Telehealth Interventions Aimed at Parents and Caregivers of Children Living in Rural Settings: A Systematic Review

ABSTRACT

In recent years, and especially due to COVID-19, a large number of telehealth interventions have been implemented. The large amount of information requires a differential analysis with an emphasis on rurality and the practice of parents/caregivers in the care and attention of children. The objectives of this study were to synthesize the available evidence on telehealth interventions aimed at parents and caregivers of children living in rural settings, and to identify relevant methodological aspects that are considered in such interventions. A systematic review was conducted in the Medline (Ovid), Embase, Scopus, APA—PSYCNET, Web of Science and LILACS databases. Studies published between 2000 and 2020 were considered. A narrative synthesis of the main results of the studies was performed, including basic characteristics, details of the interventions, and the main outcome measures. The quality of the studies included was assessed using the Joanna Briggs Institute Critical Appraisal tools. A total of 596 potential studies were identified, of which only nine were included. Quality assessment was consistent in all nine studies. Parents and caregivers of children with speech and language impairment, motor impairment or problems in performing activities of daily living, with behavior problems, and with autism spectrum disorder were the main populations groups benefiting from the interventions. Telehealth interventions were implemented by means of online sessions, pre-recorded sessions and self-learning modules, among others. Results, although variable, evidence positive outcomes regarding the development of multiple skills in children, their parents and family members, as well as the opportunity to provide timely access to health services. Finally, Telehealth is increasingly becoming a useful tool to provide counsel and knowledge to parents and caregivers living in rural areas that will enable them to properly manage health problems.

KEYWORDS:

• Parents
• caregivers
• telemedicine
• Rural Health Services
• remote consultation. (MeSH)

Introduction

Telehealth is known as the possibility of providing health care, health education and health counseling services remotely through different information and communications technologies including videoconferencing, mobile connection applications, and monitoring and assistance tools, among others (Catalyst, 2018; Waller & Stotler, 2018). Although the terms telehealth and telemedicine have been used interchangeably, the former comprises a large number of services that improve the quality of health care, access to health services, the productivity of health workers, increased health access coverage in rural areas, reduced healthcare provision-related costs, and even facilitate the provision of such services during health crises such as the current COVID-19 pandemic (Smith et al., 2020; Koonin et al., 2020).

By March 2021, a search in the Medline (PubMed) database using the “telehealth” and “telemedicine” terms yielded more than 35,000 records, of which, 54% have been published in the last five years, which makes it evident that not only publications addressing this topic, but also the use of telehealth has increased. Within these records, there are many related to technology, intervention programs, innovations in infrastructure, new adaptations such as simulated use and 3D, among others. Furthermore, it is worth noting that, at least in the United States, more than 50% of health institutions have some telehealth program (Tuckson et al., 2017), and that the number of specialized services using this technology is increasing, including telepsychiatry, teleophthalmology, telerehabilitation, and recently, even teletherapy (Fairweather et al., 2022).

Multiple studies and reviews have shown the benefits of telehealth, particularly in the rural context. Telehealth has overcome physical displacement, geographical and technological barriers and has had a positive impact on many processes involved in the provision of health services in rural areas (Jennett et al., 2003).

Additionally, it is considered as one of the necessary tools for the provision of specialized health services to people living in remote areas (Jarvis-Selinger et al., 2008; Jennett et al., 2003), to those living in vulnerable communities and in those where the general health status is worse, and/or who lack the necessary resources to go to a hospital for assistance (Smith et al., 2008; Moffatt & Eley, 2010). It is considered a necessary tool for providing health care services to all those who live in remote areas, which is estimated to be more than 44% of the world population, as more than half of them need health care services (World Bank Group, 2019; Mikou et al., 2019).

Thus, rurality is understood as the population, housing, context and sociocultural development that implies living outside an urban area or urban cluster, having a population of less than 10,000 people or living in places with limited access to public services due to geographical barriers (Hart et al., 2005; Health Resources and Services Administration (HRSA), 2021).

In this sense, rural populations with the above conditions have been benefiting more frequently from the use of telehealth in terms of access to health services; in recent years, the satisfaction of this population with this technology has been measured by several studies, which have reported significant positive outcomes, including the reduction of waiting times for receiving care, the avoidance of exhausting and costly trips, and the reduction of the burden on the family members of patients, among others, as they are no longer required to go to intermediate or large cities (Orlando et al., 2019).

The general characteristics of telehealth interventions in the rural context include the possibility of receiving health assistance via videoconference, completing specific forms and questionnaires live, evidencing current health needs, and actively interacting with trained health professionals (Fischer et al., 2020; Speyer et al., 2018; Tuckson et al., 2017).

Regarding the place where this technology is used, it has been described that telehealth interventions are usually carried out in local schools and primary care centers or hospitals, which involves the mobilization of people even in rural areas (Campbell et al., 2020; Hilty et al., 2020). Among the population groups using telehealth in rural areas, it has been reported that there is a great diversity of groups that benefit from it (Disler et al., 2020; Hilty et al., 2020) including the family, and especially children, one of the most important target populations at present (Harrison et al., 2014; Hilty et al., 2020).

Undoubtedly, the COVID-19 pandemic has become a new challenge for parents and caregivers of children since, given the measures implemented to slow down the transmission of the virus, their possibility of attending schools and other care centers has been limited (Cruz & Zeichner, 2020) although this situation has been questioned lately (Ludvigsson, 2020). In fact, according to data from the United Nations Educational, Scientific and Cultural Organization (UNESCO), worldwide more than 1.5 billion students have been affected by the physical closing of schools and universities, while 9.4% of the world population have been affected by the closing of schools alone (United Nations Educational Scientific and Cultural Organization (UNESCO, 2021). As time passes, we obtain more data that allows the measurement of the negative impact of the current pandemic on the well-being, development and health of children around the world (Van Lancker & Parolin, 2020; Xiang et al., 2020).

The pandemic has not only affected children, but also their parents and caregivers, especially those who are socioeconomically vulnerable, a situation which was worsened by the pandemic (unemployment, informal employment, etc.), and/or live in remote or rural areas, since they generally don’t have the time or financial resources to support the learning processes of their children, nor the minimum tools to support, with the help of a health professional, the mental, physical, social and relational well-being of their children (Masonbrink & Hurley, 2020; Van Lancker & Parolin, 2020).

The reasons for conducting this review are summarized in the different abovementioned sections. Firstly, we are aware of the general and specific benefits of telehealth in rural areas. Secondly, we are currently facing a pandemic that tests the development, use and application of this technology in the general population. In this sense, children, together with their parents, have been one of the population groups most affected by the COVID-19 pandemic, since their roles at home have been modified, thus affecting different skills related to the fulfillment of children’s health, educational and social development needs, among others.

Finally, understanding the above scenario in rural communities, as well as their vulnerability, makes it necessary to rethink how telehealth interventions can be improved in the context of global health crises such as the current pandemic. The final aspect is the information gap that we identified regarding rural telehealth interventions that do not require the mobilization of people, even to physical spaces (e.g. local schools or primary care centers) in their rural communities.

Therefore, The objectives of this study were to synthesize the available evidence on telehealth interventions aimed at parents and caregivers of children living in rural settings, and to identify relevant methodological aspects that are considered in such interventions.

Methods

Design

A systematic review was conducted following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins et al., 2019) and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) (Moher et al., 2009).

Study selection criteria

• - Types of participants: parents and caregivers of children aged 2–12 years or parent/caregiver-child dyads.

• - Types of interventions: Telehealth, telemedicine, telerehabilitation, telecare interventions and/or interventions derived from the practice of medicine and/or health sciences to deliver care at a distance by means of video and audio tools.

• - Types of outcome: The basic characteristics of the studies, the intervention details and the main outcome measures will be described.

• - Types of studies: All types of primary studies are included.

• - Context: Studies focused on the implementation of these interventions in rural settings. Due to the possible variability of the term “rural” in different countries, studies that explicitly stated that the intervention was carried out outside major cities or places considered as urban areas or in places with limited access to public and private services due to geographic aspects were included.

• - Exclusions: Interventions that involved the mobilization of participants to training centers (schools) or health centers (rural primary care centers) or any other institution, or their physical attendance to a meeting held in a specific location, even if such places were located in rural areas.

Search methods

An advanced search was carried out in January 2021; studies published between January 2000 and December 2020 were considered. The search was conducted in the following databases: Medline (OVID), Embase, Scopus, APA—PSYCNET, Web of Science, and LILACS. The search strategy was based on the use of controlled and free terms such as “parent”, “father”, “mother”, “caregiver” with “child” and “children” for the population group, and “telemedicine”, “telehealth”, “telecare”, “remote consultation” with “rural” for the intervention. Studies published in languages other than English were not included. The full search strategy and search reports are presented in Appendix 1.

Search by other resources

A complementary search was carried out in Google Scholar; likewise, a snowball search was also conducted.

Data extraction and analysis

Studies were independently selected by two authors after reading their titles and abstracts, as well as by performing a full-text reading; disagreements were solved through open discussion. Finally, the data of the selected studies were extracted independently by other two other authors who used a standardized format for such purpose. The meta-aggregation synthesis of the evidence was based on the identification of similarities between the documents that were retrieved, and a categorical analysis of the information was performed by establishing variables and making comparisons between studies in terms of study population, objective of the intervention, type of intervention and outcome measurements. The analysis was conducted with an emphasis on interventions and results, thus promoting a comprehensive view of the evidence.

Quality evaluation

The risk of bias of the selected studies was assessed by four authors using the Joanna Briggs Institute tools, particularly the critical appraisal criteria for Quasi-experimental studies (Tufanaru et al., 2020), Qualitative research (Lockwood et al., 2015) and Case series (Munn et al., 2020).

Data synthesis

A description of the results of each study was made by emphasizing the basic characteristics of each one (referencing data, country, participants, specific setting), the details of the intervention (objective and operational details), and the main outcome measures. Due to the high heterogeneity among the studies selected, a pooled analysis of results was not possible.

Results

Search results

The initial search yielded a total of 596 records; after duplicates were removed, 253 studies were screened by reading their titles and abstracts; of these, 77 were selected for full-text reading, and 68 were rejected for inclusion due to specific reasons, which are described in Appendix 2. Finally, nine studies were included for full analysis (Ashburner et al., 2016; Guðmundsdóttir et al., 2017, 2019; Heitzman-Powell et al., 2014; Hines et al., 2019; Ingersoll & Berger, 2015; Kelso et al., 2009; Kohlhoff et al., 2019, 2020). The screening and selection process of studies is shown in Figure 1 in accordance with the PRISMA standards.

Figure 1. Flow diagram PRISMA.

Quality evaluation results

All nine studies were evaluated and included according to the assessment tools; the specific details of this evaluation are described in Figure 2. There were five quasi-experimental studies (Guðmundsdóttir et al., 2017, 2019; Heitzman-Powell et al., 2014; Ingersoll & Berger, 2015; Kelso et al., 2009) none of them had a control group, and only one (Kelso et al., 2009) did not report multiple measurements; in addition, all of them properly reported the measurements, how their samples were obtained, and the statistical analysis of data according to the study design proposed.

Figure 2. Quality evaluation.

As for the qualitative studies (Ashburner et al., 2016; Kohlhoff et al., 2020), they fully complied with the items evaluated by the assessment tool, obtaining outstanding results in terms of research methodology, social representation and the resulting analysis. Finally, case series studies (Hines et al., 2019; Kohlhoff et al., 2019), fully reported the proposed evaluation, being noteworthy the inclusion criteria, the identification of the methods used and of participants, together with the most relevant results, which were correctly analyzed.

General characteristics

Regarding study design, as noted above, five were quasi-experimental two, qualitative (Ashburner et al., 2016; Kohlhoff et al., 2020) and two, case series (Hines et al., 2019; Kohlhoff et al., 2019). Most of them (44%) were conducted in Australia (Ashburner et al., 2016; Hines et al., 2019; Kohlhoff et al., 2019, 2020), followed by the United States of America (33%) (Heitzman-Powell et al., 2014; Ingersoll & Berger, 2015; Kelso et al., 2009) and Iceland (Guðmundsdóttir et al., 2017, 2019).

All studies included in this review comprised a total of 64 parents and caregivers along with 15 nuclear families. Regarding the specific characteristics of participants, children with any kind of speech and language impairment, motor impairment or problems in performing activities of daily living (Kelso et al., 2009), with behavior (control or reaction-related) problems (Kohlhoff et al., 2019, 2020), and with autism spectrum disorder (Ashburner et al., 2016; Guðmundsdóttir et al., 2017, 2019; Heitzman-Powell et al., 2014; Hines et al., 2019; Ingersoll & Berger, 2015). Further information is presented in Table 1.

Table 1. General characteristics and population of the studies.

REFERENCE	Country and geographic location	Population details
Kelso et al. (2009)	United States of America. Four families from a remote area of a large western state were selected through responses to a flyer announcing the field test of VHVs	Each family had at least 1 child younger than 3 years who currently received services through part C early intervention services. Two families received speech and language therapy via VHVs. Another participated in occupational therapy and the fourth in physical therapy
Heitzman-Powell et al. (2014)	United States of America. Seven Families were recruited through existing service	Parents from four families participated in this evaluation of the OASIS Training Program
Ingersoll and Berger (2015)	United States of America. 27 parents. Recruitment focused on underserved communities by residence in a rural area	Parents of a child with autism spectrum disorders (ASD) between the ages of 27 and 73 months
Ashburner et al. (2016)	Australia. Queensland. Four parents of children with autism spectrum disorders (ASD) from rural and remote locations	Four mothers who had participated in a week-long face-to-face early intervention program delivered by an ASD-specialist in their local area in the past 18 months were invited to participate in a week-long follow-up program delivered via remote technologies
Guðmundsdóttir et al. (2017)	Iceland. Family criteria included living in a rural location 35–165 km distance from the trainer’s location. Three caregivers of children with autism. Two families and one special education teacher	The families were selected in collaboration with the State Diagnostic and Counseling Center in Iceland according to predetermined selection criteria
Guðmundsdóttir et al. (2019)	Iceland. Three families. Criteria also included living in a rural location at 35–165 km and 259–311 km from the trainer’s location	The families were selected in collaboration with the State Diagnostic and Counseling Center according to predetermined selection criteria regarding age (3–6 years), diagnosis, and geographic location of the family
Hines et al. (2019)	Australia. Four mothers and one teacher. Rural and remote	Participants were four children aged between 5 and 8 years, their mothers, and one child’s teacher. Participants lived in inner regional, remote or very remote Australia
Kohlhoff et al. (2019)	Australia. Two families living in a rural context	Two case studies are reported of families living in rural Australia. Each family has a child aged 2–3 years with disruptive behaviors
Kohlhoff et al. (2020)	Australia. Ten parents lived in a regional, rural or remote area of the Australian state of New South Wales (NSW)	Parents (n = 10) with a child aged 2–4 years referred to a community-based child behavior treatment clinic located in south-western Sydney

Interventions

The interventions reported by the nine studies, as well as the means used for their implementation, are described in Table 2. Interventions varied in including speech and language therapy, occupational therapy and physical therapy activities and services (Kelso et al., 2009), as well as psychology and specific behavioral interventions (Kohlhoff et al., 2019, 2020) and actions aimed at providing knowledge and training on the management of the autism spectrum disorder variability (Ashburner et al., 2016; Guðmundsdóttir et al., 2017, 2019; Heitzman-Powell et al., 2014; Hines et al., 2019; Ingersoll & Berger, 2015).

Table 2. Main interventions, means and results.

Reference	Intervention	Main results
Kelso et al. (2009)	Therapy sessions were scheduled by the interventionists and were conducted over the desktop Web conferencing system. Each interventionist was in an office at the central early intervention program location	Parents liked that sessions were recorded and could be watched again later and that visits could occur even when traditional visits were not possible, such as when the child was ill, or weather prevented travel
Heitzman-Powell et al. (2014)	The OASIS modules covered general information about autism, basic ABA principles and procedures, how to use ABA procedures to teach new skills, reduce challenging behavior, generalize skills to other settings, how to collect and analyze data for data-based intervention decision making, and how to work with treatment teams and other providers	The Parents Improve Their Implementation of ABA Procedures: across all parents, the mean pretest performance was 30.6% (range = 14%–46%), and the mean posttest performance was 71.8% (range = 51%–83%). The mean pre- to posttest skill gain across all parents was 41.23 percentage points (range = 28%–59%)
Ingersoll and Berger (2015)	Self-Directed Group: Access to the secure, password-protected ImPACT Online website for up to 6 months. Therapist-Assisted Group: Access to the ImPACT Online website and were encouraged to work through the program at the same pace as the self-directed group	Participants in the therapist-assisted group were more likely to engage with the website than those in the self-directed group: F 2,24 = 17.65, P < .001. In total, 85% of participants completed the program, with a significantly greater completion rate in the therapist-assisted group (N = 27): χ^2 1 = 5.06, P = .03
Ashburner et al. (2016)	Programs (a) similar structure with five daily sessions of 1.5 h duration (Four working with the families only, and one for a team discussion); (b) the same number and discipline of local service providers; and (c) similar interventions targeting the same skill areas for each child	The qualitative content analysis revealed five themes: (a) upskilling of parents and local service providers; (b) reducing cost, time and travel; (c) flexible, regular, ongoing support; (d) enabling families to access support from home, and (e) enhancing connections between team members
Guðmundsdóttir et al. (2017)	The intervention involved teaching caregivers methods to increase children’s socio communicative behavior. Training consisted of a package of behavior intervention procedures based on the Sunny Starts program	The results from the two families show that teaching caregivers via telecommunication, following in situ training, was effective in increasing their skills
Guðmundsdóttir et al. (2019)	The methods taught to the parent in Sunny Starts and in this study are represented by the acronym and mnemonic Teaching “DANCE” (D—decide, A—arrange, N—now, C—count and contemplate, E—enjoy) which describes teaching strategies based on naturalistic behavioral intervention procedures	The results from the three families show that teaching parents via brief in situ training and ongoing telecommunication training increased their skills and had a positive effect on the children's skills, especially social attending
Hines et al. (2019)	Relationship-based, person-centered approaches employing collaborative coaching techniques that developed parents’ and teachers’ capacities to meet children’s learning and support needs (Early Childhood Intervention Australia 2016)	Parents and teachers were unanimous that effective therapeutic relationships with children had developed. Two parents noted that their children were more readily engaged because they were in a comfortable, familiar environment
Kohlhoff et al. (2019)	The first phase of the PCIT program, CDI, aims to improve the quality of the parent–child relationship and provide the parent with skills to manage non-dangerous but undesirable child behaviors. PDI program, which aims to improve child compliance	Case 1 and Case 2 over the course of the IPCIT program improved child behavior, increased parenting confidence and a closer, warmer parent–child relationship
Kohlhoff et al. (2020)	The recommended standard of care for childhood with disruptive behavior disorders is parent-training based behavior therapy, of which parent–child interaction therapy (PCIT) has been identified as one of the most effective programs	Pre-treatment results suggested that parents’ primary motivations for seeking treatment were behavior of the target child and the negative impacts on other members of the family. Post-treatment results indicated that parents experienced positive outcomes and numerous benefits from the I-PCIT program

Intervention actions focused on providing training and counseling with the purpose of achieving the early promotion of different skills including language, daily living activities and behavior through multiple strategies carried out by therapists and that considered the context of the family as a social unit (Kelso et al., 2009).

Regarding behavioral interventions, a parent–child interaction therapy program based on behavioral learning, attachment theory and social-emotional aspects was identified; the goals of said intervention were to improve the quality of the parent–child relationship, to provide parents with skills for the adequate management of child behavior problems, and to provide them with proper knowledge about the characterization of child behavior so that they were able to treat their behavior adequately (Kohlhoff et al., 2019). In addition, another study reporting an intervention with a similar structure was also identified; in this case, however, the intervention included the training of parents or caregivers to give direct orders and develop skills related to positive parenting, language improvement and the provision of differential care of problematic behaviors in children (Kohlhoff et al., 2020)

Regarding autism, the component most frequently addressed by the studies included in this review, an online training program on autism and ABA (applied behavior analysis) procedures known as OASIS (Online and Applied System for Intervention Skills) was identified. This program was composed of eight modules that allowed online participation and included online activities addressing generalities of autism, ABA procedures, how to control challenging behaviors, and the development of skills for their proper management (Heitzman-Powell et al., 2014).

Another online training program known as ImPACT Online was also identified: this program consisted of 12 self-learning lessons that required participants to dedicate more than 80 min for successful completion; the intervention was designed to be implemented in only one group which was asked to log in to the site where the lessons were to be taken, and in another group in which a therapist held up to 24 30-min sessions per week (Ingersoll & Berger, 2015).

Another study reported an intervention in which both face-to-face and remote programs were combined by including five daily 1.5-hour sessions with families, group intervention activities, the participation of therapists and specialized health care providers, and the promotion of behavioral management skills and communication and social interaction skills, as well as of better practices involving children’s feeding, play engagement, emotions, and independence (Ashburner et al., 2016).

Other programs consisted of, on the one hand, reality-based behavioral and social-communicative interventions aimed at parents and adapted from previous interventions such as Sunny Starts Teaching; and, on the other, the teaching of specific components based on parent and child components of decision, organization, current response, evaluation, and contemplation (Guðmundsdóttir et al., 2019). Finally, collaborative coaching emerges as a technique that seeks parents and teachers to develop a series of skills necessary for the management and care of children (Hines et al., 2019).

The technological tools most commonly used included cameras, microphones, loudspeakers and computers, the latter owned by the families (Heitzman-Powell et al., 2014; Ingersoll & Berger, 2015; Kelso et al., 2009; Kohlhoff et al., 2019, 2020) or provided by those responsible for conducting the study (Ingersoll & Berger, 2015), as well as smartphones and tablets (Ashburner et al., 2016; Kohlhoff et al., 2019, 2020).

On the other hand, the main means used to perform such interventions included general videoconferencing (Ashburner et al., 2016; Guðmundsdóttir et al., 2017, 2019; Hines et al., 2019; Ingersoll & Berger, 2015), web conferencing (Kelso et al., 2009; Kohlhoff et al., 2019), self-learning modules (Heitzman-Powell et al., 2014) and live video teleconferencing (VTC) for telehealth purposes (Kohlhoff et al., 2020). Finally, Skype (Guðmundsdóttir et al., 2017, 2019; Hines et al., 2019; Ingersoll & Berger, 2015), Health Direct Video Call (Kohlhoff et al., 2019, 2020), Macromedia Breeze and Adobe Connect Pro (Kelso et al., 2009), Cisco WebEx Meeting Center™ (Ashburner et al., 2016) and Learning Management Systems (LMS) (Heitzman-Powell et al., 2014) were the programs most frequently used.

Outcomes

Different outcomes were identified in the interventions reported by the nine studies. Parents reported having learned new therapeutic techniques for the comprehensive development and substantial improvement of communication with their children (Kelso et al., 2009). Regarding behavioral management, the reduction of disruptive behaviors to non-clinical levels, a decreased frequency of behavioral crises, and a higher level of trust between parents and children were reported (Kohlhoff et al., 2019). In addition, according to another study, the main outcomes included substantial improvements in children's behaviors, parental well-being and family relationships (Kohlhoff et al., 2020).

Regarding studies focusing on children with autism spectrum disorder, an increased level of knowledge by parents (a 39 percentage points increase) and a significant improvement in the implementation of procedures (a 41.23 percentage points increase) was evidenced after the intervention (Heitzman-Powell et al., 2014). Other results include the fact that the mediation of a therapist in the intervention allows for a higher program completion rate (p =  0.03) and that parents attended more content lessons along with activity lessons (p =  0.05) (Ingersoll & Berger, 2015). Furthermore, qualitative analyses reported that parents indeed improve their skills with the help of health care providers, and that they prefer support to and from home, together with the improvement of family relationships (Ashburner et al., 2016).

Furthermore, results here identified confirmed the potential of telehealth as a mediator for achieving the acquisition of knowledge, improving the skills of families, increasing their access to evidence-based interventions, and improving the skills of children, especially social skills, thus obtaining positive responses in everyday life (Guðmundsdóttir et al., 2017, 2019).

Other findings included being able to refer to and review session recordings at different times (Kelso et al., 2009), the parents’ preference for leading the interaction with children (Kelso et al., 2009) and the parents’ perceived high or very high overall satisfaction with the interventions (Heitzman-Powell et al., 2014; Ingersoll & Berger, 2015; Kelso et al., 2009). In relation to the technology used, parents expressed concerns with technological tools such as computer accessories and peripherals (Ashburner et al., 2016; Kelso et al., 2009) and Internet connection (Ashburner et al., 2016). However, and despite such concerns, they preferred and recommended the use of these technologies as an approach to modernity (Kohlhoff et al., 2020).

Discussion

Undoubtedly, the literature on telemedicine, as well as its uses and applications have changed over time due to technological advances (Marcin et al., 2015) but above all due to the COVID-19 pandemic (Smith et al., 2020; Wosik et al., 2020). For this reason, given the scarce information about telehealth interventions in rural settings, and as an extended response to the current pandemic, we conducted a systematic search of studies published between 2000 and 2020 reporting the implementation of telehealth interventions aimed at parents and caregivers of children living in rural areas and that did not require them to mobilize to a rural health center or educational institution.

In general, it was found that most interventions consisted of online or videoconference sessions, specifically designed teleconferences, pre-recorded sessions, self-learning modules, among other tools. Likewise, interventions were focused on the development of skills in both children and parents, and main outcomes included the enhancement of independence, communication, behavior management and daily life skills of children, their parents, relatives and caregivers.

In this review only a few studies reporting telehealth interventions met the inclusion criteria and the objective of the study and thus were included for analysis (Ashburner et al., 2016; Guðmundsdóttir et al., 2017, 2019; Heitzman-Powell et al., 2014; Hines et al., 2019; Ingersoll & Berger, 2015; Kelso et al., 2009; Kohlhoff et al., 2019, 2020). This is a relevant finding, since this panorama had been previously suggested by Banbury et al. (Banbury et al., 2018) who reflected on the potential of videoconferencing to reach homes located not only in urban but also in rural areas.

It should be noted that the low number of studies included in this review may be explained by the situation reported by Bradford et al. (Bradford et al., 2016) who described a low reporting trend despite identifying a wide range of health services (especially medical specialties) using this technology in Australia or, as it has been proposed, by the fact that, unfortunately, projects aimed at bringing telehealth to rural areas are not properly identified in middle or low-income countries where, in fact, this technology is needed the most (Combi et al., 2016).

As for the interventions, these predominantly consisted of videoconferences or audio and video calls (Ashburner et al., 2016; Guðmundsdóttir et al., 2017, 2019; Heitzman-Powell et al., 2014; Hines et al., 2019; Ingersoll & Berger, 2015; Kelso et al., 2009; Kohlhoff et al., 2019) a trend that has already been described as the best option at the time (Banbury et al., 2018; Campbell et al., 2020; Orlando et al., 2019).

In relation to the devices used, it was evident that computers continue to be the most used and that tablets or smartphones are used to a lesser extent (Banbury et al., 2018; Campbell et al., 2020). In this regard, although a possible increase in the use of the latter had been noted (Banbury et al., 2018; Bradford et al., 2016), as of the cut-off date of the search (2020), a higher use of these devices than the one already reported was not evidenced. Regarding the technological structure used to reach rural areas, all nine studies reported the use of a common infrastructure focused on the possibilities of rural Internet (Campbell et al., 2020; Orlando et al., 2019).

As it has been the case of other reviews, we also identified a wide range of health outcomes measures, mainly described qualitatively and/or suggested by parents in relation to their children (Banbury et al., 2018). Specifically, results are in line with what has been reported by other studies, mainly general acceptance of interventions by parents (Banbury et al., 2018; Bradford et al., 2016; Campbell et al., 2020; Parsons et al., 2017), adherence and proper use of technology (Banbury et al., 2018; Parsons et al., 2017) or specific outcomes such as skills related to communications, behavior, control of health activities, autonomy and independence (Banbury et al., 2018; Bradford et al., 2016; Brophy, 2017; Parsons et al., 2017). We then agree with multiple perspectives that advocate for a better way of measuring outcomes right from the start of the intervention by considering both clinical and other outcomes to effectively justify the use of telehealth (Armfield et al., 2014; Bradford et al., 2016).

In terms of outcomes obtained in families with children with autism spectrum disorder, this review joins a set of reviews that state the possibility of improving behavioral, socioemotional, and communication skills using telehealth as a valid alternative (Ashburner et al., 2016; Guðmundsdóttir et al., 2017, 2019; Heitzman-Powell et al., 2014; Hines et al., 2019; Ingersoll & Berger, 2015; Parsons et al., 2017). Although we are aware that this topic must be extensively addressed in the rural setting, we believe this is a first approach to the autism spectrum disorder-rural setting relationship and to develop specific interventions aimed at parents in this situation (Parsons et al., 2017). Other outcomes such as satisfaction and perception of rural telehealth interventions remain underexplored despite the fact that less than two years ago the need to increase the availability of relevant literature was discussed (Orlando et al., 2019).

As it has been described by previous reviews, it was evident that studies included for analysis had a small sample size, which makes it moderately complex to measure the results in terms of impact. This finding was also reported by other reviews where in fact the low sample size, together with the lack of sufficient statistical power, the absence of sufficient statistics and the inclusion of repetitive data were criticized (Banbury et al., 2018; Brophy, 2017; Parsons et al., 2017).

Some reviews have reported the presence of technical difficulties, especially in the implementation and execution of the sessions; somehow, the studies included in this review did not report such difficulties in depth (Banbury et al., 2018). Therefore, a more detailed description of these problems is important to know how technological characteristics are configured in rural areas and even more in the context of remote communication (Brophy, 2017; Combi et al., 2016).

It is widely known that most high-income countries, especially those in North America, Europe and Oceania, have a greater technology infrastructure, while low- and middle-income countries face greater difficulties in providing their inhabitants with access to internet services and advanced information and communication technologies (Akhlaq et al., 2016; Lewis et al., 2012). Although worldwide the use of internet, social networks and smartphones has increased in general, low- and middle-income countries still face challenges in terms of funding, identification of priorities in the provision of eHealth and mHealth services, the implementation of educational interventions aimed at achieving a proper use of technological tools, and the development of healthcare applications.

Finally, rurality must not be only considered as a geographical or infrastructure barrier, but also as an opportunity to design better interventions (eHealth and mHealth) with rurality in mind, as rural populations live in a completely different setting than most of the people for which these interventions are usually designed for. Several studies have highlighted the opportunities for telehealth to conquer spaces, contexts and services that can still be modified and adapted for the community (Shah & Badawy, 2021).

Limitations

As mentioned above, only studies published in English between 2000 and 2020 and indexed in the databases described in the methodology section were considered in this review, so it is likely there are other studies meeting the inclusion criteria that were not included. Another limitation was the complex definition of “rurality” as an inclusion criterion, since a large number of studies were excluded as they failed to meet such definition, especially those conducted in rural contexts but with occasional visits to rural centers or home visits, or those conducted in peri-urban areas that, in a very broad sense, could be considered as initial transition areas to rural areas.

Conclusions

Undoubtedly, telehealth is a useful tool to provide counsel and knowledge to parents and caregivers living in rural areas that will enable them to properly manage health problems affecting their children. This review compiles a series of studies describing interventions that can benefit people living in rural areas without requiring them to mobilize to specific centers, even if such places are also located in rural areas, and that can be currently used in the context of the COVID-19 pandemic.

Based on the results reported here, it is possible to say that most interventions focused on therapeutic and behavioral management aids, as well as on improving the understanding of the autism spectrum disorder. In general, positive outcomes include the improvement of children’s skills to perform activities of the daily living, a better control of disruptive behaviors, improved parent–child and family relationships and functional independence, as well as the reduction of costs and waiting times to access health services, among others. Finally, rethinking the analysis of purely rural telehealth interventions is one of the most important areas for further research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research was supported by the “Convocatoria para la financiación de proyectos de semilleros de investigación en la Facultad de Medicina de la Universidad Nacional de Colombia 2020” internal call code 2020-1s of the Faculty of Medicine - Universidad Nacional de Colombia. The study funder has no role in any of the study results.

Notes on contributors

Jaime Moreno-Chaparro

Jaime Moreno-Chaparro, OT, MSc (c). Is an Occupational Therapist and Junior Researcher of the Occupation and Social Inclusion Research Group and “Telehealth for Childhood Wellbeing” Research Group of the Faculty of Medicine at Universidad Nacional de Colombia. He's currently a MSc Candidate in Clinical Epidemiology at Pontificia Universidad Javeriana (Bogotá, Colombia).

Eliana I. Parra Esquivel

Eliana I. Parra Esquivel, OT, MEd, PhD. She's an Occupational Therapist, Full Professor and Researcher at the Department of Human Occupation, the Occupation and Social Inclusion Research Group and the “Telehealth for Childhood Wellbeing” Research Group of the Faculty of Medicine at Universidad Nacional de Colombia. Master's in education from Pontificia Universidad Javeriana and PhD in Education from Universidad Santo Tomás (Bogotá, Colombia).

Angy Lucia Santos Quintero

Angy Lucia Santos Quintero, OT. She's an Occupational Therapist and Researcher of the “Telehealth for Childhood Wellbeing” Research Group of the Faculty of Medicine at Universidad Nacional de Colombia (Bogota, Colombia).

Laura Paez

Laura Paez, OT. She's an Occupational Therapist and Researcher of the “Telehealth for Childhood Wellbeing” Research Group of the Faculty of Medicine at Universidad Nacional de Colombia (Bogota, Colombia).

Sandra Martinez Quinto

Sandra Martinez Quinto, OT. She's an Occupational Therapist and Researcher of the “Telehealth for Childhood Wellbeing” Research Group of the Faculty of Medicine at Universidad Nacional de Colombia (Bogota, Colombia).

Bayron Esteven Rojas Barrios

Bayron Esteven Rojas Barrios, OT. He's an Occupational Therapist and Researcher of the Occupation and Social Inclusion Research Group and “Telehealth for Childhood Wellbeing” Research Group of the Faculty of Medicine at Universidad Nacional de Colombia (Bogota, Colombia).

Juan Felipe Samudio

Juan Felipe Samudio, OT. He's an Occupational Therapist and Researcher of the “Telehealth for Childhood Wellbeing” Research Group of the Faculty of Medicine at Universidad Nacional de Colombia (Bogota, Colombia).

Karol Madeline Romero Villareal

Karol Madeline Romero Villareal, Eng. She's a Biological Engineer and Researcher of the “Telehealth for Childhood Wellbeing” Research Group of the Undergraduate School, Academic Direction, Vice-rectory at Universidad Nacional de Colombia (La Paz, Colombia).

Appendix 1.

Search strategy

Table

Electronic search report No. 1
Database	Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R)
Platform	Ovid
Search date	10-01-2020
Search date range	January 2000—December 2020
Language restrictions	English
Search strategy	1. exp Parents/ (116162) 2. exp Fathers/ (9331) 3. exp Mothers/ (45042) 4. exp Caregivers/ (38219) 5. Carers.mp. (13062) 6. Family Caregivers.mp. (7192) 7. 1 or 2 or 3 or 4 or 5 or 6 (161345) 8. exp Child/ (1937985) 9. Children.mp. (1068978) 10. exp Child, Preschool/ (930486) 11. 8 or 9 or 10 (2245719) 12. 7 and 11 (78512) 13. exp Telemedicine/ (31832) 14. Telehealth.mp. (6403) 15. eHealth.mp. (4433) 16. exp Telerehabilitation/ (451) 17. Telecare.mp. (781) 18. Teletherapy.mp. (5751) 19. Telepractice.mp. (140) 20. Remote consultation.mp. (5033) 21. 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 (43109) 22. exp Rural Population/ (61004) 23. Rural Spatial Distribution.mp. (125) 24. Rural Communit*.mp. (12172) 25. exp Rural Health Services/ (13087) 26. exp Rural Health/ (23512) 27. rural.mp. (172488) 28. 22 or 23 or 24 or 25 or 26 or 27 (172488) 29. 21 and 28 (3354) 30. 12 and 29 (51) 33. limit 30 to yr="2000 – 2020” (50)
Results	50

Table

Electronic search report No. 2
Database	EMBASE
Platform	EMBASE
Search date	10-01-2020
Search date range	January 2000—December 2020
Language restrictions	English
Search strategy	1. ‘parent’/exp (251239) 2. ‘father’/exp (29778) 3. ‘mother’/exp (148024) 4. ‘caregiver’/exp (85586) 5. #1 OR #2 OR #3 OR #4 (329934) 6. ‘child’/exp (2965692) 7. ‘preschool child’/exp (635927) 8. #6 OR #7 (2965692) 9. #5 AND #8 (161217) 10. ‘telemedicine’/exp (45566) 11. ‘telehealth’/exp (52783) 12. ‘ehealth’/exp (52783) 13. ‘telerehabilitation’/exp (1049) 14. ‘telecare’/exp (33) 15. ‘teletherapy’/exp (701) 16. ‘telepractice’/exp (11) 17. ‘remote consultation’/exp (10663) 18. #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 (52800) 19. ‘rural population’/exp (49266) 20. ‘rural spatial distribution’/exp (88) 21. ‘rural community’/exp (49266) 22. ‘rural health care’/exp (13777) 23. ‘rural health’/exp (1313) 24. ‘rural area’/exp (55857) 25. #19 OR #20 OR #21 OR #22 OR #23 OR #24 (114485) 26. #18 AND #25 (2530) 27. #9 AND #26 (38) 28. #9 AND #26 AND [2000-2020]/py (38)
Results	38

Table

Electronic search report No. 3
Database	SCOPUS
Platform	SCOPUS
Search date	10-01-2020
Search date range	January 2000—December 2020
Language restrictions	English
Search strategy	(((“Parent*” OR “Father*” OR “Mother*” OR “Caregiver*” OR “carer*” OR “Family Caregiver*”) AND (“Child*” OR “Children” OR “Child, Preschool”)) AND ((“Telemedicine” OR “Telehealth” OR “eHealth” OR “Telerehabilitation” OR “Remote Consultation” OR “Telecare” OR “Teletherapy” OR “Telepractice”) AND (“Rural Population” OR “Rural Spatial Distribution” OR “Rural Community” OR “Rural Health Services” OR “Rural Health” OR “rural”))) AND(PUBYEAR >2000 AND PUBYEAR <2020)
Results	155

Table

Electronic search report No. 4
Database	APA—PSYCNET
Platform	APA—PSYCNET
Search date	10-01-2020
Search date range	January 2000—December 2020
Language restrictions	English
Search strategy	Any Field: (((“Parent*” OR “Father*” OR “Mother*” OR “Caregiver*” OR “carer*” OR “Family Caregiver*”) AND (“Child*” OR “Children” OR “Child, Preschool”)) AND ((“Telemedicine” OR “Telehealth” OR “eHealth” OR “Telerehabilitation” OR “Remote Consultation” OR “Telecare” OR “Teletherapy” OR “Telepractice”) AND (“Rural Population” OR “Rural Spatial Distribution” OR “Rural Community” OR “Rural Health Services” OR “Rural Health” OR “rural”))) AND Year: 2000–2020
Results	86

Table

Electronic search report No. 5
Database	LILACS
Platform	LILACS advanced platform (iAH)
Search date	10-01-2020
Search date range	January 2000—December 2020
Language restrictions	English
Search strategy	(tw:((tw:((tw:((“Parent*” OR “Father*” OR “Mother*” OR “carer*” OR “caregiver*” OR “Family Caregiver*”))))) AND (tw:((tw:((“Child*” OR “Children” OR “Child, Preschool”))))))) AND (tw:((tw:((tw:((“Telemedicine” OR “Telehealth” OR “eHealth” OR “Telerehabilitation” OR “Remote Consultation” OR “Telecare” OR “Teletherapy” OR “Telepractice”))))) AND (tw:((tw:((“Rural Population” OR “Rural Spatial Distribution” OR “Rural Community” OR “Rural Health Services” OR “Rural Health Center” OR “Rural Health” OR “rural”))))))) AND (year_cluster:[2000–2020])
Results	88

Table

Electronic search report No. 6
Database	Web of Science
Platform	Web of Science [V.5.35] (SCI-EXPANDED, SSCI, A & HCI, ESCI)
Search date	10-01-2020
Search date range	January 2000—December 2020
Language restrictions	English
Search strategy	ALL = (((“Parent*” OR “Father*” OR “Mother*” OR “Caregiver*” OR “carer*” OR “Family Caregiver*”) AND (“Child*” OR “Children” OR “Child, Preschool”)) AND ((“Telemedicine” OR “Telehealth” OR “eHealth” OR “Telerehabilitation” OR “Remote Consultation” OR “Telecare” OR “Teletherapy” OR “Telepractice”) AND (“Rural Population” OR “Rural Spatial Distribution” OR “Rural Community” OR “Rural Health Services” OR “Rural Health” OR “rural”))) T= 2000-2020.
Results	122

Appendix 2.

Studies rejected with reasons.

Table

	Reference	Reason
1	Hilty, D. M., Sison, J. I., Nesbitt, T. S., & Hales, R. E. (2000). Telepsychiatric consultation for ADHD in the primary care setting. Journal of the American Academy of Child and Adolescent Psychiatry, 39(1), 15-16.	It is not a primary study
2	Elford, D. R., White, H., St John, K., Maddigan, B., Ghandi, M., & Bowering, R. (2001). A prospective satisfaction study and cost analysis of a pilot child telepsychiatry service in Newfoundland. Journal of Telemedicine and Telecare, 7(2), 73-81.	The context is not rural
3	Kopel, H., Nunn, K., & Dossetor, D. (2001). Evaluating satisfaction with a child and adolescent psychological telemedicine outreach service. Journal of Telemedicine and Telecare, 7(2_suppl), 35-40.	Not focused on parents and / or caregivers
4	Savard, L., Borstad, A., Tkachuck, J., Lauderdale, D., & Conroy, B. (2003). Telerehabilitation consultations for clients with neurologic diagnoses: cases from rural Minnesota and American Samoa. NeuroRehabilitation, 18(2), 93-102.	Not focused on children
5	Young, T. L., & Ireson, C. (2003). Effectiveness of school-based telehealth care in urban and rural elementary schools. Pediatrics, 112(5), 1088-1094.	Not focused on parents and / or caregivers
6	Goodenough, B., & Cohn, R. J. (2004). Parent attitudes to audio/visual telecommunications in childhood cancer: an Australian study. Telemedicine Journal & e-Health, 10(Supplement 2), S-15.	Not focused on parents and / or caregivers
7	Marcin, J. P., Ellis, J., Mawis, R., Nagrampa, E., Nesbitt, T. S., & Dimand, R. J. (2004). Using telemedicine to provide pediatric subspecialty care to children with special health care needs in an underserved rural community. Pediatrics, 113(1), 1-6.	The context is not rural
8	Ozuah, P. O., & Reznik, M. (2004). The role of telemedicine in the care of children in under-served communities. Journal of telemedicine and telecare, 10(1_suppl), 78-80.	It is not a primary study
9	Greenberg, N., Boydell, K. M., & Volpe, T. (2006). Pediatric telepsychiatry in Ontario: Caregiver and service provider perspectives. The journal of behavioral health services & research, 33(1), 105-111.	Not focused on parents and / or caregivers
10	Harper, D. C. (2006). Telemedicine for children with disabilities. Children's Health Care, 35(1), 11-27.	Face-to-face intervention in a local center
11	Savin, D., Garry, M. T., Zuccaro, P., & Novins, D. (2006). Telepsychiatry for treating rural American Indian youth. Journal of the American Academy of Child & Adolescent Psychiatry.	Not focused on parents and / or caregivers
12	Sulzbacher, S., Vallin, T., & Waetzig, E. Z. (2006). Telepsychiatry improves paediatric behavioural health care in rural communities. Journal of telemedicine and telecare, 12(6), 285-288.	It is not a primary study
13	Bensink, M., Wootton, R., Irving, H., Hallahan, A., Theodoros, D., Russell, T., … & Barnett, A. G. (2007). Investigating the cost-effectiveness of videotelephone based support for newly diagnosed paediatric oncology patients and their families: design of a randomised controlled trial. BMC health services research, 7(1), 1-8.	It is not a primary study
14	Bensink, M., Armfield, N., Irving, H., Hallahan, A., Theodoros, D., Russell, T., … & Wootton, R. (2008). A pilot study of videotelephone-based support for newly diagnosed paediatric oncology patients and their families. Journal of telemedicine and telecare, 14(6), 315-321.	The context is not rural
15	Witmans, M. B., Dick, B., Good, J., Schoepp, G., Dosman, C., Hawkins, M. E., … & Witol, A. (2008). Delivery of pediatric sleep services via telehealth: the Alberta experience and lessons learned. Behavioral sleep medicine, 6(4), 207-219.	Not focused on parents and / or caregivers
16	Atkinson, N. L., Saperstein, S. L., Desmond, S. M., Gold, R. S., Billing, A. S., & Tian, J. (2009). Rural eHealth nutrition education for limited-income families: an iterative and user-centered design approach. Journal of medical Internet research, 11(2), e21.	Intervention carried out by other electronic systems
17	Bensink, M. E., Armfield, N. R., Pinkerton, R., Irving, H., Hallahan, A. R., Theodoros, D. G., … & Wootton, R. (2009). Using videotelephony to support paediatric oncology-related palliative care in the home: from abandoned RCT to acceptability study. Palliative medicine, 23(3), 228-237.	The context is not rural
18	Scharer, K., Colon, E., Moneyham, L., Hussey, J., Tavakoli, A., & Shugart, M. (2009). A comparison of two types of social support for mothers of mentally ill children. Journal of Child and Adolescent Psychiatric Nursing, 22(2), 86-98.	Intervention carried out by other electronic systems
19	Davis, A. M., James, R. L., Boles, R. E., Goetz, J. R., Belmont, J., & Malone, B. (2011). The use of TeleMedicine in the treatment of paediatric obesity: feasibility and acceptability. Maternal & child nutrition, 7(1), 71-79.	Face-to-face intervention in a local center
20	Gallagher, K. S., Davis, A. M., Malone, B., Landrum, Y., & Black, W. (2011). Treating rural pediatric obesity through telemedicine: Baseline data from a randomized controlled trial. Journal of pediatric psychology, 36(6), 687-695.	Face-to-face intervention in a local center
21	Hopper, B., Buckman, M., & Edwards, M. (2011). Evaluation of satisfaction of parents with the use of videoconferencing for a pediatric genetic consultation. Twin Research and Human Genetics, 14(4), 343-346.	The context is not rural
22	Mulgrew, K. W., Shaikh, U., & Nettiksimmons, J. (2011). Comparison of parent satisfaction with care for childhood obesity delivered face-to-face and by telemedicine. Telemedicine and e-Health, 17(5), 383-387.	Face-to-face intervention in a local center
23	Pepler, A., Boydell, K. M., Teshima, J., Volpe, T., Braunberger, P. G., & Minden, D. (2011). Transforming Child and Youth Mental Health Care via Innovative Technological Solutions. Healthcare quarterly (Toronto, Ont.), 14, 92-102.	The context is not rural
24	Bradford, N., Young, J., Armfield, N. R., Bensink, M. E., Pedersen, L. A., Herbert, A., & Smith, A. C. (2012). A pilot study of the effectiveness of home teleconsultations in paediatric palliative care. Journal of Telemedicine and Telecare, 18(8), 438-442.	The context is not rural
25	Constantinescu, G. (2012). Satisfaction with telemedicine for teaching listening and spoken language to children with hearing loss. Journal of telemedicine and telecare, 18(5), 267-272.	The context is not rural
26	Houston, K. T., & Stredler-Brown, A. (2012). A Model of Early Intervention for Children with Hearing Loss Provided through Telepractice. Volta Review, 112(3).	It is not a primary study
27	Jacob, M. K., Larson, J. C., & Craighead, W. E. (2012). Establishing a telepsychiatry consultation practice in rural Georgia for primary care physicians: A feasibility report. Clinical pediatrics, 51(11), 1041-1047.	Face-to-face intervention in a local center
28	Chen, H. T., Tseng, M. H., Lu, L., Sie, J. Y., Chen, Y. J., Chung, Y., & Lai, F. (2014). Cloud computing-based smart home-based rehabilitation nursing system for early intervention. Advanced Science Letters, 20(1), 218-221.	Intervention carried out by other electronic systems
29	Hanlon-Dearman, A., Edwards, C., Schwab, D., Millar, M. C., & Longstaffe, S. (2014). “Giving voice”: evaluation of an integrated telehealth community care model by parents/guardians of children diagnosed with fetal alcohol spectrum disorder in Manitoba. Telemedicine and e-Health, 20(5), 478-484.	Face-to-face intervention in a local center
30	Guiberson, M., Rodríguez, B. L., & Zajacova, A. (2015). Accuracy of telehealth-administered measures to screen language in Spanish-speaking preschoolers. Telemedicine and e-Health, 21(9), 714-720.	Face-to-face intervention in a local center
31	Klitzman, P., Armstrong, B., & Janicke, D. M. (2015). Distance as a predictor of treatment attendance in a family based pediatric weight management program in rural areas. The Journal of Rural Health, 31(1), 19-26.	Face-to-face intervention in a local center
32	Langkamp, D. L., McManus, M. D., & Blakemore, S. D. (2015). Telemedicine for children with developmental disabilities: a more effective clinical process than office-based care. Telemedicine and e-Health, 21(2), 110-114.	Face-to-face intervention in a local center
33	Reese, R. J., Slone, N. C., Soares, N., & Sprang, R. (2015). Using telepsychology to provide a group parenting program: A preliminary evaluation of effectiveness. Psychological Services, 12(3), 274.	Face-to-face intervention in a local center
34	Davis, A. M., Sampilo, M., Gallagher, K. S., Dean, K., Saroja, M. B., Yu, Q., … & Sporn, N. (2016). Treating rural paediatric obesity through telemedicine vs. telephone: Outcomes from a cluster randomized controlled trial. Journal of telemedicine and telecare, 22(2), 86-95.	Face-to-face intervention in a local center
35	Gardner, K., Bundy, A., & Dew, A. (2016). Perspectives of rural carers on benefits and barriers of receiving occupational therapy via information and communication technologies. Australian occupational therapy journal, 63(2), 117-122.	Intervention carried out by other electronic systems
36	Guiberson, M. (2016). Telehealth measures screening for developmental language disorders in Spanish-speaking toddlers. Telemedicine and e-health, 22(9), 739-745.	Face-to-face intervention in a local center
37	Iacono, T., Dissanayake, C., Trembath, D., Hudry, K., Erickson, S., & Spong, J. (2016). Family and practitioner perspectives on telehealth for services to young children with autism. Stud Health Technol Inform, 231, 63-73.	Not focused on parents and / or caregivers
38	Ramkumar, V., Selvakumar, K., Vanaja, C. S., Hall, J. W., Nagarajan, R., & Neethi, J. (2016). Parents’ perceptions of tele-audiological testing in a rural hearing screening program in South India. International journal of pediatric otorhinolaryngology, 89, 60-66.	Not focused on parents and / or caregivers
39	Smith, N. M., & Satyshu, R. D. (2016). Pediatric diabetes telemedicine program improves access to care for rural families: role of APRNs. Pediatric nursing, 42(6), 294-300.	Face-to-face intervention in a local center
40	Wakefield, C. E., Sansom-Daly, U. M., McGill, B. C., Ellis, S. J., Doolan, E. L., Robertson, E. G., … & Cohn, R. J. (2016). Acceptability and feasibility of an e-mental health intervention for parents of childhood cancer survivors:“Cascade”. Supportive Care in Cancer, 24(6), 2685-2694.	The context is not rural
41	Bagayoko, C. O., Niang, M., Anne, A., Traoré, D., Sangho, H., Traoré, A. K., & Geissbuhler, A. (2017). The delegation of tasks in the era of e-health to support community interventions in maternal and child health: lessons learned from the PACT-Denbaya project. Medecine et sante tropicales, 27(4), 354-359.	Study in language not included
42	Brinkel, J., Dako-Gyeke, P., Krämer, A., May, J., & Fobil, J. N. (2017). An investigation of users’ attitudes, requirements and willingness to use mobile phone-based interactive voice response systems for seeking healthcare in Ghana: a qualitative study. Public Health, 144, 125-133.	Intervention carried out by other electronic systems
43	Salomone, E., & Maurizio Arduino, G. (2017). Parental attitudes to a telehealth parent coaching intervention for autism spectrum disorder. Journal of telemedicine and telecare, 23(3), 416-420.	It is not a primary study
44	McLellan, L. F., Andrijic, V., Davies, S., Lyneham, H. J., & Rapee, R. M. (2017). Delivery of a therapist-facilitated telecare anxiety program to children in rural communities: a pilot study. Behaviour Change, 34(3), 156-167.	Face-to-face intervention in a local center
45	Modi, D., Desai, S., Dave, K., Shah, S., Desai, G., Dholakia, N., … & Shah, P. (2017). Cluster randomized trial of a mHealth intervention “ImTeCHO” to improve delivery of proven maternal, neonatal, and childcare interventions through community-based Accredited Social Health Activists (ASHAs) by enhancing their motivation and strengthening supervision in tribal areas of Gujarat, India: study protocol for a randomized controlled trial. Trials, 18(1), 1-14.	It is not a primary study
46	Stuckey, R., & Domingues-Montanari, S. (2017). Telemedicine is helping the parents of children with neurodevelopmental disorders living in remote and deprived areas.	It is not a primary study
47	Subramaniam, S., Brunson, L. Y., Cook, J. E., Larson, N. A., Poe, S. G., & Peter, C. C. S. (2017). Maintenance of parent-implemented discrete-trial instruction during videoconferencing. Journal of Behavioral Education, 26(1), 1-26.	Face-to-face intervention in a local center
48	Sutcliffe, C. G., Thuma, P. E., van Dijk, J. H., Sinywimaanzi, K., Mweetwa, S., Hamahuwa, M., & Moss, W. J. (2017). Use of mobile phones and text messaging to decrease the turnaround time for early infant HIV diagnosis and notification in rural Zambia: an observational study. BMC pediatrics, 17(1), 1-9.	Intervention carried out by other electronic systems
49	Bearss, K., Burrell, T. L., Challa, S. A., Postorino, V., Gillespie, S. E., Crooks, C., & Scahill, L. (2018). Feasibility of parent training via telehealth for children with autism spectrum disorder and disruptive behavior: A demonstration pilot. Journal of autism and developmental disorders, 48(4), 1020-1030.	Face-to-face intervention in a local center
50	Gielen, A. C., Bishai, D. M., Omaki, E., Shields, W. C., McDonald, E. M., Rizzutti, N. C., … & Aitken, M. E. (2018). Results of an RCT in two pediatric emergency departments to evaluate the efficacy of an m-health educational app on car seat use. American journal of preventive medicine, 54(6), 746-755.	The context is not rural
51	Hooshmand, M., & Foronda, C. (2018). Comparison of telemedicine to traditional face-to-face care for children with special needs: A quasiexperimental study. Telemedicine and e-Health, 24(6), 433-441.	The context is not rural
52	Kuravackel, G. M., Ruble, L. A., Reese, R. J., Ables, A. P., Rodgers, A. D., & Toland, M. D. (2018). Compass for hope: Evaluating the effectiveness of a parent training and support program for children with ASD. Journal of Autism and Developmental Disorders, 48(2), 404-416.	Face-to-face intervention in a local center
53	Lesher, A. P., & Shah, S. R. (2018, April). Telemedicine in the perioperative experience. In Seminars in pediatric surgery (Vol. 27, No. 2, pp. 102-106). WB Saunders.	It is not a primary study
54	Little, L. M., Wallisch, A., Pope, E., & Dunn, W. (2018). Acceptability and cost comparison of a telehealth intervention for families of children with autism. Infants & Young Children, 31(4), 275-286.	The context is not rural
55	Sharp, T. (2018). Improving equity in rural maternity care with technology. Women and Birth, 31, S44.	It is not a primary study
56	Thobias, J., & Kiwanuka, A. (2018). Design and implementation of an m-health data model for improving health information access for reproductive and child health services in low resource settings using a participatory action research approach. BMC medical informatics and decision making, 18(1), 1-10.	Intervention carried out by other electronic systems
57	Allegra, M., Arrigo, M., Ayala, A., Cusimano, G., Gentile, M., La Guardia, D., … & Messineo, L. (2019). Abilitazione e Tele-abilitazione Home-based per i Disturbi dello Spettro Autistico: il progetto ATHENA. RICERCHE DI PSICOLOGIA.	Study in language not included
58	Chai, L. K., Collins, C. E., May, C., Ashman, A., Holder, C., Brown, L. J., & Burrows, T. L. (2019). Feasibility and efficacy of a web-based family telehealth nutrition intervention to improve child weight status and dietary intake: a pilot randomised controlled trial. Journal of telemedicine and telecare, 1357633X19865855.	The context is not rural
59	Chai, L. K., Collins, C. E., May, C., Brown, L. J., Ashman, A., & Burrows, T. L. (2019). Fidelity and acceptability of a family-focused technology-based telehealth nutrition intervention for child weight management. Journal of telemedicine and telecare, 1357633X19864819.	The context is not rural
60	Dadds, M. R., Thai, C., Mendoza Diaz, A., Broderick, J., Moul, C., Tully, L. A., … & Cane, L. (2019). Therapist-assisted online treatment for child conduct problems in rural and urban families: Two randomized controlled trials. Journal of consulting and clinical psychology, 87(8), 706.	Face-to-face intervention in a local center
61	Hoffmann, A. N., Bogoev, B. K., & Sellers, T. P. (2019). Using telehealth and expert coaching to support early childhood special education parent-implemented assessment and intervention procedures. Rural Special Education Quarterly, 38(2), 95-106.	Face-to-face intervention in a local center
62	Kistler, J., Cristaldi, K. K., Queenan, C., Garber, K., Wells, E., & Mcelligott, J. T. (2019). Caregiver Perceptions of Telehealth School-based Health Centers. Health Behavior and Policy Review, 6(4), 344-352.	Face-to-face intervention in a local center
63	Marchand, G., & Healy, S. (2019). Implementation of Project CHASE (Children with Autism Supported to Exercise): A Facebook-Delivered, Parent-Mediated Physical Activity Intervention. Palaestra, 33(3).	Intervention carried out by other electronic systems
64	Modi, D., Dholakia, N., Gopalan, R., Venkatraman, S., Dave, K., Shah, S., … & Shah, P. (2019). mHealth intervention “ImTeCHO” to improve delivery of maternal, neonatal, and childcare services—A cluster-randomized trial in tribal areas of Gujarat, India. PLoS medicine, 16(10), e1002939.	Intervention carried out by other electronic systems
65	Tsami, L., Lerman, D., & Toper-Korkmaz, O. (2019). Effectiveness and acceptability of parent training via telehealth among families around the world. Journal of Applied Behavior Analysis, 52(4), 1113-1129.	The context is not rural
66	Fortini, S., Espeche, A., & Caraballo, R. (2020). Telemedicine and epilepsy: a patient satisfaction survey of a pediatric remote care program. Epilepsy Research, 165, 106370.	Face-to-face intervention in a local center
67	Mytsyk, A., & Pryshliak, M. (2020). Telepractice in the System of Providing Correctional and Developmental Services to Children with Speech Disorders: Interaction at a Distance. Journal of History Culture and Art Research, 9(3), 94-105.	It is not a primary study
68	Swanson, M., MacKay, M., Yu, S., Kagiliery, A., Bloom, K., & Schwebel, D. C. (2020). Supporting caregiver use of child restraints in rural communities via interactive virtual presence. Health Education & Behavior, 47(2), 264-271.	Intervention carried out by other electronic systems