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https://doi.org/10.1177/01939459221134374
Western Journal of Nursing Research
1 –10
© The Author(s) 2022
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DOI: 10.1177/01939459221134374
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Reviews
Health inequities in rural areas of the United States and other
developed nations are well documented (Aggarwal et al.,
2021; Anderson et al., 2015; Behrman et al., 2021; Lutfiyya
et al., 2012; Matthews et al., 2017). A perfect storm of a lag-
ging rural economy, a lower investment in resources, includ-
ing health care and education, and geographic isolation have
ultimately resulted in downstream consequences of poorer
health outcomes in rural areas (Thomas et al., 2014).
According to the Centers for Disease Control and Prevention
(CDC), rural areas experience higher rates than urban areas
for the five leading causes of death in the United States:
chronic lower respiratory disease, cancers, unintentional
injury, heart disease, and stroke (Moy et al., 2017; Yaemsiri
et al., 2019).
Telehealth has been promoted as an innovative tool to
improve access to care for rural populations (Lum et al.,
2019; Nelson, 2017; O’Kane, 2020). Telehealth encompasses
telemedicine consults, mHealth tools such as remote moni-
toring, and patient portal access. The term also includes pro-
vider-to-provider communications (e.g., store and forward
mechanisms, project ECHO). Most relevant to rural patients
is the ability to have virtual appointments with providers
who may not be located within the patient’s geographic area.
Primary care clinics have been able to set up remote visits
with specialists, allowing patients to confer from the privacy
of their primary care provider’s office on matters ranging
from mental health to dermatology to cardiac care. This
model has been well-accepted and has been used extensively
in the U.S. Veterans Affairs health system (Jacobs et al.,
2019; Lum et al., 2019) as well as in geographically remote
regions for years (Lee et al., 2019).
The onset of the COVID-19 pandemic in March 2020 dra-
matically shifted telehealth operations. Regulatory rules
within the United States’ and other nations’ health systems
were adjusted to allow providers to charge for remote tele-
health encounters based from the patient’s home, as it was
deemed unsafe for patients to travel to their providers’
offices. This global “demonstration project” has revealed
that telehealth can be highly effective in certain circum-
stances. Policies are being reconsidered to allow for video-
based and audio-only telehealth encounters in the home
setting to be reimbursed at the same rate as in-person visits
(Brotman & Kotloff, 2021; Lee et al., 2020; Mishori &
1134374WJNXXX10.1177/01939459221134374Western Journal of Nursing ResearchPullyblank
review-article2022
1Bassett Research Institute, Center for Rural Community Health,
Cooperstown, NY, USA
Corresponding Author:
Kristin Pullyblank, Bassett Research Institute, Center for Rural
Community Health, One Atwell Road, Cooperstown, NY 13326, USA.
Email: kristin.pullyblank@bassett.org
A Scoping Literature Review of
Rural Beliefs and Attitudes toward
Telehealth Utilization
Kristin Pullyblank1
Abstract
The purpose of this scoping literature review was to understand what is known about how the rural profile influences beliefs
regarding telehealth utilization. Rural nursing theory (RNT) provided a framework for the review. Search criteria were limited
to peer-reviewed studies conducted in Europe, the United States, Canada, Australia, and New Zealand. A variety of search
terms related to patient telehealth perceptions generated 213 unique articles, of which 10 met the inclusion criteria. Included
studies incorporated qualitative methodologies and were from Australia, Canada, Sweden, or the United States. The review
highlighted four themes related to the rural profile’s influence on telehealth beliefs: importance of familiar relationships,
concerns with privacy and confidentiality, acceptance of limited access to care, and resourcefulness and frugality. These
themes echo concepts within RNT. Nurses and other health professionals must acknowledge the rural profile’s influence on
a person’s decision to use telehealth in order to provide optimal care.
Keywords
patient beliefs, rural, rural nursing theory, telehealth, telemedicine
2 Western Journal of Nursing Research 00(0)
Antono, 2020). However, recent literature has reported that
during the COVID-19 pandemic rural populations were
accessing telehealth services at lower rates than the general
population (Chu et al., 2021; Hsiao et al., 2021; Jaffe et al.,
2020; Jewett et al., 2022; Poeran et al., 2021; Quinton et al.,
2021). This finding is particularly interesting because prior
to COVID-19 rural areas tended to use telehealth slightly
more than urban areas (Chu et al., 2021). It must be empha-
sized that previous to COVID-19, patients who used tele-
health—most frequently to connect with a specialist—were
overwhelmingly doing so at a local primary care office. With
COVID-19, telehealth suddenly shifted to the home. Previous
research has indicated that rural dwellers have less access to
the internet and are less likely to use health information tech-
nologies such as patient portals and mHealth applications
(Bhuyan et al., 2016; Greenberg et al., 2018). While lack of
broadband access and digital literacy have emerged as pos-
sible answers to this puzzle, researchers have suggested that
there are underlying factors beyond internet access that must
be considered (Jaffe et al., 2020; Jewett et al., 2022). One
factor the literature has largely failed to recognize is the dis-
tinct rural health-seeking profile. In the COVID-19 era, with
the onus on the individual instead of the clinician in terms of
deciding to use telehealth, understanding the rural profile
becomes a critical component of providing equitable health
care. Rural Nursing Theory (RNT) is an applicable frame-
work to explain rural populations’ unique approach to health
and health-seeking behaviors.
Rural Nursing Theory
Developed in the last quarter of the twentieth century, RNT
is based on the premise that nursing practice in a rural envi-
ronment is different from that in an urban place (Lee et al.,
2022). The three current propositions of RNT state:
(a) Rural residents define health as being able to do what
they want to do; it is a way of life and a state of mind;
there is a goal of maintaining balance in all aspects of
their lives. However, older rural residents and those
with ties to extractive industries are more likely to
define health in a functional manner—to work, to be
productive, and to do usual tasks.
(b) Rural residents are self-reliant and make decisions to
seek care for illness, sickness, or injury depending on
their self-assessment of the severity of the present
health condition and of resources needed and
available.
(c) Health care providers in rural areas must deal with a
lack of anonymity and much greater role diffusion
than providers in urban or suburban settings (Lee &
McDonagh, 2018, pp. 52–53).
Concepts such as distance, self-reliance, resilience, infor-
mal networks, informed risk, hardiness, privacy, being a
conscientious consumer, trust, and community support are
all important components of RNT (Lee & McDonagh, 2018;
Lee et al., 2022; Montgomery & Paré, 2018) that help to dis-
tinguish differences between rural and urban populations in
terms of how health is defined and how health care is sought.
Objectives
Due to the recent shift in telehealth delivery, there is a poten-
tial knowledge gap in the research regarding how the rural
profile may influence the adoption of telehealth technolo-
gies. The objective of this scoping review is to understand
the state of the science relative to rural beliefs and attitudes
toward the utilization of telehealth. The specific research
question is as follows: What is known from the literature
about how the unique rural profile contributes to beliefs
about and preferences for telehealth use?
Key Terms
Telemedicine, telehealth, eHealth, and mHealth are often
used interchangeably. Broadly, telehealth has been defined
“as the delivery and facilitation of health and health-related
services including medical care, provider and patient educa-
tion, health information services, and self-care via telecom-
munications and digital communication technologies”
(NEJM Catalyst, 2018, para. 1). For the purposes of this lit-
erature review, telehealth is used as the generic term for all
digitally mediated health-related interactions between the
provider or health care organization and the patient. This
includes patient portal use, web- or video-based communica-
tion with a provider, and remote monitoring devices. It does
not include audio-only communication via telephone with a
provider.
The term rural profile is used in this review to specifically
denote the qualities of rural residents that contribute to a
unique perspective on health and health-seeking behaviors as
delineated by RNT. Other authors have used similar terms
such as rural attitude or rural culture (Thomas et al., 2014;
Thurman et al., 2019). The rural profile includes attitudes,
behaviors, and beliefs such as self-reliance, hardiness, and
stoicism. It does not include the predisposing demographics
or social structure factors, such as sex, age, geography,
income, or family size.
Rural can mean different things to different people. While
authors should operationalize rural within their studies, this
is not always the case. Study-specific definitions of rural will
be included when available.
Methods
A scoping literature review was undertaken in order to under-
stand the extant literature regarding how the rural profile may
influence perspectives of telehealth utilization. Scoping
reviews are an appropriate method to summarize findings
Pullyblank 3
within a heterogeneous or ill-defined area of research in order
to assess the state of the science and identify any gaps (Peters
et al., 2015; Tricco et al., 2018). While there is a large body of
research on telehealth access in rural areas, the state of the
science regarding the rural profile’s influence on telehealth
beliefs and preferences for use in rural areas is unclear and
thus a scoping review is a necessary first step. The PRISMA-
ScR checklist was used as a guideline (Tricco et al., 2018). To
be included in the review, relevant literature needed to include
qualitative, quantitative, or mixed methods findings explicitly
related to rural residents’ attitudes or beliefs within the con-
text of telehealth utilization. Only peer-reviewed studies were
included. Due to the paucity of literature on RNT, articles did
not have to reference RNT. Studies that only focused on the
provider or organizational perceptions of telehealth utiliza-
tion, policy briefs, commentaries, theses and dissertations,
and other gray literature were excluded.
A comprehensive literature search was conducted using
the following databases between May and July 2022:
CINAHL, Medline, Academic Search Complete,
Anthropology Plus, APA PsycArticles, Social Sciences Full
Text, and PubMed. Delimiters included the English language
and the geographic area of Europe, Australia/New Zealand,
the United States, or Canada. Studies conducted prior to
2007 were excluded due to rapid advancements in telehealth
implementation that began in 2007 with the advent of the
iPhone, the conclusion of the first Veterans’ Health
Administration study on telehealth, and substantial invest-
ment in rural broadband in the United States (Nesbitt &
Katz-Bell, 2018). All terms were required to be found in the
title or abstract. The first set of search terms used was (tele-
health OR telemedicine OR eHealth OR mHealth) AND
rural AND (patient perceptions OR patient attitudes). The
second search included (telehealth attitudes OR telehealth
perceptions) AND rural. A final search used only the PubMed
database with the terms rural AND (telehealth OR telemedi-
cine OR eHealth OR mHealth) AND (preference OR utiliza-
tion). In addition to searching databases, manual citation
searching was conducted using reference lists from the previ-
ously identified relevant literature.
Data charting included the following key elements: set-
ting, including the definition of rural, if available; study sam-
ple characteristics; objectives; methods; and findings.
Findings not relevant to the study objective were not included
in the charting (e.g., findings from clinicians who were also
interviewed, or findings that related to patient satisfaction).
The findings were then synthesized into themes within extant
RNT constructs.
Results
Selection of Sources
The aim of this scoping review was to understand the state of
the science relative to rural attitudes and beliefs regarding
telehealth utilization. A total of 312 records were found.
After duplicates were removed (n = 99), there were 213
unique records. Of these, 176 were eliminated after the title/
abstract review for the following reasons: being a conference
abstract, protocol, or commentary (n = 9); involving only
provider/organization perspectives (n = 73); not taking place
in the delimited geographic area (n = 16); not rural (n = 14);
not related to telehealth (n = 7); not including data on rural
attitudes and perceptions toward utilizing telehealth (n = 49);
data were collected prior to 2007 (n = 8). The remaining 34
articles were reviewed in full, of which 24 were eliminated
due to insufficient descriptions of attitudes and perceptions
toward utilization of telehealth in the rural context. Because
this is a scoping review, articles were not eliminated based
on quality or scientific rigor. In total, 10 articles met the
inclusion criteria and were included in this review (Figure 1).
Characteristics of Sources of Evidence
The 10 articles were based on studies conducted in the United
States (Alexander et al., 2021; Hubach et al., 2020; Sundstrom
et al., 2020), Canada (Gibson et al., 2011; Rush et al., 2019),
Sweden (Lindberg et al., 2021), or Australia (Bradford et al.,
2015; Campbell et al., 2019; Rasekaba et al., 2021; Sabesan
et al., 2014) (Table 1). All were published between 2011 and
2021 indicating a relatively recent interest in understanding
how the rural profile may be associated with preference for
and utilization of telehealth. Only one article referenced
COVID-19 (Hubach et al., 2020) as a potential driving force
for increased utilization of telehealth in rural populations.
None of the articles used RNT and only one (Rasekaba
et al., 2021) referenced the use of a theoretical framework
to undergird the analyses. All of the studies used qualita-
tive or mixed methods designs. The objectives, and thus
the methodologies, varied across studies. Methodologies
included qualitative descriptive (Alexander et al., 2021;
Campbell et al., 2019; Lindberg et al., 2021; Rasekaba
et al., 2021; Rush et al., 2019; Sabesan et al., 2014), com-
munity-based participatory research (Gibson et al., 2011),
phenomenology (Bradford et al., 2015), and grounded the-
ory (Hubach et al., 2020; Sundstrom et al., 2020). In all
cases, a variation of inductive thematic analysis was used
to synthesize findings. Only two articles explicitly opera-
tionalized rural (Hubach et al., 2020; Sundstrom et al.,
2020). Two articles mentioned steps taken to ensure the
credibility and rigor of their studies (Gibson et al., 2011;
Rush et al., 2019).
Sample sizes ranged from 8 to 59 individuals. There was
diversity in the populations of interest among the articles.
While all populations were deemed rural, individual stud-
ies focused on women seeking reproductive health care
(Rasekaba et al., 2021; Sundstrom et al., 2020), adults with
chronic disease (Alexander et al., 2021; Rush et al., 2019),
individuals receiving cancer care (Sabesan et al., 2014),
men who have sex with men (Hubach et al., 2020),
4 Western Journal of Nursing Research 00(0)
Indigenous communities (Gibson et al., 2011), older adults
(Lindberg et al., 2021), and parents and other stakeholders
of pediatric allied health care (Campbell et al., 2019). Only
one study enrolled rural community members at large
(Bradford et al., 2015). It is important to note that
participants in all studies acknowledged the benefits of
telehealth for both the greater population, as well as for
their own rural communities. No studies found that the
majority of participants expressed an unwillingness to
engage with telehealth technologies.
Figure 1. Study Inclusion Flow Diagram.
5
Table 1. Literature Review Findings.
Reference Setting (Including Rural Definition) Sample Objective Methods and Analysis
Findings Relevant to Attitudes toward Perceptions of
Telehealth Utilization
Alexander
etal. (2021)
Western North Carolina, US
3 HPSA designated counties and
“predominantly rural”
17 community members living with
COPD; 59% male; 100% non-
Hispanic white
Explore perceptions of adopting a tele-
COPD program
Qualitative descriptive; focus
groups; inductive thematic
analysis
Themes: Benefits of telehealth would include
decreased driving distance, and increased access
and would reduce hospital visits and missed
appointments; barriers of telehealth included cost,
concerns regarding privacy and confidentiality;
establishing trust and rapport could overcome
barriers
Bradford etal.
(2015)
Queensland, Australia
Rural not defined
47 individuals; 55% male; 34% 60+;
88% had never used telehealth; 7%
Indigenous Australian
Explore community awareness,
experiences, and perceptions of
telehealth
Phenomenology; interviews;
content analysis
Themes: Distance; trust; health care still largely
paternalistic; need increased awareness of telehealth
to know to ask for it
Campbell etal.
(2019)
Queensland, Australia
Rural not defined
39 stakeholders (12 parents, 16
providers, 11 referrers)
Explore familiarity with telehealth,
willingness to use telehealth &
barriers & facilitators to acceptability
Qualitative descriptive;
semi-structured interviews;
inductive thematic analysis
Themes: Inferior quality of relationships and
communication; lack of physical touch; doubts of
self-efficacy with technology and therapy techniques;
technology barriers; improves access
Gibson etal.
(2011)
Ontario, Canada
Rural not defined
59 First Nations members; 44%
male; age not reported
Perspectives of remote and rural First
Nations community members on
tele-mental health
CBPR; interviews; qualitative
thematic analysis
Themes: Greater access & continuity of care; reduced
travel; client comfort/facilitation of disclosure;
mental health work needs to be done “in person”;
privacy, security & safety; interference with capacity
building
Hubach etal.
(2020)
Oklahoma and Arkansas, United
States
Index of Relative Rurality (IRR)
greater than .40
23 MSM; 87% white Preferences for accessing at-home
testing, HIV/STI results, and linkage
to treatment in rural MSM
Methodology and analysis from
grounded theory; interviews
Themes: Stigma, confidentiality concerns; access
to home testing; desire for prompt results and
treatment; leveraging telemedicine to interact with a
culturally competent provider
Lindberg etal.
(2021)
2 communities in northern interior
Sweden (each with a population
of <700 people)
Rural not explicitly defined
19 community members, all of
whom had used some eHealth
technology; 63% female; 61–85
years old
Describe rural, older people’s
perception of caring relations within
eHealth context
Semi-structured interviews;
qualitative content analysis
Themes: Importance of in-person caring relations;
the importance of patient-nurse caring relations;
multidirectional caring relations in eHealth
Rasekaba etal.
(2021)
Regional Victoria, Australia
Rural not explicitly defined
9 pregnant women with GDM, 3
clinicians, and 2 IT specialists were
interviewed
Chart review of 205 women with
GDM in past 12 months
Determine views of women with
GDM regarding telehealth in GDM
management
Mixed methods including chart
review and semi-structured
interviews;
qualitative thematic analysis
Themes: Telehealth more convenient in terms of
distance and time saved, less costly, less time off
work; continuity of care is important regardless of
mode of care; telehealth did not impact quality of
care;
Rush etal.
(2019)
Western Canadian province
Rural not defined
8 adults with AF; 50% male; mean
age = 70; 1 partner, 5 providers
also interviewed
Understand perceptions to telehealth
for providing AF specialty care not
found in their communities
Qualitative descriptive;
semi-structured interviews;
thematic analysis
Themes: Receptiveness based on past experiences and
rurality of services; telehealth could improve gaps in
care; self-management; care coordination
Sabesan etal.
(2014)
Rural North Queensland, Australia
Rural not defined
29 cancer patients 41% male; average
age 58; 90% nonindigenous
Patient perspective of a tele-oncology
clinic where most patients are no
longer seen face-to-face
Qualitative descriptive;
interviews; thematic analysis
Themes: Quality of the consultation, communication
and relationship, familiarity with technology and
initial fears; local support and services; coordination
of care
Sundstrom
etal. (2020)
South Carolina, United States
Counties met ORHP standard for
rural health clinics
52 women aged 18–44; 62% Black or
African American
Understand perceptions of telehealth
in rural communities (using a
community center)
Methodology and analysis from
grounded theory; interviews
Themes: Relationship-centered care; confidentiality
in a small town; benefits of telehealth (cost savings,
decreased wait times, transportation)
Abbreviations: MSM = men who have sex with men; AF = atrial fibrillation; CBPR = community-based participatory research; GDM = gestational diabetes mellitus.
6 Western Journal of Nursing Research 00(0)
Synthesis
Importance of familiar relationships. Rural people value the
familiarity of their relationships with health care providers in
their communities, and they appreciate how small communi-
ties facilitate these relationships (Shreffler-Grant, 2022;
Thurman et al., 2019; Weinert et al., 2005). This theme was
nearly universal in the review and it speaks to the RNT con-
cepts of trust and familiarity. Within the First Nations’ cul-
ture, Gibson et al. (2011) reported there was a general feeling
that trust could not be established in a virtual context due to
the lack of physical contact and thus telehealth was at times
construed as inappropriate. Some parents in Campbell et al.’s
(2019) study echoed these concerns regarding their chil-
dren’s virtual appointments with allied health professionals.
Sundstrom et al. (2020) studied rural women’s percep-
tions of seeking reproductive health care via a community
telehealth center. The participants in this study expressed
concern over the ability to trust a provider via telehealth and
described mediated communication as impersonal. Older
rural adults in Lindberg et al.’s study also believed that face-
to-face interactions were critical for establishing authentic,
caring relationships (Lindberg et al., 2021). The recent focus
on digital solutions at the local clinics even made some par-
ticipants wary of using local in-person health care since staff
were being hired for their digital competence instead of their
interpersonal skills.
Rural individuals often indicated that they would be com-
fortable using telehealth after they had initially met the pro-
vider face-to-face (Alexander et al., 2021; Gibson et al.,
2011; Lindberg et al., 2021; Rasekaba et al., 2021; Rush
et al., 2019; Sabesan et al., 2014). Alternatively, during tele-
health interactions that took place within a clinic setting,
having a local nurse or medical assistant was seen as com-
forting to some patients (Gibson et al., 2011; Rush et al.,
2019; Sabesan et al., 2014).
Findings from Hubach et al.’s (2020) research describing
preferred methods of HIV/STI screening in a sample of rural
men who have sex with men are somewhat discordant with
the other articles. In this study, participants struggled with
stigma from their local providers and the fear of being outed
within their communities. For participants in this study, it
was difficult to form close relationships with the local pro-
viders and having the option to use telehealth to communi-
cate with an LGBTQ-affirming provider was seen as a
benefit.
Concerns with privacy and confidentiality. Lack of anonymity is
one of the original concepts from RNT (Long & Weinert,
2022). The related concepts of privacy and confidentiality
remain important factors in terms of health-seeking behav-
iors among rural populations (Swan & Hobbs, 2018). In this
review, even though people living in rural areas were accus-
tomed to the lack of anonymity in their communities, some
were concerned with the privacy and confidentiality of their
health information and how the mediated use of technology
may infringe upon their privacy. In total, 4 of the 10 studies
raised confidentiality and privacy concerns related to tele-
health. There are some nuances that will be important to
note, particularly concerning how telehealth services are
delivered and the relative risks of familiarity versus confi-
dentiality in a small town.
If telehealth was offered in a community location, some
people expressed concern that everybody in town would
know their business. There were concerns about people
being able to overhear their conversations even if the encoun-
ter took place in a private office (Gibson et al., 2011;
Sundstrom et al., 2020). Some participants in the reviewed
studies expressed apprehension about their conversation
being recorded without their knowledge; that others would
be listening in on the other end; and voiced concerns regard-
ing data theft (Alexander et al., 2021; Sundstrom et al.,
2020). These concerns are also related to the concept of trust,
and participants described the need for reassurance that the
technology would not violate their privacy (Sundstrom et al.,
2020).
Alternatively, telehealth could be seen as protecting pri-
vacy and confidentiality. Hubach et al. (2020, p. 472) noted
that “accessing care locally could mean attending clinics
where community members worked and create opportunities
for confidentiality to be breached.” In small communities, it
is difficult to remain anonymous. Thus, telehealth may create
a safer, more private environment than face-to-face encoun-
ters for stigmatized health concerns.
Acceptance of limited access to care. According to RNT, place
shapes one’s broader worldviews, leading to an acceptance
of the limitations of living in a rural area (Lee & McDonagh,
2018). In Rush et al.’s study on telehealth perspectives for
older rural adults with atrial fibrillation, patients who were
satisfied with their current rural health services could not
articulate how telehealth would improve care (Rush et al.,
2019). The authors described this as “a rural mindset that
was accepting of what they had and pride in looking after
themselves, suggesting subtle resistance to the intrusiveness
of telehealth” (Rush et al., 2019, p. 139). Lindberg et al.
(2021) noted that some of their participants would rather
wait until the local doctor was available at the rural clinic
instead of using telehealth for perceived nonurgent concerns.
Other individuals living in remote areas were willing to
travel over the course of several days to meet with a special-
ist as they did not consider any alternative ways to receive
health care (Bradford et al., 2015).
This acceptance of living in a rural area incorporates the
concept of self-reliance. Rural residents understand that liv-
ing in a rural area means there will be limited and sparsely
distributed resources. This sense of self-reliance also rein-
forces an insider–outsider perspective. Some study partici-
pants had a difficult time understanding the benefits of
telehealth—an “outsider” technology—and therefore
Pullyblank 7
expressed an unwillingness to use it (Bradford et al., 2015;
Campbell et al., 2019; Rush et al., 2019). Other participants
commented that implementing telehealth services would
limit capacity-building efforts within the rural community
(Gibson et al., 2011).
Resourcefulness and frugality. According to RNT, the concepts
of resources and distance impact health-seeking behaviors
(Lee et al., 2019). Rural characteristics include resourceful-
ness and frugality (Mennenga et al., 2022), and participants
in most of the studies endorsed using telehealth because it
was economical (Alexander et al., 2021; Bradford et al.,
2015; Gibson et al., 2011; Rasekaba et al., 2021; Sundstrom
et al., 2020). Telehealth is a particularly useful tool to reduce
travel time and costs. Telehealth could alleviate the transpor-
tation issues that some rural residents indicated were a bar-
rier to receiving care especially if they did not have their own
vehicle or had to travel many hours while not feeling well
(Bradford et al., 2015; Rasekaba et al., 2021; Sabesan et al.,
2014; Sundstrom et al., 2020).
In addition to saving time and money, telehealth was also
able to alleviate some of the emotional stresses associated
with visiting a provider’s office. Participants often reported
feeling less vulnerable and more relaxed interacting with
their providers through telehealth (Bradford et al., 2015;
Campbell et al., 2019; Gibson et al., 2011; Hubach et al.,
2020; Sundstrom et al., 2020). Telehealth also allowed par-
ticipants to avoid long waits in potentially crowded waiting
rooms (Sabesan et al., 2014; Sundstrom et al., 2020).
The RNT concept of self-reliance connects to the theme
of resourcefulness and frugality. The adage “necessity is the
mother of invention” is mentioned in Jakobs’ (2022) discus-
sion of self-reliance in frontier communities. Connecting to
health care in a way that is not only more cost-effective but
also potentially gives the patient more autonomy and flexi-
bility, demonstrates this independent spirit and the ability to
get by with limited resources.
Discussion
In this scoping review, 10 studies addressing how the rural
profile influences beliefs about telehealth utilization were
identified. Four themes were developed: the importance of
familiar relationships, concerns with privacy and confidenti-
ality, acceptance of limited access to care, and frugality and
resourcefulness. These themes contained robust RNT con-
cepts including trust, familiarity, lack of anonymity, place,
self-reliance, resources, and distance.
Similar themes are found in the larger body of literature
regarding rural health-seeking behaviors (Brown & Schafft,
2019; Cheesmond et al., 2019; Fennell et al., 2018; Lee et al.,
2022; Thurman et al., 2019). A pervasive “rural deficit” dis-
course has led some rural individuals to feel they are second-
class citizens and has emphasized the unwritten cultural
norms regarding power relationships and inclusion and
exclusion practices in rural communities (Simpson &
McDonald, 2017). This distrust or mistrust of newcomers
and outsiders (and by association, the technology they bring)
may contribute to slower adoption of telehealth in rural areas
(Brown & Schafft, 2019; Lee et al., 2022).
In addition, rural communities are generally closely knit
due to limited social networks and scarce resources (Keller
& Owens, 2020; Maclaren, 2018; Phillips & McLeroy,
2004). There is a relative lack of anonymity, and according to
RNT, a general expectation among both clinicians and
patients is that they will know one another on both a profes-
sional and personal level (Glover, 2019; Paré et al., 2022;
Scharff, 2022). Therefore, interactions with health care pro-
viders tend to be more relational than transactional (Farmer
et al., 2012; Scharff, 2022), which may also lead to a prefer-
ence for in-person health care interactions. Conversely, this
sense of tight community may also encourage some individ-
uals to use telehealth when they realize that doing so would
alleviate some pressure on their local health care staff and
free up availability for other patients in the community who
may need the in-person care more urgently (Lindberg et al.,
2021).
Implications for Policy, Practice, and Research
There is an assumption that people living in rural areas will
utilize telehealth if they have the technological capabilities, in
terms of infrastructure and digital literacy. Thus, recommenda-
tions for programs and policies are focused on increasing
broadband access and providing people with the appropriate
resources they need in order to use telehealth (DeGuzman
et al., 2020; Shaw et al., 2021). This review indicated that
equipped with these resources, many rural people are amenable
to telehealth because of the associated time and financial sav-
ings. However, clinicians and policy makers also need to
understand that the unique rural profile shapes beliefs about
telehealth utilization. Again, due to this perception of being
“less than,” and similar to other disparate groups, a trusting rap-
port needs to be established between providers and rural com-
munity members in order to make telehealth an effective and
acceptable form of care delivery. Lindberg et al. (2021) and
Currie et al. (2015) have suggested that health care administra-
tors, nurses, and clinicians should consider framing telehealth
not as replacing traditional care, but as supplementing it. That
is, individual clinicians should be using a mix of in-person and
telehealth interactions instead of relying on separate telehealth-
only teams. The initial in-person visit prior to engaging in tele-
health seems to be important for many rural people in order to
establish trust and rapport and assuage any concerns about
breaches of privacy. Similarly, having trusted local nurses or
clinicians present during a telehealth encounter originating
from a local clinic may be an essential strategy to encourage
telehealth adoption. The review also indicated the dearth of
data available regarding the rural profile and perceptions of
telehealth utilization. While the intent of the study was not to
assess actual utilization, future research efforts could explore
the relationship between the rural profile and telehealth uptake.
8 Western Journal of Nursing Research 00(0)
Limitations
There are several limitations to this scoping review that must
be acknowledged. First, search criteria were limited to devel-
oped nations that have large rural populations. Understanding
rural perceptions of telehealth access in developing countries
was not the intent of this review. However, the delimiters
placed on geography could have excluded some relevant
studies. Second, there was a paucity of literature regarding
how the rural profile may impact telehealth acceptance and
utilization using the defined search terms. Future work could
undertake a more systematic review, particularly now that
the COVID-19 pandemic has prompted numerous studies
related to telehealth implementation in rural settings. It may
be helpful to include audio-only telehealth as a search term
to broaden results and inform findings. Third, all but one of
the evaluated studies examined marginalized populations
which limits generalizability.
Conclusion
The results from this scoping review revealed that there is a
large gap in the knowledge base pertaining to how the rural
profile contributes to beliefs about telehealth utilization.
RNT is an applicable, yet underutilized, a middle-range the-
oretical framework that could be used to explore this topic
further. Understanding how the rural profile can influence a
person’s decision to use telehealth under various circum-
stances is not only important for nurses and other health care
professionals but is critical to public health initiatives as
well. The improvements in broadband access in rural areas
will certainly help alleviate barriers to health care for some
individuals. But unless rural health-seeking behaviors are
accounted for when implementing telehealth programs, it is
likely that the disparity in access to health care will only
increase.
Authors’ Note
The author Kristin Pullyblank is also affiliated with Decker College
of Nursing and Health Sciences, Binghamton, NY.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Kristin Pullyblank https://orcid.org/0000-0003-0200-1333
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