Hype,evidence gaps and digital divides: Telehealth blind spots in rural Australia

Abstract

Despite high unmet demand for health services across rural Australia, uptake of telehealth has been slow, piecemeal and ad hoc. We argue that widespread failure to understand telehealth as a socio-technical practice is key to understanding this slow progress. To develop this argument, we explore how technocentric approaches to telehealth have contributed to critical blind spots. First, the ‘hype’ associated with the technological possibilities of telehealth discourages thoughtful consideration of the unanticipated consequences when technologies are rolled out into complex social fields. Second, it contributes to critical gaps in the telehealth evidence base, and particularly a paucity of analyses focussing on the experiences of service users and patients. A third blind spot concerns the limited attention paid to the social determinants of health and digital divides in rural areas. The final blind spot we consider is an apparent reluctance to engage community stakeholders in co-designing and coproducing telehealth services. We used an iterative approach to identify studies and commentary from a range of academic fields to explain the significance of the telehealth blind spots and how they might be addressed. Insights suggest how expanding understanding of the social dimensions of telehealth could enhance its accessibility, effectiveness and responsiveness to community needs and contexts.

Keywords

issues in research methodology social inequalities in health technology in healthcare

The promise (and yet to be realised) potential of telehealth

In Australia, a geographically vast, yet highly urbanised country, there is long-standing anticipation that telehealth and other digital technologies will enable timely and cost-efficient health services to be delivered to residents living across its regional and sparsely populated rural and remote areas. Despite high unmet demand for health services across rural Australia, however, uptake of telehealth has been slow, piecemeal and ad hoc (Jang-Jaccard et al., 2014), and similar trends are observed in other countries (Olivera Hashiguchi, 2020: 347). This is attributed to the considerable and complex challenges in coordinating the technological, regulatory, financial, professional and cultural adaptions that are required to make telehealth work (Greenhalgh et al., 2017; Jang-Jaccard et al., 2014). We argue that widespread failure to understand telehealth as a socio-technical practice is also key to understanding slow progress in consolidating telehealth in rural service systems. While this conceptualisation of telehealth is not novel (e.g. see Alami et al., 2019; Coakes and Coakes, 2009; Eason et al., 2013; Greenhalgh et al., 2017; Peddle, 2007), we show how overlooking its social dimensions contributes to problematic blind spots that hamper the accessibility and effectiveness of telehealth services.

Colloquially a blind spot is a perspective where the view is partially obscured. We identify four and these are: the hype that accompanies technological innovations; gaps in the telehealth evidence base; neglect of the social determinants of health; and the absence of service user and community involvement in co-designing telehealth services. We focus on rural Australia where strong interest in telehealth is driven by declining availability of place-based services and concerns for health disparities between urban and rural populations. Various schemata have been devised to categorise contexts of remoteness outside of Australia’s capital cities. The Australian Bureau of Statistics (ABS, 2016) classifies four kinds of non-urban settlements: ‘outer regional’, ‘rural’, ‘remote’ and ‘very remote’. These distinctions evoke the immensity of Australia’s hinterlands and varied socio-spatial contexts for delivering and accessing health services beyond urban areas. For brevity we use the descriptor ‘rural’ to refer to non-urban settings understanding that this represents diverse socio-spatial contexts. Persistent health disparities between urban and rural populations include higher rates of chronic disease, medical complications and lower survival rates for conditions, such as cancer (Australian Institute of Health and Welfare [AIHW], 2016). Chronic health workforce shortages, and reduced access to health-promoting infrastructure, programmes and activities are compounding factors (AIHW, 2019a). Health disparities between Aboriginal and non-Aboriginal Australians are also implicated in urban – rural health inequalities (AIHW, 2019b). While there are more Aboriginal people living in urban areas, Aboriginal Australians represent higher proportions of the populations of many rural and remote locations.

The need to minimise in-person contacts in the wake of the COVID-19 pandemic raised hopes that telehealth will finally secure its place in rural health service systems. This is because a key barrier – funding – has finally been addressed. After years of federal governments resisting changes to Medicare reimbursement models, the availability of subsidised telehealth services was significantly expanded to cover medical, nursing, midwifery and allied health services. Early analyses show that the volume of phone consultations with General Practitioners (GPs) increased from 0% to 34%, although there were negligible changes in consultations via video conferencing (0% to 1%), and 34% were for mental health consultations (Snoswell et al., 2020). Since peaking in April 2020, data from Australia, Canada and the US shows subsequent declines in the use of telehealth services across all three countries (Mehrotra et al., 2021). It remains uncertain whether reducing potential for virus transmission or funding reforms is the most pertinent factor driving demand for telehealth services, and there is emerging evidence that patients have highly mixed responses to the modality (Isautier et al., 2020; Javanparast et al., 2021). These insights suggest that contingencies associated with COVID-19 have increased acceptance of telehealth in some circumstances, however, they may not have resolved other challenges to embedding telehealth in rural service systems.

Telehealth: A promissory potential

Telehealth refers to an expanding bundle of practices that encapsulate the multiplying possibilities of information and telecommunication technologies for delivering clinical care and allied health services, health education and public health programmes at a distance (Totten et al., 2016). An early paper seeking to mark out the emerging field of telehealth identified 51 distinct definitions in the published literature (Oh et al., 2005: e2) and only a few years later, another paper found 104 definitions (Sood et al., 2007). These have only proliferated over time and ‘telehealth’ is also used interchangeably with, or incorporated into, other similar concepts, such as ‘eHealth’, ‘mHealth’, ‘virtual health’ and ‘digital health’. The latter references the evolving use of tracking and heath monitoring using smart devices, smart home technologies, real-time data harvesting and big data analyses and robotics in health care and health promotion activities and is increasingly difficult to separate out from telehealth (Lupton, 2019; Rowlands, 2019).

Telehealth has been available in Australia for almost 40 years. Early adopter and telehealth champion, physician Yellowlees (2000), pointed to studies dating back to the 1980s that described applications of telehealth across rural Australia. By the late 1990s, Australian Health Ministers established the National Health Information Management Advisory Council (NHIMA), comprising representatives from government, the private sector and consumers, to progress action on key issues related to the use of telecommunications for the delivery of healthcare. The first task was to produce a national strategy plan, Health Online: A Health Information Action Plan for Australia (National Health Information Management Council, 2000), that described itself as a framework and ‘living document’ to guide the implementation of ehealth initiatives by identifying and resolving potential obstacles. These developments persuaded commentators, including Yellowlees (2001), to predict that telehealth was poised to be mainstreamed in rural health service systems.

A decade later a bluntly titled parliamentary report, The eHealth Revolution: Easier Said Than Done (Jolly, 2011: 27) catalogued slow progress in consolidating telehealth initiatives. Among other factors, the ehealth revolution was thwarted by lack of national coordination, fragmentary funding arrangements, poor consultation with stakeholders and concerns for the privacy of health data (Jolly, 2011). Despite these challenges, stubborn optimism towards the potential of telehealth in rural Australia persisted in policy documents in ways that are typical of a promissory tone that is evident in discussions of telehealth internationally (Geiger and Gross, 2017; Pollock and Williams, 2010). This tone resurfaced in Australia’s inaugural National Rural Health Commissioner’s report although it could only point to scattered progress (Office of the Rural Health Commissioner, 2019: 43). An OECD report shows that while there is steady increase in the global growth of telehealth services across many countries (including Australia) they continue to account for only a smaller than anticipated share of health services (Olivera Hashiguchi, 2020: 15–16). It is striking that telehealth champions, who include policymakers, bureaucrats, service providers and academics, remain optimistic towards its potential yet rarely reflect on the reasons for faltering progress.

A method for exploring telehealth blind spots

Telehealth optimism is grounded in an understanding of technology as a driver of change (Greenhalgh et al., 2012). Alternatively, conceptualising telehealth as a socio-technical practice recognises that technologies acquire social significance and meaningfulness that inform their adaptability and durability. Understanding telehealth as socio-technical practice, however, involves straddling divergent paradigmatic ways of comprehending the world that has been difficult to bring together in telehealth research and practice (Coakes and Coakes, 2009: 3). This divergence is apparent in distinctive ‘organising visions’ that Greenhalgh and colleagues identified as underpinning how telehealth and telecare technologies are explained and justified by various stakeholder communities (Greenhalgh et al., 2012). Analysing the content of communicative acts addressing telehealth (e.g. academic papers, industry statements, policy documents, conference presentations and media reports) they identified four discursive themes – modernist, humanist, political economy and change management - that reflect distinctive kinds of ‘assumptions, values and world views’ about telehealth (Greenhalgh et al., 2012: 1).

Modernist discourse features strongly in public, policy and industry accounts, and some academic disciplines. Typically, it offers future-orientated, and even utopian accounts in which technology offers solutions to overwhelming problems of ageing and chronically ill populations draining available health resources. Humanist discourse tends to draw on the social sciences to focus on the lived experiences of people and their relationships, understanding technology as ‘creating as well as solving problems’ (Greenhalgh et al., 2012: 8). Political economy discourse emphasises the macro-structural dynamics, including vested financial interests, which mould health technologies, while change management discourse accepts the value of telehealth and attends to understanding barriers to successful implementation. Lupton (2014) makes broadly similar observations of paradigmatic differences in distinguishing between largely uncritical discussions of digital health technologies in the medical and public health literature and the media with studies drawing on the social sciences. In the manner of humanist discourses, the latter offer reflective accounts of the complex ways in which information and communication technologies are transforming meanings and practices of health and wellbeing.

These discursive and disciplinary schisms have constrained opportunities for constructive dialogue between those who understand technology as driving change and those who understand it as animated by social purpose. Perceiving the dominance of modernist discourse in discussions of telehealth in relation to rural health, we sought to bridge this discursive impasse by seeking out studies and commentary that offered insights into why telehealth wasn’t working in anticipated ways. In contrast to synthesising available knowledge, these aims required exploring gaps and limits in knowledge and practice, and we used Jaakkola’s (2020) explanation of a ‘conceptual methodology’ to guide the process. The method seeks to blend ‘multiple concepts, literature streams and theories’ and Jaakkola identifies four broad approaches and we adapted two of these in a stepped and empirically grounded process. First, we used a ‘typology’ approach to classify common issues across fragmented areas of research. This involved using an iterative approach to identify studies and commentary that discussed gaps and problems that were encountered. Insights were gathered from a range of academic disciplines – health, sociology, communication and technology and marketing studies – as well as journalistic accounts and policy documents. While we were particularly concerned to better understand problems associated with telehealth in rural communities, our reading was not restricted to these settings.

Emerging issues suggested the different ways in which the social dimensions of telehealth were being overlooked and we identified four broad categories – or ‘blind spots’ – because they outlined substantive gaps in knowledge and practice. The second analytic step used a ‘theory adaptation’ approach that aims to ‘revis[e] extant knowledge (. . .) by introducing alternative frames of reference to propose a novel perspective on an extant conceptualisation’ (Jaakkola, 2020: 23). Positioning telehealth within relevant social contexts and practices suggested some strategies for addressing its blind spots, although these are not exhaustive of the possibilities.

Blind spot #1: The distorting effects of telehealth hype

This blind spot arises through tendencies for new technologies, including telehealth, to attract extravagant claims for their commercial and transformative potential. The commercial potential of telehealth is noted by pundits from Fortune Business Insights (2019) who forecasted projected global growth climbing to USD$226.8 billion by 2026. Tendencies to hype technologies transformative potential are associated with understanding them as drivers of change (Greenhalgh et al., 2012). In the field of market studies, ‘hype cycles’ associated with new technologies are well-recognised: they initially attract considerable attention and inflated expectations that eventually gives way to the evocatively named ‘trough of disillusionment’ (Geiger and Gross, 2017: 445–6). Over time, qualified understanding of the potential of technological innovations can lead to subsequent periods of steady growth (Geiger and Gross, 2017).

In the meantime, the hyping of new technologies has polarising effects. At peak enthusiasm, those championing the transformative potential of emerging technologies can elicit strong resistance with effects that new technologies are frequently both ‘evangelised and vilified’ Geiger and Gross (2017: 436). Pols (2012) notes these polarising tendencies in relation to telehealth where it is either hyped or draws forth ‘soapbox’ warnings of its destructive effects on therapeutic relationships. The distorting effects of hype are illustrated in a study that tracked the hype cycle in media reporting of telehealth in Ireland over a ten-year period (Geiger and Gross, 2017). It shows how initial enthusiasm for telehealth was followed by growing concerns for the stigmatisation of some social groups, loneliness among the elderly and problems of ‘cyberchondria’. Critically, polarised views emphasising either the transformative or destructive potential of technologies have hampered capacities to gain nuanced understanding of the opportunities, unanticipated consequences and disruptive effects of telehealth in real-world settings (Alami et al., 2019). Using secondary data from telehealth projects implemented across Quebec province from 1993 to 2015, these researchers identified a raft of unintended consequences, including disruptions in existing service corridors, the effects of shifts in power relations between stakeholders and the redistribution of responsibilities in service supply chains (Alami et al. (2019). They argued that these unfolding outcomes were overlooked in ‘technology-centric’ evaluations ensuring that they recurred in subsequent programmes (Alami et al., 2019: 305).

Hype also attaches to the transformative potential of telehealth to confer citizen-consumers with unprecedented agency in (or responsibility for) monitoring, managing and coordinating their health and health care (Rowlands, 2019; Topol, 2015). With enticing commercial potential and buoyed by hype, questions of how technologies offer convenience for some, but can be exclusionary for others are disregarded. The need for public scrutiny or community discussion of how risks might be mitigated are also overlooked. These issues have become evident in the proliferation of app-based telehealth GP services such as My Emergency Doctor, Instant Consult, Hello Doctor, Doctor in a Box, DoctorsonDemand. Once such service, GP at Hand, is offered by Babylon Health, an international corporation established by a former Goldman Sachs banker. Launching in the United Kingdom in 2013 it offers online GP consultations, chatbot diagnoses for minor ailments (although there are claims that its Artificial Intelligence (AI) capabilities are ‘overhyped’, see Burgess and Kobie, 2019) and some place-based services, and is proving popular with mostly young and healthy patients. While telehealth is highly suitable for some consultations, carving these out to provide ‘stand-alone’ services is having profoundly disruptive effects in health systems. These include limited capacities to provide local, in-person services when required and segmenting caseloads to the detriment of traditional ‘bricks and mortar’ practices that are left treating increased proportions of high-needs patients (Salisbury, 2019). Further, despite accessing public funding to provide health services, the company is minimising its accountability to the community. It reportedly rejects peer review processes, a cornerstone for ensuring academic and scientific integrity, and questions the value of widely accepted approaches to research and evaluation, such as Randomised Controlled Trials (RCTs) as the gold standard for clinical trials, preferring to rely on internal quality assurance process (Burgess and Kobie, 2019).

Hype obscures the potential of technologies to usher in new kinds of inequality that are particularly relevant to telehealth. For instance, there are fears for the ‘“luxurification” of human engagement’ where ‘face-to-face services will be reserved for those who can pay a higher price’ (Bowles, 2019). These trends are already evident in the availability of ‘cold care’ options using AI and avatars to provide remote care of the elderly. Rural communities have been grappling for some time with the risks of inequalities arising through tiered service models. Declining place-based services are supplemented by a combination of ‘fly-in fly-out’ (FIFO), ‘drive-in drive-out’ (DIDO) and ‘virtual-in virtual-out’ (VIVO) models of health care delivery. While FIFO and DIDO models continue to require degrees of in-situ presence that expose service-providers to the specificity and diversity of socio-economic and spatial contexts of rural communities, virtual health care has potential to dispense with local contact altogether. If virtual services offer solutions to pressing workforce issues in rural areas, they involve risks of exacerbating inequalities when access to in-person services are determined by geography or household economic resources, and efficiency gains are prioritised over providing quality care (Perkins, 2015).

Communities might resist telehealth through concerns for its economic and social repercussions. The includes the contributions of place-based health services in stimulating local economic activity, stemming further out-migration and generating forms of human and social capital that enhances the sustainability and liveability of rural communities (Farmer et al., 2003; Prior et al., 2010). These risks are recognised in the WHO Guideline Recommendations on Digital Interventions for Health System Strengthening (2019) which state that ‘while telemedicine may enhance access to health services, it should not be used to replace or detract from efforts to strengthen the health workforce’ (p. 50). These varied issues suggest that while technology has potential to solve some problems, it can create others that cannot be perceived without a social lens. Further, the hype that attaches to technologies can stifle thoughtful discussion of, and preparation for, its unintended consequences and disruptive effects across populations, local settings and service systems.

Blind spot #2: Gaps in the telehealth evidence base

This blind spot arises through critical gaps in the telehealth evidence base. Reviewing the telehealth literature, Standing et al. (2018: 91) characterised telehealth as an ‘awkward innovation’ beset by paradoxes. One of these is that telehealth has generated an evidence base which, despite rapidly expanding over recent years, focuses on a narrow range of issues and reiterates similar kinds of barriers that remain largely unaddressed (Standing et al., 2018). Noted gaps in the evidence base include studies exploring the perspectives and experiences of service users and patients and the effects of interprofessional and collaborative practice among clinicians (Kahn, 2015; Standing et al., 2018). There is also a paucity of interdisciplinary research (Greenhalgh et al., 2017; Lupton, 2014; Pols, 2012; Standing et al., 2018), and a reliance on insights gained from pilot studies. Peddle (2007: 598) described the field of telehealth research as one of ‘perpetual pilot projects’ where analyses seldom extend beyond implementation phases (see also Eason et al., 2013; Greenhalgh et al., 2017; Hage et al., 2013; Olivera Hashiguchi, 2020). The World Health Organisation (WHO, 2019: ix) cautions that ‘enthusiasm for digital health has [. . .] driven a proliferation of short-lived implementations [. . .] with a limited understanding of their impact on health systems and people’s well-being’.

While insights from pilot projects are useful, the implications of their limitations in the telehealth evidence base are not widely acknowledged. These include limited power to generalise from the evidence they present, understand variation across local contexts and populations, or explore how telehealth is absorbed into organisational and everyday practices over time (Eason et al., 2013). There are also concerns that a pre-dominance of pilot projects may be overstating the promising outcomes of telehealth initiatives. This is attributed to the ‘Hawthorn Effect’ that postulates that pilot projects can garner extra attention and effort and this effort is susceptible to falling away in consolidation phases when impediments associated with organisational structures and processes come into play (Eason et al., 2013; Greenhalgh et al., 2017).

Meta-analyses, such as systematic reviews, offer techniques for synthesising and generalising findings from pilot and other studies and are also prominent in the telehealth evidence base. Even with carefully formulated inclusion criteria and strategies for assessing the rigour of studies, bias towards positive results from pilot projects may be replicated in systematic reviews. Further, it is difficult to distill specific insights from reviews that integrate findings involving diverse care practices, technologies and settings. This problem was noted in efforts to develop an evidence map of systematic reviews of telehealth research conducted in the US. Even within specific categories of health conditions, inevitable diversity across the studies that were examined meant that the reviews produced highly mixed findings and limited insights into how components of projects work together to achieve precise, desired outcomes (Totten et al., 2016).

Strategies for ‘realist reviews’ attempt to address some of these problems by using rigorous techniques for compiling samples of relevant studies, and then applying realist synthesis methods to explore questions of ‘what works for whom in what circumstances’ (Berg and Nanavati, 2016; Pawson, 2002: 342 ). Critical to realist synthesis approaches are insights that programmes in of themselves are not transformative. Rather, it’s the tailoring of motivations, mechanisms and resources within programmes, in response to specific contexts, which drive change. While this suggests a promising way forward, to date there are few examples of realist synthesis methods focussing on telehealth. Parker et al. (2018: 2) discuss a systematic realist review that sought to extract insights on the ‘interplay between context, mechanisms and outcomes’ of telehealth programmes targetting vulnerable populations, however, these aims were hampered by the limited descriptions of these processes that were provided.

There are concerns that population groups such as First Nations peoples, low-income households, people experiencing homelessness, living with disability or having immigrant backgrounds are largely neglected in telehealth studies (Parker et al., 2018; Standing et al., 2018). Available studies are weakened by low numbers of participants or rely on other stakeholders speaking on behalf of service users and patients. An example of this is a review of telehealth programmes for Aboriginal and Torres Strait Islander people reporting generally high satisfaction among service users, even though only two studies, each with small numbers of participants, explored patients’ perspectives (Caffery et al., 2017).

Compounding these issues, a restricted methodological and conceptual toolbox limits the kinds of insights that can be gleaned from research (Alami et al., 2019). A dearth of interdisciplinary, qualitative and ethnographic research reflects a generalised neglect of the social aspects of technology, including why technology is (or fails to be) incorporated into social practices (Eason et al., 2013; Peddle, 2007; Pols, 2012; Pols and Willems, 2011; Standing et al., 2018). Greenhalgh et al. (2017: 2) argue that there are urgent needs for telehealth research that is ‘interdisciplinary, nondeterministic, locally situated, and designed to examine the recursive relationship between human action and the wider organisation and system context’.

Qualitative and ethnographic research is well-suited for exploring phases of adoption and adaptation by generating insights into how technologies are inscribed with meaning through everyday usage. Examples of promising approaches have explored how technologies are ‘domesticated’ when relationships develop between devices and their users (Pols and Willems, 2011), and draw on the concept of ‘affordances’ to explore how telehealth technologies as situated and actualised in interactions involving particular kinds of settings, routines, resources, knowledge, abilities, social needs and personal intentions (Islind et al., 2019; Merolli et al., 2013; Shoebotham and Coulson, 2016; Steele Gray, 2020). These approaches can offer insights into why some ‘digital health technologies are successful, and others fail to work as imagined’ (Lupton, 2019: 2002). In the absence of evidence exploring the social meanings of technologies, Pols and Willems (2011: 496) suggest that telehealth remains a ‘hazardous investment’ because any understanding of its potential is drawn largely from assumptions that flow from its promises, rather than ‘lessons learned’.

Blind spot #3: The implications of social determinants of health

Social determinants of health are the economic, cultural and political contexts that frame and influence the everyday conditions of people’s lives (Navarro, 2009). These include community and work environments, income, education and literacy levels, access to healthy food, and exposure to racism, violence, stress and other negative experiences (Wilkinson and Marmot, 2003). Social determinants account for many of the health inequalities that are evident in most countries (WHO, 2008), and have long been recognised as influencing urban-rural health disparities (Dixon and Welch, 2000). Social determinants of health contribute to a conundrum formulated by the physician/researcher, Tudor Hart (1971), as the ‘law of inverse care’ . Seeking to understand why health inequalities across the UK endured despite universal health care following the implementation of the National Health Service in 1948, he postulated that the ‘availability of good medical care tends to vary inversely with the need for it in the population served’ (Tudor Hart, 1971: 406). That is, those who are most in need of health services may be least likely to access or benefit from available services.

Tudor Hart documented how industrial areas were not only ‘under-doctored’, but middle-class patients were also able to make more effective use of available resources. The law of inverse care remains relevant in explaining uneven access to health care in contemporary settings (Marmot, 2018), including circumstances that influence access and utilisation of telehealth and digital health services, information and other health-related opportunities. Indeed, evidence compiled by WHO (2019) shows that those with a higher health burden and increased needs for health services may be the least able to access and make use of telehealth services (Olivera Hashiguchi, 2020).

The concept of ‘digital divides’ evokes the implications of uneven capacities to access and deploy technologies. ‘First order’ divides are associated with reduced access to digital infrastructure, while ‘second order’ divides arise through circumstances that limit capacities to utilise and derive benefits from available technology (Dewan and Riggins, 2005). Digital divides are likely to contribute to telehealth’s ‘last mile’ problem in extending its reach into diverse rural populations (Hesse, 2019). First-order divides persist in regional Australia where, despite the national broadband network prioritising rollout in rural areas, a higher proportion of households in rural, compared to urban, areas continue to lack reliable access to digital infrastructure (Park et al., 2019). Indices used by Australian Digital Inclusion Index (ADII) to measure digital inclusion conceptualise a mix of first and second-order divides. They show that scores from rural areas are lower compared to urban areas on issues of: access (internet access, internet technology and data allowance); affordability (relative expenditure and the value of that expenditure); and digital ability (attitudes, basic skills, activities) (Thomas et al., 2020). Although gaps have been narrowing since 2014, the affordability gap widened between 2019 and 2020.

Second-order divides are associated with generational, socioeconomic, cultural and other circumstances that present opportunities to engage with and develop proficiency in using computers and other digital technologies (Thomas et al., 2018). Social-cognitive factors related to ageing or living with disability also impact on skills and reduce motivation and confidence in using digital technologies. High rates of hearing problems among First Nations communities could present similar barriers in accessing some telehealth services (AIHW, 2020). Second-order divides appear to receive limited attention in discussions of telehealth programmes. This is despite evidence for risks of digital exclusion among population groups such as low-income households, First Nations Australians, the elderly and people living with disabilities (Afshar Ali et al., 2020; Park, 2017; Thomas et al., 2017). Further, as a proportion of the population, these social groups are over-represented in rural areas. For instance, there are proportionately more people aged fifty years and older in rural areas (ABS, 2020), and fewer people in rural areas completing Year 12 than in major cities (50/74%, see AIHW, 2019c). Findings from a US study suggest that around 38% of people aged over 65 years may not be able to access telehealth because of physical and cognitive impairments, including hearing and vision loss (Lam et al., 2020). Other evidence from the US suggests that over 50% of differences in digital participation between rural and urban populations are associated with contexts related to education and income levels (Whitacre et al., 2015).

Focussing on Australia, Baum et al. (2014: 355) explore how interacting factors associated with socio-economic disadvantage leads to a ‘vicious cycle of digital exclusion’. Park (2017: 405) argues that digital exclusion arises through the combination of infrastructure shortfalls and socio-demographic circumstances that ‘create double jeopardy of digital disadvantage’ (see also Park et al., 2019). It also remains a priority to ensure that telehealth and digital programmes and resources are appropriately designed for the diversity of rural populations. This is particularly important for First Nations people who display interest in the opportunities afforded by digital technologies such as smartphones and laptops but can struggle to access internet and broadband connections in remote and very remote areas (Jones et al., 2017; Korff, 2020). This includes adapting holistic and culturally appropriate approaches for programme design, developing and curating content and information and tailoring communication channels to promote accessibility for First Nations peoples (Fraser et al., 2017; see Korff, 2020 e.g.). This should also extend to understanding the diversity of circumstances in ‘mainstream’ rural populations and the values that give meaning to everyday day life. For example, a realist review of telehealth and eHealth interventions involving ‘vulnerable’ populations concluded that they were ineffective because they conceived individuals as passive receptacles to be ‘persuaded into believing they could self-manage their conditions’ (Parker et al., 2018: 20). Emphasising the importance of tailoring services for different populations, service users were highly satisfied with programmes that were perceived to meet their needs.

Following the law of inverse care, growing reliance on telehealth while failing to consider the implications of digital divides, risks widening rural-urban health disparities (Walker, 2019). The WHO (2019) has warned of this potential where digital health interventions ‘create further inequities in some settings as consequences of poor network coverage, limited control of mobile devices, or a lack of other resources’ (p. 87). At the same time, Young (2019) cautions that the concept of ‘divides’ can tacitly privilege urban logics. He explores the risks of technological solutions that are narrowly focussed on issues of ensuring service supply or creating efficiencies can overlook community priorities and values. In such situations, individuals and communities may opt for ‘strategic disengage[ment] from some aspects of technological practice’ as a tactic of resistance (Young, 2019: 71). Understanding telehealth as a socio-technical practice facilitates increased focus on the significance of social determinants for capacities to access and engage with tele- and digital health services and practices and better prepare us to navigate the tensions that are presented.

Blind spot #4: The need to co-produce telehealth services with communities

A consistent theme across these discussions of telehealth’s blind spots is the importance of technological capacities being responsive to community contexts, capacities and priorities. Engaging and collaborating with community stakeholders to co-design and co-produce telehealth services is key to realising this potential. Strategies of co-production seek to blend experiential, theoretical, practical and technical forms of knowledge, and are increasingly recognised as critical for understanding and responding to complex and multi-faceted problems (Durose et al., 2018). While developing and implementing effective, accessible and complimentary telehealth services that meet the needs of diverse populations is an example of such a challenge, discussions of community-based engagement and collaboration are conspicuously rare in the telehealth literature. Again, assumptions across the fields of telehealth research and practices that technology is the driver of change (Greenhalgh et al., 2012: 7), rather than its affordances and meaningfulness for users (Islind et al., 2019; Pols and Willems, 2011; Steele Gray, 2020), contributes to discounting the value of soliciting community input and advice. This omission might also reflect unrelenting pressures to address chronic rural workforce shortages that have had effects of orientating rural health priorities to the needs of health care providers while deflecting attention from those of communities (Malatzky and Bourke, 2017). Reflecting on why telehealth programmes falter, however, Alami et al. (2019) underscore the importance of engaging all stakeholders – lay and professional – in processes of designing, adapting, implementing and evaluating services.

Overlooking community engagement and collaboration in telehealth research and practice is particularly puzzling when positioned alongside widespread and expanding efforts to facilitate community involvement in co-producing health services. For examples, see engagement frameworks, strategies and toolkits produced by Sunshine Coast Hospital and Health Service (2015), Government of Western Australian Mental Health Commission (2018) and the Victorian Comprehensive Cancer Centre (2021). These efforts are informed by related concepts of Patient and Public Involvement (PPI) and Consumer and Community Involvement (CCI) in health care practice and research. PPI/CCI seeks to engage and support community stakeholders to be involved in diverse activities, ranging from identifying health priorities for action, designing health care and health interventions, developing clinical practice guidelines to informing research agendas (Biddle et al., 2021; Boivin et al., 2014; Brett et al., 2014; Greenhalgh et al., 2019; Légaré et al., 2011; Lehoux et al., 2009). Aboriginal Controlled Community Health Organisations (ACCHOs) also offer a successful model for tailoring health services to community contexts that has demonstrated capacities to deliver culturally safe, comprehensive and effective health services (Panaretto et al., 2014). These capacities are attributed to a holistic and proximal understanding of local community contexts (Caffery et al., 2017), and are being harnassed to adapt and deliver telehealth services in response to the COVID pandemic (Sweet, 2020).

A welcome push to enhance community involvement in decision-making processes regarding structures and processes for health care is not without challenges. These include concerns that community engagement efforts rarely represent the diversity of populations, particularly populations considered vulnerable to being marginalised because of personal and structural circumstances, and that non-experts will struggle to grasp the complexity of issues at stake and defer to expert opinions anyway (Boivin et al., 2014). There is encouraging evidence, however, that these issues can be addressed and community stakeholders with varied professional and lived experience expertise can participate in deliberative processes that facilitate meaningful and persuasive discussions and exchanges of points of view. For instance, Boivin et al. (2014) combined ethnographic and quantitative methods in a RCT study design to explore the conditions that supported, and the outcomes of, deliberative processes involving health professionals and members of the public. They found that discussions facilitated opportunities for mutual influence that served to reorganise priorities for local action. This intermingling of perspectives and knowledge generates shared understanding that can the basis of developing ‘inclusive, provisional and actionable consensus’ in local settings (Lehoux et al., 2009).

Another criticism is that deliberative decision-making processes require investments of money, labour and time. While this is correct, considerable outlays of these resources have already been directed to developing and implementing telehealth services in rural areas even though anticipated impacts – such as moderating urban-rural health disparities – have yet to be realised. It is time to try new approaches. Encouragingly, an emphasis on community co-production chimes with a key recommendation in the Australian Rural Health Commissioner’s (2020) report for improving access to, and quality of, health services in rural areas. The report proposes a ‘Service and Learning Consortia’ model that could offer a multi-faceted approach that is designed for circumstances in rural communities and envisages ‘community members and consumers [as] co-designers of services and community champions’ (National Rural Health Commissioner, 2020: 19). It is critical that this model extends to the development and coordination of telehealth services.

Concluding remarks

Although it cannot replace needs for place-based services, telehealth has an indispensable role in rural health service systems. In this paper we have illuminated issues that have been overshadowed by the emphasis on the technical possibilities of telehealth at the expense of understanding how it is embedded in social practice. Understanding telehealth as a socio-technical practice brings social, economic, cultural and values-based perspectives into view in ways that can inform and enhance its accessibility, effectiveness and responsiveness to community needs and contexts. In summary this requires:

Adopting constructively critical stances towards health technologies that are alert to their unfolding implications, unintended consequences and risks in complex environments;

Expanding methodological toolboxes to conduct interdisciplinary and mixed methods for research that brings together the technical and social aspects of telehealth. Innovative, systematic and rigorous approaches to research are needed that integrate a focus on how best practice is adapted for local contexts;

Applying social determinants of health frameworks to understand how circumstances enhance or constrain capacities to access and utilise telehealth;

Involving diverse stakeholders – including community stakeholders – in co-designing and co-producing telehealth services. Blending multiple expert knowledge claims and normative assumptions (of experts and non-experts) can inform how technologies could be adapted to meet community needs and promote community resilience within processes of change and transformation in rural areas.

This paper outlines how selective social science perspectives, methods and concepts may be useful for realising the potential of telehealth in rural Australia. Along with expanding understanding of the social dimensions of telehealth, there remain other technical, budgetary and regulatory challenges to be resolved.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Three Rivers University Department of Rural Health (UDRH) is led, administered and operated by Charles Sturt University in consortium partnership with The University of Notre Dame, University of New South Wales and Western Sydney University. Three Rivers UDRH is supported by funding from the Australian Government under the Rural Health Multidisciplinary Training Program.

ORCID iDs

Deborah Warr

Danielle Couch

Author biographies

Deborah Warr had had conducted research in urban and rural settings and holds honorary positions at Three Rivers University Department of Rural Health at Charles Sturt University and the University of Melbourne. As a health sociologist her research focussed on an array of health-related issues and contexts, including rural health and workforce issues, relationships between health and place, place-based stigma, social determinants of health and co-producing health research with communities experiencing disadvantage and marginalisation.

Georgina Luscombe is Associate Professor – Rural Health at the University of Sydney School of Rural Health. She has a broad range of expertise in medical and allied health research, particularly in the design and implementation of research with community organisations and clinicians. A/Prof Luscombe strives to achieve fairer participation of Aboriginal people in both healthcare and research and believes that privileging of Indigenous ways of knowing will lead to improvements in health for Aboriginal people. Her main areas of expertise are in research design and statistics, and main research interests are rural health and healthcare access.

Danielle Couch is an Adjunct Research Fellow, Monash Rural Health, Monash University. She is a health sociologist with a background and expertise in public health, population health planning, digital health interventions and rural health. Dr Couch’s main research interests include surveillance, risk framing and media in relation to health, and how power and social control are applied (and resisted) in different contexts. She is currently employed in an Aboriginal Community Controlled Organisation.

References

Afshar Ali

Alam

Taylor

(2020) Do social exclusion and remoteness explain the digital divide in Australia? Evidence from a panel data estimation approach. Economics of Innovation and New Technology 29(6): 643–659.

Alami

Gagnon

Fortin

(2019) Some multidimensional unintended consequences of telehealth utilization: A multi-project evaluation synthesis. International Journal of Health Policy and Management 8(6): 337–352.

Australian Bureau of Statistics (2016) The Australian Statistical Geography Standard (ASGS) Remoteness Structure. Available at: https://www.abs.gov.au/websitedbs/d3310114.nsf/home/remoteness+structure (accessed 21 July 2021).

Australian Bureau of Statistics (2020) Regional Population by Age and Sex, Australia, 2018. Canberra, Australia: Australian Bureau of Statistics. Available at: https://www.abs.gov.au/statistics/people/population/regional-population-age-and-sex/latest-release (accessed 23 September 2021).

Australian Institute of Health and Welfare (2016) Australia’s Health 2016. Australia’s health series No. 15. Canberra, Australia: AIHW. Available at: https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx (accessed 23 September 2021).

Australian Institute of Health and Welfare (2019a) Rural & Remote Health. Canberra, Australia: Australian Institute of Health and Welfare. Available at: https://www.aihw.gov.au/reports/rural-remote-australians/rural-remote-health/contents/access-to-health-care (accessed 23 September 2021).

Australian Institute of Health and Welfare (2019b) Indigenous Health and Wellbeing. Canberra, Australia: Australian Institute of Health and Welfare. Available at: https://www.aihw.gov.au/reports/australias-health/indigenous-health-and-wellbeing (accessed 17 November 2021).

Australian Institute of Health and Welfare (2019c) Rural & Remote Health. Canberra, Australia: Australian Institute of Health and Welfare. Available at: https://www.aihw.gov.au/reports/rural-remote-australians/rural-remote-health/contents/profile-of-rural-and-remote-australians (accessed 18 November 2021).

Australian Institute of Health and Welfare (2020) Indigenous Hearing Health. Canberra, Australia: Australian Institute of Health and Welfare. Available at: https://www.aihw.gov.au/reports/australias-health/indigenous-hearing-health (accessed 21 July 2021).

10.

Baum

Newman

Biedrzycki

(2014) Vicious cycles: Digital technologies and determinants of health in Australia. Health Promotion International 29(2): 349–360.

11.

Berg

Nanavati

(2016) Realist review: Current practice and future prospects. Journal of Research Practice 12(1): 1–28.

12.

Biddle

MSY

Gibson

Evans

(2021) Attitudes and approaches to patient and public involvement across Europe: A systematic review. Health & Social Care in the Community 29(1): 18–27.

13.

Boivin

Lehoux

Burgers

, et al. (2014) What are the key ingredients for effective public involvement in health care improvement and policy decisions? A randomized trial process evaluation. Milbank Quarterly 92(2): 319–350.

14.

Bowles

(2019) Human contact is now a luxury good. The New York Times. Available at: https://www.nytimes.com/2019/03/23/sunday-review/human-contact-luxury-screens.html (accessed 7 July 21).

15.

Brett

Staniszewska

Mockford

, et al. (2014) Mapping the impact of patient and public involvement on health and social care research: A systematic review. Health Expectations 17(5): 637–650.

16.

Burgess

Kobie

(2019) The Messy, Cautionary Tale of How Babylon Disrupted the NHS. San Fransciso, CA: Wired. Available at: https://www.wired.co.uk/article/babylon-health-nhs (accessed 23 September 2021).

17.

Caffery

Bradford

Wickramasinghe

, et al. (2017) Outcomes of using telehealth for the provision of healthcare to Aboriginal and Torres Strait Islander people: A systematic review. Australian and New Zealand Journal of Public Health 41(1): 48–53.

18.

Coakes

(2009) A meta-analysis of the direction and state of sociotechnical research in a range of disciplines. International Journal of Sociotechnology and Knowledge Development 1(1): 1–52.

19.

Dewan

Riggins

(2005) The digital divide: Current and future research directions. Journal of the Association for Information Systems 6(12): 298–337.

20.

Dixon

Welch

(2000) Researching the rural-metropolitan health differential using the ‘social determinants of health’. Australian Journal of Rural Health 8(5): 254–260.

21.

Durose

Richardson

Perry

(2018) Craft metrics to value co-production. Nature 562: 32–33.

22.

Eason

Waterson

Davda

(2013) The sociotechnical challenge of integrating telehealth and telecare into health and social care for the elderly. International Journal of Sociotechnology and Knowledge Development 5(4): 14–26.

23.

Farmer

Lauder

Richards

, et al. (2003) Dr. John has gone: Assessing health professionals' contribution to remote rural community sustainability in the UK. Social Science & Medicine 57: 673–686.

24.

Fortune Business Insights (2019) Healthcare IT: Key market insights. Available at: https://www.fortunebusinessinsights.com/industry-reports/telehealth-market-101065 (accessed 7 July 2021).

25.

Fraser

Mackean

Grant

, et al. (2017) Use of telehealth for health care of Indigenous peoples with chronic conditions: A systematic review. Rural and Remote Health 17: 4205.

26.

Geiger

Gross

(2017) Does hype create irreversibilities? Affective circulation and market investments in digital health. Marketing Theory 17(4): 435–454.

27.

Government of Western Australia Mental Health Commission (2018) Working together toolkit. Available at: https://www.mhc.wa.gov.au/media/2531/170877-menheac-toolkit-web.pdf (accessed 5 August 2021).

28.

Greenhalgh

Hinton

Finlay

, et al. (2019) Frameworks for supporting patient and public involvement in research: Systematic review and co-design pilot. Health Expectations 22(4): 785–801.

29.

Greenhalgh

Procter

Wherton

, et al. (2012) The organising vision for telehealth and telecare: Discourse analysis. BMJ Open 2: e001574.

30.

Greenhalgh

Wherton

Papoutsi

, et al. (2017) Beyond adoption: A new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread and sustainability of health and care technologies. Journal of Medical Internet Research 19(11): e367.

31.

Hage

Roo

van Offenbeek

, et al. (2013) Implementation factors and their effect on e-Health service adoption in rural communities: A systematic literature review. BMC Health Services Research 13: 19.

32.

Hesse

(2019) Role of the internet in solving the last mile problem in medicine. Journal of Medical Internet Research 21(10): e16385.

33.

Isautier

Copp

Ayre

, et al. (2020) People’s experiences and satisfaction with telehealth during the COVID-19 pandemic in Australia: Cross-sectional survey study. Journal of Medical Internet Research 22(12): e24531.

34.

Islind

Snis

Lindroth

, et al. (2019) The virtual clinic two-sided affordances in consultation practice. Computer Supported Cooperative Work (CSCW) 28(3-4): 435–468.

35.

Jaakkola

(2020) Designing conceptual articles: Four approaches. AMS Review 10: 18–26.

36.

Jang-Jaccard

Nepal

Alem

, et al. (2014) Barriers for delivering telehealth in rural Australia: A review based on Australian trials and studies. Telemedicine and e-Health 20(5): 496–504.

37.

Javanparast

Roeger

Kwok

, et al. (2021) The experience of Australian general practice patients at high risk of poor health outcomes with telehealth during the COVID-19 pandemic: A qualitative study. BMC Family Practice 22(1): 69.

38.

Jolly

(2011) The e health revolution—Easier said than done. Research Paper 3 2011-12. Canberra, Australia: Parliamentary Library, Parliament of Australia. Available at: https://www.aph.gov.au/about_parliament/parliamentary_departments/parliamentary_library/pubs/rp/rp1112/12rp03 (accessed 23 September 2021).

39.

Jones

Jacklin

O’Connell

(2017) Development and use of health-related technologies in indigenous communities: Critical review. Journal of Medical Internet Research 19(7): e256.

40.

Kahn

(2015) Virtual visits—Confronting the challenges of telemedicine. New England Journal of Medicine 372(18): 1684–1685.

41.

Korff

(2020) Internet access in aboriginal communities. Available at: https://www.creativespirits.info/aboriginalculture/economy/internet-access-in-aboriginal-communities (accessed 7 July 2021).

42.

Lam

Shi

, et al. (2020) Assessing telemedicine unreadiness among older adults in the United States during the COVID-19 pandemic. JAMA Internal Medicine 180(10): 1389–1391.

43.

Légaré

Boivin

van der Weijden

, et al. (2011) Patient and public involvement in clinical practice guidelines: A knowledge synthesis of existing programs. Medical Decision Making 31: E45–E74.

44.

Lehoux

Daudelin

Demers-Payette

, et al. (2009) Fostering deliberations about health innovation: What do we want to know from publics? Social Science & Medicine 68(11): 2002–2009.

45.

Lupton

(2014) Critical perspectives on digital health technologies. Sociology Compass 8(12): 1344–1359.

46.

Lupton

(2019) Toward a more-than-human analysis of digital health: Inspirations from feminist new materialism. Qualitative Health Research 29(14): 1998–2009.

47.

Malatzky

Bourke

(2017) When the social meets health in rural Australia: Confronting the disconnect. Health Sociology Review 26(2): 190–203.

48.

Marmot

(2018) An inverse care law for our time. British Medical Journal 362: k3216.

49.

Mehrotra

Bhatia

Snoswell

(2021) Paying for telemedicine after the pandemic. The Journal of the American Medical Association 325: 431–432.

50.

Merolli

Gray

Martin-Sanchez

(2013) Health outcomes and related effects of using social media in chronic disease management: A literature review and analysis of affordances. Journal of Biomedical Informatics 46(6): 957–969.

51.

National Health Information Management Council (NHIMAC) (2000) Health online: A health information action plan for Australia. Health Information Management 29(4): 179–181.

52.

National Rural Health Commissioner (2020) Improvement of Access, Quality and Distribution of Allied Health Services in Regional, Rural and Remote Australia. Canberra, Australia: Department of Health. Available at: https://www1.health.gov.au/internet/main/publishing.nsf/Content/National-Rural-Health-Commissioner-publications (accessed 4 August 2021).

53.

Navarro

(2009) What we mean by social determinants of health. International Journal of Health Services 39(3): 423–441.

54.

Office of the National Rural Health Commissioner (2019) Discussion Paper for Consultation: Rural Allied Health Quality, Access and Distribution. Canberra, Australia: Department of Health. Available at: https://www.google.com/search?client=safari&rls=en&q=Discussion+Paper+for+Consultation:+Rural+Allied+Health+Quality,+Access+and+Distribution.&ie=UTF-8&oe=UTF-8 (accessed 4 August 2021).

55.

Rizo

Enkin

, et al. (2005) What is eHealth (3): A systematic review of published definitions. Journal of Medical Internet Research 7(1): e1.

56.

Olivera Hashiguchi

(2020) Bringing health care to the patient: An overview of the use of telemedicine in OECD countries. Health Working Papers No. 116. Paris, France: OECD Publishing. Available at: https://www.oecd-ilibrary.org/docserver/8e56ede7-en.pdf?expires=1632449229&id=id&accname=guest&checksum=AE953EBEB4FE6704CB76E602C749476E (accessed 23 September 2021).

57.

Panaretto

Wenitong

Button

, et al. (2014) Aboriginal community controlled health services: Leading the way in primary care. The Medical Journal of Australia 200(11): 649–652.

58.

Parker

Prince

Thomas

, et al. (2018) Electronic, mobile and telehealth tools for vulnerable patients with chronic disease: A systematic review and realist synthesis. BMJ Open 8: e019192.

59.

Park

(2017) Digital inequalities in rural Australia: A double jeopardy of remoteness and social exclusion. Journal of Rural Studies 54: 399–407.

60.

Park

Freeman

Middleton

(2019) Intersections between connectivity and digital inclusion in rural communities. Communication Research and Practice 5(2): 139–155.

61.

Pawson

(2002) Evidence-based policy: The promise of 'realist synthesis'. Evaluation 8(3): 340–358.

62.

Peddle

(2007) Telehealth in context: Socio-technical barriers to telehealth use in Labrador, Canada. Computer Supported Cooperative Work (CSCW) 16(6): 595–614.

63.

Perkins

(2015) Telehealth will supersede face-to-face consultations in rural Australia by 2025. Australian Journal of Rural Health 23(5): 255–256.

64.

Pollock

Williams

(2010) The business of expectations: How promissory organizations shape technology and innovation. Social Studies of Science 40(4): 525–548.

65.

Pols

(2012) Care at a Distance. Amsterdam, The Netherlands: Amsterdam University Press.

66.

Pols

Willems

(2011) Innovation and evaluation: Taming and unleashing telecare technology. Sociology of Health & Illness 33(3): 484–498.

67.

Prior

Farmer

Godden

, et al. (2010) More than health: The added value of health services in remote Scotland and Australia. Health & Place 16(6): 1136–1144.

68.

Rowlands

(2019) What is Digital Health? And Why Does it Matter? Digital Health Workforce Academy. Available at: https://www.hisa.org.au/wp-content/uploads/2019/12/What_is_Digital_Health.pdf?x97063 (accessed 23 September 2021).

69.

Salisbury

(2019) Helen Salisbury: Disruptive innovation—Technology is not the problem. BMJ 364: l1091.

70.

Shoebotham

Coulson

(2016) Therapeutic affordances of online support group use in women with endometriosis. Journal of Medical Internet Research 18(5): e109.

71.

Snoswell

Caffery

Hobson

, et al. (2020) Telehealth and coronavirus: Medicare Benefits Schedule (MBS) activity in Australia. Centre for Online Health. Available at: https://coh.centre.uq.edu.au/telehealth-and-coronavirus-medicare-benefits-schedule-mbs-activity-australia (accessed 23 September 2021).

72.

Sood

Mbarika

Jugoo

, et al. (2007) What is telemedicine? A collection of 104 peer-reviewed perspectives and theoretical underpinnings. Telemedicine and e-Health 13(5): 573–590.

73.

Standing

McDermott

, et al. (2018) The paradoxes of telehealth: A review of the literature 2000-2015. Systems Research and Behavioral Science 35(1): 90–101.

74.

Steele Gray

(2020) Seeking meaningful innovation: Lessons learned developing, evaluating, and implementing the electronic patient-reported outcome tool. Journal of Medical Internet Research 22(7): e17987.

75.

Sunshine Coast Hospital and Health Service (2015) SCHHS consumer and community engagement framework: Partnering with purpose. Available at: https://www.health.qld.gov.au/__data/assets/pdf_file/0020/1008290/schhs-consumer-community-engagement-framework.pdf (accessed 5 August 2021).

76.

Sweet

(2020) ‘The genie is out of the bottle’: Telehealth points way for Australia post pandemic. The Guardian, 13 May 2020. Available at: https://www.theguardian.com/australia-news/2020/may/13/the-genie-is-out-of-the-bottle-telehealth-points-way-for-australia-post-pandemic (accessed 23 September 2021).

77.

Thomas

Barraket

Wilson

, et al. (2017) Measuring Australia’s Digital Divide: The Australian Digital Inclusion Index, 2017. Melbourne, Australia: RMIT University. Available at: https://www.digitalinclusionindex.org.au/download-reports/ (accessed 17 November 2021).

78.

Thomas

Barraket

Wilson

, et al. (2020) Measuring Australian’s Digital Divide: The Australian Digital Inclusion Index 2020. Melbourne, Australia: RMIT University and Swinburne University. Available at: https://www.digitalinclusionindex.org.au/download-reports/ (accessed 17 November 2021).

79.

Thomas

Wilson

Park

(2018) Australia's digital divide is not going away. The Conversation. https://theconversation.com/australias-digital-divide-is-not-going-away-91834 (accessed 7 July 2021).

80.

Topol

(2015) The Patient Will See You Now: The Future of Medicine is in Your Hands. New York, NY: Basic Books.

81.

Totten

Womack

Eden

, et al. (2016) Telehealth: Mapping the Evidence for Patient Outcomes from Systematic Reviews. Rockville, MD: Agency for Healthcare Research and Quality. Available at: https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/telehealth_technical-brief.pdf (accessed 23 September 2021).

82.

Tudor Hart

(1971) The inverse care law. Lancet 297(7696): 405–412.

83.

Victorian Comprehensive Cancer Centre (2021) Framework for Consumer Engagement. Available at: https://www.viccompcancerctr.org/about-us/consumer-engagement/ (accessed 5 August 2021).

84.

Walker

(2019) Determinants of health—Are we arguing for the right things for better rural health and well-being? Australian Journal of Rural Health 27(4): 366–367.

85.

Whitacre

Strover

Gallardo

(2015) How much does broadband infrastructure matter? Decomposing the metro–non-metro adoption gap with the help of the national broadband map. Government Information Quarterly 32(3): 261–269.

86.

Wilkinson

Marmot

(2003) Social Determinants of Health: The Solid Facts. Geneva, Australia: World Health Organisation. Available at: https://www.euro.who.int/en/publications/abstracts/social-determinants-of-health.-the-solid-facts (accessed 23 September 2021).

87.

World Health Organisation (2008) Social determinants of health: Key concepts. Available at: https://www.who.int/news-room/q-a-detail/social-determinants-of-health-key-concepts (accessed 5 August 2021).

88.

World Health Organisation (2019) WHO Guideline: Recommendations on Digital Interventions for Health System Strengthening. Geneva, Australia: World Health Organization. Available at: https://www.who.int/publications/i/item/9789241550505 (accessed 23 September 2021).

89.

Yellowlees

(2001) An analysis of why telehealth systems in Australia have not always succeeded. Journal of Telemedicine and Telecare 7(2_suppl): 29–31.

90.

Yellowlees

(2000) Intelligent health systems and Third Millennium medicine in Australia. Telemedicine Journal 6(2): 197–200.

91.

Young

(2019) Rural digital geographies and new landscapes of social resilience. Journal of Rural Studies 70: 66–74.