In the previous section we analyzed which factors promote or restrain e-Health service adoption within the context, process, and content elements of change.
To summarize, we have identified, in all the elements of change (context, process and content), key promoting and restraining factors related to e-Health adoption in rural communities. The identified factors in this review strongly relate to and cover Pettigrew and Whipp’s three original core elements of change
. However, the subcategories and especially their labeling sometimes had to be adapted as the original model was more often applied within organizational instead of community settings.
In some instances we found conflicting or limited results. Here, we first saw that geographical isolation features as both a promoting and as a restraining variable. Next, we saw that pre-existing socio-economic structures, such as structures of gender inequality and caste systems, complicate balanced diffusion of e-Health throughout the community. However, three studies
[24, 49, 72, 75] reported e-Health implementations that were able to diminish social inequalities. The question remains how these pre-existing socio-economic structures shape or get changed by ICT implementation. Finally, the studies show that local participation is essential in ensuring sustainability, but that it is not easy to manage. These three contradicting findings indicate that identifying promoting and restraining factors in itself does not provide solutions for these implementation issues. In this discussion we look at interaction effects to explain these results. While interaction effects have not been extensively studied in the papers reviewed, our theoretical framework
 points towards explaining such seemingly contradictory results by taking a closer look at the interaction effects between the three change elements. We will discuss the contradictory findings below, but first address our review’s limitations.
Limitations of this research
To our knowledge, no previous review has specifically analyzed the implementation factors that influence rural e-Health adoption. Notwithstanding the interesting results, this review has some limitations. Although we were careful in developing and executing our search strategy, the fact that e-Health implementation in rural communities is an emerging, and therefore broad and diffuse, field means that we cannot be sure that we have included all the relevant findings. The variety of terms used in this field may have limited our ability to achieve an exhaustive review. Moreover, for practical reasons this study excluded non-English papers. Papers that address the antecedents of successful e-Health implementation in general were not included either. Their relevance to the specific rural context may not always be evident and therefore, they fall outside the scope of this review.
A limitation of any literature review is that the authors of the studies selected will have had different objectives, and used different methods and means of interpretation in reaching their conclusions - conclusions which do not necessarily fully align with the interests of this article.
Although Pettigrew and Whipp’s model is parsimonious, flexible, much-cited, and widely applied, we might have chosen a different theoretical lens to bring together the empirical evidence on e-Health implementation in rural communities. However, their model not only served to systematically categorize the papers’ perspectives and the identified implementation factors, it also opened our eyes to the interaction effects between the change elements.
As the included papers vary greatly in research methods applied, it was impossible to conduct a meta-analysis. Rural e-Health is an emerging research area and by excluding qualitative papers from the review, the study would miss potentially relevant implementation factors. As it was, it was deemed important to include both quantitative and qualitative studies, instead of conducting a meta-analysis, therefore we conducted a thematic analysis
[40, 41] guided by the Pettigrew and Whipp-based classification matrix. We will now address the possible interaction effects suggested by our findings and their expected impact on e-Health implementation.
Interaction between context and content: the role of geographical isolation
Although geographical isolation and the specific socioeconomic characteristics of rural communities (contextual factors) in general seem to restrain e-Health implementation, they can also create specific, contextualized needs that can be addressed with e-Health applications
[8, 12, 13, 22–25, 49, 51, 52, 59, 76, 78]. A few studies suggest that a needs-based e-Health content may compensate for the contextual factors that restrain e-Health implementation
[8, 82]. Needs-based e-Health applications seem to be able to overcome recognized socioeconomic ICT adoption barriers such as advanced age
[11, 14, 48, 49, 51, 53, 54, 60–63, 69, 83] and low incomes
[24, 46, 47, 53, 54, 62, 63, 69, 83]. This relationship is especially well researched in Western oriented countries. Schmeida and McNeal
, for example, found older people and individuals with low incomes to be more likely to use the internet in search of Medicare and Medicaid information than others. Moreover, in contrast to other studies
[24, 47, 49, 53, 60–63, 69, 83], Schmeida and McNeil found no relationship between other personal characteristics, such as gender, race, ethnicity, and education, and online searches for Medicare or Medicaid information. Similar results are reported by Bynum et al.
 who suggest that such findings “may be explained by the limited access to quality health care knowledge among these groups”
:220]. These findings suggest a strong interaction between content and context factors in determining e-Health adoption. As such, they constitute a warning against overgeneralizing the adoption effects of socioeconomic factors such as age, income, and education.
Furthermore, several studies argue that geographical isolation creates a need for e-Health because of a lack of alternative services or media in these areas
[8, 12, 13]. Shepherd et al.
 and Shaw et al.
 address this need for particular subgroups. For example, Shaw et al.
 show that individuals with poor well-being and little social support, i.e. those with a greater need for medical services, spend relatively more time on health information websites. Based on these findings, the authors claim that psychological help is of greater importance in rural communities because rural residents are more likely to feel geographically isolated from face-to-face support groups and therefore experience a greater need for e-Health solutions.
This creates a field of tension. On the one hand, rural users of e-Health applications may perceive e-Health as valuable and experience a concrete, valuable outcome from its use. On the other hand, the low network density, which defines geographical isolation, creates high barriers to sustainable e-Health implementation since it is difficult to make e-Health profitable in these circumstances. This is especially the case when targeting those with low incomes and of advanced age, groups which could most benefit from e-Health applications as is shown in
[9, 24, 62–64].
Authors have formulated conditions under which public e-Health applications might be feasible, and suggested ways to provide incentives for private e-Health suppliers
[25, 48, 55, 65] (See also the later section on interaction between content and process). However, as these authors applied slightly different definitions of ‘rural’, further research is needed to test the proposed conditions and establish whether technology design can overcome the negative associations with socioeconomic trends. On this basis, we formulate the following proposition.
Proposition 1: Geographic isolation restrains e-Health implementation, yet provided that e-Health fulfills a specific need, geographical isolation promotes its subsequent adoption.
Interaction between process and context: how e-Health can add value for underprivileged groups
As shown in the previous section, and indicated in the studies reviewed, there is an “intriguing possibility that extant community structure […] may play an important mediating role in understanding the impact of internet access [or access to other ICT] on social relationships”
:138]. Surprisingly, as shown in Figure
2, relatively little attention has been paid to the way these pre-existing socioeconomic community-level structures (i.e. context) affect the e-Health implementation process (i.e. process) and vice versa.
Although limited in number, some studies have considered the way pre-existing socioeconomic structures affect the process of e-Health implementation and adoption. Their general conclusion is that e-Health implementation usually reinforces rather than changes the pre-existing socioeconomic structures
[49, 52, 53, 64, 66, 76, 79]. This reinforcement is in itself neither inherently positive nor negative, and may occur in quite subtle ways as illustrated by Gilbert et al.
. However, there are cases in which e-Health reinforces structures of socioeconomic inequality based on income, gender, age, and education. Forestier et al.
 show, for instance, that income inequality nationally tends to increase with rising levels of telephone and internet penetration. Aminuzzaman
 found that e-Health implementation could reinforce gender inequality, even with a specific e-Health application aimed at empowering women. Also Stern and Dillman
 conclude, in reference to Norris
[86, 87], that e-Health “is a vital tool for activating the active”
:421]. None of the available findings suggest that the availability of e-Health in itself will change socioeconomic structures. The irony is that underprivileged groups, including relatively many older, rural adults, who might benefit most are, however, less likely to start using it.
However, under certain conditions, e-Health implementation does alter socioeconomic structures
[24, 49, 75, 79], enabling underprivileged groups to adopt e-Health. These projects were all implemented in regions characterized by forms of socio-economic inequality, e.g. gender-based, and located in Asian countries. Balasubraman
 studied a project that did succeed in implementing an e-Health application for rural women in a context of gender inequality. This project was successful because, in addition to handing out e-Health applications, women were trained to use the application and supported in face-to-face discussion groups, and eventually enabled to participate in developing the e-Health content. These non-technological features of the project ensured that the e-Health application reached its target group. This example illustrates that social change will only be achieved through e-Health when the actors in the implementation process are aware of the existing socioeconomic structures and strongly driven to change these structures.
Proposition 2: e-Health implementation will reinforce the socioeconomic structures already in place in a rural community unless it includes interventions specifically aimed at changing these structures.
Interaction between content and process: sustainable e-Health implementation
Remarkably, only a few studies, from different parts of the world, address sustainability
[47, 65, 84]. Almost all studies ended after the initial implementation phase, leaving unanswered the question of whether and how e-Health content becomes sustainably embedded within a community.
Hosman and Fife’s study
 is one of those few studies that explicitly deal with sustainability. They present several apparently essential conditions for sustainable rural e-Health implementation, most of which relate to leadership and the development of effective partnerships. While not focusing on sustainability, seven other papers also underline the importance of leadership and partnerships in the implementation process
[24, 25, 65, 70, 75, 80, 84]. We will discuss their findings below in order to better understand how e-Health implementation may become sustainable.
Three of the studies emphasize the importance of equal, bottom-up partnerships
[24, 65, 80]. Kanungo, in studying the implementation of local knowledge centers, for example, concludes that “sustainability hinges on collaborative frameworks”:419]. Similarly, Cecchini and Raina
, who studied a government-owned public computer network, ascribe its failure to governmental inability to establish an effective partnership with local communities and to allow these communities to acquire ownership of the e-Health project.
However, bottom-up partnerships alone may not be sufficient to ensure sustainable e-Health implementation as they also create complexity. Shin argued that calls for equal, bottom-up partnerships may be unrealistic as “the possibility that one person’s success may be another person’s failure […] is rarely mentioned”:331]. In relation to this, Wit and Berner state “the idea of mobilizing and organizing people collectively on the basis of horizontal [equal] ties and common interests does not appear to work well in most places, and, even more fatal, it appears to work less well the poorer and more dependent people are”
:928]. This is the case because “frequently, partnerships are asymmetrical, uneasy and often unsustainable, as they are based on personalized, vertical and informal relations that are frequently politicized, rather than on horizontal, collective relations rooted broadly in communities”
:931]. This leads both Hosman
 and Shin
 to suggest that e-Health implementation requires a “top-down-meets-bottom-up method”
Following this line of thought, we suggest that bottom-up and top-down implementation strategies are in fact points on two continua: centralized versus shared ownership; and horizontal versus vertical relationships between the actors. Purely bottom-up or top-down implementation strategies are rare, if they exist at all, with most studies showing some in-between form. Further, as e-Health implementation is dynamic, implementation managers may decide to change their implementation strategy over the course of the implementation process. For example, a single stakeholder initiating an e-Health implementation may later want to partner other stakeholders to create broader support and ensure the project becomes embedded in the rural community. This entails a shift in implementation strategy from a horizontal, centralized ownership strategy to a horizontal or vertical shared ownership strategy. These results suggest that it is time to stop discussing the pros and cons of bottom-up versus top-down implementation strategies, and to start thinking about the strategic management of project ownership. By strategic, we mean that the implementation should involve well-timed shifts in project ownership with an eye on sustainable adoption. We therefore suggest the following proposition.
Proposition 3: In rural communities, sustainable e-Health adoption requires strategic changes in ownership over time.