Elsevier

Nursing Outlook

Volume 53, Issue 6, November–December 2005, Pages 274-280
Nursing Outlook

Article
Access in health services research: The battle of the frameworks

https://doi.org/10.1016/j.outlook.2005.06.007Get rights and content

Background

Access is an important concept in the study of the organization, financing and delivery of healthcare services. It is also an important political symbol and policy goal.

Purpose

This article reviews the major theoretical frameworks that have been used to support the study of access and measure the degree to which healthcare systems have met standards of access.

Method

The article uses a critical review of the major works of the leading theorists in the field of access studies.

Discussion

Theories of access accept that it is a dynamic process where there is the potential for individuals and families to learn and modify their behavior. That learning and adaptation is less often explored in empirical research of access to health care.

Conclusion

Researchers should consider the more dynamic aspects of access as they attempt to understand how to improve the health care delivery system. Access models can be used to direct the formulation of better health policy if they reflect real world processes.

Section snippets

Access as Use

There is one dominant and several lesser known theories of access. The most important and most often cited is what was originally called the “Behavioral Model of Health Services Use” developed by Ronald Andersen as part of his dissertation and subsequently published with John F. Newman as a study of “Societal and Individual Determinants of Medical Care Utilization in the United States”4 and with LuAnn Aday as a “Framework for the Study of Access to Medical Care.”5 Aday and Andersen called

Access as FIT

Roy Penchansky proposed an alternative approach to understanding access that focused on the interaction of key elements that determined use of services.18, 19 Penchansky suggested the concept of “fit” between the patient’s needs and the system’s ability to meet those needs. He suggested that this fit could be measured across 5 dimensions (Figure 2): (1) availability which is the volume of physician and other health care services; (2) accessibility, the spatial or geographic relationship between

Practical Applications of Access Theories

A practical application of the “fit” concept was proposed by Taylor to underpin the development of indices of underservice.21 This combined metric has been used in the development of proposals to modify the federal Health Professional Shortage Area (HPSA) and the Medically Underserved Area (MUA) designations that are used by the federal government to allocate resources for safety-net care.22 The “fit” concept essentially suggests that there are recursive interrelationships between resources,

The dimensions of time, anticipation and experience

In general, it is possible to say that much of the analysis of access has been done using cross-sectional analysis and the models that have been used to guide that study are relatively static. They tend to relate to discrete events where a person is in need of services, seeks them out and receives some form of care, advice, or therapy, and the outcome is measured. At the population level, it is relatively fixed variables that are considered, such as overall insurance coverage, ratio of

Thomas C. Ricketts is a Professor of Health Policy and Administration at the School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.

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    Thomas C. Ricketts is a Professor of Health Policy and Administration at the School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.

    Laurie J. Goldsmith is a Post-Doctoral Fellow at the Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada.

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