Heart failure (HF) is a widespread health condition affecting many older adults in Canada. HF can significantly impair quality of life and is becoming increasingly common as populations age globally [1]. Heart failure disease management interventions (HFDMIs) aim to address these challenges by fostering self-care, enhancing well-being, and reducing recurrent hospitalizations and subsequent health care expenditure. These programs achieve this through patient education, ongoing follow-up, and improving care coordination, which in turn reduces emergency visits and promotes outpatient care [2,3].

HFDMIs encompass a wide range of interventions, including in-person interventions in hospitals, communities, or clinics, as well as remote interventions delivered through telehealth technologies, such as telephone, email, internet, text messages, telemonitoring, mobile health, video consultation, and wireless monitoring systems [4-9]. Despite its potential to improve chronic disease management, telehealth interventions are complex and multifaceted [10]. While telehealth technologies were introduced into HF management in 1998 [5], their complexity as a health delivery model becomes evident when considering the various components and interactions involved and when compared with traditional face-to-face interventions [11]. Effective implementation of telehealth interventions requires harmonizing clinical protocols, leadership support, and technological factors, along with ensuring that patient and health care providers are confident in using technology through education and training [11]. As such, understanding the specific contexts and mechanisms that make telehealth interventions effective in managing HF becomes crucial.

This study details the findings of a rapid realist synthesis, which investigated the use of telehealth solutions for vulnerable patients with HF. The synthesis is framed within the approach of critical realism (CR) [12], aiming to explore the underlying mechanisms and contexts that contribute to the significance of telehealth interventions in improving HF management among vulnerable populations. Additionally, an intersectionality lens was applied to examine how the intersecting social identities of vulnerable groups with HF may affect their access to and use of telehealth services [13].

Intersectionality highlights how different social identities, such as race, gender, age, culture, sexual orientation, socioeconomic status, and geographic location, combine to shape individual experiences [14-16]. These overlapping factors can either grant privilege or deepen inequalities, particularly in health care [14-16]. In the context of HF care, intersectionality plays a vital role in determining access to resources, medical treatment, and self-care support [14]. Patients from marginalized groups, including racialized minority groups and gender minority groups, rural residents, older adults, and people with disabilities, often struggle to receive adequate health care and telehealth services [17]. These disparities stem from systemic barriers such as economic hardship, geographic isolation, and implicit biases within health care systems [17]. The unfortunate reality is that those who require the most care often face the greatest barriers to accessing it, perpetuating health care inequities. These intersecting social identities may act as contextual factors or mechanisms that intensify disparities among marginalized populations and contribute to poorer health outcomes.

The use of telehealth has increased during the COVID-19 pandemic [18]. Nonetheless, telehealth adoption varies among demographic groups, with factors such as age, income, race, ethnicity, health literacy, digital skills, and language barriers playing significant roles. These disparities stem from challenges at multiple levels, including the patients themselves, health care systems, telehealth platforms, and overarching policies [18]. Recognizing and addressing these disparities is crucial to ensure fairness in telehealth services, optimize their impact on health care delivery, and ultimately promote telehealth equity [18].

The complexity of HFDMIs lies in the multifaceted nature of the condition, requiring innovative approaches to optimize patient outcomes. The adoption of telehealth interventions for vulnerable patients with HF is complicated by the overlapping social identities that can create barriers to accessing and using telehealth services. Although telehealth became widely accessible during the COVID-19 pandemic [19], these at-risk groups have still faced considerable barriers in making full use of telehealth options [20].

Current understandings of telehealth interventions for HF in vulnerable populations are hindered by 2 issues. First, there is a significant gap in research specifically addressing telehealth solutions tailored to marginalized patients with HF with intersecting identities, limiting insights into their effectiveness [21]. Second, addressing the complexities of telehealth in HF care for disadvantaged groups calls for advanced research methodologies, such as realist methods, that can unravel the contextual elements driving these challenges [22].

The use of theory-based research approaches to evaluate telehealth interventions has been urged in the literature [23]. There is increasing consensus that telehealth interventions should be evaluated using complexity-driven approaches [23]. In relation to such interventions, these approaches often bring complexity into various aspects, including the theoretical underpinnings of the research, the type of research questions posed, and the types of methods used. In recent years, the research review and synthesis field has seen an expansion in the variety of approaches used [24]. Among these approaches, realist synthesis has gained importance. Unlike traditional reviews that assess the effectiveness of interventions, realist synthesis aims to comprehend and analyze the underlying mechanisms that contribute to the success or failure of an intervention, offering explanatory insights rather than simple evaluations of its effectiveness [24,25]. Rapid realist syntheses are philosophically and theoretically underpinned by CR.

CR focuses on uncovering the underlying mechanisms that generate outcomes, making it an explanatory rather than purely descriptive approach. It is particularly suited for addressing “why” questions about social and health phenomena. Within intervention research, this perspective shifts attention from simply assessing effectiveness to examining the reasons behind its effects. In other words, it asks what makes an intervention work in practice. This focus is not only practically valuable but also grounded in CR’s ontological stance [12]. This study used a rapid realist synthesis approach that is underpinned by CR and intersectionality theory, which offers an in-depth understanding of how intersecting vulnerabilities, intervention components, and contextual health care factors interact to shape outcomes in HF telehealth delivery.

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram for this scoping review is shown in Figure 1, illustrating the number of studies included, excluded, and screened at each stage of the screening process (Checklist 1).

As assessed using the Mixed Methods Appraisal Tool, the studies included in this review were generally of high quality. A diverse range of methodologies and a relatively narrower geographical scope were identified among the 22 studies included in the review. The methodologies varied widely, with 8 (36.4%) studies using randomized controlled trials [29-36]. Other designs included 2 (9.1%) pretest-posttest studies [37,38], 3 (13.6%) cross-sectional or quantitative surveys [39-41], and 3 (13.6%) retrospective data collection and analysis [42-44]. The review also identified 2 (9.1%) feasibility trials [6,45], 2 (9.1%) qualitative studies [46,47], and 1 (4.55%) mixed methods study [48]. Notably, 1 (4.5%) study focused solely on developing and implementing a telehealth program for patients with HF [49]. The studies primarily examined vulnerable groups, including Black [6,29-32,35,42,44,46,47], Hispanic [30,31,33,35,39,42,47], rural [32,34,36,38,40,49], underserved [30,38,41,43], low-income [6,29,37,43-45,47], and low-education patients with HF [6,29,32,44,48]. Telehealth interventions varied, including telephone support [6,29,32,34,36,48], remote monitoring [31,38-40,42,43,45,46,48], video consultations [37,44,49], and combinations of remote monitoring and video consultations [30,47]. Other approaches included telephone case management [33] and a remote monitoring with symptom response system [35]. Among the included studies, 19 (86.4%) were conducted in the United States, indicating that the data predominantly originated from the United States. A total of 10 contexts and mechanisms were identified, of which 7 were contexts and 3 were mechanisms (Table 1).

As per the findings of the previous paper, there was a lack of integration of the intersectionality-based principles in the body of literature on HF telehealth use among vulnerable populations [26]. To build upon these findings, we wanted to explore which of these interventions worked or did not work for these vulnerable populations and how and why they worked or did not work. Therefore, a realist synthesis approach was used to build on the findings of the initial review. This rapid realist synthesis outlined important contextual factors, including family involvement, health professional training, in-person components, personalized tailoring, contextual realities and systems factors, equipment, and technical issues. The synthesis also highlighted mechanisms that can improve HF telehealth programs for vulnerable patient populations. It recognized the effectiveness of simplified interventions, including patient training, which can lead to positive outcomes such as (1) increased patient confidence and proficiency in using telehealth technologies and (2) enhanced sense of security and comfort in managing symptoms and overall health.

To further strengthen the analysis, we considered the application of intersectionality in designing, implementing, and evaluating HF telehealth programs for vulnerable populations. The review highlights the need for increased research attention to health inequities experienced by these populations, particularly in designing interventions across different countries and vulnerable or marginalized groups. This aligns with other research highlighting the importance of using various research methods, including qualitative, interpretive, or realist approaches, to comprehensively understand complexities and mechanisms of these interventions [12].

The analysis in this review indicates that while studies have focused on specific populations such as African Americans, Hispanics, and rural low-income groups, there is a need to include other vulnerable populations, including other racialized minority groups and gender minority groups, immigrants and refugees, women with intersecting social identities, and Indigenous peoples. Additionally, the review highlights the effectiveness of various telehealth interventions such as telephone support, video consultations, remote monitoring, and case management, emphasizing the importance of tailoring these interventions to meet the specific needs of vulnerable patients with HF.

Access and use inequities in telehealth services for vulnerable patients are significant, given their low educational, health literacy, and digital literacy levels [50]. Simplified interventions and training are essential to enhance their confidence and proficiency in using telehealth and remote monitoring equipment [50]. Family involvement, particularly in racialized minority groups and rural populations, is crucial for success, considering the cultural significance of family in patient care [33,34].

The review also highlights the importance of health professionals’ training in delivering effective telehealth interventions [51]. Ensuring access to HF telehealth programs for vulnerable patients, particularly within primary care clinics in community settings, is essential to maximize their benefits [12].

In-person interactions and the personalization of interventions are valued by patients, emphasizing the significance of building rapport and tailoring interventions to cultural, linguistic, and contextual needs [52]. Integrating telemonitoring data into the care team’s workflow enables prompt action and decision-making in case of clinical deterioration [12].

Communication-related issues, such as language translations, avoiding medical jargon, and using simple and understandable language, are crucial for effectively using telehealth interventions by racialized minority groups and individuals with lower health literacy [12]. The review also highlights the positive impact of telemonitoring interventions on patients’ confidence, sense of security, and comfort in managing HF symptoms, reinforcing their use [12].

This review is notable for its originality, being the first to conduct a rapid realist synthesis in this research area, and its systematic search in multiple and multidisciplinary databases. However, it is limited by its reliance on published articles in English, the exclusion of gray literature, and the inability to collect primary data from key stakeholders, which could have enhanced the findings and theory generation.

The review findings offer valuable insights for improving HF telehealth interventions in clinical practice and research. Key practice-based recommendations include simplifying telehealth interventions for patients with lower education, health literacy, and digital literacy; providing tailored training; involving family members for support; training health care professionals; incorporating in-person components; personalizing interventions; offering telehealth in community settings; integrating telemonitoring data; building trust and acceptance for self-management; and using clear language and appropriate translations for racialized minority groups.

In conclusion, this scoping review highlights the need for greater incorporation of appropriate philosophical and theoretical foundations in research on HF telehealth interventions for vulnerable populations. While intersectionality principles have been applied in problem identification and intervention development, their application in evaluation stages needs to be improved. In addressing this, future research should adopt CR and intersectionality theory and apply intersectionality principles throughout the research process. The review emphasizes the importance of HF practitioners applying intersectionality and health equity principles in clinical practice by implementing simple, personalized interventions involving family members; including an in-person component; training patients and health professionals; and integrating telemonitoring data into care workflows. By fully implementing these findings, HF telehealth interventions can significantly improve care for vulnerable patients, addressing their specific needs; enhancing access, acceptance, and use of telehealth; and ultimately reducing health inequities.