Texas is a vast state with regional differences in geography, population size, demographic, and socioeconomic characteristics. This section provides an overview of these variations and existing challenges related to health care availability and access, cultural literacy, and effectiveness in meeting health needs of Texas mothers, children, and their families.
Geography
Texas is the second largest state in the U.S. (behind Alaska) based on size by square miles. The Lone Star State encompasses approximately 262,000 square miles and accounts for 7.4% of total U.S. land area. Total Texas’ land area is equal to all 6 New England states plus Ohio, New York, Pennsylvania, and North Carolina combined[[1]]. Texas is slightly longer than it is wide with the greatest straight-line distance from the panhandle’s northwest edge to the states’ southern tip below Brownsville on the Rio Grande River spanning 801 miles[[2]]. The broadest expanse from east to west is 773 miles from Newton County’s Sabine River to the Rio Grande River’s western bulge just above El Paso[2].
Texas’ geography is as varied as it is large. Texas includes 254 counties classified as either rural or urban (Figure 1) with 88.4% of the population residing in urban counties. The 5 largest Texas metropolitan areas are located around the cities of Houston, San Antonio, Dallas, Austin, and Fort Worth with areas that encompass multiple counties. Given Texas’ immense size, the distance some individuals must travel to receive health care services can be a significant challenge to accessing and receiving services, especially for those living in rural counties(Figure 1).
Figure 1. 2018 Texas Rural and Urban County Designations
For administrative purposes, each of Texas’ 254 counties is assigned to one of 8 established public health regions (PHRs). Figure 2 outlines the 8 PHRs and the city where each regional office is located. NOTE: PHRs 8, 9/10, and 11 contain Texas-Mexico border counties.
Figure 2. Texas Public Health Regions
Population
Just as the Texas geography is varied, so is the population distribution (Figure 3). Race and ethnic composition differences, along with the high percentage of foreign-born residents, present cultural literacy and effectiveness challenges meeting maternal and child health (MCH) needs.
Figure 3. 2020 Texas Total Population
Texas also has the second-largest population size in the U.S. (behind California) with a population of over 29.1 million in 2020[[3]]. According to U.S. Census annual estimates, Texas has been one of the fastest-growing states in the nation since 2010 with a 15.9% increase in the state’s population from 2010 to 2020. The Texas Demographic Center predicts by 2050, Texas’ population will exceed 47 million people[[4]]. Most Texans live in the northeast, east, central, south, and gulf coast regions of the state (Figure 3).
Race and Ethnicity
Texas’ population is racially and ethnically diverse with 41.2% non-Hispanic White (hereafter referred to as White in the text and graphs), 39.7% Hispanic, 12.9% non-Hispanic Black (hereafter referred to as Black), 5.2% non-Hispanic Asian (hereafter referred to as Asian), and 1% American Indian and Alaska Native[[5]]. Counties with the highest proportions of Hispanic populations are primarily located in the southern and western regions of Texas along the Texas-Mexico border. In 2020, 3 major Texas cities (Brownsville, Laredo, and El Paso) were in counties where over 75% of the population was Hispanic and another 3 cities (San Antonio, Corpus Christi, and Odessa) were in counties where over 50% of the population was Hispanic (Figure 4).
Figure 4. 2020 Population Percent who are Hispanic or Latino
The distribution of the Black population in Texas (Figure 5) differed from that of the Hispanic population. Based on 2020 Texas Demographic Center data, counties with the highest Black population proportions were largely concentrated in the northeastern, eastern, and north gulf-coast regions of the state. In contrast to the Hispanic population, the Black population along the Texas-Mexico border was low and estimated to be slightly above 35,000 in 2020[[6]].
Figure 5. 2020 Population Percent who are Black
Foreign-Born
In 2020, Texas had a higher percentage of foreign-born residents (16.8%) compared to the national average (13.5%). In total, 60.9% of foreign-born Texas residents were not U.S. citizens. Over 66.4% of foreign-born Texas residents were born in Latin American countries – more than 15 percentage points higher than the national average [[7],[8]]. In 2020, approximately 35.1% of Texans spoke a language other than English at home. Almost 30% spoke Spanish at home compared with 13.2% of U.S. residents [6,7]. In 2016-2020, Texas Mexico border counties had high percentages of foreign-born residents as did several other counties in west and northwest Texas (Figure 6). Counties containing the non-border cities of Houston, Dallas, and Austin also had high concentrations of foreign-born residents. In response to these demographic and social variations, the Texas Department of State Health Services’ (DSHS) Community Health Worker (CHW) program increased the certified CHW numbers to address cultural literacy and effectiveness needs [[9]].
Figure 6. 2016-2020 Population Percent who are Foreign Born
Age
According to 2020 American Community Survey 1-year estimates, Texas is the second youngest population in the U.S., with a median age of 34.8 years, behind Utah (median age 31.1 years)[[10]].
In 2020, Texas had the second-largest population of children younger than age 18 (25.8%) in the nation[[11]] (Figure 7). About 7.0% of Texans were younger than age 5, 14.5% were ages 5 to 14, and 4.3% were ages 15 to 17. Texans younger than age 22 accounted for 31.0% of the total 2020 population. South Texas’ border counties had high percentages of individuals younger than age 22 as did several panhandle counties (Figure 8)[[12]].
Figure 7. Population Percent Under 18
Source: U.S. Census Bureau, American Community Survey 2016-2020
Prepared by: Maternal and Child Health Epidemiology Unit, Mar 2020
Figure 8. 2020 Population Percent Under 22 Years Old
Women comprised half of the total population and women between ages 18 and 44, also considered women of reproductive age, accounted for 18.7% of the total Texas population in 2020[10]. Urban counties with large metropolitan areas (including counties containing Dallas-Fort Worth, Houston, San Antonio, Austin, and El Paso) had the highest proportions of women of reproductive age (Figure 9).
Figure 9. 2020 Population Percent Who Are ages 18-44 and Female
The 2019-2020 National Survey of Children’s Health (NSCH) estimated 17.4% of Texas children ages 0-17 had a special health care need. Rates of children with special health care needs (CSHCN) among different racial and ethnic groups differed. The White group had highest proportion of CSHCN with 21.9%, followed by Black with 18.1%, then Hispanic with 15.5%, and the Asian group with the lowest CSHCN proportion with 8.9%[[13]].
Socioeconomic Characteristics
Socioeconomic characteristics such as income and poverty, education, unemployment, and crime rates are added challenges for meeting health needs of Texas mothers, children, and families. The presence of an increased number of risk factors of this nature in a community pose a danger to the health of individuals within that community throughout their entire life course.
Income and Poverty
Income inequalities exist within different Texas areas and largely reflect gender, racial, and ethnic differences. In 2020, Texas’ median household income was $63,826, per year which was slightly lower than the national median household income of $64,994 per year[[14]].
The Federal Poverty Level (FPL) is set by the U.S. Census Bureau based on income thresholds that vary by family size and composition. If a family’s total income is less than their determined income threshold, that family and every individual within it is in poverty. These poverty thresholds are used throughout the mainland U.S. and do not vary geographically. However, they are updated each year to account for inflation. According to 2020 American Community Survey estimates, Texas had a higher proportion (14.2%) of people living below the FPL than the national average of 12.8%[[15]].
The proportion of adults living below the FPL varies geographically and by sex. Among the Texas adult population aged 18 and older, counties with a large adult proportion living below the FPL in 2016-2020 were concentrated in the Texas-Mexico border region. Several Texas counties in east, north central, and the panhandle also had high rates of adults living 200% below FPL (Figure 10).
Figure 10. 2016-2020 Adult Population 200% Below the Federal Poverty Level
In 2020, the U.S. Census Bureau estimated about 15.5% of adult females lived below the FPL in Texas[14]. The Texas-Mexico border region counties had high rates of women living below the FPL, as did several rural East Texas counties, west of Fort Worth, and between Lubbock and Amarillo in the panhandle. The fastest growing major metropolitan areas – Austin, Houston, and San Antonio – had a relatively low proportion of women living below the FPL (Figure 11).
Figure 11. 2016-2020 Estimated Population Percent of Adult Females 100% Below the Federal Poverty Level
Food security refers to a household’s ability to provide enough food to keep each family member active and healthy. Along with negative health outcomes, food insecurity can make it difficult for children to learn and grow[[16]]. Overall, the U.S. food insecurity rate is 10.9% of the population. In the U.S., an estimated 14.6% of children live in food insecurity. As of 2019, there are approximately 4,092,850 food-insecure people in Texas. Nearly 1 in 5 Texas children live in a food-insecure household. There are 15 Texas counties where 30% or more children experience food insecurity.[[17]]
Education Higher educational attainment has been associated with positive health outcomes and it is crucial to understand education within the Texas context.[[18]] In 2020, among those age 25 and older, a greater percentage of both men (16.3%) and women (14.9%) in Texas had less than a high school education compared to their national counterparts (13.9% for men and 10.4% for women). In Texas, 24.7% of residents age 25 and older had a high school diploma or equivalent as their highest level of educational attainment, and 30.7% had a bachelor’s degree or higher.[[19]] Educational attainment levels are not evenly distributed throughout the state. There were 10 counties where a bachelor’s degree educational attainment or higher was greater than 40% among individuals age 25 and older.[[20]] Counties where less than 10% of the people age 25 and older had a bachelor’s degree or higher were largely clustered in south, west, and east Texas.[3]
Unemployment
Between 2016 and 2020, while Texas had a higher percentage of adults without a high school diploma compared to the nation, it had the same average rate of unemployment (4.3%) as seen nationwide (4.4%) for populations between ages 25 and 64[[21]]. Even among persons aged 25-64 without a high school diploma, Texas had a lower unemployment rate (5.7%) compared to the national average for this educational attainment group (7.9%). Consistent with nationwide trends, Texas’ unemployment rate increases as education level decreases. In 2020, the Texas unemployment rate was as low as 2.5% among those with a bachelor’s degree or higher.[20]
Crime
Crime impacts the physical, behavioral health, and wellbeing of mothers, children, and their families. Neighborhood crime can be detrimental to children’s safety by creating unstable living environments. By assessing communities where crimes occur more frequently, it is possible to identify areas where high-risk populations reside and help prevent adverse consequences. In 2020, Texas’ Crime Rate was 2,666.7 crimes per 100,000 persons[[22]].
Texas index crime statistics include 2 major crime categories - property and violent crimes. Property crimes consist of burglary, larceny-theft, and motor vehicle theft. The 2020 property crime rate was 2,223.9 crimes per 100,000 Texans a 5.9% decrease from the previous year. The highest 2020 property crime rates were primarily localized within larger Texas cities and their surrounding areas (Figure 12)[22].
Figure 12. 2020 Property Crime Rate per 100,000
Violent crimes recorded in the Uniform Crime Report include murder, rape, robbery, and aggravated assault. The 2020 violent crime rate was 442.9 crimes per 100,000 Texans, 6.6% higher than 2019. The highest 2020 violent crime rates were primarily concentrated near the larger panhandle cities - Odessa, Lubbock, and Amarillo (Figure 13). Houston, Dallas, San Antonio, Corpus Christi, and surrounding areas also had a high violent crime concentration.[22]
Figure 13. 2020 Violent Crime Rate per 100,000 People
Violence within Texas families has been recognized as a growing threat to the safety of all Texans. The 2020 Uniform Crime Report indicated 213,875 family violence incidents in Texas which is an 8.6% increase from the previous year. Although the largest percentage of family violence was between other family members (58.7%), family violence also occurred among spouses/couples (25.1%) and within parent-child relationships (16.2%). Females were more likely to be family violence victims. Of the victims whose sex was known, 70.8% were female and 29.2% were male. Conversely, of the offenders whose sex was known, 72.8% were male and 27.2% were female. The 25-29 age group had the highest family violence victim numbers followed closely by the 20-24 age group[22].
Mobility/Migration
Moving or relocating is one of life’s most stressful events and can impact individual health and well-being. For example, the Texas School Survey of Substance Use results show this life event may influence youth risk behaviors, as students in grades 7 to 12 living in their current school district for 3 years or less are more likely to use illicit drugs than those living in their current school district more than 3 years[[23]]. Additionally, sudden population number and demographic changes can lead to ill-equipped health care programs and systems that must adapt to meet their network’s changing needs[[24]]. Texas demographic data illustrates migration patterns that include moving into the state from other states and countries and moving within the state between counties. Between January 2018 and January 2020, the Texas population grew by 623,884 people. Despite the overall growth, 114 Texas counties saw no change or population loss during that time which suggests concentrated population growth in metropolitan areas and simultaneous loss in rural areas[[25]].
Out-of-State Mobility/Migration
Between 2018-2020, 4 Texas metropolitan areas (Houston, Dallas, Austin, and San Antonio) together added more people than any state in the country (except for Texas as a whole) with a collective population growth of 398,000 people[[26]]. Among these 4 fastest-growing Texas areas, 2-3% of the population consisted of people who moved to the area from out of state (out-of-state migration). Some rural counties also had high levels of out-of-state migration in 2016-2020, particularly in the parts of the state bordering Oklahoma and the panhandle, as well as in west Texas (Figure 14)[3]. Most Texas counties had little to no new residents from other states.
Figure 14. 2016-2020 Population Percent that Moved from Another State to Texas
In-State Mobility/Migration
Another aspect of mobility is the number of people who move within or between Texas counties. While out-of-state migration may reflect job growth, population mobility within a county and between counties is more complicated.
Texas counties with universities and colleges were among the highest rates of within-county relocations over a 1-year period[8]. College Station, Austin, Lubbock, and San Antonio are home to 4 of the 10 largest Texas universities which partially explain the high rates of within-county relocations in these areas. College students tend to move often within the same county to take advantage of lower rents.
Health Care Coverage and Access
Health insurance and provider access are fundamental to the health of Texans. Texas currently has the largest proportion of uninsured people in the country at 20.7% which is significantly higher than the national rate of 8.7%. Although each of Texas’ Public Health Regions’ (PHRs) uninsured numbers sit well above the national rate, there are considerable differences between them. PHR 11, the southernmost PHR, has the highest uninsured rate of 28.9% while the centrally located PHR 7 has the lowest rate of uninsured people at 16.8%.
Table 1: 2019 Population Percent <65 that is Uninsured by State and PHR
Source: United States Census Bureau (2019). Small Area Health Insurance Estimates, 2019.
Prepared by: Maternal and Child Health Epidemiology Unit, Mar 2022
Health Insurance
In 2020, Texas had higher proportions of uninsured children, women of childbearing age, and individuals living below 100% FPL than the corresponding uninsured percentages for these groups nationwide[[27],28]. In Texas, 8.4% of children younger than age 6 were uninsured and approximately 25.7% of Texas women ages 19-44 were uninsured. Furthermore, 29.5% of Texans living below 100% FPL were uninsured[27]. In addition, 2019-2020 National Survey of Children’s Health (NSCH) data showed 13.7% of children ages 0-17 in Texas had no health insurance or periods of no coverage during the year prior to the survey. This is significantly higher than the nationwide rate of 8.8% of children. An estimated 4.4% of children and youth with special health care needs (CYSHCN) had no health insurance[[28]]. Counties with high proportions of uninsured children younger than age 6 were concentrated in west Texas between Odessa and San Antonio and in the panhandle (Figure 16). The Texas-Mexico border regions and several counties outside Lubbock and Waco had high proportions of women ages 19-44 without health insurance (Figure 17).
Figure 16. 2016-2020 Children Younger than Age 6 Without Health Insurance
Figure 17. 2016-2020 Percent of Females (ages 19-44) Without Health Insurance
Access to Health Care
Given the large size of the state and the vast distances between health care points of care in rural areas, access to care in Texas can be a challenge. There has been an increase in primary care physician numbers in the past 5 years. In 2015, there were 19,902 (71.9 per 100,000 population) which grew to 22,610 (76.2 per 100,000 population) in 2020. However, 32 counties still had no primary care physicians in 2020 (Figure 18).
Figure 18. 2020 Primary Health Care Physicians per 100,000 Population
In 2019, the number of obstetricians (OB) and/or gynecologists (GYN) in Texas was 2,723. This is a slight increase from the 2,640 OB/GYNs in 2017[30]. The full range of women’s health providers include certified nursing midwives, direct entry midwives, nurse practitioners with a women’s health specialty, physician assistants focused on women’s health, and OB/GYNs. In 2019, exactly half of 254 Texas counties did not have a single women’s health provider. A total of 376,795 women ages 15-42 live in a county with no women’s health provider[[29]].
The federal Health Resources and Services Administration (HRSA) uses 4 criteria to designate Primary Care Health Professional Shortage Areas (HPSA). They consider the population-to-provider ratio, percent of the population below 100% of FPL, Infant Health Index based on Infant Mortality Rate and Low Birth Weight Rate, and travel time to the nearest source of care outside the HPSA designation area. They also consider areas with a provider shortage for a specific group of people within the area such as low-income individuals. Recruiting and retaining health care professionals is an ongoing challenge not only in rural areas, but in some urban areas as well. In rural areas, retention of health care professionals is mostly due to population size, whereas in some urban areas, access is limited because many providers do not accept Texas Medicaid or because patients are not enrolled in Texas Medicaid and are unable to pay out-of-pocket[[30]]. Most Texas counties are designated as a low-income population, geographic or high needs geographic HPSA (Figure 19).
Figure 19. September 2021 Texas Primary Care Health Professional Shortage Areas
The Title V Community Outreach Survey parent respondents indicated finding a mental or behavioral health professional was very or extremely difficult especially finding one that treats children. The National Association for School Psychologists recommends a student-to-psychologist ratio of 500:1[[31]]. In 2020, only two Texas counties, Lavaca and Goliad, met this recommendation. One hundred and five counties out of 254 Texas counties did not have a school psychologist(Figure 20).
Figure 20. 2020 Student to School Psychologist Ratio
Psychiatrist shortage is also a concern. The HPSA Mental Health scoring is based on 7 factors: population-to-provider ratio, percent of population below 100% of the Federal Poverty Line, elderly ratio, youth ratio, alcohol abuse prevalence, substance abuse prevalence, and travel time to the nearest source of care outside the HPSA designation area. The HPSA recommendation ratio for population-to-provider is 30,000 people/residents to 1 psychiatrist and 20,000 people/residents to 1 psychiatrist in areas with high needs[[32]]. One hundred and seventy counties do not have a psychiatrist and many that do have at least 1 psychiatrist that meets the HPSA criteria for the mental health shortage designation[[33]] (Figure 21).
Additional challenges exist in identifying psychiatrists who specialize in child psychiatry. The American Academy of Child and Adolescent Psychiatry considers a sufficient provider-to-population ratio to be 47:100,000. In 2019, only Kendall County met this ratio. There were approximately 646 Texas Child and Adolescent Psychiatrists with almost none operating outside of major cities[[34]].
Figure 21. 2020 Psychiatrist Numbers per 100,000 Population
Congenital Syphilis
In Texas, congenital syphilis is an emerging issue and was recently recognized as a Texas Department of State Health Services (DSHS) priority initiative. In 2019, DSHS released a Congenital Syphilis Health Advisory to: inform physicians of increased reported incidences of congenital syphilis in Texas babies, provide guidance on evaluation and treatment, and to increase physician awareness of Texas screening requirements. To help address these issues, the Maternal and Child Health (MCH) Section within the Community Health Improvement (CHI) Division is working with the Laboratory and Infectious Disease (LIDS) Division to address congenital syphilis (CS) with an emphasis on the Texas-Mexico border regions. Subject matter experts in the two Divisions meet monthly to discuss: new cases and data, existing grants and contracts, and communication and collaboration opportunities. From CHI, this includes the CHI Medical Director and MCH’s Healthy Texas Mothers and Babies Special Projects Coordinator.
In August 2017, MCH received $2.491 million from the Centers for Medicare and Medicaid Services (CMS) to implement the Zika Health Care Services grant from July 1, 2017 through June 30, 2021. Beginning in March 2020, due to decreases in Zika prevalence, MCH requested CMS widen the grant’s scope to allow local health departments (LHDs) to shift focus to congenital syphilis. CMS approved adding congenital syphilis activities to the Zika Health Care Services Program during the no cost extension period (July 2020-June 2021). This action added testing services for sexually transmitted infections including syphilis, testing supply purchases, and additional outreach, education, and awareness to Texas-Mexico border populations. Specific outreach activities included:
- Zika and syphilis prevention education to women of child-bearing age (18-44) and their partners;
- Information about the importance of syphilis testing and other sexually transmitted infections/diseases; and
- Education about the effects of Zika and syphilis on a newborn, congenital Zika complications, and congenital syphilis.
DSHS collected the following metrics related to syphilis during the grant period:
- Number of pregnant women whose partners received counseling on preventing STI/STD during pregnancy;
- Number of pregnant women who received pre and post STI/STD Test counseling;
- Number of pregnant women who received education on having their baby screened for congenital syphilis at delivery;
- Number of pregnant women who tested for syphilis during their pregnancy;
- Number of pregnant women with laboratory evidence of syphilis; and
- Number of pregnant women with laboratory evidence of syphilis who were tested during their first trimester.
Future MCH activities include:
- Working with partner organizations/collaborators to raise awareness of available services to pregnant women and women of childbearing age, such as the Healthy Texas Women Program.
- Promoting the recent DSHS Grand Rounds on congenital syphilis through partner organizations/collaborators networks.
- Promoting the new LIDS’ Congenital Syphilis Podcast and promoting attendance at Fetal Infant Mortality Reviews (FIMR) for congenital syphilis and HIV cases.
- Establishing data sharing between LIDS and Newborn Hearing Screening (Texas Early Hearing Detection and Intervention and Congenital Syphilis data).
Texas MCH will continue to monitor this emerging issue.
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[2] https://statesymbolsusa.org/symbol-official-item/national-us/uncategorized/states-size.
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[4] Texas Demographic Center. Texas Population Projections 2010 to 2050. Retrieved from https://demographics.texas.gov/Resources/publications/2019/20190128_PopProjectionsBrief.pdf
[5] U.S. Census Bureau. Population Estimates July 1, 2021. Retrieved from https://www.census.gov/quickfacts/TX
[6] Texas DSHS. (2020). Border Report Section 3 - Population and Demographics of the Texas-Mexico Border Region. Retrieved from https://www.dshs.state.tx.us/hivstd/reports/border/sec3.shtm
[7] U.S. Census Bureau (2020). American Community Survey Data: Texas, Language Spoken at Home. https://data.census.gov/cedsci/table?q=language&g=0100000US_0400000US48&tid=ACSST5Y2020.S1601
[8] U.S. Census Bureau (2020). American Community Survey Data: United States, Selected Social Characteristics in the United States. Retrieved from https://data.census.gov/cedsci/table?q=foreign%20born&g=0100000US_0400000US48
[9] Promotor(a) or Community Health Worker Training and Certification Advisory Committee (2019). 2018 Annual Report. Retrieved from https://www.dshs.state.tx.us/chs/hprc/publications/2020/CHW_factsheet_2020.pdf
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[13] Child and Adolescent Health Measurement Initiative. NSCH Interactive Data Query (2019-2020). Race and ethnicity distribution of the child population. 2019-2020 National Survey of Children’s Health (NSCH) data query. Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA MCHB). Retrieved from https://www.childhealthdata.org/browse/survey/results?q=7259&r=45&g=731
[14] U.S Census Bureau. (2020). American Community Survey Data: Income in the Past 12 Months. Retrieved from https://data.census.gov/cedsci/table?q=income&g=0100000US_0400000US48&tid=ACSST5Y2020.S1901
[15] U.S. Census Bureau. (2020). American Community Survey Data: Poverty Status in the Past 12 Months. Retrieved from https://data.census.gov/cedsci/table?q=poverty&g=0100000US_0400000US48&tid=ACSST5Y2020.S1701
[16] Feeding America: Map the Meal Gap (2020). How do you measure hunger? Retrieved from https://www.feedingamerica.org/hunger-in-america/food-insecurity
[17] Feeding America: Map the Meal Gap (2019). Child Food Insecurity in Texas. Retrieved from https://map.feedingamerica.org/county/2019/child/texas
[18] Hahn, R. A., & Truman, B. I. (2015). Education Improves Public Health and Promotes Health Equity. International journal of health services: planning, administration, evaluation, 45(4), 657–678. https://doi.org/10.1177/0020731415585986
[19] U.S. Census Bureau (2020). American Community Survey Data : Educational Attainment. Retrieved from https://data.census.gov/cedsci/table?q=education%20attainment&g=0100000US_0400000US48&tid=ACSST5Y2020.S1501
[20] U.S. Census Bureau (2020). American Community Survey Data : Educational Attainment. Retrieved from https://data.census.gov/cedsci/map?q=education%20attainment&g=0400000US48%240500000&tid=ACSST5Y2020.S1501&mode=thematic&loc=32.1731,-101.5615,z5.1026&vintage=2020&layer=VT_2020_050_00_PY_D1&cid=S1501_C02_015E&break=5&classification=Equal%20Interval
[21] U.S. Census Bureau. (2020). American Community Survey Data: Employment Status. Retrieved from https://data.census.gov/cedsci/table?q=employment&g=0100000US_0400000US48&tid=ACSST5Y2020.S2301
[22] Texas Department of Public Safety. (2020) Crime in Texas – Executive Summary. Retrieved from https://www.dps.texas.gov/sites/default/files/documents/crimereports/20/2020cit.pdf
[23] Texas Commission on Alcohol and Drugs Abuse. 1992 Texas School Survey of Substance Abuse, Grades 7-12. Retrieved from https://www.texasschoolsurvey.org/Report
[24] Perrott GS, Holland DF. (2005). The Millbank Quarterly. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690260/
[25] U.S. Census Bureau (2020). American Community Survey Data: Geographical Mobility in the Past Year for Current Residence. Retrieved from https://data.census.gov/cedsci/table?q=motility&g=0400000US48,49&tid=ACSDT5Y2020.B07201
[26] Texas Demographic Center. Texas Population Estimates Program Data. Retrieved from https://demographics.texas.gov/data/tpepp/estimates/
[27] US Census Bureau. (2020). American Community Survey Data: Selected characteristics of health insurance coverage in the United States. Retrieved from https://data.census.gov/cedsci/table?q=insurance&g=0100000US_0400000US48&tid=ACSST5Y2020.S2701
[28] Child and Adolescent Health Measurement Initiative. NSCH Interactive Data Query (2019-2020). Indicator 3.2: Currently uninsured or periods without coverage x Special health care needs status,2019-2020 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA MCHB). Retrieved from https://www.childhealthdata.org/browse/survey/results?q=8586&r=45&r2=1
[29] Health Professions Resource Center. Women and women’s health providers: metro v. non-metro, 2021. Retrieved from https://www.dshs.texas.gov/chs/hprc/publications/WomensHealthProviders.pdf
[30] HRSA Health Workforce (2020) Texas Department of State Health Services (2020). Scoring Shortage Designation. Retrieved from https://bhw.hrsa.gov/workforce-shortage-areas/shortage-designation/scoring
[31] National Association of School Psychologists (2021). Research Summaries: Shortages in School Psychology: Challenges to Meeting the Growing Needs of U.S. Students and Schools. Retrieved from https://www.nasponline.org/research-and-policy/research-center/research-summaries
[32] Bureau of Health Workforce, Health Resources and Services Administration (HRSA), United States Department of Health & Human Services (2020, March 31). Designated Health Professional Shortage Area Statistics, Second Quarter of Fiscal Year 2020, Designated HPSA Quarterly Summary. Retrieved from https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport
[33] Center for Health Statistics, Texas Department of State Health Services (2019). Psychiatrists, 2019. Retrieved from https://www.dshs.texas.gov/chs/hprc/tables/2019/PSYCH19.aspx
[34] American Academy of Child & Adolescent Psychiatry (2019). Workforce Issues. Retrieved from https://www.aacap.org/aacap/Resources_for_Primary_Care/Workforce_Issues.aspx#:~:text=There%20are%20approximately%208%2C300%20practicing,a%20child%20and%20adolescent%20psychiatrist.
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