Demystifying the Digital Divide: Disparities in Telerehabilitation Readiness Among Older Adults in the United States

Abstract

Objective: To estimate readiness of older rehabilitation users in the United States to participate in video-based telerehabilitation and assess disparities in readiness among racial and ethnic minoritized populations, socioeconomically disadvantaged populations, and rural-dwelling older adults.

Design: Retrospective cohort study using nationally representative survey data from the National Health and Aging Trends Study from 2015 and 2020. Survey-weighted regression models, accounting for complex survey design, were used to generate estimates of readiness and evaluate disparities across racial and ethnic, socioeconomic, and geographic subgroups. Odds ratios (OR) and 95% confidence intervals (CIs) were estimated for each comparison.

Setting: Home or community rehabilitation environments.

Participants: A cohort of 5274 home or community-based rehabilitation users aged 70 years or older (N=5274), representing a weighted 33,576,313 older adults in the United States.

Interventions: Not applicable.

Main outcome measure(s): Video-based telerehabilitation readiness was defined consistent with prior work; unreadiness was defined as lacking ownership of internet-enabled devices, limited proficiency of use, or living with severe cognitive, visual, or hearing impairment. Telerehabilitation readiness was categorized as "Ready" or "Unready".

Results: Approximately 2 in 3 older rehabilitation users were categorized as ready to participate in video-based rehabilitation. Significantly lower rates of readiness were observed among those living in rural areas (OR=0.75, 95% CI: 0.60-0.94), financially strained individuals (OR=0.37, 95% CI: 0.26-0.53), and among individuals identifying as Black or Hispanic (as compared with non-Hispanic White older adults: Non-Hispanic Black [OR=0.23, 95% CI: 0.18-0.30]; Hispanic [OR=0.17, 95% CI: 0.11, 0.27]).

Conclusions: Our findings highlight significant disparities in the readiness to uptake video-based telerehabilitation. Policy and practice interventions to address telerehabilitation readiness should focus not only on improving broadband access but also on technology ownership and training to ensure equitable adoption in populations with lower baseline readiness.

Keywords: Aged; Rehabilitation; Social determinants of health; Telemedicine.

Figure 1:

Overall population prevalence of telemedicine readiness from 2015 to 2020, drawn from National Health and Aging Trends Study (NHATS) data rounds 5 through 10, is depicted above. Blue bars indicate the overall weighted percentage of older rehabilitation users in the United States who were categorized as telemedicine ready. All prevalence values were estimated from survey weighted analysis of NHATS data, accounting for repeated observations of participants over time.

Figure 2:

Odds ratios and 95% confidence intervals (CIs) are depicted. Rurality was defined by rural-urban continuum codes and dichotomized as rural or urban dwelling (reference group=urban). Financial strain represents those with documented difficulty meeting basic expenses such as rent, utilities, or food during annual surveys (reference=not financially strained). For race and ethnicity (reference=non-Hispanic White), those categorized as other due to small sample sizes included those identifying as American Indian, Asian, Native Hawaiian, Pacific Islander, Alaska Native, or those who identified as more than one race.