2025 Children's of Alabmama Community Health Needs Assessment

2025 Community Health Needs Assessment Children’s of Alabama

TABLE OF CONTENTS

List of Tables.............................................................................................................................................3 List of Figures...........................................................................................................................................3 Executive Summary...................................................................................................................................4 Introduction.............................................................................................................................................. 6 Methodology............................................................................................................................................ 7 Demographic Analysis............................................................................................................................11 Health Issues..........................................................................................................................................14 Healthcare Access..................................................................................................................................19 Child Safety...........................................................................................................................................23 Other Issues...........................................................................................................................................27 Resource Adequacy................................................................................................................................28 Missing Resources...................................................................................................................................29 Focus Groups.........................................................................................................................................30. Conclusion............................................................................................................................................. 43. Appendix A. Total Population, Child Population by County ........................................................................ 44. Appendix B. Responses by County........................................................................................................... 46. Appendix C. Responses by City ............................................................................................................... 47. Appendix D. Health Issues by Parental Status ........................................................................................... 49. Appendix E. Health Issues by Professional Role......................................................................................... 50. Appendix F: Health Issues by Those Who Serve Children .......................................................................... 51. Appendix G. Safety Issues by Age Band .................................................................................................. 52. Appendix H. Safey Issues by Service Area ............................................................................................... 55. Appendix I. Safety Issues by Urban/Rural Location ................................................................................... 56. Appendix J. Safety Issues by Parental Status............................................................................................. 57. Appendix K. Safety Issues by Professional Role ......................................................................................... 58. Appendix L. Safety Issues by Those Who Serve Children ........................................................................... 60. Appendix M. Safety Issues Service Area .................................................................................................. 61. Appendix N. Safety Issues by Urban/Rural Location ................................................................................. 62. Appendix O. Safety Issues by Parental Status ........................................................................................... 63. Appendix P. Safety Issues by Professional Role.......................................................................................... 64. Appendix Q. Other Issues Comments, Categorized................................................................................... 66 Resources ............................................................................................................................................. .. 34 ActionsTaken .......................................................................................................................................... 3 6

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LIST OF TABLES

Table 1. Survey Response Options..............................................................................................................7 Table 2. Respondents by Age.....................................................................................................................8 Table 3. Respondents by Race....................................................................................................................8 Table 4. Respondents by Professional Role..................................................................................................8 Table 5. Health Issues Ranked..................................................................................................................14 Table 6. Top Health Issue by Age of Respondent........................................................................................14 Table 7: Top Health Issue by Race of Respondent.......................................................................................14 Table 8. Top Health Issue by Other Response Categories............................................................................16 Table 9. Top Health Issues, Survey vs. External Data..................................................................................18 Table 10. Top Access Issues.....................................................................................................................19 Table 11. Access Issues by Age................................................................................................................19 Table 12. Access Issues by Ethnicity/Race.................................................................................................19 Table 13. Access Issues by Geography.....................................................................................................20 Table 14. Survey Responses and External Data.........................................................................................22 Table 15. Safety Issues Ranked................................................................................................................23 Table 16. Top Safety Issues by Age of Respondent.....................................................................................24 Table 17. Top Safety Issues by Race of Respondent....................................................................................24 Table 18. Top Safety Issues by Category...................................................................................................24 Table 19. Resource Adequacy by Age of Respondents...............................................................................28 Table 20. Resource Adequacy by Race of Respondents..............................................................................28 Table 21. Resource Adequacy by Category..............................................................................................28 Table 22. Missing Resources....................................................................................................................29

LIST OF FIGURES

Figure 1. Ages of Children Served.............................................................................................................9 Figure 2. Children’s Alabama Service Area................................................................................................9 Figure 3. Children as a Percentage of the Population.................................................................................11 Figure 4. Number and Percent Change of Children In/Out of Birmingham Metro........................................12 Figure 5. Children as a Share of the Population........................................................................................12 Figure 6. Population Change by Age Band, 2020–24...............................................................................13

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EXECUTIVE SUMMARY

The 2025 Community Health Needs Assessment (CHNA) for Children’s of Alabama was conducted by the Public Affairs Research Council of Alabama (PARCA) in accordance with IRS and Affordable Care Act regulations. The study integrates quantitative data, survey responses, and focus group findings to identify the leading health, access, and safety challenges affecting children in Alabama.

The analysis included:

A statewide community survey ( ≈ 780 respondents) addressing perceived child health, healthcare access, and safety issues.

Four focus groups representing diverse populations: Pickens County (rural providers), Birmingham City School students, [Jefferson County students description TK], and West End (Jefferson County) caregivers. Secondary data from state and national sources, including the U.S. Census Bureau, Centers for Disease Control, Feeding America, and VOICES for Alabama’s Children . Respondents represented 58 of Alabama’s 67 counties; 55% resided in the Birmingham, Alabama, Metropolitan Statistical Area 1 (Bibb, Blount, Chilton, Jefferson, Shelby, St. Clair, and Walker), and 45% lived elsewhere. Sixty-eight percent lived in urban counties, 30% in rural.

Top Community-Identified Issues

HEALTH

Mental and Behavioral Health —Identified by 73% of respondents as a top concern, this issue dominates both survey and focus group results. Participants reported escalating youth anxiety, depression, and behavioral challenges, exacerbated by stigma and insufficient counseling services. Healthcare Access —Despite high pediatric insurance coverage (97%), many families—especially in rural counties—struggle to reach providers or afford services. Alabama’s pediatric provider shortages and transportation barriers persist statewide.

Child Abuse —Ranked third overall, confirmed by rising rates of indicated abuse/neglect reports (10.6 per 1,000 children).

Other concerns, such as childhood obesity, hunger, and accidental injury were rated lower, despite data showing continued prevalence.

ACCESS TO CARE

Ability to Pay for Care —70% of respondents identified cost as a major barrier. Nearly one in four Alabama children lives in poverty, and more than 45% of births are covered by Medicaid. Availability of Quality Services —Rural hospital and clinic closures have left many counties without pediatric providers; 80% of counties lack pediatric services.

Parent Education and Awareness —Parents often lack knowledge of available services or preventive care programs.

Transportation —A persistent obstacle, particularly in rural areas without public transit options.

These findings mirror Jefferson County Department of Public Health’s own community health improvement priorities, emphasizing affordability, transportation, and family education. 2

______________________________________ 1 OMB Bulletin No. 23-01

2 The Community Health Improvement Plan , 2020—2-2024. Jefferson County https://www.jcdh.org/ SitePages/Misc/PdfViewer?AdminUploadId=2587#:~:text=match%20at%20L1650%20Strategic%20 Issue,Term%20Target

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CHILD SAFETY

Substance Abuse of Caregivers/Screentime & Social Media —Tied as top concerns (mean score 5.9). Families expressed worry about the impact of parental addiction and online exposure on children’s emotional health and safety.

Suicide —Ranked second, consistent with Alabama’s high youth suicide rate (9 per 100,000, 8th highest nationally).

Firearm Injury —Ranked third; Jefferson County alone treated 387 nonfatal pediatric gunshot injuries in six months of 2023. In 2024, COA treated 69 firearm injuries in the Emergency Department. Focus group discussions reinforced these risks, linking violence exposure, mental health distress, digital stressors, and lingering effects of the COVID-19 pandemic as intersecting safety concerns for youth.

RESOURCE ADEQUACY

On a 1–10 scale, respondents rated the adequacy of community child health resources at 5.8 , indicating modest dissatisfaction. Urban respondents rated adequacy slightly higher (6.1) than rural respondents (5.2).

The most frequently cited missing resources were:

• Mental/behavioral health services (35%) • Financial or insurance assistance (15%) • Pediatric and specialty care (19% combined) • Parent education/support (8%) • Affordable childcare, food, and transportation services (6% each).

FOCUS GROUP FINDINGS

Across all four sessions, participants highlighted:

• Scarce behavioral health and specialty care in rural areas • Caregiver fatigue and kinship caregiving without legal authority. • Youth risk behaviors fueled by boredom, peer pressure, and online exposure. • Limited safe spaces and supervision for teens. • Strong trust in schools, churches, clinics, and libraries as community anchors but recognition of their resource constraints.

CROSS-CUTTING THEMES

1. Behavioral Health Crisis —Mental and emotional well-being dominate public concern and are substantiated by rising youth depression, suicide, and trauma rates. 2. Geographic and Economic Barriers —Access to affordable, local pediatric services remains a statewide inequity. 3. Family Stress and Caregiver Support —Economic hardship and kinship care arrangements strain families’ capacity to meet children’s health needs. 4. Youth Risk and Digital Exposure —Firearm injury, substance misuse, and social media pressures demand coordinated prevention strategies. 5. Community Collaboration —Schools, libraries, and clinics offer trusted entry points for outreach but require sustainable funding and integration.

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INTRODUCTION

Children’s of Alabama engaged the Public Affairs Research Council of Alabama (PARCA) to conduct primary research and secondary data analysis in support of its 2026 Community Health Needs Assessment (CHNA). PARCA conducted this work in accordance with the CHNA regulations provided by the IRS and The Patient Protection and Affordable Care Act of 2010 , the CHNA’s enabling legislation. The project design was developed in conjunction with Children’s of Alabama’s staff, based on the design and findings of the assessments conducted since 2013, executed by PARCA staff.

This year’s analysis focuses on pediatric health issues, healthcare access issues, and safety issues.

The report integrates community survey data, focus group input, and county, state, and national data to understand community concerns and where those concerns align and contradict quantitative data.

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METHODOLOGY

The analysis is based on a community survey, focus group data, and local, state, and national quantitative data.

COMMUNITY SURVEY

Children’s and PARCA conducted surveys of Alabamians to understand their views on the health, health access, and health safety issues facing children. The 2025 survey differs in its questions, distribution, and respondents. In previous years, healthcare professionals and educators were surveyed. The survey was shared with potential respondents through their professional associations, such as the Alabama School Nurses Association or the Alabama Chapter of the American Academy of Pediatrics. Those respondents were asked a series of questions concerning issues for different age groups. In contrast, the 2025 survey targets a general audience and asks respondents about issues facing issues of children of all ages. The survey was was shared at Children’s at community events, health fairs, and via external communications. The survey was also promoted to PARCA’s random sample survey panel. Respondents were asked to rank from most important to least important or serious, a range of issues concerning health, access, and safety. The options are listed in Table 1.

Table 1. Survey Response Options

Health Issues

Access Issues

Safety Issues

Accidental injury/trauma Child abuse Childhood hunger Childhood obesity Healthcare access Infectious diseases Mental/behavioral health Other

Ability to pay for care Availability of quality health care services Lack of reliable and affordable transportation Parent education Scheduling difficulty Other

Accidental poison ingestion/ exposure Alcohol/drug /tobacco use by children Behavior related to bicycles, motorcycles, or ATVs Car safety Childcare access, quality, or affordability Firearm injury Parent Education Screen time/social media Sleep Sport-related injury/safety Substance abuse of caregivers Suicide Teen driving Water safety/drowning Other

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A plurality 3 of responses (28.4%) were in the 35–44 age band, and 81% were between 25 and 64. See Table 2.

Table 2. Respondents by Age Age Range

n Percent

Under 18

14 20

1.83 2.61

18–24 25–34 35–44 45–54 55–64 65–74 75–84

104 13.59 217 28.37 152 19.87 148 19.35

83 26

10.85

3.4

85 or older

1

0.13 100

765

Respondents were able to check multiple boxes to reflect ethnicity and race, but responses were analyzed individually, so the percentages total more than 100.

Table 3. Respondents by Race Race

n

Percent

White

599 138

78.51 18.09

Black or African American

American Indian or Alaska Native

14 14 10

1.83 1.83 1.31 1.05 0.13

Other

Hispanic/Latino/Latina

Asian

8 1

Native Hawaiian or Pacific Islander

784

102.75

Profession or job status was not of great importance to the study, although respondents’ role as healthcare professionals or educators was of interest. As indicated in Table 4, 55% of respondents identified as healthcare providers and 10% as educators.

Table 4. Respondents by Professional Role Professional Role

n

Percent

Healthcare professional

419 102

55.2 13.4 10.8 10.4

Other

Businessperson

82 78 46 24

Educator

Community member

6

Elected official or government employee

3.2

Law enforcement/first responder

8

1

759

100

______________________________________ 3 The largest number but short of a majority.

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Across all respondents, 73% indicated they serve children. Almost 25% serve each age group, and 21% serve all age groups. See Figure 1.

360, 21%

453, 26%

447, 26%

464, 27%

Under 5 6 to 12 13 to 18 All Ages

Figure 1. Ages of Children Served

Additionally, 366 respondents, 45.9%, indicated they were parents or guardians of children 18 or under, compared to 50.6% who are not parents or guardians. Parental status was not provided for 28 respondents.

Responses are also analyzed by geography.

County location was determined for 769 responses, representing 58 of Alabama’s 67 counties. The largest number of responses, 350 (45.5%) were collected in Jefferson County. The second highest is Shelby County with 59 responses, equivalent to 7.7%. No responses were collected from Choctaw, Clay, Conecuh, Dale, Dallas, Lowndes, Monroe, Randolph, or Wilcox Counties. The number and percentage of responses collected from each county and from 99 cities are provided in Appendices B and C. Children’s primary service is defined as the geography where 70% of discharges originate, extending from Huntsville to Dothan. This is due to the specialty and subspecialty services provided at Children’s, which are limited in other areas of Alabama. It also coincides with the population centers of Alabama. The rest of Alabama counties comprise the secondary service area for Children’s.

Figure 2. Children’s of Alabama Service Area

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However, for this CHNA, Children’s strategically narrowed the analysis to the immediate statistical area surrounding the main down town campus—the Birmingham Metropolitan Statistical Area (Birmingham MSA), encompassing the counties of Jefferson, Shelby, Blount, Bibb, St. Clair, Chilton, and Walker. This focused approach enables a deeper, more actionable examination of local health determinants, resource gaps, and social vul nerabilities that disproportionately impact children in this densely populated hub. By prioritizing granular data from this core region, Children’s can identify targeted priorities, forge stronger community partnerships, and drive evidence-based interventions that serve as scalable models for the wider statewide footprint. This methodology aligns with IRS guidelines for CHNAs, ensuring the assessment is both comprehensive and pragmatically impactful, ultimately benefiting children and families throughout Alabama. Just over 55% of respondents reported living in the Birmingham MSA, and 43% lived outside the Birmingham MSA. County residency could not be determined by 2% of respondents. The Alabama Rural Health Association, based on 2023 guidance from the White House Office of Management and Budget, classifies 12 counties as urban: Calhoun, Etowah, Houston, Jefferson, Lauderdale, Lee, Madison, Mobile, Montgomery, Morgan, Shelby, and Tuscaloosa Counties.

Sixty-eight percent of respondents reported living in urban counties, compared to 29.6% in a rural county.

FOCUS GROUPS

PARCA staff conducted three focus groups, one with community leaders, educators, and nurses in Pickens County; one with patients and community members at a Cahaba Valley Healthcare Clinic in west Birmingham; and one with students from Birmingham City Schools. One additional focus group was conducted with student members of the William A. Daniel, Jr. Adolescent Clinic’s Youth Advi sory Board and facilitated by staff from the UAB Department of Pediatrics , with written guidance provided by PARCA staff.

Focus group insights appear throughout the report, but full analysis is in the final section of the report.

SECONDARY DATA

The needs assessment is not a comprehensive analysis of secondary data regarding children’s health. Rather, secondary data is consid ered to put community responses in context. A variety of sources were consulted, including the Census Bureau, the Centers for Disease Control and Prevention, Feeding America, VOICES for Alabama’s Children, and the Jefferson County Department of Health.

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DEMOGRAPHIC ANALYSIS

Understanding demographic data for the U.S., Alabama, and the primary and secondary regions for Children’s, is critical to understanding and interpreting CHNA data.

POPULATION

Over the last 10 years, the number of children has dropped in both the state and the nation. Children, as a percent of the national population 4 , have dropped steadily to the current rate of 21.6%. For context, in 1900, children under 18 accounted for 40% of the population. At the state level, the share dropped steadily from 2015 to 2022 and has fluctuated since. See Figure 3. At present, Alabama ranks 20 th in the nation for the highest percentage of children in the population 5 .

Figure 3. Children As a Percentage of the Population

In Alabama, between 2020 and 2024, the population of children increased by 0.3% to 1,334,857, and boys outnumber girls by 4%. 6

The share of children under 5 has also dropped year over year and is 1.9% smaller than in 2020. 7

______________________________________ 4 O’Hare, W.P. 2011. The changing child population of the United States: Analysis of data from the 2010 census. Baltimore, MD: The Annie E. Casey Foundation. Retrieved from www.aecf.org/resources/ the-changing-child-population-of-the-united-states; 2020 data: U.S. Census Bureau, 2020 Census Redistricting Data (Public Law 94-171). 5 Ibid. 6 Annual Estimates of the Resident Population for Selected Age Groups by Sex for Alabama: April 1, 2020 to July 1, 2024 (SC-EST2024-AGESEX-01). U.S. Census Bureau, Population Division. June 2025. 7 Ibid.

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The total population of the Birmingham MSA has grown by just 1% from 1,180,600 to 1,192,583. Meanwhile, the population outside of the Birmingham MSA increased by just over 120,000, a 3% increase. 8 At the same time, the population of children in the Birmingham MSA declined by 1.2% and increased by 1% outside the Birmingham MSA. 9 The Birmingham MSA accounts for 31% of the state’s under-18 population. 10 Figure 4 illustrates the year-over-year change and percentage change in the number of children under 18 in the Birmingham MSA and outside the Birmingham MSA.

Figure 4. Number and Percent Change of Children In/Out of Birmingham Metro

The absolute population of children in the Birmingham MSA is declining. So, too, is the percentage of children as a share of the population. While children make up a slightly larger share of the Birmingham MSA population, the share is steadily declining. See Figure 5.

______________________________________ 8 Annual County and Puerto Rico Municipio Resident Population Estimates by Selected Age Groups and Sex: April 1, 2020 to July 1, 2024 (CC-EST2024-AGESEX). U.S. Census Bureau, Population Division. June 2025. 9 Ibid. 10 Ibid. Figure 5. Children As a Share of the Population

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The population of children in the Birmingham MSA is also aging. Year over year, the share of children aged 14 to 17 has increased, while the share of children under 5 and 5 to 13 has declined, with the latter group declining the most. See Figure 6.

Figure 6. Population Change by Age Band, 2020–24

With a population of 150,703, Jefferson County has the most children, and Greene County, with 1,525, has the fewest. 11 Marshall County has the highest percent of children as a share of the population at 26%, and Coosa County the lowest at 16%. 12 See the full table in Appendix A.

POVERTY

Alabama ranks 6 th in the percentage of people in poverty at 16.2%, compared to a national rate of 12.6%. 13 Almost 22% of Alabama children are in poverty, compared to a national rate of 16.3%. This ranks the state 48 th in the percentage of children in poverty. 14

______________________________________ 11 Annual County and Puerto Rico Municipio Resident Population Estimates by Selected Age Groups and Sex: April 1, 2020 to July 1, 2024 (CC-EST2024-AGESEX). U.S. Census Bureau, Population Division. June 2025. 12 Annual County and Puerto Rico Municipio Resident Population Estimates by Selected Age Groups and Sex: April 1, 2020 to July 1, 2024 (CC-EST2024-AGESEX). U.S. Census Bureau, Population Division. June 2025. 13 Barries to Prosperity 2024 Dashboard.” Alabama Possible analysis of U.S. Census data. https://alabamapossible.org/wp-content/ uploads/2024/09/AP_PovertyFactSheet_2024_Web.pdf 14 “Children in Poverty in Alabama.” America’s Health Rankings. https://www.americashealthrankings.org/explore/measures/ChildPoverty/AL

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HEALTH ISSUES

Issue #1: Mental and behavioral health Issue #2: Healthcare access Issue #3: Child abuse

Mental and behavioral health emerged as the most pressing concern, with a mean rank of 2.6 and more than 73% of respondents placing it in their top three concerns. The second issue was healthcare access, with a mean of 3.6 and a median of 3. Just over half of respondents listed the issue in the top 3.

Finally, child abuse, with a mean of 3.6 and a median of 4 is the third issue. Almost 50% listed the issue in their top 3.

Healthcare access and child abuse also scored low mean ranks, signaling broad concern about access to basic medical care and the safety of children. Issues such as infectious diseases and other health issues were ranked lower on average, suggesting they are perceived as less immedi ate threats compared with mental health and basic healthcare access.

Table 5. Health Issues Ranked Rank Issue

n Mean Top 3 Count

Top 3%

1 Mental/behavioral health

788 2.6 788 3.6 788 3.7 788 4.4 788 4.4 788 4.4 788 5.3 788 7.6

579 407 373 290 286 254 138

73.5 51.6 47.3 36.8 36.3 32.2 17.5

2 Healthcare access

3 Child abuse

4 Accidental injury/trauma

5 Childhood obesity 6 Childhood hunger 7 Infectious diseases

8 Other

37

4.7

Focus groups—from rural Pickens County to Birmingham schools—described stress, anger, and grief showing up in classrooms and clinics. Providers see “kids who didn’t get help when they were young” now acting out; stigma still keeps some families from seeking counseling. Mental health is the top concern of almost every subpopulation, though the means vary. The only exception is those who do not work with children, who cite child abuse as their number one issue.

Table 6. Top Health Issue by Age of Respondent Age Band n Top Issue

Mean

Under 18 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84

12 Mental/behavioral health 20 Mental/behavioral health 103 Mental/behavioral health 215 Mental/behavioral health 153 Mental/behavioral health 150 Mental/behavioral health

2.5 2.7 2.8 2.4 2.5 2.6 2.4 2.3

79 26

Mental/behavioral health Mental/behavioral health

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“Screen time plays a lot into mental health… being depressed is like a trend.” — Birmingham student Lower mean scores signify more agreement among respondents. Thus, while the variances are minimal, there is slightly more agreement among the oldest respondents (mean=2.3) and less agreement among those aged 25 to 34 (mean=2.8).

“Parents are more receptive to physical health than mental health. They refuse to see something is wrong mentally.” — Pickens provider

Adult mental health and the corrosive effects of misinformation emerged as a topic of concern among children who participated in focus groups, especially as they reflected on their experiences during the pandemic. “I wasn’t worried about people outside of my family—my father got into conspiracy theories and was actively prepping for a societal result and that really messes with your brain when you’re like ten and constantly thinking people are going to kill you.” — Jefferson County student

Similarly, there is greater agreement among White than Black or African American respondents. See Table 7.

Table 7: Top Health Issue by Race of Respondent Race/Ethnicity n

Issue

Mean

White

595 Mental health/behavioral issues 136 Mental health/behavioral issues 10 Mental health/behavioral issues

2.5 3.0 2.2 2.1

Black or African American Hispanic/Latino/Latina:

Asian

8

Mental health/behavioral issues

American Indian or Alaska Native

14 Mental health/behavioral issues 14 Mental health/behavioral issues

2

Other

2.5

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As mentioned previously, those who do not work with children are the only response group to not list mental health/behavioral issues as their top issue. These respondents identified child abuse as the top issue. Although the mean score of 3.2 means a wider variance of answers among those respondents. See Table 8.

Table 8. Top Health Issue by Other Response Categories Category n Issue

Mean

Birmingham MS A

437 Mental health/behavioral issues 335 Mental health/behavioral issues 537 Mental health/behavioral issues 235 Mental health/behavioral issues 360 Mental health/behavioral issues 397 Mental health/behavioral issues 415 Mental health/behavioral issues 78 Mental health/behavioral issues 269 Mental health/behavioral issues 570 Mental health/behavioral issues

2.4 2.8 2.5 2.9 2.6 2.6 2.2 3.2 3.0 2.4 3.2

Outside the Birmingham MS A

Urba n

Rura l

Parent of a minor chil d

Not the parent of a minor chil d

Healthcare Professiona l

Educato r

Other professional rol e Works with childre n

Does not work with childre n

79 Child abuse

SURVEY RESPONSES COMPARED TO EXTERNAL DATA

Survey responses largely align with national and state-level data on health issues facing children. Mental health concerns are widely recognized. VOICES for Alabama’s Children reports 30,008 children with serious mental health issues receiving mental health services. 15 The number should likely be much higher, as Alabama faces provider shortages in youth mental health care—the state’s population-to-mental-health-provider ratio is 797:1, (nearly twice as bad as Jefferson County’s 443:1). The prevalence of suicide and suicide ideation also points to the mental health challenges facing children. This issue is explored in the Childhood Safety section. While mental health is no doubt a concern, the issue could also be something of a self-fulfilling prophecy. Survey responses regarding mental health and screentime/social media exposure could also reflect greater cultural awareness rather than direct experience. Community members’ emphasis on healthcare access as a child health issue is also borne out by data. Although 96.7% of Alabama children have some form of health insurance, 16 coverage does not mean access. Fifty-five of Alabama’s 67 counties are considered rural—and many of those are considered “healthcare deserts” for pediatrics. A 2020 analysis found that despite high coverage, rural Alabama lacks practicing pediatricians and specialists; health facilities and services are declining in many areas. 17 While the report is dated, the reality the report describes has altered little. “Most families are eligible for Medicaid, but if they can’t get to providers, that’s a problem.” — Pickens provider

______________________________________ 15 Alabama Profile” 2024 Kids Count Data Book. Voices for Alabama’s Children. https://alavoices.org/wp-content/uploads/2025/03/Alabama_Profile.pdf#: ~:text=Trend%20_%20Poor%20Mental%20Health,797%3A1%20Children%20With%20Serious%20Emotional 16 “Alabama Profile” 2024 Kids Count Data Book. Voices for Alabama’s Children. https://alavoices.org/wp-content/uploads/2025/03/Alabama_Profile.pdf#: ~:text=Trend%20_%20Poor%20Mental%20Health,797%3A1%20Children%20With%20Serious%20Emotional 17 Covered but Not Cared For: Identifying Pediatric Deserts in Alabama and Interventions to Affect Change. Voices for Alabama’s Children. March 2020. https://alavoices. org/wp-content/uploads/2020/03/Pediatric-Deserts.pdf#:~:text=the%20data%20and%20determine%20which,to%20public%20health%20venues%20like

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Child abuse ranked as the third-highest child health issue in the community survey. Unfortunately, external indicators confirm that child maltreatment is a persistent problem. Alabama’s rate of children with an indicated report of abuse or neglect is 10.6 per 1,000, up from 8.7 a decade prior. In other words, about 1% of children are confirmed victims of abuse annually, and the rate has worsened. 18 Likewise, traumatic injury (e.g., accidental injuries) remains a leading cause of child mortality. Alabama’s overall child death rate is 25.1 per 100,000. 19 While “accidental injury/trauma” was only a mid-tier concern in the survey, state data show accidents (car crashes, drownings, etc.) continue to threaten children’s lives, suggesting some misalignment—the community may not fully recognize how significant unintentional injuries are in child health statistics. Respondents did not identify childhood obesity and hunger as major concerns. Only 7% ranked obesity #1. However, an estimated 22% of children aged 10–17 are obese, 20 as are 39% of adults—ranking the state 45 th . 21 Similarly, only 6% indicated childhood hunger a top concern, even though 23.3% of Alabama’s children live in food-insecure households, 22 compared to 18.5% nationwide. 23 This represents a significant gap between perception and reality: External data show high childhood obesity and hunger rates, suggesting these chronic issues may be more serious than the community realizes. On the other hand, the low priority given to infectious diseases in the survey is understandable. Thanks to immunization and public health measures, Alabama has not faced major outbreaks among children in recent years. For example, childhood vaccination rates have kept diseases such as measles at bay (infant immunization coverage is around 91% nationally), and the focus has shifted toward behavioral health and chronic conditions. The survey’s de-emphasis of infectious disease aligns with this broader trend.

______________________________________ 18 “Alabama Profile” 2024 Kids Count Data Book. Voices for Alabama’s Children. https://alavoices.org/wp-content/uploads/2025/03/Alabama_ Profile.pdf#:~:text=Trend%20_%20Poor%20Mental%20Health,797%3A1%20Children%20With%20Serious%20Emotional 19 Alabama Profile” 2024 Kids Count Data Book. Voices for Alabama’s Children. https://alavoices.org/wp-content/uploads/2025/03/Alabama_ Profile.pdf#:~:text=Trend%20_%20Poor%20Mental%20Health,797%3A1%20Children%20With%20Serious%20Emotional 20 Alabama State Profile.” Trust for America’s Health. https://www.tfah.org/state-details/alabama/ 21 “Obesity.” U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/ 22 Alabama Profile” 2024 Kids Count Data Book. Voices for Alabama’s Children. https://alavoices.org/wp-content/uploads/2025/03/Alabama_ Profile.pdf#:~:text=Trend%20_%20Poor%20Mental%20Health,797%3A1%20Children%20With%20Serious%20Emotional 23 “Hunger in America.” Feeding America. https://www.feedingamerica.org/hunger-in-america

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However, since the COVID-19 pandemic, parental scrutiny around vaccines has increased and may result in reversals of both vaccines and the rate of infectious diseases. Broadly, the community survey rankings are corroborated by external data and rankings. Alabama’s child well-being metrics lag national averages in mental health support, obesity, and poverty.

Table 9. Top Health Issues, Survey vs. External Data Issue

Percent Ranking Issue in the Top 3/Ranking #1

External Metric

Source

alavoices.org

Mental/Behavioral Health

73.5% / 37% 30,000 children are receiving treatment for serious mental health issues. Provider Access: 797:1 people per mental health provider statewide

Healthcare Access

51.6% /19% Many rural counties lack pediatric services.

alavoices.org

Child Abuse/Trauma 47.9% /14% 10.6 per 1,000 children with indicated abuse/neglect

alavoices.org

Childhood Obesity

36.0% / 7% 22% of children aged 10–17 are obese.

tfah.org

Accidental Injury

36.3% / 8% Injuries: Unintentional injuries are a leading cause of child deaths. Jefferson County saw 387 non-fatal pediatric gunshot injuries in six months of 2023.

jcdh.org

alavoices.org

Childhood Hunger

32.4% / 6% Food Insecurity: 23.3% of AL children in food-insecure households

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HEALTHCARE ACCESS

Issue #1: Ability to pay for care Issue #2: Availability of quality healthcare service Issue #3: Parent education

Access questions focused on barriers to obtaining health services. Ability to pay and availability of care ranked first and second, respectively. Parent education ranked third. These three issues, plus transportation, were the top three (though perhaps in differing orders) for more than 60% of the population. See Table 10.

Table 10. Top Access Issues Rank Access Issues Ranked

Mean Top 3 Count Top 3 %

1 Ability to pay for care

2.7 2.9 2.9 3.1 3.6 5.8

535 476 484 460 315

69.8 62.1 63.2 60.1 41.1

2 Availability of quality healthcare services

3 Parent education

4 Lack of reliable and affordable transportation

5 Scheduling difficulty

6 Other

28

3.6

n=766

ACCESS ISSUES BY DEMOGRAPHICS

Ability to pay is the top issue for six of the eight age bands, with parent education the top issue for those 45 to 54 and availability of care the top for those aged 65 to 74. See Table 11.

Table 11. Access Issues by Age Age Band n

Top Issue

Mean

Under 18 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84

12 20

Ability to pay for care Ability to pay for care Ability to pay for care Ability to pay for care

2.3 1.9 2.3 2.7 2.8 2.8 2.4

101 207 148 145

Parent education

Ability to pay for care

79 26

Availability of quality healthcare services

Ability to pay for care

2

As table 12 indicates, the ability to pay for quality care is the top issue for each race/ethnic group.

Table 12. Access Issues by Ethnicity/Race Race/Ethnicity n

Top Issue

Mean

White

586 Ability to pay for care 127 Ability to pay for care

2.7 2.7 2.2 1.8 2.0 2.3

Black or African American

Hispanic/Latino/Latina:

10

Ability to pay for care Ability to pay for care Ability to pay for care Ability to pay for care

Asian

8

American Indian or Alaska Native 14

Other

14

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Across all other categories, geography is the differentiator. Those in the Birmingham MSA or urban areas emphasize the ability to pay. In contrast, those in the non-Birmingham MSA or rural areas emphasize the availability of quality care. Lack of reliable transportation is the top issue reported by healthcare professionals.

Table 13. Access Issues by Geography Category

n Issue

Mean

Birmingham MSA

427 Ability to pay for care

2.6

Outside the Birmingham MSA

324 Availability of quality healthcare services 2.6

Urban

526 Ability to pay for care

2.6

Rural

225 Availability of quality healthcare services 2.1

Parent of a minor child

390 Ability to pay for care 346 Ability to pay for care

2.6 2.7

Not the parent of a minor child

Healthcare Professional

403 Lack of reliable, affordable transportation 2.9

Educator

77 Ability to pay for care 263 Ability to pay for care 553 Ability to pay for care 79 Ability to pay for care

2.6 2.4 2.8 2.1

Other professional role Works with children

Does not work with children

SURVEY RESPONSES COMPARED TO EXTERNAL DATA

Primary care providers(PCPs) are closed on Fridays. After-hours care means a trip to Tuscaloosa or Meridian. Some families pay for an air-evacuation plan. – Pickens County focus group highlights Respondents identified availability of quality services, ability to pay, and availability of care as the most significant access problems, with each of those options ranked the #1 barrier by roughly one-quarter of respondents. Other notable access issues were parent education (lack of knowledge about health resources), cited as the top barrier by 21% of respondents, and transportation, cited by 16%.

Scheduling difficulties (such as long wait times or inconvenient clinic hours) were a lesser but present concern: 8% ranked it #1.

These community perceptions paint a picture of two core access challenges: infrastructure resource gaps (not enough providers/ services, especially specialized care) and financial/personal barriers (cost, lack of information, logistics for families).

Objective measures strongly confirm these access challenges in Alabama. As noted, health insurance coverage for children is high.

Only 3.3% of Alabama children are uninsured. 24 As discussed in the previous section, however, coverage does not equal access. Many insured children still struggle to get care due to provider shortages and other barriers. Alabama’s pediatric care infrastructure is uneven. Urban centers such as Birmingham and Mobile have pediatric hospitals and specialists, but large swaths of the state have very few or no local pediatric providers. According to a VOICES for Alabama’s Children analysis, healthcare access in rural counties is not only sparse but also declining—hospital and clinic closures have left “pediatric deserts.” For example, more than 80% of Alabama’s counties lack a pediatric subspecialist, and several rural counties have no practicing pediatrician at all. In 13 counties, the ratio of child population to pediatric providers is effectively 100,000:1 (meaning almost no pediatric doctors. 25 This is borne on by survey respondents, recognizing that the nearest pediatric specialists or mental health services could be hours away.

______________________________________ 24 Alabama Profile” 2024 Kids Count Data Book. Voices for Alabama’s Children. https://alavoices.org/wp-content/uploads/2025/03/Alabama_Profile.pdf#:~ text=Children%20in%20Foster%20Care%20Base,2023%207%2C349%202%2C837 25 Covered but Not Cared For: Identifying Pediatric Deserts in Alabama and Interventions to Affect Change. Voices for Alabama’s Children. March 2020. https://alavoices. org/wp-content/uploads/2020/03/Pediatric-Deserts.pdf#:~:text=the%20data%20and%20determine%20which,to%20public%20health%20venues%20like

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It should be noted that specialized pediatric providers and services must be concentrated in an urban area, given the sheer volume needed to support pediatric specialists. Specialty dispersion is not realistic or viable. Alabama should consider how telehealth can be utilized to address specialty care, particularly when transportation is an issue. While specialty care must be concentrated, pediatric primary care can and should be widely available throughout the state. The fact that there are care deserts is due to myriad of factors, including medical residents choosing other specialties over pediatrics, disproportionate investment in adult graduate medical education, lower compensation compared to other medical specialties, and under-investment in pediatric infrastructure by state and federal policy makers. The Jefferson County Department of Health’s Community Health Improvement Plan (CHIP) recognizes this gap as well—one of its goals was to increase the availability of mental health services for children and adults by 10% by 2024. 26 Alabama’s child poverty rate is 21.9% statewide. Rates range from 7.4% in Shelby County to 58.4% in Perry County. Worth noting, the county seats of Shelby and Perry Counties are separated by only 64 miles. Twenty-two of Alabama’s 67 counties have childhood poverty rates of 30% or higher. More than 45% of births in Alabama are paid for by Medicaid. 27 These families may struggle with indirect costs of care (transportation, unpaid time off work, etc.). Survey findings that “ability to pay” is a top concern align with these economics—poverty and healthcare affordability go hand in hand. The survey highlighted transportation difficulties. Transportation is a significant barrier statewide. The state’s population distribution, density, infrastructure, and culture make transportation a very difficult challenge to solve. Various responses have been developed with varying levels of success. Among these are Kid One Transport—a nonprofit designed to provide children with transportation to medical appointments 28 —charitable foundation pilot projects, 29 and even medical practices contracting with Uber and Lyft. 30 These organizations and initiatives are heavily dependent on third-party funding, which can be cyclical and often insufficient for meeting the demand of Alabamians across the state. The Jefferson County CHIP (2020–2024) made public transportation access a strategic priority, aiming to improve transit options countywide by 2025. 31 This was driven by the recognition that many families, particularly in rural or low-income urban neighborhoods, cannot reliably get to medical appointments. Limited bus routes, lack of vehicles, or long distances to pediatric specialists create tangible barriers. The congruence between the CHNA survey and the county’s strategic plan on this point is striking: Both identify that improving transportation is key to better child health access. Respondents noted that some parents and guardians lack information or education about available resources (“parent education” as a barrier). In many Alabama communities, there is a need for increased outreach, navigation assistance, and culturally appropriate health education so that parents know how to utilize preventive services (such as well-child visits, immunizations, and nutrition programs). Even with insurance, families often face out-of-pocket costs, co-pays, or a lack of coverage for certain services.

______________________________________ 26 The Community Health Improvement Plan, 2020–2024. Jefferson County https://www.jcdh.org/SitePages/Misc/PdfViewer?AdminUploadId=2587#:~ :text=match%20at%20L1650%20Strategic%20Issue,Term%20Target 27 2024 Alabama Kids Count Data Book. Voices for Alabama’s Children. https://alavoices.org/2024-alabama-kids-count/ 28 https://www.kidone.org/ 29 “Getting Around Birmingham Is Now Affordable and Easy” Bham Now. https://bhamnow.com/2025/06/18/what-is-the-birmingham-microtransit-how-do you-use-it-heres-what-you-need-to-know/ 30 “Non-Emergency Medical Transportation in Birmingham, Alabama.” https://www.uberhealth.com/us/en/d/nemt/birmingham-al-us/ 31 The Community Health Improvement Plan, 2020–2024. Jefferson County https://www.jcdh.org/SitePages/Misc/PdfViewer?AdminUploadId=2587#:~ :text=match%20at%20L1650%20Strategic%20Issue,Term%20Target

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