Geographic Distribution of Social Workers and Areas of Unmet Need: An Ecological Study in Texas

Background/Purpose:  The Commission on Cancer (CoC) accreditation guidelines outline patient navigation, psychosocial distress screening, and survivorship care plans as standards of high-quality, patient-centered cancer care programs.  These standards reflect oncology social work’s potential contribution to improving psychosocial outcomes for underserved patients by integrating whole-person care and traditional cancer treatment while benchmarking expectations for psychosocial care among leading cancer institutions.  Distance to accredited programs presents a challenge to accommodating the needs of rural and border residents, who suffer poorer cancer-related health outcomes compared to urban counterparts.  This study analyzes county-level demographic and socioeconomic characteristics along with cancer incidence in relation to social work’s capacity to serve rural and border areas in Texas.

Methods:  Data and measures:  Independent variables include measures of race/ethnicity, education level, unemployment, health insurance, and rural residence from the 2015 Behavioral Risk Factor Surveillance System (BRFSS) and the 2015 American Community Surveys.  The Texas Cancer Registry provided the 2015 age-adjusted cancer incidence rates.  Finally, the dependent variable consisted of the number of licensed social workers per county from the Texas State Board of Social Worker Examiners.

Analysis: Hotspot analysis of the dependent variables using the Getis-Ord Gi* statistic identifies significant high and low clusters of counties according to rates of social worker concentration, while generalized linear models analyze their relationship to the dependent variable using Poisson regression.

Results:  Significantly high clusters of social workers are found in counties surrounding large, urban cores (Houston, Dallas/Fort Worth, Austin/San Antonio).  There was no significant low cluster of counties; however, 27 of 254 counties had no licensed social workers to report and an additional 111 counties had 10 or less.

Counties with greater proportions of African American and Hispanic residents, higher educational attainment, higher rates of uninsured adults, and higher age-adjusted cancer incidence rates experienced higher odds of social worker presence.  In contrast, counties with higher unemployment rates and more residents residing in rural areas had fewer odds of social workers practicing in their communities. 

Conclusions/Implications:  Social workers are highly clustered in urban areas and practice in counties with higher proportions of African Americans, Hispanics, uninsured adults, and cancer incidence; however, over half of Texas’ counties have less than 10 licensed social workers.  Strong urban economies with educational resources to train social workers and lower unemployment naturally sustain greater numbers of social workers leaving rural areas with fewer economic resources.  Furthermore, urban areas have greater capacity to meet the CoC’s standards of care with diversified, trained workforces and established facilities, while rural hospitals are sporadic and face ever growing closure rates.  Still, telehealth and mental health interventions may provide a means to navigate cancer patients in isolated environments by addressing psychosocial barriers to attain whole-person, patient-centered care.