What Drives Health in Southwest Houston? · Azeb Yusuf Lizbeth Navarro Dr. Aisha Siddiqui Chau Le...

1Texas Health Institute

Findings from a Community-Based Survey of the Social Determinants of Health

What Drives Health in Southwest Houston?

June 2020


About Texas Health InstituteWe are a non-profit, non-partisan public health institute with the mission of advancing the health of all. Since 1964, we have served as a trusted, leading voice on public health and healthcare issues in Texas and the nation. Our expertise, strategies, and nimble approach makes us an

integral and essential partner in driving systems change. We work across and within sectors to lead collaborative efforts and facilitate connections

to foster systems that provide the opportunity for everyone to lead a healthy life.

Developed by Texas Health InstituteWith Support from Memorial Hermann Community Benefit Corporation

In Partnership with the Alliance, Bee Busy Wellness Center, Community Health Choice, Culture of Health-Advancing Together,

Chinese Community Center


ACKNOWLEDGEMENTS

the Alliance Bee Busy WellnessCenter

Culture ofHealth-AdvancingTogether

Community HealthChoice

Chinese CommunityCenter

We would also like to thank the following individuals for their contributions: Asha Minx, Suzane Abedi, Gracy Garces, Danielle Bolks, Arsel Kisanga, Tosha Atibu, Ndjabuka Francine Murhebwa, Pierrene Spitalen, Ghadah Altemimi, Samana Muzaffari, Zainab Brown, Mohammed Ali, Ileana Quirch, Haala Binyam, Emerald, Alexander Le, Maleeha, Marzia, Zarmina, Fahmida, Walayat Bibi, Bibi Amina, Thao Nguyen, Zulfigaz Zakhil, Werishmen, Daniela, Khyal Bibi, Maryam, Norya, Sheema, and Zaw.

Ankit Sanghavi, BDS, MPH, Executive DirectorNadia Siddiqui, MPH, Director of Health Equity ProgramsDennis Andrulis, PhD, MPH, Senior Research ScientistKenneth Smith, PhD, Senior Health Policy Research AnalystAfrida Faria, MPH, Health Policy Research AnalystGilberto Sauceda, Designer

Texas Health Institute Team

We are grateful to the contributions of our colleagues, partners and volunteers who provided invaluable insights and led the charge for conducting these surveys across Southwest Houston’s diverse communities.

Community Partners

Miriam Diria Aisha KoromaSophie AlbertIsaac Lian Halaa Al-Saadi Sendet SerembaMuhtan OoIsaiah SibomanaMaria CastilloBrendan Sullivan

Norman MitchellAzeb YusufLizbeth Navarro

Dr. Aisha Siddiqui Chau Le Dr. Paul Rowan Jamila Raja Chris Guzman Modupeola Keteyi Halah Abood

Pearl YangPhan Quach Sue ZhouAgnes Nguyen

Daisy Morales Jo Lynn TurnerMarisol Montero Ivana Pena


CONTENTSCONTENTS EXECUTIVE SUMMARY............................................................................................................ 5INTRODUCTION ....................................................................................................................... 14 Why Southwest Houston? .............................................................................................. 15DESIGN & METHODS ............................................................................................................... 16 Community Partnerships ................................................................................................ 16 Survey ............................................................................................................................. 16 Sampling ......................................................................................................................... 17 Survey Administration ..................................................................................................... 17 Data Analysis .................................................................................................................. 18 Limitations ...................................................................................................................... 18 Survey Respondents........................................................................................................ 18FINDINGS .................................................................................................................................. 20 What is the Health of Southwest Houstonians? .............................................................. 20 General and Mental Health Status ............................................................................ 20 Common Chronic Conditions ................................................................................... 21 HowDoSouthwestHoustoniansDefineHealth?...........................................................23 DefiningHealth...............................................................................................................23 Factors Important to Health ...................................................................................... 24 What are Top Barriers to Health? .............................................................................. 26 What are the Health-Related Social Needs? ................................................................... 28 AccesstoAffordableandHealthyFoods..................................................................28 NeighborhoodConditions.........................................................................................29 Housing.....................................................................................................................32 Transportation........................................................................................................... 33 Socioeconomicfactors..............................................................................................34 SocialConnectedness..............................................................................................34 HealthInsurance...................................................................................................... 35 PersonalHealthCareProvider..................................................................................35 ForgoingCareDuetoCost.......................................................................................36 WhatFactorsHelpSouthwestHoustoniansBeHealthy?...............................................37 TopRankedFacilitators.............................................................................................37 ImprovingNeighborhoodConditions.......................................................................38 ImprovingHealthyEatingOpportunities...................................................................39 Improving Transportation for Health .......................................................................... 40 Sources of Health Information ................................................................................... 41 What Role Can Health Care Systems Play? .................................................................... 42MOVING FORWARD .................................................................................................................. 44 Recommendation 1: Engage diverse community partners ............................................. 47 Recommendation 2: Expand health-related social needs screening ............................ 50 Recommendation3:Investininitiativesaddressingsocialdeterminants.......................52 Recommendation 4: Culturally and linguistically tailored resources............................... 55CONCLUSION ........................................................................................................................... 57REFERENCES ........................................................................................................................... 58


INTRODUCTIONSouthwest Houston is one of the nation’s most racially and ethnically diverse and densely populated communities, rich in culture and history, yet facing aconfluenceofsocial,economic,environmentaland health challenges. Nearly one in three people livebelowthefederalpovertylevel,withsomeneighborhoodshavingoneineverytwochildreninpoverty. The uninsured rate is roughly twice as high in the Southwest area (45%) than Greater Houston (23%)andthestate(19%),andfivetimeshigherthanthenation(9%).Crimeandsafetyareseriousconcerns. Together these circumstances have contributedtoworseninghealthandgrowinginequities across the region.

Thesechallengesarebeingfurthertestedandamplifiedinthefaceoftheongoingcoronaviruspandemic, underscoring the need and urgency to addresstherootdriversofhealth—includingstablejobsandincome,housing,foodsecurity,safeneighborhoods,andaccesstohealthcare—thatarecoreandcentraltobuildingresilienceofcommunitiestowithstandandbouncebackfrompublichealthemergencies.

While there is growing recognition and momentum in Greater Houston to address health more holistically workingcollaborativelyacrosssectors,littleisknownabouthowcommunitiesperceiveandprioritizethedrivers of health. What do Southwest Houstonians sayarethetopfactorsthataffecttheirabilitytoleadand achieve a healthy life? Community voices and perspectives are critical to informing priority issues, and in turn shaping tailored solutions to move the needle on health improvement.

The purpose of this initiative was three-fold:

1.Toconductafirst-of-itskind community-basedsurveytoidentifyand prioritizetheprimarysocialdeterminants driving health in Southwest Houston.

2.Toidentifydistinctneighborhoodneeds and lived experiences of diverse populations in Southwest Houston.

3.Toinformactionableandcollaborative solutions to improve population health and health equity in Southwest Houston.

DESIGN

Our Partners. TexasHealthInstitutecollaboratedwithfivecommunitypartners–theAllianceforMulticultural Community Services, Bee Busy Wellness Center, Community Health Choice, Chinese Community Center, and Culture of Health-Advancing Together. Our partners were engaged throughout the project, from informing the survey instrument to leading on-the-ground data collection across communities and helping to interpret and ground-truthfindings.

community-based surveyconducted in over two-dozen

languages anddialects to identify andprioritize the primarysocial determinants

driving health inSouthwest Houston

EXECUTIVE SUMMARY


Survey Instrument. The 54-item survey asked communitymemberstoidentifytheir:

•Self-reportedgeneralandmentalhealth

•Beliefsabouthealth

•Topbarriersandfacilitatorstohealth

•Perceptionsofhowfood,housing,transportation,neighborhoodconditions,financialcircumstances,andhealthcareaccessaffecttheirhealth

•Attitudestowardcurrentandpotentialrole of health care providers in screening health-related social needs

Survey Administration. A total of 1,000 surveys wereconductedutilizingaquotasamplingmethodolgy.Surveys were conducted electronically in-person, interview-styleinovertwo-dozenlanguagesbymorethan40trainedcommunitysurveyorsfromOctober21,2019toDecember31,2019.Criteriaforparticipationrequiredrespondentstobe18yearsofageorolderandliving in the seven Zip Code study area. Individuals were surveyed at a variety of community settings, such as apartment complexes, hair salons, places of worship, grocery stores, cafes, food pantries, and at partner organizationfacilities.

Analysis.DatawereweightedbyZipCode,race/ethnicity,andsextoberepresentativeofthegeneral population in Southwest Houston. Univariate andbivariateanalyseswereconductedonweighteddata,andmultivariateprobabilitymodelsonunweighteddatatoexaminedifferencesbetweenneighborhoodsadjusting for race/ethnicity, sex, age, and education.

77035 (Westbury) 11%

77036 (Sharpstown) 23%

77071 (Fondren) 7%

77072 (Alief) 12%

77074 (Sharpstown) 22%

77081 (Gulfton) 12%

77099 (Alief) 13%

Hispanic 32%

Non-Hispanic White 9%

Non-Hispanic Black 26%

Non-Hispanic Asian 29%

Non-Hispanic Other 4%

Refugee or Asylee 17%

Limited English Proficient 73%

Zip Code/Neighborhood

Race and Ethnicity

Characteristics of Respondents (n=1,000)

Other Characteristics


WELL

BODYlife

Physically

Important

LIVING

Wellbeing

mental care

lifeoverall

mentality

conditions

HAPPY

MIND

sick

soul

stable

overall

family

take

need

stayWORKINGDISEASE

exercise

sick

Most Common Terms Used by Southwest Houstonians to Define Health

eating

soul

exercise

family

eating

conditionsshape

happiness

stay

lifestyle

value

eating

working

wellbeing

overall

without person

important

everyone

precious

happiness

doctor

humanwithout

family

stable

overall

without

energy

free


KEY TAKEAWAYS1. Southwest Houston has a high burden of chronic disease, and wide inequities by race and ethnicity.

SouthwestHoustoniansfacehigherratesofbloodpressure(32%),diabetes(19%)anddepression(19%)than residents on average in Harris County and Texas. At the same time, some racial/ethnic groups, such as Whites and Blacks face even higher rates—especially compared to immigrants in the community. For example,BlacksofUSorigin(36%)reportedarateofdepression three times higher than Blacks identifying with African countries (12%), and twice the rate of depression than the state of Texas (17%). Asian and Hispanicsubpopulationsalsoreporteddifferingburdensof disease, with Vietnamese, for example reporting a higherrateofhighbloodpressurethanallotherAsiangroups.

2. Southwest Houstonians believe health is multifaceted and driven by more than just health care.

Southwest Houston residents were asked to report what factors are important to their health. They reported that broadersocial,economicandenvironmentaldeterminants are just as critical to their health as health carefactors.Specifically,fouroutoffivesaidthathavingaccesstoaffordableandnutritiousfoods(86%),astablejobandincome(84%),safeneighborhood(84%),affordablehousing(82%),andaccesstotransportation(81%) are just as important to their health as having health insurance (87%) and access to a doctor (85%). Thesebeliefsgenerallyheldtrueacrossallracialandethnicgroupsandneighborhoods.

3. Southwest Houston residents face a complex web of social, economic, environmental, and health care barriers to health.

Our study reveals the stark realities facing communities across Southwest Houston, highlighting the many challenges they experience in their day-to-day lives thataffecthealth.Dataonfoodinsecurity,housing,neighborhoodconditions,transportation,socialcohesion,andhealthcareaccessoverall,byracial/ethnicsubpopulationgroups,andneighborhoodsprovide important insight on the gaps people face in the opportunity to achieve health in Southwest Houston.

White African American AfricanMexican Salvadorian Other HispanicAfghani Chinese Vietnamese Other Asian

High BloodPressure

Diabetes

Depression

Top Chronic Conditions Reported inSouthwest Houston by Race and Ethnicity

46%46%

26%26%

31%

4%20%

15%40%

30%

29%30%

12%19%20%

17%23%

28%36%

12%17%

11%5%5%5%

11%12%

27%

5%1%

Health Insurance

Access to Affordable,Nutritious Foods

Access to Doctor

Safe Neighborhood

Stable Job & Income

Affordable & Quality Housing

Access to Transportation

87%

86%

85%

84%

84%

82%

81%

Percentage Reporting Very Importantor Important Factors to their Health


55%

HEALTH CARE ACCESS

FOOD INSECURITY

40%40%

36%

Were unable to pay for food when it wasneeded in the past year

Could not consume fresh fruits andvegetables because they could not afford to

Could not consume fresh fruits andvegetables because they were either notavailable or in poor quality at their store

Percent Unable to Pay for FoodWhen Needed in the Past Year

White Black Hispanic Asian

52% 48% 43%31%

65%

43% 43% 41%30%

Fondren Alief Gulfton Westbury Sharpstown

HOUSING

55% Face severe housing cost burden, spending more than half their income on rent or mortgage

TRANSPORTATION

41% Could not seek medical care due to lack of transportation

Percent Spending More than Half of TheirIncome on Rent or Mortgage

White Hispanic Black Asian

Westbury Fondren Alief Gulfton Sharpstown

62% 57% 50%

70%

19%

47%

56%69%

CRIME POLLUTION

STRAY ANIMALS FLOODING

Big Problem Somewhat of a Problem Not a Problem

NEIGHBORHOOD CONDITIONS

45%Identify three or more neighborhoodbarriers such as crime, pollution, strayanimals, flooding, and lack of walkable spaces as “big” problems to their health

49%

23%

28%

28%

35%

26%

45%

31%

24%

36%36%39%

47%44%

Without health insurance

Percent Without Health Insurance andWithout Health Care Provider

Hispanic Black White Asian

47% 46% 42%33%

20%27%

61%53%

Without a health care provider

35% Forego care due to cost

Without health insurance Without a health care provider


4. Southwest Houston residents most commonly rank food insecurity, neighborhood safety, and pollution as their number one barrier to health.

OfallthebarriersSouthwestHoustoniansface,theywereaskedtorankordertheirtopthree.Thefivemostcommonresponsesprovidedforthenumberone(topranked)barrierincluded:(1)lackofaccesstoaffordableandhealthyfoods;(2)neighborhoodcrimeandviolence;(3)pollution;(4)otherphysicalenvironmentfactors;and(5) access to health insurance and care.

5. Southwest Houstonians say thataccess to affordable and healthyfoods, neighborhood parks and cleanenvironment help them be healthy.

Residents were asked to rank order their top facilitators tohealth.Themostcommonlycitednumberonefacilitatorswere:neighborhoodconditionsincludingcleanandsafespacesandaccessiblecommunityamenities such as pools, gyms, and free exercise classes(21%);accesstowalkablespacessuchas

parksandsidewalks(20%);andaccesstoaffordable,healthyfoodsthroughfoodpantries,nearbygrocerystores, and food fairs (15%).

6. Southwest Houston residents say it is important that health care providers screen for their social needs when providing care.

At least two-thirds of Southwest Houstonians said that it is very important or important that when providing care, healthcareprovidersaskabouttheirsocialneedssuchasaccesstofood,neighborhood,financialsituation,housing and others. However, they reported that very fewprovidersactuallyaskthemquestionsabouttheirhealth-related social needs. Food insecurity was most commonlyidentifiedasbeingscreenedbyhealthcareproviders—with 12% saying they were very often/often asked this question.

Percentage Reporting their Number One (Top Ranked)

Barrier to Health

Transportation

18%

18%

15%

14%

10%

6%

19%

Affordable &Healthy Food

Access

Crime

Pollution

OtherPhysical

Environment

HealthcareAccess

Other

Percent Reporting it is VeryImportant/Important Providers Ask About

Social Needs vs. Percent ReportingProviders Very Often/Often Ask About

Social Needs

Finance

Transportation

Access to Food

Neighborhood

Housing

Very Important/ImportantVery Often/Often

69%8%

66%

5%

70%

12%

66%3%

65%4%


MOVING FORWARDOursurveyfindingsaffirmthatsolutionstomeasurablyimprove health in Southwest Houston must address the multifaceted nature of health as well as the distinct needs of communities. As we found health is not driven byanyonefactor,butbyacombinationofcomplexdeterminants that will require working across systems—health care, food, environment, housing, education, and transportation. While health systems and providers have an important role to play in addressing these root drivers, localgovernment,publichealthagencies,philanthropies,social service agencies, community development organizations,businesses,andothersarejustascritical to leading and partnering in solutions. As such,goingforward,werecognizethatmovingtheneedle on improving health in Southwest Houston will require solutions at multiple levels—community, health system,andindividual—balancingbroaderinitiativeswith tailored interventions to address the distinct needsofneighborhoodsanddiverseindividuals.

RECOMMENDATIONS1. Engage diverse community members, cross-sector partners, and subject matter experts as part of Community Action Teams dedicated to addressing food insecurity, neighborhood safety, and other urgent priorities.

WerecommendbuildingCommunityActionTeamscomprised of racially, ethically, and linguistically diversecommunitymembers,keystakeholders,andsubjectmatterexpertsfromSouthwestHouston,with each team working to develop and execute a concrete plan of action for addressing urgent priorities.Animportantstartingpointwillbetoaddress food insecurity—a priority determinant inextricablylinkedwithhigherratesofhypertension,diabetesandotherchronicconditions.Doingsowillrequirebringingtherightpartnerstothetable,suchasmembersofthecommunity,faithorganizations,andneighborhoodleadersalongsidehealthsystems,socialserviceorganizations,andfoodbankstocommittodrivingmeaningfulandsustainablechange. It will also require alignment with existing community initaitives such as the Mayor of Houston’s Complete Communties initiative in Gulfton and Alief, whilealsobuildingonsuccessfulinitiativessuchashealthycornerstores,neighborhoodfarmer’s markets, and food pharmacies.

2. Expand health-related social needs screenings and referrals across health systems.

There is clear consensus of the critical role that health care providers can play to identify and address patient’ssocialneeds.Suchcommunitybuy-in—together with evidence from around the country demonstrating that social screenings and community referrals have indeed reduced social needs and improved overall health status—provide a strong caseforfurtherexpandingandbuildingouttheseeffortsacrosshealthsystemsintheSouthwestregion,andGreaterHoustonmorebroadly.

Health Systems

Individual

• Recommendation 2: Expand health-related social needs screenings and community referral networks.

• Recommendation 3: Champion & invest in upstream community initiatives to address the social determinants of health.

• Recommendation 1: Engage diverse community members, cross-sector partners, and subject matter experts as part of Community Action Teams dedicated to addressing food insecurity, neighborhood safety, and other urgent priorities.

Community

• Recommendation 4: Provide culturally and linguistically tailored education, programs, and resources to better reach diverse individuals

Levels of Action to Improve Health and Well-Being in Southwest Houston


3. Champion and invest in evidence-informed community initiatives to address the social determinants of health.

Improving the conditions for health, and in turn healthoutcomes,willrequireashiftineffortsfocused solely on social determinants in health care to those focused on health. Health systems serving Southwest Houstonians can play a more meaningful role to champion and invest in targeted, evidence-informed interventions and innovations working in harmony with the community and other cross-sector partners to address the determinants of health outside their four walls. Many large health systems around the nation are playing a greater role to invest in the overall vitality of their communities asawayofdoingbusiness,pushingfurtherupstreamtosupportaffordablehousing,localjobs,transportation, and other social determinants of health.

4. Provide culturally and linguistically tailored programs, education and resources to better reach diverse individuals.

Ourfindingsunderscoretheimportanceofdeveloping programs and education that are tailored to the distinct needs and circumstances of diverse populations to ensure their understanding, reception and adherence to important information, guidance and access to resources. Doing so will require meeting individuals where they are; providing information through trusted messengers and voices; assuring culturally and linguistically appropriateandtailoredmessages;andrecognizingthat many individuals will require multiple touches. Ensuringculturalandlinguisticcompetencewillbecrucial across the spectrum of initiatives targeting Southwest Houstonians, including social needs screenings, community referrals, and information resources.

CONCLUSIONOur study revealed a richly detailed portrait of the lives, hopes and challenges of residents across Southwest Houston. While each community is distinct, their voices reveal shared priorities and reinforcethatthepathtohealthandwell-beingforallresidentsmustrecognizeandaddressthesocialdeterminants of health. These priorities take on greaterurgencyinthefaceofpublichealththreats,such as the ongoing coronavirus pandemic, as social, economic and health care needs not only deepen,buttheneedtoreachdiversepopulationsin trusted, culturally and linguistically appropriate waysbecomescentraltoprotectingandbuildingtheir resilience, as well as that of all people in Southwest Houston and Greater Houston.


Southwest Houston is among one of the

nation’s most racially and ethnically diverse and densely populated communities, rich in

culture and history, yet facing a confluence of

social, economic, environmental and health challenges.


Southwest Houston is among one of the nation’s most racially and ethnically diverse and densely populated communities, rich in culture and history, yet facing a confluenceofsocial,economic,environmentalandhealth challenges. While the average life expectancy atbirthforsomeintheregionis84years,residentsafew miles away can expect to live to just 75 years.1

Arobustbodyofevidencedocumentsthathealthisshapedbyfactorsmorethanjusthealthcare.Itisproducedbyconditionsinwhichpeopleareborn,grow, live, work and age, also referred to as the socialdeterminants of health.2 While there is growing recognition and momentum in Greater Houston to address health more holistically, working in collaborationacrosssectors,littleisknownabouthowcommunitiesperceiveandprioritizethedriversofhealth. What do Southwest Houstonians say are the factorsthataffecttheirabilitytoleadandachieveahealthy life? Community voices and perspectives are critical to informing and setting priorities, and shaping tailored policy interventions to move the needle on health improvement.

With support from Memorial Hermann Community BenefitCorporation,TexasHealthInstituteconductedafirst-of-its-kindcommunitysurveyinitiativeinSouthwest Houston, working in partnership with the Alliance for Multicultural Community Services, Bee Busy Wellness Center, Chinese Community Center, Community Health Choice, and Culture of Health-Advancing Together. The purpose of this initiative was three-fold:

1.Toconductacommunity-basedsurveytoidentifyandprioritizetheprimarysocial determinants driving health in Southwest Houston.

2.Toidentifydistinctneighborhoodneedsand lived experiences of diverse populations in Southwest Houston.

3.Toinformactionableandcollaborative solutions to improve population health and health equity in Southwest Houston.

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Figure 1: Southwest Houston 7 Zip Code Study Area

INTRODUCTION


Why Southwest Houston?

SouthwestHoustonisauniquecommunity,vibrantandrich in diversity. It is home to a culturally andlinguistically diverse population, with people from more than 80 countries including Mexico, Central America, Somalia, Afghanistan, and Pakistan.3 Whites comprise just12%ofthepopulation,comparedto35%and42% in Houston and Texas, respectively. Over 140 languages are spoken, and a large percentage of peoplefacelimitedEnglishproficiency.Atthesametime,SouthwestHoustonfacesacomplexwebofchronic social, economic, environmental and health challenges, which have not only remained stagnant overtime,butinsomecaseshaveworsened.4,5 These circumstanceshavebeenfurthercompoundedbytheongoingthreatofpublichealthemergenciesthatrevealtheregion’svulnerability.SouthwestcommunitieswereamongthosehardhitbyHurricaneHarvey,andintheface of the ongoing coronavirus pandemic are among neighborhoodsvulnerabletofacingadversehealth,economic, and social outcomes.

Poverty is concentrated in these communities and has grownbyasmuchas15%since2010acrosssomeneighborhoods.6 Whereas 15% and 21% of the population in Texas and Greater Houston, respectively, livebelowthefederalpovertylevel,onaverage29%ofSouthwest Houstonians live in poverty.7,8 In the neighborhoodsofGulftonandSharpstown,twoineveryfiveadultsandoneineverytwochildrenliveinpoverty,respectively.9 The Health of Houston 2018 Survey further identifiedseveralSouthwestneighborhoodsashavingsome of the highest percentage of adults facing economic hardship—a reality that has not improved since their initial 2010 survey.10

The uninsured rate is roughly twice as high in Southwest Houston(45%)ascomparedtoGreaterHouston(23%)andthestate(19%),androughlyfivetimeshigherthanthenationalaverage(9%).11 Harris Cares 2020identifiedSouthwest Houston among regions with high preventableadulthospitalizations,andrelateduncompensated care costs. Similarly, Memorial Hermann’s 2019 Community Health Needs Assessment identifiedaclusterofzipcodes—includingGulfton,Sharpstown,andAlief—ashavingthehighestnumberofinpatient discharges in the southwest region.

Crime and safety are also ongoing concerns. Alief, Gulfton,Sharpstown,Westbury,WestwoodandBraeburninthesouthwestcorridor,allfallinthetop20%ofneighborhoodswiththehighestviolentcrimerates in Houston.12 According to the Kinder Houston Area Survey, more than two-thirds of residents in SouthwestHoustonfeartheywillbecomeavictimofcrime13—a factor that often serves as a mental stressor and an impediment to outdoor physical activity across communities.

Together,thesedataonthebroadersocialdeterminantsof health paint a portrait of the daily challenges facing people of Southwest Houston. As the 2018 Health of Houston Survey revealed, while poor health outcomes in Southwest Houston have remained largely stagnant, some measures of chronic disease have indeed worsened.Forexample,therateofdiabetesrosefrom15.0%in2010to21.3%in2018inGulfton.14

5%

SouthwestHouston

GreaterHouston

Texas

Uninsured 45% 23% 19%

Figure 2: Comparing Sociodemographic Characteristics

White 12% 35% 42%Hispanic 54% 38% 40%Black 22% 18% 13%Asian 11% 7% 5%

BelowPoverty 29% 21% 15%


Community PartnershipsWepartneredwithfivecommunity-basedorganizationsanchoredin,trusted,andrepresentativeof diverse populations in Southwest Houston: the Alliance for Multicultural Community Services, Bee Busy Wellness Center, Community Health Choice, Chinese Community Center, and Culture of Health-Advancing Together. These partners were engaged throughout the course of the project, from inception and survey development to data collection sense-making and reporting out. Key leadership, staff,communityhealthworkers,navigators,andvolunteersfromeachoftheorganizationsservedasour ongoing Community Advisory Group, guiding and grounding the work in the community’s reality, while also serving as the trusted face of the project on the groundacrossneighborhoods.

SurveySurveycontentwasinformedbyourprevioushealthsurvey initiatives, as well as validated surveys in thefield,andimportantly,inputandguidancefromcommunity partners on priority topics most relevant to Southwest Houston. The purpose of the surveywastoidentifyandprioritizetheSouthwestcommunity’s experiences and perspectives on the socialdeterminantsofhealththatenableorinhibit

people’sabilitytoleadhealthylives.Wedrafteda preliminary version of the survey, compiling a list of relevant validated questions from national, state and local surveys such as the Behavior Risk Factor Surveillance System, Health of Houston Survey, American Health Values Survey, Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE), and others. Community partners reviewed and provided input on the draft survey through an in-person meeting and follow-up communication, which was folded into a finaldraft.

Thefinalsurveyincludedatotalof54questionsaskingaboutdemographics,healthstatus,beliefsaboutbarriersandfacilitatorstohealth;individualsectionsassessingexperienceswithspecificsocialdeterminants of health such as food insecurity, housing,transportation,andfinance;andexperiences and attitudes toward role of health care providers in addressing health-related social needs. Through the assistance of community partners, the survey was translated into Vietnamese, Mandarin Chinese, and Spanish.

DESIGN & METHODS


iNotwithstandingthecaveatofsamplebias,thesampleof1,000inapopulationof350,000isassociatedwithamarginoferrorof±3.09%.

SamplingTheobjectiveofoursamplingmethodologywasto:(1) capture the voice of diverse communities in Southwest Houston, including immigrants, refugees, linguistically-isolated, and (2) ensure the characteristics of the sample matched those of the overall population. To this end, we employed a quota sampling methodology that required survey interviewers to target respondentsfromspecificZipCodesandwithspecific(presumed) demographic characteristics. While not a randomsample,quotasamplingminimizessomeofthebiasesthatarisefromanunbalanced,conveniencesample.Inaddition,itenablestheuseofpopulationweights to estimate prevalence measures for the population as a whole.

Theprojectbudgetenabledustotargetasmanyas1,000interviewstobeconductedbyparticipatingcommunity partners.i THI gave each community partner a targeted quota for recruitment. The recruitment targetswerebasedonpopulationdistributionbyrace,ethnicity, and Zip Code, along with each partner’s capacity,familiaritywithandreachacrossthedifferentZipCodes,andfluencyinthelanguagesusedinthosecommunities. Community partners were required to balancetwotargets:thosebasedonraceandethnicity,andthosebasedonneighborhoodandZipCode.

Survey AdministrationSurveyswereconductedbetweenOctober21andDecember31,2019electronicallyin-person,interview-styleinmultiplelanguagesby40trainedcommunitysurveyorsutilizingtheSurveyMonkeyfieldsurveyapponSamsungtablets.Individualsweresurveyedata variety of locations across communities including apartment complexes, hair salons, places of worship, grocery stores, cafes, food pantries, and at partner organizationfacilities.Respondentswerescreenedtoinclude only those 18 years and older, and those living in the seven Southwest Houston Zip Codes of focus. At the completion of the survey, participants were given $10giftcardstonearbygrocerystores,identifiedbyourcommunitypartnersaspopularandaccessiblesitesamong their target communities.

PriortothelaunchofthesurveyinFall2019,weorganizedanumberoftrainingstopreparecommunitypartners.Asakick-off,weconvenedafour-hourin-persontrain-the-trainerworkshopinSeptember2019tofamiliarizesurveyorswiththeprocessofsurveyadministration. The purpose of the training was two-fold:(1)tobuildcommunity-basedorganizationandindividual capacity and skills to conduct survey work; and (2) ensure a clear and consistent survey administration process for the collection of quality data.

The training focused on ways to: (1) help partners understandthemeaningoftheproject;(2)describeground rules for quality, consistent, and respectful surveyadministration;(3)assistpartnersinbecomingfluentinutilizingtabletstoadministersurveysinthefield;(4)definethemeaningofthequestionsandterms used in the survey; and (5) prepare partners to trainothersurveyorsandcommunitymembers.Wedeveloped a hands-on training session with partners to engageinroleplayonsurveyadministrationutilizingthetablet.Partnerspracticedadministrationofthesurveyinvarious languages commonly spoken in the Southwest Houstonregion.Twotothreetabletswereassignedtoeachorganizationattheendofthetrainingsessionforsurveyadministration.Valuablefeedbackonthesurvey as well as the survey administration process was incorporatedbeforethelaunchofthesurvey.Followingthetraining,partnerswereencouragedtostrategizeanddeviseaplanfordatacollectioneffortsaccordingtosampleZipCodeandrace/ethnicbreakdown.

Additionalfollow-upstep-by-stepwebtutorialswereprovided,alongwithelectroniccopiesofaguidebookon how to conduct surveys and navigate the electronic platform.Ourteamconductedfinalin-personsitevisitstoeachorganizationtoensurefullpreparationbeforethe launch.

Onceinthefield,weestablishedareal-timedatamonitoring process and weekly check-in calls with each organizationtoensurequalitydatacollection.Weekly,thirty-minute check-ins served the dual purpose of monitoring data quality, as well as receiving regular qualitative summaries and anecdotes on common and distinct community experiences on what drives health in Southwest Houston.


Data AnalysisSurvey data were downloaded from SurveyMonkey, cleanedutilizingMicrosoftExcel,andanalyzedinStataVersion14.WeweightedthedatabyZipCode,race/ethnicity,andsextoberepresentativeofourtarget Southwest Houston population. Univariate andbivariateanalyseswereconductedonweighteddata.Multivariateprobabilitymodelswereanalyzedforunweighteddataexaminingdifferencesbetweenneighborhoodsbyadjustingforrace/ethnicity,sex,age, and education. Open-ended responses were analyzedthroughthematiccodingandagroundedtheory approach. Preliminary results were shared with our community partners and surveyors in late February2020tohelpwithsense-makingandcontextualizingfindings,aswellastobrainstormpreliminary recommendations for addressing identifiedpriorityneeds.

LimitationsTo capture diverse perspectives from Southwest Houston,weutilizedaquotasamplingmethodology.Despite its cost advantages to random sampling aswellasbiasreductioncomparedtotraditionalconveniencesamples,werecognizethatquotasampling has its limitations and does not fully eliminatebias.First,aswehadmorefemalesurveyors than male, recruitment and response was greater among women. The length of the surveyalsoinhibitedmanyworkingmenfromparticipating, resulting in a much larger sample of women completing the survey than men. Second, becausethesurveywasconductedinmultiplelanguages—including on-site oral interpretation andtranslationinovertwodozenlanguages—itispossiblethatsurveyorscouldhaveinfluencedresponsesastheyexplainedquestionsand/orprobedforanswers.Thereisalsoapossibilitythattermsandconceptsinoursurveymayhavebeeninterpreteddifferentlybasedoncultureandlanguage.Finally,when interpreting results, the diversity of the white populationshouldbetakenintoconsideration.Whitesin this study included a mix of ethnicities including peoplefromtheMiddleEast.Onlyabout60%identifiedasEnglish-speakingCaucasians.

Notwithstanding these limitations, however, this surveyinitiativerepresentsafirst-of-its-kindeffortto document and elevate diverse perspectives and community voices on the social determinants of health, while also translating data to inform solutions inSouthwestHouston.Ourfindingsgroundlong-known anecdotal stories and qualitative data in numbers—notonlyforSouthwestHoustonasaregion,butformoregranularneighborhoodsaswell as racially, ethnically, and linguistically diverse population groups.

Survey RespondantsA total of 1,000 residents in Southwest Houston were surveyed. Approximately 45% of respondents were fromSharpstown(77036and77074),25%fromAlief(77072and77099),12%fromGulfton(77081),11%fromWestbury(77035),and7%fromGreaterFondren(77071)neighborhoods.

Hispanicscomprised32%ofthesample,followedby29%Asians,26%Blacks,9%Whites,and4%other including multiracial individuals. Broader race categorieswerefurtherbrokendownbyethnicbackground.AmongAsians,29%wereChinese,28%Vietnamese, 24% Afghani, and 20% other Asian ethnicities. Among Hispanics, 46% were from Mexico,21%fromElSalvador,and33%fromotherLatinAmericancountries.AmongBlacks,53%wereofUSoriginand47%identifiedasbeingfromAfricancountriessuchasDemocraticRepublicoftheCongoand Nigeria.

Figure 3: Total Respondents by Zip Code

Powered by Bing©HERE


Zip Code/Neighborhood

Race and Ethnicity

Figure 4. Characteristics of Respondents (n=1,000)

77035 (Westbury) 11%77036 (Sharpstown) 23%77071 (Greater Fondren) 7%77072 (Alief) 12%77074 (Sharpstown) 22%77081 (Gulfton) 12%77099 (Alief) 13%

Hispanic 32%Non-Hispanic White 9%Non-Hispanic Black 26%Non-Hispanic Asian 29%Non-Hispanic Other 4%

SexFemale 71%Male 29%

Language Spoken at HomeLimited English Proficient 73%Spanish 37%Chinese 13%Vietnamese 11%Pastho 10%Dari 5%Other 24%

Age18-24 11%25-34 30%35-44 24%45-54 15%55-64 11% 65+ 9%

Therace/ethnicdistributiondatabyneighborhoodshowedthatHispanicscomprisedoverfiftypercentofthe Gulfton sample and just more than one-third of Alief. ForbothSharpstownandGreaterFondren,majorityofrespondentswereAsians,whereasoverfiftypercentofWestburyrespondentswereBlack.Seveninten(71%) respondents reported speaking a language other thanEnglishathome,ofwhichSpanish(37%)wasthetop language spoken. Other most frequently spoken languagesbySouthwestrespondentsincludedChinese(13%),Vietnamese(11%),anddialectsofPashtoandDari origin (15%). An additional 27 languages were reported among respondents.

Almostthree-fourthsoftherespondents(73%)reportedhavinglimitedEnglishproficiency,definedasspeakingEnglish less than “very well.” Respondents from Greater Fondren had the highest (88%) rate of limited English proficiencyandthosefromWestburyreportedthelowestrate(53%).About14%oftherespondentssaidtheywererefugeesand3%identifiedasasylees.Oursample consisted of more females (71%) than males (29%).Ascommunitysurveyorsnoted,malesweremorelikely to decline the survey due to time limitations than females, who were more willing to participate.

In terms of age, more than half of respondents (54%) were aged 25-44 years, one-fourth (26%) were aged 45-64 years, and just one in ten was 65+ years. Younger adults aged 18-24 years comprised 11% of the sample.

Nearly 72% of the respondents lived in a household consistingofthreeormoremembersand66%oftherespondents lived in a home with two or more children. One in four respondents reported less than a high schooleducation,withHispanicrespondentsbeingthemostlikely(39%)tonothavegraduatedfromhighschool.


What is the Health of Southwest Houstonians?

General and Mental Health StatusJustoverone-fifth(21%)ofSouthwestHoustoniansreported they were in fair or poor health, and 17%indicated their mental health was fair or poor. The rate of reporting fair or poor general and mental healthwassimilarbyrace/ethnicity,withtheexception of Hispanics. Hispanics reported higher rates of fair or poor general health (25%) than mental health (15%). African Americans had almost twice the rate (21%) of reporting fair or poor health status, compared to the rate for Blacks originating from

African countries (11%). Vietnamese (25%) and Chinese (21%) reported higher rates of fair or poor health status, than Afghanis (4%) and Other Asians (11%). Among Hispanics, 25% of Mexicans and 21% of Salvadorians reported fair or poor health.

Sharpstown (25%) and Gulfton (27%) had higher ratesoffairorpoorgeneralhealththanAlief(19%),Westbury(14%),andFondren(10%).

General Health

Mental Health

Excellent or Very Good Good Fair or Poor

Figure 5: Percent Reporting the Status of their General and Mental Health

42% 38% 21%

51% 31% 17%

Asian

Hispanic

Black

White

51% 31% 17%

43% 36% 21%

35% 40% 25%

52% 31% 17%

50% 33% 17%

Fondren

Gulfton

Westbury

Alief

Sharpstown

58% 32% 10%

45% 28% 27%

47% 40% 14%

36% 46% 19%

42% 33% 25%



Figure 6: Percent Reporting the Status of their General Health

FINDINGS


Common Chronic ConditionsMorethanhalfofSouthwestHoustonadults(53%)reported having one or more chronic condition(s) and 28% reported having two or more chronic conditions. Nearlyone-third(32%)ofresidentshadbeendiagnosedwithhighbloodpressure,andoneinfiveresidentsreportedbeingdiagnosedwithdiabetes(19%)anddepression(19%).Roughlyoneinten(11%)residentssaid they had asthma.

Theprevalenceofcommonchronicconditionsdifferedbyrace/ethnicity.WefoundBlacksandWhitesinSouthwest Houston reported higher rates of diagnosis ofmanychronicconditions,suchashighbloodpressure,diabetes,anddepression.Hispanics,onthe other hand, reported the lowest rates of diagnosis ofhighbloodpressure,diabetes,asthma,andheartdisease. Asians also reported the lowest rates of diagnosisofdepressionanddisability,buthigherratesofheartdisease.Importantdifferencesemergedbyadditionalrace/ethnicbreakdowns.Forexample,AfricanAmericans had almost twice the rate of many common chronic conditions than those from African countries.

Mostnotably,AfricanAmericans(36%)inSouthwestHouston reported the highest rate of depression of all racial/ethnic groups.

Vietnameseresidentshadhigherratesofdiabetes,highbloodpressure,anddepressionthanChinese,Afghani,and many other groups of Asians. Mexicans and Salvadorians reported higher rates of chronic disease than other Hispanics. Lower rates of chronic disease amongmanyimmigrantgroupsmaybetiedtoaphenomenon known as the Immigrant Health Paradox—that is, newer immigrants not yet acculturated to the AmericanwayoflifehavebetterhealthoutcomesthanU.S.citizens.15Atthesametime,becauserespondentswereaskedtoreportiftheywereevertoldbyahealthcareprovideriftheyhadacondition,theburdenofdiseasecouldbeunder-reportedamongsomegroupswho may not have ready access to health care. For example, lower rates of diagnosis among some Hispanicsmaybeduetolowerratesofcoverageand access to a dedicated health care provider, as describedlaterinthisreport.

Figure 7: Percent Reporting Diagnosis of

Specific Chronic Conditions

High Blood Pressure 32%Diabetes 19%Depression 19%Asthma 11%Disability 9%Heart Disease 6%Other Mental Health 3%Substance Abuse 2%Cancer 1%

Chronic Conditions Percentage


More than half ofSouthwest Houston

adults reported havingone or more

chronic condition(s)



Figure 8: Percent Reporting Diagnosis of Chronic Conditions

46%

37%

25%29% 28%26%

12%9%

30%

22%

14%20%

14%

7% 6%12%

16%11%9% 7%

2%8%

3%8%

Diabetes DepressionHigh Blood Pressure

Asthma Disability Heart Disease

46%46%

26%26%30%29%

12%

19%

31%

20%

4%

15%

40%

20%

5%1%

17%23%

27% 28%

17%11%

5% 5% 5%

11%12%

30%36%

12%

High Blood Pressure Diabetes Depression

White African American African Mexican SalvadorianOther Hispanic Afghani Chinese Vietnamese Other Asian

How Do Southwest Houstonians Define Health?

Defining HealthIn an open-ended question, we asked Southwest Houstonianstodefine,“whatdoeshealthmeantoyou?” Responses were varied and complex, and whenanalyzedthematically,rangedinperceptionsofhealthasbeing:holistic(e.g.,completemindandbodywellness, equating to “life” or “everything”), medical (e.g., free of disease), individualistic (e.g., a lifestyle choice), spiritual (e.g., a “precious” gift or asset from God), and a source of individual and family happiness.

Morethantwoinfive(42%)SouthwestHoustonianshadabroadandholisticoutlookonhealthdefiningitaseithercompletephysicalandemotionalwell-beingorequating it to “life” or “everything”. One in four (26%) heldamoremedicalviewofhealth,definingitasbeingfreeofdiseaseorillness(26%),andoneinfive(20%)consideredhealthtobealifestylechoiceinvolvingexercise, healthy eating, and quality sleep.

When considering racial/ethnic perspectives on the meaning of health, Whites, Blacks, and Asians weremorelikelytodefinehealthmoreholistically,whereasHispanicsweremorelikelytoequateitwithbeingdiseasefree.BlacksandAsiansbothreportedcomplete


Figure 9: Percent Reporting What They Believe Health Means

Health isLife/Everything

Other

14%12%

20%

26%28%

Note: Other includes a combination of economic stability, the well-being of family and children, having health care, and the

perspective as health being a precious gift from God.

CompleteWellness

Free ofDisease

HealthyLifestyle

Health is Life/Everything Healthy Lifestyle Complete Wellness Free of Disease Other

31%

13%

25%

38%

22%

31%

21%20%

10%15%

33%

7%9%

13%

29%29%


9% 8%13%

25%

Factors Important to Health In addition to asking questions regarding the meaningofhealth,respondentswereaskedabouttheirperceptionofhowimportantspecificsocialdeterminants of health are to their own health. By and large, Southwest Houstonians acknowledged that healthisaboutmorethanjusthealthcare.Whilemore

wellness(31%)asthetopdefinitionofhealth,whileWhitesreportedhealthasbeingthecorecomponentoflife(33%)asthetopmeaningofhealth.AlargeportionofHispanics(38%)definedhealthasbeingfree of disease. Examples of common responses from Hispanicrespondentsincluded“nothavingdiabetesorothersickness,”“thestateofbeingdiseasefree,” and “not having sickness”. The variation in perspectives on health can inform tailored education, interventions,andresourcestospecificcommunitiesfor greater impact.


thanfourinfiveresidentsidentifiedhealthinsurancecoverage (87%) and a doctor (85%) as very important or importanttotheirhealth,morethanfourinfiveresidentsalsoidentifiedaccesstoaffordable,nutritiousfoods(86%),ajob(84%),andsafeneighborhood(84%)ascritical to their health.

Allracial/ethnicgroupsaffirmthattheirhealthistiednotonlytohealthcare,butbroadersocial,environmental,and economic conditions they face. While Hispanics also cite these conditions as top factors, they have lower rates of reporting so.

Figure 10: Percent Reporting Very Important/Important on Factors Important to Their Health

Health Insurance

Access toAffordable,Nutritious

Foods

81% 76% 76%82%84% 84%87% 86% 85%

63% 63%

Culture ReligionDoctor Stable Job &Income

SafeNeighborhood

Affordable &Quality

Housing

Access toTransportation

Education Parks,Sidewalks,

Green Spaces

SafeNeighborhood

Doctor Health Insurance

Health Insurance

98% 98% 98% 97% 97%

97% 94% 94% 92% 92%

81% 81% 78% 75% 74%

96% 95% 93% 93% 88%

Doctor

White Hispanic

Black Asian

SafeNeighborhood


Foods


Foods


Foods

Doctors

Doctors

Parks,Sidewalks,

Green Spaces

SafeNeighborhood

Affordable &Quality Housing

Affordable &Quality Housing

Access to Transportation

SafeNeighborhood

HealthInsurance

Stable Job& Income

HealthInsurance


What are Top Barriers to Health?Withthepurposeofidentifyingandprioritizingwhathinders Southwest Houstonians from reaching theirbestpotentialhealth,respondentswereaskedtoreportthetopthreebarriers(inrankorder)intheir communities keeping them from leading their healthiestlifepossible.NearlyoneinfiveSouthwestHoustonianscitedaccesstoaffordableandhealthyfoodsandcrimeasthenumberone(topmost)barriertobeinghealthy.Inparticular,theycitedtherampantavailabilityoffastfoodsandunhealthyfoodoptionsasmajordeterrentstobeinghealthy.

In terms of crime,18% said that concerns with neighborhoodsafety,humantrafficking,theft,drugs,andotherformsofviolenceweretheirnumberoneimpediment to health. Fifteen percent cited pollution asthetopbarrier,includingtrash,noise,air,smell,and water. Fourteen percent cited other physical environmentbarriersasnumberone,includingtheneedfororbettermaintenanceofsidewalks,lackof green space and stray animals. While healthcare accesswasamongthetopfivebarriersreportedin

SouthwestHouston,itisimportanttonotethat90%ofresidentsidentifiedahostofstructuralbarriersbeyondthehealthcaresectorastheirnumberoneimpediment to achieving health. With respect to location,residentsinGreaterFondren(33%)andAlief (21%) were most likely to cite lack of access to affordable,healthyfoodsastheirnumberonebarrier.ResidentsinSharpstownandWestbury(24%)weremostlikelytocitecrimeastheirtopbarriertohealth,followedbyaccesstoaffordableandhealthyfoods(21%inSharpstown,and14%inWestbury).Gulftonresidents, on the other hand, were more likely to report health care access (16%) and transportation (13%)astheirnumberonebarrier.

Barriersalsovariedbyrace/ethnicity.OneinfourWhitesandBlacksreportedthatoutofallbarrierstohealth,lackofaccesstoaffordable,healthyfoodsisthetopbarriertheyencounter.Ontheotherhand,Asians cited pollution (26%) and Hispanics cited otherphysicalenvironment(18%)astopbarrierstoachievingtheirbesthealth.

Figure 11: Percent Reporting Their Number One

(Top Ranked) Barrier to Health

10%6%

14%15%18% 18% 19%

Note: Other includes socioeconomic, behavioral, and other social factors.

OtherAffordable &Healthy Food

Access

Crime Pollution Other PhysicalEnvironment

HealthcareAccess

Tranportation


22%

15% 15% 15%11%

23%18%

12% 11% 10%

18%16% 16%

10% 10%

26%21%

14% 11% 9%

A�ordable &Healthy Food

Access

Crime Other PhysicalEnvironment

Pollution HealthcareAccess

Black Hispanic

White Asian


Access

CrimeOther PhysicalEnvironment

Transportation HealthcareAccess


Access

CrimeOther PhysicalEnvironment

Personal Behavior

HealthcareAccess

Pollution OtherCrime Personal Behavior

HealthcareAccess

25%20%

15%10% 9%

16%13% 12% 11% 11%

21%19%

14% 12% 10%

24%

14% 13% 12%9%


Access

Crime Pollution HealthcareAccess

Other PhysicalEnvironment

Sharpstown Alief

Gulfton Westbury

Fondren

Crime


Access


Access

Pollution HealthcareAccess


Pollution CrimeTransportationHealthcareAccess

26% 25% 25%

8% 8%

CrimePollutionOther PhysicalEnvironment

HealthcareAccess


Access

PersonalBehavior

Crime Transportation Other PhysicalEnvironment


Figure 12: Percent Reporting Their Number One

(Top Ranked) Barrier to Health


AmongBlacks,although32%ofAfricanAmericansindicatedlackofaccesstoaffordable,healthyfoodsasthetopbarrier,thosefromAfricancountriesreportedcrime(16%)asthetopbarrier.AmongAsians, 50% of Afghanis and 25% of Vietnamese reportedcrimeasatopbarrier,whereas37%ofChinese reported pollution as the most urgent.

What are the Health-Related Social Needs?

Access to Affordable and Healthy FoodsForty percent of residents of Southwest Houston reported that they or a family

membertheylivedwithwereunabletopayforfoodwhen it was really needed in the past year. Half of Whites(52%)andBlacks(48%)reportedbeing

unabletopayforfoodinthepastyear.Overall,31%of Asians reported struggling with paying for food. Among Hispanics, 41% of Mexicans and Other Hispanicswereunabletopayforfood,whereas53%ofSalvadoriansencounteredbarriersinpayingforfood over the past twelve months.

Concernswithfoodaccessandaffordabilityvariedbyneighborhood.Two-thirds(65%)ofGreaterFondrenresidentsstatedtheyorafamilymemberhaddifficultypayingforfoodoverthepastyear.Morethan40%ofAlief,Gulfton,andWestburyresidentsand31%ofSharpstownresidentsfacedthisdifficulty.Evenaftercontrollingforsex,age,race/ethnicity, and education, Alief, Gulfton, and Fondren residents were more likely than Sharpstown residentstoreportfoodaccessandaffordabilityrelated challenges.

Figure 13: Percent Reporting Unable to Pay for Food in the Past Year

Yes No

40%60% White Black Hispanic Asian

52% 48% 43%31%


65%

43% 43% 41%30%


Inadditiontosurveyingfoodaccessandaffordability,residents of Southwest Houston were asked what was keeping them from eating healthy. Almost 75% of residentsstatedthattheywereunabletoeatabalanced,healthydietwithfreshfruitsandvegetablesduetoaffordability(i.e.,tooexpensive),poorqualityofproduce,orlackofavailabilityinneighborhoodstores.ConsideringthediversityofSouthwestHouston,9%oftherespondentsreportedthatthefruitsandvegetablesfoundinlocalstoreswereunfamiliartothemordifferentfrom their country of origin.

Neighborhood ConditionsSeveral questions sought to explicitly explore howbigofaproblemvariousneighborhoodconditions were to the health of residents in

the area. These conditions included crime, pollution, flooding,lackofsidewalks,lackofgreenspace,pollution, liquor stores, stray animals, lack of grocery stores,andabandonedhomesandlots.Forty-fivepercent of all residents reported at least three or more neighborhoodconditionsasbigproblemstotheirhealth.

Nearly half of Southwest Houstonians reported crime (48%)andpollution(45%)arebigproblemstotheirhealthintheirneighborhoods—reaffirmingprevioussentiments they shared when open-endedly discussing thetopbarrierstohealth.Morethanone-thirdofresidentsalsocitedstrayanimals(39%)andflooding(36%)asbigproblemstotheirhealth.

Inexploringracial/ethnicbreakdownofneighborhoodconditions, all groups agreed crime and pollution were bigproblemsintheirneighborhoodaffectingtheirhealth. Asians (78%) had the highest rate of reporting crimeasabigproblem,whereasWhites(64%)hadthehighest rate of reporting pollution. Hispanics, on the otherhand,hadlowerratesofreportingneighborhoodconditionswerebigproblemsaffectingtheirhealthcomparedtoallothergroups.ThesedifferencesbetweenHispanicsandothergroupsraisesomequestionsastowhetherthedifferenceisinperceptionor reality. In other words, do Hispanic residents view neighborhoodconditionsaslesspressingtotheirhealthcomparedtootherprioritiestheymaybefacing?

Figure 14: Percent Reporting Reason PreventingEating Fresh Fruits and Vegetables

Too Expensive to Buy Poor Quality Food in StoresNot Available in Neighborhood Stores Unfamiliar Fruits and Vegetables from Home CountryLack of Knowledge on Preparing Food Dislike Fruits and Vegetables

40%

22%

14%9% 7%

4%

45% of SouthwestHoustonians identifiedat least three or more

neighborhood conditions as big problems for

their health


Stray Animals Crime Pollution

39%35%

26%

36%36%

28%

49%23%

28%

45%31%

24%

26%40%

34%

29%37%

34%

26%

45%

29%

21%

51%

28%

27%39%

34%

Flooding Lack of Sidewalks Not Enough Greenspace

Many LiquorStores

AbandonedHomes and Lots

Not EnoughGrocery Stores


Figure 15: Percent Reporting Neighborhood Conditions as Big Problems for their Health


Stray Animals Crime Pollution

39%35%

26%

36%36%

28%

49%23%

28%

45%31%

24%

26%40%

34%

29%37%

34%

26%

45%

29%

21%

51%

28%

27%39%

34%

Flooding Lack of Sidewalks Not Enough Greenspace

Many LiquorStores

AbandonedHomes and Lots

Not EnoughGrocery Stores



Pollution

64%57% 56%

50% 46%

51%41%

35% 32%25%

39% 38%29% 28%

17%

78%

59%51% 51% 48%

Flooding Crime Lack of Green Space

StrayAnimal

White Hispanic

Black Asian

Crime

Pollution

FloodingPollution AbandonedHomes and

Lots

StrayAnimal

PollutionCrime LiquorStores

StrayAnimal

Crime Lack of Grocery Stores

FloodingFloodingStray Animal

50%43% 39% 39%

29%

42% 41% 40%28%

23%

49% 48% 46%37% 36%

39% 36% 32%22% 22%

Crime Pollution Flooding Stray Animal Lack of Green Space

Sharpstown Alief

Westbury Gulfton

Fondren

Pollution Crime Stray Animal Lack of Flooding

Pollution Flooding Crime Lack of Stray Animal

70%

54%45% 44%

24%

Crime Pollution Stray Animal Flooding Lack of Sidewalks

Crime Pollution Stray Animal Lack of Flooding

Grocery Stores

Sidewalks Green Space



Figure 17: Percent Reporting Their Current Housing Situation is a Big Problem

Asian White Hispanic Black

16% 15%10%

36%

Alief Westbury Sharpstown Gulfton Fondren

22%19%

15%11%

4%

As our data show, Hispanics are more likely to report beinginfairorpoorhealth,morelikelytoperceivehealthasbeingdownstreamordisease-free,mostlikelytobeuninsured,andleastlikelytohaveadedicated health care provider.

Attheneighborhoodlevel,crimeandpollutionwerealsoreportedasbigproblemsacrossallneighborhoods.Morethantwo-thirds(70%)ofFondren residents and nearly half of Sharpstown and Aliefresidentsreportedcrimeasabigproblemintheirneighborhoodaffectingtheirhealth.Evenafteradjustingfordemographicvariables,GreaterFondrenresidentsweremorelikelytoreportcrimeasabigproblemthanSharpstownandGulftonresidents.ResidentsofFondrenwerealsosignificantlymorelikelytoreportpollutionasabigproblemthanresidentsofSharpstown,Gulfton,andWestbury.Floodingandstrayanimalswerealsobigproblemsfacedbyresidentsacrossallneighborhoods.Afteradjusting for sex, age, race/ethnicity and education, differencesacrossneighborhoodslargelydisappeared, suggesting these were salient issues thattranscendedanyoneneighborhood.

Figure 18: Percent of Income Spent on Rent or Mortgage by Race and Ethnicity

Less than 1/3 of Income Between 1/3 and 1/2 of Income More than 1/2 of Income

White Hispanic Black Asian

12% 14% 17%

42%

18%

31% 28%

39%

69%

19%

55% 56%

HousingWhen asked to report their “housing situation today,” a large majority of Southwest Houston residents reported

havinghousing(93%).However,17%saidtheircurrenthousingsituationwasabigproblemtotheirhealth.Asians(36%)werethemostlikelytoreporthousingasabigproblemtotheirhealth,with69%ofthe Vietnamese population reporting so.


Evenafteradjustingforsociodemographicvariables,residents of Alief (22%) were more likely to report housingasabigproblemtotheirhealththantheotherSouthwestneighborhoods.

Whenaskedfurtherabouthousing,Southwestresidentsreportedseverehousingcostburden.Stableandaffordablehousingarestronglylinkedwithhealth.Whenhousing costs account for large portions of income, householdsstrugglenotonlytomaintainshelter,butalsofacedifficulttrade-offswithmeetingbasichumanand health needs.16

More than half (55%) of Southwest Houstonians reported spending more than 50% of their income on rentormortgage.Whites(69%)weremostlikelytospend more than 50% of their income on rent ormortgagewhereasAsians(19%)wereleastlikely.Infact, Asians were most likely (42%) to spend less than one-third of their income on housing. Just over half ofbothHispanics(55%)andBlacks(56%)reportedspending more than half of their income on housing. AmajorityofresidentsinWestbury(70%),Fondren(62%),andAlief(57%)reportedbeingseverelybur-denedbyhousingcosts.

TransportationAlthough transportation did not appear in thetopfivebarriersidentifiedbySouthwestHoustoniansaspreventingtheirabilitytobe

healthy, 41% of residents reported that transportation had kept them at some point from seeking the medical care they needed. Transportation experiences varied greatlybyraceandethnicity.AlargeportionofAsians(72%) reported that transportation kept them from seekingmedicalcare.Specifically,96%ofVietnamese,63%ofOtherAsians,and48%ofChinesereportedtransportationasabarrier.AlmosthalfofWhites(49%)indicatedtransportationasaproblemtoseekingmedical care.

Withrespecttoneighborhood,roughlyhalfofresidents in Greater Fondren (54%), Alief (48%), and Gulfton(46%)reportedtransportationasabarrierto care. Residents of Sharpstown were less likely to reporttransportationasabarriertocarecomparedtootherneighborhoodsevenaftercontrollingforsociodemographic factors.

Figure 19: Percent of Income Spent on Rent or Mortgage by Neighborhood

Less than 1/3 Between 1/3 and 1/2 More than 1/2

Sharpstown Alief Westbury Gulfton Fondren

20% 17% 16% 19%12%

33%26%

14%

30% 26%

47%57%

70%

50%62%

Figure 20: Percent Reporting Lack of Transportation Preventing Medical Care

by Neighborhood 54% 48% 46%

37%31%



Socioeconomic FactorsToconsidertheimpactoffinanceonhealth, respondents were asked how oftentheirfinancialsituationkeptthem

from getting what they needed for their health. At least one in four Southwest Houston residents (27%) indicatedthattheirfinancesalwaysorveryoftenkept them from getting what they needed for their health.AlmosthalfofWhites(48%)reportedfinancialstruggleasabarriertohealthcare.Asiansweretheleastlikelytoreporttheirfinancialsituationkeptthemfromseekingcare.Byneighborhood,Westbury(40%)andGulfton(37%)residentsweremostlikelytoreportthattheirfinancialsituationservedasabarriertoseeking care.

Social ConnectednessThe survey sought to understand the extent to which Southwest Houstonians felt socially connected to people in their

neighborhoods.ResidentswereaskedwhethertheyagreedordisagreedonafivepointLikertscaleabouttheir level of social connectivity. One in four residents strongly disagreed or disagreed with the statement “I feelconnectedtothepeopleinmyneighborhood”.Nearly one-third of Blacks felt disconnected from the peopleintheirneighborhoodwhilesAsians(11%)feltthe least disconnected.

Figure 23: Percent Reporting How Much They Agree About Being Connected to the People in their Neighborhood

Strongly Disagree/Disagree

Neutral

Strongly Agree/Agree

43% 27%

30%

Figure 24: Percent Reporting They Do Not Feel Connected to the People

in their Neighborhood by Race and Ethnicity

Black Hispanic White Asian

18%21%

32%

11%

Figure 21: Percent Reporting How Often Their Financial Situation Kept Them From

What is Needed for Health

Always/Very Often

Sometimes

Never/Rarely

32% 27%

41%

Figure 22: Percent Reporting Financial SituationAlways/Very Often Kept Them From What is

Needed for Health by Race and Ethnicity


48%

24%

36%

9%


Figure 25: Percent Reporting They HaveHealth Insurance

Yes

No47% 53%

Figure 26: Percent Without Health Insurance by Race and Ethnicity

Hispanic Black White Asian

61%47% 42%

20%

Health InsuranceAlmost half (47%) of Southwest Houston adults reported having no health insurance, ofwhich34%saidtheydidn’tknowhow

togetit.Hispanics(61%)followedbyBlacks(47%)andWhites(42%)weremostlikelytobeuninsured.Specifically,amongHispanics,47%ofMexicans,52% of Salvadorians, and 71% of other Hispanics reportedbeinguninsured.Additionally,ofalluninsured,Hispanics (57%) were most likely to say they “did not knowhowtoobtaincoverage”.AmongBlacks,thosefrom African countries (44%) reported higher rates of beinguninsuredthanAfricanAmericans(29%).Whileoverall Asians reported relatively lower rates of lacking coverage, rates were higher for some ethnic groups. For example, 40% of Afghanis reported having no health insurance.Byneighborhood,uninsuredrateswerehighand consistent (i.e., roughly 50% of people across each neighborhoodreportedhavingnohealthinsurance).

Personal Health Care ProviderPeople with a personal health care provider are more likely to access care when it is neededandexperiencebetterhealthand

health outcomes. Just over half (56%) of Southwest Houstonians have one person they think of as their personal doctor, a rate far lower than the Texas average of 68%.17 Considering race/ethnicity, while overallAsians(73%)andWhites(67%)inSouthwestHouston are more likely to have a personal doctor, Hispanics (47%) and Blacks (54%) are less likely. There islittlevariationinhavingahealthcareproviderbyneighborhood.

Almost two-thirds (66%) of Southwest residents say they usually go to a health care center or clinic when they are sick. Three in four (75%) Whites, 62% Hispanics, 72% Blacks, and 70% Asians go to a health center or clinic. Among Asians, Chinese (68%), Vietnamese(70%)andotherAsians(83%)aremorelikely to go to a health center or clinic for health care than Afghanis (40%). African Americans and those from

Figure 27: Percent with a Personal HealthCare Provider

Yes

No44% 56%

Figure 28: Percent with a Personal HealthCare Provider by Race and Ethnicity

Asian White Black Hispanic

73%67%

54%47%


Africancountriesarebothequallylikely(72%)togoto a health center or clinic. Salvadorians (72%) and Mexicans (64%) are slightly more like to visit health centers and clinics than other Hispanics (54%).

OneintenSouthwestresidentsreportedutilizingtheemergency room as their usual place of care whensick. When asked why the emergency room was utilizedfornon-urgentreasons,43%saidbecausethey did not have health insurance, 22% said becausetheydidnotknowwhereelsetogoforcare,and14%reportednotbeingabletoaffordcareanywhere else.

Forgoing Care Due to CostWe asked Southwest residents to tell us if there was a time in the past 12 months whentheyneededtoseeadoctor,but

couldnotduetocost.Nearly35%ofSouthwestHoustonians reported they did not go see a doctor whennecessaryduetocost.Specifically,overhalfofWhites (51%) and 40% of Blacks indicated forgoing careduetocost.Examiningitfromaneighborhoodstandpoint, 47% of Fondren residents stated they wereunabletoseeaproviderduetocost,comparedwithaboutone-thirdofresidentsfromallotherneighborhoods.

Figure 31: Percent Reporting Unable to See a Doctor due to Cost


51%41%

37%

23%

47%

36% 35% 34% 34%

Fondren Gulfton Sharpstown Alief Westbury

Health Center or Clinic Private Doctor's Office Emergency Room Hospital No Place for CareOther Spiritual Healer

Figure 29: Percent by Usual Place of Care when Sick 66%

20%

10% 10% 6%2% 1%

Lack of Insurance No Knowledge of Place for Care Cannot Afford Healthcare No Transportation Safe Place to Stay Access to Food

Figure 30: Percent Reporting Non-Urgent Reasonsfor Using the Emergency Room

43%

22%14% 9%

4% 3%


What Factors Help Southwest Houstonians Be Healthy?Top Ranked FacilitatorsInadditiontoidentifyingbarrierstohealth,residentswere asked to report on factors that have helped thembehealthy.Respondentswereaskedtorankorderthetopthreefacilitatorsofhealth.Twoinfive(41%) Southwest Houstonians cited a wide range ofneighborhoodamenitiesandconditions—fromaccess to sidewalks, green spaces, and parks to clean

surroundingsandcommunityamenitiessuchasnearbypools, gyms, free exercise classes, community centers, andplacesofworship–asmostimportanttokeepingthem healthy. Fifteen percent reported that access to affordablefoodwastheirbiggestfacilitatortohealth,includingfoodpantries,nearbygrocerystoresorsupermarkets,communityorganizationsassistingwithfood, and food fairs. One in ten cited health care related factorsastheirnumberonefacilitatortohealth,suchashaving health insurance, having a “Gold Card,” a doctor nearby,healthfairsandhealtheducationprograms.

Figure 32: Percentage Reporting Their Number One (Top Ranked) Facilitator of Health

9%11%

15%

21% 20%

NeighborhoodConditions &

Amenities

Access toSidewalks, Green

Spaces, Parks

Access toFood

Healthcare Access

Personal Behavior


Amenities

23%

17% 17%

10% 9%

20% 19% 18%

10% 10%

29%

19%

12% 11%8%

24% 22%

13%11%

7%

Access toSidewalks,

Green Space,and Parks

Accessto Food

SocialCohesion

HealthcareAccess

White Hispanic

Black Asian

Accessto Food

NeighborhoodConditions

& Amenities


Amenities

Access toSidewalks,


HealthcareAccess

PersonalBehaviors

Accessto Food

PersonalBehaviors

Access toSidewalks,



Amenities

SocioeconomicStatus

HealthcareAccess

PersonalBehavior

SocialCohesion

HealthcareAccess


Whites, Blacks, and Hispanics were most likely to rankneighborhoodconditionsandamenities,accesstogreenandwalkablespaces,andaccesstofoodamong their top facilitators of health. Asians, on the other hand, were more likely to report healthcare accessastheirnumberone,topfacilitatortohealth,followedbyneighborhoodconditionsandamenities.AmongAsians,32%ofChinesereportedneighborhoodfactors,and28%ofAfghanisreportedfood access as their top facilitators to health.

Almost 75% of residents in Alief, 47% in Fondren, and43%inSharpstownrankedneighborhoodconditions and green andwalkablespacesamongtheir top facilitators to health. Gulfton (24%) and Westbury(20%)residentsrankedfoodaccessasthetopmostassetinbeinghealthy.

Improving Neighborhood ConditionsThe survey asked residents to identify if they could fixonethingintheirneighborhoodtoimprovetheirhealthcircumstances,whatwouldthatbe?OneinfourSouthwestresidentsidentifiedacleanenvironment(25%)andasafeneighborhood(24%) as their top most priorities for improvement, reaffirmingwhatwereidentifiedasthetopmostbarrierstohealth.Moreso,residentswantingacleanerandsaferneighborhoodwasaconsistentfindingacrossallneighborhoods.

In addition, 12% of residents reported the need for greater social cohesion in Southwest Houston. Suggestionsincludedtheneedforgreaterneighborinteraction and communication, community events thatbringneighborhoodpeopletogether,and

22% 21%16%

10%7%

27%

20%16% 14%

11%

44%

29%

16%11%

6%

24%

14% 14%11% 9%

NeighborhoodConditions and

Amenities

Sharpstown Alief

Fondren Gulfton

Westbury

NeighborhoodConditions &Amenities

Access toSidewalks,

Green Spaces,and Parks

HealthcareAccess

Accessto Food

Beliefs

Access toSidewalks,

Green Spaces,Parks


Amenities

20%16% 14% 12% 12%

Accessto Food

Accessto Food

PersonalBehavior

Accessto Food

Social Cohesion

PersonalBehavior

Access toSidewalk,

Green Spaces,and Parks

Accessto Food

PersonalBehavior

HealthcareAccess


Amenities

Access toSidewalks,

Green Spaces,Parks

HealthcareAccess

Access toSidewalks,

Green Spaces,Parks

Beliefs HealthcareAccess


Amenities

Figure 33: Percentage Reporting Their Number One (Top Ranked) Facilitator of Health


community volunteering. Some residents also explicitly cited the need to address racism and encourage open-mindednessandrespectofdifferentcultures.Oneintenresidentscitedtheneedforbetteraccesstohealthcare, predominantly citing a need for more doctors and clinics, as well as greater outreach and information on health insurance, the health care system, and resources.

Improving Healthy Eating OpportunitiesRespondents were asked to report the one thing that would help them the most in eating more nutritious, healthy foods. Approximately 41% of Southwest Houstoniansstatedhavingmoreaffordablefreshfruitsandvegetablesinnearbystoreswouldhelpthemeathealthy.Thiswasfollowedby39%ofrespondentsreportingthatreceivingfinancialassistanceforfoodwouldfacilitatehealthyeating.About1outof10respondentsstatedhavingbetteraccesstofoodpantries or information and recipes on healthy eating wouldprovidebetterguidanceoneatinghealthy.Thesefindingsweregenerallyconsistentacrossneighborhoodswithfinancialassistanceforfoodandmoreaffordablefreshfruits/vegetablesbeingthetoptwo facilitators of healthy eating. Someimportantvariationemergedbyraceandethnicity. White (61%) and Vietnamese (60%) individuals weremostlikelytoreportthatfinancialassistancewould help them eat healthier, more nutritious foods. Africanindividualsfromothercountries(49%)andAfrican Americans (40%) were most likely to say that

havingmoreaffordablefreshfruitsandvegetablesinnearbystoreswouldhelpthemeathealthier.Chineseresidents(10%)wereleastlikelytoreportfinancialassistance as helping them eat healthier. In fact, they were most likely to report (44%) that having information on healthy recipes and food preparation would help them most with healthy eating.

Figure 34: Percentage Reporting How Neighborhood Conditions Should be Improved

9%10%12%

25% 24%

CleanNeighborhood

NeighborhoodSafety

Social Cohesion Healthcare Access

Better Sidewalks,Green Spaces,

and Parks

Figure 35: Percentage Reporting What Will Help Them Most With Eating Healthy

More affordable freshfruits/vegetables in nearby stores

Financial assistance for food

Better access to food pantries

Information and recipes on healthy eating

Other

41%

39% 10%

9% 1%


Improving Transportation for HealthResidents of Southwest Houston facing transportationbarrierstohealthcarewereaskedto name one source of transportation that would helpthembetteraccesscare.Overthree-fourths(76%)ofrespondentsstatedthathavingareliablecar would help them access medical care. Thirteen percentofresidentsstatedhavingbetterpublic

transportation would help them access medical care. Intakingacloserlook,althoughallneighborhoodsagreehavingareliablecarwouldbehelpful,25%ofWestburyresidentsstatedbetteraccesstopublictransportation would assist in health care access. The findingsarealsogenerallyconsistentacrossrace/ethnicbreakdowns.

Figure 36: Percentage Reporting What Will Help Them Most With Eating Healthy by Race and Ethnicity

Receiving Financial Assistance Affordable Fruits and Vegetables in Nearby Stores

61%

36%28%

37%43% 43%

38%

10%

60%

30% 29%

40%49%

34%41% 41%

29%34% 31%

26%

White African American African Mexican SalvadorianOther Hispanic Afghani Chinese Vietnamese Other Asian

Figure 37: Percentage Reporting What Transportation SourceWould Help Them Better Access Medical Care

76%

13%

5%

5% 1%

Reliable Car

Better Public Transportationin Community

Financial Assistance to Payfor Public Transportation

Better Sidewalks for Walking

Other


Sources of Health InformationUtilizingtrustedsourcesofinformationiscriticaltoreaching diverse communities with important messages on health, prevention, and community resources. When asked to report their primary source of health information,25%reportedahealthcareprovider,19%English-language media, 16% ethnic media, 12% social media,amongothers.However,therewasconsiderablevariationbyraceandethnicity.

One-thirdofMexicansand43%ofotherHispanicssaidthey received their health information from ethnic media. Among Asians, although the majority of Vietnamese and other Asian populations received health information from their providers, 42% of the Chinese community said they relied on information from social media and 52% of Afghanis received information from other sourcessuchasthroughneighborhoodorganizationsorfriends and family.

Figure 38: Percentage Reporting Health Source by Race and Ethnicity

English Media Ethnic Media Social Media Web Search Health Care Provider Other

Other Hispanics

Salvadorians

Mexican

Other African Countries

African Americans

Other Asians

Vietnamese

Chinese

Afghani

White0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

11% 43% 9% 6% 18% 13%

19% 33% 2% 6% 16% 23%

22% 20% 13% 12% 21% 11%

33% 5% 15% 9% 20% 18%

28% 2% 11% 15% 28% 16%

8% 1% 13% 5% 48% 24%

3%2% 9% 16% 41% 29%

7% 16% 46% 11% 12% 8%

6% 3% 3% 9% 26% 52%

16% 2% 17% 4% 42% 19%


What Role Can Health Care Systems Play?

Inadditiontoidentifyingthebroadersocial,economic, and environmental factors driving health in Southwest Houston, our survey sought to understand the current and potential role of health care providers in addressing patients’ health-related social needs. To this end, we asked Southwest residents to respond to two key questions: how often health care providers(doctors,nurses,orotherhealthcarestaff)haveaskedthemabouttheirhealth-relatedsocialneeds; and how important they feel it is for health care providers to ask these questions when providing care.

Atleasttwo-thirdsofSouthwestHoustoniansbelievethat it is very important or important that health careprovidersaskabouttheirsocialneedssuchas

accesstofood,neighborhood,financialsituation,housing and others. However, they reported that very fewprovidersactuallyaskthemquestionsabouttheirhealth-related social needs.

Whereas 70% of residents said it was very important or important that health care providers screen for their food-related needs, only 12% of residents reported beingscreenedabouttheiraccesstoaffordable,healthyfoodsveryoftenoroften.Thisfindingpointsto an important gap in the system especially as one infiveresidentsrankedaccesstohealthy,affordablefoodasatopbarriertoachievinghealth,androughly40%saidtheyorafamilymemberwereunabletopayfor food in the past year. Furthermore, in a diverse community such as Southwest Houston, cultural competency is central to providing quality care. While 57% of residents said it is very important or important forhealthcareproviderstoknowabouttheircultural

Figure 39: Percent Reporting Health Care Providers Very Often/Often Ask about Health-Related Social Needs vs. Percent Reporting it is Very

Important/Important Health Care Providers Ask These Questions

4% 3%8%

2%

12%5%

65% 66%70%

66%69%

57%

Very Often/Often Very Important/Important

Housing Neighborhood Access to Food Transportation Finance Culture and Religion


andreligiousbeliefsinprovidinghealthcare,only2%ofresidents reported that their providers asked them these questions.

Ourfindingsrevealedserioushousing-relatedchallenges facing Southwest residents. Approximately 17%ofSouthwestHoustoniansidentifiedhousingasabigproblemtotheirhealthandoverhalf(55%)ofresidentsreportedfacingseverehousingcostburden.And while 65% of residents said that it is very important/important that health care providers understand their housing situation when providing care, only 4% of residents were very often/often asked this question.

Over half of residents reported crime and pollution as bigproblemsintheirneighborhood,bothproblemsrankingasbarriersinthetopfivefactorskeepingresidentsfrombeinghealthy.Although66%ofresidentsacknowledged it is very important/important that their healthcareproviderunderstandtheirneighborhoodcircumstances,only3%saidprovidersaskaboutneighborhoodcontext.

Wefoundconsiderableagreementacrossallraceandethnic groups of the importance of screening forhealth-related social needs, yet other than food, these questions were not asked very often/often in health care settings. At least two-thirds of Whites, Blacks and Asians say that it is very important/important for health careproviderstoaskthemabouttheirhealth-relatedsocial needs when providing care. While Hispanics have slightly lower rates, the majority (i.e., more than half) saythathealthcareprovidersshouldbeaskingabouthousing,neighborhoodenvironment,accesstofood,transportation,financialsituation,andculturalandreligious preferences when providing care. Fewer than 13%ofresidentsofanyraceorethnicitysaythatthesequestionsarebeingaskedbyproviders.Indeed,thesedata reveal a clear opportunity for health care providers to play a role in screening and addressing patients’ health-related social needs, which are critical to improving overall health.

Residents no longerwant to share

information as theyare not seeing any

solutions. They needto see change.

-Community Partner

“


Oursurveyfindingsrevealthedeep,systemicbarriersand inequities facing Southwest Houstonians, not justinhealthcare,butinalmosteveryfacetoftheir daily lives—from high rates of food insecurity, neighborhoodcrime,safetyandpollutionconcernstoseverehousingcostburdenandlackofhealthcarecoverage.Whilesomeissues—suchasneighborhoodsafety, food insecurity, and pollution—were cross-cutting, others were more pronounced among specificneighborhoodsandracial/ethnicpopulationgroups. For example, Hispanics were most likely to experience health care access challenges, nearly two-thirds of whom said they were uninsured. Black Americans (not including African immigrants) reported the highest rates of depression and feeling socially disconnectedfrompeopleintheirneighborhoods,as well as high rates of food insecurity and chronic disease.AsianandHispanicsubethnicgroupsalsofaced distinct health-related needs, in many cases compoundedbylanguagebarriers.Byneighborhood,foodinsecurityandtransportationbarriersweremostcommonlycitedbyAlief,Gulfton,andGreaterFondren residents, and while crime emerged as a pervasivechallengeacrossallneighborhoods,itwasmorecommonlydocumentedbyGreaterFondrenresidentsasa“bigproblem”totheirhealth.Otherenvironmental and infrastructural factors, such as pollutionandflooding,weresharedconcernsacrossneighborhoods.

These challenges are not new to Southwest Houston. However our study sheds new light on how these experiencesvarybyraceandplace,underscoringthata“one-size-fits-all”approachwillnotyieldthe kind of meaningful change and impact that is required.Ascommunitypartnersandmembersshared, they have witnessed few improvements in opportunity and health over the years. In fact, as dataconfirm,povertycontinuestoconcentrateinSouthwest Houston, and health outcomes have either remained stagnant or have worsened for many neighborhoods.18Thesechallengesareonlybeingfurthertestedandamplifiedinthefaceoftheongoingcoronavirus pandemic, underscoring the need and urgency to address the root drivers of poor health—those drivers that also playout so frequently in

A one-size-fits-allapproach will notyield the kind of

meaningful changeand impact that is

required

Houstoninpublichealthemergenciesandarecrucialtobuildingtheresilienceofcommunitiesandtheirabilitytobounceback.

Tothatend,oursurveyfindingsaffirmthatsolutionstomeasurablyimprovehealthinSouthwestHoustonmust address the multifaceted nature of health as well as the distinct needs of communities. As wefoundhealthisnotdrivenbyanyonefactor,butbyacombinationofcomplexdeterminantsthat will require working across systems—health care, food, environment, housing, education, and transportation, and others. While health systems and providers have an important role to play in addressing theserootdrivers,localgovernment,publichealthagencies,communityorganizations,philanthropies,social service agencies, community development organizations,businesses,andothersarejustascritical to leading and partnering in solutions. As such

Figure 40: Levels of Action to Improve Health and Well-Being in Southwest Houston

Health Systems

Individual




Community


MOVING FORWARD


goingforward,werecognizethatmovingtheneedleon improving health in Southwest Houston will require cross-sector solutions at multiple levels—community, healthsystem,andindividual—balancingbroaderinitiatives with tailored interventions to address the distinctneedsofneighborhoodsandculturallyandlinguistically diverse individuals (see Figure 40).19 We identify four key recommendations for community leaders, stakeholders, philanthropies, and health systems to consider as they move forward with developing strategies and solutions to meet the needs

Figure 40: Levels of Action to Improve Health and Well-Being in Southwest Houston

Health Systems

Individual




Community


of Southwest Houstonians. These recommendations buildonevidencefromaroundthenation,whileleveraging promising initiatives and assets already in place across Greater Houston and the Southwest region. Importantly, they are grounded in rich perspectivesandguidanceprovidedbyourcommunitypartners,andalsorecognizethatvoicesfromcommunitiesofconcernmustbeapartofdesigningand developing cross-sector, multi-level solutions.


Our survey findings reveal the ongoing

challenges to health that Southwest

Houstonians experience in the places

where they live, learn, work, and play.


Our survey findings reveal the ongoing

challenges to health that Southwest

Houstonians experience in the places

where they live, learn, work, and play.

Oursurveyfindingsrevealtheongoingchallengestohealth that Southwest Houstonians experience in the places where they live, learn, work, and play. When askedtoidentifythenumberonebarriertheyfaceintheir community to achieving good health, Southwest residentsweremostlylikelytorankaccesstoaffordableand healthy foods and crime on top. Regardless of neighborhood,race,andethnicity,thesetwoissueswereprevalent and common deterrents to health for all. At the sametime,thesewerenotidentifiedasnewissuesinthecommunity.Infact,communitymembersvoicedtheirfrustrations with the lack of action over the years.

Clearly, Southwest Houstonians deserve to see their conditions, opportunities, and health improve. Doing so will require listening to and understanding their distinct needs,buildingtrust,engagingthemas‘experts’,andempoweringthemtobeapartoftailoredandtargetedsolutions that work for them. As such, we recommend buildingCommunityActionTeamscomprisedofracially, ethnically, and linguistically diverse community members,keystakeholders,andsubjectmatterexpertsfrom Southwest Houston, with each team dedicated to aspecificpriority.Researchshowsthatsmaller,action-orientedworkgroupsfocusedonaspecificprioritythatbringthecommunitytogetherwiththerightpartnerstodevelop, execute, and maintain a shared action plan yieldtangibleoutcomes.20,21

Basedonfindingsfromthisstudy,animportantstartingpointwillbetoaddressfoodinsecurity—adeterminantinextricablylinkedwithhigherratesofhypertension,diabetesandotherchronicconditions.22,23Twoinfive(40%) Southwest Houstonians reported they or someone intheirhouseholdwasnotabletopayforfood within the past 12 months. Whites and Blacks (particularlyU.S.natives)reportedbeingleastlikelytopay for food when needed, and also reported the highest ratesofdiabetes,highbloodpressure,andotherchronicconditions in Southwest Houston. Many immigrants, despite having lower rates of chronic disease than U.S.

Engage diverse community members, cross-sector partners, and subject matter experts as part of Community Action Teams dedicated to addressing food insecurity, neighborhood safety, and other urgent priorities

Recommendation 1:

natives (likely due to the Immigrant Health Paradox),24 also reported facing pervasive challenges with food insecurity. In addition, when asked why they could not consume a nutritious diet with fresh fruits and vegetables,40%ofSouthwestHoustonresidentsreportedfreshproducebeingtooexpensive,22%saidfreshproduceinnearbystoreswaspoorquality,and14%saidfreshproducewasnotavailabletothemnearby.Whenaskedtoidentifythenumberonesolutionto their current food situation: 41% said they would like toseemoreaffordablefreshproduceavailableinnearbystores,37%saidtheywouldbenefitfromfinancialassistanceforfood,10%citedtheneedforbetteraccesstofoodpantries,and9%saidinformationandeducation on healthy eating and recipes.

Buildingonthesedata,werecommendestablishingaCommunity Action Team on Building Food Security in SouthwestHoustonthatbringstogetherdiverseleadersandmembersoftheSouthwestHoustoncommunitytogetherwithsocialserviceorganizationsincludingthefoodbankandfaith-runfoodpantries,hospitalsandhealthsystems,localpublichealthdepartments,localand ethnic grocers and restaurants, and food security subjectmatterexperts.Together,theCommunityActionTeam would:

•clearlydefinefoodinsecurityconcernsin Southwest Houston

•settimeboundSMARTgoalsandobjectives

•identifyandexecutetangibleactionsand strategies for achieving goals

•addressfinancialandhumancapitalneeds

•dilineateroles,responsibilities,andtimeline for the team as a whole as well as expectations for individual partners


Aligning the Community Action Team’s work with existinginitiativesinGreaterHoustonwillbeimportanttofillgapsandamplifyimpact.Forexample,theremaybeanopportunitytoinformand align with the Mayor of Houston’s Complete Communities initiatives in Gulfton and Alief.25 The Gulfton Action Plan includes a plan to “encourage healthyeating”byexpandingweeklyfarmersmarketsand community kitchens, as well as working with areapartnerstobuildadditionalcommunitygardensandhealthycornerstoresby2023.However,manyof these actions were marked as medium to low priorities, even though the plan documents food insecurity as a “prevalent” issue in Gulfton.26 As such, aCommunityActionTeamcouldleverageandfillimportant gaps where Complete Communities and other Houston area initiatives fall short in Southwest Houston. Additionally, the Community Action Team could provide an important community voice to broaderregionalinitiatives,suchastheGreater Houston Coalition on the Social Determinants of Health which aims to reduce food insecurity in GreaterHoustonby5%by2025.27 As evidence suggests,coordinatingbroaderregionalcoalitionefforts,withtailored,bite-sizecommunitylevelactioniscentraltomeasurablyimprovingconditionsforhealth.28

Finally, the Community Action Team could look tobuildonsuccessfulpartnershipsandinitiativesaddressing the social determinants of health in other communities across Houston, such as Near Northside, Pasadena and Baytown. For example, CAN DO Houston’s Healthy Corner Store initiative, piloted in Pasadena and since then expanded to otherneighborhoodsacrossHouston,improvedavailabilityofhealthy,quality,andaffordablefoodsin areas with limited access.29Specifically,CANDOpartners with local produce vendors to deliver fresh fruitsandvegetablestotransformcornerstorestoprovide healthy options.30Suchaninitiativecouldfillan important gap facing Southwest residents, 76% of whom said that they could not consume fresh fruits andvegetablesbecauseitwaseithertooexpensive,ofpoorquality,ornotavailableinnearbystores.In addition, many Southwest residents in our survey documented food pantries, food fairs, and farmers markets as important resources for their health. Food pharmacies located at hospitals and health centers

are also promising initiatives with documented success in connecting patients to needed, nutritious foods, while decreasing hospital readmission rates and costs.31,32

Inadditiontofoodinsecurity,neighborhoodcrimeandsafety—specificallyrelatedtodrugs,humantrafficking,gangviolenceandviolentcrime—wereidentifiedaslongstandingcommunityconcerns,withlittle improvements. Many residents cited a need for moreneighborhoodwatchesandgreatersecurity.AmidCOVID-19,thisprioritytakesonanewsenseofurgencyasneighborhoodsgrapplewithrisingassault and domestic violence cases.33

ACommunityActionTeamdedicatedtotobuildingneighborhoodsafetyinSouthwestHoustoncouldbringtogetherdiversecommunitymembers—includingthosedirectlyaffectedbycrime--withmultisectorpartnerssuchascommunity-basedorganizations,lawenforcement,city/countyagencies,hospitals and health systems, and others. Such an action team could also leverage and complement Houston’s Complete Communities plans, while furtherbuildingonotherpromisingeffortsfromaround the state and nation. For example, the Building Healthy Communities initiative in California buildsonasimilarmodelasaCommunityActionTeam,workingonadefinedlocalscaletocreatebroaderimpact.Toimprovecommunitysafety,theyfocusedoncross-sector,neighborhood-levelactions such as: building people power,byengagingandempoweringcommunitymembers—especiallyresidentsaffectedbyviolence--toparticipateincommunity meetings on safety and act as change agents; building neighborhood infrastructure such as creating new, safe recreation spaces and active living programs; and expanding employment and job training opportunitiesbyrecruitinglocally;amongother actions.34Theseeffortsweremadepossiblebytheactiveengagementofcommunitymembersalongside multiple stakeholders from criminal justice, community development, major local employers, philanthropy, hospitals, schools, and others.

More than two-thirds of residents said it was important

for health care providers to understand their

social and economic circumstances


More than two-thirds of residents said it was important

for health care providers to understand their

social and economic circumstances


There is clear consensus among Southwest communitymembersofthecriticalrolethathealthcare providers can play to identify and address patient’s social needs. More than two-thirds of residents said it was important for health care providers to understand their social and economic circumstances, such as access to healthy foods, housingsituation,neighborhoodconditions,financialbarriers,andtransportation.However,12%orfewerreportedtheywereaskedthesequestionsoftenbyhealthcareproviders.Thesefindingswerelargelyconsistentbyrace/ethnicity--thatisthemajorityof all groups cited social screenings as important totheirhealthcareexperience,butfewactuallyreported experiencing it in their provider visits. Such strongcommunitybuy-in—togetherwithevidencefrom around the country demonstrating that social screenings and community referrals have indeed reduced social needs and improved overall health status35—provide a strong case for further expanding andbuildingouttheseeffortsacrosshealthsystems(bothhospitalsandhealthcenters)intheSouthwestregion,andGreaterHoustonmorebroadly.

Asoursurveyfindingsreveal,thereareconsiderablegaps in the implementation of social needs screenings across health care providers. A LandscapeMapgeneratedbytheGreater Houston Coalition on the Social Determinants of Health alsoreinforcesthesefindingsdocumentingtheinconsistent implementation of screenings across systems. Although some health systems are well on theirway,propelledbysourcessuchasfederalgrantsforAccountableHealthCommunitiestoscreen

MedicaidandMedicarebeneficiariesforsocialneeds,others are only just getting started.36 Moving all providers forward in a coordinated manner with sharedobjectivesandtechnologicalinteroperabilitywillrequireaconcerted,collectiveeffortwithadequate resources, skills training, and technical assistancetoensureprovidersofallsizesandcapacitiesareabletoparticipateandextendtheseservices to the communities they serve.37

At the same time, this upstream transition will require an intentional internal journey among health systems involvingactionssuchasaligningorganizationalstrategicplans with social determinants of health initiatives, buildingtechnologicaladaptations,andprovidingeducationandtrainingtoorganizationalleaders,staff,andhealthprofessionalstobuildworkingknowledge,understandingandbuy-inforaddressingthe social determinants of health. For hospitals and health centers in Southwest Houston, there willbeaneedtobuildaddedcapacitytoensuresocial needs screenings, community resources, and referrals to social services are provided in culturally and linguistically appropriate ways. For example, partneringwithethnicorganizationstodeveloptranslated versions of screening tools and referral resources, as well as ensuring access to navigators, community health workers, or promotores who can communicate and provide support in trusted, culturally and linguistically appropriate ways. Ensuringculturalandlinguisticcompetencywillbecentraltoensuringallpopulationscanequallybenefitfrom social screenings, referrals, and access to the resources they need.

Expand health-related social needs screenings and referrals across health systems.

Recommendation 2:


Health systems are playing a greater role to invest

in the overall vitality of their communities


Our survey results showed a myriad of social, economic, environmental and health care access challengesfacedbySouthwestHoustonians.While food insecurity and crime rose to the top of rankedbarriers,factorssuchaspollution,healthcareaccess,transportation,housingcostburdenandotherneighborhoodinfrastructuralissueswerealso of concern. For example, 41% of residents saidtransportationinhibitedthemfromseekingthecaretheyneededand55%reportedbeingseverelyburdenedbyhousingcosts,spendingmorethanhalfof their income on rent or mortgage. Health systems serving Southwest Houstonians can play a more meaningful role to champion and invest in targeted, evidence-informed interventions and innovations working in harmony with the community and other cross-sector partners to address the determinants of health outside their four walls.38,39

Many large health systems around the nation are playing a greater role to invest in the overall vitality oftheircommunitiesasawayofdoingbusiness,pushingfurtherupstreamtosupportaffordablehousing,localjobs,transportation,andothersocialdeterminants of health.40Thesesystemsrecognizethat a healthy community is critical to preserving their own economic health. As such many health systems are leading or partnering in major community invesments. For example, Greater University Circle Initiative,bringingtogetherCaseWesternUniversity,University Hospitals, and the Cleveland Clinic, andotherpartners,setouttoboostincomeandopportunities for 60,000 residents across seven surroundinglowincomeneighborhoods—similarinneed to Southwest Houston. The partners coalesced aroundfour,sharedeconomic-inclusiongoals—“buylocal, hire local, live local, and connect”.41 Similarly, Partners Health System in Boston launched a Workforce Development program to provide training,

Champion and invest in evidence-informed community initiatives to address the social determinants of health.

Recommendation 3:

internships,careercounseling,jobplacementand sustaining wages for low-income community residents.42 While outcomes data are not yet available,theseeffortsunderscoretherolethathealth systems—and other major institutions serving SouthwestHouston—canplaytobuildsustainablesolutionstoaddresstraining,jobavailability,andlivablewagestoliftresidentsoutoffinancialdistress.Shiftingupstreamisespeciallycriticalforbuildingfinancialresilienceincommunitiesintimessuchasthese—whereCOVID-19hasledtojoblosseslargelyconcentrated in Gulfton, Sharpstown, and Alief.43 Theselosseswillhaveadominoeffectworseninghousing and food insecurity, uninsured rates, access to care and other factors that ultimately also take a financialtollonhealthsystems.

Many hospitals are also addressing housing in the communities they serve. Some use their cash reserves to invest in housing projects that further their mission and margin. Others play a facilitator role, such as leveraging their position or using their accesstocheapcredittohelpliftprojectsofftheground.44 For example, Denver Health is partnering with the Denver Housing Authority to repurpose an oldbuildingonthehospitalcampusintoaffordablehousing for seniors, with some units also designated for the homeless. “It costs Denver Health $2,700 a night to keep someone in the hospital. Patients who are prime candidates for the transitional units stay onaverage73days,foratotalcosttothehospitalofnearly $200,000. The hospital estimates it would cost afractionofthat,about$10,000,tohouseapatientfor a year instead.”45 Nationwide Children’s Hospital inColumbus,OhiohasinvestedintheHealthyNeighborhoods,HealthyFamiliesinitiativesince2008,rollingouteffortsinSouthernOrchards—adiverse and economically depressed area. Programs were phased in from helping homeowners repair andimprovehousingquality,rehabilitatingvacant


andabandonedpropertiestoaddingnewaffordableapartments and providing lower cost rental units.46 Over eight years, over $22.6 million were invested in housing, with the vacancy rate declining from 25% to 6%, local high school graduation rates increasing from 64% to 79%,andcrimeratesincludinghomicidedeclining.

Transportationisalsoanotherprioritybeingaddressedbyhospitalsandhealthsystems.Forexample,someareforgingride-sharepartnershipswithLyftorUber

to provide transportation to health facilities, while othersareprovidingpublictransportationvouchers.47,48 Others—such as providers in Cleveland—have moved furtherupstreamsponsoringpublictransportationroutes for easy, regular access (every 10 minutes) to all health systems across the region.49 Initial implementation resulted in an increase of 60% in ridershiponthedesignatedbusroutethroughhealthsystems.50


The Southwest community is unique in

its demographic composition, with

an extremely diverse mix of ethnicities, cultures, and languages spoken.


The Southwest community is unique in its demographic composition, with an extremely diverse mix of ethnicities, cultures, and languages spoken. Our surveys were conductedinovertwodozenlanguages,reflectingmany diverse perspectives and realities that co-exist in the region. We also learned that health was perceived differentlybydifferentgroups.Whites,Blacks,andAsiansgenerallydefinedhealthmoreholisticallyinterms of complete wellness, whereas Hispanics were morelikelytoequateitwithbeingdisease-orillness-free.Differentgroupsalsotrustedandreliedondifferentsources of health information. Furthermore, 57% of residents felt that addressing their culture and religion were important in health care encounters, however only 2% said that health care providers often or very oftenaskedthemabouttheircultureandreligionwhenproviding care.

These,andotherfindingsfromourstudy,underscorethe importance of cultural competence in health care andinbroaderprograms,education,andresouresthataddress the social determinants of health. Culturally and linguistically tailored programs and resources are especially critical to ensure that diverse individuals receive, understand and can adhere to important information and guidance such as how to navigate the healthcaresystem,howtoobtainhealthinsurancecoverage, disease prevention and management, and access to community resources such as food pantries, transportation, and housing assistance. Doing so will require what other national initiatives51 have shown to bepromisingpracticesindeliveringpatienteducationand resources: meeting patients and community memberswheretheyareattrusted,accessiblevenues;providing information through trusted messengers and voices; assuring culturally and linguistically appropriate andtailoredinformation;andrecognizingthatmanyindividuals will require multiple touches to understand, bereceptivetoandadheretohealthandhealthcarerecommendations. As such, there are at least three

Provide culturally and linguistically tailored programs,education and resources to better reach diverse individuals.

Recommendation 4:

concreteopportunitiesforbetterreachingcommunitiesof color with critical information, education and resources in Southwest Houston in culturally and linguistically appropriate ways.

Health prevention and education: Rates of chronicdiseasevariedconsiderablybyraceandethnicity,sheddingimportantlightonwherespecificpopulationgroupsmaybenefitfromculturallycompetent prevention, education and interventions, working closely with trusted community partners. For example, Blacks (not including African immigrants) in Southwest Houston reported some of the highest ratesofhighbloodpressure,diabetes,anddepression.They were also more likely to report feeling socially disconnectedfrompeopleintheirneighborhoods.Researchnationallydocumentsthelinkbetweenexperiences of racial discrimination, poverty, and chronic stress among Blacks, which can increase vulnerabilitytochronicdiseaseandinfection.52 Experience with racism is also tied to mistrust in health systems among Blacks.53 As such, reaching Black communities with critical health education, resources, and services will require an approach centered in cultural competency, working through trusted channels and messengers, such as faith institutions, Black communityorganizationsandleaders,andBlackmedia.Thisisespeciallyimportantinthefaceofpublichealththreats,suchasCOVID-19,whereSouthwestcommunities with large concentrations of African Americans are often hard hit.54

Health insurance outreach and education: Our study found that almost half of Southwest residents havenohealthinsurance,and34%ofthemdonotknow how to get it. Among those who do not know where to go or how to get health insurance, more than half (57%) were Hispanic—with Mexicans and other Hispanics disproportionately more likely to not know howtogaincoveragethanSalvadorians.Thesefindings


alsobeprovidedinmultiplelanguages,workingthrough trusted, culturally competent social and community health workers. For example, almost 15% of residents said they could not consume fresh fruitsandvegetablesbecausetheseproducewereunfamiliaranddifferentfromtheirhomecountry,orbecausetheydidnotknowhowtopreparethem.Forty-four percent of Chinese said they would benefitfromrecipesandinformationonhealthierfoodpreparation.Theremaybeopportunitiestopartnerwithcommunityorganizationstoprovidefood resources, demonstrations, and classes which areculturally-andfaith-tailored,aswellasofferedinmultiple languages.

point to the need for continued attention, outreach, andeducationtodifferentcommunitiesofHispanicorigin with important information and resources on health insurance enrollment. Doing so will require working through trusted sources (e.g., ethnic media) and in-language navigators to dispel fear or stigma, especiallyrelatedtopubliccharge.

Social services and community resources: Community referrals, resources, and informationtohelpconnectcommunitymemberstoaffordable,healthyfoodoptions,neighborhoodresources, transportation, and other services must


needs,whilealsopointingtobroadercommunitywideinitiatives, such as those expanding access to affordablehealthyfoodoptionsandbuildingsafe,resilient communities. These priorities take on greater urgencyinthefaceofpublichealththreats,associal,economic and health care needs not only deepen, buttheneedtoreachdiversepopulationsintrusted,culturallyandlinguisticallyappropriatewaysbecomescentraltoprotectingandbuildingtheirresilience,aswellas the resilience of all people in Southwest Houston and Greater Houston.

“The data helps showthat hospitals should

be working withcommunity partnersto make the lives ofHouston residents

easier. [It] should becollaborative.”

-Community Partner

“

Our study revealed a richly detailed portrait of the lives, hopes and challenges of residents across Southwest Houston. While each community is distinct, their voices reveal shared priorities and reinforce that the path to healthandwell-beingforallresidentsmustrecognizeand address the social determinants of health. For Southwest Houston, these priorities centered in addressingnotjusthealthcare,butfactorsbeyondit,suchasfoodinsecurityandneighborhoodsafety.Residentsstronglyaffirmedtheroleofhealthcareproviders in screening for and addressing these

CONCLUSION


1 National Center for Health Statistics. (2018). U.S. small-area life expectancy estimates project (USALEEP): Life expectancy estimates, 2010-2015. National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/nvss/usaleep/usaleep.html

2WorldHealthOrganization.(2017).Aboutsocialdeterminantsofhealth.Retrievedfromhttps://www.who.int/social_determinants/sdh_definition/en/

3Brinley,A.,&Hilbig,A.(2019,October4).HowaHouston,Texasneighborhoodcenterisusingdiversitytostrengthenaneighborhood.Brookings.Retrievedfromhttps://www.brookings.edu/blog/theavenue/2019/10/04/how-a-houston-texas-neighborhood-center-is-using-diversity-to-strengthen-aneighborhood/

4MemorialHermannSouthwestHospital.(2019).2019CommunityHealthNeedsAssessment.Retrieved from http://www.memorialhermann.org/uploadedFiles/_Library_Files/Community_Benefit/MH_Southwest_CHNA.pdf

5HealthofHoustonSurvey.(2019).Areaprofileacrossindicators(2018).Houston,TX:InstituteforHealthPolicy,TheUniversityofTexasSchoolofPublicHealth.Retrievedfromhttps://hhs2010.sph.uth.tmc.edu/AreaProfileReport/

6HoustonCommunityDataConnections,KinderInstituteforUrbanResearch,version1.0.Retrievedfrom https://www.datahouston.org/dashboard.html

7HealthofHoustonSurvey.(2019).Areaprofileacrossindicators(2018).Houston,TX:InstituteforHealthPolicy,TheUniversityofTexasSchoolofPublicHealth.Retrievedfromhttps://hhs2010.sph.uth.tmc.edu/AreaProfileReport/

8U.S.CensusBureau.2018DemographicProfileDatabyZipcode;U.S.CensusBureau.2018DemographicProfileDatabyState.

9HoustonCommunityDataConnections,KinderInstituteforUrbanResearch,version1.0.Retrievedfrom https://www.datahouston.org/dashboard.html

10Lake,D.M.(2019,September18).Fromlackoffoodtochronicillness,2018HealthofHoustonSurvey sheds light on residents. UT Health News. Retrieved from https://www.uth.edu/news/story.htm?id=58e82906-c98a-4149-9ff4-f9959e191c23

11Berchick,E.,BarnettJ.,&Upton,R.(2019).CurrentPopulationReports,P60-267(RV),HealthInsurance Coverage in the United States: 2018. U.S. Census Bureau. U.S. Government Printing Office,Washington,DC.Retrievedfromhttps://www.census.gov/library/publications/2019/demo/p60-267.html

12CityofHouston&KinderInstituteforUrbanResearch-UrbanDataPlatformTeam.(2018).HoustonCrime(Part1)Reports-2009-2017[Dataset].RiceUniversity-KinderInstitute:UDP.https://doi.org/10.25612/837.97532O4O586D

13Klineberg,StephenL.(2019).The2019kinderHoustonareasurvey:Trackingresponsestotheeconomicanddemographictransformationsthrough38yearsofHoustonsurveys.RiceUniversityKinderInstituteforUrban.https://doi.org/10.25611/t7y9-j987

14Lake,D.M.(2019,September18).Fromlackoffoodtochronicillness,2018HealthofHoustonSurvey sheds light on residents. UT Health News. Retrieved from https://www.uth.edu/news/story.htm?id=58e82906-c98a-41499ff4-f9959e191c23

15Hall,E.&Cuellar,N.G.(2016).ImmigranthealthintheUnitedStates:Atrajectorytowardchange.JournalofTransculturalNursing,27(6),611–626.doi:10.1177/1043659616672534

16CountyHealthRankingsandRoadmaps.(2020).Severehousingcostburden.Retrievedfromhttps://www.countyhealthrankings.org/app/texas/2020/measure/factors/154/description

17 United Health Foundation. America’s Health Rankings analysis of CDC, Behavioral Risk Factor Surveillance System, 2018. Retrieved from https://www.americashealthrankings.org/explore/annual/measure/dedicated_health_care_provider/state/TX48

18HealthofHoustonSurvey,HHS2017-18ABriefSummary,Houston,TX:InstituteforHealthPolicy,UTHealthSchoolofPublicHealth,2019.https://sph.uth.edu/research/centers/ihp/health-of-houston-survey-2010/HHS2018%20final%20report_9-6-2019.pdf

19Castrucci,B.andAuerbach,J.(2019,January).MeetingIndividualSocialNeedsFallsShortof

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