Experiences of healthcare access during the COVID-19 pandemic in remote Indigenous communities in Northwest Territories, Canada

ABSTRACT

The COVID-19 pandemic disrupted healthcare access globally through restrictions aimed at limiting virus transmission. Using a cross-sectional design, this project explored perceived barriers to and facilitators of healthcare access during the pandemic in remote Indigenous communities in Northwest Territories (NWT), Canada. Convenience sampling was utilised to recruit self-identifying Indigenous adults (≥18 years) within 10 NWT communities. Information was collected through an interviewer-administered questionnaire exploring experiences with, barriers to, and facilitators of healthcare access during the COVID-19 pandemic. Among the 287 participants (mean age 41.63 years; 66.55% women), 17.42% reported having avoided healthcare service utilisation during COVID-19 due to the risk of exposure. Of participants with a current prescription, 15.73% reported difficulty accessing prescription medications. Some partcipants (7.69%) reported difficulty accessing traditional medicines and healers. The participants reported that many services were disrupted by shortages of healthcare providers, service delays and cancellations, public health measures, and medical travel disruptions. A total of 35.89% of participants utilised virtual care, and while many found it was convenient for certain needs, some reported that it was inadequate. The findings highlight the perceived challenges to healthcare access in NWT during the pandemic. These challenges are closely tied to the healthcare context in the region, which depends heavily on medical travel and visiting specialist clinics.

Introduction

Access to health care refers to the ability of individuals to obtain necessary medical services without delay, so that health can be maintained or improved as effectively as possible [1]. Globally, the COVID-19 pandemic had serious social, economic, and environmental effects [2], resulted in over seven million deaths worldwide [3] and caused widespread disruptions to access to healthcare [4]. The impact of the COVID-19 pandemic on healthcare access was multifaceted. COVID-19 has resulted in waves of patients requiring care, which has strained resources and service capacity and created high-risk environments for further viral transmission, thereby affecting access across a wide range of services [5]. Globally, measures were introduced within healthcare settings to prevent outbreaks and reduce exposure risks, often cancelling non-urgent services and limiting in-person care while attempting to maintain service availability [4,6]. Disruptions to healthcare services caused by shortages of healthcare providers, supply chain issues, and service backlogs were reported in 92% of countries [4]. These disruptions were also accompanied by changes in healthcare seeking and utilisation. Overall, during the COVID-19 pandemic, the number of individuals not seeking healthcare increased by 13%–50%, primarily due to mistrust in the safety of healthcare facilities, fear of infection, and financial barriers [4].

In Canada, women, immigrants, individuals with low income, racial minorities, and individuals with chronic conditions reported more challenges accessing healthcare services during the COVID-19 pandemic compared with men, non-immigrants, individuals with higher income, White Canadians, and individuals without chronic conditions, respectively [7]. Indigenous communities in remote regions were also disproportionately affected. Indigenous individuals were more likely than non-Indigenous individuals to report unmet health needs during the pandemic [8].

Indigenous people in Canada include First Nations, Métis, and Inuit communities. In the 2021 Census, 1,807,250 people were identified as Indigenous, representing 5.0% of the Canadian population. First Nations communities accounted for the largest share of the Indigenous community (1,048,405), followed by Métis (624,220) and Inuit communities (70,545) [9]. Indigenous communities in Canada continue to experience substantial health and healthcare inequities compared with non-Indigenous people. Between 2019 and 2022, approximately half of First Nations adults living off reserve, Métis adults, and Inuit adults reported at least one chronic condition, compared with approximately two-fifths of non-Indigenous adults [10]. Indigenous communities also continue to report poorer mental health and lower life expectancy than non-Indigenous people [10,11]. These inequities occur alongside ongoing experiences of racism and discrimination in healthcare settings, with nearly one in five Indigenous community members reporting unfair treatment, racism, or discrimination from a healthcare professional in 2024 [10].

Physicians in remote and rural settings report challenges with healthcare delivery due to pre-existing health, social and infrastructure inequities, which were exacerbated during the pandemic. For instance, rural physicians have reported that limited or inadequate internet and cellphone services impeded patient access to services that had been moved to a virtual care model, defined here as care provided remotely via the phone and other communication technologies [12], and a chronic shortage of rural healthcare providers was worsened by COVID-19 travel restrictions [13]. Despite the drastic disruptions to healthcare service availability caused by COVID-19, not all services were affected, and some measures may have tempered the magnitude of the impact. In Canada, urgent and emergency healthcare services are prioritised, and their provision remains relatively stable [14]. Additionally, implementing safety measures such as mandatory facemask use and physical distancing within healthcare facilities, and communicating these measures to patients, may have reassured patients of the relative safety of care during the pandemic, thereby facilitating access [15]. Efforts have also been made to reduce the inequitable impacts of the COVID-19 pandemic. For instance, in Northern Indigenous areas in Canada, including the three territories and the Northern regions of Canadian provinces, public health authorities have implemented culturally tailored communications focused on the continued availability of healthcare services and traditional wellness practices amid broader COVID-19 restrictions [16].

Canada’s three territories, Yukon, Northwest Territories (NWT), and Nunavut, are geographically remote and sparsely populated. Spanning the Northern portion of the country, from a latitude of 60° North to the Arctic Ocean, the territories comprise 39.5% of Canada’s land mass [17] but are home to just 0.3% of the national population [18]. The territories have a primarily subarctic or tundra climate, with average winter temperatures ranging from −18 to −30°C [19,20]. These geographic and climatic conditions shape transportation access, as many communities are accessible by road only seasonally, while others are fly-in only. The Northern territories have a relatively higher proportion of Indigenous individuals than southern provinces in Canada, with 22.3%, 49.6% and 85.8% of the population in Yukon, NWT and Nunavut, respectively, being Indigenous [21].

Healthcare access in remote Indigenous communities may be shaped by overlapping geographic, social, cultural, and infrastructure-related inequities, which were intensified during the COVID-19 pandemic [22,23]. These inequities reflect broader structural conditions that shape Indigenous healthcare access in Canada. A narrative review of Indigenous healthcare access identified geographic barriers, colonialism, racism, social exclusion, and policy-level constraints as contributors to inequitable access to care [24]. Recent Canadian evidence also shows that anti-Indigenous racism in healthcare can undermine trust, worsen care experiences, and discourage care-seeking [25]. National data further indicate that First Nations, Métis, and Inuit communities continue to report unmet healthcare needs, long waits for non-urgent care, and challenges in navigating complex healthcare policies, funding, and travel outside communities to access services [8]. These barriers are especially relevant in remote Northern settings, where care often depends on medical travel and limited local service availability [26–28].

In NWT, where this project is situated, primary care is typically provided through health centres or health stations in smaller communities, with expanded services available in regional centres. Limited acute care is offered in larger communities, two of which have hospitals [29]. To access specialised care, a large proportion of NWT residents must travel, often by air, to larger communities or outside of the territory, usually to the neighbouring province of Alberta [26,30].

NWT records thousands of medical travel cases each year [28]. In 2021–2022, there were 14,089 medical travel cases, with 22% involving services accessed outside NWT; in 2022–2023, there were 17,478 medical travel cases, with 25% involving out-of-territory services [28]. Although these figures do not provide a direct pre-pandemic comparison, they illustrate the ongoing reliance on medical travel in NWT. This reliance created challenges during the pandemic, as COVID-19 travel restrictions and self-isolation requirements complicated access to out-of-community care. Although medical travel was permitted under the COVID-19 public health orders, residents were required to complete a mandatory 14-day self-isolation upon returning to NWT, often in an isolation centre away from home in one of the territory’s larger communities. Accordingly, out-of-territory appointments typically required leaving one’s community, and perhaps work and childcare responsibilities, for over two weeks [31]. This self-isolation requirement likely posed a barrier to accessing necessary care for Indigenous community members.

In March 2020, NWT introduced COVID-19 measures that affected healthcare access, including restrictions on non-resident entry, mandatory 14-day self-isolation following out-of-territory travel, gathering limits, closure of non-essential services, postponement of non-urgent procedures and medical travel, and expanded use of virtual care [32]. These measures were particularly consequential in NWT, where access to specialist services often depends on travel within or outside the territory. Health services gradually resumed in May and June 2020, including non-essential services, non-urgent surgeries, and travelling clinics providing specialist, rehabilitation, and eye care. In June 2021, travel requirements were relaxed for fully vaccinated NWT residents, non-resident essential workers, and exempted travellers. Later in 2021, NWT introduced additional protective measures, including a territory-wide indoor masking requirement in August and vaccination requirements for governmental employees, including health and social services employees, by November [32].

The Access to Health Care conceptual framework, developed by Khan and Bhardwaj (1994), conceptualises access as the emergent result of interactions between health‑system features and the characteristics of prospective users, with policy shaping the interactions [33]. It distinguishes potential access, referring to the availability, organisation, and delivery of health services, from realised access, referring to actual service use [33]. This distinction was relevant in NWT because services may be available yet difficult to use owing to medical travel requirements, public health restrictions, self-isolation requirements, provider shortages, virtual care limitations, and concerns about COVID-19 exposure. Although the framework was developed in a general healthcare context, its distinction between service availability and service utilisation remains relevant to rural and remote healthcare access research examining how service availability, acceptability, accommodation, and utilisation shape access [34,35]. Indigenous and rural healthcare studies emphasise that physical proximity alone does not ensure access when cultural safety, institutional acceptability, relationships, and service responsiveness are not adequately addressed [36,37].

Recognising the potential impact of travel restrictions on healthcare access, the Government of NWT (GNWT) introduced policy measures to allow for virtual healthcare appointments with out-of-territory providers [32,38]. Virtual care was made widely available for a broad suite of healthcare services in NWT, Canada, and globally [32,39] and likely helped buffer some disruptions to in-person care by allowing patients to connect with providers while reducing the need for travel or clinic attendance. There is evidence of such facilitation in Canada, where between April of 2020 and March of 2021, the average number of virtual services provided by physicians each month increased to 152 from 39 the year prior [40].

Existing research has examined COVID-19 in Arctic and Northern Indigenous contexts, including community responses, public health lessons, healthcare-resource constraints, and broader pandemic impacts across Circumpolar regions [41–43]. NWT-specific studies have also examined public health communication among Indigenous community members and policymakers’ perspectives on implementing COVID-19 measures in remote communities [23,44,45]. Although this literature identifies broad patterns in pandemic response and health-system challenges, the present project adds a community-member perspective by exploring the experiences of Indigenous community members and perceived barriers to and facilitators of healthcare access in remote NWT communities under COVID-19 public health measures.

Methods

Setting

This project was conducted in ten communities in NWT, Canada, which varied in population size (36–3,214 people) and in the level of transportation and healthcare infrastructure [29,46]: three large communities (>1000 people) have year-round road access and community healthcare centres, with one having a hospital; three medium communities (300–1000 people) have year-round road access and community health centres; and four small communities (<300 people) do not have year-round road access, and only some have healthcare centres. Within the ten communities, Indigenous community members comprised 65.6%–97.5% of the population [47].

Project design

This project utilised a cross-sectional design. The project adopted a community-based participatory research approach to support collaboration with participating Indigenous communities and applied Two-Eyed Seeing principles to respect both Indigenous and Western perspectives on healthcare access. Indigenous communities were engaged throughout the research process through ongoing collaboration with local community members, community organisations, and a Community Advisory Board (CAB). The CAB included Elders, local healthcare professionals, community members, government representatives, and policymakers, and provided guidance on project planning and implementation, questionnaire design and pilot testing, and the interpretation of research findings. This process helped ensure that the project activities and interview questions were locally relevant and culturally safe [45,48].

Information gathering

The participants were self-identifying Indigenous adults (≥18 years) who had lived in a participating community for at least two months. The two-month residency criterion was used to define current residence in a participating community for project eligibility.

A formal a priori power calculation was not conducted. The number of participants was determined pragmatically based on feasibility, community engagement, and the constraints of conducting research during the COVID-19 pandemic, following consultations with the CAB. Public health restrictions, travel limitations, physical distancing requirements, and the need to protect community members and research staff limited the feasibility of random sampling and larger-scale recruitment in remote and/or isolated communities. Therefore, convenience sampling was used to recruit a diverse sample of Indigenous adults from participating communities within the public health and logistical constraints of the project period.

Local research assistants (RAs) trained in each participating community supported recruitment and conducted the interviews. Recruitment approaches were adapted to each community and followed applicable public health restrictions. These approaches included direct calls to community members and organisations, social media posts, word-of-mouth, and passive advertising in community locations. Information gathering took place between April and November 2021. Because public health measures changed during the information-gathering period, participants may have completed interviews under different restriction contexts depending on the interview timing and community circumstances.

Quantitative and qualitative findings were collected through a semi-structured questionnaire administered by the local RAs in English or the local Indigenous language, and the questionnaire took approximately 45 minutes to complete. The design of the questionnaire was informed by the Access to Health Care Conceptual Framework [33]. The questionnaire was developed for this project and was not a previously validated instrument; formal psychometric validity and reliability testing were not conducted. The questionnaire was reviewed by the CAB and pilot-tested to assess clarity, cultural appropriateness, and relevance to NWT community context. No substantive concerns were identified, and minor wording changes were made to further improve the clarity of some questions.

Interviews were conducted either by telephone or face-to-face, depending on participant preference and public health guidance. Interpretation was available for participants who preferred to complete the interview in a local Indigenous language. During in-person interviews, public health precautions were followed, including mask use, sanitisation and physical distancing.

All participants completed the same interviewer-administered questionnaire, which included both closed-ended items and open-ended follow-up questions about access to healthcare services in the past six months during the COVID-19 pandemic. All healthcare access questionnaire items analysed in this paper are presented in Table 1. The closed-ended questions assessed current prescription medication use, difficulty accessing prescriptions, difficulty accessing traditional medicines or healers, use of telehealth or telephone services, and avoidance of health centres due to COVID-19 concerns. Telehealth or telephone service use was measured using a single yes/no item and therefore captured remote healthcare use broadly rather than distinguishing between video-based telehealth and telephone consultations. The open-ended follow-up questions asked the participants to describe their experiences with healthcare access, including perceived barriers and facilitators, and to elaborate on their responses.

Table 1.

Healthcare access questionnaire items were analysed in this project.

Are you currently taking any prescribed medications? (Yes/No)

If yes, have you had any trouble accessing your prescriptions during COVID-19? (Yes/No) Please explain.

During the pandemic, have you had any trouble accessing traditional healers/medicines? (Yes/No) Please explain.

During the pandemic, have you received healthcare services via Telehealth or over the phone? (Yes/No)

If yes, how do you feel about the Telehealth/phone health services? Please explain.

Have you avoided going to the health centre because you are worried about COVID-19? (Yes/No) Please explain.

The participants’ responses were recorded utilising REDCap version 8.1.1 and audio-recorded with participant permission. Open-ended responses were transcribed verbatim, translated when required, and checked by members of the research team.

Ethics, community approvals, and information governance

Ethics approval was granted by the Research Ethics Board at the University of Alberta (Protocol 00102250), and a research licence was granted by the Aurora Research Institute (No. 4884).

All participants provided verbal or written informed consent before the interviews and received a gift card honorarium. Before information gathering began, the research team engaged the participating Indigenous communities and local organisations to obtain the community-level support and approvals required for the project. Community engagement included consultation with local partners and the CAB regarding project planning, recruitment procedures, questionnaire design and pilot testing, and interpretation of findings.

Data governance was addressed through data sharing and housing agreements, memoranda of understanding, and agreements with participating communities and organisations. These agreements outlined expectations for storage, access, use, and dissemination, and were intended to support community oversight and respectful stewardship of project findings. Findings were returned to participating communities and partner organisations through plain-language summaries, community presentations or meetings, and reports were shared with the CAB and local partners.

Data analysis

Descriptive statistics were generated using SAS statistical software (SAS Version 9.4, SAS Institute Inc., Cary, NC). Exploratory Chi-square tests and univariable logistic regression were used to examine the associations between the use of telehealth or telephone service during the COVID-19 pandemic and gender, age, Indigenous identity, education level, health status, community size, and healthcare infrastructure. Community size was classified by population in small (<300 people), medium (300–1000 people), or large (>1000 people) categories. Healthcare infrastructure levels in communities were defined using GNWT classifications: Health Stations (transport-level care), Health Centres with transitional care (stabilise, hold, and transport), and Regional Health Centres (stabilise, assess, transport, or admit), each reflecting varying service levels and capacity [29]. The results are presented as odds ratios and 95% confidence intervals. All tests were two-sided, and p-values of 0.05 or lower were considered statistically significant.

A framework-informed thematic analysis was utilised to analyse the qualitative findings. A codebook was developed based on the core dimensions of the Access to Health Care framework [33], with codes organised around potential and realised access.

Potential access was represented by healthcare service availability and healthcare service delivery, including provider availability, service prioritisation, public health restrictions, service cancellations and delays, virtual care, and medical travel. Realised access was represented by healthcare service utilisation, including the avoidance of health centres due to concern about COVID-19 exposure, the use of telehealth or telephone services, and safety measures that facilitated in-person care. For this project, the framework was contextualised for remote Indigenous NWT communities by incorporating context-specific codes that reflected additional concepts identified in the data, including medical travel dependence, transportation and digital infrastructure, public health restrictions, and access to traditional medicines and healers.

A two-phase process was followed for qualitative analysis. In the first stage, after familiarisation with the data, the data were coded into categories and reviewed by team members. The codes were then reviewed by an additional team member and further analysed into themes related to healthcare access. NVivo Pro version 12 (QSR International Pty Ltd, 2018) was utilised for both stages of qualitative analysis.

Results

A total of 287 individuals participated in the project; 208 (72.47%) self-identified as First Nations, 62 (21.60%) as Inuit, and 13 (4.53%) as Métis. The mean age was 41.63 years (SD = 13.53; range: 18–90 years), and 191 (66.55%) were women. A total of 223 (77.70%) participants had completed some high school or higher education, and 213 (74.48%) rated health as 4 or 5 on a Likert scale from 1 (terrible) to 5 (excellent). The sociodemographic characteristics are presented in Table 2.

Table 2.

Sociodemographic characteristics of participating community members in 10 Northwest Territories communities (n = 287).

Age in years (mean ± SD)	41.63 (±13.53)
Variables	n (%)
Gender
Woman	191 (66.55)
Man	95 (33.10)
Declined to respond	1 (0.35)
Age group (years)*
18–29	58 (20.49)
30–49	150 (53.00)
50–65	59 (20.85)
>65	16 (5.65)
Ethnicity
First Nations	208 (72.47)
Inuit	62 (21.60)
Métis	13 (4.53)
Indigenous, not specified	4 (1.39)
Education completed
Elementary school	11 (3.83)
Junior high	43 (14.98)
High school	135 (47.04)
Post-secondary §	88 (30.66)
None/unsure/declined to respond	10 (3.48)
Current health rating from 1 (terrible) to 5 (excellent)*
4–5	213 (74.48)
3	55 (19.23)
1–2	13 (4.55)
Unsure/declined to respond	5 (1.75)

Abbreviation: SD (standard deviation).

^* Missing data < 5 not included in the analysis.

^§ Post-secondary: includes vocational or cultural training, and university education.

More than half of the participants (n = 157, 55.28%) lived in communities with a health centre with transitional care, followed by communities with a regional hospital (n = 93, 32.75%), and communities served by a health station (n = 34, 11.97%). Twenty-two (7.69%) participants had difficulty accessing traditional medicines and healers. Regarding utilisation, 50 (17.42%) participants avoided going to a health centre because of concerns about contracting COVID-19. Among the participants who reported having a current medical prescription (n = 93), 14 (15.73%) reported difficulty accessing medications during the pandemic (Table 3).

Table 3.

Healthcare service access during the COVID-19 pandemic among participants in 10 Northwest Territories communities (n = 287).

Variable	n (%)
Currently taking prescribed medications
Yes	93 (32.40)
No	193 (67.24)
Unsure/declined to respond	1 (0.35)
Trouble accessing prescriptions during COVID-19 * ‡
Yes	14 (15.73)
No	75 (84.27)
Trouble accessing traditional healers/medicines during COVID-19 *
Yes	22 (7.69)
No	244 (85.31)
Not applicable	13 (4.55)
Unsure/declined to respond	7 (2.45)
Used telehealth or over-the-phone service during COVID-19
Yes	103 (35.89)
No	182 (63.41)
Unsure/declined to respond	2 (0.70)
Avoided visiting the health centre due to concerns about COVID-19 exposure
Yes	50 (17.42)
No	235 (81.88)
Unsure/declined to respond	2 (0.70)
Healthcare infrastructure * , **
Regional Hospital	93 (32.75)
Health Centre with transitional care	157 (55.28)
Health Station	34 (11.97)

^* Missing data < 5 not included in the analysis.

^‡ Among the participants who reported having a current prescription (n = 93).

^** The total and percentage represent the participants in each community healthcare infrastructure category.

No significant association was observed between telehealth or telephone service use during the COVID-19 pandemic and participants’ age, ancestry, education level, health status, or community size. However, telehealth or telephone service use was significantly associated with gender and community healthcare infrastructure.

Logistic regression indicated that men were less likely to use telehealth or telephone services than women (OR = 0.41; 95% CI: 0.23–0.71; p = 0.001). Participants in communities with no healthcare infrastructure or only patient transport services were significantly less likely to use telehealth or telephone services than in communities with a hospital (OR = 0.27; 95% CI: 0.11–0.69; p = 0.006). Similarly, participants from communities with the capacity to stabilise, hold, and transport patients had lower odds of using these services (OR = 0.51; 95% CI: 0.30–0.86; p = 0.013) compared to communities with a hospital (Table 4).

Table 4.

Association between gender, health infrastructure, and telehealth or telephone service use among participants in 10 Northwest Territories communities (n = 287).

	Use of telehealth or telephone services*
Categories	Yes n (%)	No n (%)	OR (95% CI)
Gender*
Woman	81 (42.63)	109 (57.37)	1.0
Man	22 (23.40)	72 (76.60)	0.41 (0.23–0.71)
p-value			0.001
Healthcare infrastructure
Regional Hospital	45 (48.39)	48 (51.61)	1.0
Health Centre with transitional care	51 (32.48)	106 (67.52)	0.51 (0.30–0.86)
p-value			0.013
Health Station	7 (20.59)	27 (79.41)	0.27 (0.11–0.69)
p-value			0.006

^* Missing data are excluded from the analysis.

Thematic analysis

Guided by the Access to Health Care framework, qualitative findings were organised into two categories: potential access and realised access. Potential access included healthcare service availability and healthcare service delivery themes, while realised access included the theme of healthcare service utilisation (Figure 1).

Figure 1.

Themes and subthemes related to healthcare access during the COVID-19 pandemic in remote Indigenous communities in NWT.

These themes show how COVID-19 shaped healthcare access by disrupting service availability, changing how care was delivered, and influencing decisions about whether to seek care. The participants described prioritised access for urgent needs, but also shortages of healthcare providers, cancelled or delayed services, and restrictions affecting visiting providers and medical travel. Virtual care facilitated access for some needs but was limited by technology and service quality concerns. Healthcare utilisation was also shaped by fear of COVID-19 exposure, concern for Elders, and reassurance from safety measures in healthcare settings.

Category: potential access

Potential access refers to the availability, organisation, and delivery of healthcare services that shape whether care is accessible to community members.

Theme: healthcare service availability

Healthcare service availability refers to whether healthcare services, providers, appointments, and medicines were accessible to community members during the COVID-19 pandemic. This theme captures how pandemic-related service prioritisation, staff shortages, appointment delays or cancellations, and public health restrictions shaped the availability of local and visiting healthcare services in remote NWT communities.

Across this theme, participants described availability as uneven rather than entirely absent. Urgent, emergency, and maternal care were often protected, suggesting that some essential services remained accessible. However, non-urgent care, prescriptions, pain clinics, specialist appointments, and travelling services were more vulnerable to disruption. The quotations show that pandemic-related restrictions interacted with pre-existing healthcare shortages in remote communities, making access dependent on how a need was prioritised, whether providers could enter communities, and whether appointments could proceed despite isolation requirements or travel disruptions.

Subtheme: service prioritisation

Service prioritisation refers to the ways healthcare systems continued or expedited care for concerns considered urgent, severe, or essential, while other services were delayed, redirected, or cancelled. This subtheme shows that access during COVID-19 depended partly on how healthcare needs were categorised.

The participants described how the prioritisation of certain health concerns shaped service availability and access. One participant noted that when a health condition was considered severe, care was provided without delay:

“They thought [my health concern] was something bad, so those patients they see right away.”

A participant who gave birth during the pandemic similarly reported that maternal care was prioritised:

“The hospital here put the care of my baby ahead of COVID, so I never had an appointment changed or cancelled due to COVID, so [it was] really good. I was concerned that I may not receive the normal amount of care because of COVID but that wasn't the case. I had prenatal appointments right when they instituted masks all throughout and they were great at not cancelling.”

Participants reported that emergency services also remained available, helping to fill gaps when other services were cancelled:

“I think like when we had those couple cases in town and all appointments were being cancelled and they went to emergency services.”

However, emergency services were not always a welcome or convenient alternative, as described by one participant who had to wait in the emergency department to fill a prescription:

“I had to go to emergency just to get an inhaler… I mean it is such a headache, I waited in the hospital for over 3 hours.”

Subtheme: shortage in healthcare providers

Shortage in healthcare providers refers to the limited availability of doctors, nurses, specialists, or other healthcare professionals in communities. This subtheme reflects how longstanding workforce challenges in remote NWT communities were perceived as worsening during the pandemic, reducing appointment availability and local service capacity.

Despite some services remaining available, participants noted that the limited availability of healthcare providers was a barrier to access:

“[It was] hard to get an appointment with any healthcare professionals. I prefer to see doctors and ever since COVID hit, our community health centre has really had less services available to the community.”

One participant suggested that the pandemic may have worsened existing shortages of healthcare providers within NWT communities:

“It was already difficult to get medical professionals in our community and keep them and I think that it made it even worse.”

Subtheme: service cancellations and delays

Service cancellations and delays refer to postponed, cancelled, or slowed access to healthcare appointments, clinics, prescriptions and services. This subtheme captures how disruptions affected both local care and appointments requiring travel to larger centres.

Some participants reported that certain services within the communities, such as pain clinics, were cancelled, adversely affecting community members:

“Pain service clinics were also shut down which had a huge toll on the community.”

One participant explained that appointments requiring travel outside of the community were also delayed or cancelled:

“Well, just to see the nurse and stuff I don't think they had any barrier but having appointments and going to [the territorial capital], they were postponed or cancelled altogether for a couple months to a year.”

Service delays caused stress, as one participant described:

“It took me a month to get an inhaler, which is very stressful. I've had asthma all my life. Took three weeks to get an appointment to get a puffer.”

Subtheme: public health restrictions

Public health restrictions refer to COVID-19 measures, including travel restrictions and self-isolation requirements, that limited provider mobility, delayed appointments, or complicated access to services. This subtheme shows how restrictions designed to reduce transmission also affected healthcare service availability.

Public health restrictions were identified as barriers to healthcare service availability. For instance, one participant noted that travel restrictions affected the ability of healthcare providers to travel to the communities:

“I know that some specialist appointments were delayed. People weren't able to come into the community or into the territories.”

The participants also explained that self-isolation requirements contributed to service cancellations and delays:

“I was in isolation for a good month… a lot of my appointments were cancelled because of it.”

Theme: healthcare service delivery

Healthcare service delivery refers to how healthcare services were provided during the pandemic, particularly through virtual care and medical travel. In NWT, where specialist care often requires travel within or outside the territory, changes to delivery modes have important implications for whether care can be accessed safely, conveniently, and effectively.

Participants described virtual care and medical travel as both facilitators and barriers. Virtual care reduced the need to travel or attend facilities for simple concerns and follow-up appointments, but it was not viewed as adequate for all needs, especially when physical examination, testing, or specialist input was required. Medical travel remained essential for services unavailable locally, but pandemic travel restrictions and isolation requirements added household, work, and caregiving burdens. Together, the quotations show that service delivery in remote NWT communities depended not only on whether care existed, but also on whether the delivery mode fit the health concern, community infrastructure, and pandemic restrictions.

Subtheme: virtual care

Virtual care refers to healthcare provided through telehealth or telephone services. This subtheme captures both the convenience of remote appointments for simple or follow-up care and the limitations of virtual care when technology is unreliable or when care requires an in-person assessment.

There were several positive findings associated with the expansion of virtual care. For many participants, virtual care facilitated healthcare access and was described as a simple way to receive care:

“I thought it was pretty simple, that way I didn't have to make time to go to the hospital and make a doctor’s appointment.”

One participant noted that, for simple issues and follow-ups, virtual care was preferred because it was a more convenient and timely option than in-person services:

“I really prefer the phone health services, cause when it is something simple or a follow-up you just receive a call rather than going to the hospital or health centre and waiting an hour or half hour and having less people in the building, so for the non-emergency or non-serious part of health reasons, I prefer over the phone.”

Another participant highlighted the convenience of not having to leave the community for care:

“That would be much better than going out of town and going to the city.”

Despite some positive experiences, several participants expressed dissatisfaction, noting that the quality of virtual care was lower than in-person care:

“I found it to be less than satisfactory. I found that I didn't get the services that I would get if I was in person.”

“[I] didn't really like the telehealth. It was weird like you couldn't really get a lot of questions answered.”

One participant also noted that certain services could not be provided virtually, necessitating additional appointments:

“If you had to do a test, you couldn’t do it. You had to book a separate appointment or had to wait for the specialist to come in.”

Additionally, participants reported technological barriers to accessing virtual care:

“The services are really bad, it goes off and on for months now, you can’t communicate, you need the computer.”

Subtheme: medical travel

Medical travel refers to leaving one’s community to access healthcare services in larger centres or outside the NWT. This subtheme reflects how travel restrictions, self-isolation requirements, and household impacts made medical travel more difficult, even when services were technically available.

Several participants noted that restrictions on travel posed a notable barrier to healthcare access:

“A lot of people who required services who were expected to leave the community to receive those services were told they no longer could because of travel restrictions.”

Even when services were available through medical travel, the associated self-isolation requirements were a barrier to accessing care. For instance, one participant reported postponing medical travel because of the impact that the self-isolation regulations would have on the household:

“I am still waiting on an appointment in Alberta, and I had to put off my appointment in BC [British Columbia] because of COVID travel and having to isolate in my home which would impact the other four members [of the household].”

Category: realised access

Realised access refers to whether and how community members used available healthcare services during the pandemic.

Theme: healthcare service utilisation

Healthcare service utilisation refers to whether and how community members used available healthcare services during the pandemic. This theme captures decisions to avoid, delay, or proceed with care based on perceived COVID-19 risk, concern for others, vaccination status, and confidence in safety measures within healthcare settings.

Two factors shaped healthcare service utilisation in different ways: avoidance of services due to COVID-19 concerns and reassurance from safety measures in healthcare settings. The participants described weighing the need for care against the perceived risks of COVID-19 exposure, including concern about exposing family members, Elders, or others in the community. At the same time, visible infection-prevention measures, such as masking, symptom screening, hand hygiene, and sanitation, helped some participants feel safer accessing in-person care. Together, these findings show that service utilisation depended not only on whether services were available, but also on perceived safety, trust in prevention measures, and concern for community protection during the pandemic.

Subtheme: avoidance due to COVID-19

Avoidance due to COVID-19 refers to decisions to delay, skip, or avoid healthcare services because of concerns around infection, exposure in healthcare settings, travel to high-case areas, or risk to family and Elders. This subtheme shows how perceived risk reduced service utilisation even when care was available.

Some community members avoided healthcare service utilisation due to fear of COVID-19 exposure, as one participant noted:

“I just avoided it altogether, but I know for some people they were afraid to go even if they wanted to because they were afraid of exposing themselves.”

Avoidance may have been greater before COVID-19 vaccines became available, as reflected by one participant who “was more inclined to avoid the health centre before vaccinations were available.”

For some participants, deciding whether to access care during periods of high COVID-19 cases was difficult. Particularly, medical travel destinations are often highly populated urban centres and have more COVID-19 cases than NWT:

“It was hard whether we should go or cancel these appointments cause it was that time when cases were sky-high in Edmonton [city where many out-of-territory health services are provided] during their third wave.”

Many participants were also concerned about risking others’ health when accessing care. For instance, one participant who typically accessed traditional medicine from Elders expressed concerns about putting Elders at risk while seeking medicine:

“It was hard to see Elders cause I don't know with COVID here, it made it hard to see them and you don't want to expose them to it.”

Similarly, another participant recalled skipping an appointment to avoid exposing others to a possible COVID-19 infection:

“I had to go in for an ultrasound, however, I was coughing and we just, maybe two weeks earlier, our community came under lockdown and because I was coughing, I thought going to the hospital I thought you know, I better not.”

Subtheme: safety measures in healthcare service settings

Safety measures in healthcare service settings refer to infection-prevention practices such as masking, symptom screening, hand hygiene, and sanitation. This subtheme shows how visible safety protocols reassured some participants and helped facilitate in-person healthcare utilisation during the pandemic.

High standards for sanitation in healthcare settings encouraged service utilisation, as one participant explained:

“No, I’m not worried about COVID. It’s pretty safe. I know it’s the cleanest place.”

Similarly, another participant was reassured by the measures implemented in healthcare settings to prevent the spread of COVID-19:

“Cause when we go to the health centre, there’s usually someone there…before you go inside, they'll give you like a mask and hand sanitizer before you enter the building, and they will ask if we have any symptoms of COVID-19 or high fever or anything.”

Discussion

This project explored the lived experiences of Indigenous community members in NWT with respect to healthcare access during the COVID-19 pandemic. The quantitative findings suggest that healthcare access remained stable for most participants; however, a small proportion reported avoiding healthcare access. Qualitative findings offered insights into perceived factors and circumstances that either supported or hindered healthcare access. The findings should be interpreted within a healthcare delivery system characterised by limited local services, reliance on medical travel for specialist care, and dependence on both community-based infrastructure and out-of-community referral pathways.

Viewed through the Access to Health Care framework, the findings suggest that the pandemic affected both potential and realised access. Potential access was disrupted by reduced service availability, provider shortages, delayed or cancelled appointments, medical travel restrictions, and limitations in virtual care infrastructure. Realised access was reflected in healthcare-seeking behaviours, including avoidance of health centres because of COVID-19 concerns, use of telehealth or telephone services, and postponement of medical travel. In the NWT context, the findings show that service availability alone did not ensure access; public health restrictions, self-isolation requirements, transportation dependence and digital infrastructure influenced whether available services could be used in practice. Therefore, the pandemic did not create access barriers in isolation, but intensified existing dependencies on medical travel, visiting services and local infrastructure.

Overall, the quantitative and qualitative findings provide a more nuanced picture of how healthcare access was experienced during the pandemic. Although most participants did not report difficulty with the measured access indicators, qualitative accounts showed that access was uneven and depended on the type of service needed, whether care required travel, and whether providers or visiting clinics were available. The quantitative findings showed that some participants avoided health centres due to COVID-19 concerns; qualitative findings explained that avoidance was shaped by fear of exposure, concern about travelling to higher-case urban centres, and concern for protecting Elders, family members, and others in the community. Similarly, quantitative findings showed that telehealth or telephone service use differed by community healthcare infrastructure; qualitative findings extend this result by showing that virtual care could reduce travel and clinic attendance for simple concerns, but it depends on technology, service coordination, and whether the health concern could be addressed without an in-person assessment.

Although most participants rated health highly, this self-rated measure reflects perceived health within this project and should not be interpreted as contradicting broader evidence of Indigenous health and healthcare inequities. The finding may reflect participants’ understandings of health, resilience, or day-to-day functioning, as well as selection or response patterns.

Participants’ reports that certain healthcare services, such as emergency care, remained stable align with the strategies of national healthcare systems and the GNWT, which prioritised maintaining access to emergency and urgent care during the pandemic. For example, while overall hospital admissions for non-COVID-19 conditions declined during case surges, some critical areas, such as cardiac diagnostics, saw only moderate reductions in use [14,49]. However, many non-urgent services were postponed or cancelled entirely during the pandemic [32,50]. In remote NWT communities, this prioritisation may have protected access for acute needs while leaving non-urgent, preventive, specialist, and travel-dependent care more vulnerable to delay. Care categorised as non-urgent at the system level may still be experienced as necessary by community members, particularly where alternative local services are limited.

The limited availability of healthcare providers, as well as delayed and cancelled appointments, were the most frequently described barriers to healthcare access reported by participants. This finding was expected, as the GNWT postponed all non-essential services, non-urgent procedures, and specialist travelling clinics during the pandemic [32,51,52]. Healthcare services were also delayed or cancelled due to indirect effects, such as healthcare workforce shortages, staff redeployment, disruptions to medical travel and visiting specialist services, and reduced clinic capacity. These policy decisions have particular implications for communities where access to specialised or follow-up care already depends on scheduled visits, referrals, or travel, and the service disruptions interact with longstanding workforce shortages, limited local infrastructure, and a reliance on visiting providers and specialist travelling clinics. When services were postponed or staff availability declined, remote communities had fewer local alternatives for addressing healthcare needs. Existing staff shortages and limited infrastructure were exacerbated during the pandemic in NWT, impacting healthcare access [23,53]. For instance, territorial obstetric services were suspended because of staff shortages and equipment repair delays, requiring expectant parents to travel outside the territory weeks before due dates to await labour and delivery [54,55]. These delays contributed to an increase in wait times for healthcare. In Canada, backlogs for procedures and diagnostic services, such as breast cancer surgery, hip and knee replacement, and MRI and CT scans, accumulated due to delays and cancellations, resulting in additional wait times of 46–118 days [56]. The pandemic increased the global demand for healthcare services, providers, and health amenities, further contributing to longer wait times, especially for emergency and specialist services [14,57].

Some participants reported that restrictive public health policies, including travel restrictions and self-isolation requirements, disrupted access to healthcare services, including specialist and emergency services, and limited the availability of prescription and traditional medicines. These restrictions affected healthcare access by disrupting both medical travel for patients and travel by visiting providers to remote NWT communities. Although medical travel was permitted under public health orders, access remained difficult for some participants because travel was attached to isolation requirements and household disruption. Governments worldwide mandated service closures, physical distancing, isolation and quarantine measures to contain the spread of COVID-19 [14,57,58]. In NWT, a 14-day self-isolation period was required for anyone entering the territory. Although exemptions could be granted to essential service workers, obtaining an exemption required approval from the Chief Public Health Officer, which may have affected the availability of healthcare providers and services in remote communities [31]. One Canadian report identified that a fly-in nurse program for remote communities was halted entirely during the pandemic [59]. The pandemic and associated public health measures also hindered medical travel out of the territory as a means of accessing healthcare. Travel restrictions and mandatory isolation, either outside the community or with all household members after medical travel, led some participants to avoid or be unable to travel for care. Mandatory self-isolation after out-of-territory travel meant that an appointment could require prolonged time away from home, work, family responsibilities and community supports. For some participants, this made medical travel difficult to complete even when care was technically available. The evidence shows that similar issues arose in other rural and remote jurisdictions. For example, a study in the United States found that Indigenous patients in rural regions experienced inequitable delays in access to care because of COVID-19-related disruptions in patient transfer to facilities in urban centres [60]. However, the NWT context is distinctive because medical travel is a routine component of accessing specialist care rather than an exceptional pathway.

Healthcare systems rapidly implemented virtual care to maintain service delivery amid restrictive public health policies [39]. In NWT, new virtual care options were announced days after the public health emergency was declared [32]. Many participants reported that virtual care was convenient, especially for simple care needs, but some found it was inadequate due to technological barriers, reduced quality of care, and the inability to access certain services virtually. In this sense, virtual care functioned as a partial buffer against pandemic-related disruptions to in-person care. It was useful for simple concerns, follow-up care, and situations where avoiding travel or clinic attendance was beneficial. However, it did not fully resolve access barriers because remote care still depended on infrastructure, clinical appropriateness, and the quality of patient-provider communication. Virtual care may act as both a facilitator of and a barrier to healthcare access. This dual role may be especially important in remote NWT communities, where remote care can reduce the need for travel or in-person visits, but its usefulness may depend on digital connectivity, service coordination, and whether the health concern can be appropriately addressed without in-person assessment. In many cases, virtual care facilitated and improved the delivery of certain healthcare services, providing flexibility for patients and healthcare providers, while reducing expenses for patients related to missing work and travelling for care [13,57,61]. Research suggests that advances in virtual care during the COVID-19 pandemic may promote more equitable healthcare access in remote Canadian regions, even beyond the pandemic context [62]. Although virtual care helped mitigate some pandemic-related access issues, there were many limitations, such as unsuitability for services requiring clinical examination, a lack of consistent guidelines, lower quality patient-provider interactions, and inaccessibility to patients facing social and/or economic barriers, such as limited digital literacy or reliable phone access [13,39,63]. In this project, telehealth and telephone services were measured with a single question; therefore, the quantitative findings should be interpreted as the use of remote healthcare services broadly rather than as modality-specific uptake. This distinction is important because video-based care and telephone consultations have different infrastructure requirements and may differ in quality, privacy, clinical appropriateness, and patient-provider interaction. Similarly, participant concerns about virtual care may reflect different issues, including technological instability, limitations of telephone-based consultation, or the need for in-person assessment. Future research should distinguish phone, video, and other virtual care modalities to generate more specific guidance for remote Indigenous communities.

This project found that women were more likely than men to report telehealth or telephone service use. This association should be interpreted cautiously because the analysis was unadjusted; however, it may reflect both broader gendered patterns in healthcare seeking and pandemic-specific changes in care access [64,65]. A study in Ontario found that women’s use of virtual care increased during the COVID-19 pandemic, while men’s use did not change [66], suggesting that the difference observed in this project may partly reflect pandemic-specific changes in healthcare-seeking patterns, care coordination responsibilities, comfort with remote care, or differences in the types of health concerns for which participants sought care.

This project also found that community healthcare infrastructure was significantly associated with telehealth or telephone service use, with participants from a community with a hospital being more likely to have used virtual care than participants from a community with lower levels of healthcare infrastructure, which ranged from having none to having the capacity to stabilise, hold, and transport patients. This finding suggests that virtual care access may be linked not only to individual willingness to use remote services, but also to the local systems that help arrange, support, and connect patients to those services. Moreover, this finding highlights an important paradox: communities with fewer local healthcare services may have a greater need for remote care options, yet may also face greater barriers to using them. Virtual care does not remove the need for enabling infrastructure; it depends on reliable phone or internet connectivity, private space, appointment pathways, local support for accessing remote services, and provider availability. In remote NWT communities, lower healthcare infrastructure may therefore reflect not only fewer in-person services but also fewer local supports for arranging or participating in remote care. This may help explain why participants in communities with lower health service capacity were less likely to report telehealth or telephone service use. However, because the analysis was unadjusted, this interpretation should be considered exploratory. A scoping review of virtual care delivery across global health systems identified challenges, such as limited policies and regulations, as well as provider and patient familiarity with technology, which may be associated with a facility’s or a community’s level of infrastructure [67]. Community size was not significantly associated with telehealth or telephone service use. This finding should be interpreted cautiously because community population size may not fully reflect access-relevant conditions such as healthcare service level, provider availability, transportation access, medical travel dependence, digital connectivity, and local support needed to use remote care. The absence of statistically significant associations for age, ancestry, education, health status, and community size may also reflect limited statistical power in some subgroups rather than evidence of no relationship. Further research is required to understand the role and limitations of virtual care in healthcare delivery for remote Indigenous communities, the nature of between-group differences in virtual care utilisation, and best practices in quality care to help establish standards for this service modality.

Avoidance impaired access for some participants in this project. Participant accounts suggest that avoidance was shaped not only by fear of infection in healthcare settings, but also by concern about travelling to higher-case urban centres for medical appointments and concern for exposing family members, Elders, or others in the community, which reflects the realised-access dimension of the framework: services could remain available, but participants did not always feel able or willing to use them. There was an overall decline in healthcare-seeking behaviour and thus healthcare service utilisation. In Canada, emergency department utilisation fell to half of the expected volume during the first surge of COVID-19 cases, despite services remaining available [14], suggesting that availability alone does not guarantee access. As well, evidence suggests that 30% of adults in Canada reported delaying seeking healthcare in the first year of the pandemic due to concerns about exposure to COVID-19 and overloading the healthcare system [68]. Similar findings have been reported in other countries, with fear of infection, long wait times, and uncertainty about prevention measures within healthcare facilities cited as the main reasons [15,69–71]. Conversely, participants in another study reported that safety precautions in healthcare facilities helped mitigate such behaviours [15], which suggests that fear of COVID-19 exposure discouraged some care-seeking, whereas visible safety measures, such as masking, screening, and sanitation, reassured some participants and supported in-person care.

This project provided unique insights into perceived barriers and facilitators to healthcare access experienced by Indigenous community members living in remote communities in NWT. Some findings were consistent with experiences reported among broader Canadian and international populations during the pandemic, including service delays, avoidance of care because of infection concerns, and mixed experiences with virtual care [14,15,39,68–71]. The findings also suggest that in northern Indigenous healthcare, pandemic-related access barriers were not isolated disruptions but were layered onto existing structural inequities. In NWT, reliance on medical travel, limited local services, provider shortages, and uneven digital infrastructure meant that public health restrictions could have broader consequences for both potential and realised access [23,53]. Participants’ concerns around exposing Elders, family members, and others further highlight the importance of community relationships and responsibilities in healthcare access decisions. Although the project was not designed to characterise Indigenous cultures or lifeways broadly, it documents how pandemic-related disruptions were experienced in distinct remote Indigenous healthcare contexts.

This underscores the importance of developing emergency preparedness strategies with Indigenous communities and addressing not only service continuity, but also cultural safety, medical travel support, local capacity, and remote-care infrastructure. To inform these strategies, future research should examine how community-level infrastructure, medical travel systems, local service capacity, and distinct remote-care modalities shape potential and realised access in remote Indigenous communities.

Conducting research across ten geographically dispersed communities during the COVID-19 pandemic involved substantial logistical challenges, including public health restrictions, travel limitations, harsh weather conditions, and the complexities of conducting research in fly-in communities. Despite these challenges, this project was among the few community-based research initiatives in NWT approved to proceed during the pandemic. Information for this project was gathered between April and November 2021, spanning the major Delta variant outbreak in NWT, providing important accounts of community members’ lived experiences, and enabling the documentation of healthcare access experiences during a critical period when evidence from remote Indigenous communities remained limited. The community-based approach, the involvement of local RAs, and guidance from the CAB strengthened the project by ensuring that recruitment, data collection, and interpretation were grounded in local knowledge, culturally appropriate practices, and the priorities of participating communities. The project also examined multiple healthcare access pathways, such as health centres, medical travel, and virtual care, helping capture a broad understanding of healthcare access in remote communities during public health emergencies.

However, the project’s limitations should be considered. The number of participants was determined pragmatically based on feasibility during the COVID-19 pandemic. Convenience sampling and voluntary participation may have introduced self-selection bias. Therefore, the findings may not fully represent the experiences and perspectives of all Indigenous community members in NWT. Although the two-month residency criterion defined eligibility as a current community resident, the length of residence beyond this minimum was not measured. Therefore, the project could not assess whether healthcare access experiences differed between newer and longer-term residents. Some subgroup sizes were small, including participants aged over 65 years, which may have limited the statistical power to detect differences. The quantitative analysis used univariable logistic regression and did not assess whether observed associations were independent of potential confounders; therefore, these results should be interpreted as exploratory associations rather than explanatory effects.

Because the questionnaire was developed for this project and included single-item measures of several healthcare access experiences, formal reliability testing was not conducted. The telehealth measure combines telehealth and telephone services into a single item, limiting the ability to distinguish experiences with different remote-care modalities. The project’s cross-sectional design prevents assessment of changes from the pre-pandemic period or examination of long-term consequences. In addition, responses may have been influenced by recall bias and variation in public health restrictions over time.

Finally, the Access to Health Care framework was developed in a general healthcare context and was not designed specifically for Indigenous or remote northern communities. Therefore, we applied the framework with context-specific attention to traditional medicines and healers, medical travel, remoteness, public health restrictions, and virtual care. Although useful as an analytical lens, the framework may not fully capture Indigenous epistemologies, cultural safety, relational understandings of health, or broader structural determinants of access.

Conclusion

COVID-19 disrupted the availability and delivery of healthcare services within NWT and reduced some Indigenous community members’ utilisation of care. The reported barriers to and facilitators of healthcare access were consistent with broader pandemic-related healthcare access challenges, while also reflecting the specific context of remote NWT communities. Existing inequities in healthcare access were amplified. Geographical challenges to service delivery were additionally affected by pandemic-related travel restrictions and self-isolation requirements. While virtual care may help address these challenges, the limitations of its use and delivery highlighted in this project must be addressed.

These results can help to inform emergency preparedness and healthcare planning in remote Indigenous communities by showing where access was most vulnerable during the pandemic. Future strategies should be developed in partnership with Indigenous communities and should address service continuity, culturally safe care, medical travel supports, and remote-care infrastructure.

Funding Statement

This work was supported by the Canadian Institutes of Health Research [grant numbers FRN 172676, FRN 177783, FRN 173393 and CRC-2021-00195] and the COVID-19 Immunity Task Force through the Public Health Agency of Canada [grant number 2122-HQ-000062].

Disclosure statement

Financial support was provided by the Canadian Institutes of Health Research and the Public Health Agency of Canada. The funding agencies had no role in the study design, data collection, analysis, interpretation of findings, decision to publish, or preparation of the manuscript.

Data availability statement

All the information generated or analysed for this manuscript is included in this published article.