Understanding Older Adults’ Intention to Use Telehealth: A Qualitative Study Using the UTAUT Framework

Abstract

Introduction/Objectives:

As healthcare embraces telehealth, a need exists to understand factors that promote older adults’ telehealth usage, including the influence of age-related sensory impairments. The objective of this study was to describe older adults’ perceptions of telehealth and factors they considered before using telehealth within the framework of The Unified Theory of Acceptance and Use of Technology (UTAUT).

Methods:

This descriptive qualitative study collected data through semi-structured interviews. Twenty-four older adults were randomly selected from a pool of 103 participants who completed the initial UTAUT survey study. Individual interviews were conducted by telephone. Reflective thematic analysis was used to identify themes within the UTAUT construct that influence older adults’ use of telehealth.

Results:

Older adults identified preparedness, receptiveness, and willingness to use telehealth as important overarching factors to consider when using telehealth. These are connected to the UTAUT constructs: facilitating conditions, social influence, effort expectancy, and performance expectancy.

Conclusions:

This study supports UTAUT as an appropriate framework for assessing telehealth readiness and predicting behavioral intention to use telehealth. Our findings provide limited evidence that sensory impairments do not impact telehealth readiness unless the individual lacks appropriate adaptations.

Keywords

qualitative methods tele-medicine geriatrics access to care technology hearing vision

Introduction/Background

Telehealth has tremendous potential to overcome access barriers to healthcare.^1,2 Before the COVID-19 pandemic, telehealth was used to overcome geographic barriers and healthcare professional shortages, but it was not implemented widely.³ During the pandemic, telehealth joined in-person care as a mainstay of healthcare delivery. One of telehealth’s key features—the ability to deliver care remotely with a clinician in a different location than the patient—became a crucial need during a time of mobility restrictions and virus exposure fears. As a result, many people used remote healthcare services for the first time, and more patients and providers experienced its benefits.^1,2

However, not all populations were equally able or willing to use telehealth. Older adults, who use more healthcare services than younger adults and carry a higher risk for COVID-19 complications, were still less likely to use telehealth.^4,5 Researchers investigating reasons for reduced use of telehealth found many misperceptions. Older adults perceived (a) their medical communication would not be private, (b) their medical care would not be the same as an in-person visit, (c) health assessments would be difficult to complete, and (d) they would not be able to see or hear their provider.⁶ In addition to misperceptions, older adults are more likely to experience technological and physiological limitations such as (a) lack of internet access, (b) dementia, (c) communication, hearing, or vision impairments,^7
-9 (d) motor limitations, and (e) limited technological skills.^10
-12

Older adults’ perceptions about sensory capabilities and telehealth use are important since hearing and vision loss are common among them.¹³ Sensory or motor limitations, as stated above, are reported as potential telehealth barriers by both clinicians and patients.^6,7 Both groups believe that older adults may not be able to adequately see or hear while using telehealth, which often occurs in a digital audiovisual modality (ie, synchronous audio and video such as in videoconferencing). However, sensory losses may be particularly responsive to interventions, such as the provision of adequate hearing and vision assistive devices or the implementation of accessibility features on telehealth devices.

Although there are several reasons older adults are less likely to use telehealth, it does not appear to be related to clinical effectiveness. Evidence supports telehealth use for older adults across disorders including cardiovascular disease, diabetes, cancer,⁹ and communication disorders.¹⁴ Interventions delivered via telehealth could be effective, convenient, and provide health benefits. Telehealth benefits for older adults include “timely care, improving efficiency for physicians, enhancing communication with caregivers and patients, reducing patient travel burdens, and facilitating health outreach and education.”¹⁵ (p. 1) Unfortunately, older adults who may benefit most from health communication technologies like telehealth may reject them or face attitudinal barriers from others^6,10,16 leading to their disuse or less use.¹⁷

The literature suggests that telehealth can be an effective way to deliver care to older adults. This situation presents an opportunity to facilitate older adult telehealth usage within the lens of health behavior change by understanding the determinants of health behavior associated with telehealth usage.¹⁸ The present study considers the decision to use telehealth as a type of health behavior. As a type of health technology, telehealth use can be investigated using technology acceptance models. Literature using technology acceptance models suggests the adoption of new technology depends heavily on the beliefs held by potential technology users,¹⁹ and the eventual use of a given technology depends on a group of predictable factors.²⁰ Specifically, this study used the Unified Theory of Acceptance and Use of Technology (UTAUT), which integrates technology acceptance models and health behavior change theory²⁰ to describe (a) older adults’ perceptions of telehealth factors considered before using telehealth, and (b) how sensory impairments impacted their ability to use telehealth. See Figure 1 for an illustration of UTAUT.

Figure 1.

Unified theory of acceptance and use of technology.

Methods

This study describes the qualitative arm of a concurrent mixed-methods investigation. A descriptive qualitative design²¹ including semi-structured interviews²² was chosen because we wanted to understand the older adults’ perspectives and experiences using telehealth within the UTAUT model.²⁰ We used reflexive thematic analysis to make sense of the older adults’ shared experiences with telehealth by identifying, organizing, and providing insight into the patterns of meaning across this data set.^23,24 Next, we compared the themes and subthemes with the UTAUT constructs.

Research Characteristics and Roles

The study was collaboratively designed by a team of researchers (K.S. J.L, A.F., and R.C.) with expertise in speech-language pathology, telehealth, virtual education, and rehabilitation, including both quantitative and qualitative research backgrounds. K.S. served as the primary researcher, being responsible for data collection, processing, and analysis. K.S. background as a speech-language pathologist helped in interviewing, which may have introduced some preexisting assumptions regarding older adults’ access to telehealth. Being aware of this helped K.S. engage in self-reflection throughout the study.

Sampling and Participant Characteristics

The University of Kentucky Institutional Review Board approved this study (IRB# 70014). For the first part of the quantitative strand of the concurrent mixed method study, we recruited 65 years and older adults from Kentucky through purposeful sampling to complete a self-administered pre-existing paper questionnaire to validate the use of UTAUT²⁰ among older adults who used telehealth. Prior to the self-administration of the questionnaire, participants completed the informed consent, and the demographic survey composed of age, ZIP code (urban vs. rural), income, and race/ethnicity (see Tables 1 and 2). Income and race/ethnicity questions were informed by the AARP²⁵ survey (2006) and the United States Census.²⁶ The mean age was 72.71, the median was 72, and the range was 65 to 90. Participants represented 19 counties across Kentucky with over-representation from the Lexington and Louisville urban areas. Of the participants who responded to the telehealth experience question (n = 103), 63% indicated prior experience with telehealth. Four participants indicated having vision or hearing impairments impacting their use of telehealth, and 99 participants indicated not having a significant vision or hearing impairment.

Table 1.

Race/Ethnicity Comparison Table.

Race/ethnicity	Survey sample	Interview sample	Kentucky, Census^a	%
	N = 103	N = 23	Kentucky, Census^a
	n (%)	n (%)	Race/ethnicity
White	94 (91)	22 (96)	White	87.5
Black or African American	2 (2)	0 (0)	Black or African American	8.5
American Indian or Alaska Native	0 (0)	0 (0)	American Indian or Alaska Native	0.3
Asian	0 (0)	0 (0)	Asian	1.6
Native Hawaiian or other Pacific Islander	0 (0)	0 (0)	Native Hawaiian or Other Pacific Islander	0.1
Hispanic	1 (1)	0 (0)	Hispanic	3.9
Two or more races	1 (1)	1 (4)	Two or more races	2.0
Prefer not to answer	3 (3)	0 (0)
Other (write-in)	2 (2)	0 (0)

Vintage 2021 Population Estimate, U.S. Census QuickFacts (2021).

Table 2.

Income Comparison Table.

Income category	Survey sample	Interview sample	Kentucky, American Community survey^a
	N = 103	N = 23	%
	n (%)	n (%)	Income category	%
Less than $25 000	4 (4)	0 (0)	Up to $24 999	31
$25 000 up to $49 999	20 (19)	5 (22)	$25 000 to $49 999	30
$50 000 up to $74 999	16 (16)	6 (26)	$50 000 to $74 999	17
$75 000 up to $99 999	21 (20)	3 (13)	$75 000 to $99 999	9
$100 000 up to $149 999	20 (19)	4 (17.4)	$100 000 to $149 999	8
$150 000 up to $199 999	11 (11)	1 (4.3)	$150 000 to $199 999	2
$200 000 and above	6 (6)	3 (13)	$200 000 and above	3
Do not know	1 (1)	1 (4.3)
Missing	4 (4)	0 (0)

2020 inflation-adjusted dollars, from the 2020 American Community Survey, Age of Householder by Household Income in the Past 12 Months (U.S. Census, 2020).

Nearly all of the 103 older adults who completed the survey indicated an interest in participating in the follow-up qualitative interview study within their informed consent.²⁷ Our final sample was composed of 23 older adults randomly selected from the 100 who wanted to be interviewed. We chose to interview 23 participants because redundancy of information is usually reached after 8 to 15 interviews within a homogenous population (white, urban, older adults).²⁷ We interviewed additional participants to increase the likelihood of reaching redundancy.

When comparing the interview sample with the survey sample, we included a similar percentage (within 5%) of individuals who were older white adults of both sexes who had vision impairments and an income between $25 000 to $50 000 and $100 000 to $150 000. They also reported having similar access to resources to use telehealth. There was overrepresentation (about 6%-12% more) of those who reported knowing on how to use telehealth, lived in rural areas, and had incomes of $50 000 to $75 000 and >$200 000, and underrepresentation of incomes <$25 000, $75 000 to $100 000, and $150 000 to $200 000 (see Tables 1 to 3).

Table 3.

Demographics and Telehealth Prerequisites of Participants.

	Survey population	Interview population
	N = 103	N = 23
Demographics	n (%)	n (%)
Sex^a
Male	29 (28)	6 (26)
Female	74 (72)	17 (74)
Geography^b
Urban	73 (71)	20 (87)
Rural	25 (24)	3 (13)
No response	5 (5)	3 (13)
Age^b
Older adults (65-85)	101 (98)	22 (96)
Very old adults (>85)	2 (2)	1 (4)
Digital resources and literacy
Vision impairment impacting Telehealth usage^b,c
Yes	4 (4)	2 (9)
No	99 (96)	21(91)
Have resources needed for using telehealth^b,c
Yes	95 (92)	20 (87)
Neutral	4 (4)	2 (9)
No	4 (4)	1 (4)
Have knowledge needed to use telehealth^b,c
Yes	80 (77.6)	15 (65.2)
Neutral	13 (12.6)	4 (17.4)
No	10 (9.7)	4 (17.4)

Not collected within the survey.

Information was collected within the survey study.

The questions were answered on a Likert scale from 1 = strongly disagree, 3 = neither agree nor disagree, 5 = strongly agree.

Data Collection

Individual semi-structured interviews were conducted over the phone by K.S. from late 2021 to early 2022, within the time declared as a national Public Health Emergency.²⁸ This may have affected response rates or participants’ perceptions of telehealth.

No one was present with K.S. during the interviews, but participants may have had family members or other individuals present in the background during their interviews. Phone interviews were chosen over in-person interviews to comply with infection control procedures during the COVID-19 pandemic. Phone communication was chosen over videoconferencing to reduce response bias toward individuals who already use videoconferencing.

The interviewer used a predefined interview guide written by K.S under the guidance of J.L., who is a UTAUT model expert. The interview questions were designed to mirror the survey questions but remain open-ended to elicit in-depth responses. Although K.S. had some latitude to elicit in-depth responses via follow-up and clarification probes, interviews followed a semi-structured interview guide. Prior to interviewing, the interview guide was piloted with 2 older adults. No modifications to the interview guide were recommended.

Thirty to 60-minute interviews were conducted in a private room on a university landline and audio recorded. Interviews adhered to strategies for effective phone interviews: developing rapport, communicating responsiveness, and communicating regard for the participant and their contributions.²⁹ Fieldnotes were not taken during phone interviews. Before and after her interviews, K.S. reflected on her thoughts and feelings about older adults’ use of telehealth.³⁰

Data Processing and Analysis

The interviews were digitally recorded, transcribed, de-identified, and reviewed before they were analyzed. To ensure confidentiality and anonymity, each transcript was given a unique code, and any identifying information was removed from the transcripts. Interview transcripts were reflectively thematically analyzed by 3 trained coders to identify patterns within the participants’ responses. We used Braun and Clarke’s 6-phase approach²³ that includes: (1) familiarizing oneself with the data, (2) generating initial codes, (3) finding themes, (4) reviewing potential themes, (5) naming and defining themes, and (6) producing the report.²³ Half of the transcripts were analyzed by K.S. and the second half by G.L. The qualitative research expert, A.F., reviewed the analysis performed by K.S. and G.L.

Coders used cloud-based de-identified interview transcripts to conduct coding by highlighting and adding typed comments. Codes were compiled in a secure, cloud-based Excel file. Then they were sorted into themes and subthemes.²³ K.S. discussed the themes with A.F. until consensus was reached. K.S. created an initial thematic map with themes and subthemes which were further organized and analyzed for relationships between and across themes. The revised thematic map was evaluated against all coded units for fit. External auditing was completed by a University of Kentucky Ph.D. student with experience in qualitative interview research. After she completed the external audit, K.S. compared the themes and subthemes with the UTAUT constructs. If the theme and subtheme(s) fit within a UTAUT construct, these connections were described and illustrated. If this did not occur, a modification to the UTAUT framework would be developed. After the first half of the transcripts were analyzed, G.L. separately analyzed the second half of the transcripts. To reduce bias, G.L. did not see the thematic map Figure 2 until she completed her analysis. Following the completion of her analysis, she organized her themes and subthemes within the thematic map created by K.S., and no new themes were generated, therefore, Figure 2 was not changed.

Figure 2.

Themes of older adults’ intent and actual usage of telehealth within the unified theory of acceptance and use of technology.

Results

Participants described differences in telehealth knowledge and skills between themselves, their loved ones, community members, and coworkers in the same age group. They shared examples of differences in technological capacity and usage among their older adult peers including neighbors, spouses, and friends. For example, a participant expressed amazement at other older adults’ proficiency with technology. “I’ve seen so many older people with smartphones, and I can see ‘em where they’re doin’ all this stuff, and I’m thinkin’ – ‘How did you learn to do all that stuff? I don’t know how to do any of that stuff.’ (ID: 167)” Meanwhile, another participant, who had “been playing with computers since probably around when [interviewer’s] parents were born, (ID: 214)” expressed enthusiasm for trying all the latest technology innovations. Participants also considered our questions in the context of groups of older adults in different situations, including people with more or fewer resources or without technological experience. For example, even if a participant had adequate internet access for telehealth at home, they may have mentioned concern for older adults who did not have access to the internet at home. Lastly, the participants categorized older adults into 2 groups: older adults 65 to 85 and very old adults >85. They believed older adults were more comfortable with technology than very old adults.

Not all the participants provided favorable telehealth opinions. One participant indicated they would not use telehealth. “Yes, I could. No, I choose not to. . . If I need to see the doctor, I would actually like to see the doctor.” (ID: 444) Three other participants indicated telehealth was not their preference but would access it if mandatory. For example, “[I am] not sure [I] would do it again in the future, but [I was] grateful to have it during COVID.” (ID: 273) Others considered when telehealth should not be used, “where it’s not useful, I would think, is when you have something where you actually have to physically be in the doctor’s office, and have them examine you, uh, to be sure – or, look at something that you can’t really look at. Sometimes, usually - you know, I don’t how how – I’ve not done this – but if you had a rash on your arm or something.” (ID: 222) Many older adults may have health conditions, equipment, and knowledge needed to use telehealth, but recognize it is not useful when a physical exam is needed.

When we asked older adults questions about social influence, which is a construct within the UTAUT model, this appeared to be marginally or indistinctly associated with receptiveness to telehealth. During the phone interviews, when asked about the influence of others on their telehealth use, they typically did not have an immediate answer. Responses included “Huh! (laugh) That’s an interesting question” (ID: 700) and “I really don’t know the answer to that.” (ID: 273) One participant indicated that “it’s just never been brought up.” (ID: 488) Participants often paused and either detailed their own telehealth experiences or those of their family and friends during the pandemic and/or expressed general uncertainty about whether their social sphere used telehealth.

We generated the themes of preparedness, receptiveness, and willingness from the older adults who expressed intent to use telehealth versus their actual use of telehealth (see Figure 2). Within each of these themes, we identified supporting subthemes. We found most of the UTAUT constructs fell within each of the generated themes. As mentioned previously, social influence does not appear to be a strong indicator of whether older adults will use telehealth services and was not found to be as intricately connected to the themes.

Preparedness for Telehealth

The 2 subthemes that fall within preparedness illustrate what older adults believe is needed to have a successful telehealth visit. We identified a pattern of participants who used telehealth and also had the technology knowledge and skills for telehealth. This is consistent with UTAUT’s Facilitating Conditions construct, which refers to the individual’s perception that adequate resources are available for them to use telehealth. Support from others aligned with both UTAUT’s Facilitating Conditions construct and Social Influence. Social Influence addresses individuals’ perception that important people around them believe they should use telehealth.

Technology, knowledge, and skills

Most of the participants acknowledged they had access to the technology required for a telehealth visit. Although they had resources, many participants recognized that “people who don’t have a computer, don’t have Wi-Fi, don’t have a smartphone” (ID: 156) would have trouble accessing telehealth. If an individual does not have a computer, an older adult would not necessarily buy one to access their physician. “I have to go buy a computer if I want to talk to my doctor, that’s not gonna fly.” (ID: 444) Participants separated access to technology from technology knowledge. Participants often related learning telehealth to past workplace experiences in which they needed to learn new technology to complete work assignments. Workplace experience examples were described by those who were retired or still working. They described various experiences when they adjusted to recent technology in their lives, such as personal computers, work pagers, email, and cell phones. Thus, participants viewed telehealth innovations in the context of another technology innovation within their lifetime.

Support from others

Participants reported that some older adults would need support to use telehealth. “Older adults” in need of support could refer to the participants themselves or their peers. Participants noted that those receptive to support such as training, tech support, troubleshooting, and practical help finding devices or internet access were more likely to use telehealth. Topics requiring assistance included scheduling a telehealth appointment, finding a webcam or microphone, setting up the computer, locating an appointment link, and adjusting videoconferencing settings. One participant stated, “I would have my wife help me. Between the 2 of us, I think we’d get it done.” (ID: 811) An adult child, in another example, sets up a telehealth appointment for the parent. Other participants shared that they assumed the role of a telehealth support person for their spouse or relatives, for example, serving as their spouse’s personal “IT department.” (ID: 214)

Receptiveness to Telehealth

The subthemes reflected in receptiveness describe factors present among older adults who were willing to use telehealth. These subthemes were new technology use during the pandemic “tech savviness,” (ID: 167) psychological readiness, technology across the lifespan, and adequate hearing and vision. New technology use during the pandemic is connected to the UTAUT Social Influence construct and the other subthemes are connected to UTAUT Effort Expectancy Construct. Effort expectancy refers to how easy it is to use the technology.

New technology use during the pandemic

Social Influence not only contributed to older adults’ preparedness for telehealth, but it also contributed to their receptiveness to telehealth. The use of new technologies in the COVID-19 pandemic appeared to increase older adults’ receptiveness to technologies used for healthcare. For example, a participant reported watching their grandchild’s elementary school graduation via videoconference for the first time during the pandemic.

“Tech-savviness.”

There was a common desire for telehealth platforms to be well-designed: intuitive and simple to operate. Participants hoped telehealth designers could create systems that did not require advanced knowledge or “tech-savviness.” These individuals were discussed as having a personality trait or skill. For instance, “I’m not too computer-savvy,” (ID: 167) another reported, “I’m tech-savvy, is the word. I have all kinds of devices, and I know a little bit about [telehealth], enough to know how to do it.” (ID: 222) Participants noted that although they felt telehealth was easy, other adults who were less “tech-savvy” may not.

Psychological readiness

Beyond being tech-savvy, participants described various psychological internal states, such as fear, excitement, discomfort or comfort, anxiety, distrust, embarrassment, or hesitation impacting older adults’ telehealth usage. One participant’s relative had “a fear of using broadband.” (ID: 112) Another felt telehealth education could be “confidence building” (ID: 492) for an older adult. These internal states appeared to be associated with technology experience or access to equipment. One participant stated, “I think some people just are not in a position psychologically perhaps to adapt,” (ID: 637) and another said “technology, if you’re not used to it, and you haven’t made the effort to learn it, it can be very threatening and daunting.” (ID: 505) Others felt comfortable using telehealth, or eager to try telehealth.

Telehealth across the lifespan

Participants described the use of technology and telehealth among children to very old adults (>85 years). Our participants assumed younger people would have no problem accessing telehealth, “no big deal.” (ID: 167) On the other hand, some participants reflected that many older adults “grew up with technology.” For them “[telehealth is] a different story because [they learned] as [they went].” (ID: 492) They reflected that society views older adults as 1 group; however, they identified older adults, <85, and very old adults >85. When they discussed very old adults, participants often mentioned their parents or older relatives having difficulty with technology.

Adequate hearing and vision

The original UTAUT model²⁰ does not consider sensory impairments; hence we specifically inquired about the impact of vision and hearing impairments on telehealth readiness. Participants generally denied that their own vision or hearing impairments would interfere with telehealth use. They often mentioned either intact sensory status or assistive devices (such as glasses or hearing aids) that negated sensory impairments and allowed them to use the telehealth application. When considering themselves and others, participants had mixed perceptions to the impact sensory impairments might have on telehealth usage. Participants described instances that facilitated a telehealth visit. For example, during the COVID-19 pandemic, required mask mandates hampered using lipreading for individuals with hearing loss, but videoconferencing telehealth supported lipreading. Participants also considered telehealth barriers unique to individuals with sensory impairments, such as difficulty locating and using screen controls with visual impairments.

Willingness to Use Telehealth

The subthemes within willingness reflect the older adults’ perception of telehealth usefulness or effectiveness in meeting health needs. Individuals often noted telehealth was useful, even if remote encounters were not their personal preference. These subthemes were convenient, transportation solution, “appropriate” visit, telehealth-trained healthcare provider, and security. Willingness theme was related to the UTAUT’s Performance Expectancy construct. This construct addresses individuals’ perception that telehealth will help meet healthy goals or needs.

Convenient

Participants felt it was easy to schedule. “. . .it certainly was easy that time [I used telehealth]. I set it up by requesting an appointment and they sent me information about what time . . . here’s the thing you click on.” (ID: 156) Others appreciated the reduced wait time to see their healthcare provider “telehealth you’re not sitting in that office for an hour and 15 minutes, which is always really really good. And I think especially with older people, they are acutely aware that their time is running out. So, I think old people don’t like to wait in line.” (ID: 900)

Transportation solution

Telehealth solved transportation problems including traffic, parking, and geographical distances. A participant felt that older adults would prefer telehealth instead of driving to a large urban clinic or hospital. They “would be very happy not to have to deal with trying to find a place to park.” (ID: 492) Participants noted the benefits of telehealth for individuals living in the rural mountains of Kentucky such as ice on rural mountainous roads and the remoteness. Finally, older adults with vision loss or reduced cognition indicated they felt safe and comfortable in a telehealth visit compared to driving into a clinic. For those with reduced mobility, they too may benefit from telehealth. “So, I would assume the telehealth would be for number one, old people who are, have mobility issues. They can’t leave the house, or it’s difficult to leave the house, or painful to leave the house.” (ID: 264) Telehealth appears to allow older adults with a sensory or mobility impairment to remain independent in seeking healthcare.

Appropriate visit

Participants consistently expressed that telehealth was appropriate for certain situations. They felt telehealth was appropriate for minor conditions like sinus infections but inappropriate for serious or emergent conditions like heart issues or trauma. However, they often noted a need for screening or triage to help older adults and their providers determine which conditions would be minor “enough” to be seen via telehealth, or serious enough for an in-person visit. A participant suggested “some kind of spreadsheet or dichotomous key where, you know, is it an emergency, how do you determine an emergency. . .are you having chest pains?” (ID: 112) Telehealth was considered appropriate for follow-up visits, but not for initial visits or assessments. They felt this required hands-on assessment, “you can’t feel for lumps over telehealth!” (ID: 719) Another stated, “a doctor’s ability to diagnose a person is very dependent on a personal examination,” (ID: 101) and cited the need for smell in a physical assessment. Participants shared concerns about subtle health signs being missed during telehealth assessment.

Many older adults felt telehealth is necessary when there is a concern for either spreading or contracting COVID-19. For instance, “during the pandemic it’s almost imperative that something be available to make up for the fact that people don’t dare go out and expose themselves.” (ID: 192) Another stated ‘Okay, well, like I said, it was particularly useful during COVID when it first started over a year ago, when I, uh, did not necessarily want to, uh, to go into the doctor, uh, and just meet with her for a follow-up visit.” (ID: 222)

Telehealth trained healthcare provider

Participants preferred telehealth visits with their established providers. Older adults expected providers to be skilled in delivering healthcare using digital modalities. One participant noted that “just because you’re a physician, doesn’t mean you are techy!” (ID: 637) A participant indicated provider training should include learning effective communication over telehealth. Another felt that providers should be given adequate time to spend with their telehealth patients, so they do not appear rushed. One participant shared, “I get more frustrated when I have to do something quickly, and I don’t really know how to do it or it’s not working for me.” (ID: 222) Another shared that lipreading or auditory comprehension was more difficult, due to hearing loss, if providers spoke too quickly. As a result, the benefit of telehealth was lost.

Security

Lastly, concerns about privacy and security while using telehealth were also expressed. Participants occasionally based their decision to use telehealth on whether they felt adequate security protocols were followed. A participant indicated that security was not a concern if the health visit was not discussing something personal. “If I just needed to contact them about something really general, you know, ‘I’ve got this spot on my arm, what do you think it is?’ You know, that’s one thing, if we’re going to be talking about very personal types of illnesses or something of a very personal nature going on with you then that is another level [of security is needed].” (ID: 444) Additionally, some older adults may be reluctant to download a telehealth app needed for a telehealth visit. “I mean I’m not 90 and feeble but it surprised me the number – I’m [own age is late 60s] – I was amazed how many of my peers and very good friends could not grasp how to have coffee together on a Zoom call, you know. They didn’t want to install anything, they didn’t want to click links, what if it had a virus? Blah-blah-blah. So, I can see why [their] health went down so much last year.” (ID: 273)

Discussion

The primary aim of this study was to describe older adults’ perceptions of telehealth and the factors influencing their behavioral intention to use it. Our participants perceived preparedness, receptiveness, and willingness to use telehealth as key factors when deciding to use it for a medical visit. These factors align with UTAUT constructs and give providers factors to consider when encouraging older adults to use telehealth. These are consistent with remote healthcare best practices.^31
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Our results support the recommended telehealth practices of the Institute for Healthcare Improvement,³¹ Collaborative for Telehealth and Aging (C4TA),³³ American Psychiatric Association,³² and American Telemedicine Association.³² Similar to these organizations’ recommendations, we found our participants wanted telehealth services because it increased access to medical services, particularly during COVID-19.^31,33 They also agreed providers of telehealth need to consider accessibility and privacy when designing their telehealth platforms.^31,32 Lastly, our participants described the need for provider training so they give person-centered equitable care which included accurate diagnostic services, clear explanation of when to use telehealth services, and psychological and emotional space for patients.^31
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Beyond telehealth best practices, providers need to consider barriers for older adults using telehealth, such as ageism,¹⁷ geography, education, and income.³⁴ Healthcare providers with higher ageism scores were more likely to perceive older adults as incapable of using healthcare digital technology.³⁵ We found old age was not described as a reason for not using telehealth, rather a lack of previous experience or interest in using technology. As more older adults remain in the workforce compared to previous generations³⁶ and they move into the very old age group by around 2030,³⁶ we may see technology ageism waning. Along with ageism, access to telehealth visits is more closely associated with race, ethnicity, education, socioeconomics, age-associated sensory impairments, dementia, and self-rating of health for all age groups including older adults.⁷ Although geography was not mentioned by our participants (24% lived in a rural area), the subtheme of technology, knowledge, and skills has been described as a barrier to those in rural areas. Specifically, limited or no internet access³⁷ and lower levels of education³⁸ are more prevalent in s as barriers to telehealth.⁴ Conversely, many participants described how telehealth can reduce travel time, wait time, and cost, similar to other reports in the literature.³⁹ Most participants reported having the knowledge and resources to use telehealth. Our participants who reported previous experience with technology indicated they were able to access telehealth, which implies having a job requiring at least a high school diploma.³⁴ Our participants observed that prior workplace experience with technology aided easier telehealth access, suggesting jobs that require at least a high school diploma. They also felt the very old adults struggled with accessing telehealth which is consistent with reports indicating those over 75 were less likely to access telehealth.³⁴

A secondary aim was to determine if older adults described vision or hearing impairments as a barrier to their use of telehealth. Overall, participants stated that their vision or hearing impairments were not barriers to accessing telehealth visits when using assistive devices such as glasses and Bluetooth-enabled hearing aids to manage their sensory limitations. These findings suggest that vision and hearing impairments could be a barrier to telehealth use in the absence of assistive devices. Our findings align with evidence showing that sensory impairments influence visit modality (telehealth only, in-person only, or both) with hearing loss having less of an impact than vision followed by a dual sensory loss.^40,41 Before recommending telehealth to those with vision and hearing impairments, healthcare providers should ensure these assistive devices are available to their patients.

The availability of assistive devices is improving as technology increases and the costs for them decrease. For instance, recent access to FDA-approved over-the-counter hearing aids allows older adults to self-manage their hearing loss and improves their access to telehealth services.³³ Furthermore, as telehealth platforms evolve and embed features to amplify sound and large images, sensory impairments may not be a barrier to telehealth services.

Limitations

This exploratory study has several limitations and opportunities for future research. First, the 23 older adults who completed the interview are sufficiently large for qualitative research but are not representative. Although participants were randomly selected to be interviewed from the 100 volunteers, the interview population did not demographically represent the survey population. In the future, quota sampling may provide a more representative sample for critical demographics such as income and geography. Most participants were white, non-Hispanic, with a household income between $25 000 and $150 000 and living in an urban area. They had access to telehealth, and a few had a sensory impairment. In addition, individuals with low literacy or unreliable mail service would not have had the opportunity to complete the paper survey mailed to them. As a result, our sample does not represent this population of all older adults. Future research is needed to understand if these perceptions are like those of other racial, ethnic, economic, and geographic backgrounds.

Telephone interviews, although necessary given the global pandemic, also presented limitations. For example, if the interviewer were able to be in the participant’s home or where they would typically access telehealth, additional observations could have been made of them accessing the telehealth platform. We only had 1 participant who had impaired hearing. Although it appeared the participant provided answers to the questions, it is possible they did not completely hear the question.

Future research should focus on developing interventions to (a) reduce healthcare providers’ technology ageism, (b) increase telehealth technology and communication competencies among healthcare providers, and (c) identify the most accessible telehealth platforms for older adults with sensory impairments (magnification and Bluetooth).

Conclusion

In conclusion, this qualitative study supports UTAUT as an appropriate framework to assess telehealth readiness and predict behavioral intention to use telehealth. Our findings provide limited evidence that older adults with hearing or visual impairments can access telehealth when using appropriate assistive devices (Bluetooth and magnification). Participants confirmed that workplace technology experience and access to technology are critical to using telehealth, and healthcare providers’ perception of older adults being incapable of using technology is a barrier.

The themes and subthemes generated in this study confirm current telehealth guidelines and practices.^31
-33 Additionally, they highlight the need for using person-centered care focusing on the specific needs of older or very old adults within a telehealth visit. Older adults expressed an understanding that telehealth visits were not appropriate for all medical visits. They wanted a healthcare provider who understands how to use the technology and communicates effectively with them during their telehealth visit. Medical systems providing telehealth services should consider developing creative solutions for internet access, creating accessible telehealth platforms for those with hearing and visual impairments, and providing telehealth training for providers and patients.

Footnotes

Acknowledgements

The authors recognize and acknowledge the standards set forth regarding the transparency and openness promotion guidelines and have properly cited relevant methodologies utilized. When possible, all citations are accompanied by persistent identifiers. We openly share all coding procedures, survey instruments, and study materials—please e-mail the corresponding author. Due to ethical constraints, raw data may not be shared to maintain the confidentiality of participants. The research contained in this manuscript was not preregistered with an analysis plan in an independent institutional registry We could not have completed this research without the support of the following individuals Grace Loizou and Hannah Douglass, Ph.D., CCC-SLP.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Kentucky Speech-Language-Hearing Association, Stanley Memorial Fund Scholarship.

Ethical Approval

The University of Kentucky Institutional Review Board approved this study (IRB# 70014).

Consent to Participate

Written informed consent was obtained from all participants prior to participating in this study.

Consent for Publication

Within the informed consent, participants consented to having anonymized information shared within a research manuscript.

ORCID iDs

Anne Fleischer

Joneen Lowman

Data Availability

The interview transcripts generated during this study contain private information, and participants did not provide consent for their data to be shared with others. Therefore, the transcripts will not be made publicly available.

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