Aday and Andersen (1974) developed a health services framework with which to examine access to medical treatment. Subsequent investigators modified this framework to assess access to services for alcohol and other drug use disorders (Hser et al., 1997; Weisner and Matzger, 2002; Weisner and Schmidt, 2001). The Aday and Andersen (1974) model addresses barriers and facilitators to access using three domains: (1) predisposing, (2) enabling, and (3) need. The predisposing domain consists of individual and social facilitators and barriers. Individual factors are intrinsic characteristics that describe the propensity of individuals to use health services. Social factors include marital status, family, and social networks; these are the social contextual characteristics that influence treatment seeking. In the substance abuse field, social networks are distinguished by whether they include individuals who are influences for not using versus using substances, as well as treatment seeking versus nonseeking. The enabling domain consists of structural/financial and environmental factors. Structural/financial facilitators are similar to those for general health care and include the supply and availability of treatment and the types of treatment and medications available. The need domain includes the severity of alcohol and other drug use and comorbid mental health or medical problems.

Barriers to Access in the Military

Barriers to accessing care for SUDs can be environmental, structural, social, and/or cultural. Environmental factors, such as pressure or mandates to enter treatment, sanctions, perceptions about the effectiveness of treatment, and stigma, are unique to the behavioral health field, particularly the addiction field, and more apparent in the military than the civilian sector. Civilian individuals frequently enter SUD treatment as a result of legal, welfare, employment, or family pressures or even mandates (Weisner, 1990). The same is true in the military; most service members are assessed for the need for treatment only after receiving sanctions for a substance-related incident (e.g., driving under the influence [DUI], assault) or other drug-related infraction (e.g., possession of an illegal substance) or upon having their substance use discovered through random drug testing. Thus, the most important structural factors in the military are (1) policies that treat alcohol misuse and other drug use as a discipline problem, (2) heavy reliance on deterrence (i.e., random drug testing) as the prevention approach, and (3) the lack of a standard medical protocol for early identification and brief intervention before a disciplinary infraction occurs.

While many predisposing and need-related facilitators of and barriers to treatment in the military are similar to those in the civilian sector, some structural and environmental barriers are unique to the military—notably, policies and practices that result in random drug testing as a primary



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