Ronald Andersen

Revisiting the behavioral model and access to medical care: does it matter?

The Behavioral Model of Health Services Use was initially developed over 25 years ago. In the interim it has been subject to considerable application, reprobation, and alteration. I review its development and assess its continued relevance.

National Health Surveys and the Behavioral Model of Health Services Use

National health surveys have played an important role in the development of health services research. They have contributed to the advancement of concepts, methods, and the policy relevance of the field. One product of these surveys was the Behavioral Model of Health Services Use. This article documents a 75-year legacy by reviewing the series of national studies that have given to the form and function of health services research. It further examines the Behavioral Model through 40 years of considerable application and alteration.

Access to medical care in the U.S.: realized and potential.

This paper seeks to provide a framework for understanding differential access to medical care in the U.S. population and to suggest ways to achieve equity of access. The framework is provided by a behavioral model of health services utilization which suggests a sequence of predisposing, enabling and illness variables that determine the number of times people will visit a physician. The model is operationalized using a path analytic technique. The data come from a national survey of the noninstitutionalized U.S. population conducted in late 1975 and early 1976. The results suggest services are generally equitably distributed since age and level of illness are the main determinants of the number of services people receive. However, remaining inequities might be reduced by providing people who report no regular source of medical care with a familiar entry into the health service system.

Equity of Access to Medical Care: A Conceptual and Empirical Overview

This paper summarizes the major ethical considerations in the conceptualization and measurement of the equity of access concept, presents national and community data on the most current profile of access in the United States, and discusses the implications of these conceptual and empirical issues. Changes in health care policy and the future of the “equity of access” objective in the U.S. are also discussed.

Competing priorities as a barrier to medical care among homeless adults in Los Angeles.

OBJECTIVES The role of competing priorities as a barrier to the utilization of physical health services was assessed in a subset (n = 363) of a probability sample of homeless adults in Los Angeles. METHODS Unadjusted odds of four measures of health services utilization were calculated for those with frequent difficulty in meeting their subsistence needs. These odds were then adjusted for a range of characteristics assumed to affect the utilization of health services among the homeless. RESULTS Before and after adjustment, those with frequent subsistence difficulty were less likely to have a regular source of care (odds ratio [OR] = 0.30, 95% confidence interval [CI] = 0.16, 0.53) and more likely to have gone without needed medical care (OR = 1.77, 95% CI = 1.04, 3.00). Subsistence difficulty had no impact on the likelihood of having an outpatient visit or having been hospitalized. Conclusions remained the same after adjustment. CONCLUSIONS Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults.

The Impact of Competing Subsistence Needs and Barriers on Access to Medical Care for Persons with Human Immunodeficiency Virus Receiving Care in the United States

OBJECTIVES To examine whether competing subsistence needs and other barriers are associated with poorer access to medical care among persons infected with human immunodeficiency virus (HIV), using self-reported data. DESIGN Survey of a nationally representative sample of 2,864 adults receiving HIV care. MAIN INDEPENDENT VARIABLES Going without care because of needing the money for food, clothing, or housing; postponing care because of not having transportation; not being able to get out of work; and being too sick. MAIN OUTCOME MEASURES Having fewer than three physician visits in the previous 6 months, visiting an emergency room without being hospitalized; never receiving antiretroviral agents, no prophylaxis for Pneumocystis carinii pneumonia in the previous 6 months for persons at risk, and low overall reported access on a six-item scale. RESULTS More than one third of persons (representing >83,000 persons nationally) went without or postponed care for one of the four reasons we studied. In multiple logistic regression analysis, having any one or more of the four competing needs independent variables was associated with significantly greater odds of visiting an emergency room without hospitalization, never receiving antiretroviral agents, and having low overall reported access. CONCLUSIONS Competing subsistence needs and other barriers are prevalent among persons receiving care for HIV in the United States, and they act as potent constraints to the receipt of needed medical care. For persons infected with HIV to benefit more fully from recent advances in medical therapy, policy makers may need to address nonmedical needs such as food, clothing, and housing as well as transportation, home care, and employment support.

Expanding the Andersen Model: The Role of Psychosocial Factors in Long-Term Care Use

OBJECTIVE To examine a prevailing conceptual model of health services use (Andersen 1995) and to suggest modifications that may enhance its explanatory power when applied to empirical studies of race/ethnicity and long-term care. STUDY SETTING Twelve focus groups of African-American (five groups) and white (seven groups) individuals, aged 65 and older, residing in Connecticut during 2000. STUDY DESIGN Using qualitative analysis, data were coded and analyzed in NUD-IST 4 software to facilitate the reporting of recurrent themes, supporting quotations, and links among the themes for developing the conceptual framework. Specific analysis was conducted to assess distinctions in common themes between African-American and white focus groups. DATA COLLECTION Data were collected using a standardized discussion guide, augmented by prompts for clarification. Audio taped sessions were transcribed and independently coded by investigators and crosschecked to enhance coding validity. An audit trail was maintained to document analytic decisions during data analysis and interpretation. PRINCIPAL FINDINGS Psychosocial factors (e.g., attitudes and knowledge, social norms, and perceived control) are identified as determinants of service use, thereby expanding the Andersen model (1995). African-American and white focus group members differed in their reported accessibility of information about long-term care, social norms concerning caregiving expectations and burden, and concerns of privacy and self-determination. CONCLUSIONS More comprehensive identification of psychosocial factors may enhance our understanding of the complex role of race/ethnicity in long-term care use as well as the effectiveness of policies and programs designed to address disparities in long-term care service use among minority and nonminority groups.

Use of complementary/alternative therapies by women with advanced-stage breast cancer

BackgroundThis study sought to describe the pattern of complementary/alternative medicine (CAM) use among a group of patients with advanced breast cancer, to examine the main reasons for their CAM use, to identify patients information sources and their communication pattern with their physicians.MethodsFace-to-face structured interviews of patients with advanced-stage breast cancer at a comprehensive oncology center.ResultsSeventy three percent of patients used CAM; relaxation/meditative techniques and herbal medicine were the most common. The most commonly cited primary reason for CAM use was to boost the immune system, the second, to treat cancer; however these reasons varied depending on specific CAM therapy. Friends or family members and mass media were common primary information sources about CAM.ConclusionsA high proportion of advanced-stage breast cancer patients used CAM. Discussion with doctors was high for ingested products. Mass media was a prominent source of patient information. Credible sources of CAM information for patients and physicians are needed.

Prevalence and predictors of Highly active antiretroviral therapy use in patients with HIV infection in the United States

Background: Highly active antiretroviral therapy (HAART) became standard for HIV in 1996. Studies at that time showed that most people infected with HIV had initiated HAART, but that members of minority groups and poor people had lower HAART use. It is not known whether high levels of HAART use have been sustained or whether socioeconomic and racial disparities have diminished over time. Objectives: To determine the proportion of patients who had received and were receiving HAART by January 1998, and to evaluate predictors of HAART receipt. Design and Participants: Prospective cohort study of a national probability sample of 2267 adults receiving HIV care who completed baseline, first follow‐up, and second follow‐up interviews from January 1996 to January 1998. Main outcome variables: Proportion currently using HAART at second follow‐up (August 1997 to January 1998), contrasted with the cumulative proportions using HAART at any time before January 1998 and before December 1996. Analyses: Bivariate and multiple logistic regression analysis of population characteristics predicting current use of HAART at the time of the second follow‐up interview. Results: The proportion of patients ever having received HAART increased from 37% in December 1996 to 71% by January 1998, but only 53% of people were receiving HAART at the time of the second follow‐up interview. Differences between sociodemographic groups in ever using HAART narrowed after 1996. In bivariate analysis, several groups remained significantly less likely to be using HAART at the time of the second follow‐up interview: blacks, male and female drug users, female heterosexuals, people with less education, those uninsured and insured by Medicaid, those in the Northeast, and those with CD4 counts of ≥500 cells/&mgr;l (all p < .05). Using multiple logistic regression analysis, low CD4 count (for CD4 <50 cells/&mgr;l: odds ratio [OR], 3.20; p < .001) remained a significant predictor of current HAART use at the time of the second follow‐up interview, but lack of insurance (OR, 0.71; p < .05) predicted not receiving HAART. Conclusions: The proportion of persons under HIV care in the United States who had ever received HAART increased to over 70% of the affected population by January 1998 and the disparities in use between groups narrowed but did not disappear. However, nearly half of those eligible for HAART according to the U.S. Department of Health and Human Services guidelines were not actually receiving it nearly 2 years after these medications were first introduced. Strategies to promote the initiation and continuation of HAART are needed for those without contraindications and those who can tolerate it.

Access to Medical Care for Low-Income Persons: How do Communities Make a Difference?

This paper considers the impact of community-level variables over and above the effects of individual characteristics on healthcare acess for low-income children and adults residing in large metropolitan statistical areas (MSAs). Further, we rank MSAs’ performance in promoting healthcare access for their low-income populations. The individual-level data come from the 1995 and 1996 National Health Interview Survey (NHIS). The community-level variables are derived from multiple public-use data sources. The out-come variable is whether low-income individuals received a physician visit in the past twelve months. The proportion receiving a visit by MSA varied from 63% to 99% for children and from 62% to 83% for adults. Access was better for individuals with health insurance and a regular source of care and for those living in communities with more federally-funded health centers. Children residing in MSA