Rural use of health service and telemedicine during COVID-19: The role of access and eHealth literacy

Kathy L Rush, Cherisse Seaton, Eric Li, Nelly D Oelke, Barbara Pesut

First Published May 27, 2021


The COVID-19 pandemic has driven a greater reliance on telemedicine, yet rural access, use, and satisfaction with telemedicine and the role of eHealth literacy are unknown. Using a cross-sectional design, 279 (70.6% female) western rural Canadians completed an online survey. The majority of participants reported access to telemedicine, but nearly 1/5 lacked access to online or virtual mental health services. The majority of participants had used health care services following the declared COVID-19 pandemic in North America, and just under half had used telemedicine. Telemedicine satisfaction scores were higher among participants who had used video (M = 4.18) compared to those who used phone alone (M = 3.79) (p = 0.031). Telemedicine satisfaction and eHealth literacy were correlated (r = 0.26, p = 0.005). Participants did not want telemedicine to replace in-person consultations. Telemedicine practice requires that rural residents have the resources, ability and willingness to engage with remote care.


Well known health and health care disparities characterize at-risk populations in rural settings. Poor mental health, unhealthy behaviors (e.g. smoking), obesity, chronic diseases (e.g. cardiovascular disease, diabetes), lower life expectancy, and potentially avoidable mortality are higher in rural and remote areas than urban areas.1 Despite these greater needs, rural populations/communities face disparities in their access to health care such as physician (primary, specialist) shortages, lack of health care facilities, services and equipment, and inadequate infrastructure.2,3

Prior to the COVID-19 pandemic, telemedicine was touted as a promising solution to address these rural inequities and increase the quality and accessibility of health care. For our purposes, and following the World Health Organization, telemedicine is used interchangeably with telehealth and defined according to four elements: provides clinical support; connects users from different locations; uses information and communication technologies; and orients to health outcomes.4 Developments in remote monitoring and sensor technology have further advanced telemedicine practice providing applications for diagnosis, disease surveillance and treatment support.5 Indeed, the benefit of using technology in the delivery of mental health services to rural areas has been well documented.6 So too, cloud-based solutions have been effectively used to link rural patients with medical consultants through intermediary health care and community clinic workers.7

Despite its potential, pre-COVID-19 telemedicine uptake was slow and below expectation.8 Pre-COVID-19 evidence indicates that rural residents have lowered amenability and preference for telehealth services when local services are available (e.g. hospitals, clinics).911 How COVID-19 imposed restrictions on access to these services, and disruptions in usual rural primary care with the abrupt switch to telemedicine, have influenced rural residents’ satisfaction with telemedicine is unknown.

Although rural uptake was low, pre-COVID-19 satisfaction with telemedicine has been found to be high among patients from rural and remote areas.12 Orlando et al.,12 found high levels of satisfaction (system experience, information sharing, consumer focus and overall satisfaction) with telehealth videoconferencing among patients and caregivers living in rural and remote communities who had outpatient appointments from their local health care center with a health care provider at another center. Harkey et al.13 found patients living in rural areas had high levels of satisfaction with telehealth services for occupational therapy, physical therapy or physiotherapy, and speech-language therapy compared to in-person care. These telemedicine uses were largely for specialist care and did not necessarily reflect the massive shift that occurred with the COVID-19 pandemic that catalyzed telemedicine into all areas of practice including primary care where it had not been routinely used.

It is important to understand rural citizens’ use of, and satisfaction with telemedicine during COVID-19, especially as some have projected that post-pandemic, telemedicine will become the new normal in health care delivery.14 A recent survey suggested that patient satisfaction with telemedicine was high following COVID-1915; however, this finding was not specific to rural communities who face different challenges than their urban counterparts. For example, reliance on telemedicine used to its full capacity (e.g. video) requires adequate broadband access, which is often limited in rural and underserved settings.16 In urban Canadian communities high-speed internet doubled to 51.5 Mbps in 2020, while in rural communities it plateaued at 5.5 Mbps,17 potentially impacting the type and quality of telemedicine care rural people receive and influencing their satisfaction with this care modality.

Another factor that impacts users’ ability to use, and satisfaction with, telemedicine is electronic health (eHealth) literacy (defined as the ability to find, use and apply health information from electronic sources18). In their study of the eHealth literacy and communication technology use of remote Hawaiian community members, Witten and Humphry19 found that the eHealth literacy of this population appeared insufficient for proper understanding and utilization of technology. Although not rural-centric, a systematic review of telemedicine adoption suggested that low eHealth and/or a lack of computer literacy prevailed as barriers to widespread implementation.20 Indeed, eHealth literacy has largely been overlooked in the development of technology-based health interventions, limiting accessibility.21 Despite the fact that the COVID-19 pandemic has driven a massive shift to telemedicine to decrease person-to-person contact, and slow the spread of the virus,22,23 no research could be found examining the association between eHealth literacy and telemedicine satisfaction among rural patients. Overall, more research is needed examining rural access, use of, and satisfaction with telemedicine during the COVID-19 pandemic, as well as exploring the role of e Health literacy in patient satisfaction with telemedicine.

The purpose of this study was to describe rural health service and telemedicine usage and satisfaction in rural communities during COVID-19 as well as to explore the role of eHealth literacy in telemedicine satisfaction and gather participants suggestions for improving rural telemedicine delivery.

Research questions

  1. What proportion of rural community participants accessed health services, mental health services, and telemedicine during COVID-19?
  2. How satisfied are rural community members with telemedicine?
  3. How is telemedicine satisfaction related to eHealth literacy?
  4. What suggestions do participants have for improving telemedicine in rural areas?



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