Revisiting the Behavioral Model and Access to Medical Care: Does it Matter?

Author(s): Ronald M. Andersen

Source: Journal of Health and Social Behavior, Vol. 36, No. 1 (Mar., 1995), pp. 1-10
Published by: American Sociological Association
Stable URL: http://www.jstor.org/stable/2137284
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Revisitingthe BehavioralModel and Access to Medical Care:
Does It Matter?*
RONALD M. ANDERSEN
University at LosAngeles
ofCalifornia
of Healthand Social Behavior1995, Vol. 36 (March):1-10
Journal
TheBehavioralModelofHealthServicesUse was initially
ago. In theinterim it has been subjectto considerableapplication,reprobation,
and alteration.I reviewitsdevelopment and assess itscontinued
My intentis to review the developmentof a
model of health services' use that has
dominated my career. Others as well have
applied, criticized, and revised it (Aday and
Awe, forthcoming).Pescosolido and Kronen-
feld (forthcoming)argue thatthe best of it has
been coopted and more effectivelyapplied by
health economists and psychologists, while
medical sociologists have increasingly ig-
nored it and the kinds of health services' use
studies for which it was developed.
The model was initiallydeveloped in the
late 1960s to assist the understandingof why
families use health services; to define and
measure equitable access to health care; to
assist in developing policies to promote
equitable access; and, not incidentally,to pass
my dissertation committee at Purdue
(Andersen 1968). It was not the firstor only
model at the time, but it did attempt to
integrate a number of ideas about the
"how's" and "why's" of healthservices' use.
It was intended to assist in the analysis of
* I am mostgrateful to Lu Ann Aday forher
contribution to this manuscriptand her support
throughout she has gone
the years. Fortunately,
beyondtheseremarksand cannotbe held respon-
siblefortheircontent.Theyare an editedversion
of myacceptanceof theLeo G. ReederAwardfor
Distinguished Serviceto Medical Sociologypre-
sentedat the AmericanSociologicalAssociation
meetings in Los Angeles,California,
on August8,
1994. I verymuchappreciatethisrecognition
by
mycolleaguesof theMedical SociologySection.
Addresscorrespondence to Ronald Andersenat
Department of HealthServices,School of Public
Health,UCLA, Los Angeles,CA 90024-1772,or
sende-mailto iaqxpld@mvs.oac.ucla.edu.
1
developedover25 years
relevance.
nationalsurveydata collectedby the Center
for Health Administration Studies and the
National Opinion Research Center at the
University of Chicago whereI workedwith
Odin Anderson (Andersen and Anderson
1967).
The model of healthservices' use origi-
nally focusedon the familyas the unit of
analysis,becausethemedicalcarean individ-
ual receivesis mostcertainlya functionofthe
demographic socialandeconomiccharacteris-
tics of the familyas a unit. However, in
subsequent workI shifted to theindividualas
theunitof analysisbecause of thedifficulty
of developingmeasuresat the familylevel
thattakeintoaccountthepotentialheteroge-
neityof familymembers;e.g., a summary
measureof "familyhealthstatus."I thinkitis
generallymore efficient to attachimportant
familycharacteristicsto theindividualas the
unitforanalysis.Finally,I wantto stressthat
the model was initiallydesignedto explain
the use of formalpersonalhealthservices
rather than to focus on the important
interactionsthattakeplace as people receive
care,or on healthoutcomes.
The initialbehavioralmodel-the modelof
the 1960s-is depicted in Figure 1. It
suggeststhatpeople'suse ofhealthservicesis
a functionof their predispositionto use
services,factorswhichenableor impedeuse,
and their need for care. There is some
questionwhetherthe model was meantto
predict or explain use (Mechanic 1979;
Rundall1981). I thinkI had in mindthatit
could do both. On the one hand, each
component mightbe conceivedof as making
an independent contributionto predicting
use.
On theother,themodelsuggestsan explana-
2 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
FIGURE 1. The InitialBehavioralModel (1960s)
PREDISPOSING l ENABLING - > NEED l USE OF
CHARACTERISTICS RESOURCES HEALTH SERVICES

Demographic Personal/Family Perceived

Social Structure Community (Evaluated)

HealthBeliefs

toryprocess or causal orderingwhere the understanding use. Some effortshave been

predisposingfactorsmight be exogenous made to integrate elementsof thebehavioral
(especiallythedemographic and social struc- model with elementsof the well-known
ture),some enablingresourcesare necessary health beliefs model to explain use and
but not sufficient conditionsfor use, and especiallypreventive healthbehavior(Green
someneedmustbe definedforuse to actually et al. 1980). Othershave arguedthatwhatis
takeplace. necessaryto show strongerand meaningful
Among the predisposingcharacteristics,relationshipsbetween beliefs and use is
demographic factorssuch as age and gender specificity in measuringbeliefs,needs, and
representbiological imperativessuggesting typesofuse (Tanner,Cockerham, and Spaeth
the likelihoodthatpeople will need health 1983). If we examine beliefs about a
services (Hulka and Wheat 1985). Social particulardisease, measureneed associated
structure is measuredby a broad arrayof withthatdisease, and observethe services
factorsthatdetermine thestatusof a personin receivedto deal specifically
withthedisease,
thecommunity, hisor herabilityto cope with the relationshipswill probablybe much
presentingproblemsand commandingre- stronger thanifwe tryto relategeneralhealth
sourcesto deal withtheseproblems,andhow beliefs to global measuresof need and a
healthy orunhealthy thephysicalenvironmentsummary measureofall servicesreceivedin a
is likelyto be. Traditionalmeasuresused to givenperiodof time.My senseis thatefforts
assess social structureinclude education, to elaborateon andspecifyhealthbeliefshave
occupation,and ethnicity.The model has improvedand will continueto improveour
been criticizedfornot payingenoughatten- ability to explain some types of health
tion to social networks,social interactions,services'use, butin manycontextsenabling
and culture(Bass and Noelker1987; Guen- variablesand particularly need will continue
delman1991; Portes,Kyle,and Eaton 1992). to explain more of the variationin health
I thinkmeasuresof theseconceptsrightly fit services'use.
intothesocial structure component. Arethereanyothermajorcomponents that
Health beliefs are attitudes,values, and shouldbe added to predisposing characteris-
knowledgethatpeoplehave abouthealthand tics? One interesting candidateis genetic
health services that mightinfluencetheir factors(Trueet al. 1994). Withtheexplosive
subsequentperceptionsof need and use of development of genemapping,geneticcoun-
healthservices.Health beliefsprovideone seling,and thepossibilitiesof gene therapy,
means of explaininghow social structuregenetic measures representa potentially
mightinfluence enablingresources,perceived viable,important, and definablepredisposing
need, and subsequentuse. Social psycholo- componentwhichseems clearlydistinguish-
gistshave been concernedthathealthbeliefs able fromtheotherpredisposing components
have not been appropriately conceptualized (Rosneau 1994). Anotherpossiblepredispos-
and measuredin muchworkemployingthe ing componentwhichmay be conceptually
behavioralmodel(Beckerand Maiman1983; distinctfromthoselistedin theinitialmodel
Mechanic1979). A possibleconsequenceis is psychologicalcharacteristics. Psychologi-
thathealthbeliefsdo not appear to be as cal characteristics consideredas predisposing
important as theyreallyare in predictingand variableshave includedmentaldysfunction
REVISITING THE BEHAVIORAL MODEL 3
(Rivnyaket al. 1989), cognitiveimpairmentrelationships, it seemsto me theymightfitin
(Bass, Looman, and Ehrlich 1992), and quitenicelyas enablingresources.
autonomy (Davanzo 1994). Applicationsof the behavioralmodel and
Both communityand personal enabling myown empiricalworkhave been identified
resourcesmust be presentfor use to take and occasionallyvilifiedas overemphasizing
place. First,healthpersonneland facilities theimportance of need as theprimedetermi-
must be available where people live and nantof use at the expenseof healthbeliefs
work.Then,peoplemusthavethemeansand and social structure (Coultonand Frost1982;
know-howto getto thoseservicesand make Gilbert,Branch,and Longmate1993; Me-
use of them. Income, health insurance,a chanic 1979; Wolinskyand Johnson1991).
regularsourceof care,and traveland waiting Any comprehensive effortto model health
timesare some of the measuresthatcan be services' use must consider how peopleview
important here. theirown general health and functional state,
One concernaboutthe enablingresources as well as how theyexperiencesymptoms of
is thatorganizational factorsare not given illness,pain, and worriesabouttheirhealth
enoughattention (Gilbert,Branch,and Long- and whether or nottheyjudge theirproblems
mate 1993; Kelleyet al. 1992; Patricket al. to be of sufficient importance and magnitude
1988). I certainlyagree thatgoing beyond to seekprofessional help.My intent has never
knowingwhether ornota personhas a regular been to consider perceived need as primarily
sourceof care to understanding how medical representing some measure of pathology or
care is organizedshouldimproveour ability disease devoid of the social context.Indeed,
to explain and predictuse. Also, knowing perceivedneed is largelya social phenome-
moreaboutthevariouskindsof medicalcare non which, when appropriately modeled,
providers and typesof healthservicesorgani- should itself be largely explained by social
structure and healthbeliefs.However,within
zationsin thecommunity shouldbenefitour
ratherbroadlimitsestablishedby predispos-
understanding beyondwhat gross physician
ingand enablingfactors,thereis a biological
and hospitalbed populationratiosmightdo.
imperative thataccountsforsomeof people's
However,it seemsto me thatmoredetailed
help-seekingand consumptionof health
organizational measurescan be includedas services
(Hulka and Wheat 1985). The
additionalenablingfactorswithouttoo much biologicalimperative is betterrepresented by
damageto eitherthemeasuresor themodel. theevaluatedcomponent of need (Andersen,
Anotherexpressedconcernis thatmore Kravits,andAnderson1975). Evaluatedneed
precisemeasuresof healthinsurancebenefits represents professional judgmentabout peo-
thanhaveoftenbeenusedwiththismodelare ple's healthstatusand theirneed formedical
necessary to do justice to the potential care. Of course,evaluatedneedis notsimply,
importance of thepersonalenablingresources or even primarily,a valid and reliable
(Mechanic1979). Again,I heartily agree.We measurefrombiologicalscience.It also has a
are limitedmoreby thefeasibility and costs social component, and varieswiththechang-
of developingand implementing such mea- ingstateof theartand scienceof medicineas
suresthanby conceptuallimitations. well as accordingto thetraining and compe-
Finally,I wouldliketo allaythedoubtsand tencyof the professionalexpertdoing the
fearsof some of mycolleaguesin sociology assessment. Logical expectationsof the
thatI haveforgotten mydisciplinaryrootsand modelarethatperceivedneedwillbetter help
believethereis no place in themodelforthe us to understand care-seeking and adherence
extentand quality of social relationshipsto a medicalregimen,while evaluatedneed
(Pescosolido 1992). Such relationships can will be morecloselyrelatedto thekindand
serveas an enablingresourceto facilitateor amountof treatment that will be provided
impedehealthservices' use (Bass and No- aftera patienthas presented to a medicalcare
elker 1987; Counte and Glandon 1991; provider.
Freedman1993; Miller and McFall 1991). The outcome of the originalbehavioral
The truthof the matteris, I see the modelwas healthserviceuse measuredrather
importanceof measuresof social relation- broadlyinunitsofphysicianambulatory care,
ships. As we overcome the considerable hospitaland physicianinpatient services,and
conceptualand methodological challengesof dentalcare whichfamiliesconsumedover a
developingand using measures of social year'stime.We hypothesized thatpredispos-
4 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
ing enablingand need factorswould have 1978)?Whenthemodelwas developedin the
differentialabilityto explainuse, depending 1960s, increased utilizationwas a major
on what type of service was examined policygoal andcostwas notquitetheconcern
(Andersen1968). Hospitalservicesreceived it is today.However,I thinkthe model is
in responseto more seriousproblemsand essentiallynonnormative regardingutiliza-
conditionswould be primarily explainedby tion.Itspurposeis to discoverconditions that
need and demographic characteristics, or impedeutilization.
while eitherfacilitate
dentalservicesconsideredas morediscretion- A majorgoal of thebehavioralmodelwas
arywouldmorelikelybe explainedby social to providemeasuresof access to medicalcare
structure,beliefs,and enablingfactors.We (Figure2). A dangerin attempting a compre-
expectedall thecomponents of themodelto hensiveaccess measureis thatitmightbe too
enter into the explanationof ambulatory broad and nonspecific(Penchansky1976).
physicianuse, because theconditionsstimu- However, access is a relativelycomplex
lating care-seeking would generally be healthpolicy measureand, I think,can be
viewed as less seriousand demandingthan reasonablydefinedin multidimensional terms
those resultingin inpatientcare, but more using conceptsfromthe behavioralmodel.
seriousthanthoseleadingto dentalcare. Potentialaccess is simplydefinedas the
These outcomemeasureshave been criti- presenceof enablingresources.More en-
cized as too gross(Penchansky1976). More ablingresourcesprovidethe meansforuse,
specificmeasuresshouldrelateto a particular and increasethelikelihoodthatuse will take
condition,typeof serviceor practitioner, or place.
should be linkedin an episode of illness. Realized access is the actual use of
Such measurescould be relatedmore logi- services.Equitableand inequitableaccess are
cally to the explanatorystructureof the definedaccordingto which predictorsof
model, and mightprovidea morecomplete realized access are dominant.Value judg-
and understandableanalysis. While such mentsaboutwhichcomponents of themodel
explicitmeasuresare,in manyways,likelyto should explain utilizationin an equitable
be more informative, the more global ones healthcare systemare crucialto the defini-
still have a role to play. For example, to tion.Equityis in theeyes of thebeholder.I
informnationalhealthpolicy, global mea- have traditionally definedequitableaccess as
suresprovideneededcomprehensive indica- occurringwhendemographic and need vari-
torsof theoveralleffectsof policychanges. ables accountfor most of the variancein
Does the initialconceptof the behavioral utilization(Andersen1968). Inequitableac-
modelhave a built-inbias thatincreaseduse cess occurs when social structure(e.g.,
is always betterand to be sought (Chen ethnicity),healthbeliefs, and enablingre-
FIGURE 2. InitialMeasures of Access
POTENTIALACCESS = ENABLINGRESOURCES

REALIZED ACCESS USE OF HEALTHSERVICES

EQUITABLEACCESS DEMOGRAPHIC
CHARACTERISTICS *

USE OF
HEALTH SERVICES
NEED

INEQUITABLEACCESS = SOCIAL STRUCTURE U

HEALTHBELIEFS USE OF
ENABLINGRESOURCES HEALTHSERVICES
REVISITING THE BEHAVIORAL MODEL 5
sources(e.g., income) determinewho gets Some enabling variables can be quite
medicalcare. Otherand morerefinedstan- mutable,and they may be quite strongly
dardscouldbe used. For example,one might associatedwithutilization.The Rand Health
arguethatpeople's beliefsshouldbe consid- InsuranceStudy,forexample,demonstrated
ered, and consequentlythat use, which is quitedramatically theimpactof thechanging
determined bythosebeliefs,mightbe consid- healthinsurancebenefitstructures on health
ered equitable. Also one might employ services'use (Manninget al. 1987).
different
criteriafordefiningequitableaccess, Need was originallyconsiderednotto be a
depending on thetypeofhealthservices'use. mutablepolicyvariablebutrathertheimme-
For example,whileincomemightbe consid- diatereasonforuse to takeplace. However,
ered an inequitabledeterminant of use of people's perceivedneed for care may be
maternalandchildhealthservices,one might increasedor decreasedthrough healtheduca-
considerincomeappropriate as a predictorof tionprograms, changingtheirfinancialincen-
cosmeticsurgery. tivesto seek services,and so on. Similarly,
The conceptof mutability is importantfor evaluated needs mightalso be altered to
using the behavioral model to promote influenceuse. It seems that impositionof
equitable access, as shown in Figure 3 clinicalguidelineson managedcare systems
(Andersenand Newman1973). Policies are is an example of this process (Instituteof
impliedfirstby determining what variables Medicine 1992). The purposeis to alterthe
explainutilization.To be usefulforpromot- medical care practitioner's judgmentabout
ingaccess,a variablemustalso be considered the patient'sevaluatedneed forhealthcare
mutable,orpointtopolicychangesthatmight (Institute of Medicine1993).
bringaboutbehavioralchange. Using mutablevariablesto plan interven-
Demographicvariablesare judged as hav- tions can be criticizedas a conservative
inglow mutability, sincegenderorage cannot approach.Variancemustbe observedin the
be altered to change utilization. Social current system.A totallynew and innovative
structureis also judged relativelylow since programcannotbe studiedby this kind of
ethnicityis not changeable, and altering approach. I agree that methods such as
educational or occupational structuresis simulation or demonstrations and evaluations
probablynot a viable short-term policy to are requiredto studysuch innovativepro-
promoteaccess. Healthbeliefsarejudged as grams.
havingmediummutability since theycan be Contraryto the apparentbelief of some
altered and sometimes effect behavioral usersandcriticsoftheinitialmodel,I didnot
change. expire immediatelyafter completingmy
FIGURE 3. InitialConceptsof Mutability
MODEL COMPONENT DEGREE OF MUTABILITY

DEMOGRAPHIC LOW

SOCIAL STRUCTURE LOW

HEALTH BELIEFS MEDIUM

ENABLING HIGH

NEED (LOW?)
6 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
dissertation,and there have been some
subsequentrevisionsof the model. Phase
2-the model of the 1970s (Figure4)-was
developedby Adayand othercollaborators at
theCenterforHealthAdministration Studies,
University of Chicago (Andersen,Smedby,
and Anderson1970; Andersenand Newman
1973; Aday and Andersen1974; Andersen,
Kravits, and Anderson 1975; Aday,
Andersen,and Fleming 1980; Aday et al.
1985; Fleming and Andersen 1986). The
healthcare systemwas explicitlyincludedin
thisphase, givingrecognition to the impor-
tance of national health policy and the
resourcesand theirorganization in thehealth
care systemas important determinants of the
population'suse of services, as well as
changesin thoseuse patterns overtime.Other
developments in thisperiodincludedelabora-
tionof themeasuresof healthservices'use,
includingthoserepresenting type,site, pur-
pose, and coordinated servicesreceivedin an
episodeof illness.Also addedin Phase2 was
an explicit outcome of health services-
consumersatisfaction.We recognizedthat
use of serviceswas, froma policyperspec-
tive, a means to otherends and outcomes.
Utilizationstudiesneedto examineuse in the
contextof healthoutcomes.
A thirdphaseof themodelevolvedduring
the last decade, spurredon by the explicit
recognitionthathealthservicesare supposed
to havesomething to do withmaintainingand
improving thehealthstatusof thepopulation,
both as perceivedby the populationand as
evaluated by professionals(see Figure 5)
(Andersen,Marcus, and Mashigian,forth-
coming; Andersen, Davidson, and Ganz
1994). While the model remainsprimarily
one of use of health services, it also
acknowledgesthe externalenvironment (in-
cluding physical, political, and economic
components)as an importantinput for
understanding use of healthservices.It also
recognizespersonalhealthpracticessuch as
diet, exercise,and self care as interacting
with the use of formalhealth servicesto
influencehealthoutcomes(Evans and Stod-
dart 1990; Lalonde 1975; Public Health
Service1990).
The inclusionof healthstatusoutcomesin
Phase 3 allows us to extendthemeasuresof
access to include dimensionswhich are
particularlyimportant forhealthpolicy and
healthreform (Figure6). Theyprovidesome
answersto thequestionof whetheror not it
matters torevisitutilization
studiesandaccess
concepts. "Effectiveaccess" is established
when utilizationstudiesshow thatuse im-
proveshealthstatusor consumersatisfaction
with services. "Efficientaccess" is shown
whenthelevel of healthstatusor satisfaction

FIGURE 4. The Model-Phase 2 (1970s)

POPULATION
CHARACTERISTICS
IX
Predisposing USE OF HEALTH > CONSUMER
I SERVICES SATISFACTION
Enabling I I
I Type Convenience
Need IType
Need / | Availability
Site I
CARE
HEALTHCARE I Financing
HEALTH Purpose I
SYSTEM | Provider
TimeInterval Characteristics
Policy I
I Quality
Resources
I
Organization
REVISITING THE BEHAVIORAL MODEL 7
FIGURE 5. The Model-Phase 3 (1980s-1990s)
PRIMARY DETERMINANTS -
HEALTH BEHAVIOR -0- HEALTH OUTCOMES
OF HEALTH BEHAVIOR

Characteristics
Population Personal
Health Perceived
Health
Practices Status

HealthCareSystem UseofHealth Health

Evaluated
Services Status

Environment
External I
Consumer
Satisfaction
increasesrelativeto theamountofhealthcare tion, longitudinaland experimentalstudy
servicesconsumed(Aday 1993; Aday et al. designs,and innovativetypesof statistical
1993). analyses.I certainly
think,however,thatthe
I do feel compelledto show yetone final payoffis therein termsof betterunderstand-
Phase4 emerging model(Figure7). Whatthis ing of healthbehaviorand informing impor-
phase emphasizesis the dynamicand recur- tanthealthpolicy.
sive natureof a healthservices'use model In revisitingthe behavioralmodel, I am
whichincludeshealthstatusoutcomes(Evans convincedthat"it does matter forsociologists
and Stoddart1990; Patricket al. 1988). This to be involved"-not necessarilywith this
model portraysthe multipleinfluenceson particular model,butcertainly withstudiesof
health services' use and, subsequently, on healthservices'use andaccessto care.Health
healthstatus.It also includesfeedbackloops servicesare partof thelargestsectorof our
showing that outcome, in turn, affects economy-one thatis stillgrowing.Theydo
subsequentpredisposingfactors and per- makea difference forbetter,
or sometimes for
ceived need for servicesas well as health worse, for our societyand its people. The
behavior. currentdebate,recentdefeat,and continuing
Implementation of this model requires directionsof so-called"healthcare reform"
morecreativeand challenging conceptualiza- reinforce
mybeliefthatstudiesof equityand
FIGURE 6. AdditionalMeasures of Access
IMPROVED

EFFECTIVE ACCESS = USE OF HEALTH HEALTH STATUS

SERVICES
IMPROVED
SATISFACTION

EFFICIENT ACCESS = INCREASING: HEALTH STATUS

USE OF HEALTH SERVICES

EFFICIENT ACCESS = INCREASING: CONSUMER SATISFACTION

USE OF HEALTH SERVICES
8 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
FIGURE 7. An EmergingModel-Phase 4
HEALTH
ENVIRONMENT POPULATION CHARACTERISTICS BEHAVIOR OUTCOMES

HealthCare Personal Perceived

System Predisposing EnablingB Need Health HealthStatus
l CharacteristicsResources -l - Practices Il
_ ~~~~~~~~~~~~~~Evaluate
HealthStatus
External Use of I
Environment Health Consumer
Services Satisfaction

and effective
efficient access examinedfrom Loevy, and BarbaraKremer.1985. Hospital-
a comprehensive and systemicperspective PhysicianSponsoredPrimaryCare: Marketing
will be relevant and importantfor the and Impact.AnnArbor,MI: HealthAdministra-
indefinitefuture(Mechanic 1993). Sociolo- tionPress.
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withnewperspectives and strongdisciplinary Lairson,and Carl H. Slater. 1993. Evaluating
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Ronald Andersenis theFredand PamelaWassermanProfessor and chairof theDepartment of Health

Services,School of PublicHealthand professor of Californiaat Los Angeles.
of sociology,University
ofhealthcaresystems
includeaccessto healthservices,comparisons
His researchinterests andthehealth
of vulnerablepopulations.