Disparities in technology literacy and access negatively impact cognitive remediation scalability

The transition of computerized cognitive remediation (CR) sessions to remote delivery has proven to be feasible when proper training and equipment are available (Lynch et al., 2020; Ventura et al., 2013). The implementation of remote CR during the COVID-19 pandemic highlighted continued opportunity for valued skills training and peer interaction for some (Lynch et al., 2020), as well as challenges that may hinder its accessibility and effectiveness for others (Eberly et al., 2020; Medalia et al., 2021; Torous and Keshavan, 2020). The disparity in computer proficiency and access to the necessary technology among some people with schizophrenia-spectrum disorders becomes alarmingly clear when surveying participants’ experiences (Medalia et al., 2021). This disparity can significantly impact the implementation and efficacy of remote CR (Eberly et al., 2020; Medalia et al., 2021; Torous and Keshavan, 2020).

While the current literature on telemental health feasibility references this disparity, few studies focus specifically on feasibility of remote CR among people with schizophrenia spectrum disorders. Midst general enthusiasm (Appleton et al., 2021; Pierce et al., 2021), Medalia et al. (2021) highlighted variable technology access and independent use as potential feasibility challenges. In this letter, we provide additional data with the intent to bring greater attention to disparities in technology use and the implications for remote CR for people with schizophrenia-spectrum disorders.

In a randomized trial of computer-based CR conducted in New York City (NYC) metro area outpatient clinics (NCT03576976), adults (age 18–68) with schizophrenia-spectrum disorders participated in either twice weekly in-person clinic CR sessions (Clinic) or a hybrid of in-person clinic and remote CR (Hybrid). In-clinic sessions were clinician-led, with time dedicated to web-based cognitive exercises and group discussion. Remote CR entailed practice on web-based exercises using independently accessed devices and internet, in addition to attending one clinician-led session per week. All participants (N = 62) were care recipients with public insurance at state operated clinics, on average 44.97 (SD = 12.75) years of age with 12.06 (SD = 1.25) years of education, with over half identifying as Black or African American (59.7%) and about one-third (30.7%) as Hispanic or Latinx (see Medalia et al., 2021 for further detail). The composition of this sample is representative of the larger population of adults served in New York City OMH clinics, as per the most recent patient characteristics survey (N = 363,026).

To understand CR feasibility and accessibility, all participants (N = 62) were asked to self-report on their baseline proficiency in computer usage, frequency using a computer, and access to a computer at home. During the intervention, Hybrid CR participants tracked their access to remote cognitive exercises, while qualitative interviews with n = 17 further assessed barriers and facilitators to remote participation.

Prior to engaging in CR, 51.61% of participants reported never using a computer each week and 66.13% reported not having access to a computer at home (see Table 1). Some participants reported they are unable to afford a computer and/or the internet. To resolve the issue of access, many participants had to rely on the clinic or public resources, such as libraries. However, libraries, before closing completely during the pandemic, presented additional challenges such as lack of computer availability, long wait times, and distractions. These limitations may prevent participation in remote CR thus eliminating the opportunity to receive helpful treatments.

Table 1.

Baseline computer proficiency and access.

	Total sample (N = 62)
Computer proficiency N (%)
Turning a computer on and off
Never tried	5 (8.06%)
Not at all	6 (9.68%)
Not very easily	7 (11.29%)
Somewhat easily	10 (16.13%)
Very easily	34 (54.68%)
Using a computer keyboard to type
Never tried	1 (1.61%)
Not at all	3 (4.84%)
Not very easily	9 (14.52%)
Somewhat easily	13 (20.97%)
Very easily	34 (54.84%)
Missing	2 (3.23%)
Using a mouse
Never tried	1 (1.61%)
Not at all	3 (4.84%)
Not very easily	8 (12.90%)
Somewhat easily	13 (20.97%)
Very easily	36 (58.06%)
Missing	1 (1.61%)
Frequency using a computer each week N (%)
Never	32 (51.61%)
Once/week	8 (12.9%)
2–3 days/week	9 (14.52%)
4–5 days/week	2 (3.23%)
6–7 days/week	11 (17.74%)
Computer access at home N (%)
No	41 (66.13%)
Yes	21 (33.87%)

Limited exposure and access to computers and connectivity may explain the low proficiency in computer usage. Only 54.68% of participants rated their proficiency in computer usage as “very easily” able to accomplish the fundamentals (see Table 1), demonstrating a gap in knowledge among a considerable number of the remaining participants. Limited technology literacy was echoed in participants’ descriptions of their independent work. Participants reported frustration arising from difficulties logging onto computers and CR exercise sites, accessing and navigating the internet, and understanding or remembering steps to do the exercises independently (Medalia et al., 2021). These examples demonstrate how a lack of computer proficiency, on top of existing cognitive impairments for which individuals are seeking treatment, can lead to limitations and setbacks that can affect treatment engagement and efficacy.

Given the prevalence of cognitive impairment in individuals with schizophrenia spectrum disorders, CR is a valued intervention with shown efficacy for improving overall cognition (Lejeune et al., 2021; Vita et al., 2021). The possibility of delivering remote CR has the potential to broaden accessibility to this (and other) behavioral health services, even in a post-pandemic climate. However, the challenges presented in this paper reveal a need to implement strategies to reduce barriers to technology use associated with a lack of knowledge and access. CR participation requires technology, connectivity, and technological proficiency, which are not readily available across socioeconomic groups. Indeed, the sample characteristics and CR experiences reported here greatly contrast with those reported by Lynch et al. (2020) who described successful implementation of remote CR sessions at a private clinic serving participants with a higher SES, in the same metro area (Lynch et al., 2020).

Some educational systems faced with similar disparities in technology access provide students with computer literacy training and 24-hour access to a networked computer (Rauf, 2020). Mental health programs may also want to consider the advantages of funding technology access and literacy initiatives. This would not only facilitate participation in CR but, more broadly, expand access to virtual treatment services.