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Telehealth services for global emergencies: implications for COVID-19: a scoping review based on current evidence

BMC Health Services Research volume 23, Article number: 567 (2023) Cite this article

Abstract

Introduction

The availability of low-cost computing and digital telecommunication in the 1980s made telehealth practicable. Telehealth has the capacity to improve healthcare access and outcomes for patients while reducing healthcare costs across a wide range of health conditions and situations.

Objective

This study compares the adoption, advantages, and challenges of telehealth services between high-income (HICs) and low-and-middle-income countries (LMICs) before and during the COVID-19 pandemic.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The key search terms were: “Telehealth”, “Telehealth in HICs”, “Telehealth in LMICs”, “Telehealth before COVID-19”, “Telehealth during COVID-19”. We searched exhaustively ProQuest, Scopus, Web of Science, Google Scholar, CINAHL, and EMBASE databases from 2012. Booleans OR/AND were combined with key search terms to increase relevant search results. The literature search and selection process followed the Sample, Phenomena of Interest, Design, Evaluation, and Research (SPIDER) question format.

Results

The adoption of telehealth before COVID-19 was generally low in both HICs and LMICs. The impact of COVID-19 accelerated the adoption of telehealth at the facility level but not nationwide in both high-income countries and LMICs. The rapid adoption of telehealth at the facility level in both high-income and LMICs introduced several challenges that are unique to each country and need to be addressed.

Conclusion

The lack of national policies and regulations is making the adoption of telehealth at the national level challenging in both high and low-middle-income countries. Governments and Stakeholders of healthcare must consider telehealth as a healthcare procedure that should be deployed in clinical working procedures. Primary quantitative and qualitative studies must be conducted to address challenges encountered during the pilot implementation of telehealth services in both high-income countries and LMICs before and during pandemics.

Peer Review reports

Introduction

The availability of low-cost computing and digital telecommunication in the 1980s made telehealth practicable [1]. Telehealth is said to have gone through three generations. The first generation was reactive telehealth systems which focused mainly on social alarms. The second generation was proactive telehealth systems that automated responses based on sensor information. And the third generation is an integrated telehealth system that uses virtual communities to enhance patients’ quality of life [2]. Telehealth may be defined as the use of electronic media to assist a broad range of remote services, such as patient care, education, and monitoring [3]. Telehealth has the capacity to improve healthcare access and outcomes for patients while reducing healthcare costs across a wide range of health conditions and situations [4]. Telehealth is perceived as the mitigator of healthcare provider shortages and remote access to health services [5]. This addresses the point that telehealth presents an opportunity to improve Universal Health Coverage (UHC) [6].

It is to this effect that this study compares the adoption of telehealth between high-income countries and LMICs before and during the COVID-19 pandemic. This study also assesses the advantages and challenges of telehealth before and during the COVID-19 pandemic in the context of high-income countries and LMICs.

Methodology

Literature search

Studies were downloaded from six databases, namely: ProQuest, Scopus, Web of Science, Google Scholar, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and EMBASE. In selecting the included studies for this paper, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The key search terms were: “Telehealth”, “Telehealth in High-Income Countries”, “Telehealth in LMICs”, “Telehealth before COVID-19”, “Telehealth during COVID-19”. Booleans OR/AND were combined with key search terms to increase relevant search results. The literature search and selection process followed the SPIDER question format (see Fig. 1). Three reviewers (who are also coauthors) independently checked the title/abstracts of all the listed studies for inclusion. The full texts of potentially qualifying studies were retrieved for detailed assessment using a scoping review. An author separately tested the eligibility of potentially qualifying studies.

Fig. 1
figure 1

SPIDER question format used for study analysis

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Inclusion and exclusion criteria

The eligibility criterion were the study must be published in the English language. Studies published before 2012 were excluded from this study. Grey literature, dissertations, and unpublished studies were excluded from this study. Only peer-reviewed published studies with high indexing were included. Studies that addressed the title, key search terms, and objectives of the study were included.

Included studies were first classified into high-income countries and LMICs. The classification of these studies into high-income countries and LMICs was to determine if financial disparity played a role in the penetration of telehealth before COVID-19. If yes, did the COVID-19 pandemic accelerate the use of telehealth and how was it possible in financial constraint countries? Studies conducted in high income countries were categorized under “high-income countries” while studies conducted in lower-and-middle-income countries were categorized under LMICs. The World Bank classification of countries was used for this study.

Results

A total of 1688 studies were downloaded from the databases mentioned under section 2.1. A total of 441 duplicates were removed using Mendeley referencing software. A total of 191 studies not written in English language were removed. 371 studies were not peer-reviewed publications, hence, removed. A total of 322 studies were removed for not being full-text articles. A total of 363 studies remained for full-text review. Post-full-text review, a total of 317 studies were removed for not relating to the study title or objectives, or key search terms. A total of 46 studies remained and were included in this study. Figure 2 (PRISMA chart) summaries the results of this study.

Fig. 2
figure 2

PRISMA flow chart showing literature search and selection of studies

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The classified studies were further grouped into “before COVID-19 pandemic” and “during COVID-19 pandemic”. The grouped studies were placed under the subject matter they addressed. Table 1 shows the distribution of included studies based on the subject matter they addressed. Pre COVID-19 pandemic, some high-income countries like Portugal were adopting telehealth as a complementary healthcare service that only compensated for existing asymmetries and inadequate resources [7] (see Table 2). Other high-income countries like Australia, the United States of America, the United Kingdom, Canada, and Brazil were using telehealth systems to provide specialised services for people living in remote communities who would have traveled long distances to access specialised services [4, 108-] (see Table 3). As postulated by Van Dyk L [11], there was slow or no widespread adoption of telehealth in most low-and-middle-income countries (LMICs). Countries like Nigeria and Burkina Faso recorded slow progress with regards to telehealth adoption, and this was as a result of lack of political will [12] (see Table 4). During this COVID-19 pandemic, telehealth became a novel alternative for offering musculoskeletal physical therapy services [13] (see Table 5). However, the introduction of telehealth before and during the COVID-19 pandemic posed certain challenges for both high-income countries and LMICs.

Table 1 Results of included articles
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Table 2 Adoption of telehealth before COVID-19
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Table 3 Application of telehealth in specialised services & advantages before COVID-19
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Table 4 Challenges of telehealth implementation before COVID-19
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Table 5 Adoption of telehealth during COVID-19
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Included studies were from 19 countries. Figure 3 shows the distribution of some studies per country and the focus of the study (focus here is with regards to high-income or LMIC). There was an exception where although a study was conducted in Spain, the focus was on LMICs.

Fig. 3
figure 3

Distribution of countries based on their respective number of articles

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Discussion

A Comparison Between High-Income Countries (HICs) and LMICs on Telehealth Before COVID-19 Pandemic

In the context of both HICs and LMICs, almost no telehealth application had reached large-scale and enterprise-wide adoption as of 2012 [1]. Before the COVID-19 pandemic, the adoption of telehealth in a high-income country like the UK was poor [14] (see Table 2). A study conducted in the Queensland community in Australia showed that out of 60% of participants who were aware of telehealth, only 13% had used telehealth services [10]. It can be inferred that although people knew about telehealth before the COVID-19 pandemic, only a few used it in certain parts of a high-income country like Australia (see Fig. 3). In Portugal, telehealth was used as a complementary healthcare service and only compensated for existing asymmetries and inadequate resources before the COVID-19 pandemic [7]. In LMICs, there was a dearth of commitment and efforts to optimise the use of telehealth (see Table 3). Before the COVID-19 pandemic, countries like Nigeria and Burkina Faso recorded slow progress in the adoption of telehealth as a result of lack of political will [12]. Van Dyk L [11] stipulates that in an LMIC like South Africa, telehealth services that were successful in the pilot phase could not be sustained (see Table 4).

In context to the application of telehealth in specialised healthcare service delivery and the advantages of telehealth, telehealth was an equally effective way of treating paediatric palliative care in a high-come country like Australia even before the COVID-19 pandemic [15] (see Fig. 3). A study in Nunavut, Canada before the COVID-19 pandemic postulates that, the implementation of telehealth reduced travel costs by 50% for patients and health professionals who would have travelled to seek or render specialised healthcare services [8]. This was similar to the post-implementation benefit of telehealth in an LMIC like Mali, where patients who patronised telehealth services saved an average cost of $25 and a maximum of $75 compared to those who traveled to cities for face-to-face specialised consultation services [18]. Telepsychiatric interventions through telephone-mediated psychosocial methods were deployed by both HICs and LMICs in managing depressed medical populations before the COVID-19 pandemic [9] (see Table 3). India, which is classified as a low-and-middle-income country commercially used video conferencing (VC) before the COVID-19 pandemic to conduct teleconsultation sessions for neurological patients [20]. Sayani et. al., [21] expounded on how telehealth improved chronic disease outcomes in LMICs. Similarly, Selzler et al., [16] elaborate on how Canada used telehealth features such as telemonitoring, teleconsultation, tele-education, and telehealth-pulmonary rehabilitation to manage chronic respiratory diseases before the COVID-19 pandemic. A study that assessed the advances of telehealth over the past 10 years in the UK showed that telehealth systems provided social connectedness to the aged. Reminders were integrated into telehealth systems to alert forgetful adults to watch their favourite television programmes [2]. While the implementation of telehealth in Nepal addressed issues of real-time services as postulated by Siddiquee et al., [17], the implementation of telehealth before the COVID-19 pandemic in the U.S. and Brazil had ensured clinical data sharing and real-time collection of vital signs (see Table 3).

There were some challenges pre and post-implementation of telehealth in both HICs and LMICs before the COVID-19 pandemic (see Table 4). A qualitative study conducted in the UK showed that patients were reluctant to risk potential disruptive changes to existing highly valued face-to-face services. In the same study, it was indicated that there are difficulties in recruiting health professionals for telehealth services, where health professionals’ refusal rate was reported at 80% [23]. A study that assessed the adherence and dropout rates of individuals with chronic obstructive pulmonary disease (COPD) in telehealth interventions showed that there is a lack of knowledge on the effectiveness of telehealth for COPD care post-implementation. This made it difficult to assess the impact of telehealth on COPD management [22]. In LMICs, telehealth had not been integrated into existing healthcare systems. Some of the reasons were: limited resources, unreliable power supply, poor internet connectivity, and high cost for the poverty-stricken [24]. A barrier to the effective implementation of a telehealth system in LMICs is the lack of awareness regarding the telehealth system [25] (see Table 4).

A Comparison Between HICs and LMICs on Telehealth During COVID-19 Pandemic

The disruptive impact of COVID-19 has rapidly progressed the implementation and use of telehealth in Australian primary health care (PHC) as has occurred in other developed countries [26] (see Fig. 3). As cited in Tang & Reddy [27], the U.S. saw an increase of 154% in telehealth visits at the end of March 2022 compared to the same period in 2019 (see Table 5). A mixed-method study conducted in the UK and Canada postulates that although patients’ satisfaction with telehealth in musculoskeletal physical therapy is widely reported as high as face-to-face, widespread adoption of telehealth within physical therapy has been slow [13]. In Springfield, Massachusetts in the United States, there were 698 (39%) telehealth visits out of a total of 1788 prenatal visits. This shows that there was high adoption of telehealth by high-income countries like the U.S. during the COVID-19 pandemic [28] (see Table 5). In high-income countries, the COVID-19 pandemic forced health systems to quickly adapt to telehealth use for cancer treatment [29]. During this COVID-19 pandemic era, while specialties in some high-income countries like psychiatry, cardiology, and radiology are recording higher telehealth use, others like allergy-immunology, family medicine, and gastroenterology are recording lower telehealth use [3]. Based on responses from a study conducted in Mozambique, 69% of respondents were willing to use teleconsultation public health services for mild illness and review consultations during this COVID-19 pandemic era [30]. A study by Ranjbar et al., [31] in a low-and-middle-income country showed that out of a total of 523 nurses and midwives who participated in the study, 73.0% had a positive attitude toward telenursing and telehealth. Higher education was positively associated with the understanding of telehealth. Kazi et al., [32] make it known that telehealth was initially in its infancy in LMICs, however, the COVID-19 pandemic accelerated the demand for telehealth following social distancing protocols globally (see Table 5).

During the COVID-19 pandemic era, 78% of clinicians who took part in a study organised in the city of Makassar in Indonesia (LMIC) indicated their satisfaction with telehealth systems. 69% of participants indicated that telehealth allowed for quicker diagnosis and treatment [33] (see Table 6). In South Africa, telehealth is perceived as a mitigator of healthcare provider shortages, and remote access to healthcare services in this COVID-19 pandemic era [5]. The application of telehealth in the area of hypertension management in LMICs during this COVID-19 pandemic saw a significant reduction in blood pressure among hypertensive patients [6] (see Table 6). A study in Australia shows that telestroke has proven to be effective in the timely management of stroke conditions during the COVID-19 pandemic [34]. In resource-challenged areas in Brazil, teleconsultation was a strategic technological tool for patients to access quality healthcare in a COVID-19 pandemic era where social distancing is a new normal [35]. Implementation of telehealth in Nebraska has increased access to health services among rural residents and deeply impacted clinical practice. Clinicians in Nebraska plan to continue providing services via telehealth if policies and regulations are well-enacted post-COVID-19 [36]. The COVID-19 pandemic brought about the novel adoption of telehealth in the field of Orthopaedic Oncology in some high-income countries [37]. Evenski et al., [37] further indicated that 42% of study respondents rated tele-orthopedic services at 9.7 out of 10 (see Table 5).

Table 6 Application of telehealth in specialised services & advantages during COVID-19
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Barriers to using telehealth interventions in older adults were identified in some developed countries include knowledge gaps, lack of willingness to adopt new skills, and reluctance to technology use [39]. A scoping review conducted in the UK showed that there were no established uniform guidelines for telehealth implementation [40] (see Table 7). Although findings support the rapid adoption of telehealth in clinical care delivery in North America, the implementation of telehealth has faced critical challenges such as variations in state licensure requirements for telehealth; disparities in access to telehealth among disadvantaged populations; and lack of consistency among individual investigational review boards (IRBs) on telehealth studies [41]. The implementation of telehealth services in high-income countries often results in challenges stemming from the lack of attention to change management [42]. In a study conducted in rural Bangladesh (LMIC), exemplary barriers to telehealth adoption that were identified and confirmed (p<0.01) were: lack of organisational effectiveness, health staff motivation, patient satisfaction, and trustworthiness. In this same study, lack of Information Communication and Technology (ICT) infrastructures and allocation of resources were identified as indirect barriers [43]. In LMICs, telehealth system vulnerabilities may result in inappropriate access to patient information, medical device malfunction, or breakdown of health services that are provided, which may result in ethical and legal issues [44]. Existing telehealth services in Thailand are limited to only fundamental medical consultation services [45]. Lack of governance and stakeholder support, lack of effective logistical and clinical procedures, and patients’ ability to adapt to telehealth care are the barriers to the mass adoption of telehealth services in Pakistan (LMIC) [46] (see Table 7).

Table 7 Challenges of Telehealth Implementation During COVID-19
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Conclusion

Before the COVID-19 pandemic, the use of telehealth was not common in both HICs and LMICs, and there were difficulties in its deployment. However, there were also effective applications of telehealth in specialized healthcare services, including telepsychiatric interventions and pediatric palliative care, as well as advantages for patients and healthcare workers in terms of cost savings. The impact of COVID-19 accelerated the adoption of telehealth at the facility level but not nationwide in both HICs and LMICs (see Table 2 and Table 5). The widespread implementation of telehealth is nevertheless hampered by knowledge gaps, a lack of guidelines, access inequities, and infrastructure issues, particularly in LMICs. The lack of national policies and regulations is making the adoption of telehealth at the national level challenging. The integration of telehealth into current healthcare systems and the reimbursement of telehealth services are two examples of policies that governments should develop to facilitate the use of telehealth in healthcare systems. Governments should set aside funds to upgrade the telehealth-related infrastructure and resources, including broadband internet access, telecommunication networks, and the purchase of telemedicine hardware. Healthcare professionals should be trained on how to use telehealth protocols and technology, including how to incorporate telehealth into their current practice and how to use electronic medical records. Governments should set up legal guidelines to safeguard patient information security, confidentiality, and privacy in telehealth systems. There were limited studies on telehealth with regards to LMICs. This research did not include articles from all HICs and LMICs. Inclusions were limited to studies written in English language, peer-reviewed journals, and studies published on or after 2012. This means that studies with equally good information which did not meet the inclusive criteria were excluded. Therefore, findings from this study may not be generalised. To increase the specificity of the research topic and methods, the study purposefully concentrated on the term of "telehealth" while omitting comparable concepts like "telemedicine" and "digital health". By ignoring the potential contributions of other similar concepts, this strategy may have hampered the generalizability of the findings, perhaps limiting the study's scope. Future research should focus on examining the subtleties and connections between various digital health topics. However, the study advances knowledge of the function of telehealth in global emergencies, and readers are urged to evaluate the results in light of the methodology and telehealth.

Primary quantitative and qualitative studies must be conducted to address challenges encountered during the pilot implementation of telehealth in both HICs and LMICs before and during the COVID-19 pandemic. Addressing these challenges will help countries adopt telehealth at a national level. LMICs must find innovative solutions to address peculiar challenges such as inadequate financial resources for mass-scale telehealth implementation, especially in sub-Saharan Africa.

Availability of data and materials

Pieces of Literature analysed during the current study are available online and can also be made available through the corresponding author upon request.

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Acknowledgements

We wish to render our sincere gratitude to the Management and Staff of University of Cape Coast, School of Allied Health Sciences, Department of Health Information Management for their resources, time and contributions during the period of this research.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. School of Allied Health Sciences, Department of Health Information Management. University Post Office, University of Cape Coast, Cape Coast, Ghana

    Jonathan Kissi, Caleb Annobil, Nathan Kumasenu Mensah & Zenobia Wooduwa Asmah

  2. Department of Epidemiology, Biostatistics and Disease Control, University for Development Studies, Tamale, Ghana

    Joseph Owusu-Marfo

  3. Faculty of Health and Allied Health, Department of Public Health, Catholic University College of Ghana, Sunyani, Ghana

    Ernest Osei

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  1. Jonathan Kissi
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  2. Caleb Annobil
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  5. Ernest Osei
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  6. Zenobia Wooduwa Asmah
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Contributions

Conceptualization, JK formal analysis, investigation, and data curation, JK, and CA,. formal data analysis and results interpretation, JK, CA, NKM and JOM. writing, original draft preparation, JK and CA; writing, review and editing, EO, and ZWA. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Jonathan Kissi.

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Kissi, J., Annobil, C., Mensah, N.K. et al. Telehealth services for global emergencies: implications for COVID-19: a scoping review based on current evidence. BMC Health Serv Res 23, 567 (2023). https://doi.org/10.1186/s12913-023-09584-4

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Keywords

BMC Health Services Research

ISSN: 1472-6963

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