Rural Older Adults Research Articles

RURAL SYSTEM-BASED COPING STRATEGIES FOR ADVANCING RESEARCH AND HEALTHCARE WHILE TRANSITIONING TO THE NEW NORMAL

Abstract The pandemic brought about many changes at a system level that were necessary to facilitate continuity of research and the practice of healthcare. Rural and underserved populations were and continue to be the hardest to reach both before and during the COVID-19 pandemic. Therefore, the innovative coping strategies that were implemented during the pandemic are essential to continue as we transition into the endemic stage and realize our new normal as researchers and practitioners. This symposium will highlight adaptations made to research and practice during the COVID-19 pandemic that will apply to future system-level strategies. Drs. Wiese and Park will present results from an online exercise intervention for rural older adults that are at risk of cognitive decline. Drs. Ilardo and Zell will present a roadmap inspired by the pandemic to promote food equity. Drs. Zell and Haque will address rural solutions to polypharmacy issues using an interdisciplinary team approach. Dr. Monaghan-Geernaert will discuss important implications that international caregivers have in fulfilling caregiving gaps in the US, followed by Dr. Freeman et al.’s discussion of rural, long-term care facilities (LTCF) experiences during the pandemic. These system-based coping strategies have policy implications for rural healthcare as we transition to the new normal.

BUILDING COMMUNITY-BASED PARTNERSHIPS TO PROMOTE DIVERSE, INTERGENERATIONAL SERVICE-LEARNING OPPORTUNITIES

Abstract The next generation of healthcare providers require experiential learning opportunities which incorporate participation from historically marginalized, diverse populations. A longstanding interprofessional gerontology service-learning program with a measured ability to positively influence student perspectives working with older adults while reducing rates of social isolation among older participants, underwent recent changes in the recruitment of older adults to ensure increased participation from historically marginalized populations. Building partnerships with community-based organizations serving BIPOC, LGBTQ+, and rural older adults played an integral role in building a more diverse participant group for shared, intergenerational learning. Opportunities for student reflection via group debriefs and individual, written reflections promote a greater understanding and preparedness to work with diverse older adult populations.

Factors associated with quality of life, depressive symptoms, and perceived stress among rural older adults living with HIV in the United States.

Rural older people living with HIV (PLH) in the United States are a population of growing size and significance. A better understanding of factors associated with quality of life (QOL), depressive symptoms, and stress in this population-especially modifiable factors-could inform future interventions. Online or on paper, we surveyed 446 PLH aged 50+ residing in rural counties across the United States (Mage = 56, 67% male, 67% White, and 23% Black). Associations between social support, HIV stigma, satisfaction with medical care, discrimination in health care settings, and structural barriers and health-related QOL, depressive symptoms, and perceived stress were assessed using multiple linear regressions. Controlling for demographics, greater social support was associated with better QOL, fewer depressive symptoms, and less stress. Greater HIV stigma was associated with more depressive symptoms and stress. Satisfaction with care was associated with better QOL and less stress. Discrimination in medical settings was associated with lower QOL and more depressive symptoms and stress. Finally, experiencing more structural barriers was associated with lower QOL and more depressive symptoms and stress. In addition to engagement in care and viral suppression, QOL and mental health are also critical considerations for rural older PLH. Increasing social support, reducing or providing skills to cope with HIV stigma, improving quality of care, reducing discrimination and stigma in medical settings, and reducing or mitigating the impact of structural barriers present potential targets for interventions aiming to improve the well-being of older rural PLH.

Internet access, support, usage divides, and depressive symptoms among older adults in China: A nationally representative cross-sectional study

ObjectiveThis study examines the associations between multiple sub-dimensions of the digital divide, including Internet access, support, usage divides, and depressive symptoms among older adults as well as the potential moderating effects of rural/urban status on these associations in China. MethodsData were obtained from the 2018 China Longitudinal Aging Social Survey, which provided a nationally representative sample of 11,418 participants aged 60 years and older. Multivariate linear regression models were used to analyze the associations between digital divide and depressive symptoms. The moderating role of rural/urban status was tested based on the interaction terms. ResultsAfter controlling for the covariates, access to Internet devices, support for Internet use from family, and using the Internet for communication, entertainment, or as instruments, were found to be significantly associated with a lower level of depressive symptoms (P < 0.05), and compared with no access to the Internet, accessing and using the Internet was significantly related to decreased depressive risks (P < 0.001), whereas access to the Internet with non-use was not statistically significant. Additionally, the associations between multidimensional aspects of the digital divide and depressive symptoms were moderated by rural/urban status, with these associations being significantly stronger among rural older adults (P < 0.05). ConclusionsThis study highlights the importance of assessing the associations between digital divide and depressive symptoms from the multidimensional perspectives of access, support, and usage. Policy interventions targeting various aspects of the digital divide should be implemented to ensure active Internet engagement among older adults, especially those living in rural areas.

Association of unmet long-term care needs with depression and anxiety among older adults in urban and rural China

This study examined the association of unmet long-term care (LTC) needs with depression and anxiety in older adults and explored urban-rural disparities. Cross-sectional data for 1896 respondents with a mean age of 91.58 years was from the 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS). Depression and anxiety were assessed using the 10-item Center for Epidemiological Studies Depression Scale (CESD-10) and the 7-item Generalized Anxiety Disorder Scale (GAD-7), respectively. Unmet LTC needs were self-reported by older adults with functional limitations. Research methods included regression analyses, decomposition analyses, sensitivity analyses. Results showed that unmet LTC needs, depression, anxiety were more severe in rural older adults. Unmet LTC needs were significantly and positively related to depression and anxiety, but their associations with CESD-10 scores, depressive and anxiety symptoms were stronger in urban older adults. Urban-rural disparities in unmet LTC needs explained about 20%-40% of disparities in depression and anxiety. The findings highlighted the role of meeting LTC needs in reducing depression and anxiety, and that LTC policymakers should not ignore the needs of urban older adults and focus solely on rural older adults.

Cognitive outcome measures used for assessing urban and rural disparities in dementia and cognition: A scoping review

AbstractBackgroundEvidence of disparities in dementia and cognition by gender, race/ethnicity, and income‐level of countries has long been available. A growing body of literature examining urban/rural disparities has been recently accumulating. Most of the studies comparing within‐country regions indicate that rural older adults have a greater cognitive disadvantage and higher risk for dementia than their urban counterparts. These findings are not consistent across all studies. The purpose of this study was to examine the literature on rural/urban disparities in dementia and cognitive aging.MethodA scoping review of 16 studies examining differences in dementia and cognitive functioning of urban and rural older adults was conducted. Studies were categorized by country. Relevant information from their methods was systematized, based on their populations/samples, outcome measures and main finding of cognitive advantage (rural&lt;urban, urban&gt;rural, rural = urban).ResultMost of the studies addressing rural and urban disparities have been conducted in large, industrialized countries. The main focus of the studies reviewed has been on comparing dementia rates, not healthy aging. Most studies have administered cognitive screening questionnaires to identify dementia cases (MMSE, Modified MMSE, Telephone Interview for Cognitive Status, CSI‐D, etc.). The criteria used to define rurality and urbanity varied from study to study.ConclusionRegions of the world with larger rural areas are underrepresented in the study of rural and urban disparities of dementia and cognitive aging. From the group of studies reviewed, important conceptual and methodological lessons were identified. The variability in the operational definition of rurality between studies is a major challenge for consolidating the literature on urban and rural disparities in dementia and cognitive aging. A culturally appropriate neuropsychological battery could be used to identify true urban and rural disparities in cognitive functioning. None of the studies examined whether the assessment tools and cognitive factors were comparable for both rural and urban older adults, assuming the tests are equivalent across regions. Research focusing on the measurement equivalence of neuropsychological batteries between rural and urban regions are warranted.

Examining the Moderating Roles of Social Isolation and Social Technology Use in Health Disparities of Cognitive Impairment

AbstractBackgroundThere are profound racial disparities in cognitive impairment and dementia. Black and rural older adults are nearly twice as likely to develop dementia compared to White and urban‐dwelling older adults, respectively. However, the way social factors affect these racial and rural‐urban disparities in dementia prevalence remains poorly understood. Social isolation is associated with poorer cognitive outcomes among older adults, yet social technology use may provide a means to reduce social isolation. This research examines how two social factors—social isolation and social technology use influence racial and rural disparities in cognitive impairment and dementia.MethodData was extracted from the 2014 to 2018 waves of the Health and Retirement Study (N = 5,358). Participants (aged 50‐102) completed survey measures of social isolation, loneliness, and frequency of online social communication (e.g., use of Facebook, Skype). The modified Telephone Interview for Cognitive Status was used to operationalize dementia. The validated TICS classification system was used to classify scores with a cognitive status of dementia (scores ≤6), cognitive impairment (score of 7‐11), or cognitively normal (scores ≥12). Data was analyzed using structural equation models.ResultAcross all groups, frequency of social technology use moderated the negative relationship between social isolation and cognitive impairment, controlling for age, education, gender, wealth, and general computer usage. More frequent social technology use was associated with cognitively normal status among older adults who reported greater degrees of social isolation. In terms of health disparities, the results revealed racial, but not rural‐urban, differences in the relationship between frequency of social technology use and cognitive status. Frequent social technology use was associated with improved cognitive status in Black American older adults but not White older adults, irrespective of their level of social isolation.ConclusionSocial technology may offer a means to mitigate cognitive decline; the potential benefit of such technology may be particularly promising among Black older adults.

The Effectiveness of the Otago Exercise Program on Fall Prevention in Rural-Dwelling Older Adults

<h3>Research Objectives</h3> To develop a sustainable, outcomes-based fall prevention program for rural Michigan older adults using the evidence-based Otago Exercise protocol in collaboration with community-based agencies serving older adults. <h3>Design</h3> Rural dwelling older adults have a higher prevalence of falls compared to non-rural older adults. In Michigan, Over 26% of older adults live in rural communities. Additionally, Isabella, Clare, and Gratiot counties are designated as medically underserved. Otago Exercise protocol is implemented to provide free fall prevention education resources to reduce falls and promote independence. Participants are screened before beginning the exercise protocol and complete balance assessments at baseline, three, six, nine, and twelve months to assess strength and balance as an outcome. <h3>Setting</h3> Classes are instructed by exercise trainers virtually via Zoom and at sites across Isabella, Clare, and Gratiot counties. <h3>Participants</h3> Criterion for inclusion are age 60 years or older, low to moderate assessed fall risk and living independently in the community. There are 68 participants enrolled in the program. <h3>Interventions</h3> Evidence-based Otago Exercise Program that incorporates seventeen strength and balance exercises over a year. <h3>Main Outcome Measures</h3> The primary outcome measurement is the comparison of baseline balance assessment to progression throughout the program. Score averages of the participants' peer group are utilized to analyze results. Below average scores indicate increased fall risk. <h3>Results</h3> Assessment of the Otago protocol utilizes the three-step balance assessment consisting of the Chair Stand Test, Four-Stage Balance Test, and Timed Up-and-Go. After six months of the program, average improvement of about 29.40% in the Four-Stage Balance Test, 2.40% in the Timed Up-and-Go test, and 20.30% in the Chair Stand test has been shown. <h3>Conclusions</h3> Results from participants who have completed six months within the program show improvement on balance assessment scores. It can be concluded that compliance with the Otago Exercise Program results in increased balance in participants and overall decreased fall risk. <h3>Author(s) Disclosures</h3> This program received funding from Region VII Area Agency on Aging. Institutional IRB provided a determination of "not research". We are declaring no conflicts of interest.

Tooth Loss, Cognitive Impairment and Fall Risk: A Cross-Sectional Study of Older Adults in Rural Thailand.

Tooth loss is associated with both cognitive impairment and fall risk. However, the relationships between these variables are complex and bidirectional. Observed associations have been reported in separate studies but data on rural-dwelling older adults remain sparse. This cross-sectional study investigated socioeconomic and dental factors affecting cognitive functions, and the association between tooth loss, cognitive functioning, and fall risk. Two hundred and thirty-one rural-dwelling older adults (60−74 years old) were recruited from a single Dental Service Unit. Cognitive function and fall risk were assessed with the Mini-Mental State Examination and the Morse Fall Scale, respectively. Oral examinations were performed by a dentist using the Community Periodontal Index of Treatment Needs form. 38.1%, had >16 tooth loss. Socioeconomic data and health status were obtained from a questionnaire and interviews. Age, Activities of Daily Living (ADL) score, and the number of teeth lost was significantly associated with impaired cognitive function. Chi-square analysis showed that cognitive function was also associated with fall risk. Past research suggests that much cognitive impairment and fall risk is induced by tooth loss. Service planners need to be aware of the complex bidirectional relationships between these variables and give higher priority to dental services that can improve the general health status and social functioning of older rural adults.

The Interactions of Food Security, Health, and Loneliness among Rural Older Adults before and after the Onset of COVID-19

Older adults and those living in rural areas face unique challenges to health and food security which were exacerbated during the COVID-19 pandemic. We examine the interrelationships among food security, physical health, and loneliness among rural older adults before the onset of and during the COVID-19 pandemic. Using data from a cross-sectional household survey of older adults in rural Indiana, administered May 2020 through July 2020, our results show a higher prevalence of food insecurity, poorer physical health, and increased loneliness after the onset of the pandemic. Path analyses confirmed the interrelationship between food security, health, and the absence of loneliness before and after the onset of COVID-19. Loneliness emerged as a major pathway through which the pandemic impacted quality of life, particularly affecting older women and physical health. Policy initiatives should consider the unique experiences and challenges associated with rural life among older adults and create food security initiatives that incorporate socialization while also considering the challenges associated with poor physical health in older age. Furthermore, our analysis shows that those who are vulnerable to food security, poor health, and loneliness in the absence of a global pandemic remain vulnerable during a pandemic.

Complexity of Transferred Geriatric Adults Requiring Emergency General Surgery: A Rural Tertiary Center Experience

IntroductionAs the American population ages, the number of geriatric adults requiring emergency general surgery (EGS) care is increasing. EGS regionalization could significantly affect the pattern of care for rural older adults. The aim of this study was to determine the current pattern of care for geriatric EGS patients at our rural academic center, with a focus on transfer status. Materials and methodsWe performed a retrospective chart review of patients aged ≥65 undergoing EGS procedures within 48 h of admission from 2014 to 2019 at our rural academic medical center. We collected demographic, admission, operative, and outcomes data. The primary outcomes of interest were mortality and nonhome discharge. Univariate and multivariate analyses were performed. ResultsOver the 5-y study period, 674 patients underwent EGS procedures, with 407 (60%) transferred to our facility. Transfer patients (TPs) had higher American Society of Anesthesiology (ASA) scores (P < 0.001), higher rates of open abdomen (13% versus 5.6%, P = 0.001), and multiple operations (24 versus 11%, P < 0.001) than direct admit patients. However, after adjustment there was no difference in mortality (OR 1.64; 95% CI, 0.82-3.38) or nonhome discharge (OR 1.49; 95% CI, 0.95-2.36). ConclusionsAt our institution, the majority of rural geriatric EGS patients were transferred from another hospital for care. These patients had higher medical and operative complexity than patients presenting directly to our facility for care. After adjustment, transfer status was not independently associated with in-hospital mortality or nonhome discharge. These patients were appropriately transferred given their level of complexity.

Impact of aging on food consumption in rural China: Implications for dietary upgrading and health improvement.

The issue of population aging in rural China is getting profound; nevertheless, its impact on food consumption has not been well evaluated. This study aims to examine the relationship between rural aging and family food consumption in rural China. Using the statistical yearbook data and the nationally representative household-level data from the China Rural Fixed Observation Points, this study compares the evolution of food consumption between rural and urban residents from 1985 to 2020 and analyzes the structure of food consumption expenditure of rural residents. Next, this study further investigates the impact of aging on food consumption in rural households with ordinary least squares. (1) The principal foods consumed by rural residents in 2020 are meat and meat products (36.8%), grain (24.5%), and vegetables (10.9%). (2) An increase in older adults has decreased the absolute consumption of all foods, while it increased relative consumption of meat and meat products, aquatic products, edible oil and fats, poultry, eggs, and sugar. (3) Due to differences in the structure of young adults' food consumption, older adults would increase their consumption of fruits and vegetables if they lived with younger adults. The findings of this study suggest that rural older adults may increase their consumption of fruits and vegetables by advocating intergenerational cohabitation while maintaining their intake of protein to achieve a balanced dietary structure and improve their health condition.

Effect of the Use of Home and Community Care Services on the Multidimensional Health of Older Adults.

Home and community care is an important way to actively respond to population aging and to promote healthy aging. This study aims to estimate the effect of using home and community care services on the multidimensional health of older adults. We used data from the China Health and Retirement Longitudinal Study conducted in 2018 and relied mainly on the propensity score matching method for data analysis. The results showed that using home and community care increased the probability of maintaining and improving physical health by 2.9%, decreased the score of depression by 0.471, and improved the score of cognitive function by 0.704. Using home and community care also increased the probability of actively participating in life by 4.1% and elevated the score of life satisfaction by 0.088. The heterogeneity analysis showed that the use of home and community care had a significant effect on promoting all health indicators in rural older adults and a more obvious promoting effect on the social adaptation of urban older adults. Using home and community care significantly promoted the multidimensional health of people aged 60 to 79 years but had no impact among people aged ≥ 80 years. The use of home and community care significantly improved all health indicators in non-disabled older adults. Whereas, it only improved the levels of cognitive function and life satisfaction in disabled older people. Using this form of care significantly improved all health indicators in those with low socio-economic status, but it only had a partial positive effect on the multidimensional health of those with high socio-economic status. Our results are of importance to the government as they may be used to further improve the quality of home and community care services for the targeted older population.

New Dimension on Quality of Life Differences among Older Adults: A Comparative Analysis of Digital Consumption in Urban and Rural Areas of China.

The purpose of this study was to compare the variability in quality of life in the area of digital consumption among older adults in urban and rural China during the COVID-19 pandemic. This study proposed a low-cost mixed research method, and the methodology used a quantitative study of a large regional sample combined with a qualitative study of a small regional sample. Data for the large-scale area sample were obtained from the China family panel study (CFPS) dataset, and data for the small-scale regional sample were obtained from Nanjing, China. The quantitative analysis of the large-scale regional sample used the least squares regression analysis (OSL) and propensity score matching (PSM). The qualitative analysis of the small-scale regional sample used the selection optimization and compensation (SOC) model. The findings show that economic income is a direct driver of digital consumption. Digital consumption had a significant positive relationship with the quality of life for urban and rural older adults. In addition, the study established the semantic network relationships of the coping strategies of digital consumption of older adults and their drivers. Finally, the theoretical and practical implications of these findings are discussed in the context of other related studies.

Probabilistic linguistic fuzzy cognitive maps: applications to the critical factors affecting the health of rural older adults

BackgroundAchieving healthy ageing has become the only way for China to alleviate the pressure of ageing, especially in rural areas. However, the factors affecting the health of rural older adults are numerous and complex. It is important to identify the critical factors that affecting the health of older adults in rural areas and provide decision-making support for targeted health interventions.MethodsTo overcome some limitations of existing works, an extended probabilistic linguistic fuzzy cognitive map model is proposed in this paper as a useful tool for modeling the cause-effect relationship between factors. The proposed model integrates the advantages of probabilistic linguistic term sets and fuzzy cognitive maps. In the end, to rank and identify the critical factors affecting the health, a novel similarity measure based on Euclidean distance and Z-mapping function is proposed.ResultsThe proposed model can effectively deal with the uncertainty of experts and reflect different opinions of groups well. In terms of representing uncertainty and ambiguity, the proposed method outperforms other models in modeling complex systems. In the real-world case analysis, we find that education is the most important factor affecting the health of rural older adults, followed by previous occupational experiences, psychology, and physical exercise, among other things. Intergenerational relationship has become another important factor affecting the health of rural older adults in China as the development of Chinese society.ConclusionsFrom a macro perspective, social economic status, living environment, lifestyle, and health management, are the variables that have the greatest impact on the health of rural older adults. As a result, providing more precise health interventions with the characteristics of factors influencing health is a crucial guarantee for preserving and improving the health of rural older adults in China.

Regional Difference in the Effect of Food Accessibility and Affordability on Vegetable and Fruit Acquisition and Healthy Eating Behaviors for Older Adults.

The food environment has been determined to affect a range of healthy eating and health indicators, but the study on the regional difference of food environment effects on these outcomes is limited. This study aimed to examine whether food environment factors influence vegetable and fruit acquisition and healthy eating behaviors in urban and rural areas using a nationwide dataset. The study participants were community-dwelling older adults aged 65 years and older (n = 830) who participated in the 2019 Consumer Behavior Survey for Food provided by the Korea Rural Economic Institute. Food environment factors were assessed using questionnaires measuring perceived food accessibility and affordability. The negative perceptions of food environment were related to lower vegetable and fruit acquisitions and poor healthy eating behaviors. The higher risks of low vegetable and fruit acquisitions in older rural adults were related to a negative perception of food accessibility only (odds ratio [OR]: 2.34, 95% confidence interval [CI]: 1.27-4.32 for vegetable; OR: 1.96, 95% CI: 1.02-3.75 for fruit). For older urban adults, negative perceptions of both food accessibility and food affordability were related to the increased risk of low vegetable acquisition (OR: 2.03, 95% CI: 1.07-3.83 for food accessibility; OR: 2.52, 95% CI: 1.26-5.04 for food affordability). In terms of healthy eating behaviors, for those who perceived that either food accessibility or affordability was poor, older urban adults were less likely to have various and healthy food eating behaviors when they had a negative perception of affordability (OR: 0.47, 95% CI: 0.25-0.90 for variety; OR: 0.23, 95% CI: 0.11-0.46 for eating healthy foods); however, older rural adults were less likely to have the behaviors when they had a negative perception of accessibility (OR: 0.49, 95% CI: 0.21-0.97 for variety; OR: 0.28, 95% CI: 0.13-0.63 for eating healthy foods). In conclusion, the negative perceptions of food accessibility and affordability were related to low vegetable acquisition and poor healthy eating behaviors. The effects of food accessibility and affordability on vegetable and fruit acquisitions and healthy eating behaviors were different between urban and rural areas.

Aging in Rural Communities.

Population aging is occurring worldwide, particularly in developed countries such as the United States (US). However, in the US, the population is aging more rapidly in rural areas than in urban areas. Healthy aging in rural areas presents unique challenges. Understanding and addressing those challenges is essential to ensure healthy aging and promote health equity across the lifespan and all geographies. This review aims to present findings and evaluate recent literature (2019-2022) on rural aging and highlight future directions and opportunities to improve population health in rural communities. The review first addresses several methodological considerations in measuring rurality, including the choice of measure used, the composition of each measure, and the limitations and drawbacks of each measure. Next, the review considers important concepts and context when describing what it means to be rural, including social, cultural, economic, and environmental conditions. The review assesses several key epidemiologic studies addressing rural-urban differences in population health among older adults. Health and social services in rural areas are then discussed in the context of healthy aging in rural areas. Racial and ethnic minorities, indigenous peoples, and informal caregivers are considered as special populations in the discussion of rural older adults and healthy aging. Lastly, the review provides evidence to support critical longitudinal, place-based research to promote healthy aging across the rural-urban divide is highlighted. Policies, programs, and interventions to reduce rural-urban differences in population health and to promote health equity and healthy aging necessitate a context-specific approach. Considering the cultural context and root causes of rural-urban differences in population health and healthy aging is essential to support the real-world effectiveness of such programs, policies, and interventions.

Impact of higher payments for rural home health episodes on rehospitalizations.

Home health agencies delivering care in rural counties face unique challenges when providing care to older adults; long travel times between each visit can limit the number of patients seen each day. In 2010, Medicare began paying home health (HH) providers 3% more to serve rural beneficiaries without evaluating the policy's impact on patient outcomes. Using 100% Medicare data on postacute HH episodes from 2007 to 2014, we estimated the impact of higher payments on beneficiaries outcomes using difference-in-differences analysis, comparing rehospitalizations between rural and urban postacute HH episodes before and after 2010. Our sample included 5.6 million postacute HH episodes (18% rural). In the preperiod, the 30- and 60-day rehospitalization rates for urban HH episodes were 11.30% and 18.23% compared to 11.38% and 18.39% for rural HH episodes. After 2010, 30- and 60-day rehospitalization rates declined, 10.08% and 16.49% for urban HH episodes and 9.87% and 16.08% for rural HH episodes, respectively. The difference-in-difference estimate was 0.29 percentage points (P = .005) and 0.57 percentage points (P < .001) for 30- and 60-day rehospitalization, respectively. Increasing payments resulted in a statistically significant reduction in rehospitalizations for rural postacute HH episodes. The add-on payment is set to sunset in 2022 and its impact on access and quality to HH for rural older adults should be reconsidered.

Enabling Rural Telehealth for Older Adults in Underserved Rural Communities: Focus Group Study

Telehealth is often suggested to improve access to health care and has had significant publicity worldwide during the COVID-19 pandemic. However, limited studies have examined the telehealth needs of underserved populations such as rural communities. This study aims to investigate enablers for telehealth use in underserved rural populations to improve access to health care for rural older adults. In total, 7 focus group discussions and 13 individual interviews were held across 4 diverse underserved rural communities. A total of 98 adults aged ≥55 years participated. The participants were asked whether they had used telehealth, how they saw their community's health service needs evolving, how telehealth might help provide these services, and how they perceived barriers to and enablers of telehealth for older adults in rural communities. Focus group transcripts were thematically analyzed. The term telehealth was not initially understood by many participants and required an explanation. Those who had used telehealth reported positive experiences (time and cost savings) and were likely to use telehealth again. A total of 2 main themes were identified through an equity lens. The first theme was trust, with 3 subthemes-trust in the telehealth technology, trust in the user (consumer and health provider), and trust in the health system. Having access to reliable and affordable internet connectivity and digital devices was a key enabler for telehealth use. Most rural areas had intermittent and unreliable internet connectivity. Another key enabler is easy access to user support. Trust in the health system focused on waiting times, lack of and/or delayed communication and coordination, and cost. The second theme was choice, with 3 subthemes-health service access, consultation type, and telehealth deployment. Access to health services through telehealth needs to be culturally appropriate and enable access to currently limited or absent services such as mental health and specialist services. Accessing specialist care through telehealth was extremely popular, although some participants preferred to be seen in person. A major enabler for telehealth was telehealth deployment by a fixed community hub or on a mobile bus, with support available, particularly when combined with non-health-related services such as internet banking. Overall, participants were keen on the idea of telehealth. Several barriers and enablers were identified, particularly trust and choice. The term telehealth is not well understood. The unreliable and expensive connectivity options available to rural communities have limited telehealth experience to phone or patient portal use for those with connectivity. Having the opportunity to try telehealth, particularly by using video, would increase the understanding and acceptance of telehealth. This study highlights that local rural communities need to be involved in designing telehealth services within their communities.

Protective and high-risk social activities associated with homebound status among older adults in rural Japan

Becoming homebound can be devastating for older adults in rural communities. This study aimed to identify protective or high-risk social activities associated with homebound status among the rural young old (ages 65–74) and the oldest old (ages ≥ 75). We used data from a survey of older adults in a rural community of Japan in 2014. Questions covered sociodemographic characteristics, homebound status (i.e., going out less than once a week), physical and psychological status, and social activities. Using survey data, we conducted logistic regression analysis to identify protective and high-risk social activities associated with homebound status. Of the 1,564 participants, 51.0 % were the oldest old, and the mean age was 75.2 (±7.0) years. The prevalence of homebound status was 10.5 % total: 5.2 % among the young old and 15.7 % among the oldest old and highest among the female oldest old (19.4 %). The main protective social activity for the young and the oldest old was visiting friends’ houses (adjusted odds ratio [AOR] 5.38, 95 % confidence interval [CI] 1.64–17.64 and AOR 3.49, 95 % CI 1.07–11.42, respectively). For the young old, specific high-risk social activities were advising family and friends (AOR 0.07, 95 % CI 0.01–0.62) and activities to support older adults (AOR 0.17, 95 % CI 0.03–0.84). For the oldest old, a protective social activity was participating in long-term care prevention programs (AOR 28.94, 95 % CI 1.90–441.63). To prevent rural older adults from becoming homebound, support should be provided according to protective and high-risk social activities for age groups, with particular attention to safe socialization amid the threat of COVID-19.