UCSF

Background and Significance: Telehealth may help redress rural healthcare shortages in the United States and improve related rural health disparities. However, following the COVID-19 pandemic-related telehealth expansion, telehealth utilization has been lower overall among rural populations compared to urban populations. Certain populations are also more likely to use audio-only telehealth, with implications for care quality. To further understanding of telehealth utilization disparities, the purpose of this dissertation was therefore to describe demographic and telehealth encounter characteristics of a population of rural adults and to explore telehealth experiences among this population.Methods: Three studies were conducted for this dissertation. The first was a scoping review of the literature examining rural patients’ experiences with video telehealth in the United States and methods of patient experience assessment. The second study was a retrospective chart review of adults who lived in rural California ZIP codes and utilized telehealth at one urban medical center from December 2021 to December 2022 (N = 9,359). This study analyzed demographic and telehealth encounter characteristics by three degrees of rural status. The third study used interpretive phenomenology qualitative methods to explore rural patients’ lived experiences with telehealth (N = 16) and the value and meaning they assigned to telehealth. Results: There were 24 articles included in the scoping review. Most studies (70%, n = 16) assessed rural telehealth patient experience using questionnaires, alone or in combination with interviews (n = 11). The majority of surveys were study-developed. Most studies employed convenience sampling (n = 18). Quantitative patient experience outcomes fell under categories of patient satisfaction, telehealth care characteristics, patient-provider rapport, technology elements, and access. In scoping review studies, qualitative themes were most often presented as telehealth benefits and drawbacks. Findings from the demographic analysis showed that the most rural telehealth patients were older, and a higher proportion were White. Although American Indian, Asian, Black, and Latino patients together comprised 25% of the sample, this was lower than the average of rural counties in California. Video visit use and patient portal activation were significantly lower among patients who were older, Latino race or ethnicity, primary Spanish speakers, and publicly insured. Spanish-speaking patients had the lowest use of video telehealth visits. In the qualitative study, participants’ valuations of telehealth were informed by their experiences of rural healthcare scarcity and remote rural living. Interview participants all experienced telehealth as a positive healthcare service, which was seen as a resource to support rural healthcare access and a rural way of life. Conclusion: Findings of this dissertation study substantiate concerns of rural telehealth access disparities, particularly among patients who are older, of minoritized race or ethnicity, and Spanish-speaking. Ongoing research is needed to understand how underserved rural populations are utilizing telehealth, as well as to understand variation in utilization between regions and healthcare settings. Findings from all three studies highlight the underrepresentation of populations of color in rural telehealth research. Future research should use sampling methods to account for representation of rural population subgroups specific to study regions. To help remedy rural telehealth utilization disparities, policy should address patient-level telehealth barriers by supporting measures such as healthcare navigation resources, culturally tailored telehealth patient outreach, digital access assessment, and patient digital education. Policy should also support telehealth infrastructure and development in rural safety net providers.