Review Article

Innovative shortcuts and initiatives in primary health care for rural/remote localities: a scoping review on how to overcome the COVID-19 pandemic

AUTHORS

name here
Renata Elisie Barbalho
1 (Brazilian) MSc, General Practitioner and Infectious Diseases Specialist * ORCID logo

name here
Simone Schenkman
2 PhD, Postdoctoral Researcher ORCID logo

name here
Amandia Sousa
3 PhD, Public Health Researcher ORCID logo

name here
Aylene Bousquat
4 Distinguished Associate Professor ORCID logo

CORRESPONDENCE

*Ms Renata Elisie Barbalho

AFFILIATIONS

1, 2, 4 Politics, Management and Health Department, Faculty of Public Health, University of São Paulo, Av. Dr. Arnaldo 715, Cerqueira César, São Paulo, SP 01246-904, Brazil

3 Institute Leônidas e Maria Deane, Oswaldo Cruz Foundation (Fiocruz), Rua Terezina, 476 - Adrianópolis, Manaus, Amazonas 69058278, Brazil; and Politics, Management and Health Department, University of São Paulo, São Paulo 01246-904, Brazil

PUBLISHED

19 October 2023 Volume 23 Issue 4

HISTORY

RECEIVED: 10 February 2023

REVISED: 19 May 2023

ACCEPTED: 13 June 2023

CITATION

Barbalho R, Schenkman S, Sousa A, Bousquat A.  Innovative shortcuts and initiatives in primary health care for rural/remote localities: a scoping review on how to overcome the COVID-19 pandemic. Rural and Remote Health 2023; 23: 8236. https://doi.org/10.22605/RRH8236

AUTHOR CONTRIBUTIONSgo to url

This work is licensed under a Creative Commons Attribution 4.0 International Licence


abstract:

Introduction:  The COVID-19 pandemic has emerged as one of the greatest challenges to societies, world health systems and science in the past century, making it imperative to restructure care networks. Therefore, it is essential to discuss the role and initiatives of primary health care (PHC) to deal with it. However, regarding the response to the pandemic, including the current global effort against COVID-19, the nuances of the rural/remote PHC context in the pandemic is barely visible. Rural and remote communities have differentiated health risks, such as socioeconomic disadvantages, difficulties in mobility and access to health services, in addition to linguistic and cultural barriers. This scoping review aimed to analyze the set of individual and collective initiatives and innovations developed to face the COVID-19 pandemic, within the PHC scope, in rural and remote areas.
Methods:  A scoping review methodology was applied to peer-reviewed articles. Eight databases were searched to identify scientific articles published in English, Spanish and Portuguese, initially from January 2020 to July 2021, complemented by a rapid review of articles published from January 2022 to April 2023. The main focus sought in the literature was the set of initiatives and innovations carried out within the PHC scope in rural and remote locations during the pandemic, as well as the comparison with pre-pandemic situations and between different countries. The bibliographic information of each search result was imported into Rayyan (Intelligent Systematic Review), followed by the screening and eligibility stages, performed independently by two reviewers, with a third reviewer being accessed in case of conflicts.
Results:  This review included 54 studies, with publications mostly from Australia, Canada, the US and India. The main PHC initiatives were related to access; to the roles of community health workers and health surveillance; and to the importance of placing, retaining and valuing human resources in health. Cultural, equity and vulnerability issues occupy a major place among the initiatives. Regarding the innovations, telehealth and customized communication are highlighted. From an organizational point of view, rural and remote locations showed enormous flexibility to deal with the pandemic and to improve intersectoral activities at the local level. The description of rurality and remoteness is practically coincident with that of the specific populations, present in geographic areas of difficult sociospatial and cultural access. Rarely, there is an index to measure rurality, or its description deals with the need to overcome distances and obstacles. 
Conclusion:  The findings highlight and summarize knowledge about initiatives and innovations developed to face the COVID-19 pandemic, within the PHC scope in rural and remote areas in the world. This review has identified collective, clinical, intersectoral and, mainly, organizational health initiatives. An articulation between different government levels would be paramount in evaluating the implementation of policies and protocols in rural and remote locations for future sanitary crises. Innovations and lessons learned are equally relevant in strengthening health services and systems. This issue calls for considerable further exploration by new reviews and empirical research that seek evidence to assess the sustainability and effectiveness of the implemented measures to face post-pandemic difficulties and other adversities.

Keywords:

COVID-19 pandemic, health services accessibility, organizational innovation, primary health care, rural health services, telehealth.

full article:

Introduction

The current COVID-19 pandemic has emerged as one of the greatest challenges to societies and to global health systems and science in the past 100 years, making it imperative to restructure health networks and systems1. Fast and articulated responses are crucial to face these challenges, among them the definition of the role and responsibility of primary health care (PHC)2.

The scientific community responded very quickly to this exceptional health emergency and important articles were published focusing on the role of PHC3,4. However, the particularity of the rural context regarding the role of PHC in the pandemic was scarcely studied in the first year of the COVID-19 pandemic5. It is worth recalling that in rural areas a strong PHC is even more important, as it is able to reduce health inequities between urban and rural territories6.

The definition of rural and urban spaces includes some elements that are important for the creation of planning and management actions of the territories, even though they capture only part of the reality. These elements are based on political-administrative criteria, population size, population density, morphological territory patterns, economic activities and a population’s way of life7

Rural communities have differentiated health risks that add to the growing needs of their populations. They suffer chronically from socioeconomic disadvantages; difficulties in mobility, transport and access to health services; in addition to linguistic and cultural barriers. Added to these factors are the insufficient infrastructure of health services, the limitation of clinical equipment and the difficulty regarding the retention of health professionals in these regions5.

In 2009, the OECD added the criterion of accessibility to the typology of population density, with the influence of distance from the rural area to the urban center. This criterion is translated, then, by the displacement time between non-urban areas and urban centers, delineating areas close to cities or remote areas8.

In this work, we propose to conceptualize PHC in the light of Vuori9, especially under four different forms of understanding: a set of activities, a level of care, a strategy for organizing health services and a guiding philosophy of actions in a health system.

In the international literature, PHC is guided by structuring axes, considered by their essential and derived attributes, which consist of first contact, longitudinality, integrality and coordination of care, family and community orientation, and cultural competence, respectively. In this sense, in addition to being a strategy for organizing health systems and services, PHC is based on a model for changing clinical and care practice10. In this way, PHC is ideally composed of multidisciplinary teams supported by integrated reference systems so that priority is given to the most vulnerable, and health inequalities are reduced – maximizing community and individual autonomy, participation, and control, and involving intersectionality11.

Furthermore, we understand PHC as a combination of primary care and public health functions in order to provide integrated care; a means to empower people and communities, and intersectoral actions12.

At the interface of PHC and rural and remote locations, an important international integrative review carried out by Franco et al defined three basic categories to outline the most relevant strategies: access to health services, health organization and the health workforce13. Access was related to geographic aspects, users' displacement needs and access to hospital and specialized services, the healthcare organization (including structure and resources), operation of health services, and community-based management. Regarding the health workforce, the following stood out: professional profile and role, and attraction/retention factors. The authors highlighted the cross-cutting actions in relation to these three assessed dimensions: community work, extension and visitation models, information and communication technologies, access to assistance and professional training and development, equitably distributed according to population health needs11,13,14.

In line with the different individual and collective approaches, a quick and comprehensive review of the main international protocols highlighted the main dimensions outlined in PHC when facing the COVID-19 pandemic: public health, focused on epidemiological surveillance and care flows; the clinical dimension (continuity of care via telehealth); the organizational dimension; and the systemic dimension15.

A vast literature on the COVID-19 pandemic and its clinical and epidemiological management has been published since the start of the pandemic in 2020. Less frequent, however, is the approach of literature in the pandemic in the PHC context. Even less is known about the complex relationship between the ways of coping with the pandemic in remote locations, while having PHC as the main reference. Thus, the objective of this scoping review was to analyze the set of initiatives and innovations, both individual and collective, that were developed to face the COVID-19 pandemic within the scope of PHC, in rural and remote areas, during the first 18 months of the pandemic.

Methods

The methodology used for the present study was a scoping review16 aiming to carry out a literature mapping based on several study designs of the main concepts of the field of interest.

The scoping review allows evaluation of different types of studies, although it does not provide definitive evidence-based answers, being especially useful when the subject is complex and urgent, and when there are considerable gaps, even in the presence of emerging and hectic evidence, as is the present case. Thus, it allows the definition of key concepts and sources of evidence that can inform practices, policy formulation and research. In this process, it is essential to guarantee methodological rigor and transparency; the possibility of critical evaluation of the set and synthesis of the results, even without individualized and formal evaluation of the quality of the studies; and the balance between breadth and depth17.

In 2005, Arksey & O'Malley published the first methodological framework for conducting scoping reviews, as a six-step iterative process: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; (5) collating, summarizing and reporting the results; and (6) optional consultation16. Subsequently, Levac et al improved these steps, including the relationship between the research objective and question, balancing the feasibility of the study with the necessary scope, carrying out the selection in groups in an iterative way, including quantitative summaries and thematic analyses, identifying the implications of the studies for practice and policies, and making consultation mandatory18. More recently, Peters et al added the need to align the research objectives and questions to the inclusion criteria; the planning of the stages of identification, selection, extraction and presentation of evidence; the performance of a synthesis of the results, relating it to the objectives; and the formulation of conclusions and their practical implications19.

Based on the objective outlined in this study, the following research question is proposed: ‘What individual and collective initiatives and innovations were developed within the scope of PHC to face the COVID-19 pandemic, in rural and remote areas?’ We also sought to answer two derived questions: ‘What are the necessary organizational and intersectoral initiatives?’ and ‘What are their challenges?’

Search words (Table 1) were identified based on a decision made by the researchers, aiming to allow the screening of the titles and abstracts of studies that encompassed the population, the concept and the context20 guiding the review question. The population included traditional peoples, primary care users and communities attached to the territory. The concept was related to organizational, individual and collective initiatives to face the pandemic and the selected context was both clinical (PHC) and spatial (remote/rural locations).

The literature search was limited to publications in English, Portuguese and Spanish, initially limiting them to studies published between January 2020 and July 2021, complemented by a rapid review, including other relevant articles published between January 2022 and April 2023. The focus sought in the literature comprised the initiatives and innovations carried out within the scope of PHC in rural locations during the COVID-19 pandemic, as well as comparisons with pre-pandemic situations and between different countries.

The literature search was carried out in the PubMed and DOAJ, Gale, Onefile, Web of Science, Wiley, Proquest and SAGE databases. The bibliographic information of each search result was imported into Rayyan (Intelligent Systematic Review; https://www.rayyan.ai). Subsequently, articles in duplicate were removed and the abstracts were reviewed. The flowchart in Figure 1 depicts all the steps taken from the identification of the studies and their quantitative data. Selection, eligibility and inclusion steps are detailed below.

Titles and abstracts were independently evaluated (blinding) by two researchers, leading to the exclusion of studies that did not meet the inclusion criteria or that included any of the exclusion criteria defined by the researchers, as shown in Table 2. To resolve disagreements between the two researchers in this initial evaluation (only nine articles), a third researcher who had not participated in the first phase provided her opinion, which allowed reaching a final decision on the inclusion of the initial studies. The articles were classified according to the inclusion and exclusion categories, in addition to an intermediate category (‘maybe’), so that they could be reassessed with greater precision and later defined through agreement among the researchers.

After this, the studies included in the first phase were read in full by two researchers, who independently reviewed them. The reading in full allowed the charting and summarizing of these articles in a data extraction instrument, built after testing some elements of analysis, which resulted in an analytical extraction table that allowed categorizing the items according to the content that answered the research question. The elements in this table (Appendix I) were independently analyzed by the researchers, defining which studies would be included or excluded, after their full reading and synthesis.

We also checked for updates: a rapid review was carried out by two researchers for recent works in PubMed databases, published between 2022 and 2023. Thus we added 16 new articles, out of 44, which were also considered and will be thoroughly discussed along with the other results.

The articles were classified not only by country of study and origin of the first author, but also as sensitive or specific, according to their scope and comprehensiveness in relation to the inclusion and exclusion criteria. Thus, although a relevant set of studies did not fully meet the inclusion criteria, their reading was maintained to support the discussion, since they had important intersections between pairs of the PHC, rural and remote, and COVID-19 triad.

Based on the theoretical framework used in the review, the third researcher, once again, participated in the decision on the discordant articles, which allowed proceeding to the discussion of the review.

An important part of this analysis can be seen in the word clouds relating the answers of the articles to the research questions and their relationship with PHC and rural and remote locations. From these intersections, the word clouds were constructed, using the same language, aiming to visualize the frequency and relevance of the identified terms, in an open categorical way, as a representation of a hierarchical list of the selected extracts. Thus, the more frequently the term was identified, the larger its size, allowing a quick visualization of its magnitude and relevance in the qualitative analysis. Based on core PHC operational and strategic levers12, a cognitive map was also included, aiming to offer a synthesis of the observed and analyzed concepts (Appendix II).

Table 1:  Keywords for electronic database searchtable image

Table 2:  Review inclusion and exclusion criteria table image

table imageFigure 1:  PRISMA flow diagram for scoping review process. 

Ethics approval

This work was a literature review and relied on secondary materials; thus, it did not require ethics review.

Results

The main initiatives in PHC were related to healthcare access, but also to the coordination of care, comprehensiveness and longitudinality. Regarding innovations, telecare and customized communication stand out, as well as the role of community health workers and health surveillance, and the importance of retaining professionals and valuing human resources in health. Cultural, equity and vulnerability issues occupy an important space among the initiatives (Fig2).

Most articles included originated in Australia, Canada, the US and India. In Africa, articles from Nigeria, South Africa and the Greater Horn of Africa (Djibouti, Eritrea, Ethiopia, Kenya, Somalia, South Sudan, Sudan, Tanzania and Uganda) stood out. In Latin America, Argentina, Brazil, Ecuador and Peru stand out. In Europe, Spain, Denmark and the UK were also present.

An interesting point is that the description of rurality and remoteness is practically superimposed with that of the specific populations, present in geographic areas of difficult sociospatial and cultural access (Fig3). Very few studies indicate an index to measure rurality – presenting, at best, vague descriptions of rurality and remoteness, which are illustrated in the distances and obstacles to overcome.

Most of the publications analyzed are research articles, but editorials, letters to the editor, short reports, comments, special communications and guidelines were also included, provided they contained the relevant information to answer the research question. In particular, attention is drawn to the continuing education guideline for telecare, a publication of the Spanish Society of Primary Care Physicians21. This guideline offers a step-by-step guide for carrying out remote consultations, differentiating teleconsultation from video consultation, and providing instructions from consultation planning and opening, to the information necessary for clinical management, as well as communication with the patient and instructions in case of clinical worsening or need for validation with a face-to-face consultation21.

The main initiatives identified, classified by dimension, along with the factors that facilitate or limit its implementation, are listed in Table 3. It is noteworthy that the initiatives specific to rural and remote locations are predominantly of an organizational nature, while there is a scarcity of initiatives in the other dimensions, mainly in the collective action one. Another important aspect is that access to and the quality of health care were present in all dimensions. Moreover, the issue of retaining professionals and attracting the health workforce deserves to be highlighted in the organizational dimension22,23.

We found new evidence that shed light on the set of initiatives, most of them also in the organizational dimension, such as asynchronous forms of communication24, medical education25, human resources training and mental health support26. In the clinical field, the most recently published studies also address initiatives on new models of assessment and virtual screening27, in addition to the provision of remote antiviral treatment28. In the systemic dimension, the most recent evidence regards the articulation of intersectoral workgroups29.

Table 3:  Top-ranked initiatives and their facilitating and limiting factors3-5,21-65†¶table image

Table 4 presents the identified vulnerabilities, based on the approach of populations that are difficult to reach, called ‘last mile populations’66 and their specific vulnerabilities in rural and remote locations, which lack goods and services of all kinds, with health care being part of this context. Thus, all types of vulnerability found in the selected articles were aggregated.

Table 4:  Top vulnerabilities found in the scoping review, by typetable image

table image Figure 2:  Word cloud of primary healthcare initiatives related to the COVID-19 pandemic in rural and remote locations.

table image Figure 3:  Word cloud of the description of rurality and remoteness.

Discussion

The initiatives that are more specific to the rural and remote locations deal with communication with society, as well as different types of telehealth care, in addition to aspects related to the health workforce, such as training and strategies for attracting and retaining human resources22. Logistics and supply issues are also worth mentioning.

Not surprisingly, the least discussed issues in relation to rural and remote locations were the expansion of nursing and community health worker activities, which, although present, have a lower magnitude, since they are already routinely placed, even outside the pandemic period, and which has become a reality for non-remote locations in this context67.

Multiprofessional support, in turn, shows significant scarcity in rural and remote locations, and it is precisely in these environments that PHC health professionals end up expanding their roles and performing more complex actions locally, precisely because of the difficulty of interacting with specialized professionals68.

More recently, some studies have shown that the COVID-19 pandemic has broadened the medical curriculum, preparing graduate and postgraduate students with intersectoral accountability concerns and providing a reliable workforce in rural remote settings, with a PHC focus inside the community according to its needs25. In addition, some authors point out that, just as important as recruiting and retaining the workforce in rural and remote locations, is the maintenance of professional development and mental health support, which may help tackle these issues in the ongoing health workforce26.

As for the specific communication and access initiative, the COVID-19 pandemic has rapidly and dramatically changed primary care services in the short term, changing many visits from traditional face-to-face meetings to telehealth-only meetings53.

The comparison in the use of telecare before and after the pandemic shows that there was a considerable increase in urban regions, although it was previously more often used in rural and remote regions, as it occurred in Canada. This is due to the greater availability of technological infrastructure and the ability to use technologies. In rural and remote locations, there is a greater proportion of isolated elderly people with chronic diseases, who would benefit intensely from telecare, reducing their risks of contact and displacement, but the initiatives are hindered by the acceptance of this type of contact and, mainly, by structural obstacles54.

The study by Jetty et al showed that populations lacking healthcare, particularly in rural communities, are less likely to have access to the technology needed to support virtual video consultations53. Among the several reasons for demographic disparities in telehealth use are the distrust regarding the use of technology to obtain care, and poor health or a lack of technological literacy in seeking medical care, especially in relation to the technological engagement of patients aged 65 years and over, as well as among those with chronic conditions. Detailing this issue, Hanjani et al reported that these populations – the elderly and those with chronic diseases – had less contact with their family doctors and PHC services during the COVID-19 pandemic55, which puts them in a situation of greater isolation and vulnerability, including having increased health risks associated with drug use in unadjusted doses.

On the other hand, the authors argue that telehealth drug reviews can positively impact clinical and financial outcomes, through asynchronous communication such as email and text messages, which are well accepted by patients. Thus, rural pharmacists worked together with community nurses, using videoconferencing technologies to review medications, enabling their delivery to the patients’ homes55.

It can also be pointed out that asynchronous forms of communication were mentioned as an initiative that yielded high levels of satisfaction during the pandemic for both users and professionals (94–99%), especially for the management of diagnostic test results and prescriptions24. New models of assessment, such as virtual triages, were proposed, mainly to help rural, remote and underserviced areas, and those without a family physician, and they can be useful for vaccination purposes or in the long term27.

Considering that these technologies have been increasingly used to provide drug access and review services, particularly for patients in rural and remote areas, it is crucial to promote funding for all types of interaction and communication with users, and invest in education, training and inclusion of vulnerable populations to the use of telehealth services for a better quality of service delivery during the COVID-19 pandemic21,54. Some authors draw attention to a firmly, well established and inclusive telehealth policy in PHC delivery models, in order to reduce health inequities in regional, rural and remote localities56.

In the other dimensions, we depict the need for rapid test usage in public health, due to the great distances users have to travel to access more complex tests. Clinical initiatives address the reduction of risk factors, such as smoking57, related to the isolation of communities and mental health problems, in addition to remote treatment, which is so relevant in these areas, but still shows important infrastructure deficiencies. A novel approach in the set of initiatives in the clinical dimension was related to delivering time-critical COVID-19 antiviral therapeutics to individuals across large, remote and logistically complex regions. An Australian study evidenced that a variety of modes of transport were used to transfer medicines between these regions, not only efficiently, but also in a culturally safe way for First Nations people28.

In the intersectoral dimension, the main initiatives are focused on the One Health strategy, which unifies human, animal and environmental health, more evident in pastoral communities and localities58, and food and nutritional security, with the risks of shortages in remote locations, especially in those without sufficient agricultural activities69. On the other hand, there is a greater scarcity related to initiatives aimed at sharing information, reducing inequalities and articulating different levels of government, which ignore mostly rural or remote locations, regarding their specific needs.

The main managerial innovations are related to diagnostic telecare21,59, remote monitoring and treatment (including rehabilitation and mental health) and IT applications related to epidemiological and health surveillance, and interdisciplinary teaching and research aspects60. Innovations in telehealth are addressed in some studies as potential strategies to reduce inequities, since they are characterized as a resource that results in improvement in healthcare access59,60.

Other possibilities for innovation include opportunities to increase vaccination rates with community strategies, further expansion of the scope of practices carried out by nurses and family doctors, improving communication between PHC and other levels of care, and improving the logistics of essential health supply chains.

Moreover, the diversified actions of collectives and community associations evidenced during the pandemic allow the activation of a very comprehensive social network, highlighting the importance of maintaining a well-established bond with the community in non-emergency times too, as a way of strengthening PHC. Health communication and education actions, population-wise, reinforce the importance of social isolation and other factors to avoid contagion in the community and favor the identification of people in a state of greater vulnerability70.

Although a large rural population is affected by COVID-19 worldwide and in many developing countries rural settlements constitute a large proportion of the population compared to urban cities61, the focus tends to be on population risk and disease severity in high-density urban communities. Interestingly, much of the media coverage of case and death counts revolves around urban areas and city hospitals, with limited information on what happens in rural and remote areas, which potentially reflects on the difficulties when coping with the pandemic in these areas5.

Considering that the majority of COVID-19 cases will be mild71, the essential attributes of PHC10 reinforce its potential for the exercise of safe and favorable patient care in the context of COVID-19, since the dimensions of care, case monitoring and community articulation constitute important mechanisms for rapid response to the pandemic72, especially in rural and remote locations.

Cultural issues deserve to be highlighted, since in remote locations there are specific peoples, such as those living by the water, in the forests and interior, such as riverside populations, Indigenous peoples, maroons (quilombolas) and Aboriginal Australians. The geographical aspects and barriers to overcome, as well as environmental adversities73, are issues that must integrate the formulation and implementation of public policies. The pandemic has further highlighted this need, considering that central governments must create protocols and regulations that consider local diversities, being inefficient otherwise62. The greatest difficulties in accessing and navigating health systems have also become critical in coping with the pandemic. Post-pandemic health needs deserve special attention, particularly regarding mental health and rehabilitation, as well as the pressure exerted on health services due to the pent-up demand during the pandemic74.

Socioeconomic vulnerabilities were also exacerbated during the pandemic, given the damage caused to essential workers and their families, who were exposed without adequate protection and lost their lives, given the mistakes made when dealing with the pandemic, especially in its initial phase. Thus, situations of orphaned children, living on the streets and exposed to exploitation, have increased75.

Ethnic and racial vulnerabilities have increased, such as delays in caring for people with complications related to COVID-19, which were evidenced to disproportionately affect racial and ethnic minority populations. There were more deaths among black people and three times more hospitalizations of Latino ethnicities than of non-black and non-Latino people at the beginning of the pandemic63. Similarly, Logan et al demonstrated that, in rural areas of the US, there are significant disparities between white and black populations, with the latter showing higher mortality rates64. These disparities represent a confluence of structural racism with other social and economic factors that increase the risk of COVID-19 exposure and disease-related complications among demographically vulnerable populations.

Ethnic vulnerabilities are also added to migratory vulnerabilities23,58. For immigrant communities living in rural areas, issues related to the status of migratory legality have a different impact on access to health care. Latino migrant farm workers show higher rates of health disparities and occupational hazards, with poorer access to care due to a constellation of factors that are legal, financial, cultural and geographic in nature64. Other issues, such as social isolation, negatively affect Latino immigrants in US regions and lead to additional barriers to care and a higher incidence of mental health issues. Thus, immigration acts as a social determinant of health, which can negatively affect the wellbeing of these individuals, especially during a global public health crisis such as a pandemic.

Vulnerabilities of gender, ethnicity, capacity and citizenship status also intensified during the pandemic, with higher rates of violence and indifference by society, including in situations of structural racism in health services65. The elderly, with chronic diseases, also suffered from difficulties in care and continuity of care, especially those in long-stay institutions55.

Such social determinants of health and other structural vulnerabilities in rural areas greatly affect their populations, which results in higher rates of chronic and life-limiting diseases, lack of access to mental health care, and greater diagnostic and therapeutic difficulties for several clinical conditions, including infectious diseases64.

Limitations

The scoping review, while fully answering the research question, did not allow evidence for the effectiveness of PHC practices; however, the method offers a panoramic analysis of initiatives implemented internationally. From this perspective, we qualitatively evaluated the articles, so that we could provide a more consistent classification to readers.

The fact that we worked with only three languages (English, Spanish and Portuguese) also represents a limiting factor; however, during the pandemic, most articles were published in English, due to the need to share the findings quickly and globally. Less than 1% of the articles found in the first search were written only in other languages.

We found a relevant set of studies that, although not meeting the inclusion criteria, were very rigorous, and were still read for the discussion, as they showed some important intersections between pairs of the PHC, rural and remote, and COVID-19 triad.

Finally, we are aware of epistemic injustices brought by an imbalance in power relations. Health knowledge and its diffusion are still colonial, with many implicit hierarchical assumptions, sometimes without considering the cultural competences of people from rural and remote regions76. Thus, another limitation is that some successful experiences in less developed countries may not be present, due to inequalities in the production of studies and publications.

Conclusion

The research question was fully answered by the review, having identified public, clinical, intersectoral and, mainly, organizational health initiatives. It is important to point out that remote locations have great potential for intersectoral activities at the local level, due to the strong articulation that is necessary between the different areas. From the organizational point of view, rural and remote locations showed enormous flexibility to face the pandemic, regarding the different levels of care.

The distance between the different levels of government has been further intensified during the pandemic, in the formulation of policies and protocols that had to be adapted to rural and remote locations for their implementation. It would be very important to articulate the different levels, with the officialization of national public health agencies and plans adapted to each local reality, aiming at assessing their implementation for future crises.

The results highlight and synthesize the knowledge about initiatives and innovations developed to face the COVID-19 pandemic, within the scope of PHC, in rural and remote locations worldwide. Innovations and lessons learned are equally relevant for the strengthening of health services and systems. This issue is still quite limited, so it needs to be further analyzed in new reviews seeking evidence to assess the sustainability and effectiveness of the implemented measures aimed at facing post-pandemic difficulties and other adversities. Moreover, empirical research in rural and remote regions is essential to address health inequities in future health crises.

Acknowledgements

A. Bousquat is a Conselho Nacional de Desenvolvimento Científico e Tecnológico–CNPq fellow in research productivity.

Funding

S. Schenkman is a postdoctoral researcher thanks to grant# 2022/0546-1, São Paulo Research Foundation (FAPESP).

Conflicts of interest

The authors declare no conflicts of interest.

references:

1 Bousquat A, Giovanella L, Medina M, Magalhães De Mendonça M, Luiz A, et al. Challenges for primary care in dealing with the Covid-19 pandemic in the SU. [In Portuguese]. Available: web link (Accessed 20 September 2023).
2 Stein KV, Goodwin N, Miller R. From crisis to coordination: challenges and opportunities for integrated care posed by the COVID-19 pandemic. International Journal of Integrated Care 2020; 20(3): 7. DOI link
3 Garg S, Basu S, Rustagi R, Borle A. Primary health care facility preparedness for outpatient service provision during the COVID-19 pandemic in India: cross-sectional study. JMIR Public Health and Surveillance 2020; 6(2): e19927. DOI link
4 Siedner MJ, Kraemer JD, Meyer MJ, Harling G, Mngomezulu T, Gabela P, et al. Access to primary healthcare during lockdown measures for COVID-19 in rural South Africa: an interrupted time series analysis. BMJ Open 2020; 10(10): e043763. DOI link, PMid:33020109
5 O'Sullivan B, Leader J, Couch D, Purnell J. Rural pandemic preparedness: the risk, resilience and response required of primary healthcare. Risk Management and Healthcare Policy 2020; 13: 1187-1194. DOI link, PMid:32904086
6 United Nations. United Nations Sustainable Development Goals. New York, NY: United Nations Publications, 2017.
7 Instituto Brasileiro de Geografia e Estatística. Classification and characterization of Brazil's rural and urban spaces. [In Portuguese]. Available: web link (Accessed 26 January 2023).
8 OECD. Regional, rural and urban development. Available: web link (Accessed 26 January 2023).
9 Vuori H. Health for all, primary health care and general practitioners. The Journal of the Royal College of General Practitioners. 1986; 36(290): 398-402. PMid:3806483
10 Starfield B. Primary care: balancing health needs, services and technology. [In Portuguese]. Brasília: Brasil: Ministério da Saúde, 2002.
11 Thomas SL, Wakerman J, Humphreys JS. What core primary health care services should be available to Australians living in rural and remote communities? BMC Family Practice 2014; 15(1): 143. DOI link, PMid:25143194
12 World Health Organization & United Nations Children's Fund (‎UNICEF). Operational framework for primary health care: transforming vision into action. Available: web link (Accessed 26 April 2023).
13 Franco CM, Lima JG, Giovanella L. Primary health care in rural areas: access, organization and health workforce in an integrative literature review. [In Portuguese]. Cadernos de Saúde Pública 2021; 37(7). DOI link, PMid:34259752
14 Almeida PF, Santos AM, Cabral LM, Fausto MCR. Context and organization of primary health care in remote rural communities in Northern Minas Gerais State, Brazil. Cadernos de Saúde Pública 2021; 37(11): e00255020-0. DOI link, PMid:34877992
15 Haldane V, Zhang Z, Abbas RF, Dodd W, Lau LL, Kidd MR, et al. National primary care responses to COVID-19: a rapid review of the literature. BMJ Open 2020; 10(12): e041622. DOI link, PMid:33293398
16 Arksey H, O'Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology 2005; 8(1): 19-32. DOI link
17 Pham MT, Rajić A, Greig JD, Sargeant JM, Papadopoulos A, McEwen SA. A scoping review of scoping reviews: advancing the approach and enhancing the consistency. Research Synthesis Methods 2014; 5(4): 371-385. DOI link, PMid:26052958
18 Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implementation Science 2010; 5(1): 69. DOI link, PMid:20854677
19 Peters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. International Journal of Evidence-Based Healthcare 2015; 13(3): 141-146. DOI link, PMid:26134548
20 Peters MDJ, Godfrey CM, McInerney P, Soares CB, Khalil H, Parker D. The Joanna Briggs Institute reviewers' manual 2015: methodology for JBI scoping reviews. 2015. Available: web link (Accessed 20 November 2022).
21 Eguia H, Vinciarelli F, Villoslada Muñiz RL, Sanz García FJ. Non-presential consultation in times of coronavirus: information for Primary Care physicians. [In Spanish]. SEMERGEN, Sociedad Española de Medicina Rural y Generalista (Ed Impr). 2020; 46(8): 560-565. DOI link, PMid:33239153
22 Campbell N, Stothers K, Swain L, Cairns A, Dunsford E, Barker R. Allied health service-learning student placements in remote northern Australia during COVID‐19. Australian Journal of Rural Health 2020; 28(5): 514-520. DOI link, PMid:32985072
23 Malayala SV, Vasireddy D, Kadali RAK, Alur RS, Koushik K. Healthcare access in medically underserved areas during the COVID-19 era: an international medical graduate perspective from a rural state. Cureus 2020; 12(12): e12254. DOI link
24 Fuster-Casanovas A, Vidal-Alaball J. Asynchronous remote communication as a tool for care management in primary care: a rapid review of the literature. International Journal of Integrated Care 2022; 22(3): 7. DOI link, PMid:36043028
25 Murray R, Cristobal F, Shrestha S, Tandinco FD, De Maeseneer JM, Verma S, et al. COVID-19 fosters social accountability in medical education. Rural and Remote Health 2022; 22: 6998. DOI link, PMid:35538625
26 Tham R, Pascoe A, Willis K, Kay M, Smallwood N. Differences in psychosocial distress among rural and metropolitan health care workers during the COVID‐19 pandemic. Australian Journal of Rural Health 2022; 30(5): 683-696. DOI link, PMid:35511109
27 Fitzsimon J, Gervais O, Lanos C. COVID-19 assessment and testing in rural communities during the pandemic: cross-sectional analysis. JMIR Public Health and Surveillance 2022; 8(2): e30063. DOI link, PMid:35022158
28 Galloway S, Taunton C, Matysek R, Hempenstall A. Seeking to improve access to COVID-19 therapeutics in the remote Torres and Cape communities of Far North Queensland during the first COVID-19 omicron outbreak. Rural and Remote Health 2022; 22: 7657. DOI link, PMid:36262083
29 Nott S, Colbran R, Edwards M. Rural health workforce response to Australia's recent natural disasters and emergencies, with a focus COVID-19. Rural and Remote Health 2023; 23: 8130. DOI link
30 Hengel B, Causer L, Matthews S, Smith K, Andrewartha K, Badman S, et al. A decentralised point-of-care testing model to address inequities in the COVID-19 response. The Lancet Infectious Diseases 2020; 21(7): e183-e190. Available: web link
31 Reinders S, Alva A, Huicho L, Blas MM. Indigenous communities' responses to the COVID-19 pandemic and consequences for maternal and neonatal health in remote Peruvian Amazon: a qualitative study based on routine programme supervision. BMJ Open 2020; e044197-7. Available: web link, DOI link, PMid:33376182
32 Siedner MJ, Harling G, Derache A, Smit T, Khoza T, Gunda R, et al. Protocol: leveraging a demographic and health surveillance system for Covid-19 surveillance in rural KwaZulu-Natal. Wellcome Open Research 2020; 5: 109. DOI link, PMid:32802963
33 Fitts MS, Russell D, Mathew S, Liddle Z, Mulholland E, Comerford C, et al. Remote health service vulnerabilities and responses to the COVID‐19 pandemic. Australian Journal of Rural Health 2020; 28(6): 613-617. DOI link, PMid:33216416
34 Montag D, Barboza M, Cauper L, Brehaut I, Alva I, Bennett A, et al. Healthcare of Indigenous Amazonian Peoples in response to COVID-19: marginality, discrimination and revaluation of ancestral knowledge in Ucayali, Peru. BMJ Global Health 2021; 6(1): e004479. DOI link, PMid:33414155
35 Kippen R, O'Sullivan B, Hickson H, Leach M, Wallace G. A national survey of COVID-19 challenges, responses and effects in Australian general practice. Australian Journal of General Practice 2020; 49(11): 745-751. DOI link, PMid:33123716
36 John O, Gummidi B, Jha V. Continuum of care for non-communicable diseases during COVID-19 pandemic in rural India: a mixed methods study. Journal of Family Medicine and Primary Care 2020; 9(12): 6012. DOI link, PMid:33681035
37 Stanhope J, Weinstein P. Learning from COVID-19 to improve access to physiotherapy. Australian Journal of Primary Health 2020; 26(4): 271. DOI link, PMid:32669194
38 Papadimos T, Soghoian S, Nanayakkara P, Singh S, Miller A, Saddikuti V, et al. COVID-19 blind spots: a consensus statement on the importance of competent political leadership and the need for public health cognizance. Journal of Global Infectious Diseases 2020; 12(4): 167. DOI link, PMid:33888955
39 Glazier RH, Green ME, Wu FC, Frymire E, Kopp A, Kiran T. Shifts in office and virtual primary care during the early COVID-19 pandemic in Ontario, Canada. Canadian Medical Association Journal 2021; 193(6): e200-e210. DOI link, PMid:33558406
40 Melvin SC, Wiggins C, Burse N, Thompson E, Monger M. The role of public health in COVID-19 Emergency response efforts from a rural health perspective. Preventing Chronic Disease 2020; 17(70): 200256. DOI link, PMid:32701430
41 Gardiner FW, Bishop L, Churilov L, Collins N, O'Donnell J, Coleman M. Mental health care for rural and remote Australians during the coronavirus disease 2019 pandemic. Air Medical Journal 2020; 39(6): 516-519. DOI link, PMid:33228907
42 Rosa WE, Fitzgerald M, Davis S, Farley JE, Khanyola J, Kwong J, et al. Leveraging nurse practitioner capacities to achieve global health for all: COVID‐19 and beyond. International Nursing Review 2020; 67(4): 554-559. DOI link, PMid:33006173
43 Campbell N, Stothers K, Swain L, Cairns A, Dunsford E, Rissel C, et al. Health services in northern Australia depend on student placements post COVID‐19. Australian and New Zealand Journal of Public Health 2020; 44(6): 521-522. DOI link, PMid:33104283
44 O'Reilly F, McLoughlin M, Hamilton D, Todd J. Pop-up COVID-19 vaccination clinics for vulnerable groups in the Midlands. Rural and Remote Health 2023; 23: 8161. DOI link, PMid:36802739
45 Sialubanje C, Mukumbuta N, Ng'andu M, Sumani EM, Nkonkomalimba M, Lyatumba DE, et al. Perspectives on the COVID-19 vaccine uptake: a qualitative study of community members and health workers in Zambia. BMJ Open 2022; 12(11): e058028. DOI link, PMid:36418116
46 Nelson D, Cooke S, McLeod B, Nanyonjo A, Kane R, Gussy M. A rapid systematic review on the experiences of cancer survivors residing in rural areas during the COVID-19 pandemic. International Journal of Environmental Research and Public Health 2022; 19(24): 16863. DOI link, PMid:36554740
47 Fitzpatrick KM, Ody M, Goveas D, Montesanti S, Campbell P, MacDonald K, et al. Understanding virtual primary healthcare with Indigenous populations: a rapid evidence review. BMC Health Services Research 2023; 23(1): 303. DOI link, PMid:36991410
48 Jones LS, Russell AJ, Brosnan MJ. Digitally mediated service provision for children's social, emotional and mental health: key indicators for evaluation. Rural and Remote Health 2023; 23: 7747. DOI link, PMid:36646049
49 Mathew S, Fitts MS, Liddle Z, Bourke L, Campbell N, Murakami-Gold L, et al. Telehealth in remote Australia: a supplementary tool or an alternative model of care replacing face-to-face consultations? BMC Health Services Research 2023; 23(1): 341. DOI link, PMid:37020234
50 Hayes C. 'Attorneys of the Poor': the lived experience of general practitioners working in disadvantaged parts of rural Ireland. Rural and Remote Health 2023; 23: 8141. DOI link
51 Eggleton K, Bui N, Goodyear-Smith F. COVID-19 impact on New Zealand general practice: rural-urban differences. Rural and Remote Health 2022; 22: 7185. DOI link, PMid:35168362
52 Humphreys JS, Wakerman J. What progress can the Australian Journal of Rural Health celebrate on its thirtieth anniversary? Australian Journal of Rural Health 2022; 30(5): 566-569. DOI link, PMid:36217998
53 Jetty A, Jabbarpour Y, Westfall M, Kamerow DB, Petterson S, Westfall JM. Capacity of primary care to deliver telehealth in the United States. The Journal of the American Board of Family Medicine 2021; 34: S48-S54. DOI link, PMid:33622818
54 Chu C, Cram P, Pang A, Stamenova V, Tadrous M, Bhatia RS. Rural telemedicine use before and during the COVID-19 pandemic: a repeated cross-sectional study. Journal of Medical Internet Research 2021; 23(4): e26960. DOI link, PMid:33769942
55 Hanjani LS, Bell JS, Freeman C. Undertaking medication review by telehealth. Australian Journal of General Practice 2020; 49(12): 826-831. DOI link, PMid:33254216
56 Caffery LA, Muurlink OT, Taylor‐Robinson AW. Survival of rural telehealth services post‐pandemic in Australia: a call to retain the gains in the "new normal.". Australian Journal of Rural Health 2022; 30(4): 544-549. DOI link, PMid:35612267
57 Mistry SK, Ali AM, Rahman MdA, Yadav UN, Gupta B, Rahman MA, et al. Changes in tobacco use patterns during COVID-19 and their correlates among older adults in Bangladesh. International Journal of Environmental Research and Public Health 2021; 18(4): 1779. DOI link, PMid:33673087
58 Griffith EF, Pius L, Manzano P, Jost CC. COVID-19 in pastoral contexts in the greater Horn of Africa: implications and recommendations. Pastoralism 2020; 10(1): 22. DOI link, PMid:33072249
59 Sieck CJ, Rastetter M, McAlearney AS. Could telehealth improve equity during the COVID-19 pandemic? The Journal of the American Board of Family Medicine 2021; 34: S225-S228. DOI link, PMid:33622843
60 Ozair A, Singh KK. Delivering high-quality, equitable care in India: an ethically-resilient framework for healthcare innovation after COVID-19. Frontiers in Public Health 2021; 9: 18 February. DOI link, PMid:33681137
61 Omoronyia O, Ekpenyong N, Ukweh I, Mpama E. Knowledge and practice of COVID-19 prevention among community health workers in rural Cross River State, Nigeria: implications for disease control in Africa. Pan African Medical Journal 2020; 37: 50. DOI link, PMid:33209177
62 Crooks K, Casey D, Ward JS. First Nations peoples leading the way in COVID‐19 pandemic planning, response and management. Medical Journal of Australia 2020; 213(4): 151. DOI link, PMid:32691433
63 Mayfield CA, Sparling A, Hardeman G, de Hernandez BU, Pasupuleti N, Carr J, et al. Development, implementation, and results from a COVID-19 messaging campaign to promote health care seeking behaviors among community clinic patients. Journal of Community Health 2021; 46: 728-739. DOI link, PMid:33128160
64 Logan RI, Castañeda H. Addressing health disparities in the rural United States: advocacy as caregiving among community health workers and Promotores de Salud. International Journal of Environmental Research and Public Health 2020; 17(24): 9223. DOI link, PMid:33321718
65 Singh DR, Sunuwar DR, Shah SK, Karki K, Sah LK, Adhikari B, et al. Impact of COVID-19 on health services utilization in Province-2 of Nepal: a qualitative study among community members and stakeholders. BMC Health Services Research 2021; 21(1): 174. DOI link, PMid:33627115
66 Davison CM, Bartels SA, Purkey E, Neely AH, Bisung E, Collier A, et al. Last mile research: a conceptual map. Global Health Action 2021; 14(1): 1893026. DOI link, PMid:33736574
67 Feyereisen S, Puro N. Seventeen states enacted executive orders expanding advanced practice nurses' scopes of practice during the first 21 days of the COVID-19 pandemic. Rural and Remote Health 2020; 20: 6068. DOI link, PMid:33264566
68 Hibberd J, Carter J, McCoy M, Rafiq M, Varma A, Sanghera R, et al. General practice in the time of COVID-19: a mixed-methods service evaluation of a primary care COVID-19 service. International Journal of Environmental Research and Public Health 2021; 18(6): 2895. DOI link, PMid:33809000
69 Das S, Rasul MdG, Hossain MS, Khan A-R, Alam MA, Ahmed T, et al. Acute food insecurity and short-term coping strategies of urban and rural households of Bangladesh during the lockdown period of COVID-19 pandemic of 2020: report of a cross-sectional survey. BMJ Open 2020; 10(12): e043365. DOI link, PMid:33310813
70 Geraldo SM, Farias SJM de, Sousa FOS. The role of Primary Care in the context of the COVID-19 pandemic in Brazil. [In Portuguese]. 2021; 10(8): e42010817359. DOI link
71 Ai J-W, Zi H, Wang Y, Huang Q, Wang N, Li L-Y, et al. Clinical characteristics of COVID-19 patients with gastrointestinal symptoms: an analysis of seven patients in China. Frontiers in Medicine (Lausanne) 2020; 9 June. DOI link, PMid:32656221
72 Medina MG, Giovanella L, Bousquat A, Mendonça MHM, Aquino R. Primary health care in times of COVID-19: what to do? [In Portuguese]. Cadernos de Saúde Pública 2020; 36(8). DOI link, PMid:32813791
73 Lawrence-Bourne J, Dalton H, Perkins D, Farmer J, Luscombe G, Oelke N, et al. What is rural adversity, how does it affect wellbeing and what are the implications for action? International Journal of Environmental Research and Public Health 2020; 17(19): 7205. DOI link, PMid:33019735
74 Prvu Bettger J, Thoumi A, Marquevich V, De Groote W, Rizzo Battistella L, Imamura M, et al. COVID-19: maintaining essential rehabilitation services across the care continuum. BMJ Global Health 2020; 5(5): e002670. DOI link, PMid:32376777
75 Govender K, Cowden RG, Nyamaruze P, Armstrong RM, Hatane L. Beyond the disease: contextualized implications of the COVID-19 pandemic for children and young people living in Eastern and Southern Africa. Frontiers in Public Health 2020; 8: 19 October. DOI link, PMid:33194933
76 Bhakuni H, Abimbola S. Epistemic injustice in academic global health. The Lancet Global Health 2021; 9(1): e1465-e1470.

appendix I:

Appendix I: List of extracted itemstable image

appendix II:

Appendix II: Cognitive map of items extractedtable image

You might also be interested in:

2021 - A rapid review of evidence to inform an ear, nose and throat service delivery model in remote Australia

2018 - Does rural generalist focused medical school and family medicine training make a difference? Memorial University of Newfoundland outcomes.

2009 - Descriptive epidemiology of blood pressure in a rural adult population in Northern Ghana