Sage Journals: Discover world-class research

Abstract

Background

Equity-deserving groups face well-known health disparities that are exacerbated by rural residence. Health technologies have shown promise in reducing disparities among these groups, but there has been no comprehensive evidence synthesis of outcomes.

Purpose

The purpose of this systematic review was to examine the patient, healthcare, and economic outcomes of health technology applications with rural living equity-deserving groups.

Research Design

The databases searched included Medline and Embase. Articles were assessed for bias using the McGill mixed methods appraisal tool.

Analysis

Data were synthesized narratively using a convergent integrated approach for qualitative and quantitative findings.

Results

This evidence synthesis includes papers (n = 21) that reported on health technologies targeting rural equity-deserving groups. Overall, patient outcomes - knowledge, self-efficacy, weight loss, and clinical indicators - improved. Healthcare access improved with greater convenience, flexibility, time and travel savings, though travel was still occasionally necessary. All studies reported satisfaction with health technologies. Technology challenges reported related to connectivity and infrastructure issues influencing appointment quality and modality options. While some studies reported additional costs, overall, studies indicated cost savings for patients.

Conclusions

There is a paucity of research on health technologies targeting rural equity-deserving groups, and the available research has primarily focused on women. While current evidence was primarily of high quality, research is needed inclusive of equity-deserving groups and interventions co-designed with users that integrate culturally sensitive approaches. Review registered with Prospero ID = CRD42021285994.

Keywords

rural equity-deserving groups health technology

Introduction

Individuals living in rural areas face significant healthcare access barriers,^1–3 including provider shortages, geographical hurdles, high-speed internet unavailability, and service scarcity.^3,4 Overall, evidence suggests a widening gap in mortality and morbidity between rural and urban populations.⁵ Studies point to rural populations being older, unhealthier, less affluent, and scoring lower on social determinants of health than urban populations.⁶ Superimposed on rural location are socio-demographic factors that have been shown to impact health and health inequalities and are heterogeneous between and within rural communities.^7,8 One USA study hypothesized that rural dwellers would outlive their urban counterparts if social demographics and healthcare access were similar.⁹

Building on the literature on urban-rural health and healthcare disparities, there is an emerging body of knowledge focusing specifically on the needs and challenges of equity-deserving groups living in rural areas. Equity-deserving groups are comprised broadly of Black, Indigenous, Persons of Colour (BIPOC); Persons with Disabilities; Women; and Lesbian, Gay, Bi-Sexual, Trans, Queer, and 2-Spirit (LGBTQ2S*) individuals.¹⁰ These population groups face additional barriers in accessing resources due to systemic disadvantage and discrimination and are acutely affected by inequitable access to healthcare.¹¹ Evidence shows existing and widening health disparities between equity-deserving and non-equity-deserving groups.^12–14 One USA-based study showed that rural areas with predominantly black and indigenous populations had the highest premature death rates.¹⁵ Studies have demonstrated disparities among rural women compared to urban women across a wide range of healthcare services, including preventive care,¹⁶ cardiac care,¹⁷ and cancer care.¹⁸ Similarly, the disparities in access, health outcomes, and experiences of sexual and gender minorities in rural areas are well documented.¹⁹

Digital technologies emerging in the new millennia have shown promise in addressing inequitable healthcare access in rural communities.²⁰ Digital technologies include software or hardware that utilize computers, smartphones, tablets, and wearables to deliver care, facilitate communication, and monitor health status. The availability of varied online technologies for providing education and healthcare (e.g., appointments, lab results review) shows enormous potential and benefit for rural health delivery and access.³ However, research has shown barriers to digitalization in rural areas, including socio-cultural (e.g., distrust, fear), technical (e.g., lack of connectivity), economic (e.g., costs), and regulatory-institutional (e.g., data management).²¹

There is also increasing demand from equity-deserving groups for digital solutions to address healthcare access barriers. Mounting evidence suggests that equity-deserving groups find technology-enabled healthcare acceptable for a variety of services, such as palliative care,²² chronic disease management,²³ health promotion,²⁴ and mental health.²⁵ Despite preliminary evidence supporting health technologies for equity-deserving groups in rural communities, no comprehensive synthesis of health technologies targeting rural equity-deserving groups has been conducted. Equitable care and inclusive technologies for equity-deserving groups are a priority for healthcare systems.²⁶ A systematic review of the current state and progress of evidence in this domain to date could be a valuable addition to this growing body of knowledge and have meaningful implications for practitioners and policymakers.

The purpose of this systematic review was to examine the patient, healthcare, and economic outcomes of health technology applications used with rural living equity-deserving groups. Specific questions included: (1) Do health technologies serving equity-deserving populations in rural communities improve outcomes (i.e., patient-reported, clinical indicators, healthcare-related, cost-related) and; (2) What are the economic implications of the use of health technologies (i.e., cost of telehealth interventions) for equity-deserving rural populations.

Methods

This study used a mixed studies systematic review to maximize the scope of evidence by integrating mixed studies.²⁷ It is important to distinguish mixed studies reviews from mixed methods reviews, as the former involves the integration of studies with diverse designs (Quantitative, Qualitative, Mixed Methods), while the latter specifically encompasses reviews that include only studies employing mixed methods, integrating both quantitative and qualitative approaches.²⁷ In health research, mixed studies reviews prove particularly valuable given the intricate and context-specific nature of the phenomena, enabling a comprehensive understanding of the multifaceted challenges and opportunities inherent in complex contexts such as health technology applications used with rural living equity-deserving groups.²⁷

Search Strategy

The search strategy was developed in conjunction with a health sciences librarian (RJ) who grouped keywords, subject headings, and MeSH terms into the main subject areas: “rural,” “equity-deserving groups,” and “health technology.” Before finalization, the search strategy was reviewed by all team members for appropriateness (See Appendix A). The databases searched included Medline and Embase. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.²⁸ Database searches were limited to publications from the previous decade (2011) to October 11, 2023, to capture relevant technology and emerging innovations. Records generated by the search were managed using Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia) for organization, removal of duplicates, screening, full-text review, and quality assessment.

Inclusion/Exclusion Criteria

Included studies met the following criteria: (1) a health technology intervention for patients (inclusive of virtual visits, wearables, apps, and websites); (2) rural populations or settings; (3) one or more equity-deserving groups (i.e., Black, Indigenous, and Persons of Colour (BIPOC), Persons with Disabilities, Women, or Lesbian, Gay, Bi-Sexual, Trans, Queer and 2-Spirit (LGBTQ2S*)); and (4) Geographical location of Canada, USA, Australia, or New Zealand. Studies were limited to English-speaking countries with similar geographical rurality challenges (topographically, bandwidth infrastructure). Studies were excluded if they were not original research (e.g., editorials), protocols, pilot or feasibility studies, review articles, or focused on children or youth under 19 years of age.

Article Selection

Following standard review guidelines, dual reviewer (LB & MF) title and abstract screening was completed on a 20% sample of records from the final citation library (with duplicates removed) against the stated inclusion and exclusion criteria.²⁹ Following the dual screening, conflicts were resolved, inclusiveness criteria were clarified, and modifications were made as appropriate with three team members (LB, MF, & KLR). Following screening calibration, the remaining title and abstract screening were conducted independently by two team members (LB & MF), consistent with systematic review methodologies.²⁹ Conflicts were assessed and resolved using consensus by two team members (LB & MF). The full-text review process was piloted with 10 articles to calibrate the process before the remaining articles were reviewed independently by two team members (LB & MF),²⁹ and any disagreements were resolved through discussion with a third team member (KLR). The final search results are presented in a PRISMA diagram (Figure 1).

Figure 1.

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71.

Quality of Evidence

Articles were assessed for bias using the McGill mixed methods appraisal tool (MMAT; version 2018).³⁰ The MMAT was the most appropriate risk of bias tool as it allows for tailored appraisal based on study design^27,31 and has been used extensively in previous mixed studies reviews.^32–34 No studies were excluded based on the risk of bias assessment.^27,31,35 Each study design was scored “yes” or “no” according to five criteria to create a total score ranging from 0 (high risk of bias) to 5 (low risk of bias). A single reviewer (MF) conducted risk of bias assessments that were verified by a second reviewer (LB).

Data Extraction

The data extraction focused on equity-deserving groups, the health technology interventions, and three important categories of outcomes: (1) patient-related (e.g., health metrics, satisfaction), (2) healthcare-related (e.g., access, utilization), and (3) cost-related. The data extraction tool, developed in Excel (see Appendix B), was piloted using two included studies before being entered into Covidence for final extraction.²⁹ Data extraction was then conducted by a single reviewer (MF), which was checked for correctness and completeness by a second reviewer (LB).²⁹ Findings related to each of the outcomes, whether significant or non-significant) were extracted and did not undergo recalculations or transformation. Significant results refer to statistical significance unless specified as clinical significance.

Analysis

Study characteristics were analyzed descriptively (e.g., countries/equity-deserving populations represented, health technologies used, research design). Findings were synthesized narratively from extracted study outcomes and grouped according to each research question (patient, healthcare, and cost-related outcomes).²⁹ Quantitative and qualitative findings were integrated within appropriate outcome groups to enhance understanding of both effectiveness (quantitative) and experience (qualitative).³⁶

Findings

Overview of Studies

The 21 studies that met the inclusion criteria included 4240 participants and were conducted in three countries: Australia (n = 3), Canada (n = 2), United States (n = 17). Study research designs included qualitative (n = 1), quantitative randomized control trial (11), quantitative non-randomized (n = 7), and quantitative descriptive (n = 1). Only one paper had a lower MMAT rating of 3, indicating a risk of bias, and all other papers had mid to high quality ratings of 4 or 5, indicating a lower risk of bias (Table 1). The broad service categories represented in the studies included cancer care (n = 4), chronic disease management (n = 2), mental health (n = 3), perinatal care (n = 5), weight loss (n = 6), and infectious disease (n = 1). A summary of included articles is presented in Table 2.

Table 1.

MMAT Quality Rating.

Study ID	Title	Rating	Notes
Ahlers-Schmidt 2021	Promoting Safe Sleep, Tobacco Cessation and Breastfeeding to Rural Women During the COVID-19 Pandemic: Pre-Post Study.	4	confounders not accounted for in design and analysis
Arnold 2022	Rural patients highly satisfied with gynaecological oncology care via telehealth.	4	No rationale provided
Badour 2023	Improvement in Post-traumatic Stress Symptoms Following an Internet-based Cognitive-Behavioral Intervention for Insomnia: An Open Trial among Rural Appalachian Women.	4	Risk of sampling bias
Befort 2016	Weight loss maintenance strategies among rural breast cancer survivors: The rural women connecting for better health trial	4	Low adherence to intervention
Belkora 2012	Decision support by telephone: Randomized controlled trial in a rural community setting	5
Champion 2023	Comparative Effectiveness of 2 Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening Among Women in the Rural US: A Randomized Clinical Trial.	5
Griffin 2018	My Quest, an Intervention Using Text Messaging to Improve Dietary and Physical Activity Behaviors and Promote Weight Loss in Low-Income Women.	4	3.4 not clear in study description
Hageman 2017	Web-Based Interventions Alone or Supplemented with Peer-Led Support or Professional Email Counseling for Weight Loss and Weight Maintenance in Women from Rural Communities: Results of a Clinical Trial.	5
Hageman 2019	User Engagement Associated with Web-Intervention Features to Attain Clinically Meaningful Weight Loss and Weight Maintenance in Rural Women.	3	Limited information provided regarding randomization and blinded assessing
Ireland 2020	'I didn't feel judged': exploring women's access to telemedicine abortion in rural Australia.	5
Johnston 2019	Using Smartphones to Improve Treatment Retention Among Impoverished Substance-Using Appalachian Women: A Naturalistic Study.	3	3.4 and 3.5 not adequately addressed
Joshi 2015	Comparison of Socio-Demographic Characteristics of a Computer Based Breastfeeding Educational Intervention Among Rural Hispanic Women.	4	No information on blind intervention
Kapinos 2019	The Use of and Experiences With Telelactation Among Rural Breastfeeding Mothers: Secondary Analysis of a Randomized Controlled Trial.	4	2.4 not addressed
Kupzyk 2020	Behavior-Specific Cognitions Moderate Rural Women's Responsiveness to Web-Based Interventions for Weight Loss.	4	adherence not reported
Mashru 2017	Management of infectious diseases in remote northwestern Ontario with telemedicine videoconference consultations.	3	4.4 and 4.5 not properly addressed
O'Neal 2022	Differential impact of telehealth extended-care programs for weight-loss maintenance in African American versus white adults.	4	No information on blind assessment
Shore 2012	Characteristics of telemental health service use by American Indian veterans.	5
Solomons 2018	Examination of the Patient-Focused Impact of Cancer Telegenetics Among a Rural Population: Comparison with Traditional In-Person Services.	4	incomplete outcome data
Tobe 2019	Diagnosing hypertension in Indigenous Canadians (DREAM-GLOBAL): A randomized controlled trial to compare the effectiveness of short message service messaging for management of hypertension: Main results.	4	2.4 not addressed
Weinert 2011	Computer intervention impact on psychosocial adaptation of rural women with chronic conditions.	4	No blind assessment
Leighton 2019	Implementation and Impact of a Maternal Fetal Medicine Telemedicine Program.	4	Insufficient information provided about confounder variables

Seven articles provided a definition for rurality. These were based on designation by U.S. census,³⁷ Rural-Urban Commuting Area Codes provided by U.S. Department of Agriculture, Economic Research Service,^38,39 National Rural Health Association Policy Position,⁴⁰ Federal designation as medically underserved area/medically underserved population by U.S. Census Bureau,⁴¹ Accessibility and Remoteness Index (Australia),⁴² and 25 miles outside a town or a city of 12,500 or more.⁴³

There were very few equity-deserving groups represented in the sample. Most studies (n = 17) focused on women, one on African Americans, and four Indigenous peoples, and of these, one targeted Indigenous people with disability. In 10 of the studies on women, the majority (over 90%) of the sample was Caucasian, two Australian studies did not report ethnicity,^42,44 and the other two studies that focused on women had 43%⁴⁵ and 69%⁴⁶ Caucasian representation, and one study included only Hispanic women.⁴⁰ Technology targeting equity-deserving groups included smartphone applications (n = 2), phone (n = 5), videoconferencing (n = 7), SMS (n = 2), website (n = 5), electronic newsletter (n = 1), and pre-recorded presentations (n = 1). The technologies were delivered to participants synchronously (n = 9), asynchronously (n = 10), or in combination (n = 2) (see Table 2).

Table 2.

Summary of Included Articles.

Author, year, country	Study design, quality rating	Sample	Service category	Technology intervention	Outcomes
(Ahlers-schmidt et al., 2021)United States	Study design = quantitative nonrandomizedQuality rating = 4	Sample size = 242Mean age = not reportedEquity group = womenPercent caucasian = 60%–69%Income level = not reported	Perinatal	Videoconference, pre-recorded presentations shared with participants: Safe sleep community baby showers which bring together pregnant and support individuals to celebrate pregnancy and receive education. Education topics include risk reduction strategies to prevent sleep-related infant deaths, including safe sleep position and surface, breastfeeding, and tobacco-free environments. The program was adapted to virtual during COVID-19	Patient outcomes: In-person participants showed an increase in intention to follow safe sleep practices related to anticipated sleep position (pre: 128/144, 89% vs post: 142/144, 99%; p < .001), anticipated sleep surfaces (pre: 126/145, 87% vs post: 140/145, 97%; p = .001), anticipated crib items (pre: 86/130, 66% vs post: 123/130, 95%; p < .001), and discussing safe sleep with others (pre: 90/138, 65% vs post: 132/138, 96%; p < .001. Virtual participants showed in increase in intention to only placing their baby on the back to sleep (pre: 63/74, 85% vs post: 74/74, 100%; p = .001), safe sleep surfaces (pre: 60/73, 82% vs post: 71/73, 97%; p = .001), inclusion of only safe items in the crib (pre: 58/73, 80% vs post: 71/73, 97%; p < .001), and discussing safe sleep with others (pre: 53/73, 73% vs post: 73/73 100%; p < .001). No differences in anticipated safe sleep practices were observed between in-person and virtual groupsHealthcare outcomes: Satisfaction with events was high in both groups. No significant differences in satisfaction between in-person and virtual participants (p = .27)
(Arnold et al., 2022)Australia	Study design = mixed methodsQuality rating = 4	Sample size = 53Mean age = 56Equity group = womenPercent caucasian = not reportedIncome level = not reported	Cancer care	Videoconference: Women with a suspected or proven diagnosis of a gynaecological malignancy receive pre and post surgery consultations using video telehealth services	Healthcare outcomes: Mean overall satisfaction was 90.5% (SD 8.7%, median 93.8%, IQR 80.0– 98.8). The lowest overall patient satisfaction was 77.5% and highest 100%. Themes emerging from the open questions were emotions experienced by women (fear and anxiety leading up to survey), communication (central to consultations), relationship building (positive influence), and acceptability of the service (satisfaction with service)
(Badour et al., 2023)United States	Study design = quantitative nonrandomizedQuality rating = 4	Sample size = 37Mean age = 55Equity group = womenPercent caucasian = 95%Income level = not reported	Mental health	Website: Participants were given 9 weeks to complete six once-weekly modules from the “sleep healthy using the internet” program covering insomnia overview, sleep restriction, stimulus control, cognitive restructuring, sleep hygiene, and relapse prevention	Patient outcomes: PTSD symptoms decreased significantly from pre- to post-treatment, t(36) = −2.81, SE = 0.65, p = .008. PTSD symptoms reduced significantly when adjusting for pre-treatment insomnia and depression severity, F(1,34) = 4.06, p = .05
(Befort et al., 2016)United States	Study design = quantitative randomized controlled trialsQuality rating = 4	Sample size = 172 mean age = 57.0 (8.1)Equity group = WomenPercent caucasian = 99%Income level = not reported	Cancer care	Phone: Rural breast cancer survivors who lost >5% of their starting weight during a 6-months lifestyle intervention (delivered through weekly group conference calls) were randomized to one of two 12-months interventions for weight loss maintenance, continued biweekly phone-based group counseling or mailed newsletters. The maintenance phone sessions incorporated a social cognitive approach to relapse prevention using problem solving. Newsletters were mailed at the same frequency as the phone sessions and covered the same educational content plus updates unique to each group	Patient outcomes: Phone group participants regained less weight (3.3 [4.8] kg) compared with newsletter participants (4.9 [4.9] kg; p = .03). Adjusting for phase1 weight loss, percent weight loss from baseline to 18 months was significantly higher in phone group (10.6% [7.8]) compared with newsletter (9.3% [8.0]); p = .03)Cost: Program costs totaled $280/participant in group phone counseling and $88/participant in the newsletter condition
(Belkora et al., 2012)United States	Study design = quantitative randomized controlled trialsQuality rating = 5	Sample size = 67Mean age = 59Equity group = womenPercent caucasian = 90%Income level = 48% >150% over federal poverty	Cancer care	Phone: Rural women with a diagnosis of breast cancer received telephone or in-person consultation planning. Consultation planning consisted of question coaching and sharing of a typed list of questions in preparation for doctor appointments	Patient outcomes: The pre-intervention scores were not statistically distinguishable between groups, nor were the change scores, either per-protocol or after intent-to-treat imputationsCost: The sample means were not statistically distinguishable for intervention cost, in person ($144 SD=$199), telephone ($154, SD=$195)
(Champion et al., 2023)United States	Study Design = Quantitative randomized controlled trialsQuality Rating = 5	Sample Size = 963Mean Age = 58.6Equity Group = WomenPercent Caucasian = 97%Income level = 19% < $40,000	Cancer Care	DVDs and Phone: The DVD interactively assessed and provided messages for health beliefs, including risk of developing the targeted cancers and barriers, benefits, and self-efficacy for obtaining the needed screenings. Patient navigators counselled women on barriers to obtaining screenings. The intervention also supported obtaining screening for all or any tests outside of guidelinesat baseline	Patient Outcomes: the DVD/Patient Navigator intervention, but not the DVD intervention alone, was significantly more effective than usual care (OR, 4.01; 95% CI, 2.60-6.28; p < .001) for promoting an up-to-date screening status for any of the cancers at 12 months. Cancer screening intention (OR, 1.85; 95% CI, 1.33-2.59; p < .001), higher knowledge (OR, 1.20; 95% CI, 1.01-1.42; p = .04) and self-efficacy (OR, 1.07; 95% CI, 1.002-1.14; p = .047) had greater odds of being up to date. Those living in less disadvantaged rural areas were more likely to obtain cancer screening (OR, 0.99; 95% CI, 0.98-0.998; p = .03)Technology Cost: $326,012 for the DVD intervention and $344,829 for the DVD/PN intervention
(Griffin et al., 2018)United States	Study Design = Quantitative nonrandomizedQuality Rating = 4	Sample Size = 104Mean Age = 36.1 (8.1)Equity Group = WomenPercent Caucasian = 43%Income level = 64% <25000/yr	Weight loss	SMS; Weekly electronic newsletters: Participants received short health tips, exercises, goal-setting prompts, and reminders via text messages. Weekly electronic newsletters provided tips, recipes. Self-monitoring of body weight was required weekly	Patient Outcomes: Significant reduction in mean bodyweight (204.3 vs 199.6lb; t⁵⁵ = 3.047; p = .004) and mean BMI (34.7 vs 33.9); t⁵⁵ = 3.254; p = .002) from pre-to post-assessment
(Hageman et al., 2017)United States	Study Design = Quantitative randomized controlled trialsQuality Rating = 5	Sample Size = 301Mean Age = 53.9 (6.9)Equity Group = WomenPercent Caucasian = 97.3%Income level = 77% > $40,000/yr	Weight loss	Website; email: Intervention comprised of website access or website supplemented with email counselling or peer-led discussion board. Website with messages and self-tracking. Content focused on healthy eating and activity lifestyle modification to target ≥5% initial body weight loss. The tracking tool permitted daily self-tracking of weight, calorie intake, fat grams, pedometer steps, physical activity, and weekly goals. Professional email counselling focused on weight loss or guided weight maintenance	Patient Outcomes: The intervention groups did not differ significantly from each other in body weight and waist circumference. Mean weight loss at 6 months ranged from 4.0 to 5.8 kg, representing from 4.2% to 6.2% of initial body weight. Mean decreases in waist circumference ranged from 4.6 to 6.2 cm. Average weight increased approximately 2 kg from 6°months to 18°months. Weight change was significantly related to website utilization (𝑟 = −0.25,p < .01), with greater participation correlated with greater success with weight loss and weight maintenance over the trial
(Hageman et al., 2019)United States	Study Design = Quantitative randomized controlled trialsQuality Rating = 5	Sample Size = 201Mean Age = 54.4 (6.9)Equity Group = WomenPercent Caucasian = 99%Income level = 85% full or part-time employed; 77% >$40,000/yr “high socioeconomic status”	Weight loss	Website; email: Intervention comprised of website access or website supplemented with email counselling or peer-led discussion board. Website with messages and self-tracking. Content focused on healthy eating and activity lifestyle modification to target ≥5% initial body weight loss. The tracking tool permitted daily self-tracking of weight, calorie intake, fat grams, pedometer steps, physical activity, and weekly goals. Professional email counselling focused on weight loss or guided weight maintenance	Patient Outcomes: Women in the web-based with email counselling intervention group were 1.79 times more likely to meet the weight-loss targets when compared to the web-only group (b = 0.29, se = 0.14, p = .036). Women with low engagement with self-tracking were 0.31 times as likely to meet the weight loss targets as highly engaged women (b = −1.12, se = 0.29, p < .001). women with low (b = −1.37, se = 0.32, p < .001) and moderate (b = −0.97, se = 0.31, p = .002) message engagements were 0.25 and 0.38°times as likely, respectively, to achieve the weight-loss targets when compared to women with high engagement
(Ireland et al., 2020)Australia	Study Design = QualitativeQuality Rating = 5	Sample Size = 11Mean Age = 23 to 38 rangeEquity Group = WomenPercent Caucasian = Not reportedIncome level = Not reported	Perinatal	Phone: Medical abortion services performed using telephone	Healthcare Outcomes: Access to telemedicine services required high-level English and digital literacy skills to search and identify the telemedicine service online. While medical abortion was within scope of practice for local GP women reported they were unhelpful with providing this service. They also experienced stigma. Even with telemedicine women were burdened with travel for screening checks. All study women highly valued the technical care offered by telemedicine staffCost: Costs of $AUD250–350 compared to $AUD1500 for surgical abortion
(Johnston et al., 2019)United States	Study Design = Quantitative nonrandomizedQuality Rating = 5	Sample Size = 98Mean Age = 27.89 (18-40 range)Equity Group = WomenPercent Caucasian = 98%Income level = 93% unemployed	Mental Health and Substance Use	App: Smartphone-based relapse-prevention system, A-CHESS (Addiction-Comprehensive Health Enhancement Support System) compared to non-equivalent control. Women were provided basic smartphones for the 6-months intervention duration. The app included (1) communication with addiction experts and peer support groups, including confidential chat rooms and private messaging; (2) timely monitoring, feedback related assessment, and links to interventions addressing relapse risk; (3) reminders and alerts to encourage adherence to therapeutic goals; (4) one-touch communication with the patient’s counsellor and/or case manager; (5) addiction-related educational materials and tools; and (6) customizable location-based resource. Case managers and counselors could access patient check-in data before appointments and after lapses	Patient Outcomes: A-CHESS patients stayed in treatment for a mean of 410 days, vs 262 days for the comparison group. App use decreased over time, almost half of the patients (46.8%) still logged use in during final month. No change in reports of substance use between study intake and follow-up. Without control or comparison group responses, no pre-post differences can be attributed to A-CHESS.
(Joshi et al., 2015)United States	Study Design = Quantitative randomized controlled trialQuality Rating = 4	Sample Size = 46Mean Age = 25Equity Group = Women; HispanicPercent Caucasian = 0%Income level = 74% <$30,000 household income	Perinatal	Computer Program: The intervention group received education using a computer-based breastfeeding educational support program. The control group received bilingual breastfeeding printed educational material during their prenatal visit	Patient Outcomes: There was no significant difference between study groups in breastfeeding knowledge (intervention mean = 23, SD = 4; control mean = 22, SD = 4), breastfeeding self-efficacy (intervention mean = 53, SD = 12; control mean = 56, SD = 10), and breastfeeding attrition (intervention mean = 28, SD = 6; control mean = 28, SD = 5)
(Kapinos et al., 2019)United States	Study Design = Quantitative randomized controlled trialsQuality Rating = 4	Sample Size = 94Mean Age = 26 (5)Equity Group = WomenPercent Caucasian = 95%–97%Income level = Not reported	Perinatal	App & Videoconference: Telelactation services connect breastfeeding mothers to remotely located International Board-Certified Lactation Consultants through audio-visual technology	Patient Outcomes: Most telelactation users (43/47, 91%) expressed satisfaction with the help received. Telelactation users were more likely to be working at 12°weeks postpartum (21/31, 68%; p = .02) compared to nonusers (26/63, 41%). Telelactaion users were less likely to have prior breastfeeding experience (users 12/31, 39%, p = .02; nonusers 41/63, 65%) and to have breastfed exclusively prior to discharge from the hospital (users 16/31, 52%, p < .001; non users 51/63, 81%)Healthcare Outcomes: 41% (34/83) of video calls occurred outside of regular business hours (defined as any time between 8°AM and 6°PM, excluding weekends). The majority of telelactation users found the app was helpful (41/47, 87%) and were satisfied (43/47, 91%). 36/47 (78%) did not report experiencing any technical difficulties
(Kupzyk et al., 2020)United States	Study Design = Quantitative randomized controlled trialsQuality Rating = 4	Sample Size = 200Mean Age = 53Equity Group = WomenPercent Caucasian = 98%Income level = 50% ≥ $60,000	Weight loss	Website: Comparison between a and website intervention enhanced with either Web discussion or professional email counseling. The website offered features of goal setting and tracking options for weight, food intake, and activity and messaging about lifestyle changes for healthy eating and activity. The Discussion group had access to asynchronous discussion with the peer leader providing primers on a fixed schedule. The professional email counselor was a registered dietitian who provided personalized e-mails on women’s logging and goal setting on the Website	Patient Outcomes: For women with low perceived barriers to healthy eating and activity, the Email group had greater weight loss. Women with a high number of perceived barriers performed better in the Discussion group. Women with high self-efficacy for eating responded better to the Email condition than the Discussion condition. For women with lower eating self-efficacy, the Discussion condition was more beneficial. Women with high self-efficacy for activity responded better to the Email condition than the Discussion condition. For women with lower activity self-efficacy, the Discussion condition was more beneficial
(Leighton et al., 2019)United States	Study Design = Quantitative nonrandomizedQuality Rating = 4	Sample Size = 455Mean Age = 28.6Equity Group = WomenPercent Caucasian = 96%Income Level = N/A	Perinatal	Videoconference: Teleconsult centers were established in rural areas where high-risk pregnancies could consult over video with maternal fetal medicine specialists. Tele-ultrasounds were also performed for real time transmission of images to the specialist	Patient Outcomes: There were no significant differences between groups on Cesarean rates (>40%) and fetal deaths (2%). Telemedicine consultation had lower rates of premature delivery (p = .022) and lower rates of NICU use (p < .001). Length of NICU stay was shorter in the telemedicine consultation group compared with the in-person group (p < .001). Telemedicine were 0.65 times as likely to have a NICU stay for their baby (p = .02) and 0.20 times as likely to have babies with NICU stays longer than 1°day (p < .001) as the in-personHealthcare Outcomes: 80% of participants were very satisfied with the telemedicine visit and 83% had strong confidence in the physician’s telemedicine careCost: Telemedicine appointments saved patients $90.28 per consult
(Mashru et al., 2017)Canada	Study Design = Quantitative nonrandomizedQuality Rating = 3	Sample Size = 76Mean Age = 45.1Equity Group = IndigenousPercent Caucasian = 1%Income level = Not reported	Infectious Disease	Videoconference: Telehealth consultations with an infectious disease specialist in urban center through region telehealth clinics supported by a nurse	Healthcare outcomes: Overall patient satisfaction was 98% in the nine questions asked of each patient
(O’Neal et al., 2022)United States	Study Design = Quantitative randomized control trialQuality Rating = 4	Sample Size = 410Mean Age = 55.6Equity Group = African AmericanPercent Caucasian = 80%Income level = 47% < $50,000 household income	Weight loss	Phone: During Phase 1 of Rural LEAP, all participants received a 16-weeks, standard behavioral weight-loss program. This program was conducted in person, in groups of 4–16 participants led by trained health coaches. Participants who completed 50% of Phase 1 and Month 4 visit were randomly assigned to individual or group telephone counseling, or an educational control condition for extended care. Both individual and group calls occurred biweekly during months 5–10 and monthly during months 11–16. The educational control group received 18 weight-management education modules with the same content as the telephone groups. The modules were delivered via mail or email	Patient Outcomes: After taking into account Phase 1 wt loss, gender, and BMI, the study found a significant impact of the treatment condition (p = .003). The control group had a significant weight regain of 2.49 kg (95% CI: 1.47, 3.52), while the individual and group conditions had non-significant weight regains of 0.02 kg (95% CI: −1.08, 1.03) and 0.84 kg (95% CI: −0.27, 1.96), respectively. There was not a significant difference in weight regain between conditions among African-American participants. African American participants randomized to the individual condition regained 3.45 kg more (95% CI: −6.04, −0.86) from Month 4 to Month 16 than White participants
(Shore et al., 2012)United States	Study Design = Quantitative descriptiveQuality Rating = 5	Sample Size = 85Mean Age = 58 (9)Equity Group = DisabilityIndigenousPercent Caucasian = 0%Income level = Not reported	Mental Health and Substance Use	Videoconference: rural telemental health clinics connect patients to mental health services focused on PTSD using videoconference. Clinics utilize an outreach worker at the patient site	Healthcare Outcomes: Patients' use of any health services (both general medical and mental health services) significantly increased from 63 (74%) before telemental health intake to 78 (92%) after (p < .01), as did the proportion receiving appropriate psychotropic medication from 22 (26%) before telemental health intake to 60 (71%) after (p < .01)
(Solomons et al., 2018)United States	Study Design = Quantitative nonrandomizedQuality Rating = 4	Sample Size = 174Mean Age = 55 (15.5) remote; 49 (13.5) in-person p = .02Equity Group = WomenPercent Caucasian = 91%Income level = N/A	Weight loss	Videoconference: Rural hospital sites that provided telegenetic counselling for hereditary breast and ovarian cancer. Site had clinical staff who assisted telegenetic visits, including equipment, paperwork, provision of educational resources, and blood draws	Patient Outcomes: Knowledge increased significantly from pre to post counselling in both the telehealth (3.7 [2.25]; 6.6[1.54]; p < .0001) and in-person (4.1[2.18]; 6.9[1.63] p < .0001). There were no significant differences between groupsHealthcare Outcomes: 13% reported traveling ≥50 miles or more to their telegenetics appointment; 81% would have traveled ≥50 miles to access in-person services. Telegenetic services required fewer patients or supports miss work and eased child care needs. 90% of technical problems reported were adequately addressed. Over 90% of respondents were satisfied across all the satisfaction questions
(Tobe et al., 2019)Canada	Study Design = Quantitative randomized controlled trialsQuality Rating = 4	Sample Size = 142Mean Age = 48.7 (12.8) active messages; 49.1(13.1) passive messagesEquity Group = IndigenousPercent Caucasian = 0%Income level = Not reported	Chronic Diseases	SMS: Hypertension control using active (SMS with hypertension specific messaging) or passive (SMS on health behaviors). 12 active messages and 26 passive messages were sent twice weekly on Mondays and Thursdays. BP readings were sent to study servers and then faxed to primary care provider	Patient Outcomes: The mean systolic BP difference between groups from baseline to final was 0.8 (95% CI −4.2 to 5.8 mm Hg) and diastolic −1.0 (95% CI −3.7 to 1.8 mm Hg, p = .5). Achieved BP control was 37.5% (25.6% ‐ 49.4%, 95% CI) in the active group and 32.8% (20.6% ‐ 44.8%, 95% CI) in the passive group (difference in proportions −4.74% (−21.7% to 12.2%, 95% CI, p = .6)
(Weinert et al., 2011)United States	Study Design = Quantitative randomized controlled trialQuality Rating = 4	Sample Size = 309Mean Age = 55.5Equity Group = WomenPercent Caucasian = 91%Income level = 32% > $35,000	Chronic Diseases	Website: 11 weeks 24 h access to a website with a peer-led virtual support group and self-study health modules focused on web skills and chronic disease self-management	Patient Outcomes: The computer-based group was estimated to have an acceptance of illness score of 2.0 points higher (95% CI = 0.8-3.3, p = .001) on scale of 14 to 70, a depression score of 3.1 points lower (95% CI = 0.8-5.4, p = .010) on a scale of 0 to 60, and a stress score of 2.4 points lower (95% CI = 0.7-4.1, p = .005) on scale of 0 to 56

Outcomes were themed according to patient, healthcare, and costs, and sub-themes generated within each of the main themes. Significant and non-significant findings are reported.

Patient Outcomes

Fifteen articles reported on patient outcomes, including knowledge, self-efficacy, and weight loss.^{38–41,43,45–51}

Knowledge

Knowledge was measured as an outcome in three studies, with consistent findings of technology use yielding knowledge improvements similar to usual care and with no between-group differences. Two studies used videoconference compared to in-person delivery for educational^46,47 and counselling⁴⁷ interventions, while the third study compared a computer-based educational intervention to printed educational material.⁴⁰ However, in one study, pregnant or post-partum women receiving a sleep intervention via videoconference sessions were more likely to know about local resources at the end of the sessions compared to in-person sessions (p < .001).⁴⁶

Self-Efficacy

Domain-specific self-efficacy was reported in two studies with mixed findings. Rural women with cancer who received a decision support telephone intervention showed a significant increase in their confidence to be informed and involved in care (decision self-efficacy) compared to rural women who had usual in-person care (p = .006).⁴¹ In contrast, in another study, breastfeeding self-efficacy was not significantly different between Hispanic pregnant women receiving the computerized education intervention compared to those receiving print education.⁴⁰

Psychosocial

Psychosocial outcomes (social support, acceptance, depression, and stress) were measured in one study examining the impact of an 11-week web-based intervention for women with chronic diseases.⁴³ The intervention group showed significantly better scores in acceptance of illness score (p = .001), depression (p = .010), and stress (p = .005) compared to the control group.⁴³

Weight Loss

Five studies exploring diverse technology-based interventions (telephone, text, web-based) found significant improvements in weight lost, regained, and/or maintained in rural women following the interventions.^{38,39,43,45,48,49} Women cancer survivors in a group telephone weight-maintenance intervention regained significantly less weight than the mailed printed newsletter group that received no individual contact (3.3[4.8] vs 4.9[4.9], p = .03).³⁸ In a comparison of individual versus group telephone-based extended-care with educational control between African American and White adults, researchers found differential treatment effects on weight regain.⁴⁹ Compared to the control group, white adults in the individual telephone condition and African American adults in the group condition regained less weight during the 12-months weight maintenance period.⁴⁹

Web-based interventions alone or when enhanced with other modalities, were found to achieve significant weight loss outcomes.⁴⁵ In a comparison of a web-based versus web and email intervention, 48% of all women achieved a clinically significant weight loss of ≥5% in 6 months, and 37% had a significant weight loss of ≥5% at 18 months.⁴⁸ Women who received messaging engagement and self-tracking email counselling along with the web-based intervention were 1.65 times more likely to meet the weight-loss targets when compared to the web-only group (p = .046).⁴⁸ Self-tracking had no unique effects, but highly engaged women were between 3.75 and 2.33 times more likely to meet weight-loss targets compared to low (b = −1.32, se = 0.34, p < .001) or moderately (b = −0.85 se = 0.31, p < .007) engaged women, respectively.⁴⁸ Another comparative study of a web-based intervention with either peer support or professional counselling enhancements showed similar weight-loss averages (∼2.7 kg) after 30 months.⁵⁰ However, baseline eating self-efficacy moderated treatment success with high self-efficacy women more likely to meet weight-loss targets in the counselling group and lower eating self-efficacy women more likely to meet weight-loss targets in the peer-support group compared to the other condition.⁵⁰ One study using a one-group 12-weeks text-message intervention for rural low-income women found a significant post-intervention reduction in mean body weight (204.3 vs 199.6 lbs, p = .004) and BMI (34.7 vs 33.9, p = .002).⁴⁵

Asttrition Intention

Breastfeeding attrition intention did not differ significantly between breastfeeding pregnant rural Hispanic women receiving computerized education compared to print education.⁴⁰

Cancer Screening Uptake

In their three-armed RCT comparing usual care, DVD messaging, and DVD plus telephone calls with a trained patient navigator social worker, Champion et al.⁵¹ found the DVD plus patient navigator intervention significantly more effective than usual care (OR 4.01; 95% CI 2.60-6.28; p < .001) in promoting up-to-date cancer screening at 12 months (breast, cervical, colon). The DVD intervention alone was not significantly different from usual care.⁵¹ People living in less disadvantaged rural areas were more likely to undergo cancer screening (OR 0.99; 95% CI 0.98-0.998; p = .03) compared to those in more disadvantaged rural areas.⁵¹

Clinical Outcomes

Three studies measured clinical indicators.^52–54 In their RCT, Tobe et al.⁵² found both passive and active text message-based hypertension management intervention reduced Blood Pressure among rural indigenous Canadians in 1-year follow-up, but there was no between-group difference. In another study, women who had a perinatal telemedicine consultation had lower rates of premature delivery (p = .022) compared to those receiving in-person services.⁵⁴ In their pre-post non-randomized study, Baldour et al.⁵³ found a significant reduction in Post Traumatic Stress Disorder (PTSD) symptoms following a 9-week, six-module web-based insomnia program for women with PTSD (t(36) = −2.81, SE = 0.65, p = .008). PTSD symptoms were reduced significantly after adjusting for baseline insomnia and depression (F(1,34) = 4.06, p = .05).⁵³

Healthcare Outcomes

Twelve articles reported healthcare outcomes related to access, utilization, patient satisfaction with the service, and technology challenges.

Access

Six articles reported on healthcare access^{37,42,47,54–56} and the greater ease and convenience in accessing health services because of the technology-enabled services delivery. An RCT that provided intervention participants with 24-h access to lactation consultants found that 41% (34/83) of video calls occurred outside of regular business hours (between 6:01 p.m. and 7:59 a.m.), giving patients access to otherwise unavailable services.³⁷ Similarly, a chart review of First Nations veterans who had received mental health services via videoconference saw a significant increase in access to any other health service (p < .01).⁵⁶ Over half the women receiving telehealth perinatal care reported having saved over 2 h in round trip driving time, over 75% reported the telehealth visit allowed for a family member to attend, and, for 11% of the women, telehealth prevented them from forgoing care.⁵⁴ In another study, patients found videoconference more accessible, not only reporting saved travel time but also saving missed work and easing childcare needs.⁴⁷

Ireland et al.’s ⁴² qualitative study, guided by the Patient-Centred Access model, found that rural women were able to access remote telephone abortion services not provided by their local primary care providers despite it being within their scope of practice.⁴² Receiving remote abortion services saved them from one to 16 h of travel time compared to in-person services; however, they were still required to travel for screening checks prior to their telehealth appointment.⁴²

Despite improved access, technology-enabled services did not remove all barriers.^42,47,55 Only 14.7% of telehealth appointments for infectious disease consultations required no travel, but the remaining 85.3% of appointments involved travel to a central hub that housed the telehealth infrastructure; however, the study was of lower methodological quality.⁵⁵ Similarly, for patients receiving videoconference genetic cancer counselling, 13% reported travelling 50 miles or more for their appointments at the remote clinic with telehealth infrastructure, but 81% would have travelled similar distances for in-person services.⁴⁷

Ireland et al.⁴² similarly discussed challenges with accessing telemedicine abortion services. Women reported challenges in transitioning from telehealth to in-person follow-up services.⁴² Additionally, the authors noted that the service required women to have high digital literacy and self-efficacy, alongside other favourable situational or personal circumstances such as transport, thus inadvertently perpetuating known health inequities for certain rural population cohorts, especially minority, Indigenous, marginalised, or socially vulnerable women, who may be in the greatest need for access to reproductive health services.⁴²

Healthcare Utilization

One study reported healthcare utilization. Leighton et al.⁵⁴ found in their study, lower NICU use (p < .001) and shorter length of NICU stay (p < .001) among rural perinatal women receiving telemedicine consultation, compared to in-person consultations. Additionally, women in the telemedicine group were 0.65 times as likely to have a NICU stay (p < .02) and 0.20 as likely to have NICU stays longer than 1 day (p < .001) compared to women receiving in-person consultations, indicating no negative impacts on healthcare utilization from the use of telemedicine services.

Patient Satisfaction with Services

Eight studies reported patient satisfaction with technology-enabled healthcare services.^{37,41,42,44,46,47,54,55} Satisfaction was high with videoconference, ranging from 80%⁵⁴ to over 90%, with three studies reporting as high as 98% satisfaction,^44,46,55 with another reporting “general” satisfaction with videoconference appointments.⁴⁷ Women using an app for lactation support similarly had high (91%) satisfaction.³⁷ The one study that compared videoconference with in-person care found no significant difference in patient satisfaction.⁴¹ However, between-study comparisons were difficult because of variability in the satisfaction measures used which included qualitative responses (n = 1), standardized Likert scale measures (ranging from 1 to 16 Likert point items) (n = 6), and no measures described (n = 1).

In one study inviting open-ended responses from Australian women with gynecological malignancies about their experiences receiving telemedicine consultation, satisfaction and acceptability were high.⁴⁴ Participants valued the relationship building with the specialist and meeting them pre-operatively but valued the local team presence during the consultations to help interpret the information and to provide emotional and practical support. Women valued communication and gained helpful, clear, detailed information and explanations, had their questions answered, and had no suggestions for improvement. Similarly, women accessing remote abortion services were “pleasantly surprised” by staff professionalism and would recommend services to other women.⁴² The telemedicine services provided adequate and appropriate information, made the initial screening process timely and smooth, met expectations, was trusted, and didn’t make them feel judged.⁴²

Technology Challenges

Four studies reported limitations to care and challenges due to the technology.^37,47,55,57 During remote genetic cancer counselling, a minority of patients (5%–9%) reported problems with picture freezing and loss of internet; however, 90% of those reporting problems felt they were adequately addressed.⁴⁷ Similarly, restrictions from poor cell tower coverage and internet access limited engagement with an app-based service for rural women.⁵⁷ Conversely, of participants receiving a telelactation intervention, 50% did not have any video calls, because of discomfort with video (11%), no problems with breastfeeding (26%), no longer breastfeeding (8%), and being too busy (7%).³⁷ For those receiving remote cancer genetic counselling 32% would have preferred an in-person appointment and 13% did not feel the health technology addressed their needs.⁴⁷ Similarly, clinicians in one study reported limitations to videoconference consultations regarding infectious diseases due to poor image resolution and hands-on physical exams.⁵⁵

Costs

Eight articles discussed the costs of the technology-enabled interventions but varied widely in the metrics they used to report costs.^{37,38,41,42,45,51,54,57} While some studies reported the actual program costs of delivering the intervention,^38,41,45,51 other studies reported the direct patient costs,^42,54 or patient costs related to ownership of the required technologies.^37,45,57

Program Costs

Four studies reported additional program costs to traditional in-person services,^38,41,45,51 and three acknowledged the additional costs as overall low-cost options for delivering health services.^38,41,45 Griffin et al.’s⁴⁵ text message weight loss intervention program costs $159/month for all participants, compared to commercially available weight loss programs, which charge each participant between $66 to $204 for a 12-weeks program. Champion et al.’s⁵¹ study to increase cancer screening calculated the cost of their DVD intervention at $326,012 and for the DVD plus patient navigator intervention at $344,829. This cost included the costs of the DVDs, personnel time cost for DVD production and distribution, and consultant costs for DVD production. Befort et al.³⁸ reported increases in both total program (primarily provider-related) and participant (average hourly wage for all program activities) costs for their group phone counselling compared to the usual mailed newsletter: total program costs of $280 vs. $88 and participant costs of $270 and $189 for the group phone counselling and mailed newsletter respectively. Conversely, Belkora et al.⁴¹ calculated the cost for their telephone cancer decision support intervention as an average overhead charge ($4.99) multiplied by provider time and found the telephone ($48) cost less than in-person ($78).

Patient Costs

Costs to patients were reported in five studies.^{37,42,45,54,57} One Australian-based study discussed medical abortion services, for which patients had to directly pay out-of-pocket, despite the healthcare system having a public universal insurance scheme.⁴² The remote medical abortion services cost women $250AUD (charged through the phone companies) compared to $1500AUD for an in-person surgical abortion.⁴² Despite this apparent benefit of the remote service, the researchers do not make explicit if there were any differences in the treatment approaches between the two types of abortion services. Researchers estimated the average cost saving for women receiving telehealth perinatal care of $90.28 per consultation in saved travel using national gas prices and average hourly wage.⁵⁴

Technology Ownership Costs

Three studies reported on economic implications for patients of their interventions related to technology ownership rather than direct cost.^37,45,57 Of participants in an app-based telelactation study, 97% had a smartphone at baseline³⁷ compared to participants of an app-based substance use intervention, where no participants had smartphones at baseline because they could not afford them.⁵⁷ Similarly, Griffin et al.⁴⁵ reported the costs associated with their weight loss intervention included the cost of cell phone ownership, text messaging, and cellular data.

Discussion

The purpose of this systematic mixed studies review was to examine the impact of health technology-enabled interventions serving equity-deserving populations in rural communities. Although outcomes varied across the 21 studies, overall patient and healthcare outcomes improved. Few studies examined the cost implications of health technologies, but early evidence supports cost savings for patients, except for the cost of technology (e.g., smartphone, cellular data plan). The health technology interventions used in the review studies generally improved outcomes comparable to or better than usual in-person care. However, only 11 studies employed RCTs to provide the most rigorous evidence in establishing causality. Further, there were few and highly variable outcomes examined in the reviewed studies, and outcomes were highly specific to the intervention focus, such as weight loss in response to a technologically enabled weight loss intervention, thus making it difficult to draw conclusions about the broader impact of the technologies.

Despite the focus of the studies on equity-deserving groups, a finding from this work was the underrepresentation of all equity-deserving groups except for women. This finding is consistent with the historical underrepresentation of racial and ethnic minorities (people of color) in randomized controlled trials, with a recent study reporting a total minority inclusion of only 3.95% from all RCTs published in the United States during the last 25 years.⁵⁸ Further, of the 21 studies included in the review, the majority were targeted at predominantly Caucasian women and addressed “highly gendered” health issues, such as perinatal weight loss and breast cancer. In the few studies that had representation from multiple ethnic groups, beginning evidence suggests differential impacts of telehealth extended care programs for weight loss maintenance between African-American and white adults - racial groups may benefit from different technology-enabled approaches.⁴⁹ Although there have been pilot and exploratory studies aimed at health technologies for rural equity-deserving groups, few studies have rigorously tested their effectiveness.

Except for the perinatal studies that were explicitly directed at women, studies did not address how the technologies were tailored to the specific needs of the equity group. Yet beginning evidence from this review for the differential effects of technology-enabled interventions points to the need to tailor technology interventions to user needs. Equally relevant is having technology-based interventions culturally tailored to the needs of equity-deserving groups. Im et al.⁵⁹ identified several specific considerations in the cultural tailoring of technology-based interventions for racial and ethnic minority groups, including technology literacy and preferences; language issues; cultural attitudes, beliefs, and values; intervention staff competence; security and confidentiality issues; and time and geographical constraints. User-centered designs are increasingly being used for tailoring interventions and are especially important as technology increasingly penetrates rural communities, as a result of the COVID-19 pandemic.

Findings showed that health technology interventions targeted at rural women and indigenous communities had high levels of satisfaction, consistent with other literature on rural populations⁶⁰ and urban-based racial minority populations.⁶¹ Studies have shown that equity-deserving groups can have lower satisfaction with healthcare,^62,63 which can, in turn, impact patients' ability to access health services.⁶⁴ The high satisfaction reported among the equity-deserving groups in studies included in this review suggests that health technologies generally improved access to health services for these equity-deserving groups. Decreased travel time is a well-established benefit of health technologies.⁶⁵ Similar to our findings, poor infrastructure in rural and remote communities, inclusive of reliable internet and cellular networks, has been shown to contribute to challenges with technology solutions in healthcare.^66,67 Overly complex health systems limit the uptake of health technologies in rural communities.⁶⁸ However, there is a potential bias related to volunteer participants who may have self-selected, are more highly motivated, and are more inclined to be favourable to these technology services.⁶⁹

There are costs associated with health technology services. Current findings resonate with other studies, that remote health services save patients money in time and travel.⁶⁵ Yet, in some cases, rural participants were still required to travel to access services, a requirement that may in part be addressed as infrastructure development continues to advance in rural communities to allow a full suite of digital tools (e.g., video). However, findings give preliminary evidence of the implied cost of these interventions, particularly the need for technology to utilize services, such as cellular data plans, smart devices, or computers.

Strengths/Limitations

Findings highlight promising evidence for the use of a range of technology modalities across various health services to effect positive outcomes for rural equity-deserving groups. Yet, the findings highlight an emphasis on predominantly white women and an under-representation of many rural equity-deserving groups. The inclusion of only four high-income English-speaking countries may be seen to be a limitation in underrepresenting the scope of technology for equity-deserving groups. Still, for this review, it was important to ensure homogeneity regarding rurality and infrastructure to provide common contexts for drawing meaningful conclusions. Additionally, the diversity of healthcare issues, methodologies, and outcome measures limited the interpretability of findings and the generality of conclusions. Although the COVID-19 pandemic catalyzed the rapid emergence of health technology and a burgeoning of pilot and proof of concept studies to test these emerging technologies, they reflect limited outcomes-focused studies, thus their exclusion from this review.

Conclusion

The use of health technologies for rural women and Indigenous communities showed improved outcomes, high satisfaction, and the potential for low-cost health services. Evidence from the current review indicates that further work is needed to develop knowledge specific to the gaps in understanding of the technologies' influence on equity-deserving groups in rural communities outcomes. Specifically, considerations for the cultural appropriateness of health technologies with underrepresented equity-deserving groups, such as Indigenous populations,^70–73 ethnic minorities,^22,74,75 and persons with disabilities.⁷⁶ While a body of evidence has supported the use, development, and acceptability of health technologies for rural equity-deserving groups, there is a paucity of research testing these interventions. Advancing this promising work through the use of stronger designs (e.g., RCTs), will contribute to a stronger evidence base for health technology applications across a diversity of equity-deserving groups. Yet real-world applications are imperative as they account for the user, their context, and the influence of technology on outcomes. Understanding the experiences of and outcomes that matter to these equity-deserving populations is a strategic research area to better tailor technology-enabled interventions to the users of the technology. Leveraging qualitative work, which to date has been limited, will provide much needed insights to complement the need for more robust research designs. By addressing these gaps in the research, we can better tailor technology-enabled interventions to the unique needs of these populations, ultimately advancing the field of health technology for underserved communities.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Lindsay Burton

Author Biographies

Lindsay Burton is a PhD student at the University of British Columbia Okanagan in the School of Nursing. Her research focus is primarily on technology solutions for older adults to promote equitable access to health services.

Fathi Milad is the Director of Analytics and Business Intelligence in the Ministry of Social Development and Poverty Reduction, BC Public Service and a PhD Student at the University of British Columbia Okanagan in the School of Nursing. Milad’s areas of research include health equity and health system optimization.

Robert Janke is the Deputy University Librarian at the University of British Columbia Okanagan. His research interests include librarians’ support of researchers throughout the research lifecycle, librarians’ roles on research teams, survey design as it relates to response rates, and information literacy and evidence-based nursing practice.

Kathy L. Rush is a Professor and Graduate Program Coordinator in the School of Nursing, University of British Columbia. Her program seeks to enhance the health and health services equity of adults/older adults in urban and rural communities through use of technological, digital, and social innovations. Recently, she has expanded the scope of her research to advance digital equity for marginalized groups (older adults, rural/remote citizens, women, developing countries). Many of her publications have emphasized telehealth and other technology applications (e.g., virtual care, mobiles, personal health records) to support health and healthcare in rural communities.

References

Belasco

Gong

Pence

, et al. The impact of rural health care accessibility on cancer-related behaviors and outcomes. Appl Health Econ Health Pol 2014; 12: 461–470.

Russell

Humphreys

Ward

, et al. Helping policy-makers address rural health access problems. Aust J Rural Health 2013; 21: 61–71.

Douthit

Kiv

Dwolatzky

, et al. Exposing some important barriers to health care access in the rural USA. Publ Health 2015; 129: 611–620.

Bosco

Oandasan

. Review of family medicine within rural and remote Canada: education, practice, and policy. College of Family Physicians of Canada, 2016.

Cross

Califf

Warraich

. Rural-urban disparity in mortality in the US from 1999 to 2019. JAMA, J Am Med Assoc 2021; 325: 2312–2314.

Denny

Davidson

. Area-based socio-economic measures as tools for health disparities research. Policy and Planning 2012; 103: 4–6.

Lavergne

Kephart

. Examining variations in health within rural Canada. Rural Rem Health 2012; 12: 1848.

Canada.ca . Social determinants of health and health inequalities - Canada.ca. https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html (accessed 26 April 2022).

Gong

Phillips

Hudson

, et al. Higher US rural mortality rates linked to socioeconomic status, physician shortages, and lack of health insurance. Health Aff 2019; 38: 2003–2010. DOI: 10.1377/hlthaff.2019.00722.

10.

Public Service Alliance of Canada . Human rights – PSAC ontario, 2021, https://ontario.psac.com/topics/human-rights/ (accessed 3 December 2021).

11.

Braveman

. Health disparities and health equity: concepts and measurement. Annu Rev Publ Health 2006; 27: 167–194.

12.

Orsi

Margellos-Anast

Whitman

. Black-white health disparities in the United States and Chicago: A 15-year progress analysis. Am J Publ Health 2010; 100: 349–356.

13.

Moore

Ricaldi

Rose

, et al. Disparities in incidence of COVID-19 among underrepresented racial/ethnic groups in counties identified as hotspots during June 5–18, 2020 — 22 states, February–June 2020. MMWR Morb Mortal Wkly Rep 2020; 69: 1122–1126 DOI: 10.1377/hblog20200708.894552/full.

14.

Strutz

Herring

Halpern

. Health disparities among young adult sexual minorities in the U.S. Am J Prev Med 2015; 48: 76–88.

15.

Henning-Smith

Hernandez

Hardeman

, et al. Rural counties with majority black or indigenous populations suffer the highest rates of premature death in the US. Health Aff 2019; 38: 2019–2026.

16.

Cordasco

Mengeling

Yano

, et al. Health and health care access of rural women veterans: findings from the national survey of women veterans: health and health care of rural women veterans. J Rural Health 2016; 32: 397–406.

17.

Bossard

Latifi

Fabbri

, et al. Increasing mortality from premature coronary artery disease in women in the rural United States. J Am Heart Assoc 2020; 9: e015334.

18.

Wei

Zhou

, et al. Rising mortality rate of cervical cancer in younger women in urban China. J Gen Intern Med 2019; 34: 281–284.

19.

Rosenkrantz

Black

Abreu

, et al. Health and health care of rural sexual and gender minorities: a systematic review. Stigma and health 2017; 2: 229–243.

20.

Marcin

Shaikh

Steinhorn

. Addressing health disparities in rural communities using telehealth. Pediatr Res 2016 79: 169–176.

21.

Ferrari

Bacco

Gaber

, et al. Drivers, barriers and impacts of digitalisation in rural areas from the viewpoint of experts. Inf Software Technol 2022; 145: 106816.

22.

Elk

Emanuel

Hauser

, et al. Developing and testing the feasibility of a culturally based tele-palliative care consult based on the cultural values and preferences of southern, rural african American and white community members: a program by and for the community. Health Equity 2020; 4: 52–83.

23.

Venter

Burns

Hefford

, et al. Results of a telehealth-enabled chronic care management service to support people with long-term conditions at home. J Telemed Telecare 2012; 18: 172–175.

24.

Albright

Krantz

Backlund Jarquin

, et al. Health promotion text messaging preferences and acceptability among the medically underserved. Health Promot Pract 2015; 16: 523–532.

25.

Aisenberg

Dwight-Johnson

O’Brien

, et al. Building a community-academic partnership: implementing a community-based trial of telephone cognitive behavioral therapy for rural latinos. Depress Res Treat 2012; 2012: 257858.

26.

Cohen

Schultz

McGibbon

, et al. A conceptual framework of organizational capacity for public health equity action (OC-phea). Can J Public Health; 104. DOI: 10.17269/CJPH.104.3735.

27.

Pluye

Hong

. Combining the power of stories and the power of numbers: mixed methods research and mixed studies reviews. Annu Rev Publ Health 2014; 35: 29–45.

28.

Moher

Liberati

Tetzlaff

, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6: e1000097.

29.

Garritty

Gartlehner

Kamel

, et al. Interim guidance from the cochrane rapid reviews methods group. Cochrane Rapid Rev 2020; 2020: 1–2.

30.

Hong

Pluye

Fàbregues

, et al. Mixed methods appraisal tool (MMAT), version 2018. User guide. McGill 2018: 1–11.

31.

Pace

Pluye

Bartlett

, et al. Testing the reliability and efficiency of the pilot Mixed Methods Appraisal Tool (MMAT) for systematic mixed studies review. Int J Nurs Stud 2012; 49: 47–53.

32.

Rush

Burton

Van Der Merwe

, et al. Atrial fibrillation care in rural communities: a mixed methods study of physician and patient perspectives. BMC Fam Pract 2019; 20: 144.

33.

Rush

Howlett

Munro

, et al. Videoconference compared to telephone in healthcare delivery: a systematic review. Int J Med Inf 2018; 118: 44–53.

34.

Peek

STM

Wouters

EJM

van Hoof

, et al. Factors influencing acceptance of technology for aging in place: a systematic review. Int J Med Inf 2014; 83: 235–248.

35.

Hong

Pluye

Fàbregues

, et al. Mixed methods appraisal tool (MMAT), version 2018. Registration of copyright; 1148552.

36.

Stern

Lizarondo

Carrier

, et al. Methodological guidance for the conduct of mixed methods systematic reviews. JBI Evid Synth 2020; 18. https://journals.lww.com/jbisrir/fulltext/2020/10000/methodological_guidance_for_the_conduct_of_mixed.3.aspx

37.

Kapinos

Kotzias

Bogen

, et al. The use of and experiences with telelactation among rural breastfeeding mothers: secondary analysis of a randomized controlled trial. J Med Internet Res 2019; 21: e13967.

38.

Befort

Klemp

Fabian

, et al. Weight loss maintenance strategies among rural breast cancer survivors: the rural women connecting for better health trial. Obesity 2016; 24: 2070–2077.

39.

Hageman

Pullen

Hertzog

, et al. Web-based interventions alone or supplemented with peer-led support or professional email counseling for weight loss and weight maintenance in women from rural communities: results of a clinical trial. J Obes 2017; 2017: 1–21.

40.

Joshi

Amadi

Meza

, et al. Comparison of socio-demographic characteristics of a computer based breastfeeding educational intervention among rural hispanic women. J Community Health 2015; 40: 993–1001.

41.

Belkora

Stupar

Loucks

, et al. Decision support by telephone: randomized controlled trial in a rural community setting. Patient Educ Counsel 2012; 89: 134–142.

42.

Ireland

Belton

Doran

. I didn’t feel judged’: exploring women’s access to telemedicine abortion in rural Australia. J Prim Health Care 2020; 12: 49.

43.

Weinert

Cudney

Comstock

, et al. Computer intervention impact on psychosocial adaptation of rural women with chronic conditions. Nurs Res 2011; 60: 82–91.

44.

Arnold

Anderson

Roeder

. Rural patients highly satisfied with gynaecological oncology care via telehealth. Aust N Z J Obstet Gynaecol 2022; 62: 280–285.

45.

Griffin

Struempler

Funderburk

, et al. My quest, an intervention using text messaging to improve dietary and physical activity behaviors and promote weight loss in low-income women. J Nutr Educ Behav 2018; 50: 11–18.e1.

46.

Ahlers-Schmidt

Schunn

Hervey

, et al. Promoting safe sleep, tobacco cessation and breastfeeding to rural women during the COVID-19 pandemic: pre-post study. JMIR Pediatr Parent 2021; 4: 1–11.

47.

Solomons

Lamb

Lucas

, et al. Examination of the patient-focused impact of cancer telegenetics among a rural population: comparison with traditional in-person services. Telemedicine and e-Health 2018; 24: 130–138.

48.

Hageman

Mroz

Yoerger

, et al. User engagement associated with web-intervention features to attain clinically meaningful weight loss and weight maintenance in rural women. J Obes 2019; 2019: 1–7.

49.

O’Neal

Perri

Befort

, et al. Differential impact of telehealth extended-care programs for weight-loss maintenance in African American versus white adults. J Behav Med 2022; 45: 580–588.

50.

Kupzyk

Pozehl

Pullen

, et al. Behavior-specific cognitions moderate rural women’s responsiveness to web-based interventions for weight loss. J Nutr Educ Behav 2020; 52: 474–482.

51.

Champion

Paskett

Stump

, et al. Comparative effectiveness of 2 interventions to increase breast, cervical, and colorectal cancer screening among women in the rural US: a randomized clinical trial. JAMA Netw Open 2023; 6: E2311004.

52.

Tobe

Yeates

Campbell

NRC

, et al. Diagnosing hypertension in Indigenous Canadians (DREAM-GLOBAL): a randomized controlled trial to compare the effectiveness of short message service messaging for management of hypertension: main results. J Clin Hypertens 2019; 21: 29–36.

53.

Badour

Martinez

Hood

, et al. Improvement in post-traumatic stress symptoms following an internet-based cognitive-behavioral intervention for insomnia: an open trial among rural appalachian women. 2023. https://muse.jhu.edu/article/903063https://muse.jhu.edu/related_content?type=article&id=903063

54.

Leighton

Conroy

Bilderback

, et al. Implementation and impact of a maternal-fetal medicine telemedicine program. Am J Perinatol 2019; 36: 751–758.

55.

Mashru

Kirlew

Saginur

, et al. Management of infectious diseases in remote northwestern Ontario with telemedicine videoconference consultations. J Telemed Telecare 2017; 23: 83–87.

56.

Shore

Brooks

Anderson

, et al. Characteristics of telemental health service use by American Indian veterans. Psychiatr Serv 2012; 63: 179–181.

57.

Johnston

Mathews

Maus

, et al. Using smartphones to improve treatment retention among impoverished substance-using appalachian women: a naturalistic study. Subst Abuse 2019; 13: 117822181986137.

58.

Gutiérrez

Frausto

, et al. Minority representation in clinical trials in the United States: trends over the past 25 years. Mayo Clin Proc 2021; 96: 264–266.

59.

Chee

, et al.

What to consider in a culturally tailored technology-based intervention?

Comput Inform Nurs 2018; 36: 424.

60.

Harkey

Jung

Newton

, et al. Patient satisfaction with telehealth in rural settings: a systematic review. Int J Telerehabilitation 2020; 12: 53.

61.

Truong

Yeganeh

Cook

, et al. Using telehealth consultations for healthcare provision to patients from racial/ethnic minorities: a systematic review. medRxiv 2021; 2021(08.25): 21262592.

62.

Stransky

Jensen

Morris

. Adults with communication disabilities experience poorer health and healthcare outcomes compared to persons without communication disabilities. J Gen Intern Med 2018; 33: 2147–2155.

63.

Blosnich

. Sexual orientation differences in satisfaction with healthcare: findings from the behavioral risk factor surveillance system, 2014. LGBT Health 2017; 4: 227–231. https://home.liebertpub.com/lgbt

64.

Levesque

Harris

Russell

. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013; 12. DOI: 10.1186/1475-9276-12-18.

65.

LeBlanc

Petrie

Paskaran

, et al. Patient and provider perspectives on ehealth interventions in Canada and Australia: a scoping review. Rural Rem Health 2020; 20. DOI: 10.22605/RRH5754.

66.

Bokolo

. Use of telemedicine and virtual care for remote treatment in response to COVID-19 pandemic. J Med Syst 2020; 44: 1–9.

67.

Bauerly

McCord

Hulkower

, et al. Broadband access as a public health issue: the role of law in expanding broadband access and connecting underserved communities for better health outcomes. J Law Med Ethics 2019; 47: 39–42.

68.

Hage

Roo

Van Offenbeek

MAG

, et al. Implementation factors and their effect on e-Health service adoption in rural communities: a systematic literature review. BMC Health Serv Res 2013; 13: 1–16.

69.

Riffenburgh

. Planning studies: from design to publication. Stat Med 2012: 1–26.

70.

Cueva

Kuhnley

Lanier

, et al. Promoting culturally respectful cancer education through digital storytelling. Int J Indig Health 2016; 11: 34–49.

71.

Dingwall

Puszka

Sweet

, et al. Evaluation of a culturally adapted training course in Indigenous e-mental health. Australas Psychiatr 2015; 23: 630–635.

72.

Brooks

Novins

Noe

, et al. Reaching rural communities with culturally appropriate care: a model for adapting remote monitoring to American Indian veterans with posttraumatic stress disorder. Telemed J e Health 2013; 19: 272–277.

73.

Lennstrom

Slaney

Buchwald

, et al. Culturally-tailored text-messaging intervention for smoking cessation in rural American Indian communities: rationale, design, and methods. Contemp Clin Trials Commun 2019; 15: 100363.

74.

Mendu

Boukhechba

Gordon

, et al. Design of a culturally-informed virtual human for educating hispanic women about cervical cancer. Int Conf Pervasive Comput Technol Healthc 2018; 2018: 360–366.

75.

Watts

Gazaway

Malone

, et al. Community Tele-pal: a community-developed, culturally based palliative care tele-consult randomized controlled trial for African American and White Rural southern elders with a life-limiting illness. Trials 2020; 21: 672.

76.

Gentile

Cowan

Harper

, et al. Reaching rural Ohio with intellectual disability psychiatry. J Telemed Telecare 2018; 24: 434–439.

The Landscape of Health Technology for Equity Deserving Groups in Rural Communities: A Systematic Review

Abstract

Background

Purpose

Research Design

Analysis

Results

Conclusions

Keywords

Introduction

Methods

Search Strategy

Inclusion/Exclusion Criteria

Article Selection

Quality of Evidence

Data Extraction

Analysis

Findings

Overview of Studies

Patient Outcomes

Knowledge

Self-Efficacy

Psychosocial

Weight Loss

Asttrition Intention

Cancer Screening Uptake

Clinical Outcomes

Healthcare Outcomes

Access

Healthcare Utilization

Patient Satisfaction with Services

Technology Challenges

Costs

Program Costs

Patient Costs

Technology Ownership Costs

Discussion

Strengths/Limitations

Conclusion

Footnotes

Declaration of conflicting interests

Funding

ORCID iD

Author Biographies

References