Community Development Initiatives (CDI) at Angelo State University was privileged during 2015 to lead an important yearlong study of regional health needs. CDI conducted the Survey of Health and Behavioral Health Needs of the Poor & Extremely Poor in West Texas between January and December of 2015.

The study covered 20 counties including Coke, Concho, Crockett, Edwards, Irion, Kimble, Kinney, Mason, McCulloch, Menard, Mills, Reagan, Runnels, San Saba, Schleicher, Sterling, Sutton, Tom Green, Upton and Val Verde. CDI and 72 community-based organizations across the region collaborated to complete a detailed face-to-face interview with a sample representing the more than 39,000 residents of the 20 counties living in poverty. CDI-trained members of many local communities were included in the study to help conduct interviews. Working along with CDI’s own research staff, they completed 597 interviews, including 280 (46.9%) with respondents from the more than 14,000 “extremely poor” residents in the region who live on incomes below half of the poverty level.

Interviewers collected information on more than 170 health-related factors. These included 31 items modeled on questions answered in 2013 by respondents representing the general adult population of Texas in an annual survey called the Behavioral Risk Factor Surveillance System (BRFSS).

Conducted statewide by the Texas Department of State Health Services, the BRFSS is part of a national CDC (Centers for Disease Control & Prevention) effort to track and monitor behavior and health risks in the overall population. By including 31 related items, the project gained the ability to compare responses of poor and extremely poor residents to the general regional population as reported in the BRFSS results.

A general result of these comparisons is that the level of health risk among poor residents in the region is much higher than the general population.

For instance, most knowledgeable citizens recognize that people in poverty often do not have a personal doctor, and frequently have trouble paying the cost of going to see one. However, many would not anticipate the large gaps the survey revealed between the poor and the overall adult population on these important factors affecting access to health care.
Many people also know that low income adults are more likely to smoke or use tobacco products. Fewer would guess, however, that 25 percent more local adults in poverty are current tobacco users. In fact, more than four of every ten (43.4%) of the 275 Tom Green County residents interviewed in survey of the poor and extremely poor reported they smoke or use tobacco. This compares to an estimate from the 2013 BRFSS of 18.7 percent for the overall adult population of the county. A higher level of exposure to second-hand smoke in the home is a related issue for local residents living in poverty.

Meanwhile, the American Lung Association’s recent 2016 State of Tobacco Control report gives Texas a straight “F” grade for creating access to tobacco cessation services, despite estimates that smoking costs Texans over $8.8 billion annually and more than 28,000 die from smoking-related causes.

Obesity is another significantly elevated health risk within the local poverty population. The interview data indicates that 44.6 percent of the poor in Tom Green County are obese compared to 32.8 percent of the overall county population according to the BRFSS. The added level of difficulty reported by the poor in getting access to fresh fruits and vegetables aggravates the problem.

The excess number of people in poverty who report being diagnosed with depression is one of the most telling findings from the survey. One of two (50.2%) poor and extremely poor residents of Tom Green County confirmed to interviewers that they were told by a professional they had depression or anxiety. A comparable item in the 2013 BRFSS indicated that medical or mental health professionals similarly diagnosed 15.1% of the county’s overall adult population.

Gregory Rowe, executive director of the regional MHMR Services, touched on the potent importance of this disparity in his excellent recent appeal to raise awareness of mental illness. In the May 12 edition of the Standard Times, Mr. Rowe wrote, “. . . people living with a serious mental illness die 25 years earlier than other Americans, largely because of other treatable medical conditions that are complicated by mental illness.”

Based on these and other findings from the survey, CDI identified hundreds of needs for reducing health risks across the 20 counties in the study region. These included 20 challenging issues for Tom Green County.

To gain a sense of the priority that should be attached to various needs, the project team contacted a wide variety of key informants comprised of community leaders and stakeholders who work every day in health care, or in the trenches providing services to the poor. Thirty-eight key informants in Tom Green County rated each of the 20 issues identified by CDI from the survey results.

The key informants used a rating system to assign priorities. They rated every issue on each of four separate factors including: 1) Prevalence – the number of people potentially affected; 2) Significance – the consequences of not addressing the need; 3) Impact – the impact on vulnerable populations; and 4) Feasibility – the likelihood that the community takes action. Informants used higher ratings on a five-point scale to assign a greater sense of Prevalence, Significance, Impact, or Feasibility to an issue. Of course, lower scores signaled less priority.

TOP SEVEN PRIORITIES

The average of the four ratings provided the overall priority score for each issue. The process resulted in the following seven top priorities for Tom Green County: 1) increase ability to address needs of growing numbers of seniors and children; 2) prevent diabetes and reduce hospitalization for diabetes; 3) increase investment in community health needs; 4) prevent obesity; 5) reduce cost and other barriers to care; 6) increase services for depression; and 7) increase services for alcohol and drug abuse.

Concerted efforts to work together as a community on any one of these priorities could lead to immense improvements in the quality of life among the county’s poverty population while averting countless early deaths from preventable causes and saving millions or billions of dollars in avoidable economic costs to the community. To us, the most challenging result from the rating process is the relatively timid sense of feasibility conveyed by the key informants. Feasibility, as noted, refers to the assessment by key informants of the likelihood of the community taking action on a given health-related need.
For the top Tom Green County priorities, feasibility ratings from the 38 key informants ranged from 2.9 (for the need to reduce cost and other barriers to care) to 3.7 (for addressing the needs of seniors and children). The average feasibility rating for the top seven priorities was 3.3 on the 5-point scale.

This finding shows the key informants generally held only a moderate sense that community actions to address priority health needs are feasible. The finding clashes with much stronger assessments from key informants that the top priority health needs strongly impact vulnerable groups and carry significant consequences if not addressed.
Like the beloved journalist and Texas commentator Molly Ivins quipped, “It’s a low-tax, low-service state – so shoot us. The only depressing part is that, unlike Mississippi, we can afford to do better. We just don’t.”

For the sake of a vibrant community and sustainable economy in the future, we hope Tom Green County’s local leaders and citizens will come together to work in ways like never before to solve just one of the challenging, high priority health and behavior risks.


Dr. Casey Jones co-authored this article with Dr. Kenneth Stewart. Dr. Jones is a recently retired professor of political science at ASU.

Methodist Healthcare Ministries of South Texas and the San Angelo Health Foundation provided support for The Survey of Health and Behavioral Health Needs of the Poor & Extremely Poor in West Texas. The observations expressed in this article are strictly those of the authors and do not necessarily reflect the views of Methodist Healthcare Ministries or the San Angelo Health Foundation.

Susan McLane served as project director for The Survey of Health and Behavioral Health Needs of the Poor & Extremely Poor in West Texas. Cera Cantu served as research assistant to the project. 

This article first appeared in the San Angelo Standard-Times, June 2, 2016.