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      Re-revisiting Andersen’s Behavioral Model of Health Services Use: a systematic review of studies from 1998–2011

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          Abstract

          Objective: This systematic review aims to assess the use and implementation of the Behavioral Model of Health Services Use developed by Ronald M. Andersen in recent studies explicity using this model.

          Methods: A systematic search was conducted using PubMed in April 2011. The search strategy aimed to identify all articles in which the Andersen model had been applied and which had been published between 1998 and March 2011 in English or German. The search yielded a total of 328 articles. Two researchers independently reviewed the retrieved articles for possible inclusion using a three-step selection process (1. title/author, 2. abstract, 3. full text) with pre-defined inclusion and exclusion criteria for each step. 16 studies met all of the inclusion criteria and were used for analysis. A data extraction form was developed to collect information from articles on 17 categories including author, title, population description, aim of the study, methodological approach, use of the Andersen model, applied model version, and main results. The data collected were collated into six main categories and are presented accordingly.

          Results: Andersen’s Behavioral Model (BM) has been used extensively in studies investigating the use of health services. The studies identified for this review showed that the model has been used in several areas of the health care system and in relation to very different diseases. The 1995 version of the BM was the version most frequently applied in the studies. However, the studies showed substantial differences in the variables used. The majority of the reviewed studies included age (N=15), marital status (N=13), gender/sex (N=12), education (N=11), and ethnicity (N=10) as predisposing factors and income/financial situation (N=10), health insurance (N=9), and having a usual source of care/family doctor (N=9) as enabling factors. As need factors, most of the studies included evaluated health status (N=13) and self-reported/perceived health (N=9) as well as a very wide variety of diseases. Although associations were found between the main factors examined in the studies and the utilization of health care, there was a lack of consistency in these findings. The context of the studies reviewed and the characteristics of the study populations seemed to have a strong impact on the existence, strength and direction of these associations.

          Conclusions: Although the frequently used BM was explicitly employed as the theoretical background for the reviewed studies, their operationalizations of the model revealed that only a small common set of variables was used and that there were huge variations in the way these variables were categorized, especially as it concerns predisposing and enabling factors. This may stem from the secondary data sets used in the majority of the studies, which limited the variables available for study. Primary studies are urgently needed to enrich our understanding of health care utilization and the complexity of the processes shown in the BM.

          Translated abstract

          Zielsetzung: Ziel dieses systematischen Reviews ist es, einen Überblick zum Verständnis und zur Anwendung des von Ronald M. Andersen entwickelten ‚Behavioral Model of Health Services Use‘ (BM) in aktuellen empirischen Studien zu geben, die dieses Modell explizit verwendet haben.

          Methoden: Im April 2011 wurde eine systematische Suche in PubMed durchgeführt. Die Suchstrategie hatte das Ziel, alle Publikationen zu identifizieren, in denen das BM in seinen unterschiedlichen Versionen zur Anwendung kam. Die Suche schloss Publikationen ein, die im Zeitraum von 1998 bis März 2011 in englischer oder deutscher Sprache veröffentlicht wurden. Insgesamt konnten 328 Artikel identifiziert werden. Das Auswahlverfahren wurde von zwei Gutachterinnen unabhängig voneinander in drei Arbeitsschritten (1. Titel/Autor, 2. Abstract, 3. Volltext) mit a priori festgelegten Einschluss- und Ausschlusskriterien durchgeführt. Für die Analyse konnten 16 Publikationen eingeschlossen werden. Die Datenextraktion dieser Publikationen erfolgte zunächst mit 17 Kategorien, die u.a. Angaben zum Autor, Titel, Studienpopulation, Studienziel, Methodologie enthielten. In einem weiteren Analyseschritt wurden diese in sechs Hauptkategorien zusammengeführt, welche primär zur Deskription der Ergebnisse genutzt werden.

          Ergebnisse: Die Vielzahl der Treffer zeigt, wie weitflächig das BM im Analysezeitraum eingesetzt wurde. Die Publikationen beziehen sich dabei auf sehr unterschiedliche Bereiche des Versorgungssystems und umfassen eine Vielzahl von Erkrankungen. Es zeigte sich, dass die BM-Version, publiziert in 1995, am häufigsten verwendet wurde. Obgleich sich alle Publikationen auf das BM beziehen, findet sich in der Operationalisierung dessen eine hohe Heterogenität. Zur Erfassung der ‚predisposing factors‘ des BM wurden meist folgende Variablen verwendet: Alter (n=15), Familienstatus (n=13), Geschlecht (n=12), Schulbildung (n=11) und Ethnizität (n=10). Die am häufigsten verwendeten Variablen zur Beschreibung der ‚enabling factors‘ waren Einkommen/finanzielle Situation (n=10), Krankenversicherung (n=9) und ein „feste/r“ Hausarzt/-ärztin (n=9). Als ‚need factors‘ berücksichtigten nahezu alle Studien den allgemeinen Gesundheitsstatus (n=9) und die subjektive Einschätzung des eigenen Gesundheitszustandes (n=13) sowie eine Vielzahl unterschiedlicher Erkrankungen. Trotz der in den einzelnen Studien berichteten Zusammenhänge zwischen den einzelnen Faktoren und der Inanspruchnahme der Gesundheitsversorgung, zeigte sich in der Gesamtschau der Ergebnisse eine erhebliche Inkonsistenz. Insbesondere scheinen die den Studien zugrunde liegenden Kontextbedingungen und die unterschiedlichen Studienpopulationen einen erheblichen Einfluss auf die Existenz eines Zusammenhangs und desen Stärke und Richtung zu haben.

          Schlussfolgerungen: Das BM dient zahlreichen Studien als theoretisches Analysemodell. Die damit verbundene Vorstellung einer hohen Vergleichbarkeit der Studienergebnisse wird durch die großen Unterschiede in der Operationalisierung des Modells reduziert. Zwar besteht ein gewisser „Standardkatalog“ von Variablen, der jedoch klein ist und sich durch erhebliche Unterschiede bei der Variablenkonstruktion auszeichnet. Besonders betroffen sind die ‚predisposing factors‘ und die ‚enabling factors‘. Eine Ursache könnte darin bestehen, dass die Mehrzahl der Studien Sekundärdatenanalysen und damit in der Variablenauswahl Einschränkungen unterworfen sind. Damit ist zum besseren Verständnis der im BM dargelegten Wirkungspfade die Durchführung von Primärstudien dringend geboten.

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          The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people.

          (1) To present the Behavioral Model for Vulnerable Populations, a major revision of a leading model of access to care that is particularly applicable to vulnerable populations; and (2) to test the model in a prospective study designed to define and determine predictors of the course of health services utilization and physical health outcomes within one vulnerable population: homeless adults. We paid particular attention to the effects of mental health, substance use, residential history, competing needs, and victimization. A community-based probability sample of 363 homeless individuals was interviewed and examined for four study conditions (high blood pressure, functional vision impairment, skin/leg/foot problems, and tuberculosis skin test positivity). Persons with at least one study condition were followed longitudinally for up to eight months. Homeless adults had high rates of functional vision impairment (37 percent), skin/leg/foot problems (36 percent), and TB skin test positivity (31 percent), but a rate of high blood pressure similar to that of the general population (14 percent). Utilization was high for high blood pressure (81 percent) and TB skin test positivity (78 percent), but lower for vision impairment (33 percent) and skin/leg/foot problems (44 percent). Health status for high blood pressure, vision impairment, and skin/leg/foot problems improved over time. In general, more severe homeless status, mental health problems, and substance abuse did not deter homeless individuals from obtaining care. Better health outcomes were predicted by a variety of variables, most notably having a community clinic or private physician as a regular source of care. Generally, use of currently available services did not affect health outcomes. Homeless persons are willing to obtain care if they believe it is important. Our findings suggest that case identification and referral for physical health care can be successfully accomplished among homeless persons and can occur concurrently with successful efforts to help them find permanent housing, alleviate their mental illness, and abstain from substance abuse.
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            Societal and individual determinants of medical care utilization in the United States.

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              Understanding the context of healthcare utilization: assessing environmental and provider-related variables in the behavioral model of utilization.

              The behavioral model of utilization, developed by Andersen, Aday, and others, is one of the most frequently used frameworks for analyzing the factors that are associated with patient utilization of healthcare services. However, the use of the model for examining the context within which utilization occurs-the role of the environment and provider-related factors-has been largely neglected. To conduct a systematic review and analysis to determine if studies of medical care utilization that have used the behavioral model during the last 20 years have included environmental and provider-related variables and the methods used to analyze these variables. We discuss barriers to the use of these contextual variables and potential solutions. The Social Science Citation Index and Science Citation Index. We included all articles from 1975-1995 that cited any of three key articles on the behavioral model, that included all articles that were empirical analyses and studies of formal medical care utilization, and articles that specifically stated their use of the behavioral model (n = 139). Design was a systematic literature review. We used a structured review process to code articles on whether they included contextual variables: (1) environmental variables (characteristics of the healthcare delivery system, external environment, and community-level enabling factors); and (2) provider-related variables (patient factors that may be influenced by providers and provider characteristics that interact with patient characteristics to influence utilization). We also examined the methods used in studies that included contextual variables. Forty-five percent of the studies included environmental variables and 51 percent included provider-related variables. Few studies examined specific measures of the healthcare system or provider characteristics or used methods other than simple regression analysis with hierarchical entry of variables. Only 14 percent of studies analyzed the context of healthcare by including both environmental and provider-related variables as well as using relevant methods. By assessing whether and how contextual variables are used, we are able to highlight the contributions made by studies using these approaches, to identify variables and methods that have been relatively underused, and to suggest solutions to barriers in using contextual variables.
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                Author and article information

                Journal
                Psychosoc Med
                Psychosoc Med
                GMS Psychosoc Med
                GMS Psycho-Social-Medicine
                German Medical Science GMS Publishing House
                1860-5214
                25 October 2012
                2012
                : 9
                : Doc11
                Affiliations
                [1 ]Osnabrück University, School of Human Sciences, Dept. of New Public Health, Osnabrück, Germany
                [2 ]Charité – Universitätsmedizin Berlin, Berlin School of Public Health, Berlin, Germany
                [3 ]Hannover Medical School, Medical Psychology Unit, Hannover, Germany
                Author notes
                *To whom correspondence should be addressed: Birgit Babitsch, Osnabrück University, School of Human Sciences, Dept. of New Public Health, Albrechtstr. 28, 49069 Osnabrück, Germany, Phone: +49 541 969-2266, Fax: +49 541 969-2450, E-mail: birgit.babitsch@ 123456uni-osnabrueck.de
                Article
                psm000089 Doc11 urn:nbn:de:0183-psm0000891
                10.3205/psm000089
                3488807
                23133505
                1be72ba9-ac1f-4fcd-8899-26f9f4775000
                Copyright © 2012 Babitsch et al.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free to copy, distribute and transmit the work, provided the original author and source are credited.

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                Article

                Clinical Psychology & Psychiatry
                enabling factors,need factors,systematic review,predisposing factors,behavioral model of health services use,health services utilization

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