Advisor(s)

Kevin Fontaine

Committee Member(s)

Christopher Hudson
Gregory Pavela
Sarah MacCarthy
Teneasha Washington

Document Type

Dissertation

Date of Award

6-1-2026

Degree Name

Doctor of Philosophy (PhD)

School

School of Public Health

Department

Public Health

Abstract

Alabama remains one of the worst states in the nation for adult mental health access despite decades of reform and explicit commitments to improving care. Framing access as the ability to recognize need, locate services, reach them, enter care in a reasonable time, and continue or adjust care, this mixed-methods, three-paper dissertation examines how Alabama’s adult mental health system structures those pathways and how adults and providers navigate its constraints. It argues that inadequate access in Alabama contributes not only to suicide, psychiatric hospitalization, and disability, but also to shortened lifespan in the context of high burdens of chronic disease, and that these outcomes reflect a chronic, system-level failure rather than an absence of underlying illness. Guided by social determinants of health, the social ecological model, and systems theory, the dissertation integrates historical, quantitative, and qualitative perspectives. Paper 1 (historical–policy) traces how geography, race, law, financing, institutional downsizing, and crisis-oriented reform have produced enduring feedback loops—such as segregation, underinvestment, and reliance on safety-net, emergency, and carceral settings—that constrain the availability and organization of community-based care. Paper 2 (quantitative) analyzes pooled 2022–2023 National Survey on Drug Use and Health data to show that adults in Alabama are at least as likely as adults nationally to report any and serious mental illness, yet more often report unmet or delayed treatment, greater reliance on informal or crisis services, and a distinctive configuration of barriers, including concerns about cost, insurance coverage, social judgment, and the risk of losing jobs or relationships. Paper 3 (qualitative) draws on in-depth interviews with 26 licensed mental health providers to illuminate how economic precarity, limited literacy, neighborhood and technological barriers, local social norms, stigma, and workforce strain intersect in everyday practice to narrow, complicate, or foreclose workable options for treatment. Together, the three studies develop and apply a determinants-of-access framework that reconceptualizes Alabama’s access crisis as a historically produced, multi-level, self-reinforcing system entangled with broader social and economic conditions, highlighting concrete leverage points for policy and practice—particularly in strengthening community-based, preventive, and ongoing services—and identifying directions for future research on how to build more acceptable, navigable, and sustained pathways into mental health care for adults in Alabama.

Keywords

access;adults;Alabama;mental health;social determinants;theory

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