. 2020 Apr; 6:20.
doi: 10.21037/mhealth.2019.10.04.

Telehealth for rural diverse populations: telebehavioral and cultural competencies, clinical outcomes and administrative approaches

Donald M Hilty 1 Melanie T Gentry 2 Alastair J McKean 3 Kirsten E Cowan 4 Russell F Lim 5 Francis G Lu 6 
  • PMID: 32270012
  •     65 References
  •     10 citations


Rural health care settings are challenged to provide timely and evidence-based care, particularly for culturally diverse patients with behavioral health disorders. Telepsychiatry and telebehavioral health improve access to care and leverage scarce resources. This scoping review from January 2000 - July 2019 was conducted to see if the literature had data for two related the research questions, "What are the components of culturally competent, telepsychiatric clinical care, and what approaches have clinicians and systems taken to implement and evaluate it?" The review focused on key words in four concept areas: (I) competencies; (II) telehealth in the form of telepsychiatry, telebehavioral or telemental health; (III) culture; and (IV) health. It was done in accordance with the six-stage scoping review process in PubMed/Medline and other databases. The screeners reviewed the full-text articles for final inclusion based on inclusion (mesh of the key words) and exclusion (e.g., need for only, skills abstractly discussed) criteria. From a total of 1,118 papers, the authors found 44 eligible for full text review and found 7 papers directly relevant to the concepts. Few studies specifically discuss skills and competencies of both telehealth and cultural factors. Many organizations are attending to cultural competencies and approaches to care, but there are no specific competencies that integrate telepsychiatry or telebehavioral health with culture. Existing telepsychiatric (i.e., video, social media, mobile health) and one set telebehavioral health competencies included cultural component, including use of interpreters and language matters. Administrative adjustments are suggested to promote culturally competent care by telehealth via clinical, educational, quality improvement, program/system evaluation, and other (e.g., finance and reimbursement) interventions. More structured research is needed on development, implementation and evaluation of combined competencies in rural settings.

Keywords: Culture; competency; health; rural; telebehavioral.

Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care.
Joseph R Betancourt, Alexander R Green, J Emilio Carrillo, Owusu Ananeh-Firempong.
Public Health Rep, 2003 Jun 20; 118(4). PMID: 12815076    Free PMC article.
Highly Cited.
Hispanics and telepsychiatry.
J Edwin Nieves, Kathleen M Stack.
Psychiatr Serv, 2007 May 31; 58(6). PMID: 17535953
A feasibility study of the use of asynchronous telepsychiatry for psychiatric consultations.
Peter M Yellowlees, Alberto Odor, +3 authors, Donald Hilty.
Psychiatr Serv, 2010 Aug 03; 61(8). PMID: 20675845
The clinical application of the biopsychosocial model.
G L Engel.
Am J Psychiatry, 1980 May 01; 137(5). PMID: 7369396
Highly Cited.
Cultural competence: a systematic review of health care provider educational interventions.
Mary Catherine Beach, Eboni G Price, +9 authors, Lisa A Cooper.
Med Care, 2005 Mar 22; 43(4). PMID: 15778639    Free PMC article.
Highly Cited. Systematic Review.
When nurses double as interpreters: a study of Spanish-speaking patients in a US primary care setting.
V Elderkin-Thompson, R C Silver, H Waitzkin.
Soc Sci Med, 2001 Apr 05; 52(9). PMID: 11286360
A framework for telepsychiatric training and e-health: Competency-based education, evaluation and implications.
Donald M Hilty, Allison Crawford, +8 authors, Su-Ting Li.
Int Rev Psychiatry, 2015 Nov 06; 27(6). PMID: 26540642
Rural-urban differences in depression treatment and suicidality.
K Rost, M Zhang, +2 authors, G R Smith.
Med Care, 1998 Jul 23; 36(7). PMID: 9674626
Videoconference diagnosis and management of Choctaw Indian dementia patients.
Myron F Weiner, Heidi C Rossetti, Kasia Harrah.
Alzheimers Dement, 2011 Nov 08; 7(6). PMID: 22055972    Free PMC article.
Cultural aspects of telepsychiatry.
Jay H Shore, Daniel M Savin, Douglas Novins, Spero M Manson.
J Telemed Telecare, 2006 Apr 28; 12(3). PMID: 16638232
Non-English speakers consulting with the GP in their own language: a cross-sectional survey.
George K Freeman, Harbinder Rai, +3 authors, Margaret Maxwell.
Br J Gen Pract, 2002 Jan 17; 52(474). PMID: 11794324    Free PMC article.
Telepsychiatry and other technologies for integrated care: evidence base, best practice models and competencies.
Donald M Hilty, Nadiya Sunderji, +2 authors, Robert M McCarron.
Int Rev Psychiatry, 2019 Mar 02; 30(6). PMID: 30821540
The effectiveness of telemental health: a 2013 review.
Donald M Hilty, Daphne C Ferrer, +3 authors, Peter M Yellowlees.
Telemed J E Health, 2013 May 24; 19(6). PMID: 23697504    Free PMC article.
Highly Cited. Review.
Cultural competence education for health professionals.
Lidia Horvat, Dell Horey, Panayiota Romios, John Kis-Rigo.
Cochrane Database Syst Rev, 2014 May 06; (5). PMID: 24793445
Highly Cited. Systematic Review.
The State and Sustainability of Telepsychiatry Programs.
Carolyn Lauckner, Pamela Whitten.
J Behav Health Serv Res, 2015 Mar 22; 43(2). PMID: 25794639    Free PMC article.
Continuing education training focused on the development of behavioral telehealth competencies in behavioral healthcare providers.
V Gifford, B Niles, +2 authors, J Polaha.
Rural Remote Health, 2012 Dec 18; 12. PMID: 23240871
Telepsychiatry integration of mental health services into rural primary care settings.
John C Fortney, Jeffrey M Pyne, +5 authors, Jürgen Unützer.
Int Rev Psychiatry, 2015 Dec 05; 27(6). PMID: 26634618
Limited English proficiency as a barrier to mental health service use: a study of Latino and Asian immigrants with psychiatric disorders.
Giyeon Kim, Claudia X Aguado Loi, +3 authors, Rebecca S Allen.
J Psychiatr Res, 2010 Jun 12; 45(1). PMID: 20537658
Transcultural telepsychiatry and its impact on patient satisfaction.
Davor Mucic.
J Telemed Telecare, 2010 Apr 29; 16(5). PMID: 20423935
A Framework for Competencies for the Use of Mobile Technologies in Psychiatry and Medicine: Scoping Review.
Donald Hilty, Steven Chan, +2 authors, Robert Boland.
JMIR Mhealth Uhealth, 2020 Mar 05; 8(2). PMID: 32130153    Free PMC article.
Using e-health to enable culturally appropriate mental healthcare in rural areas.
Peter Yellowlees, Shayna Marks, Don Hilty, Jay H Shore.
Telemed J E Health, 2008 Jun 27; 14(5). PMID: 18578685    Free PMC article.
Feasibility and acceptability of clinic-based telepsychiatry for low-income Hispanic primary care patients.
Jenny Chong, Francisco Moreno.
Telemed J E Health, 2012 Mar 20; 18(4). PMID: 22424078
A qualitative needs assessment for development of a cultural consultation service.
Hendry Ton, Alan Koike, +2 authors, Donald M Hilty.
Transcult Psychiatry, 2005 Nov 05; 42(3). PMID: 16268240
A lexicon of assessment and outcome measures for telemental health.
Jay H Shore, Matt C Mishkind, +24 authors, Alexander Vo.
Telemed J E Health, 2014 Jan 31; 20(3). PMID: 24476192
Patient-physician racial concordance and the perceived quality and use of health care.
S Saha, M Komaromy, T D Koepsell, A B Bindman.
Arch Intern Med, 1999 May 18; 159(9). PMID: 10326942
Highly Cited.
A developmental model for rural telepsychiatry.
Jay H Shore, Spero M Manson.
Psychiatr Serv, 2005 Aug 10; 56(8). PMID: 16088015
Role-blurring and ethical grey zones associated with lay interpreters: three case studies.
Charles Brua.
Commun Med, 2008 Jan 01; 5(1). PMID: 19363881
Physician cultural competence and patient ratings of the patient-physician relationship.
Kathryn A Paez, Jerilyn K Allen, +2 authors, Lisa A Cooper.
J Gen Intern Med, 2009 Feb 06; 24(4). PMID: 19194767    Free PMC article.
Medical decision support for remote general practitioners using telemedicine.
I J Armstrong, W S Haston.
J Telemed Telecare, 1997 Jan 01; 3(1). PMID: 9139758
Barriers to Use of Telepsychiatry: Clinicians as Gatekeepers.
Kirsten E Cowan, Alastair J McKean, Melanie T Gentry, Donald M Hilty.
Mayo Clin Proc, 2019 Dec 07; 94(12). PMID: 31806104
Highly Cited. Review.
An Update on Telepsychiatry and How It Can Leverage Collaborative, Stepped, and Integrated Services to Primary Care.
Donald M Hilty, Terry Rabinowitz, +4 authors, John Fortney.
Psychosomatics, 2018 Mar 17; 59(3). PMID: 29544663
Collaborative management to achieve treatment guidelines. Impact on depression in primary care.
W Katon, M Von Korff, +5 authors, J Russo.
JAMA, 1995 Apr 05; 273(13). PMID: 7897786
Highly Cited.
Moving into the neighborhood: preparing residents to participate in a primary care environment.
W E Greenberg, R H Paulsen.
Harv Rev Psychiatry, 1996 Jul 01; 4(2). PMID: 9384982
Use of standard Webcam and Internet equipment for telepsychiatry treatment of depression among underserved Hispanics.
Francisco A Moreno, Jenny Chong, +2 authors, Seenaiah Byreddy.
Psychiatr Serv, 2012 Oct 03; 63(12). PMID: 23026854
Social Media and Networking Competencies for Psychiatric Education: Skills, Teaching Methods, and Implications.
Isheeta Zalpuri, Howard Y Liu, +3 authors, Donald Hilty.
Acad Psychiatry, 2018 Oct 05; 42(6). PMID: 30284148
Financial benefits of a pediatric intensive care unit-based telemedicine program to a rural adult intensive care unit: impact of keeping acutely ill and injured children in their local community.
James P Marcin, Thomas S Nesbitt, +2 authors, Robert J Dimand.
Telemed J E Health, 2004 Jan 01; 10 Suppl 2. PMID: 23570207
Community transformation through culturally competent nursing leadership: application of theory of culture care diversity and universality and tri-dimensional leader effectiveness model.
Mina L Shapiro, June Miller, Kathleen White.
J Transcult Nurs, 2006 Apr 06; 17(2). PMID: 16595398
Telepsychiatry services for Korean immigrants.
Jiali Ye, Ruth Shim, +3 authors, George Ruth.
Telemed J E Health, 2012 Dec 14; 18(10). PMID: 23234426    Free PMC article.
A Framework of Interprofessional Telebehavioral Health Competencies: Implementation and Challenges Moving Forward.
Marlene M Maheu, Kenneth P Drude, Katherine M Hertlein, Donald M Hilty.
Acad Psychiatry, 2018 Oct 05; 42(6). PMID: 30284147
Overcoming the triad of rural health disparities: How local culture, lack of economic opportunity, and geographic location instigate health disparities.
Tami L Thomas, Ralph DiClemente, Samuel Snell.
Health Educ J, 2014 Sep 23; 73(3). PMID: 25242822    Free PMC article.
Diversity initiatives in academic psychiatry: applying cultural competence.
Russell F Lim, John S Luo, Shannon Suo, Robert E Hales.
Acad Psychiatry, 2008 Aug 13; 32(4). PMID: 18695029
Culture and rural health.
Jane Farmer, Lisa Bourke, +4 authors, Nicole Johnson.
Aust J Rural Health, 2012 Sep 25; 20(5). PMID: 22998197
Rural versus suburban primary care needs, utilization, and satisfaction with telepsychiatric consultation.
Donald M Hilty, Thomas S Nesbitt, +2 authors, Robert E Hales.
J Rural Health, 2007 Apr 03; 23(2). PMID: 17397373
Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care.
G E Simon, M VonKorff, C Rutter, E Wagner.
BMJ, 2000 Feb 25; 320(7234). PMID: 10688563    Free PMC article.
Highly Cited.
Culture and psychiatric education.
Russell F Lim, Francis G Lu.
Acad Psychiatry, 2008 Aug 13; 32(4). PMID: 18695027
Culture and ethnicity in clinical care.
J T Berger.
Arch Intern Med, 1998 Nov 04; 158(19). PMID: 9801174
Language barriers in Vienna hospitals.
F Pöchhacker.
Ethn Health, 2000 Sep 14; 5(2). PMID: 10984829
Increasing trend of wearables and multimodal interface for human activity monitoring: A review.
Preeti Kumari, Lini Mathew, Poonam Syal.
Biosens Bioelectron, 2016 Dec 09; 90. PMID: 27931004
Transcultural psychiatry made simple--asynchronous telepsychiatry as an approach to providing culturally relevant care.
Peter M Yellowlees, Alberto Odor, +8 authors, Donald Hilty.
Telemed J E Health, 2013 Mar 05; 19(4). PMID: 23451812    Free PMC article.
Scoping studies: advancing the methodology.
Danielle Levac, Heather Colquhoun, Kelly K O'Brien.
Implement Sci, 2010 Sep 22; 5. PMID: 20854677    Free PMC article.
Highly Cited.
Practice guidelines for videoconferencing-based telemental health - October 2009.
Peter Yellowlees, Jay Shore, Lisa Roberts, American Telemedicine Association.
Telemed J E Health, 2010 Dec 29; 16(10). PMID: 21186991
Patient and provider perspectives on using telemedicine for chronic disease management among Native Hawaiian and Alaska Native people.
Vanessa Hiratsuka, Rebecca Delafield, +2 authors, Marjorie Mala Mau.
Int J Circumpolar Health, 2013 Aug 27; 72. PMID: 23977642    Free PMC article.
Pitfalls in communication with Hispanic and African-American patients: do translators help or harm?
T R Brooks.
J Natl Med Assoc, 1992 Nov 01; 84(11). PMID: 1460681    Free PMC article.
The need for a new medical model: a challenge for biomedicine.
G L Engel.
Science, 1977 Apr 08; 196(4286). PMID: 847460
Highly Cited.
The Need to Implement and Evaluate Telehealth Competency Frameworks to Ensure Quality Care across Behavioral Health Professions.
Donald M Hilty, Marlene M Maheu, Kenneth P Drude, Katherine M Hertlein.
Acad Psychiatry, 2018 Nov 15; 42(6). PMID: 30426453
What's known about implementing co-located paediatric integrated care: a scoping review.
Rheanna E Platt, Andrea E Spencer, +6 authors, Lawrence S Wissow.
Int Rev Psychiatry, 2019 Mar 27; 30(6). PMID: 30912463    Free PMC article.
Culture and health.
A David Napier, Clyde Ancarno, +24 authors, Katherine Woolf.
Lancet, 2014 Dec 03; 384(9954). PMID: 25443490
Highly Cited.
Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda.
Enola Proctor, Hiie Silmere, +5 authors, Melissa Hensley.
Adm Policy Ment Health, 2010 Oct 20; 38(2). PMID: 20957426    Free PMC article.
Highly Cited.
Rural primary care providers' perceptions of their roles in the provision of mental health services: voices from the plains.
J M Geller.
J Rural Health, 2002 Apr 11; 15(3). PMID: 11942565
Identifying Gaps in the Cultural Competence/Sensitivity Components of an Undergraduate Medical School Curriculum: A Needs Assessment.
Sana Loue, Amy Wilson-Delfosse, Kristen Limbach.
J Immigr Minor Health, 2014 Sep 17; 17(5). PMID: 25225077
Health workforce cultural competency interventions: a systematic scoping review.
Crystal Jongen, Janya McCalman, Roxanne Bainbridge.
BMC Health Serv Res, 2018 Apr 04; 18(1). PMID: 29609614    Free PMC article.
Systematic Review.
Language access and Latino health care disparities.
Eliseo J Pérez-Stable.
Med Care, 2007 Dec 01; 45(11). PMID: 18049339
Telepsychiatry: Effective, Evidence-Based, and at a Tipping Point in Health Care Delivery?
Donald Hilty, Peter M Yellowlees, Michelle B Parrish, Steven Chan.
Psychiatr Clin North Am, 2015 Aug 25; 38(3). PMID: 26300039
Primary Care-Based Models for the Treatment of Opioid Use Disorder: A Scoping Review.
P Todd Korthuis, Dennis McCarty, +6 authors, Roger Chou.
Ann Intern Med, 2016 Dec 06; 166(4). PMID: 27919103    Free PMC article.
Highly Cited. Review.
The diffusion of telehealth in rural American Indian communities: a retrospective survey of key stakeholders.
Elizabeth Brooks, Spero M Manson, +2 authors, Jay H Shore.
Telemed J E Health, 2011 Nov 16; 18(1). PMID: 22082106    Free PMC article.
A Survey Comparing Adult and Child Psychiatry Trainees, Faculty, and Program Directors' Perspectives About Telepsychiatry: Implications for Clinical Care and Training.
Kali Orchard, Cesar Cruz, Erica Z Shoemaker, Donald M Hilty.
J Technol Behav Sci, 2021 Jan 28; 6(2). PMID: 33501373    Free PMC article.
Sensor, Wearable, and Remote Patient Monitoring Competencies for Clinical Care and Training: Scoping Review.
Donald M Hilty, Christina M Armstrong, +3 authors, Elizabeth A Krupinski.
J Technol Behav Sci, 2021 Jan 28; 6(2). PMID: 33501372    Free PMC article.
A Survey of Residents/Fellows, Program Directors, and Faculty About Telepsychiatry: Clinical Experience, Interest, and Views/Concerns.
Cesar Cruz, Kali Orchard, Erica Z Shoemaker, Donald M Hilty.
J Technol Behav Sci, 2021 Feb 16;. PMID: 33585672    Free PMC article.
Telemental Health Use and Refugee Mental Health Providers Following COVID-19 Pandemic.
Lindsey Disney, Orion Mowbray, Dana Evans.
Clin Soc Work J, 2021 May 11; 49(4). PMID: 33967352    Free PMC article.

;. PMID: 34843197
Association of Physician Characteristics With Early Adoption of Virtual Health Care.
Kori S Zachrison, Zhiyu Yan, +3 authors, Lee H Schwamm.
JAMA Netw Open, 2021 Dec 31; 4(12). PMID: 34967876    Free PMC article.
Shifting to Tele-Mental Health in humanitarian and crisis settings: an evaluation of Médecins Sans Frontières experience during the COVID-19 pandemic.
Khasan Ibragimov, Miguel Palma, +7 authors, M. S. F. Mental Health Working Group.
Confl Health, 2022 Feb 16; 16(1). PMID: 35164807    Free PMC article.
Advancing Liver Cancer Prevention for American Indian Populations in Arizona: An Integrative Review.
Timian M Godfrey, Edgar A Villavicencio, +4 authors, David O Garcia.
Int J Environ Res Public Health, 2022 Mar 26; 19(6). PMID: 35328956    Free PMC article.
Center the margin: Equity-Based Assessment and Response Strategies to Reach Underserved Communities Using a Telehealth Service Delivery Model.
Denisha Gingles.
Behav Anal Pract, 2022 Apr 06;. PMID: 35378773    Free PMC article.
Challenges and strategies for promoting health equity in virtual care: findings and policy directions from a scoping review of reviews.
Suman Budhwani, Jamie Fujioka, +10 authors, James Shaw.
J Am Med Inform Assoc, 2022 Feb 22; 29(5). PMID: 35187571    Free PMC article.