This article, titled “National Health Surveys and the Behavioral Model of Health Services Use,” was authored by Ronald Max Andersen and published in Medical Care in July 2008. It serves as a comprehensive review, documenting a 75-year legacy of national studies that have shaped the field of health services research.
The article highlights two primary contributions:
- The evolution of national health surveys: These surveys have played a crucial role in advancing concepts, methods, and the policy relevance of health services research. They have provided essential information for policymakers, providers, and researchers over 75 years, allowing for the assessment of healthcare system performance, the burden of costs on various stakeholders, and factors affecting access to care for different populations. The author provides a somewhat personalized account, emphasizing early surveys that either preceded or influenced his own work, and lists other major, more recent health surveys. Key historical surveys discussed include:
- The Committee on the Cost of Medical Care Studies (1928-1933), which undertook the first national population survey and documented the uneven burden of healthcare costs.
- The National Health Survey (NHS) (1935-1936), a massive cross-sectional survey that was the first to document national health disparities related to income and to include the African American population.
- The Health Information Foundation (HIF)/Center for Health Administration Studies (CHAS)-National Opinion Research Center (NORC) Surveys (1953-1971), which were the first national health care use and expenditure surveys based on a full-area probability sample and introduced the computation of sampling errors. Ronald Andersen was directly involved in the 1963 survey as a doctoral student and study director, using its data for his dissertation.
- Later government-led initiatives, such as the National Center for Health Statistics (NCHS) National Health Interview Survey (NHIS) (since 1957) and the NCHSR/AHRQ Medical Expenditure Surveys (since 1977), which grew out of the work of the HIF/CHAS surveys.
- Surveys sponsored by foundations like the Robert Wood Johnson Foundation Surveys of Access to Medical Care (since 1975) and other initiatives like the Medicare Current Beneficiary Survey and the Health and Retirement Study.
- The development and application of the Behavioral Model of Health Services Use: This model was a direct product of these national surveys, developed by Ronald Andersen for his dissertation. It has undergone considerable application and alteration over four decades.
- The initial model (Phase 1) suggested that people’s use of health services is a function of their predisposition to use services, enabling factors that facilitate or impede use, and their need for care. A primary goal was to define and measure equitable access to care, which the author traditionally defines as occurring when predisposing demographic and need variables account for most of the variance in utilization, while inequitable access is indicated when social structure, health beliefs, and enabling resources determine who receives medical care.
- The model evolved through subsequent phases, explicitly including the health care system and consumer satisfaction (Phase 2), recognizing personal health practices and health status as outcomes (Phase 3), and acknowledging the dynamic and recursive nature of these relationships with feedback loops (Phase 4).
- The most recent phase (Phase 5) emphasizes the importance of both contextual and individual determinants in understanding health services use. Contextual characteristics, measured at an aggregate level, include factors that predispose (e.g., community age structure), enable (e.g., supply of medical personnel), or suggest a need for individual use (e.g., mortality rates). This phase also added the “process of medical care” – the behavior of providers interacting with patients – as a type of health behavior.
The article concludes by noting that while policy concerns and methods evolve, many core issues remain consistent across decades of national studies, such as the government’s need for information, public expectations regarding national health insurance, and access to medical care. The Behavioral Model is considered a significant legacy for organizing previous single-factor studies into a comprehensive framework for multivariable analyses.
Reference: Andersen, R. M. (2008). National health surveys and the behavioral model of health services use. Medical Care, 46(7), 647–653.