The cornerstone of professional public health practice is measurement. The form of the measurements may be assessing community needs, assets, gaps in service, barriers to access or it may be in evaluating the impact of intervention programs designed to produce tangible good. This foundation of assessment underpins the development of health policy and provides the information necessary to assure the population access to essential services.
The San Antonio community is one of the eight largest metropolitan areas in the nation. The direct provision of health services is estimated to account for six billion dollars and employs more than 65,000 people in the local economy. Related industries employ approximately 34,000 individuals with a total payroll of $1.4 billion. Together the medical/health sector provides more than 99,000 jobs (19.2% of the area total) with an annual payroll of more than $2.6 billion and accounts for more than $6 billion in total economic activity.
The School of Public Health has a distinguished record of assessment and evaluation work in this community that assures the most rigorous methods are applied to the complex measurement tasks in community health assessment. Examples are:
The Center for Transforming Health Systems at the School of Public Health has had a major impact on San Antonio, although this is usually behind the scenes and in collaboration with other agencies. For example:
- Preparation of census tract, vital statistics, and other community analysis for a grant application for Kellogg Foundation funding for a community-based public health initiative. This led to the award of funding for the Primary Health Care Review of San Antonio City Council District 4. This was a community-based project which gave faculty and students experience in working with community residents and leaders and in the community research process, and which employed community residents as interviewers and staff for the survey. It remains the only community-based quantitative health information for any part of San Antonio.
- The District 4 study has been extensively used by hospitals in San Antonio for planning. It is currently the foundation for a neighborhood and multi-sectoral project to develop health and other services in the Sky Harbor area (south and west of Kelly AFB). CHPS faculty and staff assist with this planning process.
- Kellogg Foundation funding also assisted the development of an Associate Degree program for Community Health Workers through the Alamo Community College District. This created a new entry level grade of health care providers, with the opportunity to continue studies in environmental or human health professions, and assisted applicants who were usually the first person in their family to go to college. CHPS faculty and staff worked with ACCD personnel and potential employers to plan and develop the curriculum and infrastructure for this program.
Working directly with other community agencies, projects have included:
- Assisting the Partnership for Hope / Urban Institute study Health and Poverty in San Antonio: A Profile of Needs and Services. CHPS staff provided analysis of extant data, and set up, conducted, and analyzed focus groups and interviews among community residents, community leaders, and health care providers.
- Reviewing a resolution prepared by leaders of Communities Organized for Public Service and the Metropolitan Alliance, and priority clarification for the use of the Lutheran General Hospital facility. The community organizations successfully influenced the purchase of Lutheran General Hospital by the Bexar County Hospital District, and its subsequent development into the University Center for Community Health, which includes the Texas Diabetes Institute.
- Assisting the San Antonio Health Care Partnership with extant data analysis and planning for the SAISD Rogers and Connell Middle School catchement areas. Community residents in this area have developed programs for adolescents and children, crime prevention, and to support older people to enable them to remain in their homes as long as possible.
- Conducting a community needs assessment for San Antonio hospitals (now known as the Bexar County Health Collaborative) for use in attaining eligibility for Disproportionate Share reimbursement. This was based on existing data, comparing it with Healthy People 2000 objectives, and prioritized by hospital representatives. More recently in 2002 and 2006 the Collaborative has repeated the assessments to provide some longitudinal data on trends in health indicators.
- Conducting a community-based needs assessment of Uvalde County for the Uvalde County Health Coalition, as part of the establishment of a system of Community Oriented Primary Care.
- Instructing and coordinating UTHSC Medical School Family Practice students in an extant and qualitative data assessment of north central San Antonio, the area served by the UHS Basse Road Clinic. This assessment is in use for policy decisions by the clinic and hospital system, and introduces medical students to the community, to the life of their patients outside the doctor’s office, and to the assessment process.
- In progress: Assessment of the service area of the Benitia Family Center in west San Antonio by a Family Practice Medical Student. The Benitia Family Center is a family counseling and educational center of the Missionary Catechists of Divine Providence. In response to the concern of the Executive Director about lack of bonding between parents and children, a student from SPH (who is a registered nurse and lactation consultant) is exploring the possibility of outreach to mothers and newborns.
- In progress: Assessment of the area within the boundary of the San Antonio Independent School District for the Texas Diabetes Institute (TDI). This involves students at SPH and the UTHSCSA School of Nursing in a collaborative project based on a request from the community advisory board of TDI.
- The District 4, Benitia, TDI, and Basse assessments together examine contiguous census tracts from Mission Road to Loop 410 south and southwest, Highway 90 west, Culebra Road, back across central and east San Antonio to Loop 410 east, and north central San Antonio to north of San Antonio airport. While the key questions behind each assessment differ, there is a substantial data base on the census tract level which at present is not connected. Apart from the Basse area, San Antonio north of Commerce Street has never been analysed. There is evidence of an aging population in north San Antonio, especially inside Loop 410. The counties surrounding Bexar county have had very little attention.
The Community Assessment class taught here at SARC has promoted community-based assessment, and community assets mapping, identifying strengths as well as perceived need. The community development theories of John McKnight and the pragmatic methods of rapid participatory assessment are taught to the students as the framework for the community assessment process. The key questions for investigation come from community members. Time and money factors are kept in mind. The use of existing data in all its forms is taught as the first level of assessment. This is usually inexpensive and relatively easily available, but only provides the skeleton of a community. Qualitative data collection by focus groups and interviews is the next level of assessment. This can be done inexpensively and fairly easily, depending on the information required. Qualitative data adds form to a community, giving beliefs, opinions and values. Quantitative data collection – statistically valid surveys – are expensive, difficult, and lengthy, even with rapid techniques, and are discussed but rarely performed. They are a spotlight on the community, giving factual information about community concerns. Currently, we have a contract with Comal County United Way to conduct an assessment with partners including Kronkosky Foundation, McKenna Health Foundation, City of New Braunfels and the county government. We are developing similar contracts with Nueces County, and Webb counties. The long range plan to support the CTSA here is to have an assessment for each of the 38 counties in the South Texas Region. These assessments will form the backbone of a region wide community data information system that will augment the AACIS data project we will be hosting locally.
SPH students have worked with community residents and leaders to identify community resources on which they can build, as well as areas of concern to community residents. Students have discussed plans for change, emphasizing community-supported planning. Student class and intern projects have included:
- Nueces County/Corpus Christi, and last year’s evaluation of the Victoria Courts and North East Community Collaboratives from McKnight’s perspective.
- In San Antonio, interns have worked with the Family Health Foundation (mapping Medicaid providers and population served, writing mental health and safety guidelines and assessment), the Texas Dept. of Health (Neural Tube Defect Project), San Antonio Metropolitan Health District (stories for patient education about clinic visits for children, etc), and the Center for Health Policy Studies (policy analysis).
