Relationship of Rurality and Confidence in Video Skills With Persistent Nonuse of Video Appointments for Health Care

Abstract

Introduction

Limited research has examined how technology and digital literacy may affect patients' use of video visits. This study explored the relationship of demographic factors and patient-reported confidence in digital literacy skills to access to video visits among patients who never used them during the COVID-19 pandemic.

Methods

Using existing survey data, the current study examined data from respondents who did not engage in video appointments but instead attended face-to-face appointments between April and December 2020 for nonemergent health concerns. A multivariable logistic regression model was used to investigate whether demographic and social determinants of health factors, context of care (primary care or psychiatry/psychology), and digital literacy confidence were associated with video visit engagement. Collinearity was assessed using the variance inflation factor.

Results

This study found that living in rural areas and having a self-reported lack of confidence in logging video appointments using the Mayo Clinic patient portal were associated with persistent nonuse of video appointments in a cohort of patients who did not use video visits at this institution during the early part of the COVID-19 pandemic.

Discussion

The research findings reported herein reveal that individuals living in rural areas and those who lack confidence in logging into patient portals to access video visits tend to persistently avoid using video appointments. More investment is needed at the federal and corporate levels to improve digital connectivity. Digital navigators and community involvement can promote digital adoption.

Conclusion

To encourage digital competency in rural communities, it is important to implement support strategies through community stakeholders and other resources.

Introduction

Since the COVID-19 pandemic, there has been a surge in the use of remote digital health care services. Video appointments, as opposed to face-to-face (f2f) visits, are a mode of delivery that has potential advantages for patients. For example, those living in rural and remote areas may be able to access specialized health care via video while avoiding the time and expense associated with traveling to a facility.¹ Importantly, evidence shows that video visits provide comparable health care quality to traditional f2f visits for many nonemergent conditions,^1–3 such as management of psychiatric symptoms,^4,5 common primary care diseases, and pain. Even with the option of video visits for nonurgent medical needs, a considerable number of patients still prefer to attend appointments f2f and have yet to engage in telehealth services. Exploring the reasons for this persistent nonuse of video visits, despite attempts to improve digital connectivity, will enable health care institutions to address targeted remedies to support and encourage patients to use video visits for their care when necessary. Promoting facilitators and reducing barriers to digital health care engagement can improve access to needed care and foster greater health equity.

To have a successful experience with a health care–related video visit, individuals must have access to a smart device, such as a computer, mobile phone, or tablet, and to a broadband (BB) internet connection.⁶ Additionally, it is vital to have digital literacy, which refers to skills in using digital technology along with ease and comfort in engaging in digital experiences (video visits in this case).⁷ For example, for an individual to connect to a video appointment with their health care practitioner, they likely need general internet skills such as connecting to BB internet and accessing email to receive a video connection link. Patients also need skills to be able to access their patient messaging system account (commonly known as a patient portal)⁸ to begin video appointments, which requires locating and logging into their institution-specific patient portal.^9,10 Additional video appointment–related skills include locating, navigating, and using the camera on a smart device or computer.

Evidence suggests that social determinants of health (SDOH) such as race, ethnicity, education, and income could impact the choice between f2f and video visits.^11,12 For example, more advanced age, low education, poor digital access (BB internet and smart devices), and personal preferences are associated with lower engagement with video visits.¹³ However, limited research has examined whether and how technology and digital health literacy may impede patients from using video visits. To the authors’ knowledge, research thus far has yet to study digital literacy at a granular level of necessary skills required for a successful experience with a video health care visit and their association with persistent nonuse of video appointments. This study examined demographic factors and patient-reported confidence in digital literacy skills and their impact on video visits in a cohort of patients who never used video visits during the COVID-19 pandemic.

Methods

Setting

Mayo Clinic is a large health system spanning the states of Minnesota, Wisconsin, Iowa, Florida, and Arizona. Its main campuses are in Rochester, MN; Phoenix, AZ; and Jacksonville, FL. Mayo Clinic enterprise also includes other community-based Mayo Clinic Health System (MCHS) clinics and hospitals in Minnesota, Wisconsin, and Iowa. Study approval was obtained from the Mayo Clinic Institutional Review Board (IRB 21-00453).

Study design

Secondary data were obtained from a one-time cross-sectional survey administered to Mayo Clinic and MCHS patients.

Data collection and procedure

The present article reports on data from a broader study examining factors associated with patient engagement in video health care visits. In the larger study, potential Mayo Clinic and MCHS patients who had previously permitted the use of their medical records for research were identified through the electronic health record and mailed an invitation letter to participate. Interested individuals were asked to provide a completed Health Insurance Portability and Accountability form and a one-time paper survey. Mayo Clinic’s Survey Research Center mailed surveys to potential participants in a prelabeled return envelope on July 7, 2022. Reminder letters were sent to nonresponders between August 17, 2022, and August 19, 2022. Phone call reminders were made to nonresponders from October to December 2022. The study was closed for enrollment in January 2023. Survey respondents received a sheet of forever stamps valued at $5 for their study participation. The survey response rate was 11% (321/3000).

Using the existing survey data, the current study examined data from respondents who did not engage in video appointments but did attend f2f appointments from April to December 2020 (during the early stages of the COVID-19 pandemic) for nonemergent health concerns.

Inclusion criteria in the analysis sample of the current study were as follows: 1) individual aged 18 years or older as of April 2020, 2) who is a patient of Mayo Clinic Midwest (Rochester, MN, or MCHS), Mayo Clinic Florida, or Mayo Clinic Arizona, and 3) who attended only f2f appointments and no video appointments for nonemergent outpatient clinical care in primary care, psychiatry, or psychology at a Mayo Clinic or MCHS during the period from April through December 2020. This study focuses on both primary care and psychiatry/psychology because these are settings that patients visit for nonemergent health maintenance monitoring and medical management, which are noninvasive services and include a broad variety of medical and psychiatric conditions, making them suitable for video appointment. Patients not meeting the inclusion criteria were excluded.

Survey instrument and measures

Guided by the results of a qualitative study (described elsewhere)¹⁴ and a scoping literature review, the authors developed the survey items. The paper survey was pretested with the study staff and took approximately 10 to 15 minutes to complete. The self-report survey included 21 items asking patients about their digital access, including BB internet connections (Do you have access to broadband/high-speed internet for personal use?) and smart devices (Do you have access to a device that can connect to the internet [eg, cell phone, computer, tablet {eg, iPad}]?), digital literacy (assessed by asking questions about comfort, confidence, and need for assistance when engaging with technology), use of the patient portal (Mayo Clinic patient messaging system) and video appointments, attitudes and beliefs toward face-to-face as opposed to video appointments, barriers experienced in accessing video appointments, and patient-level demographic and SDOH factors (Supplementary Material S1). Rurality was ascertained from patient zip codes to identify corresponding rural–urban commuting area codes C with 2 rural and urban categories.¹⁵

Eight items assessing confidence in different aspects of digital literacy confidence were assessed on a 4-point scale, with response options including “not at all confident,” “a little confident,” “somewhat confident,” and “very confident” and also including an option for “have never done this task” (indicating that the individual had never engaged in the activity/skill).

Importantly, even though the study population consisted of individuals who had not engaged in a video visit between April and December 2020, by the time the survey was disseminated in 2022, more patients were likely oriented to and made aware of video appointment procedures through self-learning or other education efforts by health care institutions. Thus, the survey item “Have you ever had a video appointment with a health care provider?” with responses “Yes” and “No” was used to categorize participants as either “persistent nonusers of video” (those who responded “No” to the question) or as “ever-video users” (those who responded “Yes” to the question).

Statistical methods

A multivariable logistic regression model was used to investigate whether demographic and SDOH factors (age, gender, race/ethnicity, education, rural/urban residence, marital status), context of care (primary care or psychiatry/psychology), and digital literacy confidence (independent variables) were associated with video visit engagement (dichotomous dependent variable: persistent nonusers and ever-video users). Collinearity was assessed using the variance inflation factor.

In the current analyses, 6 items assessing digital literacy confidence were collapsed into dichotomous variable responses of “confident” (anyone who responded “very confident”) and “not confident” (anyone who responded anything other than “very confident”). Two additional questions assessed digital literacy confidence surrounding use of the patient portal; because of moderate collinearity, these items were ultimately removed to reduce the number of predictors in the final model.

Results

Table 1 reports the demographic information on the total sample (N = 321) and persistent nonusers of video appointments. Respondents were 54% female and 71% White, and the average age was 57.4 ± 16.4 years. This study had a response rate of 11% (321 out of 3000).

Table 1:

Demographic information on the total sample (N = 321) and persistent nonusers of video appointments

Demographic variable	Total (N = 321)	Persistent nonusers of video (n = 160)
Age, y
Mean (SD)	57.44 (16.40)	60.43 (16.85)
Range	18.11–90.01	18.11–90.01
Gender
Woman	172 (53.6%)	77 (48.1%)
Man	149 (46.4%)	83 (51.9%)
Race
Non-White	89 (29.1%)	47 (30.3%)
White	217 (70.9%)	108 (69.7%)
Unknown	15	5
Education
Up to 12th grade	30 (9.3%)	16 (10.0%)
Some college, no degree	22 (6.9%)	9 (5.6%)
Associate’s degree	36 (11.2%)	18 (11.2%)
Bachelor’s or advanced degree	169 (52.6%)	84 (52.5%)
Declined to answer	64 (19.9%)	33 (20.6%)
Marital status
Married	238 (77.0%)	117 (75.0%)
Single, separated, divorced, or widowed	71 (23.0%)	39 (25.0%)
Unknown/declined to answer	12	4
Rural vs urban
Rural	39 (12.1%)	27 (16.9%)
Urban	282 (87.9%)	133 (83.1%)
Portal (online patient messaging system)
No	55 (17.1%)	38 (23.8%)
Yes	266 (82.9%)	122 (76.2%)

SD, standard deviation.

Table 2 presents the multivariable model predicting persistent nonuse of video appointments. The multivariable model indicates that rural residence (odds ratio [OR] = 3.00; 95% confidence interval [CI] = 1.32–7.16, p = 0.010) and not being confident in logging into video appointments using the Mayo Clinic patient portal (OR = 2.88; 95% CI = 1.50–5.67, p = 0.002) were associated with persistent nonuse of video appointments.

Table 2:

Multivariable model predicting persistent nonuse of video appointments.

Variable		95% Confidence Interval
	OR	Lower limit	Upper limit	P value
(Intercept)	0.16	0.04	0.70	0.016
Age	1.01	0.99	1.03	0.256
Gender, man	1.604	0.95	2.68	0.076
Specialty
General internal medicine	0.56	0.09	3.55	0.521
Psychiatry and psychology	0.78	0.08	5.94	0.808
Race, White	0.64	0.36	1.15	0.136
Education
Some college, no degree	1.50	0.39	5.84	0.554
Associate’s degree	1.60	0.49	5.40	0.440
Bachelor’s or advanced degree	2.13	0.80	5.94	0.138
Declined to answer	2.10	0.67	6.74	0.204
Marital status, Single, separated, divorced, or widowed a	1.14	0.58	2.26	0.705
Residence, Rural	3.00	1.32	7.16	0.010 b
Not completely confident locating the camera or webcam on your device	1.96	0.74	5.33	0.177
Not completely confident logging into your video appointment using the Mayo Clinic patient portal	2.88	1.50	5.67	0.002 b
Not completely confident connecting to the internet	3.21	0.86	14.36	0.098
Not completely confident using email	0.56	0.12	2.32	0.434
Not completely confident logging into the Mayo Clinic patient portal	0.39	0.10	1.40	0.150
Not completely confident sending a message to your doctor using the Mayo Clinic patient portal	0.94	0.34	2.66	0.909

^aMarried or living with a partner is designated as the reference group.

^bStatistically significant value.

OR, odds ratio.

Discussion

This study aimed to investigate the association between demographic factors, self-reported confidence in digital literacy–related tasks, and persistent reluctance to use video appointments for nonemergent care. Specifically, the study focused on individuals who did not adjust to the changing digital landscape and abstained from using video appointments at least through 2022 (when the survey was administered). They are referred to herein as “persistent nonusers” of video appointments. This study suggests that living in a rural area and having a self-reported lack of confidence in logging into video appointments using the Mayo Clinic patient portal were associated with persistent nonuse of video appointments in a cohort of patients who did not use video visits at the authors’ institution in the early COVID-19 pandemic.

This study contributes to the existing literature on digital health care indicating that rural patients are more likely than urban patients to persistently avoid video appointments for nonemergent outpatient care. Emerging research since the COVID-19 pandemic has provided information on the barriers to engaging in telemedicine, such as video visits in rural areas. These studies have established that substantial barriers for the rural population include the absence of high-speed BB internet connections, a lack of smartphones or devices, and a general lack of desire to use video visits.^1,16 These findings showcase an interesting disconnect between the objective of providing digital health care access to rural residents and the actual digital connectivity of rural America with larger health care systems.

Correcting the lack of BB internet connections in rural areas requires more substantial investment and infrastructure, which is often not profitable for internet service providers.¹⁷ This creates a large gap in internet services in rural regions. Furthermore, even if BB internet is available, it is often at a deficient speed that is insufficient for video health care appointments. In addition, the rural population has a lower median income than the urban population; thus, the rural residents often forgo acquiring BB internet and smart devices in favor of satisfying critical needs.¹⁸ One possible way to approach this problem is by informing patients and families about public wireless networks and hotspots that can be used for nonemergency video appointments with their health care practitioners. This solution has been well-received by patients, except for those who have to travel long distances to access a public wireless network or hotspot, as traveling to these locations could potentially add another barrier. In addition, patient privacy and confidentiality must remain a priority, which may be more challenging on public wireless networks.¹⁹

Research has shown that some individuals, regardless of their area of residence, prefer f2f appointments over video appointments because of personal reasons.¹⁴ Such preferences may be due to some individuals having greater confidence in engaging in video visits whereas others do not. In this study, confidence, in the context of a video appointment, means confidence in the digital skills required to participate in such an appointment. This study found that a self-reported lack of confidence in logging into video appointments using patient portals was associated with persistent nonuse of video appointments. This finding reflects the idea that, if patients perceive themselves as “not confident” in video logging tasks, they are discouraged from using video appointments. To initiate a health care–related video appointment, the patient must navigate several additional portal-related steps beyond the essential first step of locating and logging into the patient portal. Studies have examined the barriers and facilitators of patient portal use.²⁰ For example, Medicaid patients and those with lower educational attainment, no health insurance, no regular doctor, and lower English proficiency were found to be less likely to access and use specific functions of their patient portals.^21,22 To the authors’ knowledge, no study has examined the patient portal–related tasks associated with video appointments.

Health care institutions typically distribute generic educational material with instructions on how to log into the patient portal and, specifically, how to access a scheduled video visit. However, individuals may not always use them. It is plausible that these instructions are too complex and incomprehensible to individuals who have not used video appointments before. The authors recommend that health care systems engage with local communities and stakeholders, especially patients, to assess the digital literacy and technological competency needs of diverse groups within their community. The health care systems can collaborate with local stakeholders such as policymakers, churches, libraries, and others to organize digital fairs. These fairs can be used to assess the digital skills of the community and provide relevant education. Exploring the use of digital literacy navigators who can support patients in this new digital age may offer another approach to meeting patients where they are regarding digital skills.

This study has several limitations, such as the fact that the study (paper-based survey) experienced a low response rate, which may have led to selection bias, resulting in a study population that does not accurately represent the target population and a set of respondents who differ systematically from nonrespondents. Although the authors attempted to include participants from various backgrounds, the majority of patients in this study were White, resided in urban regions (only 12% of the total sample was rural), and did not report encountering substantial social difficulties. This limits the extent to which the findings reported herein can be generalized. This study’s generalizability may be further limited by the fact that the sample was derived solely from Mayo Clinic patients. Although the authors were unable to assess whether patients sought care outside Mayo Clinic via video visits, the study did enroll paneled patients, who had their primary care practitioners at Mayo Clinic, which reduces the likelihood of video visits being conducted outside of the authors’ health care system. According to FAIR Health,²³ a national database of private and Medicare claims data, only 0.1% of all claims nationally in 2019 were related to telehealth. This percentage was even lower in rural areas. These data suggest that it is highly unlikely for patients with a primary care provider at Mayo Clinic to seek video-based care outside this clinic. It is important to note that FAIR Health data include various telehealth technologies, such as mobile health, remote patient monitoring, and store-and-forward technologies. To gather diverse data, the authors included respondents from both Mayo Clinic Arizona and Mayo Clinic Florida. However, despite receiving more responses from Florida, this study lacked diversity. Research has shown that participation rates vary based on race, with Black and Hispanic populations being the most underrepresented groups.²⁴ Because of the extremely low proportion of other races, all races other than White were combined into a single non-White category. This limited the authors’ ability to study interrace differences in persistent nonusers of video. Future research should investigate how video usage patterns vary among more diverse patient populations. This study may have also experienced recall bias because of its reliance on self-reported data. However, the authors did verify eligibility and the existence of a f2f appointment through the Mayo Clinic’s electronic health record system. This study also had several strengths, including that the sample was drawn from a multistate institution spanning rural and urban settings and that it employed novel confidence-based questions to better understand patients’ digital competence and experience.

Conclusion

This study observed that living in rural areas and lacking confidence in logging into patient portals to access a video visit was associated with persistent nonuse of video appointments in a cohort of patients who did not use video visits at the authors’ institution in the early part of the COVID-19 pandemic. More substantial federal- and corporate-level investment is needed to improve digital connectivity for patients residing in these areas. In addition, digital access and skills should be encouraged through health care and community-wide stakeholder partnerships.

Supplementary Material

online supplementary file 1