The Impact of a Doctor of Physical Therapy Program’s Community-Based Outreach on

Participants with Neurologic Conditions in Two Rural Communities

Author(s): Leah Bridge, Taylor Mills, & Lara Nasser

Research Advisor: Jamie Haines PT, DScPT

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan

April 22th, 2020

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at

Central Michigan University

In partial fulfillment of the requirements of the

Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

Jamie Haines PT, DScPT

Date of Approval: ________________
Introduction

Approximately twenty percent of Americans live within a rural community and seventy-five percent of
United States counties are categorized as rural. 1 The United States Census Bureau prefers to define
“urban” as a region with 50,000 or more people and define “rural” as areas that do not meet the definition
of urban.2 The term “rural” is also thought to include factors such as a person’s environment, experiences,
and perceived stereotypes.1 Image 1 illustrates the rural counties within the state of Michigan. 3

Image 1:3

Since the 1990s, research has shown that rural communities in the United States have greater health
disparities when compared to their urban counterparts. 1, 2, 4, 5 These health disparities are based on
economic factors, along with social and cultural differences. 3 People living in rural regions typically have
limited access to higher education and are generally sicker than those living in urban areas with higher
rates of chronic conditions.4, 6, 7 Access to both primary care and specialized services are often limited in
rural communities.1 In recent years, there has been movement to address these health disparities and
provide the care needed in rural communities through community interaction. 8, 9

Community-based participatory research (CBPR) aims to provide information to community members

through the use of the research process with the ultimate goal being to impart an action and facilitate
social change to reduce and/or eliminate health disparities within a community. 8, 10 It has been found that
CBPR can be an effective approach to target the gap between health disparities in communities and
within specific populations through the use of mixed quantitative and qualitative methods. 8, 11 CBPR has
been used to improve local socialization, encourage participant empowerment, emphasizing team
building, address health issues, and provide education about medical conditions for improved overall
quality of life.8, 9, 11 Although not frequently performed in rural settings, CBPR programs have been found
to be successful for individuals with chronic, neurologic conditions by assessing participants’ health
outcomes and quality of life through functional outcome measures and qualitative data collection. 8, 11

Living with a neurologic condition can lead to isolation from family, friends, and the community. 8 CBPR
programs have been specifically designed to integrate individuals with neurologic conditions back into
the community to engage in education, social support activities, and physical activity. 8, 12 The American
Physical Therapy Association’s (APTA) Code of Ethics states that physical therapists have a duty to
advocate for the reduction of health disparities, improve access to healthcare services, and address the
health, wellness, and preventative health care needs of people. 13 Most profoundly, physical therapists
should support organizations that meet the health needs of people who are economically disadvantaged,
uninsured, and underinsured.13

Universities, and specifically Doctor of Physical Therapy (DPT) programs, often serve the local
surrounding community by offering programs that integrate student learning with service. 14 Central
Michigan University’s (CMU) main campus is located in Mount Pleasant, Michigan, which is the
northernmost professional physical therapy program in Michigan. CMU has an extension program located
in the Upper Peninsula at Michigan Technological University in Houghton, Michigan. The extension
program in Houghton was developed to address the shortage of physical therapists in this rural area.
CMU’s DPT program aims to serve these two rural communities through the use of community outreach
programs. Table 1 provides socioeconomic information about the two rural areas as compared to the state
of Michigan.16 These programs, which are the focus of this study, support the goals of the CMU DPT
program to “engage in service activities that promote the wellbeing of their patients and contribute to the
advancement of their community and the profession.” 15

Table 1: General Socio-economic Characteristics16

Socioeconomic Characteristics State of Mount Pleasant, Houghton City,
Michigan MI MI

Population 9,995,915 25,338 7,993

Race
White alone 79.3% 85.5% 84.4%
Black or African American alone 14.1% 3.9% 2.1%
Hispanic or Latino 5.2% 4.1% 2.3%
Asian alone 3.4% 3.3% 9.4%
Two or more races 2.5% 5.6% 3.0%

Persons 65 years and over 17.2% 8.4% 9.4%

Persons in poverty 14.2% 37.8% 38%

Education
High school graduate or higher 90.2% 92.7% 93.3%
Bachelor's degree or higher 28.1% 45.8% 54.3%
 Persons without health insurance 6.1% 8.0% 7.7%

Three free community-based outreach programs offered through the DPT program are the focus of this
study: Physical Therapy-Chippewa Outreach Neurorehabilitation and Education with Community Teams
(PT-CONECT), MOVE! for Health exercise class, and Hands for Health (HFH), a pro-bono physical
therapy clinic.

PT-CONECT is a program embedded in the DPT curriculum designed to bring people with neurologic
conditions in the local community together with students in the classroom. Community partners volunteer
to work with students for five classroom sessions and are provided with a physical therapy evaluation
with assessment results, home exercises, and resources to manage their conditions. MOVE! for Health is
a student-run, faculty supervised, weekly, group exercise class for individuals in the community living
with Parkinson's Disease and Multiple Sclerosis. Hands for Health is a student-run, faculty supervised,
pro-bono physical therapy clinic that serves those in the community with barriers to accessing physical
therapy services. Students evaluate and treat individuals who are uninsured or underinsured while being
mentored by DPT faculty.

There is minimal research investigating the impact of university outreach programs on those who utilize
these services. The purpose of this study was to explore the impact of a Doctor of Physical Therapy
program’s community-based outreach programs on community members with neurologic conditions from
two rural communities.

Methods

The research study protocol was reviewed by the Central Michigan University Institutional Review Board
(IRB), who, per institutional policy, reported this work did not require IRB review.

Setting
The community outreach programs were offered in Mount Pleasant and Houghton, Michigan. Participants
were interviewed on campus in the physical therapy departments.

Sampling and Recruitment

Prior to enrolling participants in the study, the interview protocol and survey were piloted by three people
involved in the outreach programs to gain their feedback. Pilot study feedback was integrated into the
final version of the interview protocol and survey.

Study participants were recruited from a pool of community members who had engaged in at least one
outreach program associated with the physical therapy department as a sample of convenience. The
research study utilized purposive sampling due to the participant population characteristics involving
those with neurological conditions. Inclusion criteria included individuals with neurological conditions,
18 years or older, and participation in at least one of the DPT community outreach programs. Exclusion
criteria included individuals who did not have an existing neurological condition. Flyers were created and
physically handed to community members in either the MOVE! for Health, Hands for Health, or PT-
CONECT program. The flyer provided the individual with the purpose of the study and methods of
contact. The flyer was also published to a closed CMU-related Facebook page that included members of
the community who have neurologic conditions. Flyers were emailed to individuals who heard about the
study and wanted to receive more information on the topic. Community members contacted the
researchers and enrolled in the study. Interviews were scheduled at a time convenient for the participant.
A reminder email and/or phone call was used to contact the community participant two days prior to their
scheduled session.

Survey and Interview Instrument

Prior to beginning data collection, community participants signed an informed consent document.
Participants were informed that they could decline to answer questions or drop out of the study at any
time. The 33-question survey collected demographic information to gain insight on their education level,
age, income, and distance traveled to receive healthcare services. A five-point Likert scale ranging from
strongly agree to strongly disagree was utilized for the remaining questions which focused on
participants’ experience with the outreach program(s). Following the questionnaire, a semi-structured
interview consisting of twelve questions was conducted and audio recorded. Researchers utilized
standardized follow-up question prompts as needed for clarity and elaboration during the interviews.

Data Analysis
All interview sessions were transcribed by a third party unrelated to the study and checked for accuracy
by a member of the research team. Any changes to the transcriptions were due to spelling errors and did
not require discussion among the research team. The constant comparative method was used to detect
common themes from participant responses. Four researchers independently coded data to identify major
themes and collectively came to a consensus on the details supporting each theme.

Results

This study included 29 community partners with 21 individuals living around the Mount Pleasant region
and 8 individuals living in Houghton. For both cohorts, all 29 participants drove 30 miles or less to see
their primary physician. However; a large majority of participants in both cohorts had to drive over 30
miles and up to 150+ miles to see their neurologist with 49% of the Houghton group having to drive over
100 miles.

Approximately 52% of individuals living in Mount Pleasant and 62% of individuals living in Houghton,
Michigan reported their average household income at or above $50,000. Half of the Houghton cohort and
approximately 43% of the Mount Pleasant cohort received a bachelor’s degree or higher. Results of all
participant demographics and survey questions are found in Table 2 and Table 3.

In the study, only the active participants in the community-based programs were interviewed and
surveyed. To eliminate bias, researchers investigated the reason(s) for community members not returning
to participate in the community-based programs in Mount Pleasant and Houghton, MI. Reason(s)
included: relocation during winter months, currently receiving physical therapy services elsewhere,
residing in an area too far to travel to the programs’ site, scheduling conflicts, transportation issues, did
not like the group targeted setting, illness, passed away, admitted to a nursing home, too frail to attend,
and/or limited space in the program to accommodate all members interested.
Table 2: Demographics

Mount Pleasant, Houghton, MI %

MI (n= 21) (n=8) (n=29)
Sex Male 14 (67%) 2 (25%) 55.2%

Female 7 (33%) 6 (75%) 44.8%

Age 25-39 0 (0%) 1 (12%) 3.5%.
40-64 3 (14%) 0 (0%) 10.3%
65 and older 18 (86%) 7 (88%) 86.2%
Average household $0-$24,999 4 (19%) 0 (0%) 13.8%
income $25,000-$49,999 6 (29%) 3 (37.5%) 31.0%
$50,000-$74,999 4 (19%) 3 (37.5%) 24.1%
$75,000-$99,999 2 (9%) 2 (25%) 13.8%
$100,000-$124,999 4 (19%) 0 (0%) 13.8%
$125,000-$149,999 1 (5%) 0 (0%) 3.5%
Race Caucasian 20 (95%) 8 (100%) 96.6%
Hispanic 1 (5%) 0 (0%) 3.4%
Non-Hispanic 0 (0%) 0 (0%) 0%
Highest level of High school degree or 8 (38%) 3 (37.5%) 37.9%
education less
Some college but no 4 (19%) 1 (12.5%) 17.3%
degree
Bachelors or graduate 9 (43%) 4 (50%) 44.8%
degree
Community-Based MOVE! Only 7 (33%) 4 (50%) 37.9%
Program PT-CONECT Only 5 (24%) 2 (25%) 24.1%
Participation HFH Only 1 (5%) 0 (0%) 3.5%
2 or more programs 8 (38%) 2 (25%) 34.5%
Distance to 0-15 miles 11 (53%) 7 (88%) 62.1%
Community-Based 16-30 miles 3 (14%) 1 (12%) 13.8%
Program (MOVE!, 31-45 miles 1 (5%) 0 (0%) 3.4%
Hands for Health, 46-60 miles 3 (14%) 0 (0%) 10.3%
and/or PT-CONECT) 61-75 miles 2 (9%) 0 (0%) 6.9%
76+ miles 1 (5%) 0 (0%) 3.4%
Distance to primary 0-15 miles 16 (76%) 7 (88%) 79.3%
physician 16-30 miles 5 (24%) 1 (12%) 2.7%
31-45 miles 0 (0%) 0 (0%) 0%
46-60 miles 0 (0%) 0 (0%) 0%
61-75 miles 0 (0%) 0 (0%) 0%
Distance to 0-15 miles 6 (28.5%) 0 (0%) 20.7%
neurologist
16-30 miles 2 (9.5%) 0 (0%) 6.9%

31-45 miles 3 (14%) 0 (0%) 10%

46-60 miles 1 (5%) 0 (0%) 3.5%

61-75 miles 3 (14%) 1 (12.5%) 13.8%

85 miles 1 (5%) 0 (0%) 3.5%

100 miles 0 (0%) 2 (25%) 6.9%

120 miles 1 (5%) 0 (0%) 3.5%

 125 miles 0 (0%) 1 (12.5%) 3.5%

150+ miles 2 (9.5%) 1 (12.5%) 10%

n/a (do not see a 2 (9.5%) 3 (37.5%) 17.3%

neurologist)

Table 3: Survey Response Results

Survey Questions Program Strongly Neutral Strongly
Agree/Agree Disagree/Disagre
e

My participation in the involved program(s) MOVE! for Health 20 1 0

helped me improve my physical function.
PT-CONECT 12 1 0

Hands for Health Pro-bono clinic 1 0 0

My participation in the outreach program(s) MOVE! for Health 19 2 0

allowed me to be more active.
PT-CONECT 11 2 0

Hands for Health Pro-bono clinic 1 0 0

My participation in the outreach program(s) MOVE! for Health 17 4 0

improved my quality of life.
PT-CONECT 11 2 0

Hands for Health Pro-bono clinic 1 0 0

My participation in the outreach program(s) MOVE! for Health 21 0 0

was a beneficial and rewarding experience.
PT-CONECT 13 0 0

Hands for Health Pro-bono clinic 1 0 0

It would be beneficial to have more 28 1 0

community-based programs in a location near
me.

I would recommend this experience to others. 29 0 0

I would be interested in participating in a 29 0 0

similar experience in the future.

I enjoyed the opportunity to work with a 29 0 0

student physical therapist while I participated in
this program(s).

I felt the student group that I worked with 29 0 0

displayed a high level of professionalism
throughout the program.
I felt the student group that I worked with 29 0 0
displayed strong communication skills
throughout the program.

Regarding PT-CONECT: I felt the ease of 13 0 0

access and general atmosphere of space
provided was good to work in.

Regarding PT-CONECT: The available 13 0 0

equipment helped me improve the overall
quality of the outreach program(s) I
participated in.

Three main themes were identified from the interviews: sense of connectedness, improved self-awareness
and knowledge about the neurological condition, and appreciation for the student and participant
interaction. Identified main themes and supporting subthemes are summarized in Table 4.

Table 4: Identified Main Themes and Subthemes

Overarching theme: Empowerment

Main Theme(s) Sub Theme(s) Examples

Sense of Connectedness Support “You’re connected with other people with the same situation”

“I think the comradery is great for him, and I think it’s been good for him to see other
people with Parkinson’s well or, or other diseases, similar diseases but you don’t feel
like you’re the only one in the world type of thing. I think it’s been good for him to see
others.”

“You form friendships in there. With other people with the same problem.”

Motivation & Mood “You feel like you know more parts of the community. And, it does, like I said, it does
make me feel happier and more empowered that I can participate in the program.”

“If there’s one thing I’ve learned from MOVE! and the PT-CONECT program is that you
can’t give up, you’ve got to keep reinforcing those motor functions…”

“One of the emotional burdens that you have to carry, and address is depression. And
I’ve never felt… I’ve been a person susceptible to depression but in and with
Parkinson’s it can, it needs to be addressed and so there has been a mood change in as
much as I enjoy looking and I look forward to the days that I come to class. I know that
the other participants share that we are, so you know we talked about it and that’s a
support group for example then.”

Self-Awareness & Knowledge Importance of “I know that if I don’t exercise and don’t keep on these large movements that I will
about Neurologic Condition Exercise & slowly waste away”
Movement to
Manage Symptoms “You can physically improve your strength and ability to balance and the ability to be to
 be out in public”

“I was diagnosed with MS and I was not physically active when I was diagnosed, and it
was not a big deal. And now, I am more physically active twenty-one years into my
diagnosis than ever because [the students] all light a fire under my butt two days a
week.”

Education “I’m blessed with that where I can have a little fun and learn from them too. I enjoy
coming.”

“It keeps me aware of what’s going on in my body.”

“[I got] a little more explanation as to what’s going on. Why [Parkinson’s Disease]
occurs. Things to avoid in your lifestyle and things that you should embrace.”

Student Interaction
Aiding in DPT “I would have to stress to them that physical therapy students become the most important
Student people in the lives of people like me. The therapist is the one that is going to make you
Development the best you know, even more than the doctors, the therapists the ones in the trenches that
work with you. And, so if you want a better quality of life the therapists become the most
important people.”

“Because … the students learn more about what I am going through and what they can
expect from people like this, then they can tailor their learning, their experiences to help
other people more.”

“I think it’s a great thing… that not only I learn something from them but I kind of feel
like it was a twofold thing because I gave back to them….”

Collaboration with “You feel good that the students are doing something to learn, but it also, they’re doing
Students something to help me, so it’s kind of assisting each other.”

“Students have that way of having that sort of unconditional hope and that unconditional
hope is infectious.”

Sense of Connectedness
Participants reported feeling a sense of connectedness from participating in the outreach program(s) that
they were involved in. It appeared that these programs provided support, motivation, and social
interaction that were not previously received. One participant reported, “I have met so many people here.
I’ve been here most of my life in Mount Pleasant and never have I met as many people as I have through
this.” Participants also commented on meeting new people and building relationships within their
community, which helped to reduce feelings of isolation and allow them to feel physical and emotional
connectedness. A caregiver noted that “Parkinson’s people tend to draw back and isolate themselves
whereas in the smaller community, look at here, you’re drawing people from all over mid-Michigan to
CMU and so you’re like a little family.”

Support

Participants overwhelmingly reported that being a part of the program made them feel positively
supported, by both students and other participants in the group. A community participant commented,
“Just being around other people, friendly people…. that cares about me and gets me through this. So
yeah, yeah I think it’s help[ed] out quite a bit just being around the people here.” Several individuals also
mentioned having limited outside support from family and/or their rural community, with one participant
stating, “other than the college, I have no support.” Another participant stated, “It feels like I don’t have
as many choices on options to handle what I’m going through.” One community partner commented,
“Absolutely necessary program, especially in a rural area which has very little to offer for rehab services, as well as
for people who have little or no insurance benefits to help them continue therapy.” Participants noted the
university program(s) helped to address lack of resources and/or aided in providing more support for their
neurological condition. One participant stated, “I feel a little better knowing you know, being with other
patients that I’m not the only one like that to begin with.”

Motivation & Mood

The connectedness felt while participating in the programs appeared to provide motivation to keep
exercising weekly, to be more active outside of the programs, and to further engage in social situations
and relationships. One participant expressed how she felt motivated and encouraged by the community
outreach program she participated in. “I like the social aspect. I like the physical. I love the people. It’s
encouraging seeing people moving.” Participants believed that their participation in the outreach
program(s) had a positive effect on their mood and emotional state as well. A participant revealed, “I love
coming here because even if you feel a little down... once I get in here and see the smiles on these young
kids. It’s invigorating.” A number of participants felt that not only did the exercises improve their moods,
but the program(s), other participants, and DPT students helped keep them positive and hopeful. One
participant stated, “I didn’t want to come because I didn’t feel good and once I got here, this group, the
kids, and the patients, just don’t let you be [down] like that.”

Self-Awareness & Knowledge of Neurologic Condition

The second theme identified was improved awareness about the neurological condition the participant
was living with. Awareness was improved through education and exercise.

Importance of Exercise and Movement to Manage Symptoms

Most participants commented on how the program(s) helped them understand the importance of exercise
to remain as independent as possible with their neurologic condition. Some noticed how exercise could
allow them to stay active and healthy as stated, “I think having been through these experiences with PT-
CONECT and MOVE! has helped reinvigorate my attitude about exercise.” The participants stated that
the program(s) allowed them to become more physically active than they previously were, while at the
same time gaining strategies to address current symptoms, such as balance and strength impairments.
With the management of their symptoms one participant stated, “you can physically improve your
strength and ability to balance and the ability to be ah, to be out in public.” Another stated, “a
community-based program is so very important in my life because it is the only way that I get better.” A
caregiver discussed how these programs have impacted their loved one’s daily life and safety, “Well I
notice that the MOVE! has been very beneficial and that his gait is stronger, his balance is improved
when he focuses on balance.” Lastly, a participant stated how these programs have helped maintain their
physical ability to move around by improving the management of their symptoms, “I cannot state enough
how important these things are because without an experience like this I would be losing ground in my
ability to get around and the students have been phenomenal. So, this has been a great experience.”

Education Provided Insight on Neurologic Conditions

All participants mentioned that they learned more about their condition by participating in these
programs. Students introduced exercises, strategies to manage symptoms, and ideas on how to continue to
be more active at home. A participant stated how the education provided has enhanced their knowledge
about their neurologic condition by stating, “You can always learn. I really wasn’t sure about Parkinson’s
except for you know being stiff and starry eyed down the road. But I’m thinking no, they help you in your
exercises. Boy, they come up with a lot of exercises you think just amazing. It’s a big help.”

Student Interaction
The third major theme identified was the student-participant interaction. All participants enjoyed the
collaboration with students and valued their role in helping students learn.

Aiding in DPT Student Development

Participants in the study volunteered to take part in community outreach programs and by doing so
provided the DPT students with hands-on experience working with individuals with neurologic
conditions. The students learned how to apply their classroom education to real life situations with the
objectives of improving functional mobility as stated by a participant “I think it’s a great thing um, to be
able to learn new things, ah, from younger students or younger people and the idea that not only I learn
something from them but I kind of feel like it was a twofold thing because I gave back to them because
they got to work on the public basically.”

Collaboration with Students

The students utilized evidence-based practice and newly minted research in order to create the best
exercise approach for participants. The participants stated that the personal relationships created resulted
in a willingness to try the novel exercises provided by students, “it was nice to interact with people in
their 20’s and they’re very enthusiastic and they’re really excited about their field and they want to try out
new things and say ‘oh let’s do this.” Another participant mentioned, “The enthusiastic and tireless
students were so good for me. To be able to have so many volunteers help with the program and stay
upbeat and friendly was just what I needed.”

Discussion

The purpose of this study was to explore the impact of a Doctor of Physical Therapy program’s
community-based outreach programs on community members with neurologic conditions from two rural
communities. The study’s findings indicated that participants were provided with a sense of
connectedness through supportive relationships, improved knowledge about their neurological condition,
and valued the student and participant interaction. An overarching theme of empowerment was identified
to help participants independently manage their condition through improved knowledge and health
awareness.

The obstacles faced by individuals living in rural areas remain different than those living in urban areas. 1,
4-9
Economic factors, social differences, educational shortcomings, and isolation of living in a rural area
all create the existing health care disparities. 17 The findings support previous studies that those living in
rural environments often have to travel greater distances in order to access appropriate health care
providers.1, 2, 4, 5, 7 Physician access in rural areas is 39.8 physicians per 100,000 people compared to 53.3
physician per 100,000 in urban areas.17 This unbalanced distribution of physicians has a negative impact
on the health of rural communities.1, 17 Pro-bro clinics, such as the one used in this study, aid in bridging
the gap and have been shown to be beneficial in rural communities where there is limited access to
healthcare.18

This study supports current literature describing how it is difficult to define the term “rural” within a
community.1,2 Numerous community partners in the Mount Pleasant region did not consider their location
to be rural, although by definition it is; whereas community partners living in Houghton in the Upper
Peninsula of Michigan did feel they lived in a rural environment with extreme limitations to access of
outside healthcare resources. Unlike most rural communities, income and level of education were not
identified as disparities in this study. The researchers suspect that this is due to the close proximity of a
university in each location. Despite this, this study showed that participants still reported having limited
access to healthcare resources and felt they positively benefited from the community outreach program(s).

Overall, the university-based outreach programs appeared to provide an empowering foundation for
people living with a neurologic condition by providing social and emotional support, education, and a
greater sense of community involvement, which is supported by current literature. 8-11, 19 Specifically, this
study differs from general community-outreach programs, such as Commission on Aging and local
community centers, because it involved university-based programs and offered a student learning and
partnership component. The interaction of the DPT students with the community provided a unique
educational experience to students, as well as free, hands-on support to community partners.

The study’s findings on community-based programs may be beneficial to individuals who have been
diagnosed with a neurological condition to improve their sense of empowerment, provide connectedness
through a group setting, promote self-awareness through healthcare education, and expand DPT student
knowledge and learning. DPT educational programs in or near rural areas should consider how they can
improve access to support and education for people with neurologic conditions since there is a value to
both parties, while also addressing health disparities. Further research is warranted in order to form a
clearer definition of the term “rural,” narrow the health care gap for individuals living in rural
communities, and further assess the benefits of community outreach programs in rural areas.

Limitations

Purposive sampling was used to recruit community members with neurologic conditions who participated
in at least one community outreach program associated with the DPT program. This study’s patient
population was broad and consisted of individuals with multiple neurologic conditions that were not
equally represented. This may have jeopardized the external validity, and the results cannot be
generalized to an entire neurologic population or another DPT program. The sample size was small.
Several of the participants participated in other exercise programs outside of those studied, which may
have influenced their experiences with the programs from the university.

Conclusion

University-based outreach programs, such as those through DPT programs, are imperative to surrounding
rural communities in order to provide necessary healthcare services, while also promoting the American
Physical Therapy Association’s Code of Ethics to address health disparities and the healthcare needs of
community members. Both students and community members can benefit through these efforts, while
providing empowerment, improving overall quality of life, and addressing health disparities to those with
limited access to healthcare in rural communities.

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