A Qualitative Systematic Review of the Impact Telehealth has on Accessibility to Healthcare in Canadian Rural Communities 

by Anmol Virk, RN, BSN, BS Biomed. Physiology

Kamal Kang, BS Biology

Priya Kooner, RN, BSN, BS Biology

Sara Fatehifar, RN, BSN, LPN, BA Leadership

Citation: Virk, A., Kang, K., Kooner, P., & Fatehifar, S. (2025). A qualitative systematic review of the impact telehealth has on accessibility to healthcare in Canadian rural communities . Canadian Journal of Nursing Informatics, 20(1). https://cjni.net/journal/?p=14296

Abstract

Background: Telehealth networks are becoming an increasingly widespread means of access to healthcare globally. However, the need for improvement in the delivery of healthcare via telehealth networks is critical, especially in rural and remote communities. Despite its many benefits, barriers such as access to technology, physician retention, and potential language barriers prevent optimal functionality of these networks. This review will explore the impact of telehealth networks in relation to accessibility to healthcare in rural communities, as well as barriers preventing telehealth networks from operating at their full potential.

Methods: For this systematic review, relevant qualitative articles that answered the question “in rural communities, does the implementation of telehealth improve accessibility to healthcare?” were collected. They were collected from the following databases: CMAJ open resource, NCBI, Pubmed, Proquest, CINAHL and BMC women’s health. The search strategy consisted of three steps that focused on searching by keywords. The inclusion criteria for our review consisted of qualitative, academically peer reviewed journals that were published in English (Meline, 2006).

These studies ranged from January 11, 2007, to February 1, 2022. Geographically, the studies must have been conducted in Canada, in rural communities, and inclusive of participants who had limited access to healthcare. Furthermore, participants were able to communicate their experiences effectively, with the use of technology, consent, and no barriers to language. Participants consisted of a mature population who were willing to express their experiences openly through interviews and questionnaires. The exclusion criteria in our review consisted of quantitative studies that included theoretical and conceptual framework of design and book series (Meline, 2006). Studies that were not done in English were excluded. Participants consisting of minors, and those who refused telemedical health for reasons such as breach of privacy, lack of consent, mistrust, and lack of effective communication were excluded as well (Meline, 2006).

Results: In all, ten articles met the inclusion criteria and were reviewed. All articles that were selected point to telehealth being a positive addition to healthcare, rather than a negative. Some participants noted that telehealth will allow for physicians to be recruited and retained in rural areas, while others emphasized that it is a tool to bridge the gap of accessibility. Moreover, participants pointed out that telehealth brings better access to specialized services, improved continuity of care, and more information which is readily available.

Conclusion: The healthcare system has seen shortages of staff in rural communities which has resulted in members having limited access to healthcare. Telehealth has been introduced to increase access where it is limited. Studies that have been done note that the implementation of telehealth will increase access to healthcare in rural communities.

Background

When access to healthcare among rural populations is compared to that of urban populations, there is an evident discrepancy in access (Sibley & Weiner, 2011). Statistics Canada (2018a) defined rural communities in Canada as those which are situated outside of population centers and are characterized by having a population of less than 1,000 people based on the most up to date population census. The term population center is used to refer to urban areas of a small, medium, or large population, with large urban areas having populations of greater than 100,000 (Statistics Canada, 2018b). Telehealth networks are becoming progressively prevalent throughout the country, and they have the potential to address the concern of rural community accessibility to health services. The objective of this systematic review is to identify factors which facilitate or impede accessibility of rural communities to telehealth networks to work toward improving their accessibility to healthcare. Telehealth networks directly benefit not only the community members using the services, but they also hold potential to provide physicians and other health care providers with increased job flexibility as well as more opportunities to advance health directives in smaller communities.

This review aims to specifically address the functionality and use of current telehealth networks and determine ways in which these networks can be optimized to ensure impartial and readily available access to health care services. To do this, it is important to recognize which communities require implementation of such networks, how many people seek healthcare services, the availability of physicians and nurses to provide care, as well as challenges which prevent efficacy of these networks. The challenges are often associated with a lack of organization and collaboration among the different teams that contribute to the setup of these networks, including but not limited to governance and regulatory bodies, administrative teams, and clinical teams (Alami et al., 2018). The target population includes members of rural communities in Canada with accessibility barriers to healthcare services. This population includes those that have an unmet need for health services due to living in rural areas. This review will also aim to identify the need for the implementation of and improvement of existing telehealth networks.

Reviewing and compiling existing literature on this topic is essential for enhancing accessibility to health services in rural areas via means of telehealth networks. It is important to understand what is meant by a “telehealth network”. Telehealth networks are characterized by technology which supports “remote delivery of healthcare services” which may be carried out through secure video calls, over the phone, or even through live chats (Benefits by Design (BBD), 2022, p. 1). Although we are in an era of seemingly easy access to smartphones, computers, tablets, and technology, this remains a barrier to providing telehealth services in rural communities. Moreover, it is important to note factors that have been studied which aid in reliable delivery of remote care, as well as factors that impede it. Creating a database of information regarding these factors is important to facilitate policy and structural changes which can ameliorate the delivery of remote healthcare to rural communities. Ensuring an appropriate, reliable, and trustable means of health care is accessible to members of rural communities is important. The Canada Health Act outlines the main objective of the Canadian health care policy to “facilitate reasonable access to health services without financial or other barriers” (Government of Canada, 2020, p. 1). Considering this, all individuals residing in Canada should have impartial access to health care services, regardless of their geographic location.

Existing literature outlines many themes which point toward the public increasingly adopting the use of remote health care services. The COVID-19 pandemic, for example, gave way to the shift toward virtual care services in hopes of following continuity of care even when in-person contact was prohibited (Chan-Nguyen et al., 2022). The adoption of virtual care methods during the pandemic also gave rise to challenges and benefits associated with this method of care. Multiple researchers have identified access to health care to have been inequitable, even before the COVID-19 pandemic (Bambra et al., 2018; Gkiouleka et al., 2018 as cited in Chan-Nguyen, 2020). Disparities in the allocation of health and social support services affect various populations differently, including rural communities which already have barriers to health care services (Chan-Nguyen et al., 2022). It is also mentioned that since many telehealth networks function differently and are continuously being developed, there is a concern for lack of retention of practicing health care providers (Alami et al., 2018). There also exists a need to recognize the ability of rural community members to adapt to various technologies and systems used to implement telehealth services (Bardwell et al., 2021). Participants in a previous study communicated the importance of bridging the accessibility barrier to telehealth services, the importance of group dynamics and strong leaders for implementation, as well as a preference for extended session time when using the services (Guilcher et al.,2013).

Based on the existing literature, this review aims to identify gaps in telehealth accessibility, extract insights from the experiences of individuals in rural communities and highlight areas requiring improvement to enhance both the access to and reliability of telehealth services in rural Canada. The findings are intended to support the development and refinement of current telehealth networks, ensuring that future systems are implemented in an informed, strategic manner. This will help facilitate access to competent and reliable remote healthcare services and may contribute to the recruitment and retention of physicians and other healthcare professionals in rural areas. Additionally, the review’s findings can inform regulatory and governance bodies, guiding policy changes that benefit both patients and healthcare providers, as well as the organizations delivering telehealth services.

Objectives and Research Question

For this systematic review, the question of interest is: does the implementation of telehealth improve accessibility to healthcare in rural communities? This is a simple yet well-developed question, as it will form the basis for the entire review protocol (Bettany-Saltikov, 2012). The overall objective will be described, with the sub objectives included. The framework that will be utilized is population of interest, intervention, and outcome (PIO) which is a derivative of PICO (population, intervention, comparison, and outcomes).

Before outlining the objectives, it is important to understand what is meant by “rural”, so the reader knows the geographic areas being utilized and the population of interest. As mentioned previously, rural regions are defined to be those outside of population centers with a population equal to or less than 1000 people (Statistics Canada, 2018a). Even though these rural communities may be scarcely populated, it is pertinent to ensure impartial access to healthcare for all members of the country. It is unknown exactly how telehealth will impact the practice of healthcare in rural and remote regions (Gagnon et al.,2006). The overall objective is to know how the implementation of telehealth will improve accessibility to healthcare in Canadian rural regions.

Therefore, it is helpful to know how many citizens are using the healthcare system yearly, and what their average number of visits to healthcare providers such as walk-in clinics, their family physicians, or even where the hospital is. These statistics should also include the number of potential visits which are missed due to inaccessibility to health services. The above information can be compared to the utilization of telehealth, over the same length of time and the number of usages. Of course, we need to use the assumption that ‘accessibility’ in this situation is measured by the utilization of the healthcare system. There are other sub objectives that affect the main question.

These include the following:

Retention and recruitment of physicians: The retention and recruitment of physicians must be balanced between work and home life, and financial reward. Finding physicians who wish to offer services with minimal in-person care, due to their telehealth obligations may be difficult (Alami et al., 2018).

The funding required for technology and equipment (visual and audio) along with education that is needed to teach patients how to utilize telehealth.

The increased challenges of providing services for patients with chronic disease being guided via telehealth (self-management).

The impact of telehealth on healthcare delivery in rural and remote regions remains uncertain (Gagnon et al., 2006). It is also unclear how much financial support the federal and provincial governments will allocate toward expanding telehealth services in these communities (Gagnon et al., 2006). Enhancing telehealth networks through effective policymaking requires strong leadership and collaboration among multiple stakeholders (Alami et al., 2018). Numerous challenges can affect the success of telehealth, with accessibility and effective management ranking among the most critical issues to address.

Methods

Inclusion Criteria

Choosing articles with the appropriate study design includes qualitative studies that are published in English, ranging from the dates January 11, 2007, to February 1, 2022, including participants with limited access to healthcare. The quality of criterion consists of peer reviewed, academic journals (Meline, 2006). Subjects are included in the study if they were from Canada, have limited access to healthcare due to living in rural areas, and are willing to experience telehealth and share their experiences. Subjects should be able to communicate without barriers in language (Meline, 2006). Subjects should also be comfortable with the use of technology and are willing to undergo communication via video interviews with signed consent. Other types of outcome measures include willingness to answer questionnaires to describe their experiences with telehealth regarding healthcare (Meline, 2006).

Exclusion Criteria

Studies published before January 11, 2007, and after February 1, 2022, were excluded from this review. Only studies published in English were considered, with non-English publications excluded (Meline, 2006). The review also excluded theoretical and conceptual research designs, quantitative methodologies, and book series (Meline, 2006). Studies conducted outside of Canada or those focused on non-rural healthcare access were not included. Additional exclusion criteria involved studies with participants who were minors, individuals with psychological illnesses, or those unable to read. Furthermore, participants who declined to engage in telehealth due to unfamiliarity with the technology, lack of consent, privacy concerns, or mistrust were also excluded (Meline, 2006).

Search Strategy

For this systematic review the databases used to find articles included CMAJ open resource, NCBI, Pubmed, Proquest, CINAHL and BMC Women’s Health. The keywords used when searching the databases were: qualitative research, nursing, telehealth, accessibility, rural area, rural community, COVID-19 pandemic, peer review, remote, Canada and virtual care: all of these can be visualized in Figure 1.

Figure 1:

Mind map of keywords used for search

Our initial search involved querying the selected databases using a limited set of keywords. Upon identifying relevant articles, we reviewed them and expanded our list of keywords, enabling a more comprehensive search in the second phase. Additionally, we sought to determine whether a systematic review on our specific topic already existed (Bettany-Saltikov, 2012). After a thorough search, we found no existing reviews that met our exact criteria, which justified proceeding with our own systematic review. This initial stage was instrumental in identifying studies aligned with our research questions, allowing us to focus on relevant literature while effectively excluding unrelated articles.

The second stage of our research utilized the same databases outlined previously; however, we employed the expanded list of keywords developed during the initial search. This refinement allowed us to identify additional studies that more closely aligned with our research criteria. By using more specific search terms, we were able to retrieve articles that were more directly relevant to our topic of interest. As a result, this stage led to the successful identification of several studies deemed suitable for further analysis.

The final stage of our research involved a thorough review of the studies identified in the second stage. Specifically, we examined the reference lists of these articles to identify any additional studies relevant to our research question (Bettany-Saltikov, 2012). This backward reference searching strategy proved effective, allowing us to uncover several valuable studies that further enriched our review and aligned closely with our topic of interest.

To determine the eligibility of studies for inclusion in our systematic review, we initially screened titles and abstracts against our predefined inclusion and exclusion criteria. This approach allowed us to efficiently exclude studies that were not relevant to our research topic, minimizing time spent on inapplicable literature. In most cases, the information provided in the title and abstract was sufficient to assess a study’s alignment with our criteria.

Quality Assessment

To assess the quality of the selected studies, all four authors screened the titles and abstracts of each. Then, each study was read thoroughly from beginning to end by two authors to determine if it met the inclusion and exclusion criteria, as well as if it was of good quality. All authors reached a consensus with the studies that were ultimately used in terms of their quality and relevance to the systematic review.

The quality of each article was determined by answering the following critical appraisal questions (University of Hawaii, 2022):

1. Is the question of the study relevant?
2. Does the study offer anything new to existing knowledge?
3. Was the design of the study relevant to the type of question being asked?
4. Are the potential sources of bias addressed?
5. Was the analysis of the results performed correctly?
6. Does the data justify the conclusion?
7. Were there any conflicts of interest?

If the study passed all the above questions, it was deemed good quality and kept for the systematic review. However, if it did not, the study was omitted. To omit a study, both authors that were thoroughly reviewing each study came to a consensus on the quality.

Data Extraction

To facilitate data extraction, a structured table (Table 1) was developed to organize information from the included studies. The table consisted of the following columns: author, publication date, sample, methodology, results, conclusion, and uncertainties surrounding the findings. To ensure the validity of the extracted data, two researchers independently extracted data from each article and compiled their findings. The compiled data were then reviewed by all four researchers to verify accuracy. Any discrepancies were discussed and resolved through online meetings until a consensus was reached.

Table 1:

Data extracted from each selected study

Results

All the studies that were used in this systematic review pointed toward telehealth increasing the accessibility of healthcare to rural communities. Nonetheless, some studies did point out reservations that participants had towards it. To begin, Gagnon et al. (2006) noted that telehealth would help in improving healthcare in remote communities through making healthcare more accessible and available. That is, services that would otherwise be difficult to get to, would now be easier to access, such as specialty care. Moreover, it was noted that continuity of care would be better since follow-up appointments would be easier to perform (Gagnon et al., 2006). Similarly, Sevean et al. (2009) found that telehealth was cost efficient when it came to traveling and aided in physical limitations.

One of the main limitations identified by participants was the concern that telehealth might eventually replace in-person healthcare services (Gagnon et al., 2006). This concern is valid, as face-to-face interactions with healthcare providers remain a critical component of comprehensive care. Another limitation, highlighted by Chan-Nguyen et al. (2022), was limited technological literacy. The introduction of unfamiliar technologies contributed to mistrust and concerns over potential breaches of privacy. Additionally, Gagnon et al. (2007) noted that while telehealth is only one of several factors, it could contribute positively to the recruitment and retention of physicians in rural and remote areas. By allowing physicians to consult from home or office settings, telehealth may improve work-life balance and encourage new medical graduates to consider practicing in underserved regions. Similarly, Guilcher et al. (2013) found that participants generally had positive experiences with telehealth, particularly noting its role in increasing healthcare access for individuals living in remote communities.

Recommendations

The studies analyzed in this systematic review offered valuable implications for future research and practice. Many emphasized the urgent need for more physicians in rural areas to improve healthcare access, identifying telehealth as a promising solution to address this shortage. Recognizing that telehealth is an emerging technology, the studies collectively call for further research to assess its long-term effectiveness and broader impacts. For example, Gagnon et al. (2007) highlighted telehealth as one factor that could alleviate workforce shortages in remote and rural communities. They recommended longitudinal studies to track the evolution of telehealth’s effects across diverse healthcare settings over time.

Similarly, Gagnon et al. (2006) suggested that telehealth implementation could improve patient care and contribute to a more equitable distribution of physicians nationwide, thus enhancing healthcare access in underserved regions. They further stressed the need for ongoing theoretical and methodological development to establish a shared understanding of telehealth across different levels of the healthcare system. Guilcher et al. (2013) also advocated for additional long-term research to evaluate whether recent improvements enhance the telehealth experience in rural communities.

Alami et al. (2018) recommended adopting a systemic vision that acknowledges the complexities of health systems and evolving technologies, emphasizing the importance of understanding how technological advancements influence decision-making processes. They also noted that, due to variability among telehealth networks and traditional care delivery models, the impact of telehealth on healthcare provider retention remains unclear and warrants further investigation.

Bardwell et al. (2021) highlighted the need to address potential biases and power dynamics in qualitative research, particularly in interviews co-led by research assistants. They cautioned that interviewer influence could lead to positive bias, overshadowing clients’ genuine perspectives. Consequently, future research should strive to minimize such biases to ensure findings authentically reflect patients’ experiences.

Limitations

Although this systematic review involved comprehensive search and quality assessment of selected studies, several limitations remain. First, the heterogeneity among the included articles precluded conducting a meta-analysis, which would have enabled a statistical comparison of study findings and strengthened the review’s conclusions. Additionally, all included studies were published in English. While this aligns with the review’s focus on Canadian rural communities, it potentially excludes important perspectives, particularly from First Nations populations, many of whom reside on reserves where elders and others may not be fluent in English. It also excludes French studies (Canada’s other primary language). This language limitation may result in the omission of valuable insights regarding telehealth implementation and adaptation. Finally, the review’s search strategy was limited by the number of databases utilized. Consequently, some relevant studies may have been missed if they were indexed in databases not included in the search, potentially affecting the comprehensiveness of the review.

Conclusion

This systematic review highlights various aspects supporting the positive impact of telehealth implementation in rural communities. If digital information and communication technologies can expand access to healthcare services in urban areas, it stands to reason that similar benefits should extend to rural populations. While delivering healthcare remotely in rural regions may involve higher initial costs, the value of equitable healthcare access is universal, regardless of geographic location.

The academic literature included in this review identified several challenges that must be addressed to ensure successful telehealth adoption within rural communities. Many of these challenges can be mitigated through collaboration with local leaders. Key examples include the need to ensure adequate availability of physicians, nurses, and other healthcare personnel in rural regions. Engagement from Indigenous community leaders, municipal elected officials, and regional healthcare decision-makers is critical and should be prioritized. Although the initiative may require substantial investment, such collaboration will enhance quality of life and healthcare delivery for rural residents and their families.

Notably absent from the reviewed studies is emphasis on the importance of local technology experts, whose presence is vital to maintaining and supporting telehealth infrastructure. Moreover, decisive action from the Government of Canada, both federal and provincial is essential to demonstrate commitment to expanding telehealth in rural areas. The federal government should lead the development of a clear agenda, outlining necessary commitments and ensuring transparent communication with regional authorities.

As supported by the literature (Gagnon et al., 2006), informed modification of existing networks and the implementation of new telehealth systems will significantly improve health outcomes and continuity of care for rural populations by overcoming geographic barriers to access. Successful integration requires collaboration among rural community members including Elders and Indigenous leaders, governing and regulatory bodies, and healthcare providers to develop appropriate policies, delivery methods, technology access, and strategies to address barriers. Incorporating diverse perspectives will facilitate the optimal delivery of remote healthcare and foster trust and acceptance of telehealth services within rural communities.

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