Year of Award


Document Type


Degree Type

Doctor of Philosophy (PhD)

Degree Name

Public Health

Department or School/College

School of Public and Community Health Sciences

Committee Chair

James Caringi

Commitee Members

Curtis Noonan, Sophia Newcomer, Duncan Campbell, Jennifer Robohm


Access to Healthcare, Health Systems Research, Mental Health, Rural Health


University of Montana


Access to healthcare is a complicated public health challenge. Healthcare access is multi-dimensional and combines characteristics of individuals, their households, and their social and physical environments with system-level characteristics of healthcare delivery systems, organizations and healthcare providers. Access encompasses five dimensions: approachability, acceptability, availability, affordability and appropriateness. This dissertation investigates these five dimensions of access to healthcare in the context of two populations of interest: 1) persons who reside in rural areas and 2) persons who experience mental health challenges. Both persons in rural areas and persons with mental health challenges have structural barriers to healthcare access. Additionally, rural health and mental health are complex characteristics as there are many levels of rurality and multiple diagnosable mental illnesses. To address these considerations, this dissertation was comprised of three studies. The first study quantified barriers to healthcare access among US adults with and without mental health challenges. A cross-sectional study design was employed using data from the 2017-2018 National Health Interview Survey. This study focused on three of the dimensions of access: approachability, availability and affordability. The other two studies investigated rural and mental health-specific challenges in Montana, a region of the US at the intersection of structural barriers for both rural health and mental health. The majority of Montana counties are classified as rural, and several mental health indicators among persons in Montana are two-fold the comparable national averages. Next, a qualitative study of Montana healthcare providers was used to identify social, cultural and programmatic barriers to healthcare access among persons who reside in Montana. This study focused on two of the dimensions of access, acceptability and appropriateness, that are often less understood and harder to quantify. The third study employed an ecological study design utilizing three data sources: a regional health workforce information services company that maintains up-to-date provider data, the Montana Department of Health and Human Services and the American Community Survey. This study tested a relationship between the density of healthcare provider per capita and suicide across Montana counties. Together, the results from these three studies suggest the following: across the US, affordability-related barriers to healthcare access continue to be a pressing concern among most Americans, and mental health challenges may associate with more barriers to healthcare access. In Montana, a friction exists between aspects of patients’ rural identities and healthcare systems, and communication within Montana’s healthcare systems is fragmented. Conjointly, these findings suggest one overarching implication. Disparities in access to healthcare at the individual-level compound with disparities in access to healthcare at the system-level, just as they do within the context of rural health and mental health. In order to effectively address disparities in access to healthcare in the US, the individual and the system must both be carefully considered.



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