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2018/07/19

Review: Health-seeking behavior factor determinants based on Andersen’s

Behavioral Model of Health Service Use

The concept of studying health-seeking behavior has evolved over time. One
of the most widely acknowledged models to explain the health-seeking behavior is
the Behavioral Model of Health Services Use (BM), which was developed in 1968. In
their most recent explication of the behavioral model of health services use,
Andersen et al. (2013) presented a conceptual framework that emphasizes
contextual and individual determinants of access to medical care. Contextual means
the circumstances and environment of health care access. Context includes health
organization and provider-related factor as well as community characteristics.
Contextual factors are measured on the aggregate rather than the individual level.
These aggregate levels range from units as small as the family to those as large as a
national health care system. In between are work groups, provider organizations,
health plans, neighborhoods, local communities, and metropolitan areas. Individuals
are related to these aggregate units through membership (family, work group,
provider institutions, or health plan) or residence (neighborhood, community,
metropolitan area, or national health system).
The behavioral model of health services utilize suggests the major components
of contextual characteristics are divided in the same way as individual characteristics
determining access (R. M. Andersen, Davidson, and Baumeister 2013):
1. Existing conditions that predispose people to use or not use services
(predisposing factors).
 Contextual factors predisposing individuals to the use of health
services include the demographic factors, social factors, and beliefs.
Demographic factors
Demographic factors of a community include its age, gender, and
marital status composition.
- Age.
A community populated primarily by older person might well have a
different mix of available health services and facilities from one in
which the majority are younger parents and children (R. M. Andersen,
Davidson, and Baumeister 2013).
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- Gender
Gender refers to socially constructed characteristics of women and
men – such as norms, roles, and relationships between groups of
women and men. Gender varies from one group community to
another and can be changed. While people are born male or female,
they are taught appropriate norms and behaviors – including how
they should interact with others of the same or opposite sex in
households, communities, and workplaces. When individuals or
groups do not "fit" gender norms they often face stigma,
discriminatory practices or social exclusion, which have adverse
health effects. It is important to be sensitive to different identities that
may not necessarily match the category of binary men or women.
Norms, roles, and gender relationships affect people's vulnerability
to health conditions and diseases and also affect people's access to
health care and health outcomes. (WHO 2017).
- Marital status composition
Marital status was found to be associated with utilization of health
services in many studies (Babitsch, Gohl, and von Lengerke 2012).
Marital status is not only related to the levels of service utilization but
also to the type of services utilized and the circumstances in which
they are accepted (Pol and Thomas 2001). The changing in marital
status composition could have substantial implication for health and
health care utilization (Iwashyna and Christakis 2003).

Social factors
Social factors describe how supportive or detrimental the communities
where people live and work might be to their health and access to
health services. Relevant measures include educational level, ethnic
and racial composition, employment status, and crime rate.
- Educational level
Education was significantly associated with utilization of health
service. In some study, group or community with lower levels of
education are less likely to utilize the health services, has the lower
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odds of scheduling a routine health examination, and has fewer

contact with a doctor than the higher levels of education group or
community (Babitsch, Gohl, and von Lengerke 2012).
- Ethnic and racial composition
Various studies reported associations between ethnicity or nativity
and the utilization of health services. Two studies conducted in the
US found that black non-Hispanics, Hispanic, Asians or other racial
ethnics group, and non-Hispanic others were significantly less likely
than white non-Hispanics to receive treatment (R. M. Andersen et al.
2002; Dhingra et al. 2010). Blacks were found to consume more
physicians care than other ethnic groups (Broyles, McAuley, and
Baird-Holmes 1999). A study in Malaysia reported the first action for
consulting a physician when experiencing any health problems were
less likely among Chinese and Indian compare to Malay and the
Indian were more likely to consult a pharmacist as the first action
when facing any health problem (Dawood et al. 2017)
- Employment status
Health care utilization has been associated with employment status
(Macassa and Hiswåls 2014). Unemployed people associated with
the increased of health care utilization (D’Arcy and Siddique 1985;
Dragun, Russo, and Rumboldt 2006; Macassa and Hiswåls 2014).
However, others study reported that unemployed persons were more
likely to delay contact with healthcare services due to cost and were
less likely to have access to healthcare than their employed
counterparts. It is argued that the delay in using health care by
unemployed persons found in other studies might be related to the
fact that as unemployment persists, economic resources dwindle
and less money directly or indirectly worsens the prerequisites for
good health (Pharr, Moonie, and Bungum 2012). The relationship
between unemployment and health may be explained by a)
causation, where unemployment precipitates a decline in health,
perhaps through the combination of effects arising from loss of
income, increased unhealthy lifestyle, loss of self-esteem, and
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psychological distress, and in some settings, reduced access to

care; b) selection, where a person’s health status, gender,
nationality, previous exposure to unemployment, or other personal
characteristics, simultaneously place them at risk for both
unemployment and poor health
- Crime rate
Crime could affect health services utilization through two
mechanisms in the behavioral model. Crime could lead to a need for
health care, since as neighbors become less trustworthy of each
other. This could make them less willing to expose themselves to
potential harm by going outside and participating in healthy activities,
as well as an increase in stress. This may not only affect health
through a sedentary lifestyle and stress, but also an accumulation of
neglecting preventive care. This would lead to a decrease in health
over time, creating a need for HCU in the future (Eiler 2017).
Beliefs
Beliefs refer to an underlying community or organizational values and
cultural norms and common political perspectives regarding how health
services should be organized, financed, and made accessible to the
population (R. M. Andersen, Davidson, and Baumeister 2013). A
community-based participatory study on Puerto Rican Latinas living in
the Capital District of New York State identified women preferring to be
seen by a Latino doctor and using alternative medicine as being
significantly more likely to delay care (Insaf, Jurkowski, and Alomar
2010). Trust in and familiarity with the medical organizations were also
significantly associated with the use of health services. The odds of
routine health examinations were lower in African American men who
reported less trust in medical organizations and who believed that they
should keep their concerns and emotions private (Hammond, Matthews,
and Corbie-Smith 2010). Non-urgent patients who visited emergency
departments without first seeking care from a primary care provider
reported that they had done so because they felt more familiar with the
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emergency department (11%) and trusted its services (7%) (Surood and
Lai 2010).
 Individual predisposing factors include the demographic and social
factors.
Demographic factors
Demographic factors such as sex and age of the individual represent
biological imperatives suggesting the likelihood that people will need
health services. Age and sex are intimately related to health and illness.
However, they are still considered to be predisposing conditions
inasmuch as age and sex are not considered a reason for seeking
health care. Rather, people in different age groups have different types
and amounts of illness and consequently different patterns of medical
care (R. Andersen and Newman 2005). Being female was positively
related to health-seeking behavior and being male seem most likely to
decrease health-seeking behavior (Magaard et al. 2017). People
Genetic susceptibility also potentially influences need, by increasing
disease incidence. Genetic susceptibility also potentially influences
need, by increasing disease incidence. Genetic testing for rare,
monogenetic diseases involves testing single genes (such as familial
hypercholesterolemia, fragile X syndrome, Duchenne muscular
dystrophy, Huntington’s disease, and BRCA1 and BRCA2 mutations for
breast cancer). However, more prevalent conditions such as
cardiovascular diseases, age-related macular degeneration, type-2
diabetes, depression, and many types of cancer have a multifactorial
and polygenetic etiology involving hundreds or thousands of genetic
variants, making the development of relevant genetic susceptibility
measures extremely challenging. In the case of multifactorial conditions,
family history can serve as an adequate source of risk differentiation (R.
M. Andersen, Davidson, and Baumeister 2013).
Social factors
Social factors determine the status of a person in the community as well
as his or her ability to cope with presenting problems and command
resources to deal with those problems. Social factors include
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individual`s education, occupation, social relationships (e.g., the

presence of family or friend and affiliations with religious and other
community organization), and health beliefs (e.g., attitudes, values, and
knowledge related to health and health services).
- individual`s education and occupation
Education and occupation measure the location (status) of individual
in the society. These characteristics suggest what the lifestyle of the
individual may be, and they point to the physical as well as the social
environment of the individual and associated behavior patterns
which may be related to the use of health services (R. Andersen and
Newman 2005).
- Social relationship
People’s social networks, such as the presence of family and friends
and affiliations with religious and other community organizations that
can potentially facilitate (or impede) access to services (R. M.
Andersen, Davidson, and Baumeister 2013)
- health beliefs
What an individual thinks about health may ultimately influence
health and illness behavior. Like the other predisposing variables,
health beliefs are not considered to be a direct reason for using
services but do result in differences in inclination toward the use of
health services. For example, families who strongly believe in the
efficacy of treatment of their doctors might seek a physician sooner
and use more services than families with less faith in the results (R.
Andersen and Newman 2005)
2. Enabling conditions that facilitate or impede the use of service (enabling
factors).
 Contextual factors
Enabling factors in contextual level include health policies, financing
characteristics, and organization.
Health policies
Health policies are the sound decisions that are made related to health
or influence health achievement.
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Financing characteristics
Financing characteristics are explained by a series of contextual
measures that indicate potentially available resources to pay for health
services (such as per capita community income and wealth), incentives
to purchase or provide services (such as the relative price of medical
care and other goods and services), the methods of compensating
providers, per capita expenditures for health services, and health
insurance coverage rates.
Organization
Organization refers to the amount and distribution of health services
facilities and personnel as well as how they are structured to offer
services. Structures include the supply of services in the community,
how healthcare is organized, and outreach and education programs.
 Individual factors
Financing and organization of health services factors are considered to
serve as conditions that enabling the individual to utilize services.
Financing
Financing of health services for the individual involves the income and
wealth available to the individual to pay for services. Financing also
includes the effective price of health care which is determined by the
individual’s health insurance status and cost-sharing requirements.
Organization
Organization of health services for the individual describes whether or
not the individual has a regular source of care and the nature of that
source (private doctor, community clinic, or emergency room).
Organizational factors also include means of transportation, travel time
to the health services and waiting time for healthcare.
- Source of care
- Means of transportation
- Travel time to health services
- Waiting time for healthcare
3. Need or conditions that laypeople or healthcare providers recognize as
requiring medical treatment (need factors).
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 Contextual factors
At the contextual level, the need factors include the environmental need
characteristics and the population health indices.
Environmental need characteristics
Environmental need characteristics include health-related measures of
the physical environment, among them the quality of housing, water,
and air. Other measures suggesting how healthy the environment might
be are injury or death rate, such as rate of occupational injury and
disease and related deaths, as well as death rates from motor vehicle
accidents, homicides, and firearms.
- the quality of housing
- water
- air
- injury or death rate
Population health indices
Population health indices are overall indicators of community health,
including epidemiological indicators of mortality, morbidity, and
disability.
- Mortality
- Morbidity
- Disability
 Individual factors
At the individual level, the need factors differentiated between the
perceived need for health services (i.e., how people view and
experience their general health, functional state and illness symptoms)
and evaluated need (i.e., professional assessments and objective
measurements of patient’s health status and need for medical care).
The perceived need for health services
- how people view and experience their general health
- functional state
- illness symptoms
Evaluated need
Several
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Table 1 Contextual and individual determinant factors according to Andersen et al.

(2013) behavioral model of health services use.
Contextual Individual
Predisposing Demographic: age, gender, and Demographic: sex, age, and
marital status composition. genetic susceptibility
Social: educational level, ethnic and Social: education, occupation,
racial composition, measures of ethnicity, social relationships,
spatial segregation, employment and health beliefs.
level, and crime rate.
Enabling Health policies Financing: income and
Financing: per capita community wealth, health insurance status
income and wealth, the relative and cost-sharing
price of medical care and other requirements.
goods and services, the methods of Organization: private doctor,
compensating providers, per capita community clinic, or
expenditures for health services and emergency room, means of
health insurance coverage rates. transportation, travel time to
the health services and waiting
time for healthcare
Need Environmental: the quality of The perceived need: how
housing, water, and air, people view and experience
occupational injury and disease and their general health, functional
related deaths, death rates from state and illness symptoms
motor vehicle accidents, homicides, Evaluated need: professional
and firearms. assessments and objective
Population health indices: measurements of patient’s
epidemiological indicators of health status and need for
mortality, morbidity, and disability medical care

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