Access in health services research: The battle of the
frameworks
Thomas C. Ricketts, PhD
Laurie J. Goldsmith, MSc
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 health-
care 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 indi-
viduals and families to learn and modify their behav-
ior. 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 under-
stand 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.
A
ccess to health care has been the subject of much
study and there are multiple theories of how access
is structured or works.1,2 Those theories or frame-
works have not often been compared and the unity of
the thought behind them has not been much explored. A
review of access theory as it applies to nursing has
appeared; Racher and Vollman emphasized how access
as a concept was “nebulous and obscure” to most of the
public as well as policymakers and practitioners.3 The
empirical research that has been driven by these frame-
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, On-
tario, Canada.
Reprint requests: Thomas C. Ricketts, PhD, Professor of Health Policy
and Administration, School of Public Health, University of North
Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services
Research, Campus Box 7590, Chapel Hill, NC 27599-7590.
E-mail: tom_ricketts@unc.edu
Nurs Outlook 2005;53:274-280.
0029-6554/05/$–see front matter
Copyright © 2005 Mosby, Inc. All rights reserved.
doi:10.1016/j.outlook.2005.06.007
274 V O L U M E 5 3 ● N U M B E R 6 N U R S I N G
works often suffers from a similar failure to consider
the full breadth of what might constitute “access” and
often ignores the importance of time and experience
and the feedback loops that exist in any access system.
This article reviews the development of the leading
theories of access and their critical elements and argues
that reconciling them is a priority issue for research.
Policy-oriented research on access should give greater
consideration to processes of change and adaptation for
individuals and populations as well as for systems and
policies.
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 Utiliza-
tion 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 “more of a political
than an operational idea” but that it had “for some time
been an expressed or at least implicit goal of health
policy.”5 That description of the place of access in
policy continues to hold and, given the general accep-
tance of the Andersen, Aday, Newman framework for
access, the concept has taken hold in research as an
organizing framework which is often used to influence
policy making.
The key thing that Andersen and his colleagues
noted was that earlier concepts of use of health care
focused on 2 major alternative dimensions: the charac-
teristics of the population versus the characteristics of
the delivery system. They also noted that it was the use
of service and outcomes of the use process that could be
used to measure access. They expanded this structure to
identify 5 components: (1) health policy, (2) character-
istics of the health delivery system, (3) characteristics
of the population at risk, (4) utilization of health
services, and (5) consumer satisfaction as representative
of a “framework” for the study of access. These
components were labeled “predisposing” (generally
characteristics of individuals) or “enabling” (system or
structural characteristics). The biological imbalance of
O U T L O O K
The battle of the frameworks
He alth care
Predisposing
S y s te m Need
C ha r ac t e ri s t ic s
Enabling
Exte r nal
R esourc e s
E nvir on me nt
Figure 1. The Andersen Model of Access.
individuals was termed “need” and was also considered
an important component of the core conceptualization.
The overall framework included causal links and paths
between and among the elements that led to an outcome
of “appropriate utilization.” This more or less linear
flow was a bit at odds with Andersen’s original con-
ceptualization of access as functioning in a more
cybernetic fashion, with individuals and systems “learn-
ing” from prior attempts at use or assessment of needs.
The early users of this access concept attempted to
create global indicators of access that focused on both
process and outcomes. The process indicators were
what have become the “usual” measures of having a
“regular source of care”; the travel time to care; ability
to get an appointment in a reasonable time; and in-
office waiting time. These have persisted as access
measures and are regularly included in national surveys
fielded by the Centers for Disease Control and Preven-
tion (CDC) in their Behavioral Risk Factor Surveillance
Survey (BRFSS)6,7; by the Agency for Healthcare
Research and Quality’s (AHRQ) Medical Expenditure
Panel Survey (MEPS),8 and the Center for Studying
Health System Change and their Community Tracking
Survey (CTS).9,10
The development of outcome measures by Andersen
and colleagues focused on utilization and, later, con-
sumer satisfaction as outcome measures. Their empha-
sis on use was supported by their reference to Donabe-
dian: “The proof of access is use of service, not simply
the presence of a facility.”11 More specifically, they felt
“appropriate” utilization was a key indicator of access.
Based on this logic, 2 ratios were proposed: the Symp-
toms-Response-Ratio (SRR), and the Use-Disability-
Ratio (UDR).12 These ratios were used in large evalu-
ations of programs intended to expand access to
primary care.
Andersen, himself, “revisited” this model of access
20 years after its original appearance and re-empha-
sized the role of feedback loops in the system.2 In the
1995 version, the “phase 4” model proposed by
Andersen (Figure 1), the outcomes are fed back to the
core access process that bundles predisposing charac-
teristics, enabling resources and need together. They
combine to then determine health behavior (use and
Ricketts and Goldsmith
P e r c ei v e d
Personal
Health Status
Health
Practices
Evaluated
Health Status Figure 2. Penchansky’s Elements of Access.
Use of
Health
Con sume r
Se r vic e s
Satisfaction
personal health practices), and that behavior feeds back
onto that central process core.
Aday also came back to the 1968 model to describe
the structure of health services research as a mechanism
for assessing the efficiency, effectiveness and equity of
health care.13,14 The model used to describe the process
was derived from the access framework and, in its first
iteration in 1998, included a general outcome measure
of “health” status for individuals and communities. In
the 2004 edition, health status was viewed more as a
central characteristic of populations that depended on a
web of influences. The value of using health status as an
outcome was reiterated in an empirical study of safety-
net ambulatory care services on a low-income, urban
population.15 The use of the Andersen framework in
that study was supported by a commentary that empha-
sized how it could be used to structure an assessment of
“contextual” factors.16 This extended related work that
focused on community characteristics as an important
element in assuring access and which supported the
need to measure policy effects at the community level
in order to understand how well systems can support or
ensure access.17
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 the providers of health care and the users of
care; (3) accommodation describes the organization and
content of the healthcare system as it relates to the ease
with which people can use care (clinic hours, waiting
time, and length of waiting time for an appointment);
(4) affordability is the financial ability of the population
to use the care provided by the system and the percep-
tion of value on the part of patients; and (5) acceptabil-
ity, which represents the attitudes of the users of health
care toward the providers, and vice versa. Subse-
quently, Penchansky and colleagues did use this con-
cept in empirical studies.20
Practical Applications of Access Theories
A practical application of the “fit” concept was
proposed by Taylor to underpin the development of
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The battle of the frameworks
Figure 3. Access as “FIT” among Resources, Need, and
Demand. Reprinted with permissions from PAHO Scien-
tific Publication.
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) designa-
tions that are used by the federal government to allocate
resources for safety-net care.22 The “fit” concept essen-
tially suggests that there are recursive interrelationships
between resources, needs, and demands that can be
measured. This structure is illustrated in Figure 3.
Julio Frenk extended the work of Penchansky and
Thomas crediting Donbedian for the idea, to suggest
that “fit” was a process of adjustment between the
population and the health care delivery system.23
Frenk also noted the internal problem of using terms
which have not been clearly defined but are used
interchangeably (access, accessibility, availability).
Frenk tried to clear this up by organizing a series of
“domains” for access. Frenk sketched a narrow,
intermediate and broad domain for the consideration
of the accessibility concept, shown in Figure 4. Frenk
proposed that accessibility is a term to be used
strictly in the narrow domain to describe a popula-
tion’s ability to receive care once it is needed and
desired. Frenk defined several other concepts that are
important in understanding his use of the term
“accessibility.” Availability refers to the existence of
health care resources while taking into account their
productivity, or ability to produce healthcare ser-
vices. Accessibility describes the possibility of a
person receiving care that it is needed. Resistance,
which is important in understanding the difference
Need f o r c a r e Des i r e f o r c a r e S ea r c h f o r c a r e
Availability
(Intermediate Domain)
Access
(Broad Domain)
Figure 4. Frenk’s Domains of Access, Availability, and
Accessibility.
276 V O L U M E 5 3 ● N
Ricketts and Goldsmith
between availability and accessibility, is defined as
“the set of obstacles which arise from health re-
sources that stand in the way of seeking and obtain-
ing care.” Accessibility, availability, and resistance
are all terms which describe the health care delivery
system, while access is reserved for a description of
the population’s ability to obtain care if they need
and want it. Frenk offers the term “utilization power”
(in contrast to purchasing power in an economic
sense) as a synonym of access to avoid further
confusion over the meaning of the term “access.” To
Frenk, then, access is the ability of a person to utilize
health care given a need and/or desire to obtain it,
while accessibility is really the degree to which a
person needing and seeking care actually receives
care.
The Institute of Medicine (IOM) published a study of
access to health care in America with a focus on
indicators to track changes in access over time.1 The
IOM carefully defined access as “the timely use of
personal health services to achieve the best possible
outcome.” This definition repeats the emphasis on
utilization but focuses on the individual patient and
rates developed from individual encounters in the med-
ical care system. The tight link drawn by the IOM
between system characteristics and appropriate use
reflect more of the interactive and cyclical processes
described in the “fit” concept that the more linear
Andersen framework.
However, it is the Andersen-inspired models and
frameworks that have been used more often to guide
research and evaluation studies on access than the “fit”
approaches of Penchansky and Frenk and others. A
special issue of Health Services Research, published in
1998, summarized the concept of access and empha-
sized the Andersen framework and how it had been
used in studies. In that issue, Gold reviewed the
development of the concept and its relationship to
policy initiatives24 and Eden described how access
measures are operationalized in commonly used survey
data.25 That review illustrates the breadth of the appli-
cation of the Andersen framework.
Eden’s review described 7 major “access topics” that
were covered in the major population-based surveys:
The National Health Interview Survey (NHIS), the
Medical Expenditure Panel Survey (MEPS), the Medi-
care Current Beneficiary Survey (MCBS), the Medicare
Initiation of care CONTINUITY
Managed Care Access Survey (MMCAS), the Con-
sumer Assessment of Health Plans (CAHPS), the Com-
Accessibility munity Tracking Study Household Survey (CTS), Get-
(Narrow Domain) ting Behind the Numbers survey (GBN), National
Survey of America’s Families (NSAF), and the Survey
of Family Health Experiences (SFHE). Individual indi-
cators were provided under each for a total of 36
discrete variables. The topics and the indicators are
summarized in Figure 5.
U M B E R 6 N U R S I N G O U T L O O K
The battle of the frameworks
Data from Eden (1998)
Figure 5. Topics and Indicators of Access in Major
Population-based Surveys.
These indicators represent a “core” set of mea-
sures of access which can allow populations to be
compared. However, indicators such as “reason for
hospital stay” can be a complex index in itself. There
are other examples of complexity that are included in
all the access frameworks. The concept of prevent-
able hospitalizations, for example, has often been
suggested as an indicator of access to primary
care.1,26-28 The logic behind the identification of
ambulatory care sensitive condition hospitalizations
or preventable hospitalizations as indicators of ac-
cess system failure is complex and probabilistic.
Nevertheless, rates of preventable hospitalizations
have become common in assessments of health care
delivery systems and are often interpreted as indica-
tors of the quality of primary care available to
populations as well as their access to primary care. In
this instance, access has become a component of
quality, potentially reducing the salience of access.
The various outcome measures or indicators of
access have not been subjected to a careful study of
their interaction. Although most large-scale studies
include nearly all elements of access described in the
figure above, they are often reported in the scientific
literature with a focus on a single aspect such as
“usual source of care,”29 or which focus on a general
assessment of access in relation to costs30 or to
system structure.31 There is evidence that certain
aspects of any of the proposed access frameworks or
models have much less influence on outcomes. For
example, local supply of practitioners does not cor-
relate highly with use of services or satisfaction with
care,32,33 and the role of “usual source of care” is not
significant in affecting use of services.34 What has
been shown to be more important is insurance cov-
erage, race and ethnicity, and income.35,36
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Ricketts and Goldsmith
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 practitioners to
population, and organizational characteristics such as
staffing, hours, or physical amenities. In reality, people
have many opportunities to react to needs or perceived
needs, and their reaction depends largely on how they
anticipate the system will react to them, how much they
trust the system, and how much benefit they feel they
will derive from using health care.37 This process
depends a great deal on how people perceive the
healthcare system and healthcare itself. Studies of
attitudes toward the health care systems and its effects
of use have not been numerous although this is seen as
an important factor in the process of care.
Understanding how and when a person seeks to use
healthcare services and when that process starts and
ends can shed some light on how well access models
and frameworks can be applied in real-world policy-
making or management. There are 3 types of events that
can activate the access process: seeking screening,
becoming ill and aware of the illness, or becoming
injured or suffering an illness that others can detect. The
reactions to these conditions or events can be such that
the subsequent step taken by the patient is either
reassuring and builds confidence for future use, or is
negative and creates resistance to further use or causes
the person to seek alternative use. The satisfaction of
the person with the care that is given may actually be
independent of that process and determined by their
predisposing outlook on the possibilities they consid-
ered when they chose to seek care. They could be happy
with the care given and its results but are unlikely to
return or to have learned anything about the system. Or,
they could be unhappy and unsatisfied but have learned
how to negotiate the system and are more likely to
return. That outcome may be more positive in its
eventual effects than a report of “satisfaction” with care
if the patient is able to make a more informed choice.
This process has been outlined in terms of the respect
shown to a person; Blanchard and Lurie demonstrated
that persons who were shown disrespect were more
likely to avoid subsequent necessary care-seeking.38
Attitude toward the caregiver or care system by the
patient is also important in the choice to access or use
health care.39,40 Analysis of the NMES data in the
studies by Fiscella and colleagues found that, after
controlling for sociodemographic traits, persons with
/ D E C E M B E R N U R S I N G O U T L O O K 277
The battle of the frameworks
higher levels of skepticism were less likely to use
appropriate services and skepticism was associated with
higher mortality. A study of the interaction of patients
with primary care physicians found that the develop-
ment of trust had important effects on continuity of
care.41 Another study found that trust was a key
predictor in whether a patient would choose to leave a
primary care practice in a managed care system.42
The process of care-seeking and resolution of needs
involves interactions with practitioners and institutions
that may or may not persist. Practitioners often move or
change the content of their practice, and institutions and
organizations constantly change their scope and their
locations; the places where people go to seek and
receive care regularly appear and disappear, especially
in fast growing or contracting communities. There is
little known about this structural transition in the
system. There are few studies of transitions and their
effects on how and whether people receive appropriate
care. An analysis of the Community Tracking House-
hold Survey data found that change in “usual source of
care” was associated with greater unmet needs and
lower satisfaction with care, but those reporting a
change were more likely to report a physician visit than
those without a change.34
The role of agents in this process, whether they be
physicians, nurses, family members or others, is not all
that well understood in a framework of access. For
example, in mammography screening, there is some
research that looks at the simultaneous input of physi-
cians and patients on whether or not to get screened43
and the role of the physician appears more crucial than
others in the process. Andersen initially focused on
families and their life cycles as the context in which to
examine access to and use of healthcare services44; this
inclusion of a potential agency structure does not
appear to have been pursued in subsequent research
using the framework.
This more dynamic picture of the system of access or
utilization was considered in Andersen’s original work,
where he focused more on the behavioral aspects of the
process and how behavior was affected by learning;
“Theoretically, use of health services can be viewed
simply as another form of human behavior.”44 He later
re-emphasized the importance of learning in the frame-
work of access, where the “. . .outcome, in turn, affects
subsequent predisposing factors and perceived need for
services as well as health behavior.”2 This would imply
that much more attention needs to be paid to use of care
over time.
The research that has been done that formally con-
siders the temporal aspects of access has generally
fallen under the rubric of “continuity of care.” Conti-
nuity in primary care is usually described as repeat
visits to the same practitioner or practice or some
formal attempt to follow-up on care.45,46 Rarely, how-
ever, are there studies of how people change as a result
278 V O L U M E 5 3 ● N U M B E R 6 N U R S I N G
Ricketts and Goldsmith
of their use of services (a temporal, experiential pro-
cess) and how different components or elements of that
system differentially affect use and satisfaction (a
process that speaks to the transition of patients through
the system from one element to the next). The changes
that people undergo as a result of using health services,
or seeking to use them, should be an important, if not
central, aspect of an access theory.
The importance of the feedback of experience and its
effects on outcomes has recently been emphasized as a
weak point in systems of care.47 This is seen by the
nursing profession as the challenge to managing the
“critical pathway” for patients.48 This notion of a
critical pathway does suggest that there are models for
attending to important processes within frameworks
that describe the access process. Guidance for the
management of chronic care has suggested that coordi-
nation of services may help with temporal changes in
patient needs,49 but there is no apparent structure to
guide the development of attitude and trust among
patients. It might be said that efforts to build “patient
literacy” and competency as activated consumers of
health care may be useful points of view in developing
a comprehensive theory or framework for access that
considers patient learning as a key element.50
The Problem of Non-Use
Evaluating the performance of any health care deliv-
ery system intended to increase or guarantee access
should include a measure of non-use as much as actual
utilization. In surveys of populations, people are often
asked whether they have delayed or simply not gotten
care due to some barrier factor such as inability to pay
or distance to a provider. These measures of non-use are
assigned to the population rather than to a particular
system or location of care, rarely are they correlated
and, if there is some connection drawn, it is usually to
identify problems in the community rather than to
assess the performance of a safety net organization.
Non-use is generally not well understood. Delay in
care may be due to myriad short-term conditions and
decisions that are a function of how an individual
interacts with their environment. Likewise, there are
processes internal to the individual that might cause a
person to deny pain or ignore symptoms. Care-seeking
also involves a wide range of agents and intermediaries
whose jobs may be to fiscally “gate-keep” and control
utilization. There is also the process of eligibility
determination which poses a barrier for use to many
people in itself and often results in a patient being
denied care or the patient being frustrated and abandon-
ing their search for care. There is evidence that there are
active attempts to deter patients from seeking care by
arbitrary denial of benefits or referrals, or denial of care,
or deflection of the patient as a part of risk-avoidance or
de-marketing.51
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The battle of the frameworks
Reconciling Frameworks and Building a
Unified Field
In conceptualizations of access, the “dynamic axes”
of learning and adaptation may be present but, if they
are considered, they seldom are considered to be
important or dominant characteristics of the process.
We continue to hear how the healthcare system suffers
from a lack of coordination. The near universal agree-
ment that this is the case can be seen as abundant
evidence that we do not know how to integrate parts of
the system that change over time or across space.
Achieving a policy goal of equal, equitable or effective
access will require that we give primary consideration
to these dynamic parts of the process and pay less
attention to the more static elements of resources and
structure. This proposal is, in one sense, an application
of “systems” thinking, where the consequences of
decisions concerning structure and process are recog-
nized, measured against standards, then changes are
made and their effects are anticipated.52
For access frameworks to be useful for stimulating
change, they must relate to a functioning system that is
capable of learning. Research that identifies predispos-
ing factors as the most important determinants of
appropriate use of care—realized access—must recog-
nize that those factors are the hardest to change but that
the delivery system must be changed to accommodate
them. The same holds for enabling factors; insurance
status and income cannot easily be modified. However,
there are instances where processes that determine
eligibility can change the apparent insurance status of
individuals based on their predisposing characteristics.
This usually occurs when a person presents in the
system and the transition is motivated after the care-
giving process has already begun. An access framework
should be able to identify the intersections of predis-
posing and enabling components where the transforma-
tion from potential to realized access occurs. At these
points it may be possible to estimate the effects of
changes on access.
We have recognized that failures in quality are often
due to systemic failures, especially in communications
between elements of the health care delivery system.
The same can be said of access, but there is a special
place for access in the consideration of quality because
access, itself, is essentially a component of high quality
health care. By solving problems of access, which
means ensuring effective access, we are ensuring one
part of the metric of quality.
We must recognize that individuals have “careers” in
their interaction with the healthcare system, that they
move from neophytes to adepts in certain ways, or
never make that transition and suffer the consequences
(or the perceived benefits). In a similar sense, commu-
nities and populations exhibit patterns of learning and
adaptation. There is an ecology of access where the
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Ricketts and Goldsmith
desirable competencies that promote effective use of
services compete with competencies to avoid interac-
tions that negatively affect people’s self-worth, sense of
trust and community. In practical, policies, we should
also accept that individuals who use the healthcare
system seek value for the effort and money they put into
care-seeking. They function as patients and consumers
who learn from their experience and choose to reject or
accept the care they are provided, to the extent they
have a choice.
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