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
at LosAngeles
University
ofCalifornia
Journal
of Healthand Social Behavior1995, Vol. 36 (March):1-10
developedover25 years
TheBehavioralModelofHealthServicesUse was initially
it has been subjectto considerableapplication,reprobation,
ago. In theinterim
and assess itscontinued
relevance.
and alteration.I reviewitsdevelopment
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 Kronenfeld (forthcoming)argue thatthe best of it has
been coopted and more effectivelyapplied by
health economists and psychologists, while
medical sociologists have increasingly ignored 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
and her support
contribution
to this manuscript
she has gone
the years. Fortunately,
throughout
beyondtheseremarksand cannotbe held responsiblefortheircontent.Theyare an editedversion
of myacceptanceof theLeo G. ReederAwardfor
Distinguished
Serviceto Medical Sociologypresentedat the AmericanSociologicalAssociation
in Los Angeles,California,
on August8,
meetings
1994. I verymuchappreciatethisrecognition
by
mycolleaguesof theMedical SociologySection.
to Ronald Andersenat
Addresscorrespondence
of HealthServices,School of Public
Department
Health,UCLA, Los Angeles,CA 90024-1772,or
sende-mailto [email protected].
1
nationalsurveydata collectedby the Center
for Health Administration
Studies and the
National Opinion Research Center at the
of Chicago whereI workedwith
University
Odin Anderson (Andersen and Anderson
1967).
The model of healthservices' use originally focusedon the familyas the unit of
analysis,becausethemedicalcarean individual receivesis mostcertainly
a function
ofthe
socialandeconomiccharacterisdemographic
tics of the familyas a unit. However, in
subsequent
workI shifted
to theindividualas
theunitof analysisbecause of thedifficulty
of developingmeasuresat the familylevel
thattakeintoaccountthepotentialheterogeneityof familymembers;e.g., a summary
measureof "familyhealthstatus."I thinkitis
to attachimportant
generallymore efficient
to theindividualas the
familycharacteristics
unitforanalysis.Finally,I wantto stressthat
the model was initiallydesignedto explain
the use of formalpersonalhealthservices
rather than to focus on the important
interactions
thattakeplace 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
contribution
to predicting
use.
On theother,themodelsuggestsan explana-
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
2
FIGURE 1. The InitialBehavioralModel (1960s)
PREDISPOSING
CHARACTERISTICS
l
ENABLING
RESOURCES
-
>
NEED
Demographic
Personal/Family
Perceived
Social Structure
Community
(Evaluated)
l
USE OF
HEALTH SERVICES
HealthBeliefs
toryprocess or causal orderingwhere the understanding
use. Some effortshave been
predisposingfactorsmight be exogenous made to integrate
elementsof thebehavioral
and social struc- model with elementsof the well-known
(especiallythedemographic
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
in measuringbeliefs,needs, and
demographic
factorssuch as age and gender specificity
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
is measuredby a broad arrayof withthatdisease, and observethe services
structure
thatdetermine
thestatusof a personin receivedto deal specifically
factors
withthedisease,
hisor herabilityto cope with the relationshipswill probablybe much
thecommunity,
thanifwe tryto relategeneralhealth
presentingproblemsand commandingre- stronger
sourcesto deal withtheseproblems,andhow beliefs to global measuresof need and a
thephysicalenvironmentsummary
measureofall servicesreceivedin a
healthy
orunhealthy
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
need will continue
and culture(Bass and Noelker1987; Guen- variablesand particularly
delman1991; Portes,Kyle,and Eaton 1992). to explain more of the variationin health
I thinkmeasuresof theseconceptsrightly
fit services'use.
Arethereanyothermajorcomponents
component.
intothesocial structure
that
Health beliefs are attitudes,values, and shouldbe added to predisposing
characteriscandidateis genetic
knowledgethatpeoplehave abouthealthand tics? One interesting
health services that mightinfluencetheir factors(Trueet al. 1994). Withtheexplosive
of genemapping,geneticcounsubsequentperceptionsof need and use of development
healthservices.Health beliefsprovideone seling,and thepossibilitiesof gene therapy,
means of explaininghow social structuregenetic measures representa potentially
enablingresources,perceived viable,important,
and definablepredisposing
mightinfluence
need, and subsequentuse. Social psycholo- componentwhichseems clearlydistinguishgistshave been concernedthathealthbeliefs able fromtheotherpredisposing
components
have not been appropriately
conceptualized (Rosneau 1994). Anotherpossiblepredisposand measuredin muchworkemployingthe ing componentwhichmay be conceptually
behavioralmodel(Beckerand Maiman1983; distinctfromthoselistedin theinitialmodel
Mechanic1979). A possibleconsequenceis is psychologicalcharacteristics.
Psychologithathealthbeliefsdo not appear to be as cal characteristics
consideredas predisposing
as theyreallyare in predicting
and variableshave includedmentaldysfunction
important
REVISITING THE BEHAVIORAL MODEL
3
it seemsto me theymightfitin
(Rivnyaket al. 1989), cognitiveimpairmentrelationships,
(Bass, Looman, and Ehrlich 1992), and quitenicelyas enablingresources.
Applicationsof the behavioralmodel and
autonomy
(Davanzo 1994).
Both communityand personal enabling myown empiricalworkhave been identified
resourcesmust be presentfor use to take and occasionallyvilifiedas overemphasizing
of need as theprimedetermiplace. First,healthpersonneland facilities theimportance
must be available where people live and nantof use at the expenseof healthbeliefs
(Coultonand Frost1982;
work.Then,peoplemusthavethemeansand and social structure
know-howto getto thoseservicesand make Gilbert,Branch,and Longmate1993; Meuse of them. Income, health insurance,a chanic 1979; Wolinskyand Johnson1991).
effortto model health
regularsourceof care,and traveland waiting Any comprehensive
how peopleview
consider
services'
use
must
timesare some of the measuresthatcan be
their
health
and
functional
own
general
state,
here.
important
of
One concernaboutthe enablingresources as well as how theyexperiencesymptoms
factorsare not given illness,pain, and worriesabouttheirhealth
is thatorganizational
or nottheyjudge theirproblems
(Gilbert,Branch,and Long- and whether
enoughattention
to
be
of
sufficient
importance
and magnitude
mate 1993; Kelleyet al. 1992; Patricket al.
has never
help.My intent
1988). I certainlyagree thatgoing beyond to seekprofessional
been
to
consider
need
as
perceived
primarily
ornota personhas a regular
knowingwhether
representing
some
measure
of
or
pathology
how medical
sourceof care to understanding
disease
devoid
of
the
social
context.
Indeed,
care is organizedshouldimproveour ability
to explain and predictuse. Also, knowing perceivedneed is largelya social phenomemodeled,
moreaboutthevariouskindsof medicalcare non which, when appropriately
itself
be
social
should
largely
explained
by
and typesof healthservicesorganiproviders
healthbeliefs.However,within
structure
and
shouldbenefitour
zationsin thecommunity
ratherbroadlimitsestablishedby predisposunderstanding
beyondwhat gross physician
ingand enablingfactors,thereis a biological
and hospitalbed populationratiosmightdo.
thataccountsforsomeof people's
imperative
However,it seemsto me thatmoredetailed
help-seekingand consumptionof health
measurescan be includedas services
organizational
(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 peothanhaveoftenbeenusedwiththismodelare ple's healthstatusand theirneed formedical
necessary to do justice to the potential care. Of course,evaluatedneedis notsimply,
of thepersonalenablingresources or even primarily,a valid and reliable
importance
agree.We measurefrombiologicalscience.It also has a
(Mechanic1979). Again,I heartily
and costs social component,
are limitedmoreby thefeasibility
and varieswiththechangsuch mea- ingstateof theartand scienceof medicineas
of developingand implementing
suresthanby conceptuallimitations.
well as accordingto thetraining
and compeFinally,I wouldliketo allaythedoubtsand tencyof the professionalexpertdoing the
fearsof some of mycolleaguesin sociology assessment. Logical expectationsof the
rootsand modelarethatperceivedneedwillbetter
thatI haveforgotten
mydisciplinary
help
believethereis no place in themodelforthe us to understand
and adherence
care-seeking
extentand quality of social relationshipsto a medicalregimen,while evaluatedneed
can will be morecloselyrelatedto thekindand
(Pescosolido 1992). Such relationships
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
challengesof dentalcare whichfamiliesconsumedover a
conceptualand methodological
thatpredisposdevelopingand using measures of social year'stime.We hypothesized
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
4
ing enablingand need factorswould have 1978)?Whenthemodelwas developedin the
abilityto explainuse, depending 1960s, increased utilizationwas a major
differential
on what type of service was examined policygoal andcostwas notquitetheconcern
(Andersen1968). Hospitalservicesreceived it is today.However,I thinkthe model is
regardingutilizain responseto more seriousproblemsand essentiallynonnormative
that
explainedby tion.Itspurposeis to discoverconditions
conditionswould be primarily
while eitherfacilitate
or impedeutilization.
characteristics,
need and demographic
dentalservicesconsideredas morediscretion- A majorgoal of thebehavioralmodelwas
arywouldmorelikelybe explainedby social to providemeasuresof access to medicalcare
a comprebeliefs,and enablingfactors.We (Figure2). A dangerin attempting
structure,
of themodelto hensiveaccess measureis thatitmightbe too
expectedall thecomponents
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
terms
viewed as less seriousand demandingthan reasonablydefinedin multidimensional
those resultingin inpatientcare, but more using conceptsfromthe behavioralmodel.
Potentialaccess is simplydefinedas the
seriousthanthoseleadingto dentalcare.
These outcomemeasureshave been criti- presenceof enablingresources.More encized as too gross(Penchansky1976). More ablingresourcesprovidethe meansforuse,
specificmeasuresshouldrelateto a particular and increasethelikelihoodthatuse will take
or place.
condition,typeof serviceor practitioner,
Realized access is the actual use of
should be linkedin an episode of illness.
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 judgof themodel
and understandableanalysis. While such mentsaboutwhichcomponents
explicitmeasuresare,in manyways,likelyto should explain utilizationin an equitable
the more global ones healthcare systemare crucialto the definibe more informative,
still have a role to play. For example, to tion.Equityis in theeyes of thebeholder.I
definedequitableaccess as
informnationalhealthpolicy, global mea- have traditionally
whendemographic
and need variindica- occurring
suresprovideneededcomprehensive
torsof theoveralleffectsof policychanges. ables accountfor most of the variancein
Does the initialconceptof the behavioral utilization(Andersen1968). Inequitableacmodelhave a built-inbias thatincreaseduse cess occurs when social structure(e.g.,
is always betterand to be sought (Chen ethnicity),healthbeliefs, and enablingreFIGURE 2. InitialMeasures of Access
POTENTIALACCESS
=
ENABLINGRESOURCES
REALIZED ACCESS
USE OF HEALTHSERVICES
EQUITABLEACCESS
DEMOGRAPHIC
CHARACTERISTICS
*
USE OF
HEALTH SERVICES
NEED
INEQUITABLEACCESS
=
SOCIAL STRUCTURE
HEALTHBELIEFS
ENABLINGRESOURCES
U
USE OF
HEALTHSERVICES
5
REVISITING THE BEHAVIORAL MODEL
Some enabling variables can be quite
sources(e.g., income) determinewho gets
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
theimpactof thechanging
ered, and consequentlythat use, which is quitedramatically
on health
bythosebeliefs,mightbe consid- healthinsurancebenefitstructures
determined
ered equitable. Also one might employ services'use (Manninget al. 1987).
Need was originally
fordefining
considerednotto be a
equitableaccess,
different
criteria
on thetypeofhealthservices'use. mutablepolicyvariablebutrathertheimmedepending
For example,whileincomemightbe consid- diatereasonforuse to takeplace. However,
of use of people's perceivedneed for care may be
ered an inequitabledeterminant
maternal
andchildhealthservices,one might increasedor decreasedthrough
healtheducaas a predictor
of tionprograms,
considerincomeappropriate
changingtheirfinancialincentivesto seek services,and so on. Similarly,
cosmeticsurgery.
for evaluated needs mightalso be altered to
is important
The conceptof mutability
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
what variables Medicine 1992). The purposeis to alterthe
impliedfirstby determining
judgmentabout
explainutilization.To be usefulforpromot- medical care practitioner's
ingaccess,a variablemustalso be considered the patient'sevaluatedneed forhealthcare
mutable,orpointtopolicychangesthatmight (Institute
of Medicine1993).
bringaboutbehavioralchange.
Using mutablevariablesto plan intervenDemographicvariablesare judged as hav- tions can be criticizedas a conservative
sincegenderorage cannot approach.Variancemustbe observedin the
inglow mutability,
be altered to change utilization. Social current
system.A totallynew and innovative
is also judged relativelylow since programcannotbe studiedby this kind of
structure
ethnicityis not changeable, and altering approach. I agree that methods such as
or demonstrations
educational or occupational structuresis simulation
and evaluations
policy to are requiredto studysuch innovativeproprobablynot a viable short-term
promoteaccess. Healthbeliefsarejudged as grams.
since theycan be
havingmediummutability
Contraryto the apparentbelief of some
altered and sometimes effect behavioral usersandcriticsoftheinitialmodel,I didnot
expire immediatelyafter completingmy
change.
FIGURE 3. InitialConceptsof Mutability
MODEL COMPONENT
DEGREE OF MUTABILITY
DEMOGRAPHIC
LOW
SOCIAL STRUCTURE
LOW
HEALTH BELIEFS
MEDIUM
ENABLING
HIGH
NEED
(LOW?)
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
6
dissertation,and there have been some
subsequentrevisionsof the model. Phase
2-the model of the 1970s (Figure4)-was
at
developedby Adayand othercollaborators
Studies,
theCenterforHealthAdministration
of Chicago (Andersen,Smedby,
University
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
to the importhisphase, givingrecognition
tance of national health policy and the
in thehealth
resourcesand theirorganization
of the
determinants
care systemas important
population'suse of services, as well as
overtime.Other
changesin thoseuse patterns
in thisperiodincludedelaboradevelopments
tionof themeasuresof healthservices'use,
type,site, purincludingthoserepresenting
servicesreceivedin an
pose, and coordinated
episodeof illness.Also addedin Phase2 was
an explicit outcome of health servicesconsumersatisfaction.We recognizedthat
use of serviceswas, froma policyperspective, a means to otherends and outcomes.
studiesneedto examineuse in the
Utilization
contextof healthoutcomes.
A thirdphaseof themodelevolvedduring
the last decade, spurredon by the explicit
recognition
thathealthservicesare supposed
to havesomething
to do withmaintaining
and
improving
thehealthstatusof thepopulation,
both as perceivedby the populationand as
evaluated by professionals(see Figure 5)
(Andersen,Marcus, and Mashigian,forthcoming; Andersen, Davidson, and Ganz
1994). While the model remainsprimarily
one of use of health services, it also
acknowledgesthe externalenvironment
(including physical, political, and economic
components)as an importantinput for
use of healthservices.It also
understanding
recognizespersonalhealthpracticessuch as
diet, exercise,and self care as interacting
with the use of formalhealth servicesto
influencehealthoutcomes(Evans and Stoddart 1990; Lalonde 1975; Public Health
Service1990).
The inclusionof healthstatusoutcomesin
Phase 3 allows us to extendthemeasuresof
access to include dimensionswhich are
forhealthpolicy and
particularly
important
healthreform
(Figure6). Theyprovidesome
answersto thequestionof whetheror not it
matters
torevisitutilization
studiesandaccess
concepts. "Effectiveaccess" is established
when utilizationstudiesshow thatuse improveshealthstatusor consumersatisfaction
with services. "Efficientaccess" is shown
whenthelevel of healthstatusor satisfaction
FIGURE 4. The Model-Phase 2 (1970s)
POPULATION
CHARACTERISTICS
IX
Predisposing
I
USE OF HEALTH
SERVICES
Enabling
I
I
Need
Need
/
Policy
I
Resources
I
Organization
CONSUMER
SATISFACTION
I
Type
Convenience
|
Availability
IType
Site
HEALTHCARE
CARE
HEALTH
SYSTEM
>
I
I
Purpose
|
Financing
I
Provider
TimeInterval
Characteristics
I
Quality
REVISITING
THE BEHAVIORAL
7
MODEL
FIGURE 5. The Model-Phase 3 (1980s-1990s)
PRIMARY DETERMINANTS
OF HEALTH BEHAVIOR
-
HEALTH BEHAVIOR
-0-
HEALTH OUTCOMES
Characteristics
Population
Personal
Health
Practices
Perceived
Health
Status
HealthCareSystem
UseofHealth
Services
Health
Evaluated
Status
I
Environment
External
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 betterunderstandmodel(Figure7). Whatthis ing of healthbehaviorand informing
Phase4 emerging
imporphase emphasizesis the dynamicand recur- tanthealthpolicy.
In revisitingthe behavioralmodel, I am
sive natureof a healthservices'use model
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
on healthservices'use andaccessto care.Health
health services' use and, subsequently,
healthstatus.It also includesfeedbackloops servicesare partof thelargestsectorof our
showing that outcome, in turn, affects economy-one thatis stillgrowing.Theydo
forbetter,
or sometimes
for
subsequentpredisposingfactors and per- makea difference
ceived need for servicesas well as health worse, for our societyand its people. The
current
debate,recentdefeat,and continuing
behavior.
of this model requires directionsof so-called"healthcare reform"
Implementation
conceptualiza- reinforce
mybeliefthatstudiesof equityand
morecreativeand challenging
FIGURE 6. AdditionalMeasures of Access
IMPROVED
EFFECTIVE ACCESS
=
USE OF HEALTH
SERVICES
HEALTH STATUS
IMPROVED
SATISFACTION
EFFICIENT ACCESS
=
INCREASING:
HEALTH STATUS
USE OF HEALTH SERVICES
EFFICIENT ACCESS
=
INCREASING:
CONSUMER SATISFACTION
USE OF HEALTH SERVICES
JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
8
FIGURE 7. An EmergingModel-Phase 4
ENVIRONMENT
HealthCare
System
l
External
Environment
HEALTH
BEHAVIOR
POPULATION CHARACTERISTICS
Predisposing EnablingB Need
-l
CharacteristicsResources
Personal
Health
-
Practices
_
Use of
Health
Services
OUTCOMES
Perceived
HealthStatus
Il
~~~~~~~~~~~~~~Evaluate
HealthStatus
I
Consumer
Satisfaction
access examinedfrom Loevy, and BarbaraKremer.1985. Hospitaland effective
efficient
and systemicperspective PhysicianSponsoredPrimaryCare: Marketing
a comprehensive
and Impact.AnnArbor,MI: HealthAdministrawill be relevant and importantfor the
tionPress.
future(Mechanic 1993). Socioloindefinite
Aday,
Lu Ann, Charles E. Begley, David R.
gists, particularlyour youngercolleagues
and strongdisciplinary Lairson,and Carl H. Slater. 1993. Evaluating
withnewperspectives
the Medical Care System:Effectiveness,
Effiand methodologicaltraining,have special
ciency,and Equity. Ann Arbor,MI: Health
to maketo thesestudies(Pescocontributions
Press.
Administration
solido and Kronenfeld,forthcoming).In Andersen,RonaldM. 1968. BehavioralModel of
conclusion,I would like to paraphrasethe
Families' Use of Health Services. Research
"old soldier's quote" of General Douglas
SeriesNo. 25. Chicago, IL: CenterforHealth
"Old medicalsociologistsnever
MacArthur:
of Chicago.
Studies,University
Administration
die, theyjust stopbeingcitedin theJournal Andersen,Ronald M. and Odin W. Anderson.
1967. A Decade of Health Services.Chicago,
ofHealthand Social Behavior."
of ChicagoPress.
IL: University
RonaldM. andJohnF. Newman.1973.
Andersen,
REFERENCES
of Medi"Societaland IndividualDeterminants
in the United States."
cal
Utilization
Care
Aday,Lu Ann. 1993. "Access to Whatand Why?
Milbank Memorial Fund QuarterlyJournal
Toward a New Generationof Access Indica51:95-124.
tors."ProceedingsofthePublicHealthConference on Records and Statistics.Washington, Andersen,Ronald M., Pamela Davidson, and
PatriciaGanz. 1994. "SymbioticRelationships
Office.
Printing
D.C.: U.S. Government
of Qualityof Life, HealthServicesResearch,
Aday,Lu AnnandRonaldM. Andersen.1974. "A
and OtherHealth Research." Qualityof Life
fortheStudyof Access to Medical
Framework
Research3:365-71.
Care." HealthServicesResearch9:208-20.
Aday,Lu AnnandWilliamC. Awe. Forthcoming. Andersen, Ronald M., Marvin Marcus, and
"A ComparMichaelMashigian.Forthcoming.
Models." In Hand"HealthSourcesUtilization
Oral
Health
on
ative
Perspective
Systems
1.
Vol.
Research
book of Health Behavior
Promotionand Disease Prevention."In Oral
ofHealthBehavior:Personaland
Determinants
Health Promotion:Socio-Dental Sciences in
Social, editedby D.S. Gochman.New York:
Action,editedby L.K. Cohen and H.C. Gift.
Plenum.
Copenhagen,Denmark:Munsksgaard.
Aday, Lu Ann, Ronald M. Andersen, and
V. Fleming.1980. HealthCare in the Andersen,Ronald M., Bjorn Smedby,and Odin
Gretchen
W. Anderson. 1970. Medical Care Use in
U.S.: Equitablefor Whom?BeverlyHills, CA:
Swedenand the UnitedStates-A Comparative
Sage.
Analysisof Systemsand Behavior. Research
Aday, Lu Ann, Ronald M. Andersen,Sarah
REVISITING THE BEHAVIORAL MODEL
Series No. 27. Chicago, IL: CenterforHealth
Administration
Studies,University
of Chicago.
Andersen,RonaldM., JoannaKravits,and Odin
W. Anderson,eds. 1975. Equity in Health
Services:EmpiricalAnalysesin Social Policy.
Boston,MA: BallingerPublishing
Company.
Bass, David M., WendyJ. Looman, and Paul
Ehrlich. 1992. "Predictingthe Volume of
Healthand Social Services:Integrating
Cognitive Impairment
into the ModifiedAndersen
Framework."The Gerontologist
32:33-43.
Bass, David M. andLindaS. Noelker.1987. "The
Influenceof FamilyCaregiverson Elders' Use
of In-HomeServices:An ExpandedConceptual
Framework."Journalof Health and Social
Behavior28:184-96.
Becker,MarshallH. and Lois A. Maiman. 1983.
"Models of Health-RelatedBehavior." Pp.
539-68 in Handbookof Health,Health Care,
and the Professions,editedby D. Mechanic.
New York:The FreePress.
Chen, MartinK. 1978. "Commenton Health
StatusIndices and Access to Medical Care."
American
JournalofPublicHealth68:1027-28.
Coulton,Claudiaand AbbieK. Frost.1982. "Use
of Social and HealthServicesby theElderly."
JournalofHealthand Social Behavior23:33039.
Counte,MichaelA. andGeraldL. Glandon.1991.
"A Panel Studyof Life Stress,Social Support,
and the Health Services Utilizationof Older
Persons."Medical Care 29:348-61.
Davanzo, Joan E. 1994. "The Relationship
BetweenAutonomy
and MedicareUtilization
in
an ElderlySample." Ph.D. Dissertation,Departmentof Health Services, Universityof
Californiaat Los Angeles,Los Angeles,CA.
Evans,RobertG. and GregoryL. Stoddart.1990.
"ProducingHealth,ConsumingHealthCare."
Social Scienceand Medicine31:1347-63.
Fleming, Gretchenand Ronald M. Andersen.
1986. Can AccessBe ImprovedWhileControllingCosts?Chicago:PluribusPress.
Freedman,Vicki A. 1993. "Kin and Nursing
HomeLengthsof Stay:A BackwardRecurrence
Time Approach."JournalofHealthand Social
Behavior34:138-52.
Gilbert,Gregg H., Lawrence G. Branch, and
Jefferey
Longmate.1993. "DentalCare Use by
U.S. VeteransEligible for VA Care." Social
Scienceand Medicine36:361-70.
Green,LawrenceS., MarshallK. Kreuter,Sigrid
G. Deeds, and Kay B. Partridge.1980. Health
EducationPlanning:A DiagnosticApproach.
Palo Alto,CA: Mayfield.
Guendelman,Sylvia. 1991. "Health Care Users
Residingon theMexicanBorder:WhatFactors
DetermineChoice of the U.S. or Mexican
HealthSystem?"Medical Care 29:419-29.
Hulka, Barbara S. and JohnR. Wheat. 1985.
9
"Patternsof Utilization:The PatientPerspective." Medical Care 23:438-60.
Institute
of Medicine. 1992. Guidelinesfor Clinical Practice.Washington,
D.C.: NationalAcademyPress.
Institute
of Medicine.1993.AccesstoHealthCare
in America.Washington,
D.C.: NationalAcademyPress.
Kelley,MichelleA., JanetD. Perloff,NaomiM.
Morris,andWangyueLiu. 1992. "Primary
Care
Arrangements
and Access to Care Among
AfricanAmericanWomen in Three Chicago
Communities."
Womenand Health 18:91-106.
Lalonde, Marc. 1975. A New Perspectiveon the
HealthofCanadians.Ottawa,Canada: InformationCanada.
Manning, Willard G., Joseph P. Newhouse,
NaihuaDuan, ArleenLebowitz,and M. Susan
Marquis. 1987. "Health Insurance and the
Demand for Medical Care." AmericanEconomicReview77:251-77.
Mechanic,David. 1979. "Correlatesof Physician
Utilization:Why Do MultivariateStudies of
PhysicianUtilizationFind TrivialPsychosocial
and Organizational
Effects?"Journalof Health
and Social Behavior20:387-96.
Mechanic, David. 1993. "Social Research in
Healthand the AmericanSocio-politicalContext:The ChangingFortunesof MedicalSociology." Social Scienceand Medicine36:95-102.
Miller,Baila, and StephanieMcFall. 1991. "The
Effectof Caregiver'sBurdenon Changein Frail
OlderPerson'sUse ofFormalHelpers."Journal
ofHealthand Social Behavior32:165-79.
Patrick,Donald L., Jane Stein, Miquel Porta,
CarolQ. Porter,andThomasC. Ricketts.1988.
"Poverty,HealthServices,and HealthStatusin
Rural America." The Milbank Quarterly66:
105-36.
Penchansky,
Roy. 1976. "Book Review:Accessto
MedicalCare." Medical Care 14:642.
Pescosolido,Bernice and JennieJ. Kronenfeld.
Forthcoming.
"Health,Illness,and Healingin
an UncertainEra: ChallengesFrom and For
Medical Sociology" Journal of Health and
Social Behavior:FortyYearsofMedicalSociology-The StateoftheArtand Directions
forthe
Future.
Pescosolido, Bernice. 1992. "Beyond Rational
Choice: The Social Dynamicsof How People
Seek Help." AmericanJournalof Sociology
97:1096-138.
Portes,Alejandro,David Kyle, and WilliamW.
Eaton. 1992. "MentalIllnessand Help-seeking
Behavior Among Mariel Cuban and Haitian
Refugeesin SouthFlorida." Journalof Health
and Social Behavior33:283-98.
PublicHealthService.1990.HealthyPeople2000:
NationalHealthPromotion
and Disease PreventionObjectives:Full Report,withCommentary.
10
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
andJoe
DHHS PublicationNo. PHS 91-50212. Wash- Tanner,JamesL., WilliamC. Cockerham,
Office.
Printing
ington,D.C.: U.S. Government
PhysicianUtilizaL. Spaeth.1983. "Predicting
Rundall,Thomas G. 1981. "A Suggestionfor
tion."Medical Care 21:360-69.
Improvingthe BehavioralModel of Physician True,WilliamR., JamesC. Romeis,AndrewC.
Utilization."Journal of Health and Social
Heath,Louise H. Flick,Leslee Shaw, Seth A.
Behavior22:103-104.
Eisen, JackGoldberg,and Michael J. Lyons.
H.
ThomasT. Wan, Meribeth
Rivnyak,Margaret,
Contribu1994. "Genetic and Environmental
Stegall,MaryJacobs,and S. Li. 1989. "Ambutionsto HealthCare Need and Utilization:A
latoryCare Use Among Noninstitutionalized
Paper.St. Louis,
TwinAnalysis."Unpublished
Elderly:A Causal Model." Researchin Aging
St. Louis
of
Public
Health,
MO:
School
11:292-311.
Medical
Center.
University
Cost
on
the
"Reflections
V.
1994.
Rosnau,Pauline
Consequencesof theNew Gene Technologyfor Wolinsky,FredricD. and RobertJ. Johnson.
1991. "The Use of Health Servicesby Older
Journalof TechHealthPolicy." International
46:S345-57.
Adults."Journalof Gerontology
in HealthCare 10:546-61.
nologyAssessment
of Health
and chairof theDepartment
Ronald Andersenis theFredand PamelaWassermanProfessor
of Californiaat Los Angeles.
of sociology,University
Services,School of PublicHealthand professor
andthehealth
ofhealthcaresystems
includeaccessto healthservices,comparisons
His researchinterests
populations.
of vulnerable