Equity Considerations in Telehealth Service Access with a Focus on Rural-Urban Health Inequalities

Abstract

Telehealth is widely promoted as a strategy for overcoming geographic barriers to healthcare, yet whether it consistently reduces or may exacerbate health inequalities remains uncertain. This thesis systematically assesses equity considerations in Australian telehealth services addressing rural-urban health inequalities, drawing on evidence synthesis, framework development, policy analysis, programme evaluation, and user preference research.

The thesis comprised five linked studies. A systematic review of reviews (42 reviews) mapped telehealth equity evidence to the 6A access framework, finding uneven and predominantly poor coverage. A framework review (13 frameworks) identified gaps in digital infrastructure assessment, cultural adaptation, and operational equity indicators. A policy analysis of 15 Australian telehealth documents revealed extensive equity rhetoric but weak operational mechanisms, particularly for affordability, awareness, and monitoring. Comparative case studies of two Australian telehealth programmes applied a newly developed nine-dimension equity evaluation framework, revealing distinct equity profiles and common gaps in equity-stratified monitoring. A cross-sectional survey of 2,882 NSW adults using Best-Worst Scaling found that age was the most consistent predictor of telehealth willingness variation, while geographic differences in digital confidence were largely explained by sociodemographic factors.

Five cross-cutting findings emerged: awareness is systematically neglected; digital divides are structural and multi-dimensional; policy rhetoric is not matched by implementation mechanisms; efficiency and cultural safety can be reconciled through modular service design; and preference heterogeneity supports flexible service models. The thesis contributes a nine-dimension telehealth equity evaluation framework to support more systematic assessment of telehealth equity and to inform policy, monitoring, workforce development, and service design.