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Staff-reported barriers and facilitators to the implementation of healthcare interventions within regional and rural areas: a rapid review

BMC Health Services Research volume 25, Article number: 331 (2025) Cite this article

Abstract

Background

Individuals in rural areas consistently demonstrate higher mortality and morbidity rates, and poorer access to healthcare, compared to their metropolitan counterparts. Optimizing the implementation of evidence-based interventions can reduce these inequities. Existing literature outlines numerous barriers and facilitators to the implementation of healthcare interventions, but these are generally not specific to rural areas. This rapid review aims to synthesize barriers and facilitators to the implementation of healthcare interventions in regional and rural healthcare services as reported by healthcare staff, including clinicians, managers, and administrators.

Methods

A systematic search for peer-reviewed publications was conducted using CINAHL, PsycINFO, Medline, and Embase databases (1/1/2000–29/08/2023). Eligible publications were primary research articles published in English, assessing staff-reported barriers and facilitators to implementing healthcare interventions within regional and rural areas of high-income countries. Qualitative, quantitative, and mixed-methods designs were included. Eligible healthcare settings encompassed acute, sub-acute, primary care, community health, and aged care. Barrier and facilitator data were coded and grouped into sub-themes and broader themes, with results presented narratively.

Results

Thirty-nine publications met the inclusion criteria. Most studies were conducted in Australia or the USA (both n = 18, 46%), within primary care (n = 13, 33%) or hospital settings (n = 12, 31%) in rural (n = 22, 56%) or regional (n = 9, 23%) locations. Implementation barriers and facilitators were grouped into four overarching themes: intervention-level (intervention feasibility and fit; complexity; privacy and confidentiality); staff-level (staff attitudes and beliefs; knowledge, skills, and confidence; staff roles and professional identity), patient-level (patient characteristics; attitudes), and system-level (leadership support; environmental resources and context; geographic vastness; networks and communication).

Conclusions

These findings provide essential guidance for policymakers, healthcare leaders, and researchers in planning and designing future implementation efforts in regional and rural healthcare settings. By considering factors across intervention, staff, patient, and system levels, stakeholders can address challenges and leverage local strengths to enhance implementation success and reduce health disparities.

Trial registration

PROSPERO registration number: CRD42023470736. Registered 19/10/2023.

Peer Review reports

Background

The persistent gap in health outcomes between rural and metropolitan areas represents a significant challenge for healthcare systems globally [1]. Individuals living in rural areas, which are generally characterized by geographical vastness and sparse population distribution [2], consistently experience higher mortality and morbidity rates, along with poorer access to healthcare services, compared to their metropolitan counterparts [3, 4]. These disparities in provision and access of care are influenced by a complex interplay of social, economic, geographical, and system-related factors [5].

Optimizing the implementation of evidence-based interventions (EBIs) has emerged as vital to addressing the health inequities experienced by key population groups, such as those living in regional and rural areas [6]. EBIs are broadly defined as practices, programs, policies, processes, or guideline recommendations that have been proven effective in improving health outcomes [7]. When implemented as intended, EBIs have significant potential to enhance the quality of care and outcomes for people living in regional and rural settings [8]. Yet, integrating EBIs into routine healthcare practice is challenging and complex, with many healthcare interventions not routinely adopted, delivered or sustained [9].

To support the uptake and sustainability of EBIs, the identification of context-specific barriers and facilitators (i.e. determinants) to implementation is recommended as an important step that enables the design of tailored, theory-informed implementation strategies [10]. While existing implementation research has extensively documented various determinants to implementation across a range of healthcare contexts [11,12,13], there remains a significant gap in understanding the unique experiences of regional and rural areas. Healthcare services in these areas are required to leverage strengths and overcome challenges such as geographic spread, low population density, limited infrastructure, and workforce retention to effectively implement EBIs [14]. A nuanced understanding of the factors influencing implementation in regional and rural healthcare services will be essential for bridging the health disparities between rural and metropolitan populations.

To address this gap, we aimed to synthesize barriers and facilitators to the implementation of healthcare interventions in regional and rural healthcare services as reported by healthcare staff, including clinicians, managers, and administrators. Given the significant differences between high- and low-income healthcare settings [15]—such as resources, infrastructure, health system structure, workforce, disease burden, and policy environments—this rapid review specifically focused on healthcare staff working in high-income countries. Healthcare staff are uniquely positioned to provide valuable insights into the practical realities of implementing healthcare interventions in their settings. By focusing on their lived experiences, this review will inform future implementation efforts in regional and rural areas and contribute to the design of more effective and equitable healthcare solutions.

Methods

Design

This study adopted a rapid review design, a form of knowledge synthesis that accelerates the process of conducting a traditional systematic review through streamlining or omitting various methods to produce evidence for stakeholders in a resource-efficient manner [16]. This approach met the practical need of informing the authors’ broader research program, funded by the Medical Research Future Fund in Australia under the Rapid Applied Research Translation initiative. In this review, streamlining of methods included applying limiters to the systematic search (English-language, year of publication 2000 +), using single data extraction (checked for accuracy), and omitting the critical appraisal step. Additionally, knowledge users, specifically clinicians based in regional and rural areas, were included as part of the authorship team, and participated in all stages of the review process. The Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) [17] statement and the interim guidance for the reporting of rapid reviews [18] guided the reporting of this review (See Supplementary File 1); the protocol was prospectively registered in PROSPERO (CRD42023470736).

Search strategy

A literature search was conducted on 29/08/2023 using four electronic databases (Medline, Embase, PsycINFO and CINAHL); additional studies were identified by searching the reference lists of included papers. The search was limited to articles published after 1 January 2000, aligning with the emergence of implementation science as a distinct discipline [19]. While healthcare interventions have advanced rapidly in the past decade, this broader timeframe ensured the inclusion of both foundational implementation research and recent developmentsrelevant to contemporary healthcare practices. Preliminary literature searches and key terms from relevant literature [11, 20] guided the development of a comprehensive list of search terms. The search strategy used key terms and synonyms related to the following concepts: the regional/rural context, implementation, healthcare setting, barriers and facilitators (Supplementary File 2). To increase the sensitivity of the search, key terms that mapped to specific subject headings (e.g., MeSH) were included and adapted according to each database. Additionally, truncations and expansions were applied to selected search terms.

Inclusion and exclusion criteria

A summary of the eligibility criteria for this review is provided in Table 1. Barriers and facilitators were broadly conceptualized as any factor that either hindered or promoted the implementation process of healthcare interventions and included synonymous terms, such as challenges and enablers. The designations of factors as barriers and facilitators within primary research studies were accepted as reported. Classifications of regional and rural were also accepted as reported; authors did not have to explicitly refer to a geographical classification system (e.g., Rural–Urban Continuum Codes (RUCC) [21] or Modified Monash Model [22] (MMM)) for a study to be considered eligible, although this information was extracted from included papers. Inclusion was limited to studies conducted in high-income countries, as defined by the World Bank classification [23] (as at 11 August 2023). Importantly, papers that only assessed intervention effectiveness e.g., clinical or health outcomes, rather than factors influencing the implementation process, were excluded.

Table 1 Summary of eligibility criteria for the review
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Study selection and data analysis

Database search results were imported into Endnote X9 to remove duplicates; remaining records were then uploaded to Covidence. All records were independently screened in duplicate by title and abstract; potentially relevant full-text articles were then dual-screened against pre-specified eligibility criteria. Any screening conflicts were resolved through discussion or by involving the senior author. Only full-text articles that met all inclusion criteria progressed to data extraction.

Data extraction was performed using REDCap, with each paper undergoing single data extraction. A broad team of reviewers extracted data on study characteristics, including year and country of study, description of rurality, participant characteristics, description of intervention, and methodological approaches. Two authors (AC & DM) concurrently extracted barrier and facilitator data; these data were extracted in narrative form as per the explicit reporting within each article. Following single extraction, the first author reviewed data for completeness.

A narrative synthesis approach was employed to integrate and interpret the extracted barrier and facilitator data [24]. Relevant data fields were exported from REDCap into Excel and organized into a summary table that included the name, description, illustrative quotes, and the designation of whether each item was categorized as a barrier or a facilitator within each study. This summary table was then imported into NVivo software, where two authors (AC & AB) independently coded data, applying an inductive approach to identify key concepts. These concepts were first organized into sub-themes and then grouped into overarching themes. Given most included studies did not formally use an implementation framework to collect, analyze, or present their findings, data were not coded according to a specific implementation framework. To enhance the rigor of synthesis, themes and sub-themes were discussed among the broader author team, allowing the incorporation of diverse perspectives, including input from clinicians with lived experience in implementing healthcare interventions in rural and regional areas. In addition to the narrative synthesis, summary statistics were generated to describe the study characteristics.

Results

Search results

After removing duplicates, the search yielded 3,927 citations, from which 182 full texts were examined. Ultimately, 39 publications met the inclusion criteria. The PRISMA flow diagram details the search process and reasons for exclusion (Fig. 1).

Fig. 1
figure 1

PRISMA Flow chart

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Characteristics of included studies

Characteristics of included studies are provided in Table 2. Most studies were published within the previous five years (2019–2023: n = 27, 69%) and were conducted in Australia or the United States of America (USA) (n = 18 each, 46%). The majority described their context as rural (n = 22, 56%), followed by regional (n = 9, 23%) and mixed rural/regional (n = 8, 21%). Only seven (18%) studies explicitly used a geographical classification system to define the context (Australian Statistical Geography Standard: n = 2, Urban Influence Codes: n = 2, MMM n = 1, Accessibility/Remoteness Index of Australia n = 1, RUCC n = 1). Primary care (n = 13, 33%), hospital (n = 12, 31%), and mixed healthcare settings (n = 8, 21%) were the most common healthcare settings, followed by community health (n = 3, 8%), and residential aged care (n = 3, 8%).

Table 2 Summary table of included articles (n = 39)
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Most studies exclusively used qualitative methods to collect barrier/facilitator data (n = 33, 85%) via interviews (n = 18), focus groups (n = 6), document review (n = 1), or multiple qualitative approaches (n = 8; e.g. interviews and focus groups). Five studies (13%) used mixed-methods, while one study (3%) exclusively used a quantitative approach (survey). Less than one third of studies (n = 11, 28%) reported using an implementation theory, model or framework to guide an aspect of implementation; the most common was the Consolidated Framework for Implementation Research [64] (CFIR; n = 6, 15%).

The interventions studied were diverse. Models of care were most common (n = 11, 28%). Other intervention types included clinical practices/programs (n = 9, 23%), digital health interventions (n = 6, 15%), screening/assessment (n = 5, 13%), guidelines/recommendations (n = 5, 13%), and care planning (n = 3, 8%). Furthermore, only limited priority populations were specifically targeted in these interventions. For instance, only two studies specifically focused on Aboriginal populations [26, 61], while a single study targeted a culturally and linguistically diverse group (Latino children living in the USA) [55].

Key barriers and facilitators to implementation

Key barriers and facilitators as perceived by healthcare staff, are presented below within four overarching themes: intervention-level, staff-level, patient-level, and system-level (Fig. 2). While a patient-level theme emerged from the findings, it is important to note that this theme reflects staff-reported perceptions of patient-related factors, rather than direct patient input. Specific barriers and facilitators reported in each study are detailed in Supplementary File 3.

Fig. 2
figure 2

Visual depiction of themes

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Intervention-level

Intervention feasibility and fit

One major barrier related to the implementation of healthcare interventions in regional and rural areas was a lack of intervention feasibility. Some interventions did not align with existing workflows, systems and resources, which limited their practical implementation [29, 31]. In particular, integrating digital interventions (e.g., telehealth/those involving electronic medical records (EMR)) within organizational/systems processes posed a challenge for regional and rural healthcare professionals, as it required software compatibility across different organizations, healthcare settings and platforms [30, 49, 60]. Another perceived challenge was a lack of fit or need for a given intervention. In some instances, interventions were seen as unnecessary, incompatible or irrelevant to the needs of regional or rural healthcare providers, patients, or settings [31, 37, 58, 62]. Additionally, some healthcare professionals described having limited opportunities to implement certain interventions due to a lack of presenting patients in regional and rural areas [35, 42, 46]. While this was perceived to impact intervention feasibility and utility [35], some perceived the lack of experience with an intervention and/or specific patient population to affect staff confidence and competence [42, 46].

Conversely, the adaptability of interventions, such as cancer screening programs, that were tailored to the unique context of rural primary care practices, was determined to be a key factor that enhanced adoption [51]. Example adaptations included changing EMR functions and nurse workflows [51]. Additionally, interventions that had a high perceived need among stakeholders [49, 58], and were easily integrated into existing systems/processes [27, 58] were believed to facilitate implementation. Other enabling strategies included raising awareness and need for an intervention at a community level, including other health services and organisations [26].

Intervention complexity

Complexity of interventions also posed substantial challenges to their implementation in regional and rural areas. Interventions considered overly cumbersome or detailed were perceived to negatively impact the motivation of healthcare professionals [58]. Even when interventions were considered useful, their complexity was viewed as making implementation a lengthy and challenging process [58]. Rural healthcare professionals also cited the length of guidelines/recommendations as a barrier [29]. To alleviate these problems, several facilitator strategies were suggested, including the development of clear guidelines and providing healthcare professionals with summaries (or laminated copies) of clinical recommendations/checklists [29].

Confidentiality and privacy

Staff concerns related to the confidentiality and privacy of patients were noted as a barrier to the implementation of some healthcare interventions. This was particularly evident for interventions focused on potentially stigmatizing issues, such as mental health treatment [28] or substance use screening and/or treatment [27, 43, 57], including those that involved the sharing or storage of personal information via digital platforms [27, 30, 57]. Specifically, some staff held reservations about whether patients in rural areas would be willing to engage with an intervention due to a potential risk to their privacy [57].

Staff-level

Staff attitudes and beliefs

Several studies identified staff attitudes and beliefs as crucial factors affecting the implementation process. When healthcare professionals held positive attitudes and perceived the intervention as valuable, they were more likely to engage with and support its adoption and implementation [31, 63]. While a willing and engaged healthcare workforce was highlighted as an enabler, the lack of such a workforce was posed as a barrier [58]. Challenges in engaging staff to modify professional behaviors and adhere to intervention processes were most apparent for studies focused on the management of patients with substance use disorders in rural areas [53, 56, 62]. Additionally, staff in some studies reported that healthcare professionals held negative beliefs about the potential increase in numbers of challenging patients (e.g., people who use illicit drugs) presenting to their rural health service, which diminished healthcare professionals’ motivation to adopt the intervention [25, 56]. Conversely, personal experience was observed to be an internal motivator for some rural clinicians, leading them to support and even champion an intervention [56]. Several studies also highlighted that the identification and formal appointment of champions facilitated implementation and motivated healthcare professionals to engage with the process through positive role modelling [31, 49, 51, 53].

Staff knowledge, skills, and confidence

Lack of confidence among healthcare professionals emerged as a significant barrier to the implementation process, with confidence closely tied to knowledge and skill levels. Staff who reported lower knowledge and/or skills related to the intervention often felt less prepared and capable of effectively implementing interventions, which led to a reluctance to adopt new practices [39, 46]. This lack of confidence typically stemmed from limited familiarity with the intervention or inadequate training on the intervention itself and its integration into existing organizational processes [31, 33, 48]. Addressing these barriers through enhanced training and upskilling of health professionals was frequently cited as key for optimizing implementation [27, 31, 34, 35, 42, 48, 49, 57]. Participants from rural sites, who commonly reported facing workforce recruitment and retention challenges, highlighted the need for educational opportunities to be offered at orientation and repeated at intervals to ensure that new staff, including locums, are adequately informed about intervention processes [37, 46]. Supplementing training with easily accessible resources, such as manuals and checklists (digital/physical), was also suggested to facilitate improved staff knowledge and skills [31]. Additionally, providing culturally appropriate training and employing an Aboriginal Health Liaison Officer were emphasized to support staff knowledge for healthcare interventions targeting patients of Aboriginal and Torres Strait Islander descent [42, 61].

Staff roles and professional identity

In regional and rural settings, staff roles and professional identity influenced the implementation of healthcare interventions. Reluctance emerged when staff viewed new intervention processes as outside their primary roles or were uncertain about shifting responsibilities [57, 58]. The introduction of new roles sometimes led to staff feeling undermined, especially when role changes, and the need for them, were poorly communicated [34]. Acceptance and integration of new roles were particularly compromised if staff felt there was potential to deskill a certain profession [34, 52] (e.g., potential deskilling of rural aged care nurses with the introduction of a specialist nurse practitioner role) [34]. Conversely, a well-defined framework for staff to understand role responsibilities and clear communication channels were perceived to enhance motivation and willingness to implement [45].

Patient-level

Patient characteristics

Healthcare staff reported a range of sociodemographic characteristics to profoundly influence patients' access and interaction with healthcare interventions in regional and rural areas, which hindered the implementation ability of staff due to fewer opportunities or resources to provide effective care. In the rural context, economic constraints, including lower income levels, lack of health insurance, and increased travel costs due to geographic remoteness and limited availability of local healthcare providers, were perceived to hinder engagement with follow-up care and referral to specialist services [35, 56]. Long work hours and shift work were also highlighted as prevalent in rural communities, which limited patients' availability to attend appointments, particularly in primary care [54]. Technology-related barriers, such as inadequate telehealth infrastructure within patient homes and varying levels of technological proficiency (noted as particularly challenging among older people or those with lower educational attainment) [30] were seen to impede the effective implementation of digital health interventions [28]. To overcome barriers related to patient characteristics, the implementation of targeted strategies was recommended, including tailored patient education and support [30] and practical elements such as the provision of data SIM cards for telehealth [28].

Patient attitudes

Staff perceived that patient attitudes played a significant role in patients’ engagement with healthcare interventions, with a lack of engagement impacting staff opportunities to implement. One study found that rural patients' reluctance to seek healthcare was due to a cultural mindset of only addressing health issues if severe [44]. Additionally, challenges were noted in motivating patients to adopt healthier lifestyles, specifically in relation to the management of childhood obesity [35]. The reluctance of older adults to address mental health issues also emerged as a barrier, largely driven by fear of stigma in rural communities and the belief that others were more deserving of services [50]. Conversely, staff recognized that positive patient receptivity played a crucial role in facilitating the implementation of healthcare interventions. When patients engaged with and demonstrated understanding and appreciation for an intervention, it motivated health professionals to persist with their implementation efforts [53]. Furthermore, patient education and clear information materials [29], and strong patient/provider relationships [45], were seen as key factors in fostering positive patient attitudes and improving engagement with healthcare interventions in rural and regional areas.

System-level

Leadership support

Leadership support and buy-in were commonly cited as key to driving the successful implementation and sustainability of healthcare interventions in regional and rural areas. Engaged leaders were seen as essential for ensuring adequate resourcing, clearly communicating the importance of an intervention, and fostering staff buy-in [49, 53]. Leaders were also perceived to be pivotal in supporting staff attendance at meetings and education sessions [46], addressing implementation resistance within organisations [28], and securing the appropriate skill mix of personnel required for successful intervention delivery [42]. Maintaining consistent leadership across a region was also considered crucial for ensuring sustained implementation [49]. The absence of engaged leaders and internal support was also noted as a barrier in some studies [37, 42, 56, 58]. In one study, health professionals suggested this issue was more pronounced in rural hospitals, where a small number of key individuals can impact the broader staff group [56].

Environmental resources and context

Several barriers related to environmental resources and context were emphasized by staff in regional and rural areas. For example, budget constraints and insufficient funding for staff and services notably hindered implementation efforts [34, 38, 62, 63]. Additional challenges were highlighted concerning the reimbursement of healthcare professionals for the delivery of specific services, such as childhood obesity management [35]. High staff turnover rates and shortages in regional and rural areas were commonly perceived to exacerbate heavy workloads, time pressures, and competing priorities [33, 39, 49, 52, 53]. These factors made it challenging for staff to attend educational opportunities [46] and balance routine clinical duties with the added demands of implementing new interventions and processes [63]. In one study, researchers observed that the formal designation of a person to support staff with implementation effectively mitigated workload issues [49]. Telehealth was additionally proposed to alleviate the time pressures experienced by staff in regional and rural areas by reducing the need for travel [30].

Challenges were also noted in relation to physical and technological infrastructure. Staff reported difficulties obtaining adequate physical space [30, 63] and, in some cases, highlighted the absence of specialized care units in rural areas, such as acute stroke units [33], which hindered alignment with guidelines. Inadequate technological infrastructure, including a lack of high-speed internet, suitable hardware, and compatible software, particularly impacted the implementation of telehealth interventions [28, 30, 59]. However, investment in robust, effective, and user-friendly digital platforms was recognized to enhance the adoption of telehealth interventions [28].

Geographic vastness

The implementation of healthcare interventions across geographically vast areas posed notable challenges. Infrequent healthcare visits, combined with sporadic communication between patients and clinicians, as well as clinicians themselves, were cited as barriers to consistent implementation [37]. These issues were particularly highlighted by staff in rural areas, where transportation barriers and distance to local services impacted patient access and clinician adherence to guidelines [41, 54]. Furthermore, the lack of local resources and specialist services often required patients to travel long distances to urban centers for necessary care, which staff described as especially burdensome for frail older individuals without access to personal or public transportation [50].

Despite these challenges, several facilitators emerged. The use of telehealth [30] and long-standing positive patient-provider relationships [45, 47] were perceived to improve communication, coordination, and continuity of care. The sense of community in rural areas was also considered crucial, as familiarity between clinicians and patients fostered rapport and strengthened staff commitment to their communities [38, 45]. Additionally, staff noted that regional and rural services often had the flexibility to adopt new programs and practices, leading to innovative solutions tailored to their unique contexts [42, 54].

Networks and communication

Staff identified external communication and collaboration between services and staff as a challenge to the implementation of healthcare interventions in regional and rural areas [58, 62]. Additionally, the absence of academic affiliations was noted in one study to affect a rural hospital’s ability to access new knowledge, resources, and recruit clinicians [37]. In contrast, respected and well-connected implementers within organizations were seen as instrumental in driving implementation efforts by leveraging their social networks to identify and secure resources [37]. Informal networking in smaller communities also played a crucial role in information sharing, referrals and identifying service gaps; however, reliance on informal networks was noted to create difficulties for staff new to an area [38]. Lastly, staff in one study reported that joining a collaborative network of healthcare providers (e.g., an Accountable Care Organization) facilitated benchmarking between organizations that drove performance improvements through data comparisons [51].

Discussion

This rapid review uniquely identified barriers and facilitators to the implementation of healthcare interventions in regional and rural healthcare services, as reported by healthcare staff working in high-income countries. The findings reveal a complex interplay of factors across four overarching themes: intervention-level, staff-level, patient-level, and system-level. While many identified barriers and facilitators align with those reported in other healthcare contexts [11, 12], this review highlights that some factors are amplified in regional and rural areas. Importantly, the review findings also emphasize that regional and rural healthcare services possess distinct strengths that can be leveraged to support the effective implementation of healthcare interventions.

Workforce shortages were found to be a critical system-level barrier and were perceived to significantly impact the implementation of healthcare interventions in regional and rural settings. Difficulties in recruiting and retaining healthcare professionals, alongside the lack of specialist services, were perceived to exacerbate workload pressures and time constraints for staff. This aligns with global concerns about the maldistribution of healthcare workers in rural areas, as highlighted by the World Health Organization (WHO) [65], where healthcare professionals are often required to cover a wide range of roles with insufficient support or resources. A shortage of specialists, such as mental healthcare providers, limits the availability of specialist care in regional and rural areas, placing an additional burden on generalists [66]. Programs like the Australian Government's Rural Health Multidisciplinary Training Program [67]. which offers healthcare students the opportunity to train in rural and remote communities, are valuable initiatives aimed at addressing these workforce gaps. This review underscores the ongoing imperative to sustain such programs to bridge the workforce divide (refer to Table 3 for summary of discussion key messages and potential actions).

Table 3 Discussion key messages and potential actions
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While a patient-level theme emerged in the synthesis, these findings reflect staff-reported perceptions rather than direct patient input. Many of the identified patient-level barriers, such as attitudes toward healthcare and economic constraints, stem from broader systemic inequities rather than individual choices [68]. Factors such as lower income levels, lack of health insurance, and high travel costs for medical care disproportionately impact rural populations and limit healthcare access. Addressing these challenges requires policy and structural reforms to improve healthcare access and equity in rural settings.

Digital health interventions, particularly telehealth, were identified as potential solutions to address some of the barriers associated with environmental resources and context and geographic vastness. Telehealth reduces the need for patients and healthcare providers to travel long distances, which is particularly valuable in rural areas [69]. However, this review also identified several barriers to the effective implementation of telehealth in regional and rural settings, including inadequate digital infrastructure, limited digital literacy among healthcare staff and patients, and concerns over confidentiality and privacy. These barriers reflect findings from other studies [70, 71]. While telehealth holds promise for improving access to care, its success depends on significant investment in digital infrastructure, workforce training, and equitable access to technology, as emphasized in WHOs Global Strategy on Digital Health 2020–2025 [72]. The strategy highlights the need for robust digital health systems, increased digital literacy for healthcare providers and patients, and efforts to bridge the digital divide to ensure that telehealth benefits are accessible to all populations, particularly in low-resource settings.

At the intervention level, this review emphasizes the importance of ensuring that healthcare interventions are feasible and fit with the local context. Interventions perceived as overly complex or incompatible with existing workflows and resources were seen to have limited implementation capacity. Implementation science frameworks, such as the Implementation in Context (ICON) Framework [73] and the CFIR [64], provide guidance to implementers on the elements of context that should be considered when planning for successful implementation. Additional guidance further emphasizes the importance for interventions to be tailored to local contexts, rather than attempting to directly translate interventions developed for other settings [74]. In regional and rural settings, this may involve simplifying processes and ensuring interventions are aligned with available resources, infrastructure and staff capabilities. The adaptation of interventions and the pursuit of equity-centered implementation hinge on the authentic and meaningful participation of the community. Engaging local stakeholders, such as healthcare professionals and patients, in the co-design and adaptation of healthcare interventions is an important step that may enhance intervention relevance and acceptance, improving implementation, adoption and overall effectiveness [75]. Adaptation guidance provides structured approaches for adapting interventions to new contexts [76, 77], while practical tools like the Hexagon tool [78], and the APEASE criteria [79] can help to evaluate an intervention’s fit with the local context.

This review also highlights several strengths of regional and rural healthcare settings, that if effectively leveraged, may offset some of the identified barriers, contributing to more effective implementation of healthcare interventions. For instance, strong community relationships and flexible healthcare services that can adapt to local needs were identified as valuable assets in regional and rural areas. Long-term relationships between healthcare providers and patients in these communities can also serve as a driver to enhance patient trust and engagement with new interventions. Additionally, leadership support was seen as key to the implementation of healthcare interventions. Regional and rural healthcare services should focus on fostering strong leadership and building internal capacity to drive implementation efforts and ensure that healthcare staff are adequately supported throughout the implementation process [80].

A notable strength of this review is the comprehensive search and selection process that yielded a sizeable number of included studies published since 2000. Furthermore, data synthesis and interpretation were strengthened by an author team highly engaged in rural health research, many of whom are clinicians embedded within regional and rural healthcare services. The diversity of healthcare interventions can be seen as both a strength and a limitation of this review. While the consistency of common implementation barriers and facilitators suggests broad relevance to regional and rural healthcare settings, this diversity also limited the depth of understanding for each specific intervention type. Additionally, gaps in the available literature may limit the generalizability of the findings to certain healthcare settings or interventions not addressed in the included studies. For example, few studies were conducted outside of Australia or the USA, and aged care and community health settings were underrepresented, limiting insights into implementation factors in these contexts. Furthermore, research focusing on priority populations, such as culturally and linguistically diverse or Indigenous groups was limited. Future research should prioritise an equity-focused approach to better understand and address the unique factors influencing implementation in these populations. This may involve the use of participatory methodologies that actively engage communities, while ensuring research upholds principles of self-determination [81]. Applying equity-focused implementation frameworks, such as the Health Equity Implementation Framework [82], may also enhance the cultural responsiveness and effectiveness of healthcare interventions.

While the omission of a formal critical appraisal step is common and accepted in rapid reviews, it introduces some potential for bias, particularly regarding the strength and reliability of reported barriers and facilitators. However, the consistency of themes across studies and their alignment with existing literature [11, 12] suggest that the key findings remain robust. Future research incorporating formal risk-of-bias assessments could further enhance the reliability of synthesized evidence.

Another important finding from this review is the limited application of implementation theories, models, and frameworks in rural healthcare research. The majority of studies did not report using structured frameworks, such as the CFIR [64] or the Theoretical Domains Framework [83], to guide their assessment of barriers and facilitators. This gap highlights the need for further research to understand the feasibility, relevance, and potential impact of applying these frameworks to the implementation of healthcare interventions in non-urban settings. Future studies should also consistently apply geographical classification systems to define rurality, e.g., MMM [22] or RUCC [21]. The lack of consistent use of these classifications in the studies included in this review made it difficult to compare findings across different contexts.

Lastly, although healthcare settings differ significantly between high- and low-income countries, many of the barriers and facilitators identified in this review, such as lack of intervention fit and the importance of stakeholder engagement, have also been observed in low-income healthcare contexts [84]. Future research should explore the relevance of these factors in rural low-income healthcare settings to better understand their impact on healthcare implementation.

Conclusion

This review provides valuable insights into the barriers and facilitators associated with implementing healthcare interventions in regional and rural settings, as perceived by healthcare staff in high-income countries. Addressing the challenges faced in these contexts while leveraging their inherent strengths has the potential to significantly enhance implementation outcomes and contribute to reducing the health disparity gap between rural and metropolitan populations. Policymakers, healthcare leaders, and researchers tasked with designing and implementing healthcare interventions in regional and rural areas should systematically consider barriers and facilitators across the four overarching themes: intervention-, staff-, patient-, and system-level. Conducting context-specific assessments that utilize established implementation frameworks will enable stakeholders to design tailored implementation strategies that have the capacity to effectively support healthcare staff and optimize service delivery.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

EBI:

Evidence-based intervention

PRISMA:

Preferred Reporting Items for Systematic reviews and Meta-Analysis

RUCC:

Rural-Urban Continuum Codes

MMM:

Modified Monash Model

USA:

United States of America

CFIR:

Consolidated Framework for Implementation Research

EMR:

Electronic Medical Records

WHO:

World Health Organization

ICON:

Implementation in Context

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Acknowledgements

The authors wish to acknowledge Sharina Riva for their assistance in preparing the tables for the manuscript.

Funding

This study was conducted as part of the DELIVER research program that is supported by an Australian Commonwealth funded MRFF Rapid Applied Research Translation Grant (RARUR000072). AU is supported by a Victorian Cancer Agency fellowship. AP is supported through an NHMRC Investigator Grant. SY is supported by a Heart Foundation Future Leader Fellowship (ref no:106654). LA and AWS are supported by the Rural Health Multidisciplinary Training Program (RHMT) from the Australian Federal Government’s Department of Health and Aged Care.

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Authors and Affiliations

  1. Centre for Quality and Patient Safety Research, Institute for Health Transformation, School of Nursing & Midwifery, Faculty of Health, Deakin University, Building Y, 221 Burwood Hwy, Burwood, VIC, 3125, Australia

    Anna Chapman, Devdini Mohotti, Alison M. Hutchinson & Anna Ugalde

  2. Research Unit, Colac Area Health, Colac, VIC, Australia

    Alison Buccheri & Laura Alston

  3. Deakin Rural Health, Faculty of Health, Deakin University, Warrnambool, VIC, Australia

    Alison Buccheri, Anna Wong Shee, Laura Alston, Hannah Beks & Kevin Mc Namara

  4. Grampians Health, Ballarat, VIC, Australia

    Anna Wong Shee

  5. Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC, Australia

    Catherine E. Huggins & Sze Lin Yoong

  6. Barwon Health, Geelong, VIC, Australia

    Alison M. Hutchinson

  7. Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia

    Anna Peeters

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Contributions

AC and AU conceptualized the study. AC and DM developed the review protocol, which was refined with input from all authors. DM conducted the database searches, and AB, DM, AC, and AU screened the records. Data extraction was led by AC and DM, with contributions from AB, AU, LA, AWS, and KH. Analysis was led by AC and AB, with interpretation supported by all authors. AC drafted the manuscript, with assistance from DM. All authors critically revised the manuscript and have read and approved the final version.

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Correspondence to Anna Chapman.

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The authors declare that they have no competing interests. HB is an editorial board member of BMC Health Services Research but was not involved in the peer review or decision-making process for this manuscript.

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Chapman, A., Buccheri, A., Mohotti, D. et al. Staff-reported barriers and facilitators to the implementation of healthcare interventions within regional and rural areas: a rapid review. BMC Health Serv Res 25, 331 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12913-025-12480-8

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