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BMC Health Serv Res
BMC Health Serv Res
BMC Health Services Research
1472-6963
BioMed Central London

39223581
11313
10.1186/s12913-024-11313-4
Research
The right care in the right place: a scoping review of digital health education and training for rural healthcare workers
Woods Leanna lee.woods@uq.edu.au

12
Martin Priya 3
Khor Johnson 14
Guthrie Lauren 1
Sullivan Clair 125
1 https://ror.org/00rqy9422 grid.1003.2 0000 0000 9320 7537 Queensland Digital Health Centre, The University of Queensland, Brisbane, Australia
2 https://ror.org/00rqy9422 grid.1003.2 0000 0000 9320 7537 Centre for Health Services Research, The University of Queensland, Brisbane, Australia
3 https://ror.org/00rqy9422 grid.1003.2 0000 0000 9320 7537 Rural Clinical School, Faculty of Medicine, The University of Queensland, Toowoomba, Australia
4 https://ror.org/00rqy9422 grid.1003.2 0000 0000 9320 7537 Ochsner Clinical School, Faculty of Medicine, The University of Queensland, Brisbane, Australia
5 grid.518311.f 0000 0004 0408 4408 Metro North Hospital and Health Service, Herston, Australia
2 9 2024
2 9 2024
2024
24 101113 3 2024
15 7 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Digital health offers unprecedented opportunities to enhance health service delivery across vast geographic regions. However, these benefits can only be realized with effective capabilities and clinical leadership of the rural healthcare workforce. Little is known about how rural healthcare workers acquire skills in digital health, how digital health education or training programs are evaluated and the barriers and enablers for high quality digital health education and training.

Objective

To conduct a scoping review to identify and synthesize existing evidence on digital health education and training of the rural healthcare workforce.

Inclusion criteria

Sources that reported digital health and education or training in the healthcare workforce in any healthcare setting outside metropolitan areas.

Methods

We searched for published and unpublished studies written in English in the last decade to August 2023. The databases searched were PubMed, Embase, Scopus, CINAHL and Education Resources Information Centre. We also searched the grey literature (Google, Google Scholar), conducted citation searching and stakeholder engagement. The JBI Scoping Review methodology and PRISMA guidelines for scoping reviews were used.

Results

Five articles met the eligibility criteria. Two case studies, one feasibility study, one micro-credential and one fellowship were described. The mode of delivery was commonly modular online learning. Only one article described an evaluation, and findings showed the train-the-trainer model was technically and pedagogically feasible and well received. A limited number of barriers and enablers for high quality education or training of the rural healthcare workforce were reported across macro (legal, regulatory, economic), meso (local health service and community) and micro (day-to-day practice) levels.

Conclusions

Upskilling rural healthcare workers in digital health appears rare. Current best practice points to flexible, blended training programs that are suitably embedded with interdisciplinary and collaborative rural healthcare improvement initiatives. Future work to advance the field could define rural health informatician career pathways, address concurrent rural workforce issues, and conduct training implementation evaluations.

Review registration number

Open Science Framework: 10.17605/OSF.IO/N2RMX.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-024-11313-4.

Keywords

Clinical informatics
Health informaticians
Digital health
Health personnel
Rural population
Rural health
Education
Teaching
Low-resource settings
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

Globally, healthcare workers (HCWs) face multiple pressures simultaneously: increasing demand for care, co-morbidities and condition complexity, budget pressures, and rapid digital disruption [1]. The digital disruption in healthcare promises an unprecedented circumstance to improve outcomes and strengthen health systems [2]. However, this opportunity depends on a capable healthcare workforce with adequate skills and knowledge in data and emerging technologies [3]. HCW capability in digital health and clinical informatics is increasingly acknowledged as an essential component to the delivery of high-quality patient care [4]. Universities do not yet routinely teach these curricula in clinical degrees, and the capability gap in the current workforce is often filled by brief, reactive, and on-the-job training [5]. Sustainability of healthcare includes developing a skilled healthcare workforce educated and competent in digital health [6].

The rural healthcare workforce is faced with the location-based issues of resource constraints, workforce shortages, high staff turnover rates, stress, burnout, and an ageing workforce [7]. The World Health Organization has acknowledged in a recent report (2021) the complex challenge of shortage of healthcare workers globally in rural areas [7]. This report has acknowledged that the workforce density is lower than national averages in most of these areas. In places where there isn’t a national shortage, maldistribution of the workforce has been noted [7]. Digitally enabled models of care are well placed to enhance health service delivery across vast and distributed geographic regions. However, rural health service organizations require uplift to align with their metropolitan counterparts in workforce digital readiness [8]. Building digital health capability in rural settings is critical because higher digital health capability is associated with better outcomes, including the ability to maintain an accurate patient health record, track patient experience data, track the patient journey, and mitigate clinical risks [9]. Rurality is contributing to widening digital health inequities [10] with significant efforts required to adequately manage the rural digital divide [11, 12]. Building digital capabilities of healthcare providers in rural and remote settings through education, training and support is needed [13].

Existing evidence on the education and training the rural healthcare workforce is limited. Firstly, while health science faculties are progressively integrating digital health into the undergraduate curricula for the future workforce [14–16], it is unclear how the education of current HCW is approached [14]. Despite global exemplars such as fellowship training for physicians [17], certification for nurses [18], and advanced education for clinical and non-clinical professionals [19], limited evidence of successful workforce programs to build digital health skills exist [4]. None focus on the rural healthcare setting.

Secondly, in literature reporting digital health in rural settings, there is a notable scarcity on workforce training programs. Existing studies focus on efficacy of delivered healthcare [20, 21], workforce perceptions of digital health tool implementation [22, 23] or are limited to training of specific interventions (e.g., clinical telehealth [24]). This review sought to explore the literature where these two gaps coexist, the intersection of digital health education and training and the rural healthcare workforce, and synthesize the available evidence on digital health education and training for the rural healthcare workforce.

Review question

The research questions for this review were:I. What are the existing practices and approaches to digital health education and training for rural HCWs?

II. How has digital health education and training been evaluated following implementation?

III. What are the barriers and enablers for high quality digital health education and training in the rural healthcare workforce?

Inclusion criteria

Participants

The review considered studies and reports on any members of the workforce in healthcare settings outside of metropolitan areas. The healthcare workforce refers to ‘all individuals who deliver or assist in the delivery of health services or support the operation of health care facilities’ [3]. All clinical (e.g., medical doctors, nurses, allied health professionals, pharmacists, Indigenous HCWs, pre-registration/qualification students undertaking placements in health care facilities) and non-clinical workers (e.g., administration, executive and management, clinical support, and volunteers) were considered regardless of professional body or government registration status. Patients, healthcare consumers, and the public were excluded.

Concept

The core concepts of digital health and training were combined in this review. Digital health and clinical informatics are often used interchangeably, and both were considered in this review. While digital health refers to the use of digital technologies for health [25], clinical informatics refers to more specialized practice of analyzing, designing, implementing and evaluating information and communication systems [26]. Specific digital health systems (e.g., IT infrastructure, telehealth, electronic medical records) were included. Training relates to the education or training initiatives (e.g., programs, curriculum, course) that build an individuals’ digital health capability to confidently use technologies to respond to the needs of consumers now and into the future [1]. Both education and training activities were considered. Education often refers to theoretical learning (e.g., by an academic institution, qualification), and training often teaches practical skills (e.g., employer-provided professional development, ‘just-in-time’ training) [3, 24]. This review did not consider HCW education delivered at a distance through technologies (e.g., telesupervision for clinical skills training).

Context

This review considered studies and reports from rural healthcare settings defined as outside metropolitan cities, inclusive of regional, rural, remote, and very remote settings. When the term ‘rural’ is used in this review, it refers to all areas outside major metropolitan cities as described by authors of individual studies and reports. All healthcare facilities across primary, secondary, and tertiary care settings were included in any country.

Types of sources

All research studies, irrespective of the study design, were considered. Reviews, conference abstracts and non-research sources (e.g., policy documents, program or course curriculum) were considered. The grey literature was included to capture reactionary training developed by rural health services that were not published as peer-reviewed research studies.

Methods

This review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews [27] and reported as per the Preferred Reporting of Systematic Reviews and Meta-analyses for scoping reviews (PRISMA-ScR) [28] (Additional file 1). The review protocol was registered in Open Science Framework [10.17605/OSF.IO/N2RMX].

A scoping review approach was chosen over a systematic review to address a general, formative review question on this topic that is emerging in the literature and where the literature is complex and heterogenous [29]. An initial preliminary search of the topic in the academic databases, Cochrane Library, Open Science Framework and Prospero registry resulted in a very small number of relevant articles. It was determined that a broader search strategy and inclusion of non-research sources was required, consistent with the scoping review methodology [29]. Scoping review format is also well suited to the vast, diverse healthcare education topic across different disciplines, interventions and outcomes realised [30]. Mapping and synthesis across sources in this scoping review aims to inform research agendas and identify implications for policy and practice [31].

Deviations from the protocol

There were no deviations to the protocol.

Search strategy

The three phase JBI search process was followed. An initial limited search of PubMed was performed to identify keywords on the topic, followed by an analysis of the text words and index terms contained in the title and abstract. A subsequent preliminary search in Prospero registry, Cochrane Library and Open Science Framework informed the development of a full search strategy in PubMed. The search strategy, including all identified keyworks and index terms, was adapted for each included database and information source after refining the strategy with an information specialist. The reference lists of all included sources of evidence were screened for additional studies.

The review included only studies and reports in English (due to translation resourcing limitations) in the last 10 years (due to the relative novelty of the digital transformation of healthcare). The search was conducted in August 2023. The databases searched included PubMed, Scopus, Cumulative Index for Nursing and Allied Health Literature (CINAHL), Embase, and Education Resources Information Center (ERIC). Scopus was chosen over Web of Science as it provides 20% more coverage and the relative recency of articles indexed (publish date after 1995 [32]) was not a concern for our research question. The search for unpublished studies and grey literature included Google and Google Scholar, using a modified search strategy as required. In addition, national and international stakeholders (n = 29) from Asia, the Pacific Islands, Australia, USA and the UK known to have subject matter expertise on the topic were contacted via direct email. Stakeholders were asked to share any relevant work underway or otherwise undiscoverable using our scoping review methods. The full search strategy for each information source is provided in Additional file 2.

Study selection

Following the search, identified articles were collated and uploaded into Covidence review software (Veritas Health Innovation Ltd; Melbourne, Australia) and duplicates removed. Two reviewers (among LW, JK and LG) then independently screened the title and abstract of each citation and selected studies that met the inclusion criteria. The full text articles were retrieved and uploaded into Covidence. These studies and reports were assessed independently by two reviewers (listed previously) for full assessment against the inclusion criteria. Any disagreements that arose between the reviewers at each stage of the selection process were resolved through discussion or with an additional reviewer (among LG and PM). Three meetings occurred to discuss any voting conflicts that occurred during title and abstract screening and full-text screening. Articles that did not satisfy the criteria were excluded with reasons for exclusion recorded. Search results and study selection process is presented in accordance to the PRISMA-ScR flow diagram (Fig. 1) [28]. Quality appraisal of selected studies was not conducted, consistent with scoping reviews methods [33].Fig. 1 Search results and source selection and inclusion process

Data extraction

Extracted data included the specific details about the participants, concept, context, study methods and key findings relevant to each review question. Data was extracted by one reviewer (JK) and checked by a second reviewer (LW). Data were extracted using the data extraction tool developed and piloted by the team (Additional file 3).

Data synthesis and presentation

The characteristics of the included studies were analyzed and organized in tabular format, accompanied by a narrative summary. Results of each research question was presented under separate headings. The data analysis for research question three (barriers and enablers of high-quality digital health education and training) was enhanced. We adopted the socio-institutional framework described by Smith et al [34] and used in education research [35] to classify macro, meso, micro level enablers and barriers to help improve the generalizability of the synthesized insights and identify stakeholders that are able to influence change. Gaps and limitations of the current literature were discovered from the evidence with recommendations for policy, practice and future research provided.

Results

Study inclusion

Database searching yielded 1005 articles and stakeholder engagement yielded two articles. After removing duplicates, 660 articles were screened for title and abstract, after which 29 articles underwent full text review. Of the 29 articles, 24 articles were excluded: the setting was metropolitan or otherwise inadequately described as non-metropolitan (n = 6); the intervention was not a training or education initiative for digital health or clinical informatics (n = 16), or the population was not rural healthcare workers (n = 2). In total, following full-text screening, five articles were included in the final review (Fig. 1).

Characteristics of included studies

Of the five included articles, three were academic publications including two case studies [36, 37] and one feasibility study [38] (Table 1). The two articles identified through stakeholder engagement presented course summaries [39, 40] where one described a micro-credential [40] and the other described a fellowship [39]. Most articles (n = 3) were published recently between 2021 and 2023 [38–40]. Healthcare workforce settings were distributed across the continents of the United States of America [36], Asia [37], Africa [38] and Australia [39, 40], with no articles reporting a setting in the European continent. Further study characteristics are available in Table 1. Table 1 Characteristics of included studies

Author	Geographical region	Identified gap	Type of training program	Detail of training program	Article type	Evaluation of training program	
Walden et al. 2020 [36]	Arkansas, USA	Researchers and clinicians lacked the expertise to successfully implement digital technologies in rural and medically underserved areas	Three online learning modules providing didactic content	Module 1: Commercialization as a Catalyst for Innovations in Digital health

Module 2: Clinical Validation and Testing in Digital Health

Module 3: Regulatory Considerations in Digital Health

	Case study	Not available	
Mridha and Islam 2017 [37]	Bangladesh rural villages	Limited training and inadequate medical knowledge for village doctors	Training program and eHealth content in local language containing five courses	Course 1: Origin of physiological signals of diagnostic importance

Course 2: Detecting, storing and transferring bio signals using ICT tools

Course 3: Recording and

management of information and health data

Course 4: Understanding

the function, use, management, and maintenance of different

diagnostic devices

Course 5: Networking the patient data

with the relevant experts from any place

	Case study	Not available / unclear	
Downie 2022 [38]	Tanzania’s rural Ulanga District	The REmote Consulting in primary Health care (REaCH) program was developed to support HCW in their health care delivery during the COVID-19 pandemic	Modular online training program using a train-the-trainer approach training HCW (tier 1) to cascade the training to others (tier 2) in their locality	Tier 1 trainees were predominantly senior medical figures who cascaded training to Tier 2 trainees who were health practitioners enrolled by Tier 1 trainees in local language

Eight module course delivered via Moodle, an open-source learning app using WhatsApp for facilitated discussion and PDF downloads when digital access is limited

Topics on remote consulting include:

importance; platforms for use; role change and patient care; risks and benefits; expected patient outcomes including COVID-19 spread; new issues that are different from face-to-face-care; planning care delivery; evaluating health care practice; change management

	Feasibility study	Questionnaire, qualitative interviews and document analyses	
James Cook University and Northern Australian Regional Digital Health Collaborative (JCU and NARDHC) 2023 [40]	Northern Australia	Trains practitioners to use digital health to augment and support healthcare delivery in rural and remote areas	Micro-credential consisting of an online, flexible course of three units of give modules each. Assessment items include two open-book quizzes and workbook activities	Unit 1: Digital health opportunities for rural, regional and remote Australia

Unit 2: The digital workplace

Unit 3: Digital health implementation and evaluation in rural, regional and remote locations

	Course summary	Not available

(Quality assurance includes ongoing course review, student experience, and engagement evaluation)

	
Australian College of Rural and Remote Medicine (ACRRM) 2021 [39]	Rural Australia	Digital health is one of 37 learning areas of rural and remote medicine for fellowship	Digital Health Fellowship Curriculum	The digital health learning area identifies the knowledge, skills and attributes of the core generalist in relation to digital health

Learning areas map to competencies across eight domains of rural and remote practice

	Curriculum summary	Not available	

Review findings

What are the existing approaches to digital health education and training for rural HCWs?

Training and education programs were needed due to identified gaps in knowledge, skills and expertise to support healthcare delivery in rural contexts with digital health [36–38], [40]. One article reported the target learners as village doctors, who may have “limited training and inadequate medical knowledge, yet they are generally the mainstay of health services” [37]. The mode of teaching in the included studies were four modular online learning courses [36–38], [40] and one fellowship [39]. Of the four modular online learning courses, one was supplemented by a facilitator-led train-the-trainer model [38], informed by an academic framework [41], with cohort-based discussion via a social media platform. The second was a certification in the form of a self-paced micro-credential completed individually [40]. Of the four modular online learning courses, the number of modules ranged from three to eight and covered a variety of digital health topics including innovation, commercialization, bioinformatics, technology use, data and information, professionalism, implementation and evaluation. One had a particular focus on information and communication technology tool use [37] while another focused on remote consulting [38]. The mode of delivery of the fellowship was not reported in the article.

How has digital health education and training been evaluated following implementation?

Four [36, 37, 39, 40] of the five included articles did not report an evaluation. One article in rural Tanzania described the evaluation of the train-the-trainer digital health training program using a mixed-method design [38]: (1) questionnaire informed by Kirkpatrick’s model of evaluation to capture knowledge gained and perceived behavior change on a Likert scale, (2) qualitative interviews to explore training experiences and views of remote consulting, and (3) document analysis from texts, emails and training reports [38]. Of the tier 1 trainees (senior medical figure trainers who were trained to educate their peers) that completed the questionnaire (n = 10, 83%), nine (90%) recommended the training program and reported receiving relevant skills and applying learning to daily work, demonstrating satisfaction, learning and perceived behavior change [38]. Overall, the feasibility study confirmed that remotely delivered training supported by cascade training was technically and pedagogically feasible and well received in rural Tanzania [38].

What are the barriers and enablers for high quality digital health education and training of the rural healthcare workforce?

Reported enablers and barriers are presented using the macro, meso, micro framework [34] (Table 2). Table 2 Barriers and enablers for high quality digital health education and training of the rural healthcare workforce

	Barriers	Enablers	
Macro (legal, regulatory, economic)	- Unreliability of resources such as electricity, internet, finances, government recognition or compensation, technical devices [37, 38]	- Educate, train, and support remote HCW on location [37]

- Curriculum structure that can include a combination of multi-specialty learning areas (e.g., digital health) [39]

	
Meso (local health service and community)	- Lack of clear path to develop digital health technologies [36]

- Release of staff time for training [38]

	- Training implemented alongside concurrent digital health initiatives [36, 37]

- Delivery of training in the local language [38]

	
Micro (day to day practice)	- Unawareness of educational opportunities [36]

- Staff computer literacy or technical competence [37, 38]

- Busy staff with difficulty scheduling training around their work [38]

- Technological access (smartphone capacity limits, unstable network access) [38]

	- Strong interest in development of mHealth technologies and training platforms [36]

- Dedicated ICT officers to assist with technology as needed [38]

- Providing off-line resources [38]

- Flexibility of online training [38]

- Ability to use training in their daily work immediately and train peers easily [38]

	

Discussion

This scoping review reflects the scarcity of reported digital health education and training programs in existence for rural HCWs globally. This review responds to the World Health Organization (WHO) recommendation to design and enable access to continuing education and professional development programs that meet the needs of rural HCWs [7], and the Sustainable Development Goal for inclusive and equitable quality education [42].

Concurrent challenges of people (workforce), setting (rural) and content (digital health) are reported in included articles alongside enablers and barriers to education and training programs. Included studies reported a shortage of doctors and specialists [36], lack of technical knowledge [36] (people); higher cost of delivering rural healthcare, high burden of illness [40], medically underserved population due to rural hospital closures [36] (setting); and limited use of digital health tools due to coordination challenges among non-government organisations [37] (content). These additional macro, meso and micro level factors are described by authors firstly as influencing the need for digital health programs in rural settings, and secondly, as contributing to the challenges of implementing effective programs. The rural health workforce challenges in digital health education and training reflect the broader workforce development issues experienced globally [7]. While this review sought to identify workforce development programs, the WHO model indicates the need for attractiveness, recruitment and retention to enable workforce performance (i.e., appropriate and competent multidisciplinary teams providing care) and health system performance (i.e., improving universal health coverage) [7].

In low-resource settings such as rural areas, education and training may not be prioritized among other competing workload demands. As the value of digital health transformations are realized for strengthening healthcare systems [25, 43], the value of digital health education or training programs may become realized. This value was evidenced in the implementation of the teleconsulting training intervention in rural Tanzania [38] in rapid response to supporting care delivery during the COVID-19 pandemic period. With evaluations of programs largely absent from an already small number of programs globally, it will be important for future research to focus on implementation evaluation studies. As Table 2 presents only limited enablers and barriers, more evidence is needed to build on the findings from this scoping review to inform strategies for policy and practice.

The interdisciplinarity of digital health presents challenges and opportunities for nurturing digital health expertise across the rural healthcare workforce. Included articles largely described the target learners of education and training programs as clinicians, practitioners and healthcare workforce. Walden et al. further indicated that users of online content may extend beyond rural health clinicians to healthcare administrators, researchers and providers relevant to address the regulatory factors of clinical validation and implementation [36]. Therefore, for their program of work, the University of Arkansas for Medical Sciences identified and fostered collaboration with an interprofessional team of clinicians, researchers, informaticists, a bioethicist, lawyers, technology investment experts, and educators [36]. No articles in the review described education or training health informaticians or similar digital health leadership role types, yet building defined career pathways for health informaticians is recommended [4]. Existing pedagogy shows that the learning principles of interprofessional practice is grounded in understanding one’s own practice as well as the practice of other health professionals and remains aligned to the educational needs of specific professions [44] (i.e., medicine, nursing, pharmacy). Defining new career pathways for interdisciplinary leaders in digital health within a specific clinical context, like the ‘rural health informatician’, will be important to identify or define the (hidden) specialized workforce.

Local, informal organizational initiatives for digital health learning were discovered alongside formal education or training programs in included studies. Programs were often reported in articles alongside concurrent digital health implementation or healthcare improvement programs, sometimes referred to as ‘outreach’ [36] activities. These informal initiatives included special interest groups, in-person conferences, networking events, working groups [36] and seminars [37]. Current evidence from this scoping review suggests that the efficacy and sustainability of education or training programs are reliant on integrated approaches, like the train-the-trainer [38] or academic organization approach [36], that foster translational research for rural healthcare improvement. As illustrated by Walden et al., success in digital health is likely to require a foundational environment where technologies can be discussed, developed and deployed [36]. Success in rural digital health skills acquisition likely requires a similar, longitudinal and collaborative approach beyond the confines of an online course completed individually. Previous research shows us that blended learning, which merges face-to-face with online learning, translates to better knowledge outcomes [44]. Blended learning can also overcome the barrier of rural HCWs travelling large distances to attend face-to-face training that comes at a great cost to themselves and the work unit. A key recommendation to improve the digital health training program described by Downie et al. was more face-to-face time with trainers, from the perspective of both trainee and facilitator [38]. This, however, can only be realized with targeted planning and budgeting of such offerings by involved rural healthcare organizations.

The opportunities to advance digital health education and training for rural HCWs are presented across the macro, meso and micro levels in the socio-institutional framework, with suggested relevant stakeholders suited to actioning the recommendations (Table 3). While the context for this is likely to vary across the globe, these recommendations and stakeholders are expected to provide a starting point to initiate a dialogue that can influence change. These recommendations are not meant to be prescriptive or rigid, but rather meant to flag actionable solutions that can be contextualized for any given setting. Table 3 Recommendations for policy, practice and research

Recommendations	Potential stakeholders	
Macro level	
 Address concurrent rural healthcare workforce challenges	Policy makers, healthcare organizations, funding bodies	
 Address concurrent digital infrastructure and digital literacy barriers in rural settings	Policy makers, healthcare organizations, funding bodies	
Meso level	
 Evaluate rural education and training programs to demonstrate value	Researchers, healthcare organizations	
 Develop interdisciplinary digital health pedagogy	Training and education institutions	
 Define new pathways for interdisciplinary digital health leaders	Professional peak bodies, policy makers, education and training institutions	
Micro level	
 Foster translational research and education environment for digital health capacity building	Healthcare organizations, education and training institutions, researchers	
 Blend online learning with face-to-face collaborative learning	Education and training institutions	

Strengths and limitations

It is possible that there is a greater number of published educational and training programs than those reported in this review (i.e., publication bias). To mitigate this, we used a scoping review methodology and stakeholder engagement activity to identify unpublished or emerging programs that answer the review question but may not be discoverable in the academic databases. The review is limited to articles available in the English language. The small number of programs, heterogeneity of programs and limited evaluation of programs significantly limit generalizability of findings. Due to data availability, the barriers and enablers findings summary contain an overrepresentation from a small number of studies limiting conclusions that can be drawn.

Conclusion

Digital health offers the best opportunity for innovative sustainable change to address critical issues in health and care in rural settings. Workforce education and training initiatives in rural healthcare settings are scarce, largely delivered via online training, and are rarely evaluated. Current best practice points to flexible, blended (online and face-to-face) training programs that are suitably embedded with interdisciplinary, collaborative rural healthcare improvement initiatives. More research will expand the evidence base to deliver high-quality digital health education to strengthen rural healthcare delivery. Future work to advance the field could define rural health informatician career pathways, address concurrent rural workforce issues, and conduct implementation evaluations.

Supplementary Information

Additional File 1. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

Additional File 2. Full search strategy for each information source.

Additional File 3. Data extraction instrument template.

Abbreviations

CINAHL Cumulative Index for Nursing and Allied Health Literature

ERIC Education Resources Information Centre

HCW Healthcare worker

JBI Joanna Briggs Institute

PRISMA-ScR Preferred Reporting of Systematic Reviews and Meta-analyses for scoping reviews

WHO World Health Organization

Acknowledgements

Not applicable.

Authors’ contributions

LW, PM and CS designed the study. LW, PM, JK and LG acquired data; analyzed and interpreted results and drafted the manuscript and all subsequent drafts. CS read and contributed to manuscript drafts. All authors read and approved the final manuscript draft.

Funding

No external funding.

Availability of data and materials

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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References

1. Australian Digital Health Agency The national digital health capability action plan 2022 Australia Australian Government 36
Australian Digital Health Agency. The national digital health capability action plan. Australia: Australian Government; 2022. p. 36.
2. World Health Organization Global strategy on digital health 2020–2025 2021 Geneva World Health Organization 60
World Health Organization. Global strategy on digital health 2020–2025. Geneva: World Health Organization; 2021. p. 60.
3. Agency Australian Digital Health National digital health workforce and education roadmap 2020 Sydney Australian Digital Health Agency
Australian Digital Health Agency. National digital health workforce and education roadmap. Sydney; 2020.
4. Woods L Janssen A Robertson S The typing is on the wall: Australia’s healthcare future needs a digitally capable workforce Aust Health Rev 2023 2023 25 10.1071/AH23142
Woods L, Janssen A, Robertson S, et al. The typing is on the wall: Australia’s healthcare future needs a digitally capable workforce. Aust Health Rev. September 2023;2023:25. 10.1071/AH23142.10.1071/AH23142
5. Younge VL Borycki EM Kushniruk AW On-the-job training of health professionals for electronic health record and electronic medical record use: A scoping review Knowledge Management & E-Learning: An International Journal 2015 7 436 469
Younge VL, Borycki EM, Kushniruk AW. On-the-job training of health professionals for electronic health record and electronic medical record use: A scoping review. Knowledge Management & E-Learning: An International Journal. 2015;7:436–69.
6. Thomas EE Haydon HM Mehrotra A Building on the momentum: sustaining telehealth beyond COVID-19 J Telemed Telecare 2022 28 301 308 10.1177/1357633X20960638 32985380
Thomas EE, Haydon HM, Mehrotra A, et al. Building on the momentum: sustaining telehealth beyond COVID-19. J Telemed Telecare. 2022;28:301–8.32985380 10.1177/1357633X20960638
7. World Health Organization WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas 2021
World Health Organization. WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas. 2021.
8. Woods L Eden R Pearce A Evaluating digital health capability at scale using the digital health indicator Appl Clin Inform 2022 13 991 1001 10.1055/s-0042-1757554 36261114
Woods L, Eden R, Pearce A, et al. Evaluating Digital Health Capability at Scale Using the Digital Health Indicator. Appl Clin Inform. 2022;13:991–1001. 10.1055/s-0042-1757554.36261114 10.1055/s-0042-1757554
9. Woods L Dendere R Eden R Perceived impact of digital health maturity on patient experience, population health, health care costs, and provider experience: mixed methods case study J Med Internet Res 2023 25 e45868 10.2196/45868 37463008
Woods L, Dendere R, Eden R, et al. Perceived Impact of Digital Health Maturity on Patient Experience, Population Health, Health Care Costs, and Provider Experience: Mixed Methods Case Study. J Med Internet Res. 2023;25: e45868. 10.2196/45868.37463008 10.2196/45868
10. Yao R Zhang W Evans R Inequities in health care services caused by the adoption of digital health technologies: scoping review J Med Internet Res 2022 24 e34144 10.2196/34144 35311682
Yao R, Zhang W, Evans R, et al. Inequities in health care services caused by the adoption of digital health technologies: scoping review. J Med Internet Res. 2022;24:e34144. 10.2196/34144.35311682 10.2196/34144
11. Clark CR Akdas Y Wilkins CH TechQuity is an imperative for health and technology business: Let’s work together to achieve it J Am Med Inform Assoc 2021 28 2013 2016 10.1093/jamia/ocab103 34157112
Clark CR, Akdas Y, Wilkins CH, et al. TechQuity is an imperative for health and technology business: Let’s work together to achieve it. J Am Med Inform Assoc. 2021;28:2013–6. 10.1093/jamia/ocab103.34157112 10.1093/jamia/ocab103
12. Esteban-Navarro M-Á García-Madurga M-Á Morte-Nadal T The rural digital divide in the face of the COVID-19 pandemic in Europe—recommendations from a scoping review Informatics 2020 7 54 10.3390/informatics7040054
Esteban-Navarro M-Á, García-Madurga M-Á, Morte-Nadal T, et al. The rural digital divide in the face of the COVID-19 pandemic in Europe—recommendations from a scoping review. Informatics. 2020;7:54. 10.3390/informatics7040054.10.3390/informatics7040054
13. Macklin S Understanding the pathway to consumer centred healthcare information in rural and remote Queensland 2022 Brisbane The University of Queensland
Macklin S. Understanding the pathway to consumer centred healthcare information in rural and remote Queensland. Brisbane: The University of Queensland; 2022.
14. Aungst TD Patel R Integrating digital health into the curriculum—considerations on the current landscape and future developments J Med Educ Curric Dev 2020 7 2382120519901275 10.1177/2382120519901275 32010795
Aungst TD, Patel R. Integrating digital health into the curriculum—considerations on the current landscape and future developments. J Med Educ Curric Dev. 2020;7:2382120519901275.32010795 10.1177/2382120519901275
15. Edirippulige S Gong S Hathurusinghe M Medical students’ perceptions and expectations regarding digital health education and training: a qualitative study J Telemed Telecare 2022 28 258 265 10.1177/1357633X20932436 32571157
Edirippulige S, Gong S, Hathurusinghe M, et al. Medical students’ perceptions and expectations regarding digital health education and training: a qualitative study. J Telemed Telecare. 2022;28:258–65.32571157 10.1177/1357633X20932436
16. Veikkolainen P Tuovinen T Jarva E eHealth competence building for future doctors and nurses–Attitudes and capabilities Int J Med Informatics 2023 169 104912 10.1016/j.ijmedinf.2022.104912
Veikkolainen P, Tuovinen T, Jarva E, et al. eHealth competence building for future doctors and nurses–Attitudes and capabilities. Int J Med Informatics. 2023;169:104912.10.1016/j.ijmedinf.2022.104912
17. American Medical Informatics Association. Informatics academic programs. 2022 https://amia.org/careers-certifications/informatics-academic-programs. Accessed 21 June 2022.
18. American Nurses Credentialing Center. Informatics nursing board certification examination. Maryland, USA2018, p. https://www.nursingworld.org/~490a495b/globalassets/certification/certification-specialty-pages/resources/test-content-outlines/427-tco-rds-2016-effective-date-march-2023-2018_100317.pdf.
19. Topol E The topol review: preparing the healthcare workforce to deliver the digital future 2019 United Kingdom Health Education England NHS 1 48
Topol E. The topol review: preparing the healthcare workforce to deliver the digital future. United Kingdom: Health Education England NHS; 2019. p. 1–48.
20. McCleery J Laverty J Quinn TJ Diagnostic test accuracy of telehealth assessment for dementia and mild cognitive impairment Cochrane Database Syst Rev 2021 7 7 CD013786 34282852
McCleery J, Laverty J, Quinn TJ. Diagnostic test accuracy of telehealth assessment for dementia and mild cognitive impairment. Cochrane Database Syst Rev. 2021;7(7):CD013786.34282852
21. Janjua S Carter D Threapleton CJ Telehealth interventions: remote monitoring and consultations for people with chronic obstructive pulmonary disease (COPD) 2021 Cochrane database of systematic reviews
Janjua S, Carter D, Threapleton CJ, et al. Telehealth interventions: remote monitoring and consultations for people with chronic obstructive pulmonary disease (COPD). Cochrane database of systematic reviews; 2021.
22. Xyrichis A Iliopoulou K Mackintosh NJ Healthcare stakeholders’ perceptions and experiences of factors affecting the implementation of critical care telemedicine (CCT): qualitative evidence synthesis Cochrane Database Syst Rev. 2021 2 2 CD012876 33599282
Xyrichis A, Iliopoulou K, Mackintosh NJ, et al. Healthcare stakeholders’ perceptions and experiences of factors affecting the implementation of critical care telemedicine (CCT): qualitative evidence synthesis. Cochrane Database Syst Rev. 2021;2(2):CD012876.33599282
23. Odendaal WA Watkins JA Leon N Health workers’ perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis Cochrane Database Syst Rev. 2020 3 3 CD011942 32216074
Odendaal WA, Watkins JA, Leon N, et al. Health workers’ perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2020;3(3):CD011942.32216074
24. Edirippulige S Armfield N Education and training to support the use of clinical telehealth: A review of the literature J Telemed Telecare 2017 23 273 282 10.1177/1357633x16632968 26892005
Edirippulige S, Armfield N. Education and training to support the use of clinical telehealth: A review of the literature. J Telemed Telecare. 2017;23:273–82. 10.1177/1357633x16632968.26892005 10.1177/1357633x16632968
25. World Health Organization Recommendations on digital interventions for health system strengthening. World Health Organization 2019
World Health Organization. Recommendations on digital interventions for health system strengthening. World Health Organization. 2019. 2020–2010.
26. Gardner RM Overhage JM Steen EB Core content for the subspecialty of clinical informatics J Am Med Inform Assoc 2009 16 153 157 10.1197/jamia.M3045 19074296
Gardner RM, Overhage JM, Steen EB, et al. Core content for the subspecialty of clinical informatics. J Am Med Inform Assoc. 2009;16:153–7.19074296 10.1197/jamia.M3045
27. JBI JBI manual for evidence synthesis 2020
JBI. JBI manual for evidence synthesis. 2020.
28. Tricco AC Lillie E Zarin W PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation Ann Intern Med 2018 169 467 473 10.7326/M18-0850 30178033
Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169:467–73.30178033 10.7326/M18-0850
29. Peters MDJ Marnie C Tricco AC Updated methodological guidance for the conduct of scoping reviews JBI Evid Synth 2020 18 10 2119 26 10.11124/jbies-20-00167 33038124
Peters MDJ, Marnie C, Tricco AC, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth. 2020;18(10):2119–26. 10.11124/jbies-20-00167.33038124 10.11124/jbies-20-00167
30. Shead DA Olivier B Traditional or digital health care education? JBI Evidence Synthesis 2020 18 861 862 10.11124/JBIES-20-00118 32813349
Shead DA, Olivier B. Traditional or digital health care education? JBI Evidence Synthesis. 2020;18:861–2.32813349 10.11124/JBIES-20-00118
31. Tricco AC Lillie E Zarin W A scoping review on the conduct and reporting of scoping reviews BMC Med Res Methodol 2016 16 15 10.1186/s12874-016-0116-4 26857112
Tricco AC, Lillie E, Zarin W, et al. A scoping review on the conduct and reporting of scoping reviews. BMC Med Res Methodol 2016; 16: 15. 10.1186/s12874-016-0116-4.26857112 10.1186/s12874-016-0116-4
32. Falagas ME Pitsouni EI Malietzis GA Comparison of PubMed, Scopus, web of science, and Google scholar: strengths and weaknesses FASEB J 2008 22 338 342 10.1096/fj.07-9492LSF 17884971
Falagas ME, Pitsouni EI, Malietzis GA, et al. Comparison of PubMed, Scopus, web of science, and Google scholar: strengths and weaknesses. FASEB J. 2008;22:338–42.17884971 10.1096/fj.07-9492LSF
33. Peters MD Godfrey CM Khalil H Guidance for conducting systematic scoping reviews JBI Evid Implement 2015 13 141 146
Peters MD, Godfrey CM, Khalil H, et al. Guidance for conducting systematic scoping reviews. JBI Evid Implement. 2015;13:141–6.
34. Smith T McNeil K Mitchell R A study of macro-, meso-and micro-barriers and enablers affecting extended scopes of practice: the case of rural nurse practitioners in Australia BMC Nurs 2019 18 1 12 10.1186/s12912-019-0337-z 30651717
Smith T, McNeil K, Mitchell R, et al. A study of macro-, meso-and micro-barriers and enablers affecting extended scopes of practice: the case of rural nurse practitioners in Australia. BMC Nurs. 2019;18:1–12.30651717 10.1186/s12912-019-0337-z
35. Desai D Mayne C Bates H A rapid review of the barriers and enablers of medical student participation in research in health settings. 2022 10.17605/OSF.IO/5XZWN
Desai D, Mayne C, Bates H, et al. A rapid review of the barriers and enablers of medical student participation in research in health settings. 2022. 10.17605/OSF.IO/5XZWN.10.17605/OSF.IO/5XZWN
36. Walden A Kemp AS Larson-Prior LJ Establishing a digital health platform in an academic medical center supporting rural communities Journal of Clinical and Translational Science 2020 4 384 388 10.1017/cts.2020.11 33244426
Walden A, Kemp AS, Larson-Prior LJ, et al. Establishing a digital health platform in an academic medical center supporting rural communities. Journal of Clinical and Translational Science. 2020;4:384–8.33244426 10.1017/cts.2020.11
37. Mridha M and Islam M. To improve patient care & safety of rural patients empowering the village doctors. In: EMBEC & NBC 2017: Joint Conference of the European Medical and Biological Engineering Conference (EMBEC) and the Nordic-Baltic Conference on Biomedical Engineering and Medical Physics (NBC), Tampere, Finland, June 2017 2018, pp.502-505. Springer.
38. Downie A Mashanya T Chipwaza B Remote Consulting in Primary Health Care in Low-and Middle-Income Countries: Feasibility Study of an Online Training Program to Support Care Delivery During the COVID-19 Pandemic JMIR Formative Research 2022 6 e32964 10.2196/32964 35507772
Downie A, Mashanya T, Chipwaza B, et al. Remote Consulting in Primary Health Care in Low-and Middle-Income Countries: Feasibility Study of an Online Training Program to Support Care Delivery During the COVID-19 Pandemic. JMIR Formative Research. 2022;6:e32964.35507772 10.2196/32964
39. Australian College of Rural & Remote Medicine Rural Generalist Curriculum - Fellowship 2021 Brisbane, Australia ACRRM 174
Australian College of Rural & Remote Medicine. Rural Generalist Curriculum - Fellowship. Brisbane, Australia: ACRRM; 2021. p. 174.
40. Northern Australia Regional Digital Health Collaborative and James Cook University (NARDHC and JCU). Digital Health for the Rural and Remote Health Workforce Micro-credential (Brochure). Townsville: JCU; 2023.
41. Mormina M Pinder S A conceptual framework for training of trainers (ToT) interventions in global health Glob Health 2018 14 1 11 10.1186/s12992-018-0420-3
Mormina M, Pinder S. A conceptual framework for training of trainers (ToT) interventions in global health. Glob Health. 2018;14:1–11.10.1186/s12992-018-0420-3
42. United Nations Department of Economic and Social Affairs Sustainable Development Sustainable development goals 2023
United Nations Department of Economic and Social Affairs Sustainable Development. Sustainable development goals. 2023. https://sdgs.un.org/goals. Accessed 20 Feb 2024
43. Woods L, Eden R, Canfell OJ, et al. Show me the money: how do we justify spending health care dollars on digital health? Med J Aust 2022 2022/12/12. 10.5694/mja2.51799.
44. Dizon JMR. Educating future health professionals to keep pace with changing times. LWW, 2021, p. 2904–2905.
