Graduation Date

Spring 5-8-2021

Document Type


Degree Name

Doctor of Philosophy (PhD)



First Advisor

Kathryn Fiandt, Ph.D., APRN-NP, FAANP, FAAN


Utilizing healthcare services is a complex phenomenon in the United States. While system-level barriers and facilitators of care, along with individual consumer choices, are known to affect access and subsequent use of services, the interaction among the factors that lead to utilization remains unknown. Examining access and utilization of healthcare services using a consumer framework incorporating both access barriers and facilitators and consumer-level dimensions that affect choice in seeking care may inform access and utilization research. The purposes of this dissertation were 1) to explore the presence of facilitators and barriers to care in ambulatory healthcare locations for non-emergent care needs; 2) explore the role and prominence of consumer facilitators and barriers in appointment behavior in a chronic disease population; and 3) explore alterations to access employed by organizations serving a vulnerable population (rural) during the COVID-19 pandemic. The specific aims were 1) to evaluate how patient decisions to use healthcare for non-emergent needs are shaped by access to care barriers and facilitators in U.S. ambulatory healthcare locations; 2) to examine saliency of consumer-driven healthcare utilization concepts that influence appointment behavior among a chronic disease population; and 3) to assess adaptive access strategies and health outcomes in rural Nebraska, specifically as a result of the COVID-19 pandemic. An integrative review of the literature looking at health consumer choices in ambulatory care along with a secondary data analysis of appointment behavior among emerging adults with type 1 diabetes from an endocrinology clinic informed the background and theory development of the consumer model of utilization (CMU) presented in this dissertation. A cross-sectional descriptive study of rural healthcare professionals, informed by the CMU framework, identifying adaptive access strategies and examining associations between strategies utilized during the 2020 COVID-19 pandemic, community characteristics, and health outcomes of rural populations in a midwestern state were reported. Primary results from the integrative review suggest that utilization of ambulatory services is influenced by multiple, interconnected consumer-centric variables. Incorporating the consumer-based variables of the CMU; cost, comfort, convenience, capacity, and criticality, may provide insight into the understanding of access and the subsequent utilization of ambulatory services. Descriptive statistics and bivariate analysis were used for the rural COVID-19 survey and outcomes study. Alterations in access to increase comfort through safety were implemented by most organizations (91.3%), followed by convenience (81.3%), capacity (62.5%), cost (20%). Criticality was not measured. When looking at Q4-2020 in Nebraska, the height of the pandemic, rurality was significantly associated with fewer cases of COVID-19 (p=0.00) and greater numbers of death (p=0.02). The relative risk of death for rural residents compared to urban was 1.205 (95% CI 1.05 – 1.383). Associations between adaptive access strategies and COVID-19 outcomes were examined, but relationships were not observed.

Available for download on Thursday, April 20, 2023