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Determinants of Province-Based Health Service Utilization According To Andersen' S Behavioral Model: A Population-Based Spatial Panel Modeling Study
Determinants of Province-Based Health Service Utilization According To Andersen' S Behavioral Model: A Population-Based Spatial Panel Modeling Study
Determinants of Province-Based Health Service Utilization According To Andersen' S Behavioral Model: A Population-Based Spatial Panel Modeling Study
and Ren BMC Public Health (2023) 23:985 BMC Public Health
https://doi.org/10.1186/s12889-023-15885-4
Abstract
Objective The Andersen’ s Behavioral Model was used to explore the impact of various factors on the utilization of
health services. The purpose of this study is to establish a provincial-level proxy framework for the utilization of health
services from a spatial perspective, based on the influencing factors of the Andersen’ s Behavioral Model.
Method Provincial-level health service utilization was estimated by the annual hospitalization rate of residents and
the average number of outpatient visits per year from China Statistical Yearbook 2010–2021. Exploring the relevant
influencing factors of health service utilization using the spatial panel Durbin model. Spatial spillover effects were
introduced to interpret the direct and indirect effects influenced by the proxy framework for predisposing, enabling,
and need factors on health services utilization.
Results From 2010 − 2020, the resident hospitalization rate increased from 6.39% ± 1.23% to 15.57% ± 2.61%, and
the average number of outpatient visits per year increased from 1.53 ± 0.86 to 5.30 ± 1.54 in China. For different
provinces, the utilization of health services is uneven. The results of the Durbin model show that locally influencing
factors were statistically significantly related to an increase in the resident hospitalization rate, including the propor-
tion of 65-year-olds, GDP per capita, percentage of medical insurance participants, and health resources index, while
statistically related to the average number of outpatient visits per year, including the illiteracy rate and GDP per capita.
Direct and indirect effects decomposition of resident hospitalization rate associated influencing factors demonstrated
that proportion of 65-year-olds, GDP per capita, percentage of medical insurance participants, and health resources
index not only affected local resident hospitalization rate but also exerted spatial spillover effects toward geographical
neighbors. The illiteracy rate and GDP per capita have significant local and neighbor impacts on the average number
of outpatient visits.
Conclusion Health services utilization was a variable varied by region and should be considered in a geographic
context with spatial attributes. From the spatial perspective, this study identified the local and neighbor impacts
of predisposing factors, enabling factors, and need factors that contributed to disparities in local health services
utilization.
Keywords Health Service Utilization, China, Andersen’ s Behavioral Model, Spatial spillover effects, Geography
*Correspondence:
Xiaohui Ren
renxiaohui@scu.edu.cn
Full list of author information is available at the end of the article
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Xin and Ren BMC Public Health (2023) 23:985 Page 2 of 14
Fig. 1 Proxy framework for health services utilization associated predisposing, enabling, and need factors
Xin and Ren BMC Public Health (2023) 23:985 Page 4 of 14
number of outpatient visits per year. Then, we calculated model, the health service utilization of a province will
descriptive statistics (observations, means, standard devia- be affected by the independent variables of surrounding
tions, min, max, and VIF) to describe predisposing factors, provinces.
enabling factors, need factors, and utilization of health ser- The SPEM fully considers the spatial correlation of
vice variables in 2010–2020. error terms. The SPEM is set as follows:
(3)
∑
UHS it = c + a1 PF it + a2 EF it + a3 NF it + 𝜇i + 𝜇t + 𝜑it 𝜑it = Wij 𝜑it + 𝜀it
(4)
∑ ∑
UHS it = c + UHS i(t−1) + 𝜌 Wij × UHS it + aX it + Wij × Xit 𝜃 + 𝜇i + 𝜇t + 𝜑it
(2)
∑
UHS it = c + 𝜌 Wij × UHS it + a1 PFit + a2 EF it + a3 NF it + 𝜇i + 𝜇t + 𝜑it
where W denotes the spatial weight matrix, we consider pitalization rate increased from 6.39% ± 1.23% to
the binary geographic unit matrix = 1 if i and j are neigh- 15.57% ± 2.61%. Figure 2 shows the top three prov-
bors and 0 otherwise. Under the setting of the SPAR inces with the largest increase in hospitalization rates
Xin and Ren BMC Public Health (2023) 23:985 Page 5 of 14
Table 2 Wald test and LR test result for the utilization of health service
Dependent variable Model Test Statistic P-value
were Chongqing (289.47%), Guizhou (265.74%), and higher utilization of health services were encircled by
Hunan (264.46%), while the three regions with the low- similar higher provinces, as shown in the pink part
est growth rates were Tianjin (41.29%), Beijing (45.06%) of the figure. From 2012 to 2020, Sichuan, Guizhou,
and Xinjiang (59.41%). Chongqing, Hunan, Hubei, and Guangxi areas are
The average number of outpatient visits per year High-High (H–H) positive spatial correlation in resi-
increased from 1.53 ± 0.86 times to 5.30 ± 1.54 times. dent hospitalization rate; 2) Low–High (L–H) negative
Figure 3 shows the top three provinces with the larg- spatial correlation: the provinces with lower utilization
est increase in the average number of visits were Anhui of health services were encircled by higher provinces,
(530.82%), Guizhou (505.29%), and Henan (443.06%), as shown in the red part of the figure.; 3) Low-Low
while the three regions with the lowest growth rates (L-L) positive spatial correlation: the provinces with
were Beijing (96.56%), Shanghai (116.53%) and Hei- lower utilization of health services were surrounded by
longjiang (131.69%). lower provinces, as shown in the blue part of the fig-
The spatial autocorrelation test was the first step ure.; 4.) High-Low (H–L) spatial correlation: the prov-
of spatial econometric analysis. The local Moran I inces with higher utilization of health services were
was used to describing spatial uncertainty and detect encompassed by lower ones, as shown in the dark blue
spatial clustering of the resident hospitalization rate part of the figure.
and the average number of outpatient visits during
2010 − 2020.The results of spatial clustering divided 31 Descriptive analysis using variables
provinces into four parts (Figs. 4 and 5):1) High-High Description of variables for 31 provinces was presented
(H–H) positive spatial correlation: the provinces with by mean, Std. Err, min value, max value, and VIF from
Xin and Ren BMC Public Health (2023) 23:985 Page 6 of 14
Fig. 2 Choropleth map of resident hospitalization rate in China in 2010, 2020 and its relative change during 2010 − 2020. a. Resident hospitalization
rate in 2010; b. The resident hospitalization rate in 2020; c. relative change (%) of resident hospitalization rate between 2010 and 2020
2010 to 2020 separately. All variables were included in the resident hospitalization rate decrease locally. For
the study because their VIF was less than 10. In the sub- spatially-lagged effects, a higher GDP per capita and a
sequent spatial model, the variables we used are summa- lower percentage of medical insurance participants had
rized and listed in Table 3. And the Shapiro–Wilk (SW) a promoting effect on the hospitalization rate in the sur-
test result shows that both the annual hospitalization rate rounding region. And the need factors do not affect the
of residents and the average number of outpatient visits resident hospitalization rate.
per year conform to normality. The results of the average number of outpatient visits by
dependent variables are also presented in Table 3. For the
Results of spatial panel analysis predisposing factor, considering spatially lagged effects,
Table 4 presents the estimated results of the SPDM for the region with a higher illiteracy rate, and a lower pro-
the dependent variable of resident hospitalization rate. portion of 65-year-olds may promote outpatient visits in
For the predisposing factor, locally, the population in adjacent proximity. For the enabling factor, GDP per cap-
provinces with a higher proportion of 65-year-olds and ita was associated with locally increased outpatient visits.
a lower illiteracy rate was associated with an increase For spatially-lagged effects, a higher GDP per capita and a
in the resident hospitalization rate. For spatially-lagged lower percentage of medical insurance participants had a
effects, namely, a lower proportion of 65-year-olds and promoting effect on outpatient visits in the surrounding
a higher illiteracy rate exerted auxo-action on resident region. However, life expectancy and perinatal mortality
hospitalization rate among adjacent proximity. Regard- do not affect the average number of outpatient visits.
ing enabling factors, GDP per capita, percentage of
medical insurance participants, and health resources Estimation of spatial spillovers
were associated with the resident hospitalization rate Based on SPDM estimation, we further conducted
increase, but the urbanization rate was associated with direct/indirect effects decomposition to interpret how
Xin and Ren BMC Public Health (2023) 23:985 Page 7 of 14
Fig. 3 Choropleth map of the average number of outpatients visits per year in China in 2010, and 2020 and its relative change during 2010 − 2020.
a. The average number of outpatients visits in 2010; b. The average number of outpatients visits in 2020; c. relative change (%) of the average
number of outpatients visits between 2010 and 2020
predisposing factors, enabling factors, and need factors 1.29, 2.50, and 3.79. Meanwhile, for every 1% increase
to influence the utilization of health service disparities in the percentage of medical insurance participants,
(Table 5). the direct effect of local hospitalization will increase
by 0.02%, the adjacent area will decrease by 0.06%, and
Spatial spillover effect of predisposing factors the total effect will decrease by 0.04%. For the health
For the proportion of the 65-year-old variable, the resources index rate, the direct, indirect, and total influ-
direct impact on the hospitalization rate was 0.34, and ence values of the resident hospitalization rate were 2.09,
the indirect impact was -0.83. And for the illiteracy rate, 1.60, and 3.69 respectively.
its impact on the hospitalization rate was impacted by
indirect effects (1.39) and total effects (1.34). Mean-
while, for the average number of outpatients visits, the Spatial spillover effect of need factors
impact of the proportion of 65-year-olds on it was also For perinatal mortality, its impact on the hospitaliza-
mainly reflected by the indirect effect (-0.49). For the tion rate was impacted by indirect effects (-0.89), and
illiteracy rate, the direct, indirect, and total influence total effects( -1.11).
values of the number of outpatient visits were 0.08, 0.68,
and 0.76 respectively.
Discussion
Spatial spillover effect of enabling factors By using data from China Statistical Yearbook (2010–
The direct, indirect, and total effects of the logarithm 2021), this study provided comprehensive estimates
of GDP per capita on the hospitalization rate were 1.93, of health services utilization at the provincial level
4.46, and 6.39, and the number of outpatient visits were in China. We found health services utilization was a
Xin and Ren BMC Public Health (2023) 23:985 Page 8 of 14
variable varied by region and should be considered in a southwest region, especially the hospitalization rate,
geographic context. is more pronounced and clustered. This may be mainly
because since 2010, the population gravity centers and
Spatial variations of health services utilization economic gravity centers have moved to the southwest
During 2010 − 2020, the overall health services utili- [35], and economic development and population move-
zation in China has risen steadily, which was closely ment have promoted the use of health services. At the
related to improvement in socioeconomic and medical same time, the utilization of health services in northern
conditions, new policy, health care reform and popu- is generally lower than that in southern China, and this
lation aging, and social health insurance system [32– difference may be due to the medical efficiency gradual
34]. The increase in the use of health services in the enhancement from north to south [36].
Xin and Ren BMC Public Health (2023) 23:985 Page 9 of 14
Fig. 5 Local Moran I of the average number of outpatient visits per year in China during 2010 − 2020
Health services utilization associated predisposing factors Nevertheless, due to the limitations of the physical con-
When other conditions remain unchanged, for every dition for the elderly, they are more inclined to choose
1% increase in the proportion of 65-year-olds, the local hospitals in their province. And illiteracy rate indirectly
hospitalization rate will increase by 0.34%, while the has a positive impact on the hospitalization rate. In
hospitalization rate in nearby areas will decrease by other words, the local illiteracy rate increased by 1%,
0.83%. Older adults have more medical needs [37, 38]. bringing a 1.39% growth in the adjacent hospitalization
Xin and Ren BMC Public Health (2023) 23:985 Page 10 of 14
Table 3 Descriptive statistics summarizing predisposing factors, enabling factors, need factors, and utilization of health service
variables in 2010–2020
Factors Variable Obs Mean Std Min Max VIF
Predisposing factor Sex ratio (SR, %) 186 105.03 3.61 96.91 118.62 1.38
Ethnic minority groups rate (EMGR, %) 186 32.98 29.39 0 97.45 1.79
The proportion of 65-year-olds (P65, %) 186 10.46 2.59 4.98 17.41 2.96
Illiteracy rate (IR, %) 186 5.67 5.90 0.89 41.12 2.44
Average household size (AHS) 186 2.99 0.41 2.06 4.23 2.45
Enabling factors Ln (GDP per capita) 186 10.72 0.49 9.27 12.01 3.80
Percentage of medical insurance participants (MIP, %) 186 59.58 30.65 3.16 99.99 2.36
Urbanization rate (UR, %) 186 57.48 13.42 22.67 89.30 8.37
Health resources index (HRI) 186 0.00 1.00 -2.06 4.41 2.80
Need factors Life Expectancy (LE) 186 76.20 3.10 68.17 83.67 7.51
Perinatal mortality (PM) 186 6.10 3.33 1.80 24.04 2.55
Health Services Utilization The annual hospitalization rate of residents(%) 186 13.43 4.44 3.82 22.4 NA
The average number of outpatient visits per year 186 4.68 2.12 0.69 10.72 NA
rate. The possible reason is that provinces with much which in turn allows residents to spend less on medi-
lower education people often have relatively backward cal treatment and better access to health services. But
economic development and medical level, so local resi- the impact of medical insurance participants on neigh-
dents are more likely to seek medical treatment in sur- boring provinces may be due to high health expenses
rounding provinces [39]. and the inconvenience of inter-provincial medical
For the utilization of outpatient services, the local insurance reimbursement in the past few decades,
proportion of 65-year-olds increases by 1%, reducing so residents are more inclined to use medical insur-
the outpatient visits in adjacent areas by 0.49. The main ance services in their province [14]. The results of the
reason is similar to the explanation of the hospitaliza- health resource index show that health resources can
tion rate. And, the illiteracy rate has a promoting effect promote the hospitalization rate in local and adja-
(direct, indirect, and total effect) on the average num- cent areas. In other words, provinces with rich health
ber of outpatient visits, possibly because local economic resources can not only provide adequate inpatient ser-
development and medical level. vices for their residents but also provide inpatient ser-
vices for neighboring provinces. The possible reason is
Health services utilization associated enabling factors that when residents need hospitalization services, the
Our study also shed light on the domain of enabling disease severity is often high, so they prefer to choose
factors that had the largest direct and indirect impacts hospitals with more abundant medical resources.
on provincial-level health service utilization. Under
other conditions, if the logarithm of GDP per capita
increases, the local, adjacent areas, and the total health Health services utilization associated Need factors
services utilization (both hospitalization rate and the In our study, we found that the local perinatal mortality
number of outpatient visits) will increase. The impact rate will increase by 1 unit, which can inhibit the hos-
of per capita GDP on hospitalization and the number pitalization rate in adjacent areas. The reason for the
of outpatient visits were consistent with previous stud- result may be that the perinatal mortality rate is largely
ies [40–42]. The local economic increase might pro- affected by socioeconomic status [43–46]. A higher per-
mote the development of the surrounding region and inatal mortality rate in this region means a poorer eco-
thus generate positive impacts on GDP, then subse- nomic situation, which will also have a negative impact
quently increase health services utilization in related on the surrounding economy, may bring to a higher per-
regions. The percentage of medical insurance partici- inatal mortality rate in the surrounding areas. The above
pants has a promoting effect on the local area, but an phenomenon also reflects their weak awareness of neo-
inhibiting effect on the adjacent areas and the total natal care and lack of awareness of seeking better medi-
impact. Higher insurance participation means that cal resources in other provinces. However, more specific
more residents are reimbursed for medical treatment, reasons need further study.
Xin and Ren BMC Public Health (2023) 23:985 Page 11 of 14
Table 4 The association between predisposing factors, enabling factors, need factors, and the utilization of health service
2010 − 2020: estimated from spatial panel data models
Variable Resident hospitalization rate The average number of
outpatients visits
PANEL SPDM PANEL SPDM
The influencing factors of the outpatient visits per evidence for the implementation of region-specific pol-
year varied not change with the influencing factors of icies to promote health services utilization and improve
the resident hospitalization rate, which also validated overall health in China.
that the association between the number of outpatient The current study has three limitations. First of
visits and the number of inpatient episodes was not the all, there may exist an ecological fallacy in this study,
same [47]. because this study can only explain how the influenc-
ing factors of health service utilization operate at the
provincial level, and cannot establish robust evidence
Strengths and limitations of causality. Second, the variables selected based on the
According to our knowledge, this paper is the first to predisposing factor, enabling factors, and need factors
study the utilization of provincial health services and in Andersen model may be incomplete, hence omitted
its influencing factors from a spatial perspective at variables and potential confounders were inevitable.
provincial level. By referring to the influencing fac- Third, due to the limitation of data acquisition, this
tors of Andersen Model, we established the framework study selected perinatal mortality as the demand factor,
for health services utilization. Our study may provide which has the defect of index selection.
Xin and Ren BMC Public Health (2023) 23:985 Page 12 of 14
Table 5 The association between predisposing factors, enabling factors, need factors, and the utilization of health service
2010 − 2020: estimated from spatial panel data models
Variable Direct Indirect Total
Conclusion Acknowledgements
Not applicable.
Our research found that there are differences in the
utilization of health services at the provincial level in Authors’ contributions
China, and the difference is mainly impacted by the Methodology, Y.X.; Software, Y.X.; Writing—original draft, Y.X.; Writing—review
&editing, X.R. All authors have read and agreed to the published version of the
predisposing factor (proportion of 65-year-olds and manuscript.
illiteracy rate) and enabling factors (GDP per capita,
medical insurance participants, and health resources). Funding
This research was funded by the project of the Science and Technology of
Improving equality of health service utilization is the Sichuan Province (Soft science project: Grant NO2022JDR0196).
basis for realizing health equity [48]. Moreover, justice
and equity are one of critical principles in Healthy China Availability of data and materials
Publicly available data were analyzed in this study. This data can be found
2030 [49]. The utilization of health services may interplay here: STATISTICAL YEARBOOK OF CHINA. (http://www.stats.gov.cn/tjsj./ndsj/).
between various factors. Thus, based on the results of this
article, we propose the following suggestions: 1) There are Declarations
differences in the utilization of health services among areas,
which should be formulated regional-specific strategies to Ethics approval and consent to participate
The data source of this study is provincial level data, so it does not involve
narrow the gap; 2) Policies on the use of health services ethical issues.
should be skewed towards the region with large propor- Not applicable.
tion of low-educated and older population; 3) The state has
Consent for publication
adjusted the reimbursement policy in different provinces, Not applicable.
so it is more convenient to improve the hospitalization rate
in adjacent areas. 4) Vigorously develop the regional econ- Competing interests
The authors declare no competing interests.
omy, improve the economic level of provinces.
Xin and Ren BMC Public Health (2023) 23:985 Page 13 of 14
Author details 22. Jaffee K, Shires D, Stroumsa D. Discrimination and Delayed Health Care
1
Department of Science and Technology, West China Hospital, Sichuan Univer- Among Transgender Women and Men. Med Care. 2016;54(11):1010–6.
sity, Chengdu, Sichuan, China. 2 West China School of Public Health and West 23. Goldston DB, Reboussin BA, Kancler C, et al. Rates and predictors
China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China. of aftercare services among formerly hospitalized adolescents: a
prospective naturalistic study. J Am Acad Child Adolesc Psychiatry.
Received: 2 November 2022 Accepted: 12 May 2023 2003;42(1):49–56.
24. Tareke AA, Mittiku YM, Tamiru AT, et al. Underutilization of the recom-
mended frequency of focused antenatal care services in northwest
ethiopia: using andersen’s healthcare service utilization model approach.
Clin Epidemiol Global Health. 2021;11:100746.
References 25. Kim HK, Lee M. Factors associated with health services utiliza-
1. World Health Organization. Health Equity. Available online: https://www. tion between the years 2010 and 2012 in korea: using andersen’s
who.int/health-topics/health-equity#tab=tab_1 behavioral model. Osong Public Health & Research Perspectives.
2. Braveman P. What are health disparities and health equity? We need to be 2016;7(1):18–25.
clear. Public Health Rep. 2014;129(Suppl 2):5–8. 26. Brandão D, Paúl C, Ribeiro O. Health care utilization in very advanced
3. Durey R. The Power of Human Rights for Women’s Health. Health Issues. ages: A study on predisposing, enabling and need factors. Arch Gerontol
2009;(101):21–3. https://search.informit.org/doi/10.3316/informit.65575 Geriatr. 2022;98:104561.
6825293987. 27. Kundu J, Bharadwaz MP, Kundu S. Bansod D W, The interregional disparity
4. Mao L, Nekorchuk D. Measuring spatial accessibility to healthcare in the choice of health care utilization among elderly in India. Clin Epide-
for populations with multiple transportation modes. Health Place. miol Global Health. 2021;13:100929.
2013;24:115–22. 28. Soares RR, Huang C, Boucher N, et al. Regional population mobility and
5. Rosano A, Loha CA, Falvo R, van der Zee J, Ricciardi W, Guasticchi G, outpatient retina visits in the united states during the covid-19 pan-
de Belvis AG. The relationship between avoidable hospitalization and demic. Retina. 2022;42(4):607–15.
accessibility to primary care: a systematic review. Eur J Public Health. 29. Fu L, Xu K, Liu F, Liang L, Wang Z. Regional Disparity and Patients Mobility:
2013;23(3):356–60. Benefits and Spillover Effects of the Spatial Network Structure of the
6. Linard C, Gilbert M, Snow RW, Noor AM, Tatem AJ. Population distribu- Health Services in China. Int J Environ Res Public Health. 2021;18:1096.
tion, settlement patterns and accessibility across Africa in 2010. PLoS 30. Li L, Zhou Q, Yin T, Ji Z, Zhang L. Does the Direct Settlement Policy of
One. 2012;7(2):e31743. Trans-Provincial Outpatient Expenses Aggravate the Siphoning Effect?
7. Glanz K, Lewis FM, Rimer BK. Health behavior and health education: An Empirical Study on Yangtze River Delta, China. Int J Environ Res Public
theory, research, and practice. San Francisco: Jossey Bass; 1990. https:// Health. 2021;18(19):10001.
www.med.upenn.edu/hbhe4/index.shtml. 31. Zeng L, Xu X, Zhang C, Chen L. Factors Influencing Long-Term Care
8. Jemal J, Hagos T, Fentie M, Zenebe GA. Utilization of health services and Service Needs among the Elderly Based on the Latest Anderson Model:
associated factors among fee waiver beneficiaries in Dawunt district, A Case Study from the Middle and Upper Reaches of the Yangtze River.
North Wollo zone. Ethiopia Public Health. 2022;205:110–5. Healthcare (Basel). 2019;7(4):157.
9. Dickman SL, Himmelstein DU, Woolhandler S. Inequality and the health- 32. Shryock HS, Siegel JS. The Methods and Materials of Demography. New
care system in the USA. Lancet. 2017;389(10077):1431–41. York: Academic Press; 1976.
10. Luo J, Zhang X, Jin C, Wang D. Inequality of access to health care 33. The Communist Party of China and Human Rights Protection—A 100-Year
among the urban elderly in northwestern China. Health Policy. Quest. China: The State Council Information Office of the People’s Repub-
2009;93(2–3):111–7. lic of China. [(Accessed on 1 Sept 2021)];2021 Available online: http://engli
11. Casey MM, Thiede Call K, Klingner JM. Are rural residents less likely to sh.scio.gov.cn/whitepapers/2021-06/24/content_77584416.htm
obtain recommended preventive healthcare services? Am J Prev Med. 34. Chinese Ministry of Health; Health expenditure in China 2000–2020.
2001;21:182–8. Beijing: publishing house of Peking Union Medical College; 2022. Avail-
12. Manuel JI. Racial/Ethnic and Gender Disparities in Health Care Use and able from: https://www.statista.com/statistics/279400/health-expenditur
Access. Health Serv Res. 2018;53(3):1407–29. https://doi.org/10.1111/ es-in-china/; [Accessed 2022. 07.28].
1475-6773.12705. (Epub 2017 May 8). 35. Yip W, Hsiao WC. The Chinese health system at a crossroads. Health Aff.
13. Denman L. Enhancing the accessibility of public mental health services 2008;27:460–8.
in Queensland to meet the needs of deaf people from an indigenous 36. L Longwu C Mingxing L Xinyue et al 2021 Changes pattern in the popula-
Australian or culturally and linguistically diverse background. Australas tion and economic gravity centers since the Reform and Opening up in
Psychiatry. 2007;15(Suppl 1):S85–9. China: The widening gaps between the South and North 310 127379
14. Shao S, Wang M, Jin G, et al. Analysis of health service utilization of 37. Mei K, Kou R, Bi Y, et al. A study of primary health care service efficiency
migrants in Beijing using Anderson health service utilization model. BMC and its spatial correlation in China. BMC Health Serv Res. 2023;23:247.
Health Serv Res. 2018;18:462. 38. Torpy JM, Lynm C, Glass RM. Frailty in older adults. JAMA. 2006;296:2280.
15. Lin W, Yin W, Yuan D. Factors associated with the utilization of commu- https://doi.org/10.1001/jama.296.18.2280.
nity-based health services among older adults in China-an empirical 39. Bähler C, Huber CA, Brüngger B, Reich O. Multimorbidity, health care uti-
study based on Anderson’s health behavior model. BMC Prim Care. lization and costs in an elderly community-dwelling population: a claims
2022;23(1):99. data based observational study. BMC Health Serv Res. 2015;22(15):23.
16. Wagstaff A, van Doorslaer E. Measuring and testing for inequity in the 40. Agasisti T, Bertoletti A. Higher education and economic growth: A
delivery of health care. J Hum Resour. 2000;35(4):716–33. longitudinal study of European regions 2000–2017. Socioecon Plann Sci.
17. Moreno C, Wykes T, Galderisi S, et al. How mental health care should 2022;81:100940.
change as a consequence of the COVID-19 pandemic. Lancet Psychiatry. 41. Mols RE, Bakos I, Christensen B, et al. Influence of multimorbidity and
2020;7(9):813–24. socioeconomic factors on long-term cross-sectional health care service
18. Suchman EA. Stages of illness and medical care. J Health Hum Behav. utilization in heart transplant recipients: A Danish cohort study. J Heart
1965;6(3):114–28. Lung Transplant. 2022;41(4):527–37.
19. Young JC. Non-use of physicians: methodological approaches, policy 42. Choi S. A comparative study on factors of social welfare service utiliza-
implications, and the utility of decision models. Soc Sci Med Part B Med tion between general and low-income group. Korean J Soc Welf Stud.
Anthropol. 1981;15(4):499–507. 2009;40:213–42.
20. Rosenstock IM, Strecher VJ, Becker MH. The health belief model and HIV 43. Soleimanvandiazar N, Mohaqeqi Kamal SH, Sajjadi H, et al. Determi-
risk behavior change. US: Springer; 1994. nants of Outpatient Health Service Utilization according to Andersen’s
21. Anderson JG. Health services utilization: framework and review. Health Behavioral Model: A Systematic Scoping Review. Iranian J Med Sci.
Serv Res. 1973;8(3):184–99. 2020;45:405–24.
Xin and Ren BMC Public Health (2023) 23:985 Page 14 of 14
44. Alderliesten ME, Stronks K, van Lith JM, et al. Ethnic differences in peri-
natal mortality A perinatal audit on the role of substandard care. Eur J
Obstet Gynecol Reprod Biol. 2007;138:164–70.
45. Fraiman YS, Barrero-Castillero A, Litt JS. Implications of racial/ethnic
perinatal health inequities on long-term neurodevelopmental outcomes
and health services utilization. Semin Perinatol. 2022;46(8):151660.
46. Devlieger H, Martens G, Bekaert A. Social inequalities in perinatal and
infant mortality in the northern region of Belgium (the Flanders). Eur J
Public Health. 2005;15:15–9.
47. Racape J, De Spiegelaere M, Alexander S, Dramaix M, Buekens P, Haelter-
man E. High perinatal mortality rate among immigrants in Brussels. Eur J
Public Health. 2010;20(5):536–42.
48. Pezzin LE, Fleishman JA. Is outpatient care associated with lower use of
inpatient and emergency care? An analysis of persons with HIV disease.
Acad Emerg Med. 2003;10(11):1228–38.
49. Zhu L, Peng M, Jiang L, et al. Inequality of opportunity in health service
utilization among middle-aged and elderly community-dwelling adults
in China. Arch Public Health. 2023;81:13.
50. Zhou M, Wang H, Zeng X, et al. Mortality, morbidity, and risk factors in
China and its provinces, 1990–2017: a systematic analysis for the Global
Burden of Disease Study 2017. Lancet. 2019;394(10204):1145–58.
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