Therapy services for children and youth living in rural areas of high-income countries: a scoping review

Abstract

Purpose

To identify and describe therapeutic services provided to children and youth with disabilities living in rural areas of mid- and high-income countries and to summarize the benefits, positive outcomes, and challenges related to these services.

Methods

This scoping review involved a systematic search of four academic electronic databases: MEDLINE, EMBASE, CINAHL, and Psych INFO, using a combination of subject headings and keywords related to (1) child disabilities; (2) rehabilitation: occupational therapists, speech-language pathologists, physiotherapists, audiologists, and recreation therapists; (3) multidisciplinary care team; (4) rural areas. Charting involved an iterative process whereby the full text articles meeting the inclusion criteria were abstracted using the charting form by two independent reviewers.

Results

Thirty-seven articles from seven high-income countries were included in the analysis. Twenty-seven articles reported on in-person services, and 19 on telepractice (nine evaluated in-person and telepractice). In person services included outreach programs and specialized on-site programs. Positive outcomes and challenges of in person and telepractice services in rural areas are described.

Conclusions

Findings of this review highlight the need for further research on service delivery models offered in rural areas of upper middle and high-income countries, especially those focusing specifically on the rural communities, with a clear description of services.

IMPLICATIONS FOR REHABILITATION

• This scoping review helps to advance the understanding of how therapy services are offered in rural areas of high-income countries.

• Telepractice was found to enhance ease of access to services for families living in rural areas.

• The findings of this review suggest that telepractice may be an effective means of providing therapy services to children and youth with disabilities living in rural areas of high-income countries, pending families’ access to technology.

Keywords:

• Disabilities
• rehabilitation
• child
• youth
• telepractice
• rural
• scoping review
• upper middle- and high-income countries

Introduction

Rehabilitation (or habilitation) services are interventions that aim to optimize the functioning of people with disabilities. The UN Convention on the Rights of Children (CRC) [1] applies to all children in the world and their human rights, including the right to develop to the fullest and the right to participate fully in their environment. In addition, the Convention on the Rights of Persons with Disabilities (UNCRPD) states that people with disabilities have the right to early rehabilitation services, to “enable persons with disabilities to attain and maintain maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life” [2].

For children with disabilities, access to rehabilitation therapy services, including occupational therapy (OT), physiotherapy (PT), recreational therapy (RecT), speech-language therapy (SLP), and audiology (AUD), is important for their overall development and for the maintenance of fundamental life skills [3–9]. These services enable children with disabilities to improve their engagement and participation in their various roles in life. For children with disabilities, having access to therapy services may lead to beneficial outcomes, such as improved mobility, communication, and participation in their communities. Recreation therapy is included in this review, as its primary purpose is “to restore, remediate or rehabilitate in order to improve the functioning and independence as well as reduce or eliminate the effects of illness or disability. The primary purpose of Recreation Services is to provide recreation resources and opportunities to improve health and well-being” [5, p. 226]. Recreational therapists work collaboratively with other therapists in schools [5,7] and in outpatient clinics [6]. The improved outcomes, such as these are known to promote increased quality of life for the child and for their family [3]. Children with disabilities who receive early intervention and healthcare are more likely to become productive adults, thereby reducing future social spending costs [10,11]. Yet for children with disabilities who live in rural areas, there are unique challenges to accessing rehabilitation therapy services [3].

There are several factors that can make accessing appropriate rehabilitation services difficult for rural families. These can include few accessible resources [12], including a lack of qualified professionals in rural areas, thus limiting access to specialized services [13]. When services are available in rural areas, they may not beof the same quality as those found in urban areas [12]. Because specialized services may not be available, rural families may face costs associated with having to travel to a larger urban center for these services [12,13]. Socio-economic factors for rural families can also be a considerable barrier to services, as poverty has been identified as a significant problem in rural areas [14]. Not only do goods and services often cost more, incomes in rural regions are generally lower than in urban areas [14], making any additional costs more difficult for families to absorb. Skinner and Rosenberg attributed these constraints to “the geographic, sociocultural, technological and workforce barriers in rural [areas] compared with metropolitan communities” (as cited in [15]).

The additional barriers faced by rural families with children with disabilities are especially troubling as children living in rural areas are more likely to be diagnosed with a developmental disability than children living in urban areas, and they are significantly less likely to have seen a therapist in the past year [16].

Therapy services in rural areas involve careful consideration of the unique cultures within the rural community, with the purpose of increased participation [17,18]. Rural communities have their own unique cultures [19,20]. To provide the appropriate therapies for people residing in rural communities, we must first understand the challenges in participation. One of the factors that should be considered is the nature and quality of available services in terms of outcomes. Within the literature, there is a lack of information about how therapy services are provided to children and youth with disabilities in the rural areas of upper middle and high-income countries, as well as the quality and outcomes of these services, and their benefits and challenges. A recent scoping review by Magnusson et al. [21] focused on the provision of rehabilitation services for children with disabilities living in low- and mid-income countries [21]. However, this scoping review was not specific to services provided in rural areas. It primarily focused on access to services rather than on their nature, and it did not address the services delivered in high-income countries.

There are a few systematic reviews that have examined research pertaining to access to rehabilitation, such as access to rehabilitation for people with disabilities in low- and middle-income countries [22], and studies on addressing the barriers to accessing therapy services in rural areas [3,23,24]. Furthermore, research studies pertaining to services offered in rural areas have mostly focused on access to therapy services (e.g., distance and cost of travel, waiting time), and not on the services themselves [22]. In the meantime, new technologies are becoming available and are implemented in practice. For example, telepractice, also referred to as telehealth, telerehab, or telemedicine, involves “the application of communication technologies (e.g., computer-based videoconferencing software and the internet) to enable [rehabilitation therapists] to consult and deliver services in real-time over a geographical distance” [25].

The intent of this scoping review was to examine the extent and nature of research about therapy services provided to children with a range of impairments and disabilities in rural areas of upper middle to high-income countries. More specifically, we sought to answer the following questions: What therapy services have been provided, and how they have been delivered in the rural areas of upper middle to high-income countries for children and youth with disabilities? What were the positive outcomes and challenges of providing these services? This review had the following objectives: (1) To summarize the nature of the therapy services offered in rural settings to children with disabilities; (2) To describe the positive outcomes and challenges of services provided to children, youth, and their families who live in rural settings. To answer our research question, we did not consider studies that focused solely on access to services or utilization of services, and which did not describe and evaluate specific services or their outcomes.

Methods

This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [26]. The method used in this scoping review was based on a modified initial framework for conducting scoping reviews published by Arksey and O’Malley [27] and included the following steps: (a) identifying the relevant studies; (b) study selection; (c) charting the data; and (d) collating, summarizing, and reporting the results. A scoping review was selected over a systematic review given the project’s broad focus (i.e., rehabilitation services for children with disabilities living in upper-middle to high-income countries), and the limited availability of rigorous study designs described in articles comprising traditional systematic reviews. Furthermore, this scoping review seeks to provide a descriptive overview of the relevant literature rather than a critical appraisal of the literature, which is customary in a systematic review [28].

Identifying relevant studies

This scoping review aimed to identify peer-reviewed articles published between 1 January 2009 and 18 January 2022. A comprehensive and systematic search of electronic databases was conducted using a combination of subject headings and/or keywords related to children and youth with disabilities, rehabilitation, multidisciplinary, and rural areas. The search occurred between 23 May 2019 and 12 June 2019, in four electronic databases: MEDLINE, EMBASE, CINAHL, and Psych INFO. An updated search occurred on 18 January 2022. A Health Science Librarian at Queen’s University reviewed and approved the search strategy (Table 1). The original PICO model [29]: population, intervention, comparison, and outcome were modified, as this scoping review did not focus solely on intervention effectiveness. The search strategy was informed by a modified PICO model [30]: population, interest, and outcome. The population was children and youth with impairments and disabilities; the interest was therapy services provided in rural areas; and the outcome was the benefits and challenges of providing these services. The definitions of low, lower middle, upper-middle, and high-income countries were based on the definitions of the World Bank as of July 2019–July 2020. The World Bank classifies the world's economies into four groups, based on gross national income per capita: high, upper-middle, lower-middle-, and low-income countries [31]. World Bank low-income economies and low-mid economies countries were excluded during the article or full-text screening phase (example: countries in Africa) while upper-middle income economies and high-income economies countries were included (examples include Canada, the United States of America, United Kingdom, Australia, New Zealand, Taiwan). All references were imported to Endnote X0.7 [32] and then into Covidence [33], a software platform for scoping and systematic reviews.

Table 1. Electronic database search terms.

Term	Variations
Children	Disabled child(ren); neurodevelopmental disorder(s); handicap(ped); disability(ies); disabled child; handicapped child; disabled youth; disabled young adult
Rehabilitation	Rehabilitation; activities of daily living; correction of hearing impairment; early ambulation; exercise therapy; neurological rehabilitation; occupational therapy; speech language pathology; speech therapy; recreation therapy; audiology; rehabilitation of speech and language disorders; rehabilitation; vocational; telerehabilitation; physical therapists; audiologists; occupational therapists; physical therapists; physical therapy modalities; physical therapist assistants; speech language pathologists; physical therapy specialty; audiologists, recreational therapists.
Multidisciplinary Care Team	Interdisciplinary; interprofessional; transdisciplinary; inter disciplinary; inter professional; multidisciplinary; intra professional; intra disciplinary; intraprofessional; intradisciplinary; trans disciplinary; multidisciplinary.
Rural	Rural health;, rural health services; rural population; hospitals, rural; rural, medically underserved area; health services accessibility; remote, telemedicine; telerehabilitation; health disparity; health equity.

Study selection

Inclusion criteria

The papers included in this review had to meet the following criteria: (a) were research studies in which participants were children and youth ages 0–21 years old [34,35]; (b) concerned the provision of rehabilitation services consisting of one or several of the following disciplines: occupational therapy, physical therapy, speech-language pathology, audiology, and/ or recreational therapy; (c) described and evaluated services provided in upper-middle to high-income countries to children and youth living in rural settings; (d) were published in peer-reviewed journals; (e) full text was available in English; (f) were rigorous research reviews which related to any topics concerning the research question (e.g., one of the disciplines).

Arksey and O’Malley [27] recommend that the scoping review should identify different types of literature, “regardless of study design” (p.22); therefore, both qualitative, quantitative, and mixed methods studies were included in this scoping review. Disabilities for children and youth included speech and/or language impairments, hearing loss or at risk for hearing loss, physical disabilities, learning disabilities, cognitive disabilities, ASD, sensory or language disabilities, swallowing difficulties, and traumatic brain injury (TBI). Studies that included children at risk (e.g., for otitis media) were included, as rehabilitation services include the promotion of good health and prevention activities [36] and the role of community-based rehabilitation includes promoting public awareness of all aspects of hearing loss [37].

Exclusion criteria

We excluded the following publications: (a) conference proceedings, conference abstracts, and theses/dissertations; (b) full-text articles which were not available in English; (c) research papers concerning purely medical treatment, such as cancer treatment and end of life treatment; (d) papers reporting services provided by nurses, physicians, dentists or other health care professionals not mentioned in the inclusion criteria; (e) articles which focused solely on access to services or utilization of services (and did not describe and evaluate specific services or their outcomes); (f) studies pertaining to overall health services, which did not specify the therapy disciplines were also excluded as it was not possible to determine their relevance; (g) studies which focused primarily on the adult population were excluded; (h) studies which included lower middle-income countries or low-income countries as classified by World Bank were excluded.

Charting the data

To mediate the risk of bias, two independent reviewers were involved in screening the papers and extracting data. Before data extraction, the two reviewers and the first author met to devise the content of the data charting form. Once an agreement was reached, the table was created using an excel spreadsheet. The following information was independently extracted from each study by two reviewers: authors, study aim/objective; whether the study was quantitative, qualitative, or mixed methods; country in which the study was conducted; participant characteristics; therapy disciplines; tools/measures; procedure; data analysis conducted; services provided; identified benefits and challenges of services. Any conflicts were resolved by discussion between the two reviewers until an agreement was reached.

Collecting, summarizing, and reporting the results

The results of the studies are presented using the data charting form: the author and year of publication; the country in which the study was conducted; the setting (rural only or a combination of rural and urban); the study population; the services offered; type of study (quantitative, qualitative or mixed methods) and the positive outcomes and challenges described in providing services in rural areas.

Process of screening/data extraction

The study selection process is represented by a PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram (Figure 1). A total of 5997 articles were retrieved from the four databases and uploaded to Covidence. After duplications were electronically removed, 4635 articles remained for the title and abstract screening. Titles and abstracts were screened for relevance by two independent reviewers to determine whether articles met the inclusion criteria. When disagreements on study inclusion occurred, the two reviewers met to discuss the inclusion/exclusion criteria to ensure there was an agreement, and to mediate any potential biases in the process. In the later phases of the review, an independent third reviewer resolved the conflicts. In the update stage, conflicts were resolved through a discussion between the two independent reviewers. There were a total of 200 conflicts during the title and abstract screening. Following the completion of the title and abstract screen, there were 423 studies that were then reviewed in the full-text screening phase. Nineteen disagreements in this phase were resolved through consensus amongst all three reviewers. Following this stage, the first and the fourth author (PF, BB) independently eliminated another sixteen studies, with 100% agreement, for the following reasons: (a) the articles did not address services in rural areas (n = 4); (b); not peer-reviewed (n = 1); (c) the articles addressed solely to access, not service issues (n = 8); (d) wrong age group (n = 1); (e) wrong discipline (n = 2). In the update stage, the full-text conflicts were resolved through consensus among two reviewers. Selected articles were hand searched for further relevant studies by two reviewers. Three relevant articles were identified through a hand search [38–40].

Figure 1. PRISMA diagram.

A flow chart is presented, presenting the PRISMA diagram. Five thousand nine hundred and ninety-seven studies are identified through the initial database search. One thousand three hundred and sixty two duplicates are removed. Four thousand six hundred and thirty five articles are screened at the title and abstract phase. Four thousand two hundred and twelve are excluded as they were found to be irrelevant. Four hundred and twenty three are screened at the full text stage. Three articles are found through a hand search. A final total of thirty-seven studies are included in the scoping review.

Results

Study characteristics

A total of 37 studies met the inclusion requirements for this scoping review. The 37 papers presented research conducted in seven high-income countries: Australia (n = 18); United States of America (n = 10); Canada (n = 3); Taiwan (n = 2); Iceland (n = 2); Poland (n = 1); and Guam (n = 1).

Twenty-one of the research papers were quantitative studies, nine were qualitative studies, six used mixed methods, and there was one systematic review that contained both qualitative and quantitative studies. The systematic review was included because it was a rigorous review of audiology services and access to services in rural areas of Australia. Fifteen out of the thirty-seven studies involved multidisciplinary (or interdisciplinary) teams (including disciplines of interest for this review) rather than individual disciplines. The most common multidisciplinary teams were composed of (a) Occupational Therapists (OT), Speech-Language Pathologists (SLP), and Physiotherapists (PT) (n = 7); followed by (b) OT and SLP (n = 5); (c) SLP and Audiologists (AUD) (n = 1); (d) OT, PT, SLP, AUD (n = 1) and OT, PT (n = 1). The remaining 22 studies included service provision in rural areas which consisted of individual disciplines. These were: SLP (n = 11); AUD (n = 6), OT (n = 2); PT (n = 3). These individual disciplines may have involved other discipline members which were not the focus of this review, such as medical, behaviour support services, psychology, social work, etc. These are fully listed for each study in Tables 2 and 3.

Table 2. Studies about services provided in-person.

Author and year of publication	Country	Setting	Methodology	Population characteristics	Details of service provision	Positive outcomes in rural settings	Challenges in rural settings
1. Mello et al. (2016)	United States	Rural and urban	Quantitative	Caregivers of children with ASD (n = 415; n = 101 from rural areas)	Discipline: SLP, OT, ABA and Behavior Support Services, Parent Related Services Therapy focus: ASD Method: individual Location: private clinics, school-based Duration: varied, unspecified Intensity: varied, unspecified	Rural families Access: most used service was speech language therapy Families rated services as somewhat effective Rural and urban families: Access: identified the most needed service was behaviour support service Rural and nonrural families were similarly satisfied with overall services	Rural families: Access: least likely service to be used was service coordination and self-care Less likely to access parent support groups Longer distances to travel to access the services Lower perceptions of effectiveness of behavioural support Fewer BCBA present, less likely to access recommended services
2. Williams et al. (2014)	Australia	Rural	Quantitative	PTs (n = 2) taking part in a 6 month-long post-graduate paediatric clinical and academic training	Discipline: PT Therapy focus: paediatric physiotherapy services Method: outpatient services, family-centred practice Location: clinics and community services Duration: varied, unspecified Intensity: varied, unspecified	Improved accessibility to paediatric physiotherapy	Shortage of paediatric physiotherapy services due to a lack of post-graduate clinical training opportunities in rural workforce Lack of funding for rural programs
3. Monz et al. (2019)	United States	Rural and urban	Quantitative	Caregivers (n = 5122) of children (13–17 years old) with ASD	Discipline: behavioral, developmental/relationship, SLP, OT, psychological; parent/caregiver training Therapy focus: ASD Method: individual, group, social skills training, academic support, animal-assisted activities and therapies, SCERTS, sensory integration, TEACCH and other or unknown Location: client’s home, private or public school or preschool, private clinic, daycare or before/after school program, camp, other or unknown Duration: varied Intensity: varied, median = 6.0 h/week	Rural vs. urban frequency of treatment Not as pronounced SLP and OT mostly provided at public school, and are not dependent on infrastructure (e.g., specialists’ offices)	Intensity of “any” treatment significantly greater in urban than rural setting Less frequent behavioural therapy and SLP in rural areas Less likely to receive individual sessions than in urban areas
4. Chu et al. (2017)	Taiwan	Rural	Quantitative	Children (n = 71; 35 with ASD, 36 with DD), 24–36-months-old	Discipline: SLP, OT, PT, cognitive education and other Therapy focus: ASD Method: individual Location: center-based (daycare or specialized preschool), regular preschool Duration: 1.5 years Intensity: 0–29.8 h/week (higher end being full preschool hours) varied	Children with ASD and DD improved on all domains of cognitive function	Rural children with ASD and DD had limited services and fewer options in services for autism
5. Dew et al. (2013a)	Australia	Rural	Qualitative	Carers (n = 78) of people with diverse disabilities and adults with a disability (n=10)	Discipline: SLP, OT, PT Therapy focus: person-centred community-based therapy services Method: varied, unspecified Location: client’s home, school, clinic Duration: varied, unspecified Intensity: varied, unspecified	Commitment of private practice therapists who work in rural areas	Common concerns of adults with disability and carers: Travelling long distances to access therapy Long wait times for therapy Limited access to therapy past early childhood (problems of recruiting and retaining sufficient therapists to work in rural areas)
6. Rourke et al. (2016)	Canada	Rural	Quantitative	Children (n = 218; 4–11 years old) from a community with a high rate of middle ear disease and conductive hearing loss	Discipline: AUD Focus: paediatric assessment Method: ShoeBOX Audiometer Location: school Duration: mean duration of test = 332 s Intensity: unspecified	Time efficient Largely language independent	Follow-up difficulties
7. Hussain et al. (2015)	Australia	Rural	Mixed methods	Parents (n = 17) of children (age < 18) with DD	Discipline: SLP, OT, PT, Behavioural, Psych Therapy focus: information needs around health, social services, parental perceptions and experiences of service delivery Method: varied, unspecified Location: varied, unspecified Duration: varied, unspecified Intensity: varied, unspecified	None reported	Lack of timely information about services Inadequacies in interaction with service providers (poor staff attitude, lack of experienced staff and high staff turnover) Access challenges (limited services, long wait times, travel and associated costs, and mismatch between the child’s needs and services offered) Administrative services create barriers due to unnecessary bureaucracy
8. Solovieva et al. (2014)	United States	Rural Urban	Quantitative	Individuals with traumatic brain injury (n = 722; all ages, mean age = 40 years)	Discipline: SLP, OT, acute care, inpatient/outpatient services, rehabilitation services Therapy focus: unknown (TBI) Method: varied Location: in-home, nursing home, varied Duration: varied, unspecified Intensity: varied, unspecified	Rural and urban: More felt satisfied with the rehabilitation services received than dissatisfied	Key barriers to service in rural and urban settings: Lack of knowledge of available services and resources Cost of services Difficulty navigating system Difficulty finding qualified providers knowledgeable of TBI Proximity to services
9. Ziviani et al. (2014)	Australia	Rural Urban	Qualitative	Caregivers (n = 10) of children (age ≤9 years) with physical disabilities (1 rural)	Discipline: SLP, OT, PT, social work, family support workers and other early intervention Therapy focus: paediatric Method: varied Location: in-home, nursing home, varied Duration: varied Intensity: varied	Rural and urban: Most parents were happy with responsiveness to needs of child and family Parents valued equipment services for their child with physical disabilities Most families happy with the parent provider relationship	Rural and urban: 50% dissatisfied with therapy quality (e.g., lack of goal setting, high staff-turnover) Difficulty accessing and funding equipment Poor communication and coordination of services Parents with health problems and single mothers more apprehensive about managing their child’s needs
10. Dew et al. (2013b)	Australia	Rural	Qualitative	Caregivers (n = 10) and 60 service providers (n = 60) of children (0–6 years old) with disabilities. Adults with disabilities aged 21 years+ (n = 10)	Discipline: SLP, OT, PT Early intervention (EI) for children with physical disabilities Therapy focus: paediatric Method: person-centred, individual-funding (IF) Location: varied, unspecified Duration: varied, unspecified Intensity: varied, unspecified	Identified innovative approaches to providing services to people with a disability who had IF (e.g., employing local people trained to work as therapy implementers under the direction of therapists based in larger settings)	Four service barriers: Lack of information and advice Limited local service options and capacity; Higher costs and fewer services Complexity of self-managing funding packages
11. Daal’Alba et al. (2014)	Australia	Rural and urban	Mixed methods	OTs (n = 11) working with children (0–6 years old) with a rare developmental disability	Discipline: Early OT intervention Therapy focus: paediatric Method: family-centred approach Location: home, varied Duration: varied Intensity: varied	Rural and urban: Family-centred practice increased the efficacy of therapy interventions support to families Play therapy is a critical area of intervention	None reported
12. Brown et al. (2012)	Canada	Rural and urban	Quantitative	Parents or legal guardians (n = 101) of children (6–13 years old) with ASD	Discipline: SLP, OT, PT, and others Therapy focus: ASD, paediatric Method: unspecified Location: school settings, private Duration: unspecified Intensity: unspecified	Rural and urban: Almost all children had an educational assistant and a family physician	Rural and urban, most common unmet needs: Social activities for the child Information about services and continuous service provision Rural Long travel distance impeded access to services and informal supports (e.g., support groups)
13. Eglison et al. (2011)	Iceland	Rural and urban	Qualitative	Parents (n = 17; 8 rural, 6 urban) of children (7–13 years old) with physical disabilities	Discipline: OT, SLP Therapy focus: paediatric Method: family-centered approach Location: clinic-based Duration: varied Intensity: varied	None reported	Rural Travel costs associated with accessing therapy Less access to OT and PT Structural manner in which services are provided can impede family-centered approach
14. Wisniewska et al. (2012)	Poland	Rural	Quantitative	7–8-year-olds (n = 50) with muscle imbalance	Discipline: PT Therapy focus: paediatric, muscle imbalance Method: comprehensive Location: military hospital Duration: 3-week program Intensity: varied, unspecified	Rehabilitation program eliminated muscle contractures in children and improved the postures	Difficult living conditions Poor social conditions
15. Zaidman-Zait et al. (2015)	Canada	Rural and urban	Mixed methods	Parents (n = 23) of deaf children (age 3–16 years) with additional disabilities	Discipline: AUD Therapy focus: paediatric Method: cochlear implantation Location: children’s hospital Duration: unspecified Intensity: unspecified	Rural and urban Parents satisfied with implant Improved quality of life for child	Limited availability of specialized services in rural settings
16. Barr et al. (2018)	Australia	Rural	Systematic review of quantitative and qualitative studies	Children (0–16 years of age) with hearing impairments	Discipline: AUD Therapy focus: paediatric, hearing loss services Method: varied Location: varied Duration: varied Intensity: varied	None reported	Reduced quality and frequency of service Extensive travel and associated costs Lack of information Minority groups at greater risk of poor outcomes SES influences access to services
17. White et al. (2016)	Australia	Rural	Mixed methods	14-year-old aboriginal boy with neurological meliodosis	Discipline: PT, OT, SLP Therapy focus: paediatric Method: multidisciplinary inpatient and outpatient rehabilitation Location: medical setting Duration: 9 months of inpatient admission Intensity: varied	Required intensive medical inpatient treatment	Case highlights challenges associated with discharge to a remote community where limited support services are available for a high needs patient
18. Anderson et al. (2014)	Australia	Rural and urban	Qualitative	Parents (n = 6) of school-age children with cerebral palsy, ASD and dyspraxia, who use a speech generating device (SGD)	Discipline: SLP Therapy focus: SGD Method: support for families with a new SGD Location: varied Duration: varied Intensity: varied	Rural and urban: Timely, well-coordinated and family-centred support enhanced service experience for families with a new SGD	Rural Intensity of therapy services limited in rural areas (monthly or less) Travel long distances to access therapy centres Therapist expertise is limited in SGD practice
19. Chen et al. (2017)	Taiwan	Rural and urban	Quantitative	Mandarin speaking preschoolers (n = 5; 53–70 months old) with congenital mild to profound hearing loss Parents (n = 5) and Therapists (n = 4)	Discipline: AUD Therapy focus: hearing loss Method: auditory-verbal therapy (AVT) Location: in-person vs. telepractice Duration: mean = 49 mos.; assessed and compared 2 years post-treatment Intensity: unspecified	Rural and urban: No statistically significant difference in the children’s language abilities between telepractice and in-person group outcomes Therapists found in-person assessment of speech production easier than via teleconference	None reported
20. Grogan-Johnson et al. (2010)	United States	Rural	Quantitative	N = 34 students (4–12 years old) with articulation, language and/or fluency disorders as a primary or handicapping condition related to a learning disability Parents (n = 22), educational staff and school administration staff (n = 27)	Discipline: SLP Therapy focus: articulation Method: Group A received telepractice for four months followed by in-person for four months. Group B received in-person for four months followed by telepractice for four months. Measured progress on GFT-A, National Outcomes Measurement System and progress reports. Location: in person (mainly group), telepractice (mainly individual) Duration: 8 months Intensity: IEP	Students’ performance with telepractice was similar to students’ performance in person Satisfaction with services by students, parents, SLPs, principals and e-helpers No difference in session cancellation reasons	The perceived disadvantages of telepractice included: difficulty of collaborating with classroom teachers and of relating therapy to the classroom curriculum
21. Coufal et al. (2018)	United States	Rural and urban	Quantitative retrospective study	ASHAs National Outcome Measurement System (NOMS) client cases (n = 1331) and telepractice client cases (n = 428)	Discipline: SLP Therapy focus: speech sound production in 6–9-year-olds with no communication disorders Method: varied, unspecified Location: in person, telepractice Duration: 4–9 months Intensity: varied, unspecified	Rural and urban: No significant difference between traditional in person treatment and telepractice	None reported
22. Sutherland et al. (2017)	Australia	Rural and suburban	Quantitative	Children (n = 23; 8–12 years old) with reading difficulties attending mainstream schools and referred to a specialist reading centre Parents (n = 13)	Discipline: SLP Therapy focus: assessment, CELF-4 Method: 4 standardized subtests administered via telepractice and 2 subtests in-person Location: in-person, telepractice Duration: 1–2 h Intensity: unspecified	High reliability of scores for in-person and telepractice conditions	None reported
23. Ruggero et al. (2012)	Australia	Rural and urban	Quantitative	Parents (n = 154 of 192 children (age ≤18 years) involved in speech- language pathology services	Discipline: SLP Therapy focus: individual therapy, parent training, home program, group therapy Method: unspecified Location: community health services, school/pre-school, or other. Duration: varied, up to 24 months Intensity: varied, up to 3/week	Rural and urban Parents were keen for alternative methods of service delivery but preferred individual sessions	Compared to urban families Fewer options of services for families Longer travel distances Fewer face-to-face and private sessions Less likely to be given homework
24. Anderson et al. (2015)	Australia	Rural and urban	Qualitative	SLPs (n = 13) and parents (n = 7) of children (2–18 years of age) who used speech generating devices (SGD)	Discipline: SLP Therapy focus: SGD Method: Alternative service models: parent-implemented intervention and training, peer-support networks, group services, intensive therapy camps and telepractice Location: varied Duration: varied Intensity: varied	SLPs found that rural families familiar with service limitations were especially supportive of telepractice Remote SLPs used support strategies, such as exchanging USB drives or therapy resources with families by post Rural families were more proactive and less reliant as therapy occurs less frequently Most families prefer in-person services	Rural and urban Parents felt either overwhelmed by the new information or sometimes excluded from learning opportunities Lack of flexible scheduling for learning sessions Text based training and manuals are often too difficult to understand
25. Jones et al. (2018)	Australia	Rural	Qualitative	Caregivers (n = 9) of Indigenous children (0–3 years old) with otitis media (OM)	Discipline: SLP, AUD Therapy focus: speech and language, hearing health, and school readiness Method: LiTTLe program Location: school setting Duration: 40 weeks; 4 h/day Intensity: 5 days/week	Caregivers had generally positive views of the program Caregivers felt that the program helped prepare children for school	Caregivers found strategies, such as baby talk, talking slowly, following along with the child's topic or parallel talk difficult and alien Many caregivers felt uncomfortable in a school setting
26. Gudjonsdottir et al. (2021)	Iceland	Rural and Urban	Quantitative	Families (n = 36) with children (6–18 years old) with physical disabilities (diagnoses of cerebral palsy, spinal muscular atrophy, Charcot-Marie-Tooth disease, spina bifida or Duchenne disease).	Discipline: PT Therapy focus: use and impact of mobility devices, and satisfaction with service Method: Mobility training Location: remote Duration: varied, unspecified Intensity: varied, unspecified	Rural and urban Majority of the parents reported positive effects of the mobility devices on their children’s opportunities for various activities and participation, most commonly: to go on trips, to go shopping, to travel long distances. Majority of parents were satisfied with the service delivery and professional services. No significant difference in the participants’ satisfaction with the type of the mobility device	Rural and urban Few participants reported negative effects of mobility devices on activities and participation, specifically on engaging in sports and/or leisure activities and meeting friends Less satisfaction with repair/maintenance of mobility devices and with follow-up services
27. Grogan-Johnson et al. (2011)	United States	Rural	Quantitative	School-age children (6–11 years of age) with speech sound disorders (n = 6 children who received in person therapy).	Discipline: SLP Therapy focus: outcomes of individual articulation therapy, using computer based intervention materials. It also compared in person services to telepractice services. Method: individual articulation therapy sessions, with pre and post-test measures using GFTA-2. Location: school setting, in private offices Duration: School calendar year; The in-person sessions; had a mean length of 20 min Intensity: unspecified	The in person group made significant improvement in sound production as measured by change in scores on the GFTA-2.	None reported

ASD: autism spectrum disorder; AUD: audiology; DD: developmental disability; OT: occupational therapist; PT: physiotherapist; SLP: speech language pathologist; ABA: applied behaviour therapy; SGD: speech generating device.

Table 3. Studies of services offered via telepractice.

Author and year of publication	Country	Setting	Population characteristics	Type of study	Details of service provision	Positive outcomes in rural settings	Challenges in rural settings
1. Cason et al. (2012)	United States	Rural and urban	IDEA Part C coordinators (n = 27), evaluated the utilization of telepractice for children (age ≤2 years) with disability or developmental delay.	Quantitative	Discipline: SLP, OT, PT, AUD, Early intervention development specialists, teachers of deaf and hearing, behaviour specialists, other (IFSP meeting participation) Therapy focus: unspecified Method: unspecified Location: Early intervention programs via telepractice (platform unspecified) Duration: varied, unspecified Intensity: varied, unspecified	For rural and urban settings: Natural environment (home) for testing Timely services	For rural and urban settings: Security and privacy concerns Concerns about the quality of services via telepractice and that there may be lack of evidence to support the effectiveness of a telepractice service delivery model were expressed by the IDEA part C coordinators.
2. Lee et al. (2018)	United States	Rural	Children (n = 2, 4 and 6 years old) with phonological disorders without any sensory, motoric or intellectual disabilities	Quantitative	Discipline: SLP Therapy focus: phonology Method: Multiple phonological approach Location: Prescencelearning.com teleconference platform Duration: 12–16 weeks; 30 min per session Intensity: 2 times a week	Effective for both participants	One participant dropped out of the study due to poor internet connection.
3. Guiberson, M. (2016)	United States	Rural	Spanish speaking toddlers (n = 63; 24–35 months-old; n = 22 with developmental delay) and their parents	Quantitative	Discipline: SLP Therapy focus: screening language development Method: PLS-4 Spanish; Nicoladis’ gesture system; SPS symbolic system; Linder’s complexity of play subscale; SALT; 2 parent report measures: INV and RM3L. Asynchronous feedback. Location: telepractice platform unspecified. Duration: unspecified Intensity: n/a Video recorded parent facilitated play activities and a parent pen and paper report measure of vocabulary	For rural and underserved areas: Best results with parent pen and paper survey in combination with the video recorded parent facilitated play activities	For rural and underserved areas: Video recorded play activities without the pen and paper vocabulary measure not likely a promising screening measure.
4. Constantinescu, G. (2012)	Australia	Rural	Families (n = 33) and therapists (n = 5) accessing auditory verbal therapy (AVT) program for children (6 months to 6.6 years old) with hearing loss	Quantitative	Discipline: AUD (AVT) Therapy focus: teaching listening and spoken language Method: AVT Location: AVT therapy by telepractice, using skype 5.5 and high-speed broadband access Duration: unspecified Intensity: biweekly therapy and planning sessions between therapist and parent; monthly themed ‘lesson boxes’ provided to families	Parents and therapists felt comfortable participating in the sessions via teleconferencing	Internet connection issues Therapists found it challenging to judge the child’s speech production Video quality sometimes required troubleshooting Therapists less satisfied than parents with the child’s level of interaction with the therapist via video conferencing
5. Little et al. (2018)	United States	Rural	Families (n = 17) and children (n = 18; 2–6 years old) with ASD.	Quantitative	Discipline: OT Therapy focus: child’s participation in play and social activities Method: Occupation-Based Coaching process where caregivers identified 2–3 goals, and the therapist helped the family generate their own solutions Location: zoom platform Duration: 12 weeks Intensity: unspecified	Parents and child engaged in more play activities, greater variety of skill development activities Children’s performance in activities and in goal attainment improved Increased parental satisfaction with intervention goals	N/A
6. Barr et al. (2018)*	Australia	Rural	Children (n = unspecified; 0–16 years old) with hearing impairments	Systematic review of quantitative and qualitative studies	Discipline: AUD Therapy focus: unspecified Method: unspecified Location: telepractice; platform unspecified Duration: unspecified Intensity: unspecified	Parents satisfaction with audiology services offered via telepractice, would recommend the service to other parents	N/A
7. White et al. (2016)*	Australia	Rural	A 14-year-old aboriginal boy with neurological meliodosis.	Mixed methods	Discipline: SLP, OT, PT Therapy focus: inpatient and outpatient rehabilitation Method: multidisciplinary inpatient and outpatient rehabilitation via telepractice Location: telepractice consultation and services during and after transition to rural home; platform unspecified Duration: 9 months Intensity: unspecified	Use of telepractice services enabled discharge of client to home Collaboration with other therapists in rural community	N/A
8. Chen et al. (2017)*	Taiwan	Rural and urban	Mandarin speaking preschoolers (n = 5; 53–70 months-old) with congenital mild to profound hearing loss, enrolled in auditory verbal therapy (AVT) as well as five parents’ and four therapists’ satisfaction with telepractice.	Quantitative	Discipline: AUD Therapy focus: hearing loss Method: auditory-verbal therapy (AVT) Intensity: unspecified Location: telepractice using Vidyo Protal version1.3.0.21, videoconferencing Duration: mean = 49 months; assessed and compared 2 years post-treatment Intensity: unspecified	Urban and rural: Telepractice just as effective as in-person services No significant difference between parents’ and therapists’ satisfaction on specific aspects of the programme or specific items Less travel time for majority of the families	Urban and rural: Therapists expressed difficulty in assessing the children’s speech production when using telepractice Some children had difficulty focusing on the teaching materials during telepractice sessions
9. Grogan-Johnson et al. (2010)*	United States	Rural	N = 34 students (4–12 years old) with articulation, language and/or fluency disorders as a primary or handicapping condition related to a learning disability Parents (n = 22), educational staff and school administration staff (n = 27)	Quantitative	Discipline: SLP Therapy focus: articulation, language and /or fluency Method: followed the goals in child’s IEP; individual sessions with SLP; e-helpers to provide support with telepractice equipment Location: four school districts; using an educational network and minimum bandwidth of 10 mbit/s Duration: 4 months Intensity: unspecified	Student performance with telepractice was similar to student performance in person Satisfaction with services by students, parents, SLPs, principals and e-helpers. No difference in session cancellation reasons	The perceived disadvantages of telepractice included: difficulty of collaborating with classroom teachers and of relating therapy to the classroom curriculum
10. Coufal et al. (2018)*	United States	Rural and urban	ASHAs National Outcome Measurement System (NOMS) client cases (n = 1, 331) and 428 telepractice client cases. Clients (6–9 years old) with speech sound production issues with no co-occurring communication disorders	Quantitative	Discipline: SLP Therapy focus: unspecified Method: unspecified Location: telepractice in the school setting, using a custom-built videoconferencing platform, with desktops or laptops with dual core processors and broadband internet of at least 1mbps or higher for download and upload speeds Duration: 4–9 months Intensity: unspecified	Rural and urban: Effective: no significant difference in treatment outcomes between in person services and telepractice for children (each group improved two levels as a result of therapy)	Rural and urban: SLPs were trained in the use and scoring of NOMS. The internet use was high speed (at least 1.0 mps or higher), which may be challenges for SLPs and families in rural settings. In some cases, USB sound adapter card was also needed
11. Sutherland et al. (2017)*	Australia	Rural hubs	Children (n = 23; 8–12 years old) with reading difficulties attending mainstream schools and referred to a specialist reading centre	Quantitative	Discipline: SLP Therapy focus: standardized language assessment Method: 4 standardized subtests administered via telepractice and 2 subtests in-person Location: hubs Duration: 1–2 h Intensity: one visit	Effective: telepractice can be used to assess children’s language Parents felt “somewhat comfortable” or “definitely comfortable” with the telepractice assessment	Parents were generally satisfied
12. Ruggero et al. (2012)*	Australia	Urban and rural (16 families)	Parents (n = 154 of 192 children ≤18 years old) with speech and language disorders	Quantitative	Discipline: SLP Therapy focus: individual therapy, parent training, home program, group therapy Method: unspecified Location: community health services, school/pre-school, or other Duration: varied, up to 24 months Intensity: varied, up to 3/week	Rural and urban families: Parents were keen for alternative methods of service delivery to fill the gap between assessment and treatment wait times	Rural and urban families: Families expressed a strong preference for individual therapy once they were eligible for therapy When individual therapy sessions were not possible, telehealth was not utilized extensively Rural families: 10 families from rural and remote areas travelled hundreds of kilometers each to access services
13. Anderson et al. (2015)*	Australia	Rural and urban	SLPs (n = 13) and parents (n = 7) of children (2–18 years old) who used speech generating devices (SGD) SLP in rural area (n = 1)	Qualitative	Discipline: SLP Therapy focus: SGD service delivery Method: unspecified Location: telepractice; platform unspecified Duration: unspecified Intensity: varied SLPs and parents experimented with alternative service delivery models including telepractice	Rural and urban families: Alternatives viewed as viable and useful by parents and SLPs All SLPs used telepractice or remote strategies to some extent Remote support strategies, such as exchanging USB drives or therapy resources with families by post Remote families more proactive and less reliant as therapy occurs less frequently	Rural and urban families: SLPs felt that telepractice is an appropriate supplement but not a replacement for in person therapy. Parents had limited experience with telepractice Parents preferred in person therapy
14. Sutherland et al. (2021)	Australia	Rural and urban	27 SLPs in pediatric practice (added 116 CELF-5 ax)	Mixed methods	Discipline: SLP Therapy focus: use of standardized language assessment CELF-5 Method: a post-assessment questionnaire was completed each time the SLP completed a CELF-5 assessment via telepractice Location: Telehealth platform “Coviu” Duration: 3 month trial Intensity: varied (a mean of 4.3 assessments per SLP)	Ease of using telehealth Telehealth makes it easier to provide services Effective interactions with the child on most occasions Visual and audio quality: over 92% of assessments were rated to have “ok,” “good enough,” or “perfect” visual and audio quality	Technical difficulties including internet connections Integrating CELF-5 tool in a telehealth platform Telehealth platform functionality issues
15. Johnsson et al. (2019)	Australia	Rural	Parents (n = 11), local support team members including speech pathologist, educators and learning support coordinators (n = 6), and teletherapists (n = 4) working with children on the autism spectrum (2–12 years old). 16 children were involved.	Qualitative	Discipline: support team members including SLP, OT, psychologist, education staff, teletherapists Therapy focus: Individual treatment sessions SLP, OT, psychologist and special educator Method: Teleconference treatment sessions led by SLP, OT, psychologist and special educator on one site, and a rural local support team with the client and parent at the rural site. Semi-structured interviews were conducted by phone following the interventions, to evaluate the services Location: Telehealth zoom platform Duration: One initial session to gather information followed by six teletherapy sessions Intensity: Not specified	Allows for access to specialists in rural communities The development of a competent telehealth support team takes significant number of hours initially, but the number of hours needed for training and practice get reduced over time Importance of the understanding the role and collaboration and capacity building within a teletherapy service	Establishing the need for in-person contact as part of tele-therapy program was expressed Scheduling and local staff changes Limitations on goals requiring physical interaction
16. Hayes et al. (2012)	Guam	Rural	Infants (n = 9), ages between two to three months.	Quantitative	Discipline: AUD Therapy focus: diagnostic audiological evaluations (auditory-evoked potentials and otoacoustic emissions) Method: audiological assessment via telepractice Location: remote, telehealth platform Duration: unspecified Intensity: unspecified	The paper describes how they addressed professional issues associated with the delivery of audiology services via telepractice, according to ASHA guidelines. Audiological evaluation can be offered via telepractice, in compliance with the ASHA standards	Technological problems, such as internet connectivity Logistical problems including scheduling challenges due to different time zones between Colorado and Guam
17. Grogan-Johnson et al. (2011)*	United States	Rural	School-age children (6–11 years of age) with speech sound disorders (n = 13). Seven received telepractice and six received in-person service.	Quantitative	Discipline: SLP Therapy focus: individual articulation Method: individual sessions with SLP; e-helpers to provide support with telepractice equipment Location: school setting, remote Duration: School calendar year; 20–40 min sessions Intensity: unspecified	Articulation therapy via telepractice is just as effective as in-person therapy. It was shown as being more effective than in-person therapy (when quarterly progress reports were used as a measure of progress on Individualized Education Plans (IEP)	Need for a private room for telepractice services, equipment and dedicated aide for technical support
18. Fairweather et al. (2016)	Australia	Rural	Children with communication skills difficulty (n = 19) and parents (n = 5). Children’s ages ranged from 3 to 12 years.	Mixed methods	Discipline: SLP Therapy focus: speech therapy Method: Abdobe Connect, Facetime or Skype Location: school or early childcare site- remote Duration: Twelve week period. 3–6 telepractice sessions Intensity: every two weeks	Quantitative results: Effectiveness of telepractice intervention, as the majority of the treatment goals were attained at a level expected by the SLP Qualitative results: parents viewed the therapy as feasible, practical and convenient. They reported positive effect on their child’s and their own learning	Difficulties with technology, such as internet loss, loss of sound and freezing of vision). Communication between stakeholders
19. Hines et al. (2019)	Australia	Rural	Children (n = 4; 5 years 1 month to 8 years 6 months), with a diagnosis of ASD. Their mothers and one teacher also participated in the study.	Mixed methods	Discipline: SLP, OT Therapy focus: individual therapy Location: remote varied based on the child’s need and their optimized energy levels (school, family home, library, holidays). They also changed for each child over time, based on the child’s and family’s needs. Duration: varied, up 12 weeks maximum Intensity: varied	Telepractice was highly acceptable to parents and/or teachers, especially due to access to timely and regular therapy without the cost of travel. Parents built confidence over time. Each child demonstrated improvements in specific, functional goals Effective therapeutic relationships with children were developed	Technology barriers (internet problems, platform connectivity, video) reported. Participants did not consider these occasional technology issues as obstacles to intervention. Therapists worked with parents and educators to identify solutions and alternatives.

SLP: speech language pathologist; OT: occupational therapist; PT: physiotherapist; SGD: speech generating device; AVT: auditory verbal therapy; AUD: audiology.

*Denotes studies which also included in-person services, but this chart extracted data on telepractice. The in-person results for these studies are noted in Table 2.

Most studies included participants with a variety of diagnoses (n = 19), and some had a single diagnosis as an area of focus, such as autism spectrum disorder (ASD) (n = 6), phonological disorders (n = 1), neurological melioidosis (n = 1), hearing loss or potential hearing loss (n = 5), communication difficulty (n = 1); speech disability (n = 1); muscle imbalance (n = 1), rare developmental disability (n = 1), traumatic brain injury (n = 1). The studies with a variety of diagnoses (n = 19) had a combination of children diagnosed with ASD, developmental delay, down syndrome, FASD, cognitive delay, learning disorder, cerebral palsy, spinal muscular atrophy, Charcot-Marie-Tooth disease, dyspraxia, physical disabilities with complex needs, fragile x syndrome, hearing loss, epilepsy, myelomeningocele, Asperger's, PDD-NOS, speech delays, communication disorders, language delays, spina bifida, Duchenne disease, or other neurological disorders, and other complex conditions.

Services provided

Most of the authors did not include a detailed description of the therapy services that were offered. The information reported in most articles included the disciplines providing services (e.g., OT), or the location where the services were offered (e.g., school, home, at a centre, preschool, private clinic, camp, or a hospital setting). The studies mostly focused on either in-person or telepractice interventions, with only six studies addressing the assessment services. The method of treatment (individual, group, approach used) was inconsistently reported. The duration and the intensity of the services were also inconsistently reported. Seven of the studies also reported on alternative service delivery models offered in-person (outreach programs or special programs).

In-person services

Twenty-seven studies focused on in-person services and their evaluation (Table 2). In general, limited information was provided about the details of these services. Seven studies included more detailed descriptions, and services were categorized into two categories: (a) outreach programs; and (b) special programs.

Outreach programs

Three of the studies reported on services that were provided by outreach programs, where therapists travelled to the child’s school or home setting [13,24,41]. Rourke et al. [41] investigated the prevalence of hearing loss in children in Iqaluit and Nunavut and tested the use of a portable tablet audiometer in a rural location. The children were tested in their rural schools. After a brief demonstration on how to use the tablet, they conducted self-testing by playing a predetermined computer game on the tablet. The audiometry results were then analyzed at an urban hospital. The audiometry testing was deemed to be effective. It was also efficient as multiple children could be tested at the same time and it could be performed with children who did not speak English. A systematic review of audiology services for children ages 0–16 years of age with hearing impairments living in rural areas of Australia, found that some families received outreach audiology services in their communities [13]. In an Australian study by Dew et al. [24], 78 carers of children and 10 adults with a disability living in a rural area were interviewed about accessing therapy services. In those interviews, some families spoke about the services they received in their communities. Some participants spoke about their therapist mentoring them to help them to use their local amenities, such as the gym.

Specialized on-site programs

Other than the outreach programs, four studies additionally described the provision of specialized on-site programs in the rural communities, devised for a specific population [42–45]. A study by Jones et al. [43] investigated the parent's views about a parent-implemented early childhood program focusing on language development, developing school readiness, and hearing health for Australian Aboriginal children living in a rural area. Wisniewska et al. [44] researched the effects of rehabilitation on correcting muscle imbalance in rural children. The rehabilitation was provided in a rural military hospital. Ziviani et al. [45] reported on therapy services that delivered various intervention programs, such as the provision of assistive technology, offered at schools, private practice, and community groups for children with physical disabilities. The study by Anderson et al. [42] described services offered via intensive therapy camps, as well as the use of therapy packages provided to families of children who used speech generating devices (SGD) as an intervention for communication.

In the remaining twenty studies, which included in-person services, the reporting on how the services were provided varied. The information reported had components of which methods were used (e.g., individual therapy, group therapy, consultation, approach used for therapy), and varied in reporting the intensity or duration of the therapy services.

Benefits identified for services offered in person

Of 37 papers, 27 concerned some aspect of in person services. For families living in rural areas, services offered in person provided several benefits, including (a) effective access to services, especially when there is coordination between agencies; (b) assessment and treatment efficacy; (c) child and family centred and contextualized services; (d) and building connections and community capacity. The benefits of in person service delivery model were dependent on the location/setting (i.e., close to home and flexibility) and frequency and intensity of available therapy (i.e., most often reported as not sufficient).

Effective access to services, especially when there is coordination between agencies

Five of the 27 papers reported benefits related to some aspect of access to in person therapy services. The access was improved when the services were developed and coordinated, as a result of the partnership between the university, hospital, and the government sector for PTs working in rural Australia [46]. For children with developmental disabilities, the enhanced access and positive experiences were reported by parents for SLP, OT, and PT services, when they had an opportunity to work directly with local and smaller non-government agencies in rural areas of Australia [47]. In the third study from Australia [48], six parents of children with communication disabilities who used speech generating devices valued local access to the specialized SLP services and ongoing service coordination. Lastly, over 100 parents of children with an autism spectrum disorder in Canada reported that those living in rural areas were appreciative of any therapy services provided in person at local schools [49].

Assessment and intervention efficacy

In person assessment

Two of the twenty-seven in person studies reported on the effectiveness of assessment [41,50]. The effectiveness of assessment for otitis media conducted in rural schools using a portable tablet as a means of a quick and effective solution was reported by Rourke et al. [41]. Sutherland et al. compared the effectiveness of standardized language testing (using subtests of the CELF-4) for in-person assessments vs. telepractice assessments. They found high reliability of scores for both assessment conditions [51].

In person intervention

Nine studies reported on the effectiveness of in person therapy intervention, either as relevant to children with specific diagnoses or in therapy program [39,42–44,51–55]. A majority of the studies reported that the in-person services wereeffective, and parents were generally satisfied with in-person mode of delivery. The outcomes measured and reported in the studies ranged from the overall satisfaction to child-specific or family-oriented outcomes (e.g., across ICF functioning categories: body functions, activity, participation), process related outcomes (e.g., access to service or engagement in therapy) to community-focused outcomes (e.g., disability awareness). Studies reported functional gains (e.g., ability to communicate), enhanced quality of life, assistive device provision, and setup.

One study from Australia, which reviewed family satisfaction with therapy services offered to rural and urban families, reported mixed reports on parental satisfaction with the quality of therapeutic services [45]. A study from Iceland reviewed the impact of mobility devices on participation and satisfaction with the service. Although the majority of the parents were satisfied with the service, mixed results were reported on the impact of mobility of devices on participation, with the most negative effects reported on engaging in sports or leisure activities [55].

Child and family-centered and contextualized services

One of the benefits of receiving in-person services was the ability to customize the service to the family and child’s needs. A study by Zaidman et al. [56] evaluated parent satisfaction with the cochlear program received at a Children’s Hospital in Canada. One of the positive reported outcomes from receiving the in-person service was the customization of the home-based services. A study by Dew et al. [15], found that families had greater access and choice of therapy supports with the support of the individualized funding model (IF) in Australia. In a systematic review by Barr et al. [13], examining audiology services and access to services offered in rural areas of Australia, one community provided an innovative solution to the shortage of professionals in the community by pooling funding to fly in the needed professionals to offer individualized services in the rural community.

Building connections and community capacity

The in-person support groups were appreciated for building strong connections with families in their communities. Specifically, it was found that meetings in person helped to build rapport between the family and the therapist, which was critical to assessment and intervention. Ziviani et al. [45] reported on the evaluation of carers of children from early intervention programs. Although there were mixed reports about the effectiveness of therapy services, families reported that they received effective family support and that they were able to establish positive relationships with staff. In a study by Jones et al. [43], parents and caregivers of Indigenous children with otitis media, who received a parent-implemented group intervention, expressed that they enjoyed the support they received from other parents of children, from their own community.

Another benefit of providing in-person services in rural areas was the ability to build capacity and gathering of resources (n = 5); The study by Dew et al. [24] described therapists assisting a person with a disability to use local sports amenities, such as the gym; working with local community councils to improve support for people with disabilities; or training therapy assistants to implement intervention programs.

Challenges identified for services offered in person

Despite the above-mentioned benefits, the studies also discussed numerous challenges to the provision of in-person services to rural areas. These challenges include: (a) lack of sufficient and timely information about disabilities and support information; (b) poor coordination or communication between families and therapists or agencies; (c) extensive travel time and associated costs; (d) funding challenges; (e) offering services that respect cultural differences; (f) no availability or shortage of services; and (g) long wait times to access those services.

Lack of sufficient and timely information about disabilities and support information

A frequently mentioned barrier was the lack of sufficient and timely information about disabilities and support information offered to families in rural settings [13,15,47,49,57]. In an article by Anderson et al. [48], families whose child was using a speech generating device (SGD) expressed that they required steady professional guidance in the initial stages of the device prescription: to learn how to program the device, to learn how to use it, and for technical assistance, otherwise the device may be abandoned by the family. Similarly, families also expressed that they would like more frequent monitoring of assistive devices in a study by Eglison [53]. Canadian families of school-age children with autism spectrum disorder were also concerned about the lack of information about services that were provided to them, and the lack of information on funding of services [49].

Poor coordination or communication between therapists or agencies

Coordination or communication difficulties between services was also a frequent occurrence [13,45,49,56,57]. Families expressed the importance of communication of roles, expectations, and role empowerment for parents [48,53]. In the article by Hussain et al. [47] the families discussed inadequacies in interactions with service providers. Transition planning and communication issues were identified by parents who received services in rural areas [45,53]. In a study from Iceland by Egilson et al. [53] families expressed that there was a lack of communication about the therapeutic goals, and less communication with the family once a child entered school. Families of children with autism spectrum disorder were concerned about the lack of coordination of services, not having a “go to” person, and lack of communication among service professionals [49], while the parents of children with disabilities in Australia indicated that they had to learn to navigate the system [45].

Extensive travel time and associated costs

Families living in rural areas incurred extensive travel time and travel costs to attend their child’s therapy appointments. These families reported a reduced income due to having to take time off to attend appointments including the extensive travel time [13,24,47,48,50,52,57,58]. Families expressed that this extra financial burden is difficult, given that their finances were already stretched to deal with the extra support required for a child with a disability [47]. Young adults with traumatic brain injury (TBI) also felt a financial burden from the impact of their disability. Although they were of working age, they had a decreased or no source of income as a result of their TBI [57]. In other studies, families also expressed difficulty to attend information sessions [13] and support groups [49,59], due to travel distances involved. In some cases, such as in Australia, with large rural areas, the travel distances included winding country roads or driving in the evening which was perceived as dangerous for families due to animal life, and families would have to incur further costs for overnight accommodation [47]. Families of children with disabilities expressed difficulty in managing costs associated with their child’s treatment [45]. In a study by Eglison [53], families clearly indicated that they wanted to receive services in their rural setting in their community and that the travel was taking too much of their time.

Funding challenges

Challenges with funding were identified in numerous studies [13,15,45,46,56]. Families found it challenging to be responsible for coordinating and administering individual funding in Australia [13,24] and in Canada for children who had cochlear implants [56]. An Australian study by Ziviani et al. [45] found that parents of children with disabilities expressed difficulty in applying for funding for equipment for their child.

Offering services that respect cultural differences

Some studies discussed the importance of acknowledging the cultural context and cultural sensitivity, which need to be considered when planning and implementing services in these rural communities. For example, in the study by Jones et al. [43], Indigenous children received speech and language, hearing health, and school readiness therapy services in a school setting for a period of 40 weeks. Families of children with a hearing loss did not feel that hearing aids were a viable option for their preschool children until their children were in school. Most families had bad memories of their school experiences and suggested that programs should occur in non-school settings. The systematic review by Barr et al. [13] which reviewed services offered to deaf and hard of hearing populations in rural areas of Australia identified the Indigenous population to be more at risk, as Aboriginal children have a higher incidence of otitis media. They identified the importance of building a rapport with the Aboriginal Elders when providing services to Aboriginal families. Furthermore, systemic challenges, such as not being able to bill time for contacting Aboriginal Elders were noted as a barrier to providing services.

No availability or shortage of services

No availability or shortage of services were often cited. Staff turnover was linked to the quality and quantity of services [13,15,43,45,47,50,53,56,60,61]. Often, there was an insufficient number of staff available to serve the number of children being referred [15,24,45,57,60,62]. The lack of qualified professionals to provide appropriate services was often quoted [13,47,48,50]. In the study by Barr et al. [13], families of children with autism spectrum disorder expressed their concerns that professionals often lacked expertise in the area of autism or did not have a good understanding of the needs of the family. Some families had to relocate to larger centres to access the desired service [13,42,47]. Rural families were less likely to receive parent support groups [59]. Rural families had fewer options for services [58], especially for the school-age years [24]. There are some services that are more challenging to be brought by outreach to the rural areas, and the families may need to travel for some services to the urban centres [15].

Long wait times for access to services

Three studies mentioned the long wait times for services [24,47,48]. Parents of children who needed services for speech-generating devices in Australia felt abandoned by the service as their child was transitioning to school age and they were waiting for services [48]. Australian families of children with disabilities living in rural areas expressed that they waited up to several years for accessing therapy services if they were not rated as high on priority for services. These families were frustrated with the lack of access to services, and those who could afford would hire private practitioners. Other families had to do their own work with the child at home [24]. In another study from Australia, families of children with developmental disabilities waited long periods of time to access occupational therapy or speech-language pathology services. They also expressed that even once they received access to therapies, they were limited in duration and would then be placed again on wait lists [47].

Telepractice services

While telepractice has been available in various forms and pilot projects for several years [63], it is only recently that telepractice has become more common for the delivery of services for families with children with disabilities. The category of telepractice can include several delivery modules, including telephone or email check-ins, text messages, online video communications, sometimes supplemented by parental evaluations, or more complex interventions, such as virtual reality video games for rehabilitation [64].

Of 37 papers, nineteen studies reported information about services offered by telepractice (Table 3). Out of these 19 studies, nine studies contained information about both in-person and telepractice services. Telepractice was investigated as a viable means of providing services for children and youth in rural settings and an alternative to in-person services. Telepractice for the purpose of assessment, screening, and/or treatment was explored or examined for the disciplines, including speech-language pathology, occupational therapy, physiotherapy, and audiology [13,38–40,42,51,54,58,60,62,65–73].

Telepractice assessment

Four of the studies reviewed the feasibility of assessment via telepractice [40,51,69,72]. Three out of four studies pertained to speech-language pathology assessments and screenings, such as the use of standardized language assessments [51,72] and one audiology assessment [40]. There were no studies pertaining to assessment by telepractice pertaining to occupational therapy, physiotherapy, or recreation therapy disciplines.

Telepractice interventions

In fifteen of the studies, researchers examined provision of treatment services, using telepractice [13,38,39,42,54,58,60,62,65–68,70,71,73]. Little et al. [62] investigated the efficacy of occupation-based coaching delivered via telepractice for families of young children with autism spectrum disorder living in rural areas. A 12-week coaching process was used, where caregivers self-identified 2–3 goals, and the therapists helped them to generate their own solutions. White et al. [54] reviewed the use of telepractice for transition planning of a 14-year-old boy with neurological melidosis, in his rural community.

Four out of the fifteen studies examined multidisciplinary treatment pertaining to the disciplines of relevance in this scoping review, offered via telepractice [54,60,71,73]. A study by Johnsson et al. evaluated the satisfaction of multidisciplinary services (lead OT, SLP, psychologist, and special educator) and the rural therapy support team for clients living in a rural location. The telepractice intervention consisted of a six-week program offered to children on the autism spectrum. The parents and the service provided were satisfied with the services and indicated the importance of collaboration and capacity building [73].

Benefits identified of services offered by telepractice

For families living in rural areas, telepractice options can provide several benefits, including (a) facilitated access to services; (b) child and family engagement, coaching, and family support; (c) transition and care planning; (d) treatment efficacy; (e) flexibility and costs with the availability of higher quality technology; (f) one study identified ease of using telehealth. The benefits of telepractice may be dependent on the quality of available technology and family and provider’s comfort with technology.

Access to services

For families living in rural areas, access to services can be difficult. Since the onset of the pandemic, there have been additional challenges in accessing in-person services due to the COVID-19 [74,75]. Employing telepractice options as an alternative to traditional in person therapies can increase access to services [13,38,71–73], and can improve the equity and timeliness of services [38,60,71]. Hines et al. presented four case studies of children with disabilities who received intervention via telepractice, at a site that was most convenient for them and their family. The families were interviewed about their experience. The parents expressed that they went through a “journey to acceptance” of telepractice services. The main factors supporting the parents' acceptance of telepractice services include: facilitated access to services [71] as well as the reduced cost of travel [38,71]. Some practitioners provided telepractice by phone or by email, while others exchanged USB drives or other resources with families through the mail [42]. While some parents may prefer in-person services, telepractice is useful when families are unable to attend a therapy session because of location, wait lists, or transportation difficulties [42], as well as due to COVID-19 restrictions in the provision of in-person therapy, especially for the vulnerable population [72]. Parents also indicated that telepractice programs saved them significant expense and travel time [65,71].

Child and family engagement, coaching, and family support

Telepractice can provide opportunities for family engagement and improved child and family outcomes [60] as the therapy takes place within the child’s natural environment [60]. The majority of the children who received therapy via telepractice were able to be engaged in therapy online [72]. Online occupation-based coaching showed a significant increase in play frequency, as parents engaged in more play activities with their children and tried a greater variety of skill development activities [62]. In a study by Fairweather et al., a mixed method study was used. The qualitative component of the study included interviewing the parents of children who received telepractice speech therapy intervention in rural communities of Australia about their experiences. Parents expressed a positive impact on their child’s as well as on their own learning (as they participated in the telepractice sessions) and most reported that their own confidence in doing intervention with their child has improved. They attributed their own engagement and confidence to the higher level of frequency of therapy sessions via telehealth, as compared to their experiences of lack of access to in-person therapy sessions in the past [38].

Family support was mentioned in three of the papers in relation to online support groups for families with disabilities. Families reported that online support groups are especially important during the initial stages, following their child receiving the diagnosis. This is a time that the family feels especially isolated [47] and needs to learn about their child's disability.

Transition and care planning

Telepractice can also facilitate the transition and care planning by enabling regular communication between the treating team, regional healthcare staff, and the family. This facilitates the engagement of the rural community in the provision of therapy services and encourages practical problem-solving [54].

Treatment efficacy

In terms of telepractice treatment efficacy, results from comparison studies between in-person delivery and telepractice show similar progress made by both cohorts of children [39,67,68]. Additionally, a hybrid telepractice model that includes parent reports and behavioral measures of vocabulary can provide useful information in screening toddlers for language development [69]. Among the articles that looked solely at telepractice, researchers found that telepractice was an effective service delivery model for children with phonological disorders [70], speech sound disorders [39], children with communication difficulties [38], and children with complex disabilities [71], audiological evaluations [40], and for delivering auditory-verbal therapy to preschoolers with hearing loss [65]. Parents also indicated that they were either comfortable or satisfied with the telepractice assessment of their child [40,51,76]. In the previously mentioned study by Fairweather et al., the quantitative component of the mixed methods study examined the effectiveness of the telepractice speech therapy intervention provided by telepractice in rural educational settings of Australia. The results indicated treatment effectiveness both in early childcare and in school settings [38].

Factors that were noted as relevant to the success of telepractice included: (a) developing experience in using telehealth [71,73]; (b) role of collaboration and capacity building [38,54,71,73]; (c) having telepractice support, e.g., IT team [39,42,73]. For example, in a study by Hines et al., parents of the children who received telepractice services identified relationship-building between parents and other team members as a relevant factor in telepractice service delivery. They also identified parent coaching as an important factor (e.g., how to set up activities and to use the therapy techniques). In this study, the parents said that these strong relationships were key in overcoming the technical problems related to telepractice, by learning to problem-solve together [71].

Flexibility and costs with the availability of higher quality technology

The quality and availability of technology have a direct impact on telepractice. A systematic review of telepractice in the assessment and treatment of individuals with autism spectrum disorders found that the majority of studies were implemented using comparably inexpensive, common, and transportable technology (e.g., laptops with widely available videoconferencing software). The authors posited that the use of this less expensive and more widely available technology would seem to have several potential benefits beyond the reduced monetary expense. For example, the smaller more transportable technology (e.g., laptops) allows the specialist and client more versatility and flexibility in the delivery of services because one party is not bound to a specific location or “telemedicine studio.” In rural areas of Australia, telepractice provided with consumer-grade technology was rated as having “good” or “okay” audio and visual in the majority of sessions [51].

Ease of using telehealth

In an Australian study by Sutherland et al., clinicians were surveyed about their experiences of using standardized language assessment via telepractice, after administering these standardized tests over a three-month period, to families living in rural and urban areas. These experiences were during the time of the pandemic. The clinicians who administered these tests reported on the ease of using telehealth, not only for themselves but also for their families. There was a mix of positive and negative feedback about the ease of use of the platform features for the CELF-5 standardized test. For example, some participants commented on the ease of using the whiteboard to draw with the child, seeing what the child selected, and even the child’s mouse on the screen [72].

Challenges identified for services offered by telepractice

The challenges in offering services via telepractice included: (a) poor connections and problems with technology; (b) concerns about the quality of service; (c) lack of assessment resources, such as information technology (IT) support; (d) difficulty establishing a rapport; and (e) communication among stakeholders.

Poor connection and problems with technology

Six studies indicated concerns with poor internet connections or problems with technology [38,42,66,70,72,73]. The Internet connection can be especially problematic for people who live in rural areas [38,42]. In a study by Fairweather et al., a few sessions were not able to take place due to the poor internet connection [38]. In the study by Lee et al. [70], one participant dropped out of the study because of a poor internet connection. Video quality was sometimes affected and required troubleshooting [38,66,72]. Therapists suggested that pre-recorded examples of strategies or activities could be made available to families in advance of therapy sessions [66]. In a study conducted during the pandemic, by Sutherland et al., clinicians completed a questionnaire each time they conducted a standardized language assessment via telepractice. Although most of the experiences were positive, one of the challenges described was technical difficulties. The greatest technical difficulty reported was the internet connection. Other participants also commented about problems with the integration of the standardized test (CELF-5) tool with the telehealth platform [72].

Concerns about the quality of service

Although most studies showed favourable outcomes for telepractice for assessment and intervention (as already reported in the section of facilitators for service offered via telepractice). Four studies had participants who had some concerns about the use of telepractice [38,60,66,72]. In two of the studies, the parents had a more favorable opinion about certain components of telepractice than the therapists did [65,66]. In the studies focusing on AVT therapy via telehealth, audio-verbal therapists (AVT) felt that it was difficult to judge the child’s speech production [65,66]. Therapists also indicated that it is more difficult to explain complex information via telepractice [48]. In one study, therapists showed a lower level of satisfaction with the child’s level of interaction with them via telehealth [66]. In the study by Chen et al. [65], some parents noticed that their children had difficulty focusing on the teaching materials during telepractice sessions. Therapists saw the telepractice as a supplement, not a replacement for in-person services [42,48]. In other studies, some of the parents also stated either a strong preference for in-person services over telepractice [58] and believed that there is a need for some in-person sessions in addition to the telepractice, which could in turn improve the therapist-client rapport [73]. Some Early Intervention program coordinators had concerns about the quality of services via telepractice and were questioning whether there is evidence to support the effectiveness of a telepractice service delivery model [60].

Lack of assessment and resources, such as information technology support

Concerns about the lack of necessary resources suitable for telepractice were noted in three studies [65,72,73]. In a study by Chen et al. [65], some families who received AVT therapy by telepractice reported that it was more difficult to prepare the therapy materials at home, than when receiving in person services. Some therapists expressed other challenges related to offering service at a location other than being at one’s office, such as having to wait for a client to find a piece of equipment or the distractions of siblings a home [72].

Difficulty in establishing a rapport

The difficulty in establishing a rapport was not a common theme, but it was expressed by a minority of the parents in two studies [38,73]. In a study by Johnsson et al., some parents felt that additional in-person therapy may increase rapport [73]. In a study by Fairweather et al., one out of a total of five parents stated concern about difficulties in establishing a rapport between the therapist and their child via telehealth [38].

Communication between stakeholders

In two studies, the participants expressed that there were challenges in communication between the stakeholders, in terms of scheduling and communication [38,73], as well as goals and at home follow-up [38].

Discussion

This review explored how therapy services are provided to children living with disabilities in rural areas of upper-middle to high-income countries. Even though this review targeted mid- to high-income countries, no studies on upper mid-income countries were found which met the inclusion criteria. It is possible that most up-to-date research with a focus on pediatric therapy services in rural settings occurred in low-income, low middle income, and high-income countries, but not the upper middle-income countries. A total of 37 studies met our inclusion criteria and were published between 1 January 2009 and 18 January 2022. The review revealed that children living with a disability in rural settings of high-income countries receive several therapy services (OT, SLP, PT, and AUD) but also face many barriers to care.

Challenges in accessing therapies in rural settings

The therapeutic services explored in this review were less frequently available, more difficult to access, and offered less options for families and had longer wait times, than services in urban areas. Families needed to travel long distances to see therapists and incurred costs related to the travel and taking the time off work. These findings are similar to those of Gallego et al. [3] who reported unique challenges to accessing rehabilitation therapy services for families of children with disabilities living in rural areas as related especially to restricted accessibility and financial burden [12]. Furthermore, as therapists are experiencing large caseloads in these communities, there are often challenges in communication or coordination between the therapists and the various agencies providing therapeutic care [13,45,49,53,56,57]. Families reported that they didn’t have information about their child’s disability and any support information while waiting for services [13,15,47,49,57].

Delivery of therapeutic services in rural settings: in person vs. telepractice

Most therapy services were delivered in-person as well as via telepractice to families living in rural communities in high-income countries. In-person services consisted of outreach programs where therapists travelled to the child’s home or school setting, or specialized on-site programs in rural communities devised for a specific population. Among the many benefits of in-person therapy services, included the providers’ understanding of the context of life in rural areas, and their ability to provide useful solutions grounded in the reality of the child’s family and community life.

Studies examining telepractice involved a variety of approaches. Some explored therapy services provided via video platforms, while others relied on the phone, email, or the exchange of USB drives with families through the mail. Offering telepractice services to families living in rural areas meant easier and quicker access to services, with reduced travel expenses and expenses associated with taking time off work to attend appointments. In some cases it resulted in other outcomes, such as increased parental confidence and comfort in engaging with their children during therapy appointments as well as increased parental acceptance of telepractice. Other benefits of offering telepractice services to families living in rural settings included improvements in child and family engagement, transition and care planning, treatment efficacy, family support and flexibility, and costs with the availability of higher quality technology. One of the main barriers associated with providing telepractice services for families living in rural communities involves technological considerations, such as quality internet connections and problems with technology which can hamper service delivery. Other barriers concern the quality of service, difficulty in establishing a rapport, communication between stakeholders, and a lack of assessment and resources, such as information technology support. Other studies conducted during the pandemic [64,75,77] observed additional barriers to telepractice, such as lack of sufficient resources, IT support, and lack of experience in using technology. Furthermore, there may be some limitations to telepractice depending on a specific discipline or the nature of therapeutic assessment or intervention. For example, this review also found that using telepractice for articulation therapy or auditory verbal therapy may be especially challenging with therapists reporting difficulty in their ability to judge speech production via remote connection. Delivering services via telepractice to families living in rural families offers many benefits but as Hsu et al. have stressed, for telepractice to be effective, therapists require proper training, equipment, and IT support [78]. So, how does telepractice compare with in-person service delivery? Nine of the studies reviewed explored and compared the effectiveness of both delivery modes and concluded comparable results. However, it is important to note that this body of research evidence is still emerging, and each study considered a different type of therapy setting or group of children. Furthermore, as Hsu et al. noted, the results of these types of studies may not always generalize to all clinical settings [78].

Description of services in research studies

The review also revealed several shortcomings in the literature with regards to the details of services delivered in rural settings. For instance, although fifteen out of the thirty-seven studies involved more than one discipline of interest (SLP, OT, PT, AUD, or RT), information about the level and nature of inter-disciplinary collaboration was often not clearly described in the reviewed studies. A clearer description of the role and nature of collaboration between these disciplines would provide more insight into what types of inter-disciplinary collaboration is effective or not effective in rural areas. Interdisciplinary collaborations were found to be particularly crucial when there was a shortage of therapists or specific expertise in rural areas [46–48], and an interdisciplinary approach may be especially advantageous to families and children. Additionally, many studies also lack descriptions of the details of how programs or specific services were offered to children and families living in rural areas. Only eight studies provided detailed descriptions of the therapy programs or the specific nature of the service provided. Many studies provided limited information with regards to the functional abilities, nature, or severity of the clients’ impairments. Typically, only diagnosis and age were provided, whereas the method of therapy (e.g., individual, group therapy, consultation or specific therapy approach) was not identified or described. Therefore, it was difficult to discern sufficient details required to conclude with relevance to practice, even when service delivery modes were compared. Furthermore, there were no studies describing specifically recreational therapy services. It is possible that services related to recreation and leisure have been provided in some communities not as a separate therapeutic modality, but rather within the context of OT, SLP, or PT service delivery. It is hence important such programs are described, to better understand the outcomes of services focusing specifically on leisure, recreation, or play, which provide an important developmental context for children [79].

Considerations of the impact of COVID-19 pandemic

The COVID-19 pandemic has disrupted many aspects of rehabilitation therapies. Many families have faced difficulties in accessing in person services, and have instead accessed services via telepractice [74,75]. The physical distance created between the therapist, the client, and the child, has created a need for the therapist to rely on parent coaching skills and parent involvement [78]. The switch to virtual methods of service delivery has enabled families residing in a rural area to access multidisciplinary teams or several specialists at the same telepractice from various physical sites [78]. This may help to facilitate coordination and communication between specialists. The continuation of telepractice service delivery options for families living in rural areas post-pandemic is an important consideration. Although telepractice may not be the best option for all families and children, it does offer an effective way to deliver services to families who live in rural settings. Further considerations should include removing any barriers to providing telepractice services to families living in a remote setting. This may involve providing continued funding and training of therapists offering telepractice services [64].

Cultural considerations

A few studies identified cultural context considerations as critical to planning and implementing services in rural communities. For example, offering specific programs to Aboriginal populations in non-school settings, such as modifying strategies based on parents’ input and comfort level [43]. Considering the culture of rural communities is relevant for the provision of therapy services as it can empower individuals and improve their rates of participation in treatment and in their community [17,18]. These considerations should occur not only at a clinician level but also at organizational and government levels. Gilroy et al. examined the environmental and systemic challenges associated with delivering services to Aboriginal adults with a disability in Australia. Therapists in this study experienced challenges in providing culturally appropriate services due to the systemic inflexibilities, such as organizational policies and rigid government systems [80]. The Rural and Remote Person-Centered Approach suggested by Dew et al. [24], might provide a useful template for designing services that are culturally relevant and consider the unique needs of each community. This approach involves tailoring services by determining which supports do not exist locally; bringing in outreach for the services that do not exist (e.g., expertise); enabling families to travel to centre-based support that is not possible for outreach; and exploring virtual service delivery options (e.g., telehealth, web-based systems, information, and resources) [81–83].

Limitations

A little over half of the articles in this review (n = 17) were studies that contained information about services provided in both rural and urban regions. Although we made every effort to extract any data that was specifically relevant to rural areas, it was not always possible, if the data were combined for both regions. Therefore, interpretation from the studies which contain information from both rural and urban areas needs to be done with caution. Although there were attempts made to minimize bias, there is a risk of bias from the nature of the databases chosen for the review. Only databases pertaining to rehabilitation science, psychology, and medicine were chosen for this review. This scoping review included only the research published in peer-reviewed journal articles and did not include conference proceedings. Although conference proceedings can provide more current practice information, it may be difficult to discern a rigour of the review process.

One of the initial study exclusions consisted of studies that did not mention whether the services occurred in a rural setting. With the increased use of telepractice since the COVID-19 pandemic, it is possible that some relevant telepractice studies were excluded if they did not specify that they offered services for families living in rural settings.

Future research directions

More research is required to address the needs of children with disabilities and their families living in rural areas as to the best mode of delivery, given a specific therapy assessment or intervention program. Further research is needed that focuses specifically on the rural communities and their unique needs for therapy services for children with disabilities. One study identified that recruitment of families living in rural communities due to travel distances was challenging [84]. Conducting research in the rural communities rather than having the families drive to rural centres, may help with recruitment, and yield more meaningful results. Based on the findings of this review it is recommended that in the future researchers clearly describe the services provided, their scope, nature, and method of provision, rather than only name a discipline, as well as provide more information than just a diagnosis about the children that the services concern.

Other suggestions for future research identified in this review concern services provided in rural areas in mid-income countries and the provision of culturally appropriate services in rural areas, such as in Indigenous rural communities. Moreover, examining interprofessional collaboration in rural areas may help to understand how the teams of therapists work together and with families. Research could also explore how current therapies are addressing out-of-school activity participation needs of children and youth in rural settings and consider the voice of children in future studies.

The review also revealed several areas requiring further research in rural settings including a paucity of research focusing on assessment and recreation therapy. Assessment services were widely overlooked in the pediatric literature with most studies focusing on intervention services in rural areas. Only two studies explored in person services assessment in rural settings. Yet most of the current models and frameworks point to the importance of assessing the person-environment interaction [85,86]. One in the discipline of audiology assessment, and one study in language testing by speech-language pathologists. Similar findings occurred in the telepractice studies, where only four studies explored assessment services: three in the assessment by speech-language pathologists, and one in audiology assessment. There were no studies about recreation therapy services for children and youth in rural settings. The reason for this is unknown. It is possible that services related to recreation in these communities were provided not as a separate therapeutic intervention, but rather in conjunction with other therapies within the service delivery. Further research is needed to understand if and how rural therapy services focus on supporting children’s recreation and leisure, rather than only self-care or schoolwork. The leisure, play, and recreation are an important part of childhood, and children with disabilities are at risk of limited opportunities to participate in such activities with their peers [79].

Although there has been growth in the number of studies on telepractice, further research is needed to better understand how practitioners mediate the challenges of telepractice (e.g., share materials with families in advance or solve technology breakdowns). Have the attitudes towards telepractice and about quality of service improved with its use? Are there certain treatments that are more conductive to telepractice than others? More research is also needed to investigate the use of standardized assessments and non-standardized assessments via telepractice. There is also a gap in research on how telepractice is used in modes other than video platforms (e.g., phone intervention, videogames interventions, texts, etc.) in rural communities for children with disabilities.

Lastly, this current review revealed that researchers asked parents and therapists about their perspectives and opinions on therapies, but there was a lack of research on the perspectives of children and youth about the services offered. This should be further explored in future research studies.

Conclusions

This review found the limited scope of research related specifically to therapy services provided to children and youth with disabilities and impairments living in rural areas of upper-mid and high-income countries. All studies and results present information about high-income countries, as there were no studies found for upper mid-income countries. The results of this review indicate an inconsistent, fragmented reporting on how services are provided in rural areas. Services offered in rural regions varied, including in person services (such as outreach services, specialized services) as well as via telepractice. The effectiveness of in person services and telepractice services were comparable. There was a mix of positive outcomes and challenges in the use of in person and telepractice service delivery. Overall, telepractice allowed for easier access to services for families living in rural areas. However, nuances of telepractice services, especially assessment strategies which account for environmental factors require further attention from researchers and practitioners.

Acknowledgements

The authors would like to acknowledge the support of Paola Durando for help with the search strategy, Carrie Davis, and Kelsi Herder, for screening and reviewing the papers, as well as Sabrina Monsonego for her help with editing.

Disclosure statement

No potential conflicts of interest were reported by the author(s).

Additional information

Funding

This work was supported by the AMS Phoenix Fellowship (Beata Batorowicz). Paulina Finak was supported by the Queen’s School of Graduate Studies Doctoral Award.