dnp scholarly project...

Running head: Are Rural Arkansans Interested in Telehealth as a Means to Improve Their

Access to Primary Care Services 1

Are Rural Arkansans Interested in Telehealth as a Means to Improve Their Access to Primary

Care Services?

Tiffany Wilkerson

Maryville University


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Table of Contents

Abstract………………………………………………………………………...4

Chapter I……………………………………………………………………….5

Introduction……………………………………………………………………5

Problem………………………………………………………………………..5

Background……………………………………………………………………6

Purpose/Aim………………………………………………………………..…6

Significance…………………………………………………………………...7

Support……………………………………………………………………..…8

Chapter II……………………………………………………………………..10

Search History ……………………….………………………………………10

Integrated Review of Literature…………………………..………………….10

Critique of Literature………………………………………………………...13

Theoretical Framework………………………………………………………16

Chapter III……………………………………………………………………18

Methodology…………………………………………………………………19

Needs Assessment……………………………………………………………20

Research Design/Interventions……………………………………………….20

Analysis Plan…………………………………………………………………22

Resources………………………………………………………………….….23

Budget…………………………………………………………………….…..24


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Timeline……………………………………………………………………….27

Ethics/Protection of Human Subjects………………………………………....27

Chapter IV………………………………………………………………….…28

Chapter V………………………………………………………………….….34

Conclusion ………………………………………………………………........36

References……………………………………………………………….……37

ABSTRACT. Objective: This study elicits the rural population’s interest, ideas, and concerns regarding telehealth as a means to improve access to primary care for rural Arkansans. Participants: 135 male and female respondents, 18-65 years of age, mixed-race, English-speaking, able to take an online survey, and residing outside of the city limits in


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Conway County, Arkansas. Methods: A concurrent, anonymous self-reported, cross-sectional survey using the Qualtrics survey system that respondents could take, at their own leisure, by typing a link to the survey; 10 closed-ended multiple-choice questions and two open-ended questions to elicit the rural population’s interest, ideas, and concerns regarding telehealth. Results: A total of 135 surveys; 93 complete. 32 did not meet criteria (26 due to not living outside of the city limits in Conway County, Arkansas and six due to age criteria, less than 18 or older than 65 years of age). 10 did not fully complete the survey. The Chi value was 8.766 with four degrees of freedom and a p value of .067. The Likelihood Ratio version of Chi’s p value was .041. With a larger sample of around 50 more respondents, significance may be seen. Conclusions: This study, ironically, showed that the rural population is able to utilize technology; they took an online survey. The majority of respondents indicated that they were interested in using telehealth to improve their access to primary care. The population voiced numerous ideas and concerns that were developed and reported as themes. This study gives rise to many ideas for future research to assist stakeholders interested in telehealth, access, and the rural population. Future research is needed to further answer the research question and to determine technology’s place in healthcare’s future.

Chapter I

Introduction to the Concept of Rural


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Imagine coasting down a dirt road, with the windows open, and the sun’s warmth on

one’s skin. To the left and right are woods, pasture-land, or the occasional neighbor’s home that

one waves and ‘toots’ their horn to, upon passing, to say ‘hello’. A tap of the brakes avoids

running over the dashing rabbit or slow crawling box-turtle. Here, it is not rare to see the new

mama with her springtime babies; it is rural.

People drink from their well or spring, grow or hunt much of their food, sometimes make

their soap and washing detergent, and often only go to the hospital, which is roughly 50 miles or

45 minutes away, when all of their folk-remedies fail to yield results. Many rural-residents were

born rural, as were their grandparents. Children are quickly taught how to track, fish, hunt, grow

food, identify dangerous plants, animals, and reptiles, and survive. The family-garden yields

most of what is served at mealtimes and its surplus is canned or frozen to allow for the hard

months ahead. It is hard work, but the serenity and fulfillment that one feels when they look at

the home and landscape built with their own hands, sweat, and tears, make it worth it.

Problem

Rural is defined as relating to the country, agriculture, and any place with an urban

population of 20,000 or less in a county or parish; the field of biology added the term ‘rustic’ to

the definition (Merriam-Webster Dictionary, 2015; HUD, n.d.). The American Community

Survey (ACS) defined rural based on the 20,000 or less population-parameter, described above,

as well (UofA, 2015). This population is forced to drive to town to obtain any healthcare

services. Unless rural residents qualify for home-health services, they are missing out on

primary-care services and experiencing the detriments of the lack, herein.


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Background

Individuals from rural communities often face barriers to access, whether personal or

system-based (Highfield, Ottenweller, Pfanz, & Hanks, 2014). In Arkansas, the five most

common diseases are: heart disease, cancer, stroke, lower-respiratory diseases, and unintentional

injury (Brantley, 2012). The average person in Arkansas tends to be older (39.8 years) than the

nation’s average (37.5 years), and the rural area’s median age is 41.5 years (UofA, 2015). As

people age, they are more susceptible to disparities such as chronic illness, food and nutritional

deficiencies, housing, environmental, and economic issues, as well as lack of support.

Furthermore, rural Arkansans were found to have 64.5 primary-care physicians for every

100,000 people while urban Arkansans had 139 primary-care physicians per 100,000 people

(UofA, 2015). Conway County, Arkansas, was 49th out of 75 counties in health rankings when

this project began (UofWPHI & RWJF, 2016). This is compounded by the rural population’s

lack of information needed to access equitable healthcare and resources as well as the lack of

access and use of technology in order to better-utilize primary-care services. Access that

provides ease-of-use from one’s own home, low-costs, easy-to-follow instructions, and fast

results would go a long way toward reducing disparities.

Purpose/Aim

The purpose of this scholarly project was to assess the rural population’s views of their

current access and interest in telehealth to improve access to primary health care services. As a

result of investigating the practice problem, this researcher sought to draw attention to the

disparities and the need for better access of primary care services for the rural population. This


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researcher also assessed the rural population’s ideas for improving their access and concerns

regarding telehealth.

Significance

Nursing

This information is clinically significant to providers, nurses, ancillary staff, and affects

each patient, the overall community, and the healthcare system, as a whole, because the rural

population lacks much of the knowledge needed to attain much-needed and available resources.

The knowledge and resources are needed so that the rural population is able to manage their

conditions and access healthcare in a way that is cost-effective and will ensure the best evidence-

based outcomes and a new, higher level of care. With the provider shortage, rising population

of older adults, and the retirement of many older nurses, the healthcare team must collaborate in

order to meet the needs of all involved (IOM, 2011). One must rely heavily on networking,

collaboration, and communication to coordinate and navigate the disparities; simplify and

streamline the various levels of services; and assemble a patient-friendly resource-compilation

that benefits patients, providers, the community, and the healthcare system, alike.

Healthcare

This topic is relevant to healthcare, because it is important that each facet of the

healthcare community comes together to collaborate in order to decrease the number of

disparities. Improvements are needed in healthcare and require communication of everyone

involved in order to stay abreast of the latest evidence-based practice to achieve desirable


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outcomes. This is significant to see change and to continue to improve with other healthcare

advances.

Advanced Practice Nursing

Advanced practice nurses are well-respected and trusted by many. They are in the

perfect role to listen, see and identify needs, and network to begin fixing those needs. This

project is significant in advanced practice nursing because these are the eyes, ears, networkers,

advocates, and educators of the community.

Support

Barriers, Stakeholders, and Support

Barriers to technology and rural primary-care access include: information leakage;

Health Information Portability and Accountability Act (HIPAA) violations; technical support and

internet-availability; adequate image-resolution for assessing, diagnosing, and treatment;

reimbursement; transportation; bias; time constraints; lack of education/knowledge; lack of

capital resources/costs; community and stakeholders’ support; advertisement; resource-support;

and cultural and language barriers (AHRQ, n.d.; Sadeghi-Bazargani, Tabrizi, & Azami-Aghdash,

2014; Highfield et al., 2014). Stakeholders and other supportive organizations that may support

the rural-Arkansas adult population and their access to primary-care services include: the local

Department of Health and Human Services in order to define and respond to needs, the local

Health Department for healthcare access, the local library for education and research, and

resources that assist with bills, nutrition and food, and clothing. Many of the barriers may be

erased with the utilization of one of the community’s own trusted-leaders to initiate change.


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Barriers to this project included the inability to reach out to the community and explain to them

about the project due to fear of coercion. Another barrier was that most people do not

understand what telehealth encompasses. The local newspaper, radio, and word of mouth

supported this project. The community, at large, was very supportive of this researcher and this

project; they are the stakeholders.

Benefit of Project to Practice

The costs behind incorporating technology to utilize primary-care services far outweigh

the disparities and consequences of not using it and continuing down the current path.

Fragmented care adds to the rising costs of treatment and the complexity of navigating the non-

patient-centered medical system (Wong, 2015; MacKenzie & Parker, 2015). Resources are not

adequate at this time because they are not organized and readily available for easy-access to the

general, uninformed patient. The benefit of this project to the rural population is finding their

voice, receiving attention to their needs, ideas, and concerns, and improving their outcomes in

terms of health rankings.

Chapter II


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In Chapter II, this researcher addresses the search history, literature review with themes,

critique of literature and gaps for future research, the theoretical framework, and a conclusive

summary. A critical analysis of the literature is complete with concepts/themes used in the

project. The following is a direct reflection of these elements.

Search History

This researcher began the search process by identifying key concepts: rural, self-

efficacy, telehealth, office-visits, primary-care services, and access. Next, the Maryville

University’s library databases were searched for information on the background and significance

of the problem, then for secondary sources’ references, and finally, for primary articles, until

saturation was achieved. Databases searched include: Cochrane database of systematic reviews,

Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Maryville

University’s library-database (using all databases), and Google Scholar. Search terms include:

rural population, adult, telehealth, telemedicine, telemonitoring, telepractice, telenursing,

telecare, telehealth services, traditional office visits, utilization of primary care services, health

services access, Arkansas, ages 18-65, face to face, rural*, telehealth*, primary care*, telepract*,

telenurs*, and teleservice*. Limiters include studies less than five years old, peer-reviewed,

research article, and use of AND, NOT, and OR in the search boxes.

Integrated Review of the Literature

The objective of the literature review is to examine the current state of evidence available

on the population and compare interventions and outcomes identified in the research question

(telehealth versus traditional office visits to access primary care services). There is a vast


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amount of literature concerning the rural population, primary-care services, and telehealth

services, separately, but very little information devoted to the comparison of these two

interventions (telehealth services and traditional office-visits) in relation to the rural population

and the outcome of access to primary-care services. This adds to the wealth of reasons why this

research question should be studied.

Of the six concepts, this researcher identified three main themes: rural, telehealth, and

access. These three themes combine to encompass this rural population’s disparity of lack of

access and whether or not telehealth will improve their lack of access. The following expounds

upon each theme in further detail.

Rural

This population experiences detriments in that they often live considerable distances from

their points of access to care. Mussulman et al. (2014) describe this disparity well when they

described that rural-America lags well behind national trends. This has compounded the

disparity of lack of access for the rural population. Singh et al. (2014) recognize that the rural

population is plagued with resource shortage and nonavailability of providers. Highfield et al.

(2014) acknowledge the underserved, rural population’s lack of access would improve by

information-sharing and communication afforded by the use of telehealth. Morgan et al. (2014)

reported that their findings demonstrated high user-satisfaction with telehealth in a rural clinic.

Telehealth


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Telehealth encompasses the use of technology in the form of emails, texts, calls, video-

conferencing, secure-messaging via patient portals, and point-of-care devices that relay results

for faster processing (North et al., 2014). While internet capability is a major factor, this

technology could greatly increase access for the rural population. Telehealth has the potential to

increase efficiency, improve continuity, and prevent deterioration of health in the rural

population (Berkhof, Berg, Uil, & Kerstjens, 2015). Liss et al. (2014) cite that telehealth does

not require the time, effort, or cost of traveling to clinicians’ offices that traditional office-visits

require. Mussulman et al. (2014) report a Cochrane review of telehealth versus face-to-face

visits supported that telehealth was as effective as face-to-face encounters and achieved high

levels of satisfaction. However, North et al. (2014) admitted that limited information exists on

how telehealth impacts face-to-face visits in primary care. Singh et al. (2014) cite that telehealth

is promising and cost-effective when it comes to preventing death and improving functional

recovery. It is important to assess the rural population’s interests and concerns about telehealth.

Access

Lack of access is one of the main barriers that rural populations face. Highfield et al.

(2014) cite that Healthy People 2020 objectives recognize the need for the integration of health

information and communication to improve outcomes to underserved communities. Internet and

telephone communication between patient and provider is associated with increased access to

care (Liss et al., 2014). Highfield et al. (2014) cite the lack of integration and coordination of

healthcare services, coupled by different layers of service providers, cripples access.


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It is important to assess the rural population’s perspective on their current level of access as well

as their ideas for improving their access to care as this involves them in finding a solution to this

disparity.

Critique of Literature

The literature reviewed included samples as few as six and as many as 18,486, with a mix

of patients, staff, patient-navigators, clinics, and physicians (Highfield et al., 2014; Liss et al.,

2014; Mussulman et al., 2014). Ages ranged from 18 to 91 (Liss et al., 2014; Morgan et al.,

2014; North et al., 2014). Gender was equally represented throughout the literature.

Geographically, the literature is broad in that it incorporates rural samples from the United

States, the Netherlands, Canada, and India. While efforts were made to utilize studies highest on

the ladder of evidence-hierarchy, a broad array of study-designs were used.

Two studies formed two cohorts with the comparative interventions and main concepts of

telehealth and office-visits (Berkhof, Berg, Uil, & Kerstjens, 2015; Morgan et al., 2014). Three

of the studies had follow-ups, one as far as 18 months, in an attempt to capture as much data as

possible (Jaglal et al., 2014; Morgan et al., 2014; Mussulman et al., 2014). Measurements

comprised a mix of scales, descriptive statistics, interviews, and a variety of statistical tests,

some using statistical software (Berkhof et al., 2015; Liss et al., 2014). Study designs were

clearly laid out and detailed for the reader.

Two studies showed no difference in access with office visits or telehealth (Jaglal et al.,

2014; North et al., 2014), while two other studies showed increased office visits with telehealth

(Berkhof et al., 2015; Liss et al., 2014). Other studies demonstrated the effectiveness of


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telehealth on the access of primary-care services and comorbidity outcomes (Highfield et al.,

2014; Mussulman et al., 2014; Singh et al., 2014). Patient satisfaction was high for patients

utilizing telehealth (Morgan et al., 2014). The concepts of rural, tele*, office-visits, access, and

primary care* were all central and addressed, but while studies alluded to the concept of self-

efficacy, none included it in their results.

Some authors found that education is crucial to a successful telemedicine model and that

the model must be fully-accepted by users in order to be effective (Berkhof et al., 2015; Polit &

Beck, 2017). Others found that telehealth decreases staff workload, improves accuracy and

performance, and links the underserved to resources that would, otherwise, have to be integrated

from multiple sources (Highfield et al., 2014). Still yet, many of the authors believe that, overall,

the literature is ‘debatable’, weak due to factors such as loss to follow-up, and hugely

contradictory (Berkhof et al., 2015). This trend leaves researchers insatiably hungry for

evidence-based answers.

An important area identified as a potential concern is physician’s worry that telehealth

will increase their workload, thus best-practices for providers that respond to messages, emails,

or utilize telehealth should be addressed (North et al., 2014). Another challenge is the lack of

integration and coordination of resources and services, the different layers of providers, and the

lack of assistance for patients attempting to navigate the system (Highfield et al., 2014). As

North et al. (2014) mentioned, there are many correlational causes that must be carefully handled

in studying this issue: the effects of types of access, copayments and fees, ease of making

appointments, transportation, parking, wait times, and availability of technology, just to name a


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few. This literature review has clarified much of what researchers do not know about this issue,

therefore future researchers must be careful to assimilate what is known to build rigorous studies

and avoid pitfalls.

Gaps/Areas for Future Research

Areas of further research are identified in an effort to continue the process of eliminating

this disparity. Since the evidence is largely inconclusive, researchers must identify gaps and

tackle them, collaboratively. Gaps identified were: ways to seamlessly blend and combine

resources and services, provide continual access to providers, and ongoing assistance for patients

attempting to navigate the healthcare system to improve access to primary care services.

Additional gaps include the careful control of other correlational variables, as it is imperative to

ensure sound results, the assimilation of what is known to further advance and extend the

knowledge-base, and researchers who will not hesitate to enlist help in order to ensure rigorous,

error-free results. Further study also involves the use of education alongside telemedicine to

promote self-efficacy and the rural population’s acceptance of telehealth. More research on the

workload, performance, and access to resources as an outcome of telehealth, for, both, patients

and providers, and best-practices for communicating and utilizing telehealth would be beneficial.

Finally, the rural population’s interest in telehealth and their ideas for improving access to care

and outcomes should be explored, which this study has done. The literature was, otherwise

sparse in their rural references. Outcomes, in the form of less hospitalizations and exacerbations

would be a goal for a future study. Use of scripts for patient teaching are highly recommended

in future studies to ensure consistency.


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Theoretical Framework

The theory that unified this researcher’s project is a nursing theory called Bandura’s

Social Cognitive Theory (SCT), also known as Self-Efficacy Theory (SET) (Polit & Beck,

2017). The SCT/SET theory focuses on the concept of self-efficacy, which relates to one’s own

belief that they can perform certain tasks or behaviors with a sub-concept of perseverance. The

SCT/SET is based on four principles: one’s own mastery experiences, verbal persuasion,

secondhand experiences, and physical, mental, and emotional cues such as anxiety or pain (Polit

& Beck, 2017). The concept of self-efficacy and its variable and amenable nature parallels with

the rural population’s independent-nature. This coincides with this researcher’s project because

the rural population is known for their independence, perseverance, and mastery of managing

and surviving in isolated areas. They often require reasoning before making decisions unless it

involves physical, mental, or emotional stimuli, and this population is great to listen and learn

from others’ experiences. The more of these characteristics that researchers can effectively emit,

the better the rural population will respond; therefore this framework acts as a guide for this

project.

Conclusion

Much of the literature was lacking or contradictory, in terms of the effects of telehealth

increasing or decreasing office-visits, adding to the importance of this study. This study started

at the beginning and assessed the rural population’s ideas for improving their access to care and

opinions and concerns regarding telehealth. Another facet of this study is that it used the rural


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population’s own words so that the root of the disparity and associated findings were coupled in

order to eliminate the disparity of lack of access.


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Chapter III

Chapter III details the methodology, needs assessment, project design, data collection,

data analysis, resources, project budget, timeline, and protection of human subjects. Due to the

lack of information available regarding telehealth compared to regular office visits while

assessing improved access of care for the rural Arkansan population, this researcher’s project

conducted preliminary research that produced new knowledge. A simple face-to-face office visit

for rural Arkansans is often an all-day affair since many drive over 50 miles to access care. This

requires them to accomplish most of their daily chores before leaving to go to the appointment,

try to multitask and run errands such as getting needed medications at the pharmacy, going to the

bank, and paying bills while they are in town, and then rushing home to finish chores, often

involving their animals, gardens, or farms that sustain their way of life. While some rural

Arkansans want nothing to do with technology, some do. Some would love the opportunity to

call in their temperature, heart rate (HR) or pulse, respiratory rate (RR), oxygen saturations,

blood pressure (BP), blood glucose, or daily weights instead of arranging a day-long trip into

town. This would improve access to care for rural Arkansans and assist providers in closely

monitoring rural patients with comorbidities that require frequent check-ups. Therefore the

PICOT question for this project was: Do telehealth services (I) for rural Arkansans, ages 18-65

(P), improve access to primary care services (O) as compared to traditional office-visits for

primary care services (C)?


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Methodology

The population was rural Arkansans that reside within Conway County, Arkansas,

making up the sample of 135 respondents, across a 4.5 month span. A mixed methods approach

was used to discover the rural population’s view of their current state of access to primary care,

views and concerns on telehealth as a means of improving their access, and their ideas for

improving access to primary care. The current population is 20,937 (Census, n.d.). There were

no tools or instruments to assist in answering the question, thus this researcher decided to start at

the beginning and discover the rural Arkansan population’s interest and perception of telehealth.

As data collector, this researcher constructed a 12-item survey; the first 10 questions were

closed-ended multiple choice and served to elicit the population’s views on their current access

to care and on telehealth. The last two questions were open-ended. The first question asked

respondents about their ideas for improving access to care for rural Arkansans, and the last

question asked about any concerns regarding telehealth.

Respondents typed in the URL, which took them directly to the survey home-page that

detailed inclusion/exclusion criteria that respondents had to meet before the next page opened to

the informed-consent, and finally the survey. This researcher collaborated closely with

Maryville University’s statistician, Dr. Landry. There are no ‘agencies’, here, to assist as this

population does not respect their current level of care. Not only did this researcher elicit the

rural population’s opinions on telehealth, but later realized that each completed survey served as

a representative example of a rural respondent utilizing technology.


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Needs Assessment

This project was needed to help rural communities achieve better access and outcomes; to

generate new data; support and encourage funding opportunities; and to assist other rural

communities. Shared experiences and results help to pave the way for additional research and

bring together those with interest in rural health issues (RHI hub, 2017). Healthcare must be

streamlined in order to provide services to all populations. This often necessitates collaboration,

a change in delivery processes, networking with stakeholders, continuation, and dissemination

for years to come. At this time, the delivery process involves rural Arkansans experiencing a

burden on their home and work schedules to attend office-visit appointments. This can lead to

no-shows, fewer appointments, and an inability of providers to follow patients closely to ensure

prevention and aggressive management of comorbidities and chronic conditions. This leads to a

decline in the access, quality, and outcomes of health for the rural Arkansan population.

Whereas, if patients were taught and had the opportunity to self-perform and submit vital

measures of their health, such as their temperature, HR, RR, oxygen saturations, BP, blood

glucose, and weight for regular check-ups and/or medication refills, it would improve access,

save time, and improve outcomes by having them interact and monitor their care.

Design/Interventions

Setting

This mixed methods project took place in the rural Arkansas community of Conway

County, Arkansas. Inclusion/exclusion criteria specified that participants had to live outside the

city limits in Conway County, Arkansas. This researcher used a mixed methods approach to


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discover the rural population’s view of telehealth and whether or not it might improve their

access to primary care. Participants were able to type in the URL and take the survey at any time

or location of their choosing, provided they had internet access.

Sample

This project had a sample of 135 participants. Characteristics of the sample included:

residents of Conway County, Arkansas that live outside of the city limits, ages 18-65, both, male

and female, any race or ethnicity, any education, English-speaking, and any marital or

socioeconomic status.

Inclusion Criteria

Participants had to reside outside of the city limits in rural Conway County, Arkansas so

as not to skew results from other counties of comparison. This study included all races, males,

and females. Participants had to be between the ages of 18-65 for legal and ethical purposes.

Any marital status, socioeconomic status, and education was valid, but only English-speaking

participants were included.

Exclusion Criteria

Participants could not reside in any other county other than Conway County, Arkansas;

this would skew data results. Minors or adults over the age of 65 are considered vulnerable

populations. Also, any mental handicap that would void legal consent excluded participants

from the study. This study also excluded individuals without internet access, via home, work, or

mobile phone.


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Recruitment

This researcher used the Qualtrics survey system to develop and disseminate the

anonymous, self-reported survey. This researcher also made flyers with the survey link, project

information, inclusion/exclusion criteria, and researcher’s name and contact information to leave

at 23 businesses, around the county, to gain recruitment. Written permission from business-

owners was obtained months beforehand. Word-of-mouth and advertising on local radio and in

the local newspaper also contributed to recruitment. The survey home-page detailed

inclusion/exclusion criteria that respondents had to meet before the next pages opened to the

informed consent page and survey.

Data Collection

The anonymous, self-reported surveys were compiled in the MVU Qualtrics survey

system. Data was exported and saved weekly to prevent data loss from glitches and stored on a

password-protected computer, in a locked office, within a locked home. The survey took two to

five minutes for respondents to complete.

The strict inclusion/exclusion criteria enhanced construct validity (Polit & Beck, 2017).

Advantages of this data collection method included anonymity, lack of researcher bias, short

amount of time to complete, adequate sample, and adequate length of study. Data collection was

consistent.

Analysis Plan

As a mixed methods study, this project collected, both, quantitative and qualitative data.

This researcher instituted quality-control measures to increase internal consistency and validity


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(Polit & Beck, 2017). Once criteria was met, the participant was able to complete the survey.

Data was compiled within the Qualtrics survey system and later coded. The open-ended

responses were broken down into seven words or less and transcribed into themes.

The independent variable (IV) was best represented by question one. It was labeled

NOWACCESS and was operationally defined as the participant’s view of their current access,

now, without telehealth. The dependent variable (DV) was best represented by question ten. It

was labeled TELEACCESS and is operationally defined as the participant’s view of the use of

telehealth as a means to improve access to primary care. The IV and DV resulted in nominal

data. The Chi Square was the appropriate statistical test to determine if the groups (those with

and those without telehealth) were different (Terry, 2015). This researcher also computed the

Likelihood Ratio version of the Chi Square, with the help of Maryville University’s statistician,

to determine the level of statistical significance using SPSS statistical software.

Resources

This rural county community is somewhat limited in terms of resources. The rural

residents are mistrustful of agencies and many of the healthcare providers, here, yet they are

hungry for help, change, and improvements. The community, itself, has room for rural clinics

and Advanced Practice Nurses (APNs), as there is one small hospital, a handful of clinics, and

only a handful of APNs, here. The local county health department is not overly active in

community outreach and many of the agencies do not advertise their resources, especially to the

rural population, which causes rural residents to drive twice the distance that they normally

would, to a neighboring town, to receive what they consider ‘adequate’ care.


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This researcher plans to open a rural Nurse Practitioner (NP) clinic after graduation and

has two plans for funding. This researcher’s current employer wants to build a clinic, but this

researcher has also considered compiling rural data for research and funding to open her own

clinic. There is adequate monetary resources within the community, but will require networking

with stakeholders and getting them onboard by showing them positive change and results. This

researcher was raised in this community and has adequate support from the rural community.

There are no resource concerns for personnel. As for equipment, technology, and other costs,

paper, ink, internet, electricity and light bulbs, meals, printing costs for flyers, Geek Squad and

anti-virus computer protection, as well as fuel and vehicle wear-and-tear to deliver recruitment

flyers, were the only expenditures allotted to this study, requiring a budget.

Budget

Direct costs include the paper and ink to print works associated with the study from

home, the cost for printing the recruitment flyers at a business, as well as fuel and wear-and-tear

on the vehicle while delivering flyers throughout the county. Indirect costs included items such

as the internet, electricity, light bulbs, and meals for this student on days where it was necessary

to stay close to complete/compile portions of the data/study. Geek Squad and anti-virus

protection on the research computer were necessary. The total budget was $2,260.00.

Personnel

Personnel includes consultants, team members such as statisticians, and recruited

members of the research team; salaries for the principal and co-investigators are generally not

included (MVU template, n.d.). As this researcher’s project only involved an online survey


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utilizing Maryville University’s (MVU’s) Qualtrics survey system and no face-to-face contact,

there are no allowances for personnel. Inouye & Flellin (2005) specify that investigators should

specify, finalize, and justify their budgets. The MVU statistician does not charge students for his

consultation.

Equipment/Consumable Supplies

This researcher purchased Geek Squad assistance and anti-virus protection. This was for

the researcher’s computer, where the exported data was saved and password protected and cost

$300.00. Fuel and vehicle wear-and-tear to deliver recruitment flyers to businesses throughout

the county cost $100.00. The total costs were $400.00.

Printing/Copying Expenses

This project required printing and copying, at home, as well as printing recruitment flyers

from a business. Three packages of printer paper at $5.00 each and three ink cartridges at $20.00

each cost $75.00 total. The printing business charged $175.00 to print 1,100 recruitment flyers.

The combined total cost was $250.00.

Patient Care Costs

This project only involved an online survey, therefore there are no costs related to patient

care. There were no face-to-face encounters. All participants were directed to type in the survey

link.

Other Expenses

Other expenses, such as light bulbs, electricity, internet, and meals, applied to this

project. Light bulbs cost $10.00 for a pack, electricity at $10.00/day x five months totaled


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$1,500.00, meals did not exceed $100.00. Higdon & Topp (2004) describe that the research

proposal budget is intertwined with the timeline and methodology of the research project. The

grand total budget was $2,260.00 (see Table 1). Devine (2009) details that a successful

investigator knows the size of the grant that he/she needs and then pursues ones of interest to the

research.

Table 1. Budget

1. Personnel: May include consultants, i.e., biostatisticianSalary for principal and co-investigators is not included. Dollar amount requested Name Role on project Base salary % Effort Total

N/A N/A N/A N/A N/A

TOTAL DOLLAR AMOUNT N/A

2. Equipment/Consumable Supplies: List and justify. Total

Geek squad and anti-virus protectionFuel and vehicle wear-and-tear to deliver flyers throughout the county

$300.00$100.00

TOTAL DOLLAR AMOUNT $400.00

3. Printing/Copying Expenses (i.e. for questionnaires): Itemize and justify. Total

Paper x 3 @ $5.00 eachInk x 3 @ $20.00 eachBusiness cost to print 1,100 recruitment flyers

$15.00$60.00$175.00

TOTAL DOLLAR AMOUNT $250.00

4 Patient Care Costs (i.e. parking): List and justify. Total

N/AN/A

TOTAL DOLLAR AMOUNT N/A

5. Other expenses: List and justify. Total


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Light bulbs @ $10.00/packInternet and electricity @ $10.00/day x 5 monthsMeals

$10.00$1,500.00$100.00

TOTAL DOLLAR AMOUNT $1,610.00$2,260.00

Timeline

The study was conducted over a total period of 4.5 months. This study qualified for

exempt IRB approval on June 22, 2018. The survey opened August 30, 2018 and closed on

January 15, 2019. Data saturation was obtained.

Ethics/Protection of Human Subjects

This study received exempt approval from Maryville University’s ethics committee on

June 22, 2018, before recruitment or data collection began. The largest risk to human subjects

included breach of confidentiality. The risk was minimized as all surveys were completely

anonymous and no personally identifiable information was obtained or written in the open-

responses. This researcher locked all information in a file cabinet, in the locked home-office

where it was computer password-protected, and destroyed all data by shredding it or deleting it

where appropriate, upon writing this final compilation. This researcher maintained ethical and

virtuous standards of integrity throughout the research process.


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Chapter IV

Chapter IV details the data analysis with critique and results. A goal was set to obtain

88-138 survey responses. After 4.5 months of data collection, saturation was obtained, as

responses were redundant. A total of 135 surveys met the goal; however, 32 respondents did not

meet criteria (26 due to not living outside of the city limits in Conway County, Arkansas and six

due to age <18 or >65) and 10 respondents did not fully complete the survey. The data was

coded by the researcher. The last two open-ended questions were shortened to seven words or

less to form themes. All other data were coded as “2” for yes answers, “1” for unsure answers,

and “0” for no answers. Data from questions two through nine also formed percentages and the

rest of the data also served as supplemental data to provide context, or further analysis, of the

participants’ perceptions of access to primary care in rural Arkansas.

Data Analysis

Polit & Beck (2017) cite that researchers can minimize biases by controlling confounding

variables, thus they are identified. Some confounding variables for this project include: a

respondent recently worked in healthcare and lost their job; a respondent had a recent bad

experience in the hospital; respondent social desirability bias; mental illness or depression; a

respondent started receiving home care; respondents do not understand what telehealth is; have

friends/family, or they themselves, work in healthcare; holiday seasons; no internet; as well as

those who responded are different from those who did not (Polit & Beck, 2017). The next few

paragraphs detail the quality of the data.


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Reliability and validity. In terms of validity efforts, Polit & Beck (2017) recommend

randomization as a way to control confounding variation, increase representativeness, and

decrease selection bias to support internal validity. The survey was random in that it was

completely anonymous. The anonymity helped to evade bias and the survey was an adequate

length, taking two to five minutes to complete. The inclusion and exclusion criteria increased

homogeneity of the sample, but this decreased generalizability to ages outside of 18-65, non-

English speaking, and the non-rural population. The inclusion/exclusion criteria also helped with

factors that affect the DV. An enhancement to external validity is the representativeness of the

participants. The results can be applied to that population, and the setting is representative of the

setting in which findings can be applied with replication. The use of the instrument, stability of

one’s own environment to take the survey, and homogeneity were consistent. With an

anonymous, concurrent, web-based, cross-sectional survey, this study was able to reach a large

population, quickly; allow multiple respondents to answer at once; included no travel expenses,

additional equipment, or personnel for respondents; and was able to reach unlimited distances.

The disadvantage was individuals without internet and outside of the upper-limits of the age

criteria were excluded, even if they were representative of this rural population.

Trustworthiness and rigor. The qualitative part of the survey was given concurrently with

the quantitative measures. Both types of data complemented and supported one another. This

researcher increased systematic transparency, and thus credibility and transferability by keeping

an audit trail. Tappen (2015) reports that saturation is achieved when responses become

redundant or repeat themselves. This study achieved saturation and triangulation. Terry (2015)


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cites that qualitative data is interested in the generation of new hypotheses rather than testing

existing ones. This study generated many themes to guide researchers in the future. This

researcher is confident that other researchers could achieve the same results, reflecting

applicability and transferability. There was sufficient time, or prolonged engagement, of 4.5

months, evidenced by data saturation.

Congruency. The congruency, or similarity, of the research question is actually exemplified

by the selected data collection method. Before this project, it was unclear how many of the rural

population might utilize technology, and thus telehealth. However, respondents were able to

type in the URL and take the web-based survey. The anonymous, self-reported survey was a

good choice for this population, whether it is web-based or paper form, because they liked the

anonymity and leisure of completing the survey on their own schedule. Increasing the upper-age

limit would also enhance congruency between the measurements and data and give a more

reliable reflection of the current population. The method was congruent with the measurements,

however the tool should be revamped. For instance, question nine asks respondents if they have

ever used the internet when they were currently taking an online survey. This tool/instrument

should also be tested to enhance validity. This researcher’s audit trail does provide transparency

and details adequate information to allow reproducibility by another researcher. There was

congruency between each target variable and the research question.

The IV was represented by question one and relates to the rural population’s current

access, without telehealth. The DV was represented by question ten and related to the

participant’s view of whether or not telehealth can help improve access to primary care for rural


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Arkansans. There was congruency between the question and method in that respondents were

further able to identify ideas for improving access or concerns relating to telehealth, in their own

words. This method was congruent in relation to participants since this method gave the rural

population a voice. However, the results suggest a larger sample size of around 50 more

respondents may show more significant results. There was congruence between data and

category in that, both, closed-ended and open-ended questions were used to elicit and compile

straight-forward data, yet open-ended questions gave respondents a chance to voice their ideas

and concerns, using their own words. The Chi Square examined the differences between the IV

and DV. The use of mixed methods allowed for triangulation. There is adequate information to

determine transferability. Other researchers are able to follow the audit trail in order to reproduce

results.

Quantitative Data Results. When asked if driving to see their primary care provider for

regular check-ups and medication refills seems inconvenient, 63% said yes, 13% were unsure,

and 24% said no. When asked if they were taught how, could they take their own temperature;

count their own heart rate/pulse; count their breaths per minute; take their own blood pressure;

weigh themselves; check their own oxygen saturations; and check their own blood sugar, 93%

said yes, 5% were unsure, and 2% said no. When asked if they would rather call, email/text, and

log their parameters instead of drive to their primary care provider’s office for regular check-ups

and medication refills, 78% said yes, 11% were unsure, and 11% said no. When asked if they

had access to a phone at home, 99% said yes, 1% were unsure, and no one said no. When asked

if they had internet access at home, 92% said yes, 5% were unsure, and 3% said no. When asked


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if they have a friend or family member that helps them with technology, 47% said yes, 17% were

unsure, and 36% said no. Even though taking an online survey, when asked if they had ever

used the internet before, 97% said yes, 2% were unsure, and 1% said no. When asked if they see

telehealth as a tool to improve access to primary care services in the near future, 86% said yes,

6% were unsure, and 8% said no. Finally, when asked if they would rather call in their self –

monitored data or email/text the data, 47% said email/text, 30% said either, 14% said call, 5%

said neither, and 4% were unsure.

In order to examine the differences between the two groups (those with and those without

telehealth), the chi square statistical test was performed. The Chi value was 8.766 with four

degrees of freedom and a p value of .067, which is greater than .05, thus it is not statistically

significant. However, the Likelihood Ratio version of Chi’s p value was .041, which is

statistically significant (see Table 2). It was determined that with a larger sample size, of around

50 more participants, significance may be seen. Of course, further research is needed.

Table 2. Statistical Result from Chi and Likelihood Ratio Version of Chi

Chi-Square Tests Value df Sig

Pearson Chi-Square

8.766 4 .067

Likelihood Ratio 4 .041N of Valid Cases 93


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Qualitative Data Results. The themes divide into two sub-themes of ideas and concerns

and have yielded a wealth and variety of information for stakeholders interested in the rural

population, their access to care, telehealth, and future research implications. When asked about

their ideas for improving the rural Arkansan’s access to primary care services, three major

themes emerged. First, easier access was detailed by easy-to-use telehealth; a phone application;

a system where the patient and provider can communicate and share information; open new

clinics, satellite clinics, pop-up clinics; free or low-cost services and up-front costs; free bus/van

transportation; home visits from provider, nurse, EMS; ability to take last-minute patients; ability

of patients to call; and more NPs. The second theme was funding and incentives to staff and the

third theme was education and preventative services for staff and public.

Lastly, when asked about their concerns or worries regarding telehealth, seven main

themes emerged: data and measurements (incorrect measurements, dishonesty of patients so that

they are able to get their medications); lack of personal relationship with provider (will he/she

even see the information, the provider is used to the patient and his/her needs-will that continue,

possible lack of thorough assessment, misdiagnosis, inadequate care, and foreign people or call

centers); delay in care; cost (will insurance cover); privacy and loss of data (hacking, loss of

service or reception, inclement weather, glitches, reliability, computer malfunction); patient’s

ability to communicate; and finally, education for staff and public (elderly’s full understanding

of telehealth).


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Chapter V

This chapter includes a discussion of the findings. Limitations and applications to

practice are also discussed. This project provided a wealth of ideas for future research

implications, and laid the groundwork for future studies.

Discussion

It was not until after data collection that this researcher realized the irony of using a web-

based, anonymous survey to assess the rural population’s opinion of telehealth. In hindsight, this

researcher would have sought more ways to test the survey instrument in order to establish

internal validity and strengthen the tool/instrument. The IRB was concerned about coercion if

social media was used in the recruitment efforts, but posting a link on social media, such as

Facebook, would have certainly helped with recruitment and provided a URL link to click on

instead of making respondents type it in, manually. This researcher would recommend

revamping question nine, which asks respondents if they have ever used the internet. The

respondents were taking an online survey.

For the rural population, the design features of an anonymous survey worked well. Two

exceptions were that the age criteria should incorporate older adults and the researcher should

consider those without internet to enhance external validity (Polit & Beck, 2017). Overall, the

data supports the rural population’s desire to use telehealth. The themes have yielded a wealth of

information to help guide future research, help in understanding the rural population’s ideas and

concerns regarding improving access and telehealth, and to help stakeholders who are interested

in the rural population, access to care, and telehealth.


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Limitations

In the design, confounding variables were identified early on to allow this researcher to

recognize possible interferences and stay alert for the rapid identification of anything less than a

completely anonymous survey or less than a rigorous study. While the inclusion/exclusion

criteria increased homogeneity of the sample, it decreased generalizability to ages outside of 18-

65, non-English speaking, and the non-rural population. Another limitation noted was that the

exclusion criteria did not allow those without internet to participate. In excluding those without

internet access, it decreased external validity, as did the exclusion of those greater than 65 years

of age. Thus, the upper-age limit should be raised and use of social media should be allowed to

provide a link for recruitment to increase the response rate and perhaps broaden the sample, not

to mention increase the ease of taking the survey by not making respondents type in the URL

manually. Other limitations are that the survey tool needs to be tested to increase internal

validity, including rewording question nine and providing a paper survey to include those

without internet. In light of the results, increasing the sample size to an additional 50

participants (150 total) might show statistical significance.

Application to Practice and Future Research Implications

The results helped stakeholders to understand the interests, concerns, and ideas, in the

rural population’s own words. These findings can be applied to practice to reduce disparities at

the local, state, regional, and global level. The themes produced by this study offer a wealth and

variety of future research implications. Some future research implications include: involving

technology that is easy to use from one’s own home; lower costs; easy-to-follow instructions;


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fast results; technology versus house-calls; best practices for communicating and utilizing

telehealth; telehealth’s effect on workload; education alongside telehealth to promote self-

efficacy; integration and coordination of services and resources; continued access to a provider;

assimilation of what is known with each study in order to further the knowledge-base; and lastly,

compare this study to a similar-sized rural county, with or without telehealth. The implications

give researchers various avenues to investigate.

Conclusion

This study, outlined by the research question, Are Rural Arkansans Interested in

Telehealth as a Means to Improve Their Access to Primary Care Services, leaves readers with

more information than was available when this researcher performed a literature review. This

time, the information is not separate. Now there is a study that involves the rural population,

telehealth, and access to primary care services. This project set out to give the rural population a

voice, to hear their views on their current access to care, and to hear their ideas and concerns

regarding telehealth as a means to improve their access to primary care, all in their own words.

Not only did the method used show that the rural population can utilize technology well, it

ironically demonstrated it.

It is clear that the rural population is willing to utilize technology in an effort to improve

their access to primary care services. They are willing to provide ideas and discuss their

concerns. This population yields a wealth of opportunities for future implications in research.


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References

Agency for Health Research and Quality (AHRQ). (n.d.). Health Information Technology. Retrieved from https://healthit.ahrq.gov/

Berkhof, F. F., Berg, J. W., Uil, S. M., & Kerstjens, H. A. (2015). Telemedicine, the effect of nurse-initiated telephone follow up, on health status and health-care utilization in COPD patients: A randomized trial. Respirology, 20, 279-285. http://dx.doi.org/10.1111/resp.12437

Brantley, M. (2012). UAMS issues report on rural health in Arkansas. Retrieved from www.arktimes.com/ArkansasBlog/archives/2012/11/15/uams-issues-report-on-rural-health-in-arkansas

Devine, E.B. (2009). The art of obtaining grants. Am J Health-Syst Pharm, 66, 580-587. Retrieved from https://lmscontent.embanet.com/MVU/NURS705/Readings/Devine_Reading.pdf

Higdon, J. & Topp, R. (2004). How to develop a budget for a research proposal. Western Journal of Nursing Research, 26(8), 922-929. Retrieved from https://lmscontent.embanet.com/MVU/NURS705/Readings/Higdon_Reading.pdf

Highfield, L., Ottenweller, C., Pfanz, A., & Hanks, J. (2014). Interactive web-based portals to improve patient navigation and connect patients with primary care and specialty services in underserved communities. Perspect Health Inf Manag, 11.

HUD.GOV: U.S. Department of Housing and Urban Development. (n.d.). http://www.portal.hud.gov/hudportal/HUD?src=/program_offices/comm_planning/economicdevelopment/programs/rhed

Inouye, S.K. & Flellin, D.A. (2005). An evidence-based guide to writing grant proposals for clinical research. Annals of Internal Medicine, 142(4), 274-W-36. Retrieved from https://lmscontent.embanet.com/MVU/NURS705/Readings/Inouye_Reading.pdf

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.

Jaglal, S.B., Guilcher, S., Hawker, G., Lou, W., Salbach, N.M., Manno, M., & Zwarestein, M. (2014). Impact of a chronic disease self-management program on health care utilization in rural communities: A retrospective cohort study using linked administrative data. BMC Health Services Research, 14. Doi 10.1186/1472-6963-14-198


Care Services

38

Liss, D. T., Reid, R. J., Grembowski, D., Rutter, C. M., Ross, T. R., & Fishman, P. A. (2014). Changes in office visit use associated with electronic messaging and telephone encounters among patients with diabetes in the PCMH. Annals of Family Medicine, 12(4), 338-343. http://dx.doi.org/10.1370/afm.1642

MacKenzie, A. R., & Parker, I. (2015). Introduction to quality issues in vulnerable populations. J Oncol Pract, 11(3), 185-6. http://dx.doi.org/10.1200/JOP.2015.004770

Merriam-Webster Dictionary. (2015). Rural. Retrieved from http://www.merriam-webster.com/dictionary/rural

Morgan, D.G., Kosteniuk, J., Stewart, N., O’Connell, M.E., Karunanyake, C., & Beever, R. (2014). The Telehealth Satisfaction Scale (TeSS): Reliability, validity, and satisfaction with telehealth in a rural memory clinic population. Telemed J E Health, 20(11), 997-1003. Doi 10.1089/tmj.2014.0002

Mussulman, L., Ellerbeck, E. F., Cupertino, A. P., Preacher, K. J., Spaulding, R., Catley, D., Cox, L. S., Lambart, L., Hunt, J. J., Nazir, N., Shireman, T., & Richter, K. P. (2014). Design and participant characteristics of a randomized controlled trial of telemedicine for smoking cessation among rural smokers. Contemporary Clinical Trials, 38, 173-181.

North, F., Crane, S. J., Chaudhry, R., Ebbert, J. O., Ytterberg, K., Tulledge-Scheitel, S. M., & Stroebel, R. J. (2014). Impact of patient portal secure messages and electronic visits on adult primary care office visits. Telemedicine and e-Health, 20(3), 192-198. http://dx.doi.org/10.1089/tmj.2013.0097

Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia: Wolters Kluwer.

Rural Health Information Hub (RHI hub). (2017). Conducting rural health research, needs assessment, and program evaluation. Retrieved from www.ruralhealthinfo.org

Sadeghi-Bazargani, H., Tabrizi, J.S., & Azami-Aghdash, S. (2014). Barriers to evidence-based medicine: A systematic review. Journal of Evaluation in Clinical Practice, 20(6), 793-802. http://dx.doi.org/10.1111/jep.1222

Singh, M., Agarwal, A., Sinha, V., Kumar, R. M., Jaiswal, N., Jindal, I., Pant, P., & Kumar, M. (2014). Application of handheld Tele-ECG for health care delivery in rural India. International Journal of Telemedicine and Applications, Vol 2014. http://dx.doi.org/10.1155/2014/981806


Care Services

39

Tappen, R. (2016). Advanced nursing research: From theory to practice (2nd ed.). Burlington, MA: Jones & Bartlett.

Template for Mock Budget (MVU Template). (n.d.). In (Comp.), DNP Clinical Inquiry I. St. Louis, MO: Maryville University.

Terry, A. J. (2015). Clinical research for the Doctor of Nursing Practice (2nd ed.). Burlington, MA: Jones & Bartlett.

University of Arkansas Division of Agriculture, Research, and Extension (UofA). (2015). Rural Profile of Arkansas. Retrieved from https://www.uaex.edu/publications/pdf/MP-531.pdf

University of Wisconsin Population Health Institute (UofWPHI) & Robert Wood Johnson Foundation (RWJF). (2016). County Health Rankings & Roadmaps. Retrieved from www.countyhealthrankings.org/app/Arkansas/2015/ranking/Conway/county/outcomes/overall/snapshot

Wong, S.L. (2015). Medically underserved populations: Disparities in quality and outcomes. J Oncol Pract, 11(3), 193-194. http://dx.doi.org/10.1200/JOP.2015.004259n

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