Mental Health and Substance Abuse Ranks #4 Among Alabama Voter Priorities

In late 2017, the Public Affairs Research Council of Alabama (PARCA) surveyed Alabama voters to determine their thoughts about the general direction of the state and the issues that most concern them. PARCA partnered with Samford University to survey policy professionals from across the state including academics, journalists, business and nonprofit leaders, and lobbyists. Their responses provided a list of 17 critical issues facing Alabama. PARCA partnered with USA Polling at the University of South Alabama to ask registered voters about these 17 issues. The voters’ responses generated the Top Ten list of voter priorities. Details about the survey and its methodology can be found in the full Alabama Priorities report.

Alabama Priorities

1. K-12 Education
2. Healthcare
3. Government Corruption and Ethics
4. Mental Health and Substance Abuse
5. Poverty and Homelessness
6. Jobs and the Economy
7. Crime and Public Safety
8. Job Training and Workforce Development
9. Improving the State's Image
10. Tax Reform

Key Findings

  • Voters broadly agree on the critical issues facing the state.
  • Voters are not polarized along traditional political, ideological, racial, or generational lines. There is a significant gap between the priorities of experts and the priorities of voters.
  • Policymakers have an opportunity to inform and educate voters on critical and systemic challenges facing the state.
  • Policymakers have an opportunity to respond to immediate, often highly personal issues that concern voters.
  • Elected officials and candidates have an opportunity to show leadership and to build broad coalitions to address Alabama’s most pressing challenges.

This summer and fall, PARCA will produce summary briefs on each of the top ten priorities chosen by Alabama voters. Each brief will answer four critical questions: what is the issue, why it matters, how Alabama compares, and what options are available to Alabama policymakers.

#4: Mental Health and Substance Abuse

What is the issue?

Alabama voters rank mental health and substance abuse as the 4th most important issue facing Alabama, with 56% of respondents indicating they were very concerned about the issue. A plurality of Millennials and majority of voters of every other generation are very concerned about the issue. These findings are in keeping with the State’s Community Health Improvement plan, which found Alabamians rank mental health as the second greatest health concern.[1]

Mental illness includes a range of mental health conditions from mild anxiety, treatable with counseling, all the way to major psychiatric issues requiring psychotropic medication and long-term hospitalization.

An estimated 43.6 million Americans from all backgrounds suffer from mental illness or substance abuse. If current trends continue, by 2020, there will be more people suffering from mental and substance abuse disorders than people suffering from all physical diseases worldwide.[2]

Mental illness and substance abuse disorders share some underlying causes, including changes in brain composition, genetic vulnerabilities, and early exposure to stress or trauma.[3] Individuals that suffer from drug addiction frequently experience one or more symptoms of mental health issues.[4]

Experiencing both mental illness and substance abuse, what professionals call a dual-diagnosis, is very common.

Why Does it Matter?

Mental illness and substance abuse can alter reasoning skills, coping mechanisms, emotions, and behavior. This can have a profound impact on the individual and family, but also on the broader society.

Serious and untreated mental health concerns, including substance abuse, can place a strain on the communities by increasing unemployment, crime, and healthcare costs. Substance abuse alone has been estimated to cost $504 billion in direct and indirect costs, including lost productivity, in 2015 alone.[5]

Left untreated, mental health and substance abuse disorders can hinder an individual’s ability to live a healthy, confident life, and the ability to be productive members within the community. Untreated mental health and substance abuse issues can be significant contributing factors to job loss, homelessness, criminal behavior, and premature death. Suicide and drug-related deaths have increased in the nation in recent years with suicide ranked 11th in 2014 as the leading cause of death.[6]

More than one in four adults living with a severe mental health issue is also struggling with substance abuse issues. The effects on the communities can have direct and indirect consequences. “Direct consequences can include injuries, social and legal problems, impaired health, overdose, deaths, and babies born with neonatal abstinence syndrome. Indirect consequences include higher health care costs, the spread of infectious diseases, drug-related crime, interpersonal violence, unintended pregnancy, and stress within families.”[7]

How Does Alabama Compare?

Mental health care and substance abuse are critical issues in Alabama. In 2014, Mental Health America ranked the fifty states and Washington, D.C. in a number of mental health categories.[8] Overall, in the composite ranking of 15 mental health metrics, Alabama ranked 41st, ahead of neighboring states South Carolina, Tennessee, Mississippi, but behind North Carolina, Florida, Arkansas, and Louisiana. Georgia led all Southeast states at 26. Alabama ranked 27th in overall adult mental health and 28th in overall youth mental health. Looking at individual components, Alabama ranked:

  • 30th in the number of adults suffering from any mental illness;
  • 18th in the number of adults suffering from acute suicidal ideation;
  • 9th in the number of youth suffering from a major depressive episode in the previous year;
  • 42nd in the number of adults diagnosed with any mental illness without insurance, representing 20.8% of the adult population; and
  • 48th in overall access to care, ahead of only Texas, South Carolina, and Mississippi.

In spite of all this, less than half (43.5%) of adults in Alabama living with mental illness have received any form of treatment.[9]

Alabama now faces the daunting task of combating the opioid crisis. In 2013, Alabama had the highest per capita number of opioid prescriptions in the country – 141.1 per 100 compared to the national average of 79.3 per 100 people. Since then, the rate has dropped to 120.3 per 100 in 2015 – but this number still represents 1.2 prescriptions for every man, woman, and child in Alabama.[10]

While Alabama ranks 34th in deaths from drug overdose, the number of overdose deaths continue to climb: from 169 in 1999 to 756 in 2016, a 347% increase.[11]

Lack of accessible care and lack of sufficient insurance coverage for substance users exacerbates the issue. There is a high correlation between availability of preventative mental health services and mental health treatment. Alabamians have less access to mental health services than do residents of many other states.

What Can We Do?

Access to Care

One of the most significant factors facing mental health and addiction treatment in Alabama is simply the lack of access. Alabama has one mental health provider for every 1,180 people. Mental health providers include psychiatrists, psychologists, licensed clinical social workers, counselors, marriage and family therapists, and advanced practice nurses who specialize in mental health. However, at the county level, the ratio ranges from 270:1 (Macon County) to 33,840:1 (Chambers County).[12] Focusing on just substance abuse, statewide, there are 505 beds for residential and high-intensity residential substance abuse treatment – and these beds are located in just 13 counties. There is a waiting list of 319 people.

Individuals without insurance may wait for months to see a mental health professional. More often than not, this results in a crisis that ends with the individual in the hospital or jail. In effect, Alabama’s hospital emergency departments, jails, and prisons serve as de facto mental health providers. At the same time, while most people know how to access physical health care, people may be less familiar with when and how to access mental health care.

  • The state could expand Mental Health First Aid, described as ‘CPR’ for mental health, and Crisis Intervention Training for law enforcement personnel.
  • The state could also explore a waiver, which would allow Medicaid to fund treatment of substance abuse.
  • The state could explore expanding access to substance abuse treatment, particularly residential treatment. There are currently no substance abuse facilities, public or private, in Autauga, Bullock, Coosa, Lawrence, Lowndes, Perry, Washington, or Wilcox Counties.

Mental Health Workforce

Access is largely, but not exclusively, a function of size of the mental health workforce. Alabama faces a growing workforce shortage in many industries, including mental health services. There is a particular shortage for trained professionals serving the elderly. Unaddressed, this shortage will escalate as the senior population is growing faster than other age groups.

  • The state could explore incentives to attract and retain mental health professionals.
  • The state could explore licensure regulations to allow all medical professionals to practice at the highest levels of their training and certification.

Social Stigma

Mental health experts recognize that even if there were sufficient mental health providers, there is still a significant stigma attached to accessing treatment for mental health or substance abuse issues. Moreover, often when treatment is sought, the individual is already in a state of crisis, rather than seeking care earlier.

  • The state could seek to reduce the stigma by promoting and expanding peer programs—mental health services led by, or in conjunction with a person who has experienced mental illness himself or herself.
  • The state could develop an awareness campaign for the general public.

Standards of Care

There are a number of evidence-based and standards of care treatments that could be considered for expansion or modification in Alabama.

  • The use of medication to treat opioid addiction could be expanded.
  • The state could require healthcare professionals who prescribe medication treatment for addiction, do so only in consultation with a trained mental health professional.
  • The number of state-funded residential beds for substance abuse treatment could be expanded.
  • The number of nonprofit or low-cost methadone clinics for those with heroin addictions who suffer multiple relapses could be expanded.
  • The state could create a harm reduction program for opioid users, which includes education, counseling, referrals to treatment, and needle services and which has been shown to reduce the spread of HIV and Hepatitis C and increase the likelihood an individual will seek treatment.
  • The state could expand mental health and substance abuse treatment in the corrections system, which could also help reduce recidivism rates.

Drafted by Anita Perry, graduate student, Department of Social Work, Samford University, and the staff of the Public Affairs Research Council of Alabama.

Full PDF report available here.

[1] Alabama Department of Public Health, State of Alabama Community Health Improvement Plan (2015), http://www.adph.org/accreditation/assets/CHIP_2015_RevAugust.pdf.

[2] Rosenberg, L. 2012. “Behavioral disorders: the new public health crisis.Journal of Behavioral Health Services & Research 39(1):1-2.

[3]  U.S. Department of Health and Human Services, “Mental Health and Substance Use Disorders” (2017), https://www.mentalhealth.gov/what-to-look-for/mental-health-substance-use-disorders.

[4]  U.S. Department of Health and Human Services, “Mental Health and Substance Use Disorders” (2017), https://www.mentalhealth.gov/what-to-look-for/mental-health-substance-use-disorders.

[5] U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Facing Addiction in America: The Surgeon General’s Report on Opioids (2018), https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf.

[6] U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Facing Addiction in America: The Surgeon General’s Report on Opioids (2018), https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf.

[7] Walden, Nicole. “The Opioid Crisis in Alabama” Alabama Department of Mental Health, November 27, 2017, http://www.alabamapublichealth.gov/alphtn/assets/112717handouts.pdf.

[8] Mental Health America, “The State of Mental Health in America, 2018” (2018), http://www.mentalhealthamerica.net/issues/state-mental-health-america.

[9] U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Behavioral Health Barometer Alabama, 2015, (2015), https://www.samhsa.gov/data/sites/default/files/2015_Alabama_BHBarometer.pdf.

[10] National Institute on Drug Abuse, “Alabama Opioid Summary” (2018), https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/alabama-opioid-summary

[11] U.S. Department of Health and Human Services, Centers for Disease Control, “Drug Overdose Mortality by State: 2016” (2018), https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_poisoning.htm

[12] Robert Wood Johnson, 2018 County Health Rankings, (2018), http://www.countyhealthrankings.org/app/alabama/2018/measure/factors/62/map


Poverty and Homelessness Ranks #5 Among Alabama Voter Priorities

In late 2017, the Public Affairs Research Council of Alabama (PARCA) surveyed Alabama voters to determine their thoughts about the general direction of the state and the issues that most concern them. PARCA partnered with Samford University to survey policy professionals from across the state including academics, journalists, business and nonprofit leaders, and lobbyists. Their responses provided a list of 17 critical issues facing Alabama. PARCA partnered with USA Polling at the University of South Alabama to ask registered voters about these 17 issues. The voters’ responses generated the Top Ten list of voter priorities. Details about the survey and its methodology can be found in the full Alabama Priorities report.

Alabama Priorities

1. K-12 Education
2. Healthcare
3. Government Corruption and Ethics
4. Mental Health and Substance Abuse
5. Poverty and Homelessness
6. Jobs and the Economy
7. Crime and Public Safety
8. Job Training and Workforce Development
9. Improving the State's Image
10. Tax Reform

Key Findings

  • Voters broadly agree on the critical issues facing the state.
  • Voters are not polarized along traditional political, ideological, racial, or generational lines. There is a significant gap between the priorities of experts and the priorities of voters.
  • Policymakers have an opportunity to inform and educate voters on critical and systemic challenges facing the state.
  • Policymakers have an opportunity to respond to immediate, often highly personal issues that concern voters.
  • Elected officials and candidates have an opportunity to show leadership and to build broad coalitions to address Alabama’s most pressing challenges.

In the following months, PARCA will produce summary briefs on each of the top ten priorities chosen by Alabama voters. Each brief will answer four critical questions: what is the issue, why it matters, how Alabama compares, and what options are available to Alabama policymakers.

#5: Poverty and Homelessness

What is the issue?

Poverty and homelessness is the 5th most important issue for Alabama voters, with 58% of voters indicating they are very concerned about the issue. Poverty and homelessness averaged 4.192 on 1–5 scale where 1 is “not at all concerned” and 5 is “very concerned.” The majority of every demographic and political group indicated they were very concerned about this issue.

Why are Poverty and Homelessness Important?

The standard measure of poverty is the percentage of people earning less than a specific dollar amount: the federal poverty line. The federal poverty line is adjusted for the number of people in a household and is revised annually. In 2018, the federal poverty line for a family of four is $25,100. Although the percent of the population living in poverty is in decline, over 39 million people were still in poverty in the U.S. in 2017. Poverty often creates a vicious cycle that can last generations. Poverty complicates and is complicated by almost every other challenge facing Alabama and the nation.

The U.S. Department of Housing and Urban Development defines homelessness, in part, as lacking a fixed, regular, and adequate nighttime residence or a primary residence that was not designed for or ordinarily used as a regular sleeping accommodation for people. On a single night in 2017, an estimated 553,742 people were homeless in the United States. Homeless experts and advocates question the appropriateness of the definition and the accuracy of the number, some suggesting the number to be almost double.[1]

Homelessness can:

  • create new health problems and exacerbate existing ones;[2]
  • increase the chances of entering the criminal justice system and increase the recidivism rate;[3]
  • increase substance misuse;[4] and
  • have a negative economic impact on the larger community.

How Does Alabama Compare?

Population in Poverty

The percent of the population in Alabama living below the federal poverty level has declined from 19% in 2010 to 16.9% in 2017, mirroring declines at the national level. However, the percent of people living below the poverty level in Alabama is still higher than that of the nation. In 2017, Alabama had the 6th highest poverty rate in the U.S. and the fourth highest poverty rate among 10 southeastern states.

Poverty sees no color – while black Alabamians are disproportionately poorer, with 27% living in poverty, white Alabamians are deeply affected as well, with 12% living below the poverty line.[5] Approximately thirty-one percent of Hispanics in Alabama live below the poverty line.

Children in Poverty

Similar to poverty in the total population, the percent of children living in poverty in Alabama is consistently higher than that of the nation. During the period 2010 to 2017, childhood poverty declined for the state, reaching 24.6% in 2017. When compared to southeastern states, the percentage of children in poverty in Alabama ranked higher than all states except Louisiana at 28% and Mississippi at 26.9%.

Homelessness

In 2017, there were an estimated 3,793 homeless people in Alabama, a decrease of 7.7% over the previous year and more than 37% since 2010. In the ten-year period between 2007 and 2017, Alabama’s homeless rate decreased at a faster rate than the national average – a 30% decrease in the state compared to a 14.4% decrease nationally. However, Alabama’s percentage change has been lower than a majority of its southeastern neighbors. Also, while homelessness in Alabama is trending in a positive direction, those still struggling with homelessness are sometimes those facing the most profound challenges, including addictions and mental health issues.

What Can We Do?

There is no single solution to reducing poverty or homelessness. As the causes are varied, complex, and differ from region to region across the state, so too must the responses. Private philanthropy and the faith community can do much to assist individuals and families, but the challenge is too large to be left to the private sector alone. Alabama could consider policy responses and interventions that have demonstrated success around the country, some of which are highlighted below.

  • Increased investment in education: in 2016, Alabama was 39th among U.S. states in per student spending.[6]
  • Expanded student and family support for students in Pre-K through 12th
  • Expanded investment in workforce development for under-employed and unemployed adults.
  • Expanded educational opportunities and supportive services for low-income adults.
  • Expanded access to primary healthcare, especially in rural parts of Alabama.
  • Increase family income for those in poverty through expanded employment (24% of survey respondents indicated the number of available jobs was their top economic priority) or increased wages (32% of respondents said increasing the minimum wage was their top economic priority).
  • Implement a statewide housing first model to address homelessness.

Read full PDF report here.       

[1] National Coalition for the Homeless. “Current State of Homelessness” April 2018 http://www.nationalhomeless.org/

[2] National Health Care For The Homeless Council. “Homelessness & Health: What’s The Connection?”, Fact Sheet, June 2011 https://www.nhchc.org/wp-content/uploads/2011/09/Hln_health_factsheet_Jan10.pdf

[3] Volunteers of America, “Homelessness and Prisoner Re-Entry”, https://www.voa.org/homelessness-and-prisoner-reentry

[4] National Coalition for the Homeless, “Substance Abuse and Homelessness” July 2009. http://www.nationalhomeless.org/factsheets/addiction.pdf

[5] Census Bureau’s Population Estimates Program. (2017). 2017 American Community Survey 1-Year Estimates. [Data file]. Retrieved from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_15_1YR_S1701&prodType=table

[6] “Annual Survey of School System Finances” U.S. Census Bureau https://www.census.gov/programs-surveys/school-finances.html


PARCA Annual Survey Addresses Representation in State Government, Public Education and Payday Loans

PARCA collaborated with Samford University to conduct our annual telephone survey of Alabama citizens between June 4 and July 18, 2018. The survey was directed by Dr. Randolph Horn and was under the field direction of Grace Okoro.

The survey addressed topics including the quality of representation in state government, and, in partnership with the Alabama Association of School Boards, questions about public education in Alabama, and, in partnership with the Community Foundation of Greater Birmingham, questions about payday loans.

Many trends remained the same from previous years, but some of the results were surprising.

Read the full report here. (PDF)


Jobs and the Economy Ranks #6 Among Alabama Voter Priorities

In late 2017, the Public Affairs Research Council of Alabama (PARCA) surveyed Alabama voters to determine their thoughts about the general direction of the state and the issues that most concern them. PARCA partnered with Samford University to survey policy professionals from across the state including academics, journalists, business and nonprofit leaders, and lobbyists. Their responses provided a list of 17 critical issues facing Alabama. PARCA partnered with USA Polling at the University of South Alabama to ask registered voters about these 17 issues. The voters’ responses generated the Top Ten list of voter priorities. Details about the survey and its methodology can be found in the full Alabama Priorities report.

Alabama Priorities

1. K-12 Education
2. Healthcare
3. Government Corruption and Ethics
4. Mental Health and Substance Abuse
5. Poverty and Homelessness
6. Jobs and the Economy
7. Crime and Public Safety
8. Job Training and Workforce Development
9. Improving the State's Image
10. Tax Reform

Key Findings

  • Voters broadly agree on the critical issues facing the state.
  • Voters are not polarized along traditional political, ideological, racial, or generational lines. There is a significant gap between the priorities of experts and the priorities of voters.
  • Policymakers have an opportunity to inform and educate voters on critical and systemic challenges facing the state.
  • Policymakers have an opportunity to respond to immediate, often highly personal issues that concern voters.
  • Elected officials and candidates have an opportunity to show leadership and to build broad coalitions to address Alabama’s most pressing challenges.

In the following months, PARCA will produce summary briefs on each of the top ten priorities chosen by Alabama voters. Each brief will answer four critical questions: what is the issue, why it matters, how Alabama compares, and what options are available to Alabama policymakers.

#6: Jobs and the Economy

What is the issue?

Alabama voters ranked jobs and the economy as the 6th most important issue, with 56% of respondents indicating they were very concerned about this issue. The issue ranked highly across all subgroups: political affiliations, generations, gender, and  education level, and race. The only substantive difference in subgroups found was in ideology, where the issue ranked lower for liberals than for conservatives or moderates.

Voters were also asked to identify their top priorities regarding jobs and the economy, selecting from the number of available jobs, availability of qualified workers, wage growth, or increasing the minimum wage. Thirty-two percent of respondents selected increasing the minimum wage as their top priority; 24% identified number of available jobs, followed by availability of qualified workers at 22%. Wage growth was found to be least important and was selected by 18% of respondents.

Why are Jobs and the Economy Important?

 A growing economy and a high employment rate support many measures of overall well-being, including household income, health, housing stability, tax revenue, and more.[1]  Economic growth:

  • is the most fundamental indicator of an economy’s health,[2]
  • is an important indicator contributing to poverty reduction;[3]
  • can create job opportunities and hence stronger demand for labor;[4]
  • can improve standards of living and health;[5]
  • can improve educational attainment;[6] and
  • can improve technology and infrastructure.[7]

How Does Alabama Compare?

There are numerous indicators used to determine jobs and economic growth. We consider four of the most commonly used measures, although there is much debate that these measures tell the entire story.

Gross Domestic Product

Economic health is most typically measured by the growth rate of the Gross Domestic Product (GDP), a comprehensive value of all goods and services produced.[8] Like the U.S., Alabama has enjoyed GDP growth every year between 2009 and 2017, although the state has grown at a slower rate than the nation. The state saw its lowest percentage increase of 1.9% from 2013 to 2014 and ranked only higher than Mississippi (1%) among southeastern states. Alabama’s GDP increased 3.3% from 2016 to 2017, exceeding the growth rate in Arkansas and Mississippi, but trailing other southeastern states.

Median Household Income

Median household income is the income figure that divides all households into two equal groups, with half earning more than the income and half earning less. Median income in Alabama increased annually since 2010. In 2016, according to American Community Survey 1-year estimates, Alabama’s median household income was $46,257 – 46th among all states, more than $10,000 below the national average. When compared to other Southeastern states, Alabama fared worse than all except Louisiana ($45,146), Arkansas ($44,334) and Mississippi ($41,754).

Poverty

Poverty is measured as the percentage of people earning less than a specific dollar amount: the federal poverty line. The federal poverty line is adjusted for the number of people in a household and is revised annually. The percent of population in Alabama living below the federal poverty level has declined from 19% in 2010 to 17.1% in 2016, mirroring declines at the national level. However, the percent of people living below the poverty level in Alabama is still higher than that of the nation. When compared to 10 states in the Southeast, Alabama’s poverty rate ranked 5th highest in 2016 and 7th highest among all states.

Unemployment Rate

Alabama’s unemployment rate is also decreasing, as is the national rate. In 2013, Alabama’s unemployment rate was 7.2%. By 2017, the figure had declined to 4.4%. The state’s rates are comparable to that of the U.S. during this same period. Nationally, unemployment fell from 7.4% in 2013 to 3.8% at the end of 2017. Alabama’s unemployment rate (4.4%) ranked 5th lowest among 10 Southeastern states, where Arkansas had the lowest unemployment rate of 3.7% and Mississippi had the highest of 5.1%.

What Can We Do?

The state has numerous options to support a robust economy and a strong job market, including:

  • increased investment in education: in 2016, Alabama was 39th among the states in per student spending;[9]
  • increased investment in healthcare; in 2014, state-level per capita healthcare spending was 9% lower than the national average, suggesting lower levels of insurance coverage and healthcare access;[10]
  • increased investment in infrastructure: Alabama’s infrastructure was graded a C- in a recent study by civil engineers[11]. For more in infrastructure, see PARCA’s 2017 report, How Alabama Roads Compare.[12]
  • developing an adequate, fair, and efficient tax structure: Alabama collects the least amount in state and local revenue per capita of any state in the nation. See How Alabama Taxes Compare.[13]
  • continuing ongoing work to align K-12 and post-secondary education and training offerings with the needs of employers, increasing opportunities for students and workforce quality for employers.

Although we considered four of the most commonly used measures, we cannot ignore the fact that economic growth is difficult to measure or even define. Many studies have shown both pros and cons of using the above indicators to measure growth. For example, authors have argued the validity of using unemployment rate as a measure of growth, considering the increasing number of part-time jobs versus full-time jobs.[14]  Others have argued the difficulty of measuring growth based on indicators such as standard of living, given the lack of, or consistency of data. However, this article seeks only to highlight a snapshot of Alabama’s economy and how the state compares nationally, using consistent data for all states. More comprehensive research should be done to gain more insight into changes in the state’s jobs and economy over time.

Drafted by Kenesha Reynolds-Allie, Ph.D. and the Staff of the Public Affairs Research Council of Alabama

Read the full PDF report here.


[1] Good Growth for Cities 2017, A report on urban economic wellbeing from PWC and Demos, November 2017. https://www.pwc.co.uk/government-public-sector/good-growth/assets/pdf/2017-good-growth-for-cities.pdf

[2] Bolton, S. and Khaw S., “Economic Growth”, July 2006. https://www.theguardian.com/business/2006/jul/10/ukeconomy.globalrecession

[3] Adams Jr., Richard. H, “Economic Growth, Inequality, and Poverty”, The world Bank, Poverty Reduction and Economic Management Network, February 2003.

[4] Department for International Development (DFID), “Growth: Building Jobs and Prosperity in Developing Countries” https://www.oecd.org/derec/unitedkingdom/40700982.pdf

[5] Weil, D.N. “Economic Growth”, 3rd Edition, Harlow Pearson Education Limited, 2013. Rivera IV, B., and Currais, L., “Economic Growth and Health Direct Impact or Reverse Causation”, Applied Economics Letters, 6(11), 761-764.

[6] The World Bank (2007), “Education Quality and Economic Growth”

[7] Canning, D., and Pedroni, P., “Infrastructure and Long Run Economic Growth”, Consulting Assistance on Economic Reform II Discussion Paper, 57.

[8] Bureau of Economic Analysis, U.S. Department of Economic Analysis. https://www.bea.gov

[9] “Annual Survey of School System Finances” U.S. Census Bureau https://www.census.gov/programs-surveys/school-finances.html

[10] A state-by-state breakdown of per capita healthcare spending. https://www.beckershospitalreview.com/finance/a-state-by-state-breakdown-of-per-capita-healthcare-spending.html

[11] American Society of Civil Engineers, “Report Card for Alabama’s Infrastructure”, 2015. https://www.infrastructurereportcard.org/wp-content/uploads/2016/10/ASCE-AL-Report-Card-2015-Full-Report-FINAL-web.pdf

[12] How Alabama Roads Compare. 2017. Public Affairs Research Council of Alabama. http://parcalabama.org/how-alabama-roads-compare-ninth-edition-2017/

[13] How Alabama Taxes Compare. 2017. Public Affairs Research Council of Alabama. http://parcalabama.org/how-alabama-taxes-compare/

[14] Jericho, Greg, “Why unemployment is no longer the best indicator of the economy’s health” https://www.theguardian.com/business/grogonomics/2016/aug/22/why-unemployment-is-no-longer-the-best-indicator-of-the-economys-health