A
Framework
for
the
Study
of
Access
to
Medical
Care
by
Lu
Ann
Aday
and
Ronald
Andersen
Definitions
and
aspects
of
the
concept
of
access
to
medical
care
are
reviewed
and
integrated
into
a
framework
that
views
health
policy
as
designed
to
affect
characteristics
of
the
health
care
delivery
sys-
tem
and
of
the
population
at
risk
in
order
to
bring
about
changes
in
the
utilization
of
health
care
services
and
in
the
satisfaction
of
consumers
with
those
services.
Indicators
are
suggested
for
the
measurement
of
the
various
relevant
aspects
of
access,
with
the
system
and
population
descriptors
seen
as
process
indicators
and
utilization
and
satisfaction
as
outcome
indicators
in
a
theoretical
model
of
the
access
concept.
Health
care
policy
makers,
planners,
administrators,
and
medical
care
con-
sumers
are
increasingly
voicing
their
concern
that
access
to
the
medical
care
system
should
be
improved.
A
plethora
of
programs
have
been
launched
during
the
past
decade
with
the
expressed
objective
of
achieving
equity
of
access
to
medical
care
in
the
United
States.
Some
of
these
programs
are
directed
at
increasing
the
buying
power
or
medi-
cal
know-how
of
the
health
care
consumer-e.g.,
Medicaid,
Medicare,
national
health
insurance,
and
health
education
and
nutrition
programs.
Others
seek
to
improve
the
availability
or
organization
of
medical
manpower
and
facilities-
e.g.,
development
of
family
practice
as
a
specialty,
paramedical
training
pro-
grams,
and
HMOs.
All
these
programs
are
intended
in
some
way
to
gain
equal
access
to
the
medical
care
system
for
various
groups
in
the
population.
Just
what
the
concept
of
"access"
means,
however,
much
less
how
it
might
be
measured
and
what
methods
should
be
used
to
evaluate
it,
are
ill-defined.
Thus
far,
access
has
been
more
of
a
political
than
an
operational
idea.
It
has
for
some
time
been
an
ex-
pressed
or
at
least
implicit
goal
of
health
policy,
but
few
attempts
have
been
made
to
provide
systematic
conceptual
or
empirical
definitions
of
access
that
would
permit
policy
makers
and
consumers
to
actually
monitor
the
effectiveness
of
various
programs
in
meeting
that
goal.
Supported
under
a
grant
from
the
Robert
Wood
Johnson
Foundation
to
the
Center
for
Health
Administration
Studies,
University
of
Chicago,
to
develop
a
framework
and
indexes
of
access
to
medical
care.
Address
communications
and
requests
for
reprints
to
Lu
Ann
Aday,
Ph.D.,
Center
for
Health
Administration
Studies,
University
of
Chicago,
5720
Woodlawn
Avenue,
Chicago,
IL
60637.
Health
Services
Research
208
AccESS
TO
CARE
The
purpose
of
this
article
is,
through
a
review
of
efforts
to
conceptualize
and
operationalize
"access"
to
medical
care,
to
construct
an
integrated
theoreti-
cal
framework
for
the
study
of
access
and
to
suggest
how
empirical
indicators
of
the
concept
might
be
derived
from
it.
Concepts
of
Access
Two
main
themes
regarding
the
access
concept
appear
in
the
literature.
Some
researchers
tend
to
equate
access
with
characteristics
of
the
population
(family
income,
insurance
coverage,
attitudes
toward
medical
care)
or
of
the
delivery
system
(the
distribution
and
organization
of
manpower
and
facilities,
for
example).
Others
argue
that
access
can
best
be
evaluated
through
outcome
indicators
of
the
individual's
passage
through
the
system,
such
as
utilization
rates
or
satisfaction
scores.
These
measures,
they
argue,
permit
"external
valida-
tion"
of
the
importance
of
the
system
and
individual
characteristics.
"Access"
has
been
taken
as
synonymous
with
the
availability
of
financial
and
health
system
resources
in
an
area.
Thus
a
U.S.
Department
of
Agriculture
re-
port
on
the
problems
of
health
services
in
rural
areas
[1,
p.23]
concludes
that
"rural
and
urban
people
do
not
have
equal
access
to
health
services.
Rural
areas
are
deficient
in
professional
medical
personnel,
physical
health
care
facilities,
and
the
ability
to
afford
the
financial
costs
of
illness."
"Access"
may
also
mean
that
services
are
available
whenever
and
wherever
the
patient
needs
them
and
that
the
point
of
entry
to
the
system
is
well-defined
(Bodenheimer
[2];
Free-
born
and
Greenlick
[3]).
Two
descriptive
indexes
of
the
actual
organization
and
availability
of
ser-
vices
have
been
developed
by
M.
K.
Chen
in
unpublished
work
attempting
to
develop
quantitative
indicators
of
access.
One
index
is
the
weighted
sum
of
the
appointment
waiting
time,
travel
time,
waiting
room
time,
and
actual
processing
time
for
the
patients
in
a
given
medical
care
facility;
the
second
is
the
weighted
sum
of
the
difference
between
the
ideal
and
actual
number
of
services,
person-
nel,
and
equipment
in
a given
community.
The
access
of
medical
care
consumers
to
the
system
can
also
be
inhibited
by
a
decline
in
the
number
and
availability
of
primary
care
physicians
(Rogers
[4]).
Hospital
emergency
rooms
are
increasingly
becoming
centers
for
the
re-
ceipt
of
primary
care;
the
decline
of
primary
practitioners
due
to
specialization,
the
reluctance
of
physicians
to
make
house
calls,
and
the
unavailability
of
pri-
vate
physicians
in
the
urban
inner
city
have
been
cited
to
account
for
this
trend
(Gibson
et
al.
[5]).
Two
main
aspects
of
accessibility-socio-organizational
and
geographic-
can
also
be
distinguished
(Donabedian
[6]).
Socio-organizational
attributes
include
all
those
attributes
of
the
resources,
other
than
spatial
attributes,
that
either
facilitate
or
hinder
the
efforts
of
the
client
to
obtain
care.
These
would
include
such
things
as
the
sex
of
the
individual
medical
care
provider,
the
pro-
vider's
fee
scale
and
specialization,
and
the
like.
Geographic
accessibility,
on
the
other
hand,
refers
to
the
"friction
of
space"
that
is
a
function
of
the
time
and
Fall
1974
209
Aday
&
Andersen
physical
distance
that
must
be
traversed
to
get
care.
Thus
it
can
be
argued
that
accessibility
is
something
besides
the
mere
existence
or
availability
of
resources
at
any
given
time.
But
in
considering
the
factors
that
influence
the
utilization
of
health
services,
even
the
characteristics
of
services
and
resources
are
not
enough
to
account
for
entry
or
nonentry
to
the
system.
One
must
also
consider
the
potential
consum-
er's
"willingness"
to
seek
care
(Mechanic
[7]).
This
depends
on
his
attitudes
toward
and
knowledge
about
health
care
and
the
social
and
cultural
definitions
of
illness
he
has
learned.
Further,
the
problem
in
looking
at
access
in
terms
of
criteria
such
as
cost,
availability,
internal
economy
(waiting
time,
delays
and
interruptions
in
receiv-
ing
services,
etc.),
psychological
variables,
or
health
knowledge
is
that
in
them-
selves
these
do
not
tell
us
whether
people
who
want
to
get
into
the
system
actu-
ally
do
(Shortell
[8]).
Some
type
of external
validation
is
needed
to
indicate
whether
these
factors
make
a
difference
with
respect
to
getting
care,
such
as
examining
health
care
utilization
rates
of
specific
populations
over
time
with
reference
to
these
factors.
Somers,
in
a
discussion
of
the
health
care
crisis
in
the
United
States
[9,
p.
23],
points
out
that
A
considerable
part
of
the
problem
.
.
is
the
fact
that
so
many
people
still
lack
access
to
good
health
care.
For
many,
it
is
quantitatively
deficient.
For
many
more,
including
many
in
middle
and
upper
income
categories,
it is
qualitatively
lacking,
particularly
in
the
educational
influence
of
a
good
doctor-patient
relationship,
a
lack
that
probably
disturbs
the
patient
even
more
than
it
does
the
doctor.
Implicit
in
the
characterizations
of
access
as
properties
of
the
individual
or
the
system,
then,
is
the
assumption
that
the
quantity
and
quality
of
an
individual's
passage
through
the
medical
care
system
are
affected
by
these
factors.
Actual
access
rates
may
be
gauged
by
the
utilization
for
designated
popula-
tions
or
subgroups
(Fox
[10]).
Alternatively,
access
may
even
more
appropri-
ately
be
considered
in
the
context
of
whether
those
persons
actually
in
need
of
medical
care
receive
it.
Beck
[11],
for
example,
uses
a
"medical
iceberg"
notion
to
conceptualize
access.
The
iceberg
itself
represents
the
set
of
medical
needs
that
might
be
treated
by
a
physician.
The
proportion
of
the
iceberg
above
water
represents
those
needs
that
actually
receive
the
attention of
a
physician.
The
greater
the
portion
of
the
iceberg
above
water,
the
greater
the
access
to
care
of
the
group
represented
by
that
iceberg.
Freeborn
and
Greenlick
[3]
also
suggest
that
access
implies
that
people
in
the
population
at
risk
use
services
at
rates
"proportional
and
appropriate"
to
their
existing
need
for
care.
The
Bureau
of
Health
Services
Research
has
developed
a
need-based
empirical
indicator
of
the access
concept-the
use/disability
ratio
(number
of
physician
visits
per
100
days
of
disability
experienced)-that
explicitly
operationalizes
this
concept
of
access
as
the
use
of
services
by
the
population
at
risk
relative
to
their
expressed
need
for
care
[12].
Several
"continuity"
access
indexes-the
number
of
different
providers
seen
Health
Services
Research
210
ACCESS
TO
CARE
to
get
an
illness
episode
resolved,
the
number
of
visits
to
each
provider,
and
the
reason
or
source
of
referral
to
each
provider-have
been
introduced
(Shortell
[8]
)
that
reflect
both
the
volume
and
the
pattern
of
the
process
of
seeking
care.
Andersen
et
al.
[13]
report
subjective
consumer
evaluations
of
access
gauged
by
consumer
satisfaction
with
waiting
time
in
physicians'
offices,
availability
of
care
at
night
and
on
weekends,
and
ease
and
convenience
of
getting
a
physician.
Freeborn
and
Greenlick
[3]
maintain
that
satisfaction
with
the
accessibility
of
care
can
be
evaluated
by
patients'
attitudes
regarding
the
extent
to
which
ser-
vices
are
available
at
the
time
and
place
needed
and
whether
patients
perceived
a
change
in
their
condition
as
a
result
of
care.
Recent
concern
with
the
construction
of
social
indicators
of
the
"quality
of
life"
in
the
United
States
[14],
analogous
to
the
economic
indicators
of
the
na-
tion's
financial
well-being,
suggests
a
still
broader
approach
to
the
study
of
ac-
cess,
in
which
access
to
medical
care
might
be
considered
a
kind
of
social
indi-
cator
of
both
the
process
and
the
behavioral
and
subjective
outcomes
of
the
passage
of
individuals
through
the
medical
care
system.
To
understand
how
desired
outcomes
in
a
social
system
might
be
achieved,
Kenneth
Land
has
pointed
out
in
unpublished
work,
it
is
necessary
to
specify
the
expressed
objectives
or
endpoints
as
well
as
how
the
various
determinants
of
these
outcomes
relate
to
one
another
and
to
the
desired
endpoints.
Land
terms
the
outcomes
"output"-type
social
indicators
and
the
predictor
variables
"analytic"
social
indicators;
Roos
[15],
in
presenting
a
model
to
evaluate
pro-
gram
effectiveness,
calls
these
indicators
"impact"
and
"process"
evaluative
cri-
teria,
respectively.
The
focus
on
the
more
processual
(or
independent)
variables
versus
the
outcome-type
measures
in
any
effort
to
evaluate
access
itself
depends-in
the
language
of
evaluation
research-on
whether
one
is
primarily
concerned
with
the
goals
(or
outcomes)
of
the
delivery
system
itself
or
with
how
the
elements
of
the
system
relate
to
one
another
in
achieving
these
objectives-i.e.,
with
a
goal
attainment
or
with
a
systems-type
evaluation
model
[16].
But
in
policy
research,
as
Coleman
[17]
argues,
one
must
actually
consider
three
types
of
variables:
outcome
or
dependent
variables
and
two
types
of
inde-
pendent
variables-policy
variables,
which
can
be
or
have
been
amenable
to
policy
and
hence
may
be
considered
"mutable"
or
manipulable;
and
control
variables,
which
affect
the
outcome
variables
but
are
immutable
or
nonmanipu-
lable
in
that
they
cannot
be
changed
by
public
policy.
It
is
within
these
social
indicators
and
policy
perspectives
that
the
following
theoretical
framework
for
the
study
of
access
to
medical
care
is
presented.
Framework
for
the
Study
of
Access
A
basic
framework
for
the
study
of
access,
then,
may
be
conceptualized
as
proceeding
from
health
policy
objectives
through
the
characteristics
of
the
health
care
system
and
of
the
populations
at
risk
(inputs)
to
the
outcomes
or
outputs:
actual
utilization
of
health
care
services
and
consumer
satisfaction
with
these
Fall
1974
211
Aday
&
Andersen
Framework
for
the
study
of
access.
services.
The
interrelations
of
the
variables
involved,
discussed
in
greater
detail
below,
are
presented
graphically
in
the
accompanying
diagram.
Health
Policy
Access
has
been
most
often
considered
in
a
political
context.
"Improved
ac-
cess"
to
care
is
an
important
goal
of
much
of
health
policy.
Numerous
financing,
education,
and
manpower
and
health
care
reorganization
programs
have
been
introduced
with
this
objective
in
mind.
It
may
be
well,
then,
to
characterize
health
policy
as
the
starting
point
for
consideration
of
the
access
concept.
It
is
the
effect
of
health
policy
in
altering
access
to
medical
care
that
health
planners
and
policy
makers
are
often
concerned
with
evaluating.
Characteristics
of
the
Health
Care
Delivery
System
The
components
of
the
health
care
delivery
system
in
the
diagram
are,
in
general,
those
specified
by
Andersen
et
al.
[18]
for
the
health
services
system.
The
term
"delivery
system"
is
used
to
refer
more
specifically
to
those
arrange-
ments
for
the
potential
rendering
of
care
to
consumers.
Health
Services
Research
212
ACCESS
TO
CARE
The
delivery
system
is
characterized
by
two
main
elements-resources
and
organization.
Resources
are
the
labor
and
capital
devoted
to
health
care.
In-
cluded
would
be
health
personnel,
structures
in
which
health
care
and
educa-
tion
are
provided,
and
the
equipment
and
materials
used
in
providing
health
services.
The
resources
component
includes
both
the
volume
and
the
distribu-
tion
of
medical
resources
in
an
area.
Organization
describes
"what
the
system
does
with
its
resources.
It
refers
to
the
manner
in
which
medical
personnel
and
facilities
are
coordinated
and
con-
trolled
in
the
process
of
providing
medical
services"
[18].
The
components
of
organization
are
entry
and
structure.
Entry
refers
to
the
process
of
gaining
en-
trance
to
the
system
(travel
time,
waiting
time,
etc.).
(Andersen
et
al.
term
this
component
"access"
and
define
it
as
the
"means
through
which
the
patient
gains
entry
to
the
medical
care
system
and
continues
the
treatment
process.")
Struc-
ture,
the
second
component
of
organization,
concerns
"the
characteristics
of
the
system
that
determine
what
happens
to
the
patient
following
entry
into
the
sys-
tem"
(whom
he
sees,
how
he
is
treated).
The
characteristics
of
the
delivery
system
are
aggregate,
structural
proper-
ties.
The
system
or
a
particular
delivery
organization
is
the
unit
of
analysis,
rather
than
the
individual.
The
resources
and
organization
of
the
system,
as
defined
here,
embody
the
characterizations
of
access
as
a
system
property
that
appear
in
the
literature.
Characteristics
of
the
Population
at
Risk
The
characteristics
of
the
population
at
risk
are
the
predisposing,
enabling,
and
need
components
that
Andersen
and
Newman
[19]
describe
as
the
individ-
ual
determinants
of
utilization.
The
predisposing
component
includes
those
variables
that
describe
the
"pro-
pensity"
of
individuals to
use
services.
These
properties
exist
prior
to
the
onset
of
illness
episodes.
They
include
such
things
as
age,
sex,
race,
religion,
and
values
concerning
health
and
illness.
The
enabling
component
describes
the
"means"
individuals
have
available
to
them
for
the
use
of
services.
Both
resources
specific
to
the
individual
and
his
family
(e.g.,
income,
insurance
coverage)
and
attributes
of
the
community
in
which
the
individual
lives
(e.g.,
rural-urban
character,
region)
are
included
here.
The
need
component
refers
to
illness
level,
which
is
the
most
immediate
cause
of
health
service
use.
The
need
for
care
may
be
either
that
perceived
by
the
individual
or
that
evaluated
by
the
delivery
system.
In
considering
the
population
at
risk,
the
individual
rather
than
the
system
is
the
unit
of
analysis.
Similar
information
may
be
collected
to
describe
the
popu-
lation
at
risk
and
the
delivery
system
(e.g.,
rural-urban
residence,
solo
or
group
practice
plan,
waiting
time,
etc.),
but
the
measurement
and
interpretation
of
the
indicators
will
depend
on
whether
the
individual
or
the
delivery
system
is
the
object
of
study.
The
household
survey
is
the
best
method
for
collecting
data
on
the
population
at
risk.
When
a
community
or
a
specific
delivery
organization
is
Fall
1974
213
Aday
&
Andersen
the
object
of
concern,
census
figures,
manpower
data,
or
clinic
records
may
be
the
best
sources
of
information.
Implicit
in
the
access
concept
is
the
fact
that
certain
categories
of
people
have
more
or
less
"access"
to
medical
care
than
others.
The
characteristics
of
these
categories,
which
may
be
biological
or
social
"givens"
such
as
age,
sex,
or
race
among
the
predisposing
variables
or
some
of
the
community
characteristics
(e.g.,
urban-rural)
in
the
enabling
component,
serve
to
define
these
groups.
The
more
manipulable
"beliefs"
and
enabling
variables,
such
as
income
or
health
insurance
coverage,
are
characteristics
that
health
policy
seeks
to
change
in
order
to affect
these
groups'
access
to
care.
Utilization
of
Health
Care
Services
Implied
in
the
literature
on
the
access
concept
is
that
there
should
be
some
external
validation
of
the
effect
of
the
characterisitics
of
the
population
at
risk
and
of
the
delivery
system
on
people's
entry
(or
nonentry)
into
the
system.
The
level
and
pattern
of
the
population's
actual
utilization
of
the
system
is
one
measure
that
may
be
used
to
test
the
predictive
validity
of
these
system-
and
individual-based
access
indicators.
The
utilization
of
health
services
may
be
characterized
in
terms
of
its
type,
site,
purpose,
and
the
time
interval
involved.
The
type
of
utilization
refers
to
the
kind
of
service
received
and
who
pro-
vided
it:
hospital,
physician,
dentist,
pharmacist,
etc.
[20].
The
site
of
the
medical
care
encounter
refers
to
the
place
where
the
care
was
received:
physi-
cian's
office,
hospital
outpatient
department,
emergency
room,
etc.
The
purpose
of
a
visit
means
whether
it
was
for
preventive,
illness-related,
or
custodial
care.
Preventive
care
refers
to
efforts
to
stop
illness
before
it
begins-e.g.,
checkups
and
immunizations.
Illness-related
care
may
be
either
curative
("the
process
of
treatment
which
returns
an
individual
to
his
previous
state
of
functioning,"
most
often
referring
to
the
treatment
of
acute
illnesses)
or
that
which
provides
"stabi-
lization
for
long-term
irreversible
(chronic)
illness
such
as
heart
disease
or
dia-
betes."
Custodial
care
provides
for
the
personal
needs
of
the
patient
but
makes
no
effort
to
treat
his
underlying
illness;
this
type
of
care
is
provided
mainly
in
nursing
homes
and
homes
for
the
aged.
These
three
different
reasons
or
pur-
poses
for
care-preventive,
illness-related,
and
custodial-imply
distinctly
dif-
ferent
patterns
of
care
seeking,
and
it
is
obviously
important,
in
conceptualizing
access,
to
be
able
to
specify
the
kinds
of
demands
placed
on
the
system
by
those
who
would
seek
to
gain
entrance
to
it
[19].
The
time
interval
for
a
visit
may
be
expressed
in
terms
of
contact,
volume,
or
continuity
measures.
Contact
refers
to
whether
or
not
a
person
entered
the
medi-
cal
care
system
in
a
given
period
of
time;
in
describing
access,
policy
makers
are
concerned
with
who
gets
into
the
system
but
more
especially
with
those
who
do
not.
Volume
refers
to
the
number
of
contacts
and
revisits
in
a
given
time
inter-
val.
This
measure
reflects
who
gets
into
the
system
and
how
often
he
uses
it.
Continuity
refers
to
the
degree
of
linkage
and
coordination
of
medical
services
associated
with
a
particular
illness
experience
or
episode-important
because
if
Health
Services
Research
214
AccESS
TO
CARE
the
process
of
receiving
care
is
fragmented
and
poorly
organized,
people
may
be
considered
to
lack
appropriate
access
to
the
system.
The
continuity
dimension
of
the
utilization
variable
permits
these
"level
of
integration"
aspects
of
the
process
of
obtaining
medical
care
to
be
operationalized.
It
is
important
to
specify
the
relevant
dimension
of
utilization,
since
each
reflects
different
aspects
of
the
care-seeking
process.
Further,
the
impact
of
the
various
determinants
of
utilization
may
vary
depending
on
the
type,
site,
pur-
pose,
or
time
interval
analyzed.
Consumer
Satisfaction
Consumer
satisfaction
refers
to
the
attitudes
toward
the
medical
care
system
of
those
who
have
experienced
a
contact
with
it.
It
is
different
from
the
medical
beliefs
component
of
the
predisposing
variables
in
that
it
measures
users'
satis-
faction
with
the
quantity
or
quality
of
care
actually
received.
Medical
beliefs
refer
to
diffuse
sociocultural
predispositions
toward
health
and
medicine.
Con-
sumer
satisfaction,
however,
is
probably
best
evaluated
in
the
context
of
a
spe-
cific,
recent,
and
identifiable
episode
of
medical
care
seeking.
Dimensions
of
satisfaction
that
seem
relevant
to
consider
in
eliciting
subjective
perceptions
of
access
are
satisfaction
with
the
convenience
of
care,
its
coordination
and
cost,
the
courtesy
shown
by
providers,
information
given
to
the
patient
about
dealing
with
his
illness,
and
his
judgment
as
to
the
quality
of
the
care
he
received
[13].
Interrelation
of
Factors
The
hypothesized
relationships
among
the
components
to
be
considered
in
operationalizing
the
access
concept
are
indicated
by
the
arrows
in
the
diagram.
Thus
health
policy
may
be
seen
as
intended
to
directly
affect
characteristics
of
the
delivery
system,
as
by
increasing
the
supply
of
physicians
in
an
area,
or
pro-
grams
may
be
directed
to
changing
characteristics
of
the
population
at
risk
either
directly
(as
by
insurance
coverage
or
education)
or
through
the
delivery
system
(for
example,
facilities
may
be
relocated,
thereby
reducing
the
travel
time
to
care
for
area
residents).
Some
properties
of
the
population
at
risk
(mutable)
are
capable
of
being
altered
by
health
policy,
while
others,
the
immutable
ones,
are
not.
The
latter
characteristics
are
more
properly
considered
delineators
of
groups
for
whom
"access"
differs
than
descriptors
of
"access"
per
se.
The
delivery
system
in
turn
may
directly
affect
utilization
patterns
and
the
satisfaction
of
the
consumers
with
the
system.
These
effects
are
determined
by
the
structure
itself
and
not
necessarily
mediated
by
the
properties
of
potential
users.
For
example,
members
of
group
practice
plans
are
found
to
have
lower
hospitalization
rates
than
users
of
solo
fee-for-service
plans,
and
this
difference
seems
to
persist,
independent
of
the
characteristics
of
consumers.
These
direct
effects
of
system
properties
would
be
of
special
interest
in
system-level
analyses,
where
the
system
or
organization
itself,
rather
than
the
population
at
risk,
is
the
unit
of
concern
(for
example,
comparison
of
the
effects
of
different
health
care
delivery
models
on
enrollee
satisfaction
and
use).
Further,
the
system
may
also
impact
on
the
characteristics
of
the
population
Fall
1974
215
Aday
&
Andersen
and
thereby
indirectly
affect
its
utilization
of
services
and
the
consumer's
satis-
faction
with
care,
as
through
effective
public
health
education
programs.
On
the
other
hand,
the
characteristics
of
the
population
(attitudes
toward
medical
care,
income,
etc.)
may
directly
affect
use
and
satisfaction
indepen-
dent
of
system
properties.
These
are
the
relationships
reported
most
often
in
social
survey
research
on
the
utilization
of
services
by
a
population
of
poten-
tial
consumers.
The
double-headed
arrow
between
utilization
and
satisfaction
in
the
dia-
gram
suggests
a
sequence
in
which,
over
time,
the
utilization
of
services
is
apt
to
influence
a
consumer's
satisfaction
with
the
system,
and
in
turn,
the
satisfaction
or
dissatisfaction
he
experiences
from
this
encounter
influences
his
subsequent
use
of
services.
Indicators
of
Access
Research
on
the
utilization
of
health
services
suggests
important
manipulable
(policy)
dependent
variables
and
nonmanipulable
(control)
independent
vari-
ables
that
might
be
incorporated
into
a
framework
for
the
study
of
access
to
health
care.
As
pointed
out
by
Donabedian
and
others,
"access"
implies
entry
to
the
health
care
system.
Characteristics
of
the
system
and
of
the
population
may
influence
whether
entry
is
gained,
but
the
proof
of
access
per
se
is
not
the
avail-
ability
of
services
and
resources
but
whether
they
are
actually
utilized
by
the
people
who
need
them.
Health
services
utilization
research
provides
a
frame-
work
to
describe
those
factors
that
inhibit
or
facilitate
entrance
to
the
health
care
delivery
system
as
well
as
measurements
of
where,
how
often,
and
for
what
purposes
entry
is
gained
and
how
these
inhibiting
(or
facilitating)
factors
oper-
ate
to
affect
admittance.
Two
main
categories
of
social
indicators
of
the
access
concept
may
be
speci-
fied
on
the
basis
of
the
framework
presented:
process
and
outcome
indicators.
Within
this
framework,
an
extensive
review
of
the
literature
on
the
indexes
and
correlates
of
health
services
utilization
[21]
suggests
a
number
of
measures
on
which
empirical
data
are
available
or
can
be
collected
to
evaluate
access
to
medical
care
for
a
delivery
system
or
a
population
of
potential
consumers.
Process
Indicators
The
process
indicators,
reflecting
characteristics
of
the
delivery
system
and
of
the
population
at
risk
that
affect
whether
entry
to
the
system
is
gained
and
how
satisfied
consumers
are
with
it,
may
be
further
classified
according
to
their
degree
of
manipulability
by
health
policy.
Mutable
properties-those
which
can
be
altered,
in
the
short
run,
to
affect
the
utilization
of
or
satisfaction
with
care
(medical
manpower
distribution,
insurance
coverage,
etc.),
as
suggested
earlier,
may
be
more
meaningfully
considered
social
indicators
of
the
access
concept
than
the
immutable
properties,
which
serve
more
to
define
subgroups
or
target
populations
to
whom
health
policy
should
be
directed-e.g.,
age,
sex,
race,
and
residence
groups-for
whom
access
may
differ.
In
collecting
these
Health
Services
Research
216
ACCESS
TO
CARE
measures,
either
the
system
or
delivery
organization
or
the
individuals
in
the
population
at
risk
may
be
the
units
of
analysis.
Measures
of
the
volume
and
distribution
of
resources
might
be
derived
from
analysis
of
data
on,
for
instance,
number
of
physicians,
of
hospital
beds,
and
of
ambulances
per
unit
of
population
and
per
unit
of
geographic
area.
Under
organization,
measurable
variables
that
affect
initial
entry
into
the
system
might
include
mean
travel
time,
mean
appointment
waiting
time,
and
mean
office
wait-
ing
time
for
service
users,
as
well
as
mean
response
time
from
initial
call
for
emergency
service
to
ambulance
arrival.
Data
on
type
of
practice
(solo,
part-
nership,
group),
type
of
provider
(general
practitioner,
specialist,
ancillary
per-
sonnel),
method
of
patient
triage
(number
and
kinds
of
encounter
or
admission
forms,
type
of
medical
provider
seen
first),
and
hours
provider
or
facility
is
avail-
able
for
services
would
afford
measures
of
the
variables
of
organization
structure.
Survey
data
on
the
characteristics
of
the
population
at
risk
from
which
to
derive
indicators
would
include,
among
the
variables
amenable
to
change
by
health
policy
decisions,
such
predisposing
factors
as
general
health
care
beliefs
and
attitudes,
knowledge
and
sources
of
health
care
information,
and
stress
and
anxiety
about
health;
and
among
enabling
factors,
income
and
sources
of
in-
come,
insurance
coverage
(type
of
payer,
extent
of
coverage,
method
of
pay-
ment),
regular
source
of
care,
and
ease
of
getting
to
care
(mean
travel
time,
ap-
pointment
waiting
time,
office
waiting
time
for
given
medical
episode,
etc.).
Immutable
variables
in
these
two
categories
would
include
age,
sex,
marital
sta-
tus,
previous
health
behavior,
education,
race
or
ethnicity,
family
size
and
com-
position,
religion,
and
residential
mobility
as
well
as
region
of
the
country
and
residence
(rural-urban).
Data
on
perceived
need
for
care
might
comprise
per-
ceived
health
status,
symptoms
of
illness,
and
disability
(disability
days
and
chronic
activity
limitation);
while
indicators
of
evaluated
need
might
be
derived
from
such
data
as
physician-rated
urgency
of
presenting
condition,
diagnosis,
and
surgery.
Outcome
Indicators
The
outcome
indicators,
i.e.,
utilization
and
satisfaction,
reflect
the
end
prod-
ucts
of
health
policy
regarding
"access."
These
measures
include
both
objective
and
subjective
descriptors
of
the
population's
entry
to
and
passage
through
the
system.
Both
the
objective
and
the
subjective
outcome
measures
should
be
sen-
sitive
to
variations
in
the
properties
of
the
delivery
system
or
the population.
Measures
of
utilization,
as
indicated
in
the
framework
proposed,
would
in-
clude
specification
of
the
type
of
service
used
(e.g.,
hospital,
physician,
dentist,
emergency
care,
home
care),
the
site
at
which
care
was
rendered
(home,
office,
clinic,
inpatient
hospital,
etc.),
the
purpose
of
the
care
received
(preventive,
curative,
stabilizing,
custodial),
and
the
time
interval
involved
(percent
of
pop-
ulation
at
risk
who
did
and
did
not
see
a
physician
in
a
given
time
interval,
mean
number
of
visits
to
a
physician
in
a
given
time
interval),
and
continuity
as
mea-
sured
by
number
of
different
providers
contacted
for
a
given
episode
of
illness.
Measures
of
consumer
satisfaction
would
require
data
on
such
variables
as
the
Fall
1974
217
Aday
&
Andersen
percentage
of
the
study
population
who
were
satisfied
or
dissatisfied
with
con-
venience,
cost,
coordination,
courtesy,
medical
information,
and
overall
quality
of
care
and
the
percentage
who
wanted
medical
care
but
did not
get
it,
and
why.
Discussion
Empirical
indicators
of
the
access
concept
such
as
those
outlined
within
the
proposed
framework
might
focus
on
operationalizing
the
changes
that
take
place
in
the
delivery
system
(redistribution of
resources,
for
example)
or
in
the
study
population
(more
positive
attitudes
toward
preventive
health
practices
or
uni-
versal
insurance
coverage)
as
a
function
of
health
policy.
Alternatively,
the
measures
may
be
designed
to
describe
the
effects
of
policy
on
a
population's
utilization
of
services
and
on
their
satisfaction
with
the
care
they
receive.
It
is
perhaps
most
meaningful
to
consider
access
in
terms
of
whether
those
who
need
care get
into
the
system.
One
must
recognize,
however,
that
patients'
perceptions
and
practitioners'
evaluations
of
need
may
differ.
Further,
though
diverse
factors
may
influence
whether
an
individual
enters
the
medical
care
sys-
tem
initially,
the
organization
of
the
system
to
provide
care
and
the
consumer's
level
of
satisfaction
with
it
are
apt
to
determine
whether
he
continues
to
seek
services.
The
factors
that
affect
the
behavioral
(utilization)
and
subjective
(satisfaction)
outcomes
of
seeking
care
may
be
properties
of
the
individuals
themselves
or
of
the
medical
care
system
they
seek
to
enter.
Collecting
data
on
empirical
indicators
of
the
population's
access
to
medical
care
permits
differentials
in
the
availability
and
utilization
of
services
to
be
com-
puted
and
compared
for
different
subgroups
in
the
population.
Through
such
measures,
health
care
planners
and
policy
makers
can
make
better
informed
decisions
regarding
the
progress
of
the
health
care
system
toward
achieving
equity
of
access
for
those
most
in
need
of
its
services.
Currently,
there
are
a
variety
of
competing
proposals
before
Congress
to
pro-
vide
more
universal
health
insurance
coverage
to
the
population.
Most
of
these
plans
provide
some
mechanism
for
reducing
the
financial
burden
of
care.
They
vary
substantially,
however,
in
the
emphasis
placed
on
restructuring
the
deliv-
ery
system
itself
to
minimize
the
noneconomic-organizational
and
convenience-
of-entry-barriers
to
getting
services.
The
major
federal
programs
designed
to
equalize
access
to
medical
care
in
this
country,
so
far-Medicare
and
Medicaid-have
been
primarily
economic
in
approach.
In
essence,
they
have
attempted
to
reduce
the
proportion
of
a
fam-
ily's
or
individual's
total
economic
resources
that
must
be
spent
for
medical
care.
They
have
not,
however,
attempted
to
deal
directly
with
the
noneconomic
bar-
riers
to
obtaining
services-such
as
the
unavailability
of
primary
care
providers
in
certain
areas
or
the
inconvenience
of
transportation
and
the
lengthy
queues
often
encountered
when
trying
to
see
a
physician.
The
framework
introduced
here
suggests
the
value
of
considering
the
eco-
nomic
and
organizational
aspects
together,
in
any
efforts
to
evaluate
the
success
of
existing
health
policy
or
to
predict
the
potential
effectiveness
of
any
proposed
Health
Services
Research
218
AccEsS
TO
CARE
mechanisms
for
improving
access
to
and
increasing
satisfaction
with
the
health
delivery
system
in
the
United
States.
A
quotation
from
Avedis
Donabedian
[22,
p.
111]
aptly
summarizes
many
of
the
concerns
expressed
here
with
respect
to
the
conceptualization
and
measure-
ment
of
access:
The
proof
of
access
is
use
of
service,
not
simply
the
presence
of
a
facility.
Access
can,
accordingly,
be
measured
by
the
level
of
use
in
relation
to
"need."
One
should
recognize,
however,
that
clients
and
professionals
evaluate
"need"
differently.
Fur-
ther,
one
must
distinguish
two
components
in
use
of
service:
"initiation"
and
"con-
tinuation."
This
is
because
different
factors
influence
each,
though
any
one
factor
may
influence
both.
It
is
hardly
necessary
to
emphasize
that
barriers
to
access
are
not
only
financial
but
also
psychological,
informational,
social,
organizational,
spa-
tial,
temporal,
and
so
on.
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