Digital health technologies to improve access to comprehensive primary health care in remote Northern Territory, Australia: qualitative findings from thought leader interviews

Digital health technologies to improve access to comprehensive primary health care in remote Northern Territory, Australia: qualitative findings from thought leader interviews | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Digital health technologies to improve access to comprehensive primary health care in remote Northern Territory, Australia: qualitative findings from thought leader interviews Vishnu Khanal, Emily Saurman, Nicki Newton, Kureisha Wilson, Josielli Comachio, and 17 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7837584/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Existing literature shows the potential of digital health technologies (DHTs) to improve access to Comprehensive Primary Health Care (CPHC) by overcoming various challenges to care provision. However, the usefulness of DHTs in the remote Northern Territory (NT) Australian context to support the delivery of CPHC has rarely been explored. This study aims to explore thought leaders' perspectives about the key challenges to accessing CPHC services and the role of DHTs in overcoming these challenges in the NT. Methods In-depth interviews were conducted with 17 participants who were working or had previously worked in the NT in clinical or non-clinical roles, including in leadership, governance, and management roles with the NT Health Department or Aboriginal Community Controlled Health Services. Thematic analysis was conducted using a deductive approach based on the theory of access. Results The results suggested that the key challenges to accessing CPHC in the remote NT include workforce issues (staff shortages, high staff turnover, poor continuity of care), the large distances and costs of providing care, and how health care services were organised and delivered. Participants highlighted the potential of DHTs for improving challenges relating to provider availability, continuity of care, and cost savings for health services. However, challenges to implementing digital solutions were also raised which were broadly classified as technological and non-technological. Poor digital infrastructure, intermittent connectivity, and the lack of interoperability of systems between healthcare organisations were key technological challenges. Low rates of digital device ownership and low digital literacy; the limited local availability of skilled staff to support digital solutions, and the lack of flexibility in the way appointments were organise were identified as key non-technological challenges. Conclusions There was an optimism that DHTs could substantially improve healthcare access in the NT. Telehealth, used where appropriate and in combination with face-to-face care using a hybrid approach, could improve remote patients’ access to a range of healthcare providers, reduce patients’ and providers’ need to travel and improve continuity of care. This will necessitate increased investment in training local Indigenous people to support communities’ access to DHTs and improve the quality and cultural safety of care. Digital Health Telehealth Remote Health Primary Care Aboriginal Health Background Poor access to primary health care in remote and very remote communities is a well-known and long-standing issue in Australia [ 1 , 2 ]. The small proportion of Australia’s population living in remote areas (1.2%) or very remote areas (0.8%) are widely dispersed across Australia’s considerable land mass. About 32% of the population in the remote and very remote communities identify as Aboriginal and Torres Strait Islander peoples [ 3 ]. The Australian Institute for Health and Welfare (AIHW) 2021 statistics show that people living in remote and very remote areas experience 1.2- and 1.5-times higher mortality than those living in major cities [ 3 ]. Living in remote and very remote areas is also associated with a higher burden of disease, including type 2 diabetes, hypertension and chronic kidney disease [ 3 ]. Comprehensive primary health care (CPHC) is extremely important for delivering equitable preventive, promotive, and rehabilitative health services in a cost-effective way to remote populations [ 4 ]. CPHC is the delivery of essential healthcare services from the first point of contact to enabling equitable access to health and well-being for all residents in the community. It goes beyond just the clinical services [ 5 ]. Challenges to accessing healthcare services in remote and very remote communities include limited health literacy, poor resourcing, and infrastructure, such as reliable transport and road links that support travelling long distances to get to health facilities, reliance on outreach visits for specialist services, and limited health professionals available to deliver care on site [ 1 , 2 ]. It is widely assumed that telehealth can improve access to healthcare, particularly for those living in remote and very remote communities, because of its ability to overcome proximity, transport, and local provider availability issues. Telehealth has been used to improve access to care and support provider-provider communication during urgent or emergency care situations across Australia and remote communities for decades [ 6 , 7 ]. The WHO's Global Strategy on Digital Health 2020–2025 [ 8 ] states that institutionalisation of digital health in the national health system requires decision-making and commitment by the government. Leadership readiness and innovation are crucial to trialling, implementing, and sustaining digital health technologies. In recent years, technological improvements and available bandwidth have enabled access to telephone and video calls with specialists, General Practitioners (GPs), and Allied Health Professionals for remote patients [ 9 – 11 ]. Other digital health tools, such as text messaging, have also been used to support healthcare asynchronously for remote Aboriginal and Torres Strait Islander populations [ 12 ]. However, these initiatives have primarily been delivered in regional and major cities in Australia, with minimal reports of their use in remote and very remote areas [ 13 ]. The use of digital health technologies (DHTs), including telehealth, in remote CPHC settings can be resource-intensive and increase the administrative workload for remote staff [ 9 , 14 ]. Previous studies have highlighted a range of barriers and facilitators to using DHTs from remote CPHC staff members’ perspectives [ 9 , 10 ]. However, there remains a lack of scientific evidence about the perceptions of health leaders, providers, and managers about how DHTs could be used to improve access to CPHC in remote communities. It is also important to understand how health professionals respond to the new technology because their readiness is essential for the successful implementation of any DHTs in the healthcare system. This study aimed to explore the perceptions of thought leaders about the key challenges to accessing CPHC services and the role of DHTs in overcoming these challenges in the Northern Territory (NT). Methods This study is part of a larger program being conducted with four remote Aboriginal communities in the NT (July 2022 to July 2026) to co-design, implement or optimise, and evaluate various digital health initiatives by examining the preference of health system staff and consumers. The data used in this manuscript is derived from the interviews at the initial phase of the project. The study protocol has been published elsewhere [ 15 ]. The research project was reviewed and approved by the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research ( HREC Approval Number: 2022–4275 ). Administrative approval was also obtained from the Research Governance Office, NT Health ( EFILE 2023/8720 ), and the Boards of participating Aboriginal Community-Controlled Health Services (ACCHSs). Study setting This mixed-method participatory program is currently being conducted in four very remote communities and their respective referral hospitals in the NT. Remoteness is defined using the Modified Monash Model geographical classification [ 16 ]. The study has been iteratively engaging with various stakeholders to implement and (or) evaluate various DHTs. About 26.0% of the NT population identifies as Aboriginal or Torres Strait Islander (compared to 3.2% across Australia) [ 17 ]. In remote and very remote communities of the NT, the proportion of the population who identify themselves as Aboriginal and Torres Strait Islander is more than 90% [ 17 ]. In these remote and very remote communities, CPHC services are delivered by either the NT Government or Aboriginal Community Controlled Health Services (ACCHSs). Participants and recruitment Invited participants included 'thought leaders’ working in clinical or non-clinical roles, including leadership, governance, and management roles with the NT Health Department or Aboriginal Community Controlled Health Services (ACCHSs). Thought leaders were defined in this study as individuals with an in-depth understanding of remote CPHC. Those who provided written consent were interviewed face-to-face or online via Zoom or Microsoft Teams. Prospective participants were recruited via health service nomination, self-nomination at professional development events, or nomination by project advisory group members using a purposive sampling method. Interview guide and data collection Participants were interviewed virtually or face-to-face, depending on their preference and geographic location. Interviews were conducted between February 2023 and February 2024. Two researchers were present for each interview (VK and DR or NN) where possible. A semi-structured interview guide was developed, informed by the theory of access [ 18 , 19 ] and previous work in remote primary health care and digital health context [ 9 , 20 – 22 ]. While a core set of questions was consistently applied across interviews, the guide was iteratively refined throughout the data collection process to reflect emerging insights and enhance relevance (Table 1 ). Table 1 Semi-structured one-to-one interview guide 1. Tell me about the challenges you/health professionals might face to ensure your patients can access primary health care in remote NT? 2. What do you think are the main challenges that health professionals face in providing accessible primary health care in remote NT? 3. What works well for patients to ensure their access to primary health care in remote NT? 4. We are particularly interested in the space for digital technology to help improve delivery and access to comprehensive primary health care. What digital technologies are you or other health professionals already using in remote NT to provide primary health care? 5. What can be done using digital technologies that might help address the challenges we’ve been talking about? What are the existing digital health technologies currently being used in NT? 6. Thinking more broadly about using digital technologies to improve access to PHC. What were/are the key challenges in using digital technology to ensure access to primary health care for patients? (if they are not using digital tech, explore anticipated challenges). How do you think these challenges could be resolved? (new mechanism/intervention) Data analysis All interviews were audio-recorded, transcribed by a professional transcriber [ 23 ], and checked for accuracy by the research team. Transcripts were imported into NVivo for analysis, and thematic analysis was conducted following the six steps as outlined by Braun and Clark [ 24 ]. Four transcripts were independently thematically analysed by VK, NN, and ES, who met frequently and reviewed themes to decide on a coding framework. VK then analysed the remaining transcripts, adding new codes where necessary, with NN and ES reviewing and approving the final coding framework. All authors reviewed the findings to ensure they were relevant and sound. Any disagreements with coding or interpretation of findings were resolved by discussion amongst the researchers. A deductive approach to analysis was taken in this study [ 25 ]. This helped us explore the key challenges to accessing CPHC, and how DHTs could help overcome these barriers. We used Saurman’s modification of Penchansky and Thomas’ ‘theory of access,’ [ 18 , 19 ] to deductively map codes relating to key access issues and how digital technologies could potentially address the access issues. We applied six dimensions of access to the coded data: accessibility, availability, acceptability, affordability, adequacy (accommodation), and awareness (Table 2 ). According to the theory of access, accessibility refers to geography, distance, and transport; availability to supply of health services relative to the need for CPHC services; acceptability to consumer and provider attitudes and beliefs; affordability to direct and indirect costs relative to the ability to pay; adequacy and accommodation to organisation of services; and awareness refers to communication and information with relevant users [ 18 , 26 ]. Table 2 The dimensions of access Dimensions What it relates to Examples Accessibility Proximity of health care providers to consumers relative to the ability to overcome distance Time and geographical distance Availability Supply of services relative to need Volume, and type of services to meet the needs of consumers served Acceptability Consumer and health professionals’ perception Attitude and beliefs of providers and consumers, willingness to seek healthcare from certain gender or background, and using technologies for health Affordability Financial costs relative to the ability to pay Direct and indirect costs of accessing health care. Health system related costs such as travel and accommodation; and consumer-related costs such as incidental costs for food, snacks, communication and workday loss Adequacy (accommodation) Organisation Way in which health care is offered, time and place, and the process of accessing the services. For example, walk-ins vs scheduled appointments, clinic opening time, outreach visits schedules Awareness Communication and information Consumers’ understanding of the health system health professionals’ knowledge of the context, including health literacy Adapted from Saurman [ 18 ] and Russell et al. [ 26 ]. In the second part of our analysis, the key challenges to the successful implementation of DHTs were categorised using themes outlined in previous studies [ 27 , 28 ]. These themes included technological challenges (digital infrastructure, data structure and heterogeneity) and non-technological challenges (patient factors, health service factors, public and societal factors, and policy factors). Results Characteristics of participants Data were collected from 17 thought leaders, of whom ten were female. Participants' ages ranged from 20 to 60 years. Thought leaders had between three and more than 20 years of experience in the NT healthcare system. Participants’ professional backgrounds were diverse, including rural General Practitioners (GPs), Aboriginal Health Practitioners (AHPs), Remote Area Nurses (RANs), nurse educators, coordinators of allied health services, district and primary health care clinic managers, senior leaders of the division, and community leaders. Two participants identified themselves as Aboriginal. All participants were still working in the NT. Non-clinical participants were actively involved in planning and/or rolling out digital health interventions for primary healthcare-related activities in remote areas. Challenges to accessing CPHC in remote Aboriginal communities in NT and the potential of DHTs Accessibility The issues of transport, geographical remoteness, and difficulties in travelling within the remote communities to get to the local clinics were frequently raised during discussions, with their importance highlighted. “I would say that it’s [transport] probably a significant barrier, as anything is with proximity and access, ease of access, to any service obviously means that the likelihood of engaging with the service is far stronger.” (participant 7, public health professional and manager) Most remote Aboriginal communities have resident healthcare staff who work from a local primary healthcare (PHC) clinic to deliver primary healthcare services. In many communities, in-person consultations with GPs were described to be available intermittently from the local clinic. “ I think the distance is not so great in terms of, we have a large number of remote clinical settings for primary healthcare delivery across Northern Territory. And in those remote settings, we have about 52 [PHC clinics] in the government system and another 50 [PHC clinics] in the community-controlled system. And distance is often breached [overcome] by having a presence in those remote communities, and those probably have their clinics .” (participant 11, GP and senior manager). Additionally, the definition of ‘local’ is not that simple; challenges were perceived to persist when people are in homelands, where there is no means to get to the nearest ‘local’ clinic. Homelands are small Aboriginal communities where people live on the lands that they have traditionally owned. Even when clinics are within reach, challenges exist. Participants described that a lack of access to reliable transportation, road conditions, and extreme weather can make it difficult to reach the clinic. Within the community, physically getting to the clinic was also viewed to be particularly challenging for older people and those with disabilities. In some communities, clinic staff drive around, pick people up, bring them to the clinic, and drop them home, but this is limited. “But there’s a cohort of our clients who have mobility impairment, older people, younger people, mums with prams, just getting there [to PHC clinic] physically is an issue sometimes. People have far less access to private vehicles in remote communities. There’s also less access to public transport, and there’s poorer public infrastructure.” (participant 2, allied health professional). “[in] the smaller communities ,.. a driver will go out and try and locate the people within the community, obviously if that’s a viable thing. The more remote you get obviously the less likely that is to happen, because we know there’s a lot of in-between the main communities, there’s a lot of different homelands.” (participant 3, nurse educator) Providing CPHC was perceived to include access to allied health or other visiting services such as oral health. Such comprehensive care was described as practically non-existent for Aboriginal peoples living in their homelands. There are some outreach services that come to the local clinic a few times a year. When consultations with allied health or specialist care are needed, which they often are, people have to travel to their nearest regional centre, which may be hours away. “People like to live across, into remote communities and many of those remote communities may have very limited services in their own right. So, obviously, for example, we fund an outreach programme where we fly different health professionals into communities for a couple of days at a time and take them back out again.” (participant 7, public health professional and manager) “Because yeah, I think the model, even the fly in, fly out model is not going to capture nearly enough [to meet need for health care].” (participant 3, nurse educator) It is perceived that telehealth can help address the geographical disadvantages by reducing the resources, effort, and time required to travel for both health professionals and remote consumers. Telehealth was seen as a solution to improve accessibility to doctors and other health professionals. “So if it’s not necessary to go to Darwin like for those appointments, it would be great if we could sit with her in front of a screen.” (participant 17, community leader) “Oh, I think a lot of telehealth could be done with a lot of the people traveling. Unless they physically need something done in Darwin, like a CT or an MRI or, I don't know, something that cannot be done in community, I really think that a telehealth appointment should be an option in the first instance. ...But definitely I think it would work well. … this would reduce the person having to travel and stress and all those other things, and cost too.” (participant 1, GP) Availability Staff supply, staff turnover, infrastructure and resources, including connectivity, were mentioned during the interview to affect the volume and type of comprehensive primary health care services provided in remote NT. The importance of having a supply of local Aboriginal health workers employed by the health services together with RANs was highlighted, together with current challenges related to their availability, which was perceived to be far below current needs: “The big thing that I think will improve access to primary healthcare for residents in remote communities is having trained Aboriginal Health Practitioners and [Remote Area] nurses available in their community on a reliable basis. It doesn't have to be fulltime everywhere, but it needs to be regular and reliable.” (participant 1, GP) Turnover rates for permanent staff in remote communities are very high, which results in clinics being understaffed and heavy reliance on short-term agency and locum staff. This affects the continuity of care and the relationship between clinician and patient. “Continuity is a major one with very frustrating levels of staff turnover, particularly affecting the nursing workforce.” (participant 11, GP and senior manager) It was also mentioned that the NT remote GP training was designed to help supply the much-needed GP workforce [ 29 ]. However, record low numbers of enrolments in the NT GP training were perceived to be contributing to low availability of GPs in remote communities [ 30 ] with a profound effect on access to PHC: “I've never seen lower levels of access in all of my career to primary healthcare ...We also see a rapid decline in interest in training in general practice for the Northern Territory. Of the 50 positions available, only seven were occupied in the training program this year [2023].” (participant 11, GP and senior manager) The majority of PHC clinics in remote areas do not have regular allied health professionals. Therefore, these services were described to be provided to remote communities via visiting (outreach) services. “There's many allied health specialties that visit and they have a small number of visits every year. So, there is insufficient time for those allied health practitioners to see all the people eligible for their services.” (participant 11, GP and senior manager) On the other hand, for those allied health professionals who manage to go to remote communities to provide such outreach services, there is a lack of infrastructure to support their consultations. “You know, people always say you can just find a tree [to sit under], talk to somebody. I got told that so many times. And I was, yeah, I had to hold my tongue because, you know, back in the day that might have worked, but the reality is now you need some information about clients. You can’t just [sit under the tree for all consultations]!” (participant 3, nurse educator) Participants underscored the potential benefits of telehealth in augmenting the availability of GP services, as telehealth could facilitate GP consultations in numerous communities during a single session. In contrast, in-person consultations are confined to patients within a single community. “Here's a setting where we can't have an onsite [GP or RAN], like it's that coverage. We can suddenly cover all 12 communities at any one [time], all the time. And not just that, we are available.” (participant 6, public health nurse, coordinator) In smaller communities that lack resident GPs, telehealth was perceived as a useful tool to increase the availability of PHC providers to those communities, particularly if a physical examination wasn’t required. “I think, due to lack of numbers of GPs in community, we will find that if a telehealth appointment was accessible, people would take them up as an alternative … like it would be more of appointment that would require not much of a physical assessment, …I think would be really good.” (participant 15, aboriginal health practitioner, RAN, coordinator) Telehealth was also perceived as having the capacity to offer almost an instantaneous availability of a PHC provider, without there necessarily being a requirement for additional clinical staff to support the patient: “So, it [telehealth] gives instant coverage, you don't even need one of our Remote Area Nurses... I get lots of calls just from a patient just out there on their own and them ringing through, and then they call me and then we often ..have video call.” (participant 6, Public Health Nurse, coordinator) One of the additional benefits of the DHTs highlighted was the availability of regular supervision for new GPs and nurses. One of the participants who has been using telehealth for more than five years, highlighted how they found DHTs helpful in mentoring their staff. The benefits of having real-time access to patient data for those consults was also perceived as an important benefit offered by DHTs. “I would say that's the technology is, when we get a new GP, a really cool thing is like TeamViewer or equivalent. ...you can have your trainee, or the new nurse and you can sit in on the same computer, looking at the same patient's file, and talk about the patient, and that way you can even see if they're entering things correctly. We do this now. So remote desktop access and things like Microsoft Teams, that sort of thing into, that's really good. Useful too.” (participant 9, GP) Acceptability A key aspect of acceptability raised by participants was cultural safety. Culturally safe services included considerations about whether local Aboriginal people are employed by the health service. However, the Aboriginal workforce is limited. “So, obviously, having people ideally locally from the community who become health workers, health practitioners or outreach workers here, Indigenous, allowed to bridge that gap around alleviating concerns patients may have around safety.” (participant 7, public health professional and manager) “We [visiting Allied Health Professionals] don’t have the option of using the Aboriginal Health Practitioner as an intermediary or as an initial agent to facilitate an initial meeting, so that’s harder,…so, I think a local workforce is really a major problem with the health services in remote.” (participant 2, allied health professional) A further key cultural safety consideration was the extent to which health service providers understand local Aboriginal culture and the complexities of living in remote and very remote communities: “The challenges around then cultural training and induction for staff within an organisation, another big challenge. So, what does that look like? Is there a centralised version of that for the NT? Is there a localised version of that for the service provider? Is there an even more localised version of that for the community that they may be working in? …There’s different hierarchical systems. So, it all again varies.” (participant 7, public health professional and manager) Participants indicated that care provided by a provider not previously known to patients presented a challenge to acceptability: “I think that the fact that they don’t, may not necessarily know the doctor in the first instance, it could be challenging at times but, you know, for a specialist, like they’re not going to know them anyway.” (participant 17, community leader) Having an ongoing relationship with a healthcare provider is one of the many factors that determine the acceptability of health services and cultural safety. Willingness to attend PHC clinics can diminish when staff turnover is high, and continuity of care is low: “So, it can be a bit daunting for people to go into the clinic even though it’s their clinic and their community and see people who they’ve never met before, essentially.” (participant 2, allied health professional) DHTs were seen as being helpful in building and sustaining positive healthcare relationships. Thought leaders who were already using telehealth spoke of how telehealth could work to build or even maintain the relationship between health professionals and their patients. “And if I have an ongoing five-year relationship, as I do with the patients in that clinic, when rapport is already in place and I understand that person and their family and their needs, it's quite easy to have a consultation over digital means, whether that's telephone or video conferencing. So, the continuity is one area digital technologies can improve. I would say on the other way also, where patients are in hospital and they need help with interpreting or family members to help make a critical decision about their healthcare, the ability for digital technology to broker a very important family discussion is often used...” (participant 11, GP and senior manager) Cultural safety associated with DHT-assisted healthcare is a prime concern. Concerns were raised as to whether using DHTs to consult with a health professional on a screen created barriers to interaction between patients and providers. The thought leaders who had used telehealth were mainly providing services using a hybrid model, i.e., a mix of face-to-face and virtual consultations. They also highlighted that if a health professional had key interpersonal skills like what would be required in an in-person appointment, the presence of technology was not the barrier to provider-patient interactions. “I really haven’t found it [telehealth] made too much of a difference. I felt like I built quite a good relationship with some people, and then we met face-to-face and I’m always really keen to meet face-to-face as a result, and vice versa. I can’t really see a distinct difference, yeah, which way.” (participant 3, nurse educator). “I guess that the doctors, if they’ve got a good bedside manner and, you know, you can build a rapport with person quite easily over, you know, a computer, it might be a bit more difficult on the phone I think but like a computer you can see their whole face, you can, it’s almost just like having a normal discussion face-to-face pretty much.” (participant 17, community leader) “I think it [telehealth] would work for everyone, apart from the ones if, like I said, the doctor really needs to do an actual physical exam. But we [nurses] can do it for them in front of them, and obviously we can, say, do a knee exam, and then he can see exactly where the pain is, which movement is causing that.” (participant 13, RAN) Younger populations were described to be harder to reach. However, gentle health messages using SMS were seen as a potential way to engage them with health services. “If we had an option about sending health promotion messages, again using the text reminder, not doing too much, maybe one message … and in language. Not overdoing it but gently pushing some message. I mean, if we can get through to them, at that [younger] age.” (participant 13, RAN). Furthermore, community members’ propensity to use digital technologies was seen as a positive that could support opportunities to apply these technologies for CPHC. For example, sharing targeted text messages or videos on social media, could improve health literacy and thereby promote better health: “I also think that in general, people are quite tech savvy, even though health literacy and literacy might be an issue, phone use is really high and good. So, if we could make the content that we have really connect with people’s phones, then I think we, and that is really the health promotion information that we want to give them. Small videos, YouTube, things that can easily be dropped into community Facebook pages.” (participant 10, allied health professional) Community members’ existing technology use also could be leveraged to reduce missed appointments and support medication compliance: “...text message is very helpful for appointment reminders, and medication reminders. I believe text message to remind appointment has value to reduce DNAs [did not attend appointments] as that helps patients to get organised. For those who have basic phones, I think will work. I do not see anyone having any issues with appointment reminders. I am assuming most people with phone are able to read the text message. That means the message needs to be in simple language.” (participant 16, allied health professional) Further discussion arose around what makes DHTs acceptable to health service providers and the community. The ease of DHT use emerged as the most important consideration for both health staff and consumers: “Ease of use would be probably number one. Ease of access and ease of use. I think the driver behind video telehealth is, rather than the ease of use, is the enhanced experience. I think ease of access to whatever tool you're using is critical. If clinicians don't have easy, and when I mean easy, I mean, pretty much instantaneous access, it's not going to happen.” (participant 5, manager) Affordability Affordability was perceived as a complex issue intertwined with the social determinants of health. Within affordability, two aspects, costs to the healthcare system and consumers, emerged as distinct challenges. As part of CPHC, various allied health services are sent to remote communities two or three times a year, depending on the size of the community. The participants perceived that more services are always needed; however, resources remain a major barrier. “I don’t know the figures, but I know in my last role I used to drive ten, eleven hours out to community… Yeah, fuel-wise, very expensive and just all the set up and preparation for those trips.” (participant 16, allied health professional) “I think …They're just not funded adequately to do everything they're expected to do or that they want to do for their community, or the community wants from them.” (participant 6, public health nurse, coordinator) “So many useful health promotion activities get initiated and start showing effect in the community, and all of sudden there is no funding. This is the real story around nutrition and health promotion.” (participant 16, allied health) The second major affordability issue for the health system was the expense of transporting patients to the nearby regional centre or city for further consultations or investigations. The costs for healthcare, along with transportation costs [to hospitals] for remote and very remote residents of the NT, are covered by the Government. However, there are indirect costs associated. “And then there's yeah, the expense, is that, at the same time there's the issue of sometimes people need to be seen by specialists or be flown out to secondary care.... the expenses are quite astronomical and often beyond the budget of any health service or government.” (participant 9, GP) “...how much money was wasted on booking people on the bush bus to get them to town to the specialists’ appointments. You know, they don’t turn up. You know, whatever. But we would still have to pay for that bush bus. And the same here, when we take people in. With the price of fuel now, that’s a lot of money out of your budget, in and out.” (participant 13, RAN) Affordability challenges for consumers were also reported to be prominent. Although the direct cost is paid for by various government funded services, indirect and opportunity costs were noted. For instance, if a community member had to travel to visit a health provider in a regional centre, this involved multiple days of preparation and planning, many hours of transportation via bush bus or clinic-organised transport, or flights, plus accommodation and organising necessary appointments, which all require resources. “Traveling there, coming into town [Darwin] is all paid for by Department [of health], so there's no out-of-pocket [expenses incurred by the patient]. In saying that, they [patients] do like to plan, so they do have money to come to town. If they don't do that, they'd fall, that's an impact. They don't have actually any money to them because of that financial stress that they have in community. No money meaning not even at any money, no dollar, no nothing. But traveling to Darwin [city], so if the PATS (patient assistance travel system) bus doesn't turn up to pick them up, they don't even have money to get taxi.” (participant 15, aboriginal health practitioner) In communities that are far from PHC clinics, such as homeland communities, getting to a clinic means consumers must organise their own travel, which requires resources to cover indirect healthcare costs such as fuel and food. Even when teleconsultations are available to help them avoid travel, digital technology ownership may be limited due to poverty. “It costs... like people have to go out and drive out to these communities, so it's expensive.” (participant 9, GP) “...from a financial perspective, it depends on how severe your presentation type is. So, somebody may go “Well, actually do I want to spend the money to buy fuel to drive to the clinic or do I want to buy food? How bad am I? Maybe I’ll get a lift next week, someone else will go in and I’ll go in with them and I’ll get seen then.” (participant 7, public health professional and manager) “So having a personal controlled device is often shared between many people. But also, poverty means that people will not necessarily have access to video consultations on their personally controlled device.” (participant 11, GP and senior manager) Participants felt that DHTs could not address all concerns of affordability, but they could help reduce the cost associated with delivering health services. In addition to direct costs, incidental costs associated with access to healthcare were reported to be high. “I think costs, I mean, the cost savings. Cost savings is tricky because you are... if they're employing a full-time GP to do this, that's a cost and they're going to work out. The costs of flying out to a community when you could just do a telehealth with them. For us, $800 to $1,200 flight or several hundred dollars trip, that's a significant cost.” (participant 9, senior GP) While it was widely acknowledged that setting up for DHTs and paying for personnel involved some initial cost, there was an overall agreement that it would eventually pay off. “Definitely a key position if telehealth was to come online, and it would pay for itself in the long run, so it's just a matter of getting someone in community that's really engaging and able to get people to their appointments.” (participant 15, aboriginal health practitioner, RAN, coordinator) Adequacy (Accommodation) The way services are organised and offered by the health system was identified by consumers as a barrier to accessing health services. Participants stated that the provider-centric models of care with booked appointments and delays were causing distress and agitation for patients. “She [mother-in-law] gets agitated when she has to wait too long [for an appointment]… So, and waiting, waiting for the doctor, she gets annoyed, but I say, Aunty, you got to just wait, like you got to wait your turn because they’re very busy.” (participant 17, community leader) Thought leaders highlighted that there was an ongoing mismatch between how the services are organised and people’s ability to use those services. Many services were offered in a way that did not suit community members’ lifestyles and the local contexts. “Clinics are quite westernised in that we haven't evolved them to be operating potentially in a different way, which may be more culturally palatable for people to use and that may be more appropriate.” (participant 7, public health professional and manager) For the visiting allied health services, the intermittency of outreach models with the inability to meet needs that arise between face-to-face visits also challenged the provision of adequate CPHC. “And the fairly fixed schedule of those allied health visits is not flexible to accommodate for emergent needs within a community.” (participant 11, GP and senior manager) The visiting services (e.g. allied health) for CPHCs are scheduled periodically with very limited flexibility. When there are events of cultural significance such as funerals, some of these visits need to be cancelled. These visits may be rescheduled or had to happen in the next planned dates that might be after many months, leaving consumers without health services. “it's not uncommon for there to be a significant cultural event such as a senior person that's passed away or a funeral that would normally necessitate the closure of a clinic. And it's unfortunately not uncommon for that to coincide with a visiting service that only comes once or twice a year.” (participant 11, GP and senior manager) From a health service perspective, local health staff coordinate a range of acute and specialty-related health services for patients. This was described to take a considerable amount of staff time and detrimentally affect their ability to provide adequate CPHC services. “...a lot of them [local PHC clinic staff] I think are quite frustrated with that because they see that they're spending a large amount of their time coordinating acute services and not delivering primary health services. It's a bit of a double-edged sword there.” (participant 5, manager) Poor communication and convoluted processes also add to the frustration of an already overworked clinic team. The participants also perceived that the referral system is difficult due to poor coordination and disjointed reporting forms. “Coordination among different services is a major issue. We often do not communicate well among ourselves. For instance, there is weekly meetings, where only doctors and nurses communicate, and allied health professionals hardly have space in those discussions.” (participant 16, allied health professional) “within the clinic at [name of a remote community], and the guy who’s doing that [referral] gets all them [information] directly to him, but they come in different formats....but he’s kind of dealing with the paperwork nightmare as well within the system.” (participant 2, allied health professional) Thought leaders felt that DHTs could help improve organisational issues and simplify complicated processes, such as the use of electronic appointment booking or using flexible telehealth appointments to reduce wait times. Another key benefit was that telehealth helped those who were frightened of flying and improved their access to health care. “if you had that scheduled time in a telehealth appointment where you’re just able to sit down and no wait time, it would be really, I think for her [participant’s mother] it would be quite good like, although she may not have much understanding around like what was happening, but she’d have her carers, like us, there to help her through that process.” (participant 17, community leader) An additional challenge was poor access to patient information for clinicians when a patient moved between the health services, for example, from hospital to a remote clinic, or one remote clinic to another remote clinic. “And the other part is the data piece about having everyone's health information exchanged in real time. And that's a big digital technology piece that will emerge, I think, over the next decade. But I think that you can't do integrated care and safe care without having authored information at the point of care to be considered.” (participant 11, GP and senior manager) The ability to access electronic health records that hold information from all providers and services would support access to patient information and help improve patient experience. “...having access obviously to the person's medical health records during that consultation is paramount so that you can understand because people may not be able to explain what's wrong with them or they mightn't be able to understand what's wrong with them, to share that information back at you.” (participant 7, public health professional and manager) Often, information about which health service is visiting the community and when and how to access those services was reported to be unclear or not readily available to community members. In many communities, this information is posted as a printed copy on the clinic notice board, so was not seen by community members unless they attend the clinic and read the notice board. There is an opportunity for DHTs to enhance access to such information, for example, providing details about visiting health services. “So, it would be so helpful if there was one place for each remote community, where people could put things in, so people know when people are coming and maybe, plan to come at the same time if they want to work together or plan to be separate if they’re going to be trying to use the same resources, like the same computer room or different things like that. It would be really helpful if that was part of what the digital strategy could do. I think that’s all.” (participant 10, allied health professional) Participants also suggested the possibility of streamlining the referral system using electronic forms and noted that wearable devices could help provide additional clinical data and information to remote clinicians which could inform decisions about the timing and location of follow-up care. Such remote monitoring devices were considered beneficial by allied health professionals based in cities or regional centre, as they would allow consumers to receive care without waiting for the next outreach visit. “It should all just be consolidated and coordinated within one electronic system ... and maybe those obs [observations] can be done via a wearable device for a day, or for overnight, or for a week, and that data goes to the specialist who can then go, “Okay, well that’s what’s happening. That’s great. We actually do need to see this person, let’s bring them into Darwin,” or like, “oh no, we don’t need to see them, this can be managed down in [name of a very remote community] by the local GP. We’ll give them some advice, but they don’t need to come to Darwin.” (participant 2, allied health professional) To align with the variability in training levels, technology skills, experience, interest, and demography of health staff, participants highlighted the importance of user-friendly DHTs in the remote setting. “they have to understand the technology. And that can be… One, technology, it needs to be easy. And two, it actually takes human resources to manage that technology. And I think that often gets forgotten whether it's like a technical person in the background, like managing CommuniCare.” (participant 6, public health nurse, coordinator). Awareness Awareness relates to health literacy and communication issues between health professionals and consumers. A lack of health literacy awareness, lack of timely and accurate clinical information for clinicians while attending patients, and poor understanding of medications or prescribed interventions were key issues identified in this access domain. Poor communication within the health system was also identified as an access barrier: “Then we had an incident yesterday, a lady had to go in for an appointment, but there wasn't any communication. She had two appointments, so she didn't even know about that, and we didn't know about that. So, it was a [poor] communication for the hospital to here [PHC clinic].” (participant 12, RAN) Both consumers’ and healthcare providers' lack of understanding of the health system and pathways to accessing and delivering comprehensive primary health care were also identified as a challenge to accessing healthcare: “But also, significant gaps in terms of understanding the healthcare system and how to navigate the healthcare system are often underpinned by different languages and cultural worldviews and pervasive socioeconomic disadvantage.” (participant 11, GP and senior manager) “So, that kind of awareness amongst the general population as to how to interact most appropriately with health services is an area which we still need to work on.” (participant 11, GP and senior manager) There were numerous ways that DHTs were perceived as having considerable potential to help improve awareness and communication. For example, digital literacy was seen as valuable in improving the dissemination of information. The ability to use text messages or other technology-assisted monitoring of health parameters could improve awareness and understanding for appropriate delivery of care. “I think there’s a lot of potential. As I said, I think people have really good phone literacy...and people are interested about their own health, and we have that opportunity to disseminate information.” (participant 10, allied health professional) “So, I think that [digital technology] would be a big thing of general education, in just general education, and the second one is health specific education to give people an awareness of what’s the right steps to do.” (participant 7, public health professional and manager) In our interviews, mobile applications also emerged strongly as possible DHTs helping raise awareness. Reminding patients (i.e., text messages) to increase medication adherence, sharing of health videos on certain topics, or appointment reminders to help reduce no-shows were key examples. “My general feeling is that mHealth will be the way to go, that people will have access on their phones, or maybe it’s an app that reminds them about the medication that’s due today or their check-up’s due or the specialist is coming tomorrow and they need to come to clinic, “If you’ve got diabetes, watch this video”. (participant 12, RAN) “Even just simple reminders for appointments, they trialled that in Allied Health at hospital and they found a really good uptake, improved, people were attending appointments.” (participant 10, allied health professional) “There’s heaps of potential for us to use different tools, whether it’s access to various resources that people can use to help people inform themselves about treatment or appointment reminders or reminders to book an appointment, reminders to get immunisations, that kind of thing.” (participant 10, allied health professional) One of the community leaders also stated that mHealth (ie., use of smart phone to access health care) could play a significant role in raising awareness on sensitive topics such as cervical screening among women. “It’s [Technology] great education for young ladies as well, you know, who are just like moving into that phase, like turning 18, getting Pap smears and it’s very, very important to look after your, you know, your female health. So, I think the more information, the more technology around that I think the better, you know. Absolutely. Because the ladies don’t necessarily always want to go up to the clinic … yeah.” (participant 17, female, community leader) Participants felt that DHTs could also be better used by the health system to improve communications with patients. For instance, a digital community notice board to inform consumers about outreach services in advance of visits and remind them again at the time of the visit: “I think it really is an opportunity for us to improve people’s access to health services and health information if we do it right. …provide information and videos about services available, people visiting, like what visiting services are coming over the next month and allow people to have something that they can explore and checkout.” (participant 2, allied health professional) “But maybe if we get free WiFi in community, maybe we can ping out alerts or something, I don't know. If that someone's [health provider’s] in town, then we can just tell everyone ...” (participant 11, GP and senior manager) Challenges to using digital health technology All participants used DHTs as part of their role. While they identified many ways that DHTs could improve access to CPHC in the NT, they cautioned that the potential of DHTs should not be overestimated. The quote from one of the participants summarised this well, “Now, we need to make sure we remember that, that a Telehealth… a bad face-to-face interaction isn’t made better by a bad Telehealth interaction .” (participant 2, allied health professional). Along with this, a number of challenges were also stated during interviews. The following section provides a brief information on the challenges. Supplementary Table 1 provides an extended list of quotes under each theme. Technology-related challenges Participants shared their observations that the lack of digital infrastructure is a key barrier to digital health solutions and iterated that patients in remote communities still have to depend on public payphones, which do not allow for videoconference. A participant who was working as a GP for very remote communities at the time of the interview stated, "A lot of remote health outstations still have basically a free Telstra phone booth.” (participant 1, GP). Participants further highlighted the issues associated with the instability of the platform and low bandwidth available in the remote communities as a major issue. “But mostly, the barriers with a lot of our earlier forays into particular video conferencing have been the instability of the platforms, the bandwidth available in remote communities, mostly on satellite and terrible connections feeds. So sometimes you're unable to get a video picture, but you can talk on the phone." (participant 11, GP and senior manager) Almost all participants who had experienced the old telehealth system [e.g., Cisco telehealth platform] in the NT Government (NTG) mentioned that the structure of the platform and its overly secure platform were major barriers. They perceived that it was not user-friendly and there was an issue with interoperability when the government system had to communicate with the ACCHS system. ".. So older versions of telemedicine equipment had complicated ways to log in and get through the firewall of NTG, even within the network. And that's exacerbated when you're working in a community-controlled setting, trying to get through the NTG firewall to connect and talk to a specialist colleague who works for the Northern Territory government." (participant 11, GP and senior manager) Non-technological challenges The participants also mentioned various challenges related to patients and health systems. Access to or ownership of digital device was perceived as a major issue. “I think a lot of the time the deficiency is in the remote outstations and you're lucky if you've got a phone. (participant 1, GP). Poor digital literacy was also perceived as a key barrier affecting remote patients’ ability to benefit from DHTs. “ And then there's digital literacy. So very familiar with Aboriginal friends that I've known and very vulnerable to all sorts of digital literacy issues, whether that be scams or viruses, or content that's not appropriate. As you know, it's very overwhelming.” (participant 11, GP and senior manager) Significant health system-specific barriers were also suggested. In the one hand, the process of attending telehealth could be daunting; on the other hand, the remote health staff were unable to stop and fix the issue due to their excessive workloads. "They [the PHC clinic staff] know a particular process [to attend telehealth] is terrible. They don't like it, but they don't have capacity to just stop for half an hour and say, "This process is rubbish. Well, how are we going to change it?" That's what people who are overwhelmed do. They don't have time to stop and say, "Let's fix this." (participant 5, manager) Discussion This study examined perceptions of thought leaders about the challenges to accessing CPHC in the remote NT and how DHTs can help improve access to health services. This study adds to existing knowledge by examining how DHTs can address challenges across various dimensions of access, such as accessibility, availability, acceptability, affordability, adequacy/accommodation, and awareness [ 18 , 26 ]. While DHTs were found to be useful and to have the potential to improve access across all dimensions, their role in improving access was thought to be strongest for addressing accessibility, availability, affordability, and awareness dimensions. Accessibility Participants perceived that DHTs could address some critical gaps in accessibility by reducing the need for travel. The NT covers a vast landmass (1.3 million sq km and 17.5% of Australia) [ 31 ], and having predominantly remote and very remote communities, it is not surprising that challenges were raised in relation to the NT’s vast geography. Two studies [ 9 , 32 ] from the NT have reported on how telehealth was able to increase accessibility in remote Indigenous settings. First, a study from Central Australia during the COVID-19 pandemic [ 9 ] reported that telehealth could function as a supplementary tool to improve access to a GP. Second, an earlier study from East Arnhem Land [ 32 ] reported that telehealth was able to reduce the travel and trauma associated with having to leave Country to see a health professional. Availability Supply and retention of PHC staff (availability) was repeatedly highlighted as a major issue affecting access to primary health care services. Between 2017–2019, the turnover rate in remote clinics managed by ACCHSs was 151% at the clinic level in the NT, and in the most remote clinic, it was as high as 355% [ 33 ]. There is no evidence that turnover and retention rates have improved in the post-COVID-19 pandemic period. DHTs such as telehealth could help address some issues related to staff shortage as telehealth services can be provided by staff located anywhere (so long as they had internet connectivity). Thought leaders identified that DHTs can help improve health information exchange in real time by linking remote PHC staff and their patients to distally located GPs or other health providers via telehealth. This is consistent with findings from an earlier study [ 32 ] from the NT, which demonstrated that telehealth helped improve GP availability and continuity of care. Telehealth also reduced travel time for GPs as they were not required to be onsite in remote or very remote communities where they generally didn’t live. However, for the model to work effectively, it is important that local health workers (e.g., RANs or AHPs/Aboriginal Health workers or trained workforce) are available at the patient end to assist with telehealth consultations [ 11 ]. Affordability Costs associated with travel, higher living costs due to remoteness, and direct and indirect health care costs to individuals and the health system were key issues (affordability) experienced by the health system and consumers in remote communities [ 34 , 35 ]. Even when direct medical costs are not paid by remote patients, incidental costs and systemic barriers created by widespread poverty are significant. Participants in our study perceived that DHTs have the potential to reduce some of the costs associated with accessing health care in remote areas, consistent with the NT virtual care strategy (2023) which suggests that 14% of visits could be delivered using telehealth, thereby reducing by $ 21 million health-related travel costs in the NT each year [ 31 ]. Telehealth can reduce travel costs, including fuel, accommodation, and lost wages due to absence from work, and help reduce other indirect costs, such as having to arrange for someone to look after kids or pets [ 6 , 10 ]. Participants cautioned, however, that cost savings would be offset by hidden costs associated with the operationalisation of DHTs, and that these somewhat intangible costs and benefits should be accounted for when calculating potential savings offered by DHTs [ 9 ]. Osman et al. [ 6 ] noted that increasing dependency on telehealth in remote regions might mean that resources are redirected toward urban centres and therefore result in reduced investment in the remote infrastructure which could hinder the upskilling of the remote workforce [ 36 ]. Acceptability Participants also perceived that DHTs could help improve the acceptability of health services in remote NT. A former study from the NT also suggested that being able to see the familiar faces of clinicians, i.e., continuity of care with the same clinician, via video conferencing was comforting for patients with chronic conditions [ 20 ]. Another study showed that patients were happy not having to travel if they had an option to see a clinician via video call [ 10 ]. A review [ 37 ] stated that community visits by the health staff involved in providing telehealth services was also important in forming strong relationships with Indigenous patients and families. In previous studies, it has been highlighted that an Indigenous workforce provides essential contextual knowledge, helping foster trusting relationships and cultural safety [ 9 , 37 – 39 ]. Local Indigenous health workers are therefore extremely valuable to the provision of effective PHC, supporting both non-Indigenous health staff and Indigenous patients. It is important, therefore, that local Indigenous workforce development, recruitment, and retention is at the centre of all health service strengthening efforts, including digital health initiatives [ 40 ]. Adequacy (accommodation) In this study, participants highlighted that the organisation of way in which health services were organised (i.e. accommodation and adequacy) was a key barrier to accessing CPHC, a finding which was similar to previous studies from Australia [ 1 , 10 ]. Participants felt that DHTs could help address some of these issues such as, improving coordination of the services, reducing paperwork for health staff, and offering flexibility around availability of services. A previous study [ 32 ] from the NT reported that telehealth was helpful in accommodating the needs of the community, GP, and health services. It helped the local health services to offer video consults, ensure direct supervision of the staff on the ground, and ensure patient examination was done the right way. This also facilitated shared decision-making with families, which is important in Indigenous cultures. In widely spread remote communities, it may take months to organise such family meetings. Using telehealth, the health services was able to address the adequacy issues for the remote and dispersed communities. Another potential of DHTs in this dimension was improving care coordination and quality information sharing. In Australia, electronic medical records (or eHealth records) have been developed to serve as a real-time tool that supports clinical decision-making and promotes continuity of care [ 41 ]. Such electronic health records hold significant promise for strengthening the continuity of care within the Australian healthcare system. However, this study found that there was a lack of interoperability within and between the health systems, limiting the benefits of such electronic health records. The health system is a complex environment where patients and health professionals need to navigate multiple issues. Poor oversight of patients’ information to make informed decisions, low health literacy, suboptimal awareness about various health services provided by different health workforce, disjointed communication about the travels, appointments, and follow-ups, low medication adherence, and lack of understanding of complexities of the Australian health care system were the key issues raised in this study. Awareness Thought leaders perceived that DHTs could play a significant role in improving communication. This finding is similar to those from a recent systematic review of global literature, which reported that DHTs such as telemedicine were likely to increase interprofessional communication and collaboration among different health groups [ 42 ]. Improving access to health information using DHTs was regarded as essential to uplifting health literacy and the understanding of complex health systems. In the NT and very remote Australian context, telehealth was also noted as beneficial in supporting the ongoing education of the remote clinic-based staff when they attend telehealth with specialists and other clinicians [ 9 , 10 ]. Such consultations offer an opportunity to learn from specialists who otherwise would have taken place in the regional centres or cities where those specialists are based. Challenges that come with digital health technology A number of technological and non-technological challenges, such as poor digital infrastructure, intermittent device ownership and health system readiness, were highlighted. This also includes using non-secured publicly available (e.g., Facebook Messenger, WhatsApp) as a workaround for clinicians, as messaging platforms. While these challenges are not unique to the digital health space [ 9 , 14 , 27 , 43 ].These challenges must be taken into account and addressed proactively for sustainable DHT implementations to improve health service delivery in remote settings. On-the-ground coordination to support telehealth was an important aspect identified by the participants in this study and in previous studies [ 9 , 10 ]. At times, the clients were also not comfortable talking to someone on the screen, had language barriers, had little established relationships with the clinicians in the session, or had technological issues [ 9 , 10 , 36 ]. The remote clinic staff would have to set up telehealth and sit with the clients to assist with the consultation. This would take considerable time and resources away from a regular working day [ 9 ]. A former study from the remote NT [ 10 ] also asserted that this patient-end support needs to be well-resourced so the remote staff can help the patients without having to worry about not being able to perform their day-to-day tasks. The findings highlight the need to take cautious and proactive steps to curtail the impact of increased workload on local clinic staff [ 36 , 43 , 44 ]. Strengths, limitations, and implications of current findings This study included key stakeholders in remote health across the NT, both from the NT Government and community-controlled health services. Furthermore, it has strong representations of all levels of the health workforce, both at the leadership and community level, which gives a comprehensive view. Although this research presents a comprehensive view, there is an appreciation that the different administrative regions within the NT have varied contexts. Even when these remote Indigenous communities are geographically near to one another, they vary by language, culture, clan group, education attainments, and access to infrastructure. Therefore, the findings must be carefully adapted to local contexts when considering translation. It was also our intention to use the information from these interviews to co-design digital health interventions in remote communities. In some interviews, thought leaders tended to delve deeper into the issues that may be closely related to telehealth (or mHealth) rather than overall healthcare access challenges. While DHTs have great potential to help bridge the gap in access to health care, careful considerations are needed to ensure that it does not reduce the efforts to build a critical mass for the remote health workforce, does not take resources away from investment in infrastructure (e.g. connectivity, health services buildings and roads) in the remote communities, and does not function as a band-aid solution to the health workforce crisis in remote settings within Australia. The findings from the current study have significant practical implications for remote health services. Most importantly, there was universal acceptability from the health professionals and no resistance to implementing DHTs to improve access to health care. There is an opportunity to adapt technology-enabled models of care and identify how that can work to support the incredibly diverse populations of remote NT communities, including ways to sustain successful initiatives in the midst of limited workforce availability. However, these initiatives must be co-designed with community and remote healthcare staff from the ground-up, empowering the local workforce, well-resourced, and contextualised to respond to the unique needs of the communities. The technologies must be easy for the local PHC clinic staff and patients. Resources saved by the use of telehealth should be re-directed to the local clinic to help optimise patient-end support at the community level [ 10 ]. Further research could evaluate the economic impact of telehealth in remote communities, including any unintended adverse effects on remote health infrastructure and workforce. Conclusion This study offered valuable insights into the perceptions and experiences of health system leaders in the NT regarding challenges to accessing CHPC and how DHTs could improve these challenges in remote Aboriginal communities. However, participants also cautioned that DHTs should not be viewed as a single solution for the broad range of CPHC access issues in remote NT communities, and that challenges of using DHTs exist across various layers of health service delivery. Nevertheless, there was an optimism that DHTs could substantially improve healthcare access in the NT. Declarations Competing interests The authors declare that they have no competing interests. Ethics approval and consent to participate The research project was reviewed and approved by the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (HREC Approval Number: 2022–4275) in accordance with the Declaration of Helsinki. Administrative approval was also obtained from the Research Governance Office, NT Health (EFILE2023/8720), the Boards of the participating ACCHS and respective Land Councils. All participants signed a consent form after reading the participant information sheet. Consent for publication Not applicable. Funding The current project is supported by the Digital Health CRC Limited (DHCRC). DHCRC is funded under the Australian Commonwealth’s Cooperative Research Centres (CRC) Program. This is a collaborative project among multiple partners in Australia: the Australia Government Department of Health, Disability and Ageing, Department of Health - Northern Territory Government, Primary Health Care Network Northern Territory, Aboriginal Medical Services Alliances Northern Territory, Healthdirect, Australia Digital Health Agency, Menzies School of Health Research, and The University of Sydney. Author Contribution VK wrote the first draft of the manuscript with significant contributions from ES, NN and DR. VK and NN analysed the data under the mentorship of ES. All authors, including KW, JC, KC, AP, HB, AH, SN, MM, MD, ST, PB, TC, JR, DR, DE, AL, JW, TS) provided significant input in drafting, revising and finalizing the manuscript. TS and DR are leads of this project and share equal contributions as senior authors. All authors have read and approved the final version of the manuscript. Acknowledgements We acknowledge the contributions of all the project partners and participants for their time, valuable insights during the interviews and both the formal and informal contribution to our ongoing implementation project. We also acknowledge the ongoing guidance from our community-based colleagues and cultural mentors. Data Availability Relevant data generated or analysed are included in this article. 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We can work together, talk together’: an Aboriginal Health Care Home. Aust Health Rev. 2019;43(5):486–91. Walsh L, Hemsley B, Allan M, Adams N, Balandin S, Georgiou A, Higgins I, McCarthy S, Hill S. The E-health Literacy Demands of Australia's My Health Record: A Heuristic Evaluation of Usability. Perspect Health Inf Manag. 2017;14(Fall):1f. do Nascimento IJB, Abdulazeem HM, Vasanthan LT, Martinez EZ, Zucoloto ML, Østengaard L, Azzopardi-Muscat N, Zapata T, Novillo-Ortiz D. The global effect of digital health technologies on health workers’ competencies and health workplace: an umbrella review of systematic reviews and lexical-based and sentence-based meta-analysis. Lancet Digit Health. 2023;5(8):e534–44. Erku D, Khatri R, Endalamaw A, Wolka E, Nigatu F, Zewdie A, Assefa Y. Digital Health Interventions to Improve Access to and Quality of Primary Health Care Services: A Scoping Review. Int J Environ Res Public Health 2023, 20(19). Yao R, Zhang WL, Evans R, Cao G, Rui TQ, Shen LN. Inequities in Health Care Services Caused by the Adoption of Digital Health Technologies: Scoping Review. J Med Internet Res 2022, 24(3). Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 14 Apr, 2026 Reviews received at journal 04 Dec, 2025 Reviewers agreed at journal 16 Nov, 2025 Reviews received at journal 15 Nov, 2025 Reviewers agreed at journal 15 Nov, 2025 Reviewers agreed at journal 14 Nov, 2025 Reviewers agreed at journal 14 Nov, 2025 Reviewers invited by journal 09 Nov, 2025 Editor assigned by journal 18 Oct, 2025 Submission checks completed at journal 17 Oct, 2025 First submitted to journal 17 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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interviews","fulltext":[{"header":"Background","content":"\u003cp\u003ePoor access to primary health care in remote and very remote communities is a well-known and long-standing issue in Australia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The small proportion of Australia\u0026rsquo;s population living in remote areas (1.2%) or very remote areas (0.8%) are widely dispersed across Australia\u0026rsquo;s considerable land mass. About 32% of the population in the remote and very remote communities identify as Aboriginal and Torres Strait Islander peoples [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The Australian Institute for Health and Welfare (AIHW) 2021 statistics show that people living in remote and very remote areas experience 1.2- and 1.5-times higher mortality than those living in major cities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Living in remote and very remote areas is also associated with a higher burden of disease, including type 2 diabetes, hypertension and chronic kidney disease [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Comprehensive primary health care (CPHC) is extremely important for delivering equitable preventive, promotive, and rehabilitative health services in a cost-effective way to remote populations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. CPHC is the delivery of essential healthcare services from the first point of contact to enabling equitable access to health and well-being for all residents in the community. It goes beyond just the clinical services [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Challenges to accessing healthcare services in remote and very remote communities include limited health literacy, poor resourcing, and infrastructure, such as reliable transport and road links that support travelling long distances to get to health facilities, reliance on outreach visits for specialist services, and limited health professionals available to deliver care on site [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIt is widely assumed that telehealth can improve access to healthcare, particularly for those living in remote and very remote communities, because of its ability to overcome proximity, transport, and local provider availability issues. Telehealth has been used to improve access to care and support provider-provider communication during urgent or emergency care situations across Australia and remote communities for decades [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The WHO's Global Strategy on Digital Health 2020\u0026ndash;2025 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] states that institutionalisation of digital health in the national health system requires decision-making and commitment by the government. Leadership readiness and innovation are crucial to trialling, implementing, and sustaining digital health technologies. In recent years, technological improvements and available bandwidth have enabled access to telephone and video calls with specialists, General Practitioners (GPs), and Allied Health Professionals for remote patients [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Other digital health tools, such as text messaging, have also been used to support healthcare asynchronously for remote Aboriginal and Torres Strait Islander populations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, these initiatives have primarily been delivered in regional and major cities in Australia, with minimal reports of their use in remote and very remote areas [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe use of digital health technologies (DHTs), including telehealth, in remote CPHC settings can be resource-intensive and increase the administrative workload for remote staff [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Previous studies have highlighted a range of barriers and facilitators to using DHTs from remote CPHC staff members\u0026rsquo; perspectives [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, there remains a lack of scientific evidence about the perceptions of health leaders, providers, and managers about how DHTs could be used to improve access to CPHC in remote communities. It is also important to understand how health professionals respond to the new technology because their readiness is essential for the successful implementation of any DHTs in the healthcare system. This study aimed to explore the perceptions of thought leaders about the key challenges to accessing CPHC services and the role of DHTs in overcoming these challenges in the Northern Territory (NT).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study is part of a larger program being conducted with four remote Aboriginal communities in the NT (July 2022 to July 2026) to co-design, implement or optimise, and evaluate various digital health initiatives by examining the preference of health system staff and consumers. The data used in this manuscript is derived from the interviews at the initial phase of the project. The study protocol has been published elsewhere [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe research project was reviewed and approved by the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (\u003cem\u003eHREC Approval Number: 2022\u0026ndash;4275\u003c/em\u003e). Administrative approval was also obtained from the Research Governance Office, NT Health (\u003cem\u003eEFILE 2023/8720\u003c/em\u003e), and the Boards of participating Aboriginal Community-Controlled Health Services (ACCHSs).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy setting\u003c/h2\u003e\u003cp\u003e This mixed-method participatory program is currently being conducted in four very remote communities and their respective referral hospitals in the NT. Remoteness is defined using the Modified Monash Model geographical classification [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The study has been iteratively engaging with various stakeholders to implement and (or) evaluate various DHTs. About 26.0% of the NT population identifies as Aboriginal or Torres Strait Islander (compared to 3.2% across Australia) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In remote and very remote communities of the NT, the proportion of the population who identify themselves as Aboriginal and Torres Strait Islander is more than 90% [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In these remote and very remote communities, CPHC services are delivered by either the NT Government or Aboriginal Community Controlled Health Services (ACCHSs).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants and recruitment\u003c/h3\u003e\n\u003cp\u003eInvited participants included 'thought leaders\u0026rsquo; working in clinical or non-clinical roles, including leadership, governance, and management roles with the NT Health Department or Aboriginal Community Controlled Health Services (ACCHSs). Thought leaders were defined in this study as individuals with an in-depth understanding of remote CPHC. Those who provided written consent were interviewed face-to-face or online via Zoom or Microsoft Teams. Prospective participants were recruited via health service nomination, self-nomination at professional development events, or nomination by project advisory group members using a purposive sampling method.\u003c/p\u003e\n\u003ch3\u003eInterview guide and data collection\u003c/h3\u003e\n\u003cp\u003e Participants were interviewed virtually or face-to-face, depending on their preference and geographic location. Interviews were conducted between February 2023 and February 2024. Two researchers were present for each interview (VK and DR or NN) where possible. A semi-structured interview guide was developed, informed by the theory of access [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and previous work in remote primary health care and digital health context [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. While a core set of questions was consistently applied across interviews, the guide was iteratively refined throughout the data collection process to reflect emerging insights and enhance relevance (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSemi-structured one-to-one interview guide\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"1\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Tell me about the challenges you/health professionals might face to ensure your patients can access primary health care in remote NT?\u003c/p\u003e\u003cp\u003e2. What do you think are the main challenges that health professionals face in providing accessible primary health care in remote NT?\u003c/p\u003e\u003cp\u003e3. What works well for patients to ensure their access to primary health care in remote NT?\u003c/p\u003e\u003cp\u003e4. We are particularly interested in the space for digital technology to help improve delivery and access to comprehensive primary health care. What digital technologies are you or other health professionals already using in remote NT to provide primary health care?\u003c/p\u003e\u003cp\u003e5. What can be done using digital technologies that might help address the challenges we\u0026rsquo;ve been talking about?\u0026nbsp;What are the existing digital health technologies currently being used in NT?\u003c/p\u003e\u003cp\u003e6. Thinking more broadly about using digital technologies to improve access to PHC. What were/are the key challenges in using digital technology to ensure access to primary health care for patients? (if they are not using digital tech, explore anticipated challenges). How do you think these challenges could be resolved? (new mechanism/intervention)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eAll interviews were audio-recorded, transcribed by a professional transcriber [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and checked for accuracy by the research team. Transcripts were imported into NVivo for analysis, and thematic analysis was conducted following the six steps as outlined by Braun and Clark [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Four transcripts were independently thematically analysed by VK, NN, and ES, who met frequently and reviewed themes to decide on a coding framework. VK then analysed the remaining transcripts, adding new codes where necessary, with NN and ES reviewing and approving the final coding framework. All authors reviewed the findings to ensure they were relevant and sound. Any disagreements with coding or interpretation of findings were resolved by discussion amongst the researchers.\u003c/p\u003e\u003cp\u003eA deductive approach to analysis was taken in this study [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This helped us explore the key challenges to accessing CPHC, and how DHTs could help overcome these barriers. We used Saurman\u0026rsquo;s modification of Penchansky and Thomas\u0026rsquo; \u0026lsquo;theory of access,\u0026rsquo; [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] to deductively map codes relating to key access issues and how digital technologies could potentially address the access issues. We applied six dimensions of access to the coded data: accessibility, availability, acceptability, affordability, adequacy (accommodation), and awareness (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). According to the theory of access, accessibility refers to geography, distance, and transport; availability to supply of health services relative to the need for CPHC services; acceptability to consumer and provider attitudes and beliefs; affordability to direct and indirect costs relative to the ability to pay; adequacy and accommodation to organisation of services; and awareness refers to communication and information with relevant users [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe dimensions of access\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimensions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhat it relates to\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExamples\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAccessibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProximity of health care providers to consumers relative to the ability to overcome distance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTime and geographical distance\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAvailability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSupply of services relative to need\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVolume, and type of services to meet the needs of consumers served\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConsumer and health professionals\u0026rsquo; perception\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAttitude and beliefs of providers and consumers, willingness to seek healthcare from certain gender or background, and using technologies for health\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAffordability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFinancial costs relative to the ability to pay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDirect and indirect costs of accessing health care. Health system related costs such as travel and accommodation; and consumer-related costs such as incidental costs for food, snacks, communication and workday loss\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdequacy (accommodation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOrganisation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWay in which health care is offered, time and place, and the process of accessing the services. For example, walk-ins vs scheduled appointments, clinic opening time, outreach visits schedules\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAwareness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommunication and information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConsumers\u0026rsquo; understanding of the health system health professionals\u0026rsquo; knowledge of the context, including health literacy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdapted from Saurman [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and Russell et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the second part of our analysis, the key challenges to the successful implementation of DHTs were categorised using themes outlined in previous studies [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. These themes included technological challenges (digital infrastructure, data structure and heterogeneity) and non-technological challenges (patient factors, health service factors, public and societal factors, and policy factors).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eCharacteristics of participants\u003c/h2\u003e\u003cp\u003eData were collected from 17 thought leaders, of whom ten were female. Participants' ages ranged from 20 to 60 years. Thought leaders had between three and more than 20 years of experience in the NT healthcare system. Participants\u0026rsquo; professional backgrounds were diverse, including rural General Practitioners (GPs), Aboriginal Health Practitioners (AHPs), Remote Area Nurses (RANs), nurse educators, coordinators of allied health services, district and primary health care clinic managers, senior leaders of the division, and community leaders. Two participants identified themselves as Aboriginal. All participants were still working in the NT. Non-clinical participants were actively involved in planning and/or rolling out digital health interventions for primary healthcare-related activities in remote areas.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eChallenges to accessing CPHC in remote Aboriginal communities in NT and the potential of DHTs\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eAccessibility\u003c/h2\u003e\u003cp\u003eThe issues of transport, geographical remoteness, and difficulties in travelling within the remote communities to get to the local clinics were frequently raised during discussions, with their importance highlighted.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I would say that it\u0026rsquo;s [transport] probably a significant barrier, as anything is with proximity and access, ease of access, to any service obviously means that the likelihood of engaging with the service is far stronger.\u0026rdquo; (participant 7, public health professional and manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMost remote Aboriginal communities have resident healthcare staff who work from a local primary healthcare (PHC) clinic to deliver primary healthcare services. In many communities, in-person consultations with GPs were described to be available intermittently from the local clinic.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI think the distance is not so great in terms of, we have a large number of remote clinical settings for primary healthcare delivery across Northern Territory. And in those remote settings, we have about 52 [PHC clinics] in the government system and another 50 [PHC clinics] in the community-controlled system. And distance is often breached [overcome] by having a presence in those remote communities, and those probably have their clinics\u003c/em\u003e.\u0026rdquo; \u003cem\u003e(participant 11, GP and senior manager).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAdditionally, the definition of \u0026lsquo;local\u0026rsquo; is not that simple; challenges were perceived to persist when people are in homelands, where there is no means to get to the nearest \u0026lsquo;local\u0026rsquo; clinic. Homelands are small Aboriginal communities where people live on the lands that they have traditionally owned. Even when clinics are within reach, challenges exist. Participants described that a lack of access to reliable transportation, road conditions, and extreme weather can make it difficult to reach the clinic. Within the community, physically getting to the clinic was also viewed to be particularly challenging for older people and those with disabilities. In some communities, clinic staff drive around, pick people up, bring them to the clinic, and drop them home, but this is limited.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;But there\u0026rsquo;s a cohort of our clients who have mobility impairment, older people, younger people, mums with prams, just getting there [to PHC clinic] physically is an issue sometimes. People have far less access to private vehicles in remote communities. There\u0026rsquo;s also less access to public transport, and there\u0026rsquo;s poorer public infrastructure.\u0026rdquo; (participant 2, allied health professional).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[in] the smaller communities ,.. a driver will go out and try and locate the people within the community, obviously if that\u0026rsquo;s a viable thing. The more remote you get obviously the less likely that is to happen, because we know there\u0026rsquo;s a lot of in-between the main communities, there\u0026rsquo;s a lot of different homelands.\u0026rdquo; (participant 3, nurse educator)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eProviding CPHC was perceived to include access to allied health or other visiting services such as oral health. Such comprehensive care was described as practically non-existent for Aboriginal peoples living in their homelands. There are some outreach services that come to the local clinic a few times a year. When consultations with allied health or specialist care are needed, which they often are, people have to travel to their nearest regional centre, which may be hours away.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;People like to live across, into remote communities and many of those remote communities may have very limited services in their own right. So, obviously, for example, we fund an outreach programme where we fly different health professionals into communities for a couple of days at a time and take them back out again.\u0026rdquo; (participant 7, public health professional and manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Because yeah, I think the model, even the fly in, fly out model is not going to capture nearly enough [to meet need for health care].\u0026rdquo; (participant 3, nurse educator)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIt is perceived that telehealth can help address the geographical disadvantages by reducing the resources, effort, and time required to travel for both health professionals and remote consumers. Telehealth was seen as a solution to improve accessibility to doctors and other health professionals.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So if it\u0026rsquo;s not necessary to go to Darwin like for those appointments, it would be great if we could sit with her in front of a screen.\u0026rdquo; (participant 17, community leader)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Oh, I think a lot of telehealth could be done with a lot of the people traveling. Unless they physically need something done in Darwin, like a CT or an MRI or, I don't know, something that cannot be done in community, I really think that a telehealth appointment should be an option in the first instance. ...But definitely I think it would work well. \u0026hellip; this would reduce the person having to travel and stress and all those other things, and cost too.\u0026rdquo; (participant 1, GP)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eAvailability\u003c/h2\u003e\u003cp\u003eStaff supply, staff turnover, infrastructure and resources, including connectivity, were mentioned during the interview to affect the volume and type of comprehensive primary health care services provided in remote NT.\u003c/p\u003e\u003cp\u003eThe importance of having a supply of local Aboriginal health workers employed by the health services together with RANs was highlighted, together with current challenges related to their availability, which was perceived to be far below current needs:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The big thing that I think will improve access to primary healthcare for residents in remote communities is having trained Aboriginal Health Practitioners and [Remote Area] nurses available in their community on a reliable basis. It doesn't have to be fulltime everywhere, but it needs to be regular and reliable.\u0026rdquo; (participant 1, GP)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTurnover rates for permanent staff in remote communities are very high, which results in clinics being understaffed and heavy reliance on short-term agency and locum staff. This affects the continuity of care and the relationship between clinician and patient.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Continuity is a major one with very frustrating levels of staff turnover, particularly affecting the nursing workforce.\u0026rdquo; (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIt was also mentioned that the NT remote GP training was designed to help supply the much-needed GP workforce [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, record low numbers of enrolments in the NT GP training were perceived to be contributing to low availability of GPs in remote communities [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] with a profound effect on access to PHC:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I've never seen lower levels of access in all of my career to primary healthcare ...We also see a rapid decline in interest in training in general practice for the Northern Territory. Of the 50 positions available, only seven were occupied in the training program this year [2023].\u0026rdquo; (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe majority of PHC clinics in remote areas do not have regular allied health professionals. Therefore, these services were described to be provided to remote communities via visiting (outreach) services.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There's many allied health specialties that visit and they have a small number of visits every year. So, there is insufficient time for those allied health practitioners to see all the people eligible for their services.\u0026rdquo; (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOn the other hand, for those allied health professionals who manage to go to remote communities to provide such outreach services, there is a lack of infrastructure to support their consultations.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You know, people always say you can just find a tree [to sit under], talk to somebody. I got told that so many times. And I was, yeah, I had to hold my tongue because, you know, back in the day that might have worked, but the reality is now you need some information about clients. You can\u0026rsquo;t just [sit under the tree for all consultations]!\u0026rdquo; (participant 3, nurse educator)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants underscored the potential benefits of telehealth in augmenting the availability of GP services, as telehealth could facilitate GP consultations in numerous communities during a single session. In contrast, in-person consultations are confined to patients within a single community.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Here's a setting where we can't have an onsite [GP or RAN], like it's that coverage. We can suddenly cover all 12 communities at any one [time], all the time. And not just that, we are available.\u0026rdquo; (participant 6, public health nurse, coordinator)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn smaller communities that lack resident GPs, telehealth was perceived as a useful tool to increase the availability of PHC providers to those communities, particularly if a physical examination wasn\u0026rsquo;t required.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think, due to lack of numbers of GPs in community, we will find that if a telehealth appointment was accessible, people would take them up as an alternative \u0026hellip; like it would be more of appointment that would require not much of a physical assessment, \u0026hellip;I think would be really good.\u0026rdquo; (participant 15, aboriginal health practitioner, RAN, coordinator)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTelehealth was also perceived as having the capacity to offer almost an instantaneous availability of a PHC provider, without there necessarily being a requirement for additional clinical staff to support the patient:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, it [telehealth] gives instant coverage, you don't even need one of our Remote Area Nurses... I get lots of calls just from a patient just out there on their own and them ringing through, and then they call me and then we often ..have video call.\u0026rdquo; (participant 6, Public Health Nurse, coordinator)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOne of the additional benefits of the DHTs highlighted was the availability of regular supervision for new GPs and nurses. One of the participants who has been using telehealth for more than five years, highlighted how they found DHTs helpful in mentoring their staff. The benefits of having real-time access to patient data for those consults was also perceived as an important benefit offered by DHTs.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I would say that's the technology is, when we get a new GP, a really cool thing is like TeamViewer or equivalent. ...you can have your trainee, or the new nurse and you can sit in on the same computer, looking at the same patient's file, and talk about the patient, and that way you can even see if they're entering things correctly. We do this now. So remote desktop access and things like Microsoft Teams, that sort of thing into, that's really good. Useful too.\u0026rdquo; (participant 9, GP)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eAcceptability\u003c/h2\u003e\u003cp\u003eA key aspect of acceptability raised by participants was cultural safety. Culturally safe services included considerations about whether local Aboriginal people are employed by the health service. However, the Aboriginal workforce is limited.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, obviously, having people ideally locally from the community who become health workers, health practitioners or outreach workers here, Indigenous, allowed to bridge that gap around alleviating concerns patients may have around safety.\u0026rdquo; (participant 7, public health professional and manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e \u0026ldquo;We [visiting Allied Health Professionals] don\u0026rsquo;t have the option of using the Aboriginal Health Practitioner as an intermediary or as an initial agent to facilitate an initial meeting, so that\u0026rsquo;s harder,\u0026hellip;so, I think a local workforce is really a major problem with the health services in remote.\u0026rdquo; (participant 2, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA further key cultural safety consideration was the extent to which health service providers understand local Aboriginal culture and the complexities of living in remote and very remote communities:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The challenges around then cultural training and induction for staff within an organisation, another big challenge. So, what does that look like? Is there a centralised version of that for the NT? Is there a localised version of that for the service provider? Is there an even more localised version of that for the community that they may be working in? \u0026hellip;There\u0026rsquo;s different hierarchical systems. So, it all again varies.\u0026rdquo; (participant 7, public health professional and manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants indicated that care provided by a provider not previously known to patients presented a challenge to acceptability:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think that the fact that they don\u0026rsquo;t, may not necessarily know the doctor in the first instance, it could be challenging at times but, you know, for a specialist, like they\u0026rsquo;re not going to know them anyway.\u0026rdquo; (participant 17, community leader)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHaving an ongoing relationship with a healthcare provider is one of the many factors that determine the acceptability of health services and cultural safety. Willingness to attend PHC clinics can diminish when staff turnover is high, and continuity of care is low:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, it can be a bit daunting for people to go into the clinic even though it\u0026rsquo;s their clinic and their community and see people who they\u0026rsquo;ve never met before, essentially.\u0026rdquo; (participant 2, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDHTs were seen as being helpful in building and sustaining positive healthcare relationships. Thought leaders who were already using telehealth spoke of how telehealth could work to build or even maintain the relationship between health professionals and their patients.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;And if I have an ongoing five-year relationship, as I do with the patients in that clinic, when rapport is already in place and I understand that person and their family and their needs, it's quite easy to have a consultation over digital means, whether that's telephone or video conferencing. So, the continuity is one area digital technologies can improve. I would say on the other way also, where patients are in hospital and they need help with interpreting or family members to help make a critical decision about their healthcare, the ability for digital technology to broker a very important family discussion is often used...\u0026rdquo; (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eCultural safety associated with DHT-assisted healthcare is a prime concern. Concerns were raised as to whether using DHTs to consult with a health professional on a screen created barriers to interaction between patients and providers. The thought leaders who had used telehealth were mainly providing services using a hybrid model, i.e., a mix of face-to-face and virtual consultations. They also highlighted that if a health professional had key interpersonal skills like what would be required in an in-person appointment, the presence of technology was not the barrier to provider-patient interactions.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I really haven\u0026rsquo;t found it [telehealth] made too much of a difference. I felt like I built quite a good relationship with some people, and then we met face-to-face and I\u0026rsquo;m always really keen to meet face-to-face as a result, and vice versa. I can\u0026rsquo;t really see a distinct difference, yeah, which way.\u0026rdquo; (participant 3, nurse educator).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e \u0026ldquo;I guess that the doctors, if they\u0026rsquo;ve got a good bedside manner and, you know, you can build a rapport with person quite easily over, you know, a computer, it might be a bit more difficult on the phone I think but like a computer you can see their whole face, you can, it\u0026rsquo;s almost just like having a normal discussion face-to-face pretty much.\u0026rdquo; (participant 17, community leader)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it [telehealth] would work for everyone, apart from the ones if, like I said, the doctor really needs to do an actual physical exam. But we [nurses] can do it for them in front of them, and obviously we can, say, do a knee exam, and then he can see exactly where the pain is, which movement is causing that.\u0026rdquo; (participant 13, RAN)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eYounger populations were described to be harder to reach. However, gentle health messages using SMS were seen as a potential way to engage them with health services.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If we had an option about sending health promotion messages, again using the text reminder, not doing too much, maybe one message \u0026hellip; and in language. Not overdoing it but gently pushing some message. I mean, if we can get through to them, at that [younger] age.\u0026rdquo; (participant 13, RAN).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFurthermore, community members\u0026rsquo; propensity to use digital technologies was seen as a positive that could support opportunities to apply these technologies for CPHC. For example, sharing targeted text messages or videos on social media, could improve health literacy and thereby promote better health:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I also think that in general, people are quite tech savvy, even though health literacy and literacy might be an issue, phone use is really high and good. So, if we could make the content that we have really connect with people\u0026rsquo;s phones, then I think we, and that is really the health promotion information that we want to give them. Small videos, YouTube, things that can easily be dropped into community Facebook pages.\u0026rdquo; (participant 10, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eCommunity members\u0026rsquo; existing technology use also could be leveraged to reduce missed appointments and support medication compliance:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...text message is very helpful for appointment reminders, and medication reminders. I believe text message to remind appointment has value to reduce DNAs [did not attend appointments] as that helps patients to get organised. For those who have basic phones, I think will work. I do not see anyone having any issues with appointment reminders. I am assuming most people with phone are able to read the text message. That means the message needs to be in simple language.\u0026rdquo; (participant 16, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFurther discussion arose around what makes DHTs acceptable to health service providers and the community. The ease of DHT use emerged as the most important consideration for both health staff and consumers:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Ease of use would be probably number one. Ease of access and ease of use. I think the driver behind video telehealth is, rather than the ease of use, is the enhanced experience. I think ease of access to whatever tool you're using is critical. If clinicians don't have easy, and when I mean easy, I mean, pretty much instantaneous access, it's not going to happen.\u0026rdquo; (participant 5, manager)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eAffordability\u003c/h2\u003e\u003cp\u003eAffordability was perceived as a complex issue intertwined with the social determinants of health. Within affordability, two aspects, costs to the healthcare system and consumers, emerged as distinct challenges. As part of CPHC, various allied health services are sent to remote communities two or three times a year, depending on the size of the community. The participants perceived that more services are always needed; however, resources remain a major barrier.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know the figures, but I know in my last role I used to drive ten, eleven hours out to community\u0026hellip; Yeah, fuel-wise, very expensive and just all the set up and preparation for those trips.\u0026rdquo; (participant 16, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think \u0026hellip;They're just not funded adequately to do everything they're expected to do or that they want to do for their community, or the community wants from them.\u0026rdquo; (participant 6, public health nurse, coordinator)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So many useful health promotion activities get initiated and start showing effect in the community, and all of sudden there is no funding. This is the real story around nutrition and health promotion.\u0026rdquo; (participant 16, allied health)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe second major affordability issue for the health system was the expense of transporting patients to the nearby regional centre or city for further consultations or investigations. The costs for healthcare, along with transportation costs [to hospitals] for remote and very remote residents of the NT, are covered by the Government. However, there are indirect costs associated.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;And then there's yeah, the expense, is that, at the same time there's the issue of sometimes people need to be seen by specialists or be flown out to secondary care.... the expenses are quite astronomical and often beyond the budget of any health service or government.\u0026rdquo; (participant 9, GP)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...how much money was wasted on booking people on the bush bus to get them to town to the specialists\u0026rsquo; appointments. You know, they don\u0026rsquo;t turn up. You know, whatever. But we would still have to pay for that bush bus. And the same here, when we take people in. With the price of fuel now, that\u0026rsquo;s a lot of money out of your budget, in and out.\u0026rdquo; (participant 13, RAN)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAffordability challenges for consumers were also reported to be prominent. Although the direct cost is paid for by various government funded services, indirect and opportunity costs were noted. For instance, if a community member had to travel to visit a health provider in a regional centre, this involved multiple days of preparation and planning, many hours of transportation via bush bus or clinic-organised transport, or flights, plus accommodation and organising necessary appointments, which all require resources.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Traveling there, coming into town [Darwin] is all paid for by Department [of health], so there's no out-of-pocket [expenses incurred by the patient]. In saying that, they [patients] do like to plan, so they do have money to come to town. If they don't do that, they'd fall, that's an impact. They don't have actually any money to them because of that financial stress that they have in community. No money meaning not even at any money, no dollar, no nothing. But traveling to Darwin [city], so if the PATS (patient assistance travel system) bus doesn't turn up to pick them up, they don't even have money to get taxi.\u0026rdquo; (participant 15, aboriginal health practitioner)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn communities that are far from PHC clinics, such as homeland communities, getting to a clinic means consumers must organise their own travel, which requires resources to cover indirect healthcare costs such as fuel and food. Even when teleconsultations are available to help them avoid travel, digital technology ownership may be limited due to poverty.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It costs... like people have to go out and drive out to these communities, so it's expensive.\u0026rdquo; (participant 9, GP)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...from a financial perspective, it depends on how severe your presentation type is. So, somebody may go \u0026ldquo;Well, actually do I want to spend the money to buy fuel to drive to the clinic or do I want to buy food? How bad am I? Maybe I\u0026rsquo;ll get a lift next week, someone else will go in and I\u0026rsquo;ll go in with them and I\u0026rsquo;ll get seen then.\u0026rdquo; (participant 7, public health professional and manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So having a personal controlled device is often shared between many people. But also, poverty means that people will not necessarily have access to video consultations on their personally controlled device.\u0026rdquo; (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants felt that DHTs could not address all concerns of affordability, but they could help reduce the cost associated with delivering health services. In addition to direct costs, incidental costs associated with access to healthcare were reported to be high.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think costs, I mean, the cost savings. Cost savings is tricky because you are... if they're employing a full-time GP to do this, that's a cost and they're going to work out. The costs of flying out to a community when you could just do a telehealth with them. For us, $800 to $1,200 flight or several hundred dollars trip, that's a significant cost.\u0026rdquo; (participant 9, senior GP)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhile it was widely acknowledged that setting up for DHTs and paying for personnel involved some initial cost, there was an overall agreement that it would eventually pay off.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Definitely a key position if telehealth was to come online, and it would pay for itself in the long run, so it's just a matter of getting someone in community that's really engaging and able to get people to their appointments.\u0026rdquo; (participant 15, aboriginal health practitioner, RAN, coordinator)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eAdequacy (Accommodation)\u003c/h2\u003e\u003cp\u003eThe way services are organised and offered by the health system was identified by consumers as a barrier to accessing health services. Participants stated that the provider-centric models of care with booked appointments and delays were causing distress and agitation for patients.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;She [mother-in-law] gets agitated when she has to wait too long [for an appointment]\u0026hellip; So, and waiting, waiting for the doctor, she gets annoyed, but I say, Aunty, you got to just wait, like you got to wait your turn because they\u0026rsquo;re very busy.\u0026rdquo; (participant 17, community leader)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThought leaders highlighted that there was an ongoing mismatch between how the services are organised and people\u0026rsquo;s ability to use those services. Many services were offered in a way that did not suit community members\u0026rsquo; lifestyles and the local contexts.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Clinics are quite westernised in that we haven't evolved them to be operating potentially in a different way, which may be more culturally palatable for people to use and that may be more appropriate.\u0026rdquo; (participant 7, public health professional and manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFor the visiting allied health services, the intermittency of outreach models with the inability to meet needs that arise between face-to-face visits also challenged the provision of adequate CPHC.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;And the fairly fixed schedule of those allied health visits is not flexible to accommodate for emergent needs within a community.\u0026rdquo; (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe visiting services (e.g. allied health) for CPHCs are scheduled periodically with very limited flexibility. When there are events of cultural significance such as funerals, some of these visits need to be cancelled. These visits may be rescheduled or had to happen in the next planned dates that might be after many months, leaving consumers without health services.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;it's not uncommon for there to be a significant cultural event such as a senior person that's passed away or a funeral that would normally necessitate the closure of a clinic. And it's unfortunately not uncommon for that to coincide with a visiting service that only comes once or twice a year.\u0026rdquo; (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFrom a health service perspective, local health staff coordinate a range of acute and specialty-related health services for patients. This was described to take a considerable amount of staff time and detrimentally affect their ability to provide adequate CPHC services.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...a lot of them [local PHC clinic staff] I think are quite frustrated with that because they see that they're spending a large amount of their time coordinating acute services and not delivering primary health services. It's a bit of a double-edged sword there.\u0026rdquo; (participant 5, manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePoor communication and convoluted processes also add to the frustration of an already overworked clinic team. The participants also perceived that the referral system is difficult due to poor coordination and disjointed reporting forms.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Coordination among different services is a major issue. We often do not communicate well among ourselves. For instance, there is weekly meetings, where only doctors and nurses communicate, and allied health professionals hardly have space in those discussions.\u0026rdquo; (participant 16, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;within the clinic at [name of a remote community], and the guy who\u0026rsquo;s doing that [referral] gets all them [information] directly to him, but they come in different formats....but he\u0026rsquo;s kind of dealing with the paperwork nightmare as well within the system.\u0026rdquo; (participant 2, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThought leaders felt that DHTs could help improve organisational issues and simplify complicated processes, such as the use of electronic appointment booking or using flexible telehealth appointments to reduce wait times. Another key benefit was that telehealth helped those who were frightened of flying and improved their access to health care.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;if you had that scheduled time in a telehealth appointment where you\u0026rsquo;re just able to sit down and no wait time, it would be really, I think for her [participant\u0026rsquo;s mother] it would be quite good like, although she may not have much understanding around like what was happening, but she\u0026rsquo;d have her carers, like us, there to help her through that process.\u0026rdquo; (participant 17, community leader)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAn additional challenge was poor access to patient information for clinicians when a patient moved between the health services, for example, from hospital to a remote clinic, or one remote clinic to another remote clinic.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;And the other part is the data piece about having everyone's health information exchanged in real time. And that's a big digital technology piece that will emerge, I think, over the next decade. But I think that you can't do integrated care and safe care without having authored information at the point of care to be considered.\u0026rdquo; (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe ability to access electronic health records that hold information from all providers and services would support access to patient information and help improve patient experience.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...having access obviously to the person's medical health records during that consultation is paramount so that you can understand because people may not be able to explain what's wrong with them or they mightn't be able to understand what's wrong with them, to share that information back at you.\u0026rdquo; (participant 7, public health professional and manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOften, information about which health service is visiting the community and when and how to access those services was reported to be unclear or not readily available to community members. In many communities, this information is posted as a printed copy on the clinic notice board, so was not seen by community members unless they attend the clinic and read the notice board. There is an opportunity for DHTs to enhance access to such information, for example, providing details about visiting health services.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, it would be so helpful if there was one place for each remote community, where people could put things in, so people know when people are coming and maybe, plan to come at the same time if they want to work together or plan to be separate if they\u0026rsquo;re going to be trying to use the same resources, like the same computer room or different things like that. It would be really helpful if that was part of what the digital strategy could do. I think that\u0026rsquo;s all.\u0026rdquo; (participant 10, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants also suggested the possibility of streamlining the referral system using electronic forms and noted that wearable devices could help provide additional clinical data and information to remote clinicians which could inform decisions about the timing and location of follow-up care. Such remote monitoring devices were considered beneficial by allied health professionals based in cities or regional centre, as they would allow consumers to receive care without waiting for the next outreach visit.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It should all just be consolidated and coordinated within one electronic system ... and maybe those obs [observations] can be done via a wearable device for a day, or for overnight, or for a week, and that data goes to the specialist who can then go, \u0026ldquo;Okay, well that\u0026rsquo;s what\u0026rsquo;s happening. That\u0026rsquo;s great. We actually do need to see this person, let\u0026rsquo;s bring them into Darwin,\u0026rdquo; or like, \u0026ldquo;oh no, we don\u0026rsquo;t need to see them, this can be managed down in [name of a very remote community] by the local GP. We\u0026rsquo;ll give them some advice, but they don\u0026rsquo;t need to come to Darwin.\u0026rdquo; (participant 2, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTo align with the variability in training levels, technology skills, experience, interest, and demography of health staff, participants highlighted the importance of user-friendly DHTs in the remote setting.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;they have to understand the technology. And that can be\u0026hellip; One, technology, it needs to be easy. And two, it actually takes human resources to manage that technology. And I think that often gets forgotten whether it's like a technical person in the background, like managing CommuniCare.\u0026rdquo; (participant 6, public health nurse, coordinator).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eAwareness\u003c/h2\u003e\u003cp\u003eAwareness relates to health literacy and communication issues between health professionals and consumers. A lack of health literacy awareness, lack of timely and accurate clinical information for clinicians while attending patients, and poor understanding of medications or prescribed interventions were key issues identified in this access domain. Poor communication within the health system was also identified as an access barrier:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Then we had an incident yesterday, a lady had to go in for an appointment, but there wasn't any communication. She had two appointments, so she didn't even know about that, and we didn't know about that. So, it was a [poor] communication for the hospital to here [PHC clinic].\u0026rdquo; (participant 12, RAN)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBoth consumers\u0026rsquo; and healthcare providers' lack of understanding of the health system and pathways to accessing and delivering comprehensive primary health care were also identified as a challenge to accessing healthcare:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;But also, significant gaps in terms of understanding the healthcare system and how to navigate the healthcare system are often underpinned by different languages and cultural worldviews and pervasive socioeconomic disadvantage.\u0026rdquo; (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, that kind of awareness amongst the general population as to how to interact most appropriately with health services is an area which we still need to work on.\u0026rdquo; (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThere were numerous ways that DHTs were perceived as having considerable potential to help improve awareness and communication. For example, digital literacy was seen as valuable in improving the dissemination of information. The ability to use text messages or other technology-assisted monitoring of health parameters could improve awareness and understanding for appropriate delivery of care.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think there\u0026rsquo;s a lot of potential. As I said, I think people have really good phone literacy...and people are interested about their own health, and we have that opportunity to disseminate information.\u0026rdquo; (participant 10, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, I think that [digital technology] would be a big thing of general education, in just general education, and the second one is health specific education to give people an awareness of what\u0026rsquo;s the right steps to do.\u0026rdquo; (participant 7, public health professional and manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn our interviews, mobile applications also emerged strongly as possible DHTs helping raise awareness. Reminding patients (i.e., text messages) to increase medication adherence, sharing of health videos on certain topics, or appointment reminders to help reduce no-shows were key examples.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My general feeling is that mHealth will be the way to go, that people will have access on their phones, or maybe it\u0026rsquo;s an app that reminds them about the medication that\u0026rsquo;s due today or their check-up\u0026rsquo;s due or the specialist is coming tomorrow and they need to come to clinic, \u0026ldquo;If you\u0026rsquo;ve got diabetes, watch this video\u0026rdquo;. (participant 12, RAN)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Even just simple reminders for appointments, they trialled that in Allied Health at hospital and they found a really good uptake, improved, people were attending appointments.\u0026rdquo; (participant 10, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There\u0026rsquo;s heaps of potential for us to use different tools, whether it\u0026rsquo;s access to various resources that people can use to help people inform themselves about treatment or appointment reminders or reminders to book an appointment, reminders to get immunisations, that kind of thing.\u0026rdquo; (participant 10, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOne of the community leaders also stated that mHealth (ie., use of smart phone to access health care) could play a significant role in raising awareness on sensitive topics such as cervical screening among women.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s [Technology] great education for young ladies as well, you know, who are just like moving into that phase, like turning 18, getting Pap smears and it\u0026rsquo;s very, very important to look after your, you know, your female health. So, I think the more information, the more technology around that I think the better, you know. Absolutely. Because the ladies don\u0026rsquo;t necessarily always want to go up to the clinic \u0026hellip; yeah.\u0026rdquo; (participant 17, female, community leader)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e Participants felt that DHTs could also be better used by the health system to improve communications with patients. For instance, a digital community notice board to inform consumers about outreach services in advance of visits and remind them again at the time of the visit:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it really is an opportunity for us to improve people\u0026rsquo;s access to health services and health information if we do it right. \u0026hellip;provide information and videos about services available, people visiting, like what visiting services are coming over the next month and allow people to have something that they can explore and checkout.\u0026rdquo; (participant 2, allied health professional)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;But maybe if we get free WiFi in community, maybe we can ping out alerts or something, I don't know. If that someone's [health provider\u0026rsquo;s] in town, then we can just tell everyone ...\u0026rdquo; (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eChallenges to using digital health technology\u003c/h2\u003e\u003cp\u003eAll participants used DHTs as part of their role. While they identified many ways that DHTs could improve access to CPHC in the NT, they cautioned that the potential of DHTs should not be overestimated. The quote from one of the participants summarised this well, \u003cem\u003e\u0026ldquo;Now, we need to make sure we remember that, that a Telehealth\u0026hellip; a bad face-to-face interaction isn\u0026rsquo;t made better by a bad Telehealth interaction\u003c/em\u003e.\u0026rdquo; (participant 2, allied health professional). Along with this, a number of challenges were also stated during interviews. The following section provides a brief information on the challenges. Supplementary Table\u0026nbsp;1 provides an extended list of quotes under each theme.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eTechnology-related challenges\u003c/h2\u003e\u003cp\u003eParticipants shared their observations that the lack of digital infrastructure is a key barrier to digital health solutions and iterated that patients in remote communities still have to depend on public payphones, which do not allow for videoconference. A participant who was working as a GP for very remote communities at the time of the interview stated, \u003cem\u003e\"A lot of remote health outstations still have basically a free Telstra phone booth.\u0026rdquo; (participant 1, GP).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants further highlighted the issues associated with the instability of the platform and low bandwidth available in the remote communities as a major issue.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;But mostly, the barriers with a lot of our earlier forays into particular video conferencing have been the instability of the platforms, the bandwidth available in remote communities, mostly on satellite and terrible connections feeds. So sometimes you're unable to get a video picture, but you can talk on the phone.\" (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAlmost all participants who had experienced the old telehealth system [e.g., Cisco telehealth platform] in the NT Government (NTG) mentioned that the structure of the platform and its overly secure platform were major barriers. They perceived that it was not user-friendly and there was an issue with interoperability when the government system had to communicate with the ACCHS system.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\".. So older versions of telemedicine equipment had complicated ways to log in and get through the firewall of NTG, even within the network. And that's exacerbated when you're working in a community-controlled setting, trying to get through the NTG firewall to connect and talk to a specialist colleague who works for the Northern Territory government.\" (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eNon-technological challenges\u003c/h2\u003e\u003cp\u003eThe participants also mentioned various challenges related to patients and health systems. Access to or ownership of digital device was perceived as a major issue. \u003cem\u003e\u0026ldquo;I think a lot of the time the deficiency is in the remote outstations and you're lucky if you've got a phone.\u003c/em\u003e (participant 1, GP).\u003c/p\u003e\u003cp\u003ePoor digital literacy was also perceived as a key barrier affecting remote patients\u0026rsquo; ability to benefit from DHTs. \u0026ldquo;\u003cem\u003eAnd then there's digital literacy. So very familiar with Aboriginal friends that I've known and very vulnerable to all sorts of digital literacy issues, whether that be scams or viruses, or content that's not appropriate. As you know, it's very overwhelming.\u0026rdquo; (participant 11, GP and senior manager)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSignificant health system-specific barriers were also suggested. In the one hand, the process of attending telehealth could be daunting; on the other hand, the remote health staff were unable to stop and fix the issue due to their excessive workloads. \u003cem\u003e\"They [the PHC clinic staff] know a particular process [to attend telehealth] is terrible. They don't like it, but they don't have capacity to just stop for half an hour and say, \"This process is rubbish. Well, how are we going to change it?\" That's what people who are overwhelmed do. They don't have time to stop and say, \"Let's fix this.\" (participant 5, manager)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined perceptions of thought leaders about the challenges to accessing CPHC in the remote NT and how DHTs can help improve access to health services. This study adds to existing knowledge by examining how DHTs can address challenges across various dimensions of access, such as accessibility, availability, acceptability, affordability, adequacy/accommodation, and awareness [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. While DHTs were found to be useful and to have the potential to improve access across all dimensions, their role in improving access was thought to be strongest for addressing accessibility, availability, affordability, and awareness dimensions.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eAccessibility\u003c/h2\u003e\u003cp\u003eParticipants perceived that DHTs could address some critical gaps in accessibility by reducing the need for travel. The NT covers a vast landmass (1.3\u0026nbsp;million sq km and 17.5% of Australia) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and having predominantly remote and very remote communities, it is not surprising that challenges were raised in relation to the NT\u0026rsquo;s vast geography. Two studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] from the NT have reported on how telehealth was able to increase accessibility in remote Indigenous settings. First, a study from Central Australia during the COVID-19 pandemic [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] reported that telehealth could function as a supplementary tool to improve access to a GP. Second, an earlier study from East Arnhem Land [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] reported that telehealth was able to reduce the travel and trauma associated with having to leave Country to see a health professional.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eAvailability\u003c/h2\u003e\u003cp\u003eSupply and retention of PHC staff (availability) was repeatedly highlighted as a major issue affecting access to primary health care services. Between 2017\u0026ndash;2019, the turnover rate in remote clinics managed by ACCHSs was 151% at the clinic level in the NT, and in the most remote clinic, it was as high as 355% [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. There is no evidence that turnover and retention rates have improved in the post-COVID-19 pandemic period. DHTs such as telehealth could help address some issues related to staff shortage as telehealth services can be provided by staff located anywhere (so long as they had internet connectivity).\u003c/p\u003e\u003cp\u003eThought leaders identified that DHTs can help improve health information exchange in real time by linking remote PHC staff and their patients to distally located GPs or other health providers via telehealth. This is consistent with findings from an earlier study [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] from the NT, which demonstrated that telehealth helped improve GP availability and continuity of care. Telehealth also reduced travel time for GPs as they were not required to be onsite in remote or very remote communities where they generally didn\u0026rsquo;t live. However, for the model to work effectively, it is important that local health workers (e.g., RANs or AHPs/Aboriginal Health workers or trained workforce) are available at the patient end to assist with telehealth consultations [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eAffordability\u003c/h2\u003e\u003cp\u003eCosts associated with travel, higher living costs due to remoteness, and direct and indirect health care costs to individuals and the health system were key issues (affordability) experienced by the health system and consumers in remote communities [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Even when direct medical costs are not paid by remote patients, incidental costs and systemic barriers created by widespread poverty are significant. Participants in our study perceived that DHTs have the potential to reduce some of the costs associated with accessing health care in remote areas, consistent with the NT virtual care strategy (2023) which suggests that 14% of visits could be delivered using telehealth, thereby reducing by \u003cspan\u003e$\u003c/span\u003e21\u0026nbsp;million health-related travel costs in the NT each year [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Telehealth can reduce travel costs, including fuel, accommodation, and lost wages due to absence from work, and help reduce other indirect costs, such as having to arrange for someone to look after kids or pets [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Participants cautioned, however, that cost savings would be offset by hidden costs associated with the operationalisation of DHTs, and that these somewhat intangible costs and benefits should be accounted for when calculating potential savings offered by DHTs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Osman et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] noted that increasing dependency on telehealth in remote regions might mean that resources are redirected toward urban centres and therefore result in reduced investment in the remote infrastructure which could hinder the upskilling of the remote workforce [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eAcceptability\u003c/h2\u003e\u003cp\u003eParticipants also perceived that DHTs could help improve the acceptability of health services in remote NT. A former study from the NT also suggested that being able to see the familiar faces of clinicians, i.e., continuity of care with the same clinician, via video conferencing was comforting for patients with chronic conditions [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Another study showed that patients were happy not having to travel if they had an option to see a clinician via video call [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A review [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] stated that community visits by the health staff involved in providing telehealth services was also important in forming strong relationships with Indigenous patients and families. In previous studies, it has been highlighted that an Indigenous workforce provides essential contextual knowledge, helping foster trusting relationships and cultural safety [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Local Indigenous health workers are therefore extremely valuable to the provision of effective PHC, supporting both non-Indigenous health staff and Indigenous patients. It is important, therefore, that local Indigenous workforce development, recruitment, and retention is at the centre of all health service strengthening efforts, including digital health initiatives [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eAdequacy (accommodation)\u003c/h2\u003e\u003cp\u003eIn this study, participants highlighted that the organisation of way in which health services were organised (i.e. accommodation and adequacy) was a key barrier to accessing CPHC, a finding which was similar to previous studies from Australia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Participants felt that DHTs could help address some of these issues such as, improving coordination of the services, reducing paperwork for health staff, and offering flexibility around availability of services. A previous study [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] from the NT reported that telehealth was helpful in accommodating the needs of the community, GP, and health services. It helped the local health services to offer video consults, ensure direct supervision of the staff on the ground, and ensure patient examination was done the right way. This also facilitated shared decision-making with families, which is important in Indigenous cultures. In widely spread remote communities, it may take months to organise such family meetings. Using telehealth, the health services was able to address the adequacy issues for the remote and dispersed communities.\u003c/p\u003e\u003cp\u003eAnother potential of DHTs in this dimension was improving care coordination and quality information sharing. In Australia, electronic medical records (or eHealth records) have been developed to serve as a real-time tool that supports clinical decision-making and promotes continuity of care [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Such electronic health records hold significant promise for strengthening the continuity of care within the Australian healthcare system. However, this study found that there was a lack of interoperability within and between the health systems, limiting the benefits of such electronic health records. The health system is a complex environment where patients and health professionals need to navigate multiple issues. Poor oversight of patients\u0026rsquo; information to make informed decisions, low health literacy, suboptimal awareness about various health services provided by different health workforce, disjointed communication about the travels, appointments, and follow-ups, low medication adherence, and lack of understanding of complexities of the Australian health care system were the key issues raised in this study.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eAwareness\u003c/h2\u003e\u003cp\u003eThought leaders perceived that DHTs could play a significant role in improving communication. This finding is similar to those from a recent systematic review of global literature, which reported that DHTs such as telemedicine were likely to increase interprofessional communication and collaboration among different health groups [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Improving access to health information using DHTs was regarded as essential to uplifting health literacy and the understanding of complex health systems. In the NT and very remote Australian context, telehealth was also noted as beneficial in supporting the ongoing education of the remote clinic-based staff when they attend telehealth with specialists and other clinicians [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Such consultations offer an opportunity to learn from specialists who otherwise would have taken place in the regional centres or cities where those specialists are based.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eChallenges that come with digital health technology\u003c/h2\u003e\u003cp\u003eA number of technological and non-technological challenges, such as poor digital infrastructure, intermittent device ownership and health system readiness, were highlighted. This also includes using non-secured publicly available (e.g., Facebook Messenger, WhatsApp) as a workaround for clinicians, as messaging platforms. While these challenges are not unique to the digital health space [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].These challenges must be taken into account and addressed proactively for sustainable DHT implementations to improve health service delivery in remote settings.\u003c/p\u003e\u003cp\u003eOn-the-ground coordination to support telehealth was an important aspect identified by the participants in this study and in previous studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. At times, the clients were also not comfortable talking to someone on the screen, had language barriers, had little established relationships with the clinicians in the session, or had technological issues [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The remote clinic staff would have to set up telehealth and sit with the clients to assist with the consultation. This would take considerable time and resources away from a regular working day [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A former study from the remote NT [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] also asserted that this patient-end support needs to be well-resourced so the remote staff can help the patients without having to worry about not being able to perform their day-to-day tasks. The findings highlight the need to take cautious and proactive steps to curtail the impact of increased workload on local clinic staff [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eStrengths, limitations, and implications of current findings\u003c/h2\u003e\u003cp\u003eThis study included key stakeholders in remote health across the NT, both from the NT Government and community-controlled health services. Furthermore, it has strong representations of all levels of the health workforce, both at the leadership and community level, which gives a comprehensive view.\u003c/p\u003e\u003cp\u003eAlthough this research presents a comprehensive view, there is an appreciation that the different administrative regions within the NT have varied contexts. Even when these remote Indigenous communities are geographically near to one another, they vary by language, culture, clan group, education attainments, and access to infrastructure. Therefore, the findings must be carefully adapted to local contexts when considering translation.\u003c/p\u003e\u003cp\u003eIt was also our intention to use the information from these interviews to co-design digital health interventions in remote communities. In some interviews, thought leaders tended to delve deeper into the issues that may be closely related to telehealth (or mHealth) rather than overall healthcare access challenges. While DHTs have great potential to help bridge the gap in access to health care, careful considerations are needed to ensure that it does not reduce the efforts to build a critical mass for the remote health workforce, does not take resources away from investment in infrastructure (e.g. connectivity, health services buildings and roads) in the remote communities, and does not function as a band-aid solution to the health workforce crisis in remote settings within Australia.\u003c/p\u003e\u003cp\u003eThe findings from the current study have significant practical implications for remote health services. Most importantly, there was universal acceptability from the health professionals and no resistance to implementing DHTs to improve access to health care. There is an opportunity to adapt technology-enabled models of care and identify how that can work to support the incredibly diverse populations of remote NT communities, including ways to sustain successful initiatives in the midst of limited workforce availability. However, these initiatives must be co-designed with community and remote healthcare staff from the ground-up, empowering the local workforce, well-resourced, and contextualised to respond to the unique needs of the communities. The technologies must be easy for the local PHC clinic staff and patients. Resources saved by the use of telehealth should be re-directed to the local clinic to help optimise patient-end support at the community level [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Further research could evaluate the economic impact of telehealth in remote communities, including any unintended adverse effects on remote health infrastructure and workforce.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study offered valuable insights into the perceptions and experiences of health system leaders in the NT regarding challenges to accessing CHPC and how DHTs could improve these challenges in remote Aboriginal communities. However, participants also cautioned that DHTs should not be viewed as a single solution for the broad range of CPHC access issues in remote NT communities, and that challenges of using DHTs exist across various layers of health service delivery. Nevertheless, there was an optimism that DHTs could substantially improve healthcare access in the NT.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e The research project was reviewed and approved by the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (HREC Approval Number: 2022\u0026ndash;4275) in accordance with the Declaration of Helsinki. Administrative approval was also obtained from the Research Governance Office, NT Health (EFILE2023/8720), the Boards of the participating ACCHS and respective Land Councils. All participants signed a consent form after reading the participant information sheet.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe current project is supported by the Digital Health CRC Limited (DHCRC). DHCRC is funded under the Australian Commonwealth\u0026rsquo;s Cooperative Research Centres (CRC) Program. This is a collaborative project among multiple partners in Australia: the Australia Government Department of Health, Disability and Ageing, Department of Health - Northern Territory Government, Primary Health Care Network Northern Territory, Aboriginal Medical Services Alliances Northern Territory, Healthdirect, Australia Digital Health Agency, Menzies School of Health Research, and The University of Sydney.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eVK wrote the first draft of the manuscript with significant contributions from ES, NN and DR. VK and NN analysed the data under the mentorship of ES. All authors, including KW, JC, KC, AP, HB, AH, SN, MM, MD, ST, PB, TC, JR, DR, DE, AL, JW, TS) provided significant input in drafting, revising and finalizing the manuscript. TS and DR are leads of this project and share equal contributions as senior authors. All authors have read and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eWe acknowledge the contributions of all the project partners and participants for their time, valuable insights during the interviews and both the formal and informal contribution to our ongoing implementation project. We also acknowledge the ongoing guidance from our community-based colleagues and cultural mentors.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eRelevant data generated or analysed are included in this article. De-identified data can be obtained from the corresponding author on reasonable request. The data are not publicly available due to them containing information that could compromise research participant privacy and consent.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMullan L, Armstrong K, Job J. 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The global effect of digital health technologies on health workers\u0026rsquo; competencies and health workplace: an umbrella review of systematic reviews and lexical-based and sentence-based meta-analysis. Lancet Digit Health. 2023;5(8):e534\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eErku D, Khatri R, Endalamaw A, Wolka E, Nigatu F, Zewdie A, Assefa Y. Digital Health Interventions to Improve Access to and Quality of Primary Health Care Services: A Scoping Review. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e 2023, 20(19).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYao R, Zhang WL, Evans R, Cao G, Rui TQ, Shen LN. Inequities in Health Care Services Caused by the Adoption of Digital Health Technologies: Scoping Review. J Med Internet Res 2022, 24(3).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Digital Health, Telehealth, Remote Health, Primary Care, Aboriginal Health","lastPublishedDoi":"10.21203/rs.3.rs-7837584/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7837584/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eExisting literature shows the potential of digital health technologies (DHTs) to improve access to Comprehensive Primary Health Care (CPHC) by overcoming various challenges to care provision. However, the usefulness of DHTs in the remote Northern Territory (NT) Australian context to support the delivery of CPHC has rarely been explored. This study aims to explore thought leaders' perspectives about the key challenges to accessing CPHC services and the role of DHTs in overcoming these challenges in the NT.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn-depth interviews were conducted with 17 participants who were working or had previously worked in the NT in clinical or non-clinical roles, including in leadership, governance, and management roles with the NT Health Department or Aboriginal Community Controlled Health Services. Thematic analysis was conducted using a deductive approach based on the theory of access.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe results suggested that the key challenges to accessing CPHC in the remote NT include workforce issues (staff shortages, high staff turnover, poor continuity of care), the large distances and costs of providing care, and how health care services were organised and delivered. Participants highlighted the potential of DHTs for improving challenges relating to provider availability, continuity of care, and cost savings for health services. However, challenges to implementing digital solutions were also raised which were broadly classified as technological and non-technological. Poor digital infrastructure, intermittent connectivity, and the lack of interoperability of systems between healthcare organisations were key technological challenges. Low rates of digital device ownership and low digital literacy; the limited local availability of skilled staff to support digital solutions, and the lack of flexibility in the way appointments were organise were identified as key non-technological challenges.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThere was an optimism that DHTs could substantially improve healthcare access in the NT. Telehealth, used where appropriate and in combination with face-to-face care using a hybrid approach, could improve remote patients\u0026rsquo; access to a range of healthcare providers, reduce patients\u0026rsquo; and providers\u0026rsquo; need to travel and improve continuity of care. This will necessitate increased investment in training local Indigenous people to support communities\u0026rsquo; access to DHTs and improve the quality and cultural safety of care.\u003c/p\u003e","manuscriptTitle":"Digital health technologies to improve access to comprehensive primary health care in remote Northern Territory, Australia: qualitative findings from thought leader interviews","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 17:29:44","doi":"10.21203/rs.3.rs-7837584/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-14T13:40:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-04T09:29:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274873448680487843991150244269101765532","date":"2025-11-16T20:10:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-15T06:31:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"293758650542668952886987758274719973971","date":"2025-11-15T06:11:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51106607411538313660768344413659869008","date":"2025-11-14T14:03:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211777923728615845603389113921376361168","date":"2025-11-14T12:50:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-09T12:42:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-18T09:58:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-18T02:58:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-10-18T02:55:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a334f97f-8fb8-4dce-8609-ee494ddbc141","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T22:39:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 17:29:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7837584","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7837584","identity":"rs-7837584","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}