Reaching the Unreached: Unmet Needs and the Promise of Telehealth Among People with Mobility Disabilities in Low-Resource Areas in Alabama

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

• Manuscript ID: disabilities-4185820 
• Type: Article 
• Title: Reaching the Unreached: Unmet Needs and the Promise of Telehealth Among People with Disabilities in Low Resource Areas in Alabama 

Thank you for the invitation to review the article, “Reaching the Unreached: Unmet Needs and the Promise of Telehealth Among People with Disabilities in Low Resource Areas in Alabama.” I have reviewed the manuscript indicated as v2.  

I enjoyed reading the paper. This is very important work and an often-overlooked area. I believe the article can make a meaningful contribution toward addressing the gaps in telehealth access for people with disabilities in underserved communities through lived experiences (as you mention in line 66). Generating knowledge on lived experiences can better inform the health care community to create truly accessible telehealth for people with disabilities, but I believe some revisions are necessary for the purposes of clarity and next steps. 

The title and discussion refer broadly to ‘people with disabilities’; however, the sample seems to be limited to adults with mobility disabilities. Since hearing, visual, and cognitive also fall under the disability umbrella, you might consider reframing the title and purpose statements in the paper, including acknowledging this as a limitation. 

Section 2.1 and 2.2: I have a question related to the design of this study, particularly with the participants. On line 84, I see that participants self-reported a disability and had to live in an under resourced area, but were: 1) participants screened for any prior telehealth use? If so, what telehealth modality? Video-enabled? Audio-only?  2) Was past telehealth experience an inclusion or exclusion criteria? 3) Did the authors collect baseline data on participants’ familiarity or prior use of telehealth? ... I believe it is important to include clarity on whether participants were telehealth naive or had prior telehealth exposure, as it may affect interpretation of findings, reflecting hypothetical attitudes rather than informed experience, which should be acknowledged as a limitation; and after reviewing the discussion, I am still unclear. If the authors did collect this data, it could be reported in Table 1 to provide helpful context for interpreting participant responses. 

Recommend moving line 97 up to after the sentence ending on line 86 earlier as it answers my question about what qualifies as a disability for your study.  

Can you consider including the 9-item survey you used to conduct the interview? I feel the survey inclusion would enrich the paper and provide helpful context. 

Line 112 – accessibility as in access or usability? These terminologies are different, and since disability is a core item of the paper, clarity (differentiation) is important here. 

The paper’s framing suggests limited in-person access to care (for example, representative quotes that you included in theme 5), but did you have a standard question(s) as part of your 9 item survey that elicited this information that you could include in a table (or Table 1); this might be helpful in interpreting the participant’s openness to telehealth? 

The thematic analysis is interesting. The discussion would benefit from more explicit recommendations stemming directly from participant's lived experiences. For example, what recommendations do the authors have after conducting the study for: 

1. Policy makersregarding funding, infrastructure, or telehealth reimbursement for low-resource areas? Since the voices of the participants mentioned costs, I think consideration for reimbursement (and perhaps types) for telehealth services needs be included in your recommendations. 
2. Health care providers on how to better serve patients with mobility disabilities in underserved communities? As someone who provides telehealth services, there are specific modifications that I can (and legally must) implement to make telehealth more accessible (for people with cognitive, mobility, hearing, and/or visual disabilities), but the questions I’m left with after reading your paper is...how would I take the specific accessibility modifications that I currently apply and then also apply your findings to low resourced areas to improve the priorities identified by the study for patients with disabilities?  
3. Community organizations who can help bridge gaps in food access, mental health, and transportation identified by participants. 

Section 4.5 draws heavily from the literature to suggest telehealth as a solution. The unique value of what you have done in this study is draw the voices of the participants themselves. I love that you have considered the voices of people with disabilities in economically distressed communities and making them heard; however, I’m missing those next steps as action items to conduct more research or to make practice changes. I agree with you that more research is needed to ID real solutions that make real-world changes, but as written these implications feel very broad. You say, “Considering that low-resource communities are often unsafe, remote services and use of mobile phones for getting on the internet could be a viable solution for addressing needs xxx”, yes, but what are those next steps get started in an economically disadvantaged area? You might mention: Device loan programs? Public access kiosks? Affordable Connectivity Programs? Flexible communication (for example, audio-only telehealth within state-specific permissibility), Federal resources (Telehealth Resource Centers), Local Partnerships? Community Health Workers? Since your abstract specifically notes that “poor awareness of available resources xxx”, it would address the “foundational needs for advancing health equity” as you note. 

A revision to include participant-informed recommendations may increase the practical impact of this great work. Thank you again for allowing me to read your paper and offer recommendations for improvement. 

Author Response

The title and discussion refer broadly to ‘people with disabilities’; however, the sample seems to be limited to adults with mobility disabilities. Since hearing, visual, and cognitive also fall under the disability umbrella, you might consider reframing the title and purpose statements in the paper, including acknowledging this as a limitation. 

AUTHOR RESPONSE: Thank you for your review and comments. As advised, we have added “Mobility Disabilities” within the title, purpose, and noted limitations.

Section 2.1 and 2.2: I have a question related to the design of this study, particularly with the participants. On line 84, I see that participants self-reported a disability and had to live in an under resourced area, but were: 1) participants screened for any prior telehealth use? If so, what telehealth modality? Video-enabled? Audio-only?  2) Was past telehealth experience an inclusion or exclusion criteria? 3) Did the authors collect baseline data on participants’ familiarity or prior use of telehealth? ... I believe it is important to include clarity on whether participants were telehealth naive or had prior telehealth exposure, as it may affect interpretation of findings, reflecting hypothetical attitudes rather than informed experience, which should be acknowledged as a limitation; and after reviewing the discussion, I am still unclear. If the authors did collect this data, it could be reported in Table 1 to provide helpful context for interpreting participant responses. 

AUTHOR RESPONSE: This is a great suggestion and point. We did not collect this information, thus, it is unclear whether their perspective is purely hypothetical or not. This was a difficult population to reach, which influenced us to keep the burden of the study low.

Recommend moving line 97 up to after the sentence ending on line 86 earlier as it answers my question about what qualifies as a disability for your study.

AUTHOR RESPONSE: Changed as suggested.  

Can you consider including the 9-item survey you used to conduct the interview? I feel the survey inclusion would enrich the paper and provide helpful context. 

AUTHOR RESPONSE: The questions were fully described in section 2.2 procedures. We added further detail and clarification to this section, with specification of the question #. With the icebreaker question, the total questions was actually 10, and we have made this change in the paper.

Line 112 – accessibility as in access or usability? These terminologies are different, and since disability is a core item of the paper, clarity (differentiation) is important here.

AUTHOR RESPONSE: During the interview, we intentionally did not define what access was for the participants (unless asked), to allow them to interpret the term according to their own lived experience. We have added this to section 2.2 for question #7.

The paper’s framing suggests limited in-person access to care (for example, representative quotes that you included in theme 5), but did you have a standard question(s) as part of your 9 item survey that elicited this information that you could include in a table (or Table 1); this might be helpful in interpreting the participant’s openness to telehealth? 

AUTHOR RESPONSE: We thank the reviewer for this observation. None of the interview questions directly asked participants about barriers to in-person care. Responses reflecting limited in-person access emerged organically through probing follow-up questions, particularly in response to questions 3, 4, 6, and 7. We have embellished section 2.2, which should help in providing context.

The thematic analysis is interesting. The discussion would benefit from more explicit recommendations stemming directly from participant's lived experiences. For example, what recommendations do the authors have after conducting the study for: 

1. Policy makersregarding funding, infrastructure, or telehealth reimbursement for low-resource areas? Since the voices of the participants mentioned costs, I think consideration for reimbursement (and perhaps types) for telehealth services needs be included in your recommendations. 

AUTHOR RESPONSE: An excellent suggestion. We have added two sentences to section 4.5: Policy efforts should also prioritize expanding telehealth reimbursement for mental health and supportive care services in low-resource communities, as cost was a consistent barrier to accessing care among participants. Without reimbursement structures that account for the financial constraints faced by people with disabilities living in poverty, the promise of telehealth as an access strategy will remain unrealized for those who need it most.”

1. Health care providers on how to better serve patients with mobility disabilities in underserved communities? As someone who provides telehealth services, there are specific modifications that I can (and legally must) implement to make telehealth more accessible (for people with cognitive, mobility, hearing, and/or visual disabilities), but the questions I’m left with after reading your paper is...how would I take the specific accessibility modifications that I currently apply and then also apply your findings to low resourced areas to improve the priorities identified by the study for patients with disabilities?  
2. Community organizations who can help bridge gaps in food access, mental health, and transportation identified by participants. 

AUTHOR RESPONSE: You have identified a critical weakness of the previous version of the paper, a lack of practical recommendations. To address this, we have added a paragraph to section 5, which has recommendations that can be linked to the study findings. These recommendations address your concerns as well as your comment below. Paragraph: “Health professionals serving people with mobility disabilities in low-resource com-munities can take practical steps informed by the findings of this study. Participants con-sistently described physical health as deprioritized behind survival needs such as food and housing, suggesting that providers who screen for or help address unmet basic needs during clinical encounters may see stronger engagement. Moreover, awareness of trans-portation barriers and maintenance of updated referral lists for local community resources are low-burden strategies that could improve care continuity for people with disabilities in underserved areas. Providers should also take an active role in connecting people with mobility disabilities to mental health services, as participants described being turned away from referrals despite persistent requests for support. Given that mental health dis-tress was the most urgent need reported in this study and that structural barriers limit this population's ability to seek help independently, clinical encounters represent an underuti-lized opportunity to reduce the gap between need and access. Ultimately, policy efforts should prioritize expanding telehealth reimbursement for mental health and supportive care services in low-resource communities, as cost was a consistent barrier to accessing care among participants. Without reimbursement structures that account for the financial constraints faced by people with disabilities living in poverty, the promise of telehealth as an access strategy will remain unrealized for those who need it most.”

Section 4.5 draws heavily from the literature to suggest telehealth as a solution. The unique value of what you have done in this study is draw the voices of the participants themselves. I love that you have considered the voices of people with disabilities in economically distressed communities and making them heard; however, I’m missing those next steps as action items to conduct more research or to make practice changes. I agree with you that more research is needed to ID real solutions that make real-world changes, but as written these implications feel very broad. You say, “Considering that low-resource communities are often unsafe, remote services and use of mobile phones for getting on the internet could be a viable solution for addressing needs xxx”, yes, but what are those next steps get started in an economically disadvantaged area? You might mention: Device loan programs? Public access kiosks? Affordable Connectivity Programs? Flexible communication (for example, audio-only telehealth within state-specific permissibility), Federal resources (Telehealth Resource Centers), Local Partnerships? Community Health Workers? Since your abstract specifically notes that “poor awareness of available resources xxx”, it would address the “foundational needs for advancing health equity” as you note. 

AUTHOR RESPONSE: Similar to the comment above, we have added another paragraph that addresses these more practical implications: “Translating these findings into practice requires concrete starting points. Participants described poor awareness of available resources as a primary barrier to engagement, suggesting that outreach is as important as the services themselves. Community health workers and trusted local organizations are well positioned to close this awareness gap through in-person outreach, given that participants responded to relational rather than digital communication. Device loan programs, public access kiosks, and federal affordability programs such as the Affordable Connectivity Program represent practical infrastructure solutions for communities with limited internet access. Telehealth Resource Centers, which are federally funded and regionally distributed, offer technical assistance that could help community organizations and health systems extend services into underserved areas. Where state regulations permit, audio-only telehealth options can further reduce technology barriers. Local partnerships between health systems, community organizations, and disability-serving agencies are needed to coordinate these efforts and ensure that the needs identified by participants, including mental health support, food access, and transportation, are addressed in a way that reflects the lived realities of people with disabilities in low-resource communities.”

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for your work on this important topic. 

To start off, just a few minor edits:

• Line 263: I think your quotation marks are in the wrong place. I think you've quoted part of your comment as part of a participant's comment.
• Lines 269-271: I found this quote difficult to follow. Would you be able to add punctuation?

General questions:

• What was your definition of a "community leader" and how was it determined whether the participant was a community leader or not? Were they asked directly?
• In your table of demographic characteristics, can you explain why one participant's age is unknown and another participant's disability was not specified? Did the participants refuse to answer these questions? Given your low overall number of participants, any missing information gets magnified. I am also wondering how you determined the mobility disability category. For example, spinal issues were differentiated into "spinal disorder" and "spinal stenosis", yet "lower extremity" remained a singular vague classification. Likewise, how are you differentiating arthritis vs osteoarthritis? It would have also been helpful to determine how each participant met your mobility disability criteria, such that you may be able to see from your data whether any differences existed in their responses based on severity of disability (i.e., wheelchair dependent vs. able to walk without assistive device for under a quarter mile), though it may be too late now to do so, if this information was not already collected.
• You need to comment on limitations of your study.
• What did you use for coding and analysis? Did you do it by hand? Use a program like NVivo? 
• You have seven authors listed, but in the procedures section, you only mention "the author" (line 129) as the person who did the coding and analysis. Am I correct in interpreting that there was no independent coding and analysis by different members of the team before coming back together to find consensus on any differences (if any)? You only mention that the transcription was checked by two authors, not any other part of the analysis.

Author Response

• Line 263: I think your quotation marks are in the wrong place. I think you've quoted part of your comment as part of a participant's comment.

AUTHOR RESPONSE: Thank you, we have fixed this error.

• Lines 269-271: I found this quote difficult to follow. Would you be able to add punctuation?

AUTHOR RESPONSE: Indeed, it was also difficult to follow in real life. We have added punctuation to enhance readability. “Trust due to safety or theft was a recurring issue, which impeded community involvement, as described by one participant:

"Sometimes community things, you know. You let people in just a little bit, and they take you. Give them a little inch and take them out. So it is kind of tough to trust people around your house or in community settings" (R6).””

General questions:

• What was your definition of a "community leader" and how was it determined whether the participant was a community leader or not? Were they asked directly?

AUTHOR RESPONSE: Participants were recruited through community leaders, which we have now defined: “elected neighborhood representatives serving rotating terms of one to two years.”

• In your table of demographic characteristics, can you explain why one participant's age is unknown and another participant's disability was not specified? Did the participants refuse to answer these questions? Given your low overall number of participants, any missing information gets magnified. I am also wondering how you determined the mobility disability category. For example, spinal issues were differentiated into "spinal disorder" and "spinal stenosis", yet "lower extremity" remained a singular vague classification. Likewise, how are you differentiating arthritis vs osteoarthritis? It would have also been helpful to determine how each participant met your mobility disability criteria, such that you may be able to see from your data whether any differences existed in their responses based on severity of disability (i.e., wheelchair dependent vs. able to walk without assistive device for under a quarter mile), though it may be too late now to do so, if this information was not already collected.

AUTHOR RESPONSE: We have provided further detail on the eligibility criteria section for how mobility disability was identified. Specifically, we now state in the paper that mobility disability was observed from research staff through in-person recruitment. However,  when asked later about mobility disability type over the phone call that happened at another date, participants often did not provide specifics. We also did not obtain access to access their medical records. These non-specifications, which we have now stated in Table 1, occurred more towards the back-end of recruitment, where we were making more recruitment efforts in the hospital. In retrospect, mobility device use would have been valuable information, but we wanted to keep surveys/questions as minimal as possible, because this population was/is truly difficult to reach and engage in research. We have added this as a limitation.

• You need to comment on limitations of your study.

AUTHOR RESPONSE: Thank you, we completely missed this section. The Discussion now includes a paragraph stating limitations: “Several limitations should be considered when interpreting these findings. The sample was small and recruited through convenience sampling, which limits generalizability be-yond low-resource communities in the Birmingham metropolitan area. Participants were predominantly African American and female, and findings may not reflect the experiences of men or people from other racial and ethnic backgrounds living with mobility disabilities in the Deep South. The study relied on a single phone interview per participant, which limited the depth of information that could be gathered compared to in-person or longitu-dinal methods. The interview guide was broad by design, which constrained the level of detail captured on any single topic, including telehealth readiness and specific service preferences. Additionally, participants were not screened for prior telehealth experience, and responses regarding remote service delivery may therefore reflect hypothetical atti-tudes rather than informed experience. Finally, disability status was not verified through clinical records, which introduces the possibility of misclassification.”

• What did you use for coding and analysis? Did you do it by hand? Use a program like NVivo? 

AUTHOR RESPONSE: We now specify this in the procedures, no software was used: “ The transcripts were then coded (done manually by the two analysts with no software used)…”

• You have seven authors listed, but in the procedures section, you only mention "the author" (line 129) as the person who did the coding and analysis. Am I correct in interpreting that there was no independent coding and analysis by different members of the team before coming back together to find consensus on any differences (if any)? You only mention that the transcription was checked by two authors, not any other part of the analysis.

 AUTHOR RESPONSE: Thank you for spotting this. That was an error. We now clarify that two authors transcribed all the study data, and another two authors conducted the analyses.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the revised manuscript. I appreciate the attention to detail and point-by-point revisions made. The revisions are substantive and well-grounded in the study's findings.

There is one remaining item that I've flagged for your consideration that I noticed in your revision; starting on line 457 where you mention the Affordable Connectivity Program (ACP). This program ended in 2024, making it outdated. Theoretically, I follow where you intend to go with this statement, but you might consider replacing the ACP with the Lifeline Program as it is one that is currently in effect and would be more relevant and up to date. Also, many private internet companies (Comcast or Spectrum) offer low-cost internet essentials outside of federal plans for as low as $10.

Author Response

Comment 1: There is one remaining item that I've flagged for your consideration that I noticed in your revision; starting on line 457 where you mention the Affordable Connectivity Program (ACP). This program ended in 2024, making it outdated. Theoretically, I follow where you intend to go with this statement, but you might consider replacing the ACP with the Lifeline Program as it is one that is currently in effect and would be more relevant and up to date. Also, many private internet companies (Comcast or Spectrum) offer low-cost internet essentials outside of federal plans for as low as $10.

Response 1: Thank you for bringing that to our attention. We've just removed the mention of ACP from the paper. 

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for addressing the previous comments, questions, and concerns. I am satisfied with the manuscript in its current form.

Author Response

Thank you for you assistance!