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Re-revisiting the Behavioral Model of Health Care Utilization by Andersen: A Review on Theoretical Advances and Perspectives

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Health Care Utilization in Germany

Abstract

The Behavioral Model of Health Services Use by Ronald M. Andersen and colleagues is the most widely adopted theoretical framework for analyzing and predicting health care utilization. Among other things, it is employed in the German Federal Health Reporting since 2001. It differentiates need factors, predisposing factors and enabling factors both on the contextual level and the individual level as determinants of individual health services use. From the viewpoint of social epidemiology, one of the key strengths of the Behavioral Model is its capability to systematize and empiricize equity and inequity in the access to health services by specifying need vs. predisposing and enabling factors. This strength could be even promoted by including direct effects on utilization of psychological factors (besides social factors) as contributing to inequity. Another strength of the Behavioral Model since its fifth version is that it conceptualizes need factors, predisposing factors and enabling factors both on the contextual level and the individual level in a structurally equivalent manner. Thus, not only are theoretically consistent multilevel models possible on the predictor side, but general theories of action and behavior from sociology and psychology are more easily applied on the behavior of professionals working in health policy and services. On the side of health-related behaviors (as mediating factors) and the outcomes of the model (including, since its sixth version, quality of life), the question is why these are represented as individual entities only, thus excluding relevant prevalences and incidences only from the scope of the model. Here, the Behavioral Model could be further developed by integrating assumptions of the Basic Behavioral Epidemology Model by Thomas von Lengerke and colleagues which – following the micro-micro-model of sociological explanation – allows the description and explanation of collective outcomes. Finally, regarding the empirical and statistical application of the Behavioral Model, improvements are possible by use of the methodological differentiation between mediation and moderation. For instance, it should be clarified whether only enabling factors, which according to classical social ecology tend to moderate associations between other variables (in the present case need factors and utilization), may be conceptualized and modelled as effect modifiers, or predisposing factors as well. In the context of data analyses oriented by the Behavioral Model, this would have direct implications for specifying hierarchical models and relevant interaction terms.

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Notes

  1. 1.

    The inclusion of only one supraindividual level in Fig. 2.2 is intended to increase clarity; of course, models with more than two levels are more realistic (e.g., “patients” in “wards” in “hospitals”).

  2. 2.

    Lazarsfeld and Menzel [59] developed a formal classification for individual properties as well: Absolute properties, which can be determined without recourse to characteristics of supraindividual units or to characteristics of relationships with other individuals. Relational properties, which are determined on the basis of information about relationships to other individuals. Comparative properties, which derive from a comparison of the value of an individual for an absolute or relational property with the distribution of this property in the considered collective. Contextual properties, which describe individuals by a (global, analytical or structural) property of the collective (and that are therefore invariable for all members of the collective). The somatic, psychological, and social characteristics meant in the BBEM in its present form are primarily absolute properties, which means that the model is still too simplistic in this area. Since the primary goal in this context is to specify a model that can also depict rates of behavior, we accepted this lack of clarity here for space reasons.

  3. 3.

    The macro–micro model of sociological explanation typically does not contain paths 2a–c. They were included in the BBEM because they represent central health science research interests, such as moderating effects of the mean regional income on the relationship between inhabitants’ individual income and their behavior (arrow 2a [64]), direct environmental effects on behavior without explicit mediation by psychological processes (arrow 2b [64]), and moderating policy effects on citizen participation in health policy decision making (arrow 2c [66]).

  4. 4.

    An individual’s likelihood of becoming obese is also known to increase with the incidence of obesity in the individual‘s own social network [70] (the same is true of smoking [71] and happiness [72]). Hence, the individual somatic property “obese” is apparently influenced by the supraindividual analytical property “rate of obesity within network.” However, this only applies to close social relations (friends, siblings, and partners). The relationship between the two former properties is therefore presumably moderated by the supraindividual structural property “social cohesion.” However, it has not yet been determined to what extent these relationships in turn influence obesity-associated behaviors, such as utilization of care.

  5. 5.

    This interaction could, in turn, be moderated by social variables, such as socioeconomic status. Rückert et al. [74], for instance, investigated the practice fee in the German health care system and found that in the chronically ill, the likelihood to avoid or delay a physician visit to avoid the practice fee was 2.45 times higher in the lowest income group than in the highest.

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Authors and Affiliations

  1. Center of Public Health and Health Care, Medical Psychology Unit, Hannover Medical School, Hannover, Germany

    Thomas von Lengerke

  2. Berlin School of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany

    Daniela Gohl

  3. Department of New Public Health, School of Human Sciences, University of Osnabrück, Osnabrück, Germany

    Birgit Babitsch

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Editors and Affiliations

  1. Department of Applied Social Sciences, Munich University of Applied Sciences, Munich, Germany

    Christian Janssen

  2. Institute of Social Medicine & Health Economics, Otto von Guericke University Magdeburg, City, Germany

    Enno Swart

  3. Ctr of Public Health & Health Care, Medical Psych. Unit, Hannover Medical School, Hannover, Germany

    Thomas von Lengerke

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von Lengerke, T., Gohl, D., Babitsch, B. (2014). Re-revisiting the Behavioral Model of Health Care Utilization by Andersen: A Review on Theoretical Advances and Perspectives. In: Janssen, C., Swart, E., von Lengerke, T. (eds) Health Care Utilization in Germany. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-9191-0_2

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