Proposed population-based intervention for low income in Harris County, Texas

Introduction

Despite advancements in both medical technology and service delivery within the

U.S., many communities continue to have difficulty accessing healthcare services. For

individuals who live below the poverty line, financial burdens, lack of transportation, and

limited access to primary care often lead to delayed treatments and the development of

preventable health conditions. These barriers can be seen on a community level, where there

are numerous factors relating to the social environment that impact the overall health

outcomes of individuals. Nurses involved with population health and community-based

practice must understand how social determinants impact access to care for those they serve.

This paper will explore low-income adults residing within the region of Harris County, Texas,

with an emphasis placed upon identifying limited access to healthcare as a significant social

determinant affecting overall health status. The goal of this paper is to assess the needs of the

surrounding communities while providing evidence-based recommendations for an

intervention to increase access to healthcare services.

Description of Location and Subpopulation

Harris County, Texas, contains an estimated population of approximately 5,009,302

individuals. Approximately 50.4% of individuals living in Harris County identify as female,

whereas approximately 49.6% of individuals living in Harris County identify as male. These

numbers suggest that Harris County has a balanced ratio of males to females. (U.S. Census

Bureau, 2024). The racial/ethnic breakdown of Harris County consists of approximately

43.0% Hispanic/Latino, 19.2% Black/African American, 36.4% White/Caucasian, 7.4%

Asian, and a smaller percentage of individuals identified as the other racial categories. The

above statistics demonstrate that there is a large amount of racial/ethnic diversity within

Harris County (U.S Census Bureau, 2023). For the purpose of this assessment, low-incomeadults are defined as individuals 18-64 living at or below 200% of the federal poverty level

(U.S Census Bureau, 2020).

The socioeconomic condition in Harris County demonstrates that about 16% to 18%

of Harris County’s population falls below the federal poverty threshold; this is much higher

amongst people of the Hispanic and Black ethnicities and those making under $25,000 yearly

(U.S. Census Bureau, 2023). Therefore, such socioeconomic challenges also create barriers

for these individuals, and combined with their overall lack of access to preventative health

services, will create barriers for healthy living today and in the future. The median income for

households in the county is around $63,022. In regard to education in Harris County, many of

those with lower educational attainment tend to show socioeconomic vulnerabilities. For

example, 23.7% of adults have a high school diploma or lower, which relates directly to

having lower health literacy, decreased work opportunities, and long-term health outcomes

(Texas Community Health News, 2024).

Crime and safety are major worries; approximately one-third of people living there

said they are victims of either being targeted because of their ethnicity/race, sex/gender, or

another form of discrimination that affects them mentally (e.g., by being treated differently).

Domestic violence was reported by over half of those victims (Rice University report titled:

“Crime and Victimization in Harris County: An Assessment”, 2024). In 2024, the Crime

Stoppers of Houston managed to provide solutions to 362 felony cases, 18 of which were

homicides, and 60 cases were burglary, robbery, and theft (with low-income communities

being disproportionately exposed to these crimes) (Crime Stoppers of Houston, 2024). The

crimes involving property are still concentrated in the economically disadvantaged areas.

There are additional issues associated with living in these areas (i.e., challenges to healthy

living due to the local community environment), food insecurity affects approximately thirty-

nine percent of Harris County households, more than double the national rate of 14% (KinderInstitute for Urban Research, 2025) and some demographic groups, especially

racially/ethnically disadvantaged households, have a higher prevalence of these challenges

(i.e., food insecurity). Many poor neighborhoods today not only face food shortages because

they do not have enough grocery stores to meet their needs, but they are classified as food

deserts, which means they have high use of convenience stores or places selling fast food as

their primary source of food. This contributes to increased risk for obesity and poor nutrition

(Kinder Institute for Urban Research, 2025).

The low-income neighborhoods in Harris County have a critical lack of access to

nutritious food. Food insecurity reaches about 39 percent of households in the county, or

almost three times the national rate of 13.5 percent (USDA Economic Research Service,

2025; Kinder Institute for Urban Research, 2025). A large number of poorer neighborhoods

can be considered food deserts in which the residents are forced to go a long way to get to

full-service grocery stores and fill their staple food diets with convenience stores and fast-

food outlets. One of the health outcome indicators that illustrates health inequities in Harris

County is obesity. Approximately 47.7% of adults ages 45-64 in Harris County are

considered obese, and adults who earn less than $25,000 a year are almost twice as likely to

be obese as adults who earn a higher income. (Understanding Houston, 2023). Cases of

health discrepancies are evident among the low-income adults in Harris County. Individuals

with lower incomes than 25,000/year have diabetes rates of about 18%, a high prevalence of

hypertension (more than 38%), and obesity rates (more than 52%), which are significantly

above the county-wide statistics (Harris County Public Health, 2025; Understanding Houston,

2023). These collective indicators demonstrate that low-income adults (especially those

earning less than $25,000) in Harris County are faced with several social and structural

barriers that adversely affect their access to healthcare, their economic stability, and their

overall health outcomes.Disparities exist between low-income adults in Harris County in terms of the health

and nutrition indicators described above. Approximately 14% of adults aged 18-64 years have

diabetes; over 32% of adults aged 18-64 years have hypertension; nearly 48% of adults aged

45-64 are considered obese. The prevalence of these health conditions is substantially higher

among adults with a gross income of $25,000. As a result, access to preventive and primary

healthcare services is restricted due to both distance and cost of accessing healthcare services

(Understanding Houston, 2023; County Health Rankings & Roadmaps, 2023).

Subpopulation Impact of Limited Access to Healthcare

Biggest Contributor to Morbidity and Mortality

The leading cause of preventable morbidity in low-income adults in Harris County is

limited access to healthcare, where patients who do not have health insurance go to the

emergency room at almost double the frequency of those with health insurance, and also have

substantially less access to preventative and chronic disease management services. (Harris

Health System Community Health Needs Assessment, 2023). In Harris County, residents who

are low-income encounter many obstacles to getting the basic health care services they need,

which are causing higher levels of illness and death in this area. Some examples of these

complicated factors impacting those who suffer from chronic illnesses are their lack of

insurance and the unavailability of primary care physicians in Harris County. Diabetes is

present in approximately 14% of the adults living in Harris County. In comparison,

hypertension affects more than 32% of adults, and the proportions of both of these chronic

conditions are much higher among adults living at or below 200% of the federal poverty level

(County Health Rankings & Roadmaps, 2023). Therefore, individuals who have these chronic

illnesses may not have sufficient medical care to help prevent the occurrence of

complications from these diseases that could have been prevented. This data shows that

having limited access to basic healthcare services within Harris County can create too manyemergency room visits that could have been prevented with proper medical attention. In

addition, it can make it harder for people with chronic illnesses to get the care they need,

which can lead to an early death and/or affect their overall quality of life in the long run

(Texas DSHS, 2023; CDC, 2023).

In Harris County, cardiovascular disease and diabetes are the two leading causes of

premature death for those 40 years and older who fall below the poverty line. According to

local mortality reports, heart disease is to blame for about 22% of all county deaths, while

around the same rate of deaths due to complications of diabetes occurs compared to Texas

and national death rates (Texas DSHS, 2023; CDC, 2023). The combination of delayed

diagnosis and a disjointed healthcare system (poor access to treatment) increases the chance

of developing more advanced stages of an illness when diagnosed, thereby increasing the

potential for being hospitalized and dying prematurely. State and national mortality data

indicate that preventable and treatable conditions are much higher among the uninsured than

those with insurance, and continue to evidence a greater relative mortality burden among

people below the poverty line (CDC, 2023).

Controversial Community Health Concern

One currently very hotly debated area of community health in Harris County concerns

the inappropriate use of the emergency department for health-related problems that do not

require an emergency response. Multiple reports by both public health officials and the health

care system provide documentation that supports this concern (Harris Health System

Community Health Needs Assessment, 2023; Crime Stoppers of Houston, 2024). On average,

during the year preceding the COVID-19 pandemic, adults in Harris County who did not

have health insurance utilized the emergency department at nearly double the rate of those

with health insurance (Harris Health System Community Health Needs Assessment, 2023).

The result of the overuse of emergency departments is an overall increase in the number ofpatients seen within the emergency department, resulting in longer wait times for treatment

and strain on hospital resources to accommodate the high number of patients, particularly due

to the lack of availability of affordable primary care services for individuals without health

insurance. Because of these issues, there are growing concerns regarding health equity and

the long-term viability of the health care systemin both local and statewide communities

due to the continued inappropriate utilization of the emergency department.

Community Health Concerns

Individuals in the community have expressed having difficulty obtaining timely care,

long waiting periods for appointments, and limited help in navigating the health care system,

such as making appointments and understanding benefits (Kinder Institute for Urban

Research, 2025). Similar access issues have been identified in low-income families in other

areas where poverty and social justice issues prevent people from receiving adequate health

care (Tiruneh et al., 2024). Individuals experiencing diabetes complications and hypertension

are commonly hospitalised, and their hospitalisations could often be prevented. The increased

quality of life and financial burden to both the individual and the health care system are

decreased when people cannot access adequate care (Harris County Public Health, 2025). In

addition to financial burdens, inadequate access to care contributes to decreased productivity

and higher levels of stress. An improvement in access will improve both the individual and

the system.

Emergency Room Visits and Hospital Admissions

Members of this subpopulation utilize emergency care as a primary service for

hospital admissions or emergency room visits for conditions that can be treated with

outpatient care (e.g., uncontrolled diabetes, hypertensive crises, asthma exacerbations,

infections) as well as for complications resulting from either delayed diagnosis or treatment

(e.g., preventable hospitalizations for chronic health problems), with these numbers beinglarger among low-income individuals compared to those with higher incomes (Harris Health

System Community Health Needs Assessment, 2023; Texas DSHS, 2023). Data collected at

the state level validate the claim that low-income individuals in Texas have limited access to

outpatient care and that lack of outpatient care (i.e., regular healthcare visits) contributes to

increased usage of emergency rooms and hospitalization. Costs associated with emergency

room visits and hospitalizations place additional burdens on both the patient and provider,

and essentially lead to overcrowding within hospitals.

Impact on Quality of life

Those residents of Harris County who lack regular access to healthcare endure an

inferior quality of life as a result of their inability to manage conditions that (commonly) lead

to chronic illness, as well as the burden of financial strain and/or being unable to take

preventive measures. In the county, almost forty percent of low-income families report food

insecurity, which has been shown to have strong negative associations with worse health

outcomes, more overall stress, and a lower functional status (The Kinder Institute for Urban

Research, 2025; USDA Economic Research Service, 2025). Chronic illness management

barriers, coupled with the added financial anxiety associated with accessing medical care,

result in decreased capacity of these individuals to hold jobs and perform engagements with

health-promoting activities, thus continuing the cycle of poor health and social and economic

disadvantage within a community.

Social Determinant of Health: Limited Access to Healthcare

The lack of access to healthcare is a key social determinant of poor health for adults

living on low incomes in Harris County, as high costs, limited insurance coverage, and not

having enough primary care providers lead to delays in accessing health services. Because of

the lack of regular primary care, people will often put off seeking care, resulting in an

increase in the severity of their health problem(s). This has been shown by numerous researchstudies that looked at the relationship between social needs and health care service utilisation.

Due to the lack of access to primary care, many people end up in an emergency room for

conditions that are preventable if they were able to have regular access to a primary care

doctor and/or other types of providers. Furthermore, untreated chronic conditions can result

in increased rates of morbidity and mortality within this population. Therefore, addressing

barriers to access to health care is essential for improving the overall health of populations in

Harris County.

The community health issues related to inadequate access to care have been found through

the repeated use of emergency departments, the prevalence of uncontrolled chronic

conditions, and the financial burdens of high costs associated with health care.

Available Community Resources

Several community resources are available to assist lower-income adults in Harris

County, Texas. Federally Qualified Health Centres serve individuals without insurance or

who are under-insured by providing Primary Care Services on a sliding fee scale. Federally

Qualified Health Centres provide preventive care, chronic disease management, and referral

to specialty services, resulting in a decrease in avoidable emergency department visits (Fiori

et al., 2024). Other than Federally Qualified Health Centres, the Harris Health System also

provides healthcare to low-income county residents through the Financial Assistance and

Gold Card programs, which enable low-income county residents to have access to Primary

Care, Speciality Care, and Hospital Services through the Harris Health System, even if they

do not meet the traditional eligibility criteria for health insurance coverage. Medicaid also

assists low-income adults by covering essential healthcare services to those who meet the

eligibility criteria. Collectively, these community and systemic resources provide assistance

to provide healthcare to lower-income adults; however, there are still gaps in access to

healthcare.Needed Resources

The people of Harris County need more assistance to increase their healthcare

options. These services include increased Care Coordination opportunities to help the people

who use them find out about their insurance policies and make appointments and referrals to

other providers (State of the Health System Report 2014). The evidence from community

health worker programs indicates that People who are supported through navigation services

can access medical care and coordinate with their healthcare providers (Fiori et al., 2024).

Providers of medical services in Harris County must offer more flexible hours of service as

well as develop mobile service opportunities to allow greater access to those individuals with

non-traditional work hours. The lack of sufficient transportation assistance for residents

continues to restrict the ability of those individuals to access their medical care. All of the

items mentioned above are necessary to ensure that residents of Harris County have the

ability to access medical services to reduce the number of avoidable conditions resulting from

a lack of access.

Proposed Evidence-Based Intervention

To remedy the lack of access to Healthcare faced by low-income adults, the

development of a Nurse-led Community Health Worker Care Navigation program is being

initiated. The integrated inclusion of Community Health Workers as part of an overall

problem-solving model is the most comprehensive method to effectively assess Social Needs,

while also providing ongoing assistance with Social Needs and care navigation processes to

their members. The data support the assertion that Community Health Workers positively

influence success through increased access to community resources and decreased barriers to

care, with more significant benefits to underrepresented populations (Fiori et al., 2024). The

Nurse will maintain oversight of the screening process, while also coordinating referrals to

both medical and Social Services. Community Health Workers will assist the members inrelation to appointment scheduling, insurance registration/ enrollment, and linking members

to community resources associated with their needs. The Coordinated Community Care

Model provides both clinical support and support to meet the social requirements for

members of these communities. By implementing this model, we will begin to address the

long-standing access issues that many individuals experience when seeking Healthcare.

Evidence supports this proposed method for applying Social Needs Screening

processes + Navigation Services together. This is demonstrated by Systematic reviews

showing that post-program follow-up and coordination ultimately reduce utilisation of

Emergency Room services while increasing patient engagement through their respective

Primary Care provider (Yan et al., 2022). By placing services in proximity to Community

members and supplying personalised assistance, this methodology addresses many of the

barriers, including Transportation and The Complexity of navigating the Health Care System.

For instance, monthly visits to communities identified as having the greatest need, by Mobile

Units supporting Registered Nurses (RNs) and Community Health Workers (CHWs), would

allow for screening for Social Needs and establishing Referrals for community services.

These continual interactions would foster consistency in the delivery of Care, leading to long-

term Health Management. Evidence also exists to demonstrate the Sustainability of such

interventions, by Successful Integration into the Current Health Systems (Fiori et al., 2024).

The proposed method aligns Nursing professionals’ roles within Population Health and Care

Coordination.

Conclusion

Harris County’s low-income adults are at a significant disadvantage when it comes to

accessing healthcare. They encounter barriers to being able to receive care, thus preventing

them from having a higher quality of life due to their illnesses that could have been

prevented. The limited access to care for low-income adults is due to financial, structural, andenvironmental barriers; thus, these barriers represent a significant social determinant of

health. The current resources that exist do provide some assistance, but they do not

adequately meet the needs of all low-income individuals in Harris County. A nurse-led

community health worker navigation program would be an evidence-based solution and

practical strategy to improve access for low-income residents of Harris County and improve

coordination of care for this underserved population. The nurse-led community health worker

navigation program would provide a holistic approach to both social and clinical needs,

thereby reducing health disparities and improving overall population health. Community-

based strategies, such as this one, require the involvement of nurses to lead and implement

such programs.References

CDC. (2023). Chronic disease indicators. Centers for Disease Control and Prevention.

https://www.cdc.gov/cdi/index.html

County Health Rankings & Roadmaps. (2023). Harris County, Texas. University of

Wisconsin Population Health Institute. https://www.countyhealthrankings.org

Crime Stoppers of Houston. (2024). Annual report 2024. https://crime-stoppers.org/wp-

content/uploads/2025/09/Annual-Report-FINAL.pdf

Fiori, K. P., Levano, S., Haughton, J., Whiskey-LaLanne, R., Telzak, A., Hemen Muleta, V.,

K., Chambers, E. C., & Racine, A. (2024). Advancing social care integration in health

systems with community health workers: an implementation evaluation based in the

Bronx, New York. BMC Primary Care, 25(1). https://doi.org/10.1186/s12875-024-

02376-7

Harris County Public Health. (2025). Community health assessment.

https://publichealth.harriscountytx.gov/Divisions-Offices/Offices/Office-of-

Planning-Innovation/CHA-CHIP/Community-Health-Assessment

Harris Health System. (2023). Community health needs assessment 2023.

https://www.harrishealth.org/about-us/community-health-needs-assessment

Kinder Institute for Urban Research. (2025). Food insecurity in Harris County. Rice

University. https://kinder.rice.edu

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