interact with each other in a vicious cycle, within and across generations, and contribute to high-risk environments, unhealthy behaviors, and injury, illness, and death. The list of all root causes could be much longer, but these four are core for Bexar County.
Low income and poverty, including income inequality and segregation.
Educational attainment, including low literacy and health literacy.
Criminal and juvenile justice, including barriers to employment and exposure to violence.
Adverse childhood experiences (ACE), including direct victimization and exposure.
System-Level Barriers to Effective Action. These issues hinder effective action to improve health outcomes and the environment in which health outcomes develop.
Gaps and disparities in data quality. One pattern that emerges very clearly throughout this assessment is the disparity not just in health determinants and outcomes, but also in the quality of the data about those determinants and outcomes.
Working effectively across organizations and sectors. The collective impact approach is being deployed in a number of local initiatives. Health impact investing is an emerging approach to collaboratively financing efforts to improve health outcomes.[v]
Improving Data-Driven Decision-Making
The Health Collaborative believes the time is right to create a portal to access detailed local data online, knowing that the portal’s features and content will need to evolve over time in response to changing local needs and data availability. The Health Collaborative has partnered with Community Information Now (CI:Now) a local data intermediary serving south central Texas, to create and maintain this portal. The portal will let the user:
Visually explore data for different populations and geographic areas using maps, line charts, bar charts, and other graphics.
Understand the data and use it more effectively. Graphics and notes in the platform will show and explain critical concepts like margin of error and multi-year average rates.
Export maps and charts with title, legend, data years, and source intact.
Export aggregate data tables, with metadata intact, for further processing or analysis.
Taking Action: Community Health Improvement Plan
This year will mark the third iteration of the Community Health Improvement Plan (CHIP), a community plan that identifies five priority areas, establishes objectives for change in those areas, identifies needed partners, and lays out strategies for each objective.
Healthy Eating and Active Living
Healthy Child and Family Development
Behavioral and Mental Well-Being
The 2016 CHIP process will begin in fall 2016. This assessment will inform a review and revision, if necessary, of these five focus areas and of the associated objectives and performance measures. The emphasis will be on moving from planning and consensus-building to collaborative action. Effective action will likely require infrastructure and community capacity to support active performance management or collective impact, including tracking strategies and near-term outcomes or milestones that indicate progress or the need for mid-course corrections.
[i] See for example, McGovern, L., Miller, G., & Hughes-Cromwick, P. (2014, August 21). Health Policy Brief: The Relative Contribution of Multiple Determinants to Health Outcomes. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_123.pdf
[ii] U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2010). Healthy People 2020. Washington, D.C. https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities
[iii][iii] See for example, U.S. D.H.H.S. Administration for Children and Families. (2012). Asking: “What’s Happened to You?” A Focus on Trauma-informed Care. http://www.acf.hhs.gov/programs/fysb/resource/exchange-trauma-informed-care
[iv] Centers for Disease Control and Prevention. (2014). Healthier food retail: An action guide for public health practitioners. http://www.cdc.gov/nccdphp/dnpao/state-local-programs/healthier-food-retail.html.
[v] Centers for Disease Control and Prevention, Division of Community Health. (n.d.). An introduction to impact investing in public health. http://www.cdc.gov/nccdphp/dch/pdfs/impact-investing-public-health.pdf
Figure 1.1 -- Click to Enlarge.
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