Governance and Health in Unincorporated Areas: A Qualitative Study on County-Level Challenges in Texas and California

Abstract

Background and Purpose: Approximately 37% of the U.S. population resides in unincorporated territories, which lack the formal structure and authority of an incorporated city or town and are instead governed directly by county-level officials or their statistical equivalents. County governments and their equivalents play a pivotal role in local governance across the United States, influencing community health outcomes. The impact of a community's incorporation status on social determinants of health and well-being remains underexplored. These areas often face unique challenges in developing a community’s ability to address health and social threats due to limited development and social networks, poorly built environments, and limited access to comprehensive health and social services influenced by their governance structure. This qualitative study probes the complexities of county governance in meeting the needs of unincorporated communities that impact health. Focusing on Texas (254 counties) and California (58 counties), the research investigates county-level administrators' perceived barriers, aiming to shed light on strategies to enhance social determinants of health in these often-overlooked populations.

Method: We employed purposive sampling to recruit a diverse sample of participants to explore the challenges faced by county-level administrators in addressing health needs within unincorporated communities of Texas and California. Our study focused on county administrators from California (n = 10; representing 6 of California’s ten census regions) and Texas (n = 15; representing 12 of 24 council of government regions) participating in two rounds of focus groups via Zoom. Semi-structured focus group guides facilitated the discussions underpinning our qualitative approach—questions focused on unique population, area, and policy challenges. The analysis incorporated a coding framework synthesizing the World Health Organization's Social Determinants of Health Framework with the Health in All Policies framework. Following Hsieh and Shannon's deductive content analysis method, three independent coders analyzed the transcripts. This approach allowed for a structured examination of barriers, contributing to a comprehensive understanding of the governance challenges in unincorporated areas.

Results: We identified several factors that challenge county administration in unincorporated areas. Key population issues included varying population sizes, educational disparities, economic status, cultural and linguistic barriers, social isolation, and government mistrust. Factors associated with unincorporated areas included diverse topographies, escalating climate-related threats, the logistics and economics of scaling service delivery, geographical location, and area size. Policies that hinder a county's ability to support health included state and federal funding mechanisms that do not support counties as municipal providers, restrictive land-use authority (Texas), and insufficient county capacity and revenues. Government capacity and responsiveness to unincorporated areas was impacted by the number of people represented by a county in each state.

Conclusions and Implications: The administration of county unincorporated areas and population is challenged in Texas and California due to factors that require more study, such as resident trust building, federal and state policymaking, county capacity building, and democratic representation. Most pressing, additional research and resources are needed for unincorporated areas of counties facing growing challenges posed by climate threats due to limited emergency management capacity and costs incurred.