Advisor(s)

Joseph Wolfe

Committee Member(s)

Cindy Cain
Gabe Miller
Geoffrey Silvera
Myles Moody

Document Type

Dissertation

Date of Award

6-1-2026

Degree Name

Doctor of Philosophy (PhD)

School

College of Arts and Sciences

Department

Medical Sociology

Abstract

Much of the existing literature treats mistrust as resistance or noncompliance. A structural perspective reverses that logic. It views mistrust as a reflection of institutional behavior rather than individual belief. When systems repeatedly fail to protect or repair harm, withdrawal becomes a reasonable and protective response. Structural mistrust represents both an adaptation to inequality and a cumulative record of institutional unreliability. This dissertation develops and tests a theory of structural mistrust as a collective orientation that links institutional design to individual behavior and perceived health. It makes three contributions. First, it conceptualizes structural mistrust as a product of state institutions that govern healthcare, economic stability, education, environmental governance, criminal justice, and political participation. Second, it constructs a Structural Mistrust Index using eighteen state-level indicators across these six domains. The weighted single-factor scale demonstrates high internal consistency (α = 0.8624; ω = 0.8999) and summarizes how reliably public systems perform. Third, it examines whether structural mistrust is associated with influenza vaccination and self-rated health using 2022 Behavioral Risk Factor Surveillance System data. Across logistic and multilevel models, residents of higher-mistrust states reported lower influenza vaccination (N = 304,608; OR = 0.995 per index point, p < 0.001) and poorer overall health (N = 324,797; OR = 1.003 per index point, p < 0.001). These associations were consistent across model specifications. The relationships are modest at the individual level but meaningful in aggregate, indicating that institutional reliability is linked to both engagement with care and perceptions of well-being. The findings suggest that mistrust is structured, measurable, and consequential. Structural mistrust captures how institutional performance corresponds with health behavior and perception, shifting responsibility from individuals who “fail to trust” to institutions that fail to act reliably. The Structural Mistrust Index offers a foundation for future research on how institutional reliability relates to public confidence and population health.

Keywords

Health Inequality;Institutional Reliability;Self-Rated Health;State-Level Policy;Structural Mistrust;Vaccine Uptake

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