COVID-19 has accelerated the expansion of telehealth, heralding an opportunity to integrate technology into clinical care delivery in new and purposeful ways. However, there are disparities among people in rural communities that limit opportunities to gain experience and comfort using technology for health information and services, including lower home broadband access, lower health literacy, and less use of online health information compared with urban populations. 1,2 In this survey study, we examine the use of and satisfaction with telehealth services during the pandemic in a predominantly rural sample and estimate the magnitude of the association between demographic and health characteristics, health literacy, internet access, and the odds of using telehealth. Methods SampleThe Virginia Commonwealth University institutional review board approved this study, which follows the American Association for Public Opinion Research (AAPOR) reporting guideline. Respondents were recruited through the Virginia Living Well Registry (VALW), a community-based convenience sample registry of adults residing in primarily rural Virginia counties (Rural-Urban Continuum Codes 4-9). A total of 401 participants registered to the VALW before January 2020 were invited to complete a self-administered consent and survey online or through mailed paper surveys between June 2020 and January 2021. A waiver of signed consent was obtained for mailed surveys to enable survey completion via telephone. Additional information on study methods is available in the eAppendix in the Supplement. The overall response rate was 61%. An additional 6 participants who completed the VALW after June 2020 were included. MeasuresOutcomes were self-reported telehealth use (yes vs no) and patient satisfaction with telehealth services 3 since March 2020. Telehealth included communication via telephone, video, or electronic monitoring systems. Single-item screeners were used to identify low or inadequate health literacy, 4 health insurance coverage, internet access, and overall perceived health. Health literacy was operationalized as perceived confidence completing medical forms independently, which has been shown to successfully identify individuals with low health literacy. 4 Race and ethnicity were selfreported using categories defined by Office of Management and Budget standards. Race and ethnicity were analyzed in this study because disparities in preventive care use by race/ethnicity are well documented; in Virginia, rural Black residents experience greater incidence and/or mortality for some screenable cancers compared with White residents, suggesting that there are disparities in access to care. Rurality was categorized as Rural-Urban Continuum Codes 4 to 9 using participant address. 5 Higher Perceived Stress Scale 6 scores indicated greater perceived stress and were included given the pandemic context, which may be associated with health care seeking.

There has been a steady increase in cannabis use among US adolescents over the past decade. Perceptions of risk, specifically the belief that cannabis use is not harmful, may contribute to this increased use. The purpose of this study was to evaluate parental, school, and peer influence as protective factors in perceiving there is risk of harm from monthly cannabis use. Using the 2017 National Survey on Drug Use and Health (NSDUH), the study outcome was self-reported perceived risk of harm from monthly cannabis use amongst adolescents between ages 12 and 17. The exposures were parental monitoring and support, perception of school importance, extracurricular activity participation, peer attitudes towards cannabis use, and perception of peer cannabis use. Of 12,024 eligible adolescents, about 80% reported perceived risk of harm from monthly cannabis use. Multiple logistic regression models suggest the perception of risk of harm from monthly cannabis use was significantly associated with perception of peers using cannabis, perception of peers’ disapproval of cannabis use, perception of school importance, and participation in extracurricular activities. Adolescents who perceived that monthly cannabis use was risky had high parental monitoring, low perception of peer use, high perception of peers’ disapproval of cannabis use, high perception of school importance, and participated more in extracurricular activities. These findings suggest substance use prevention programs targeting adolescent attitudes and beliefs would benefit from leveraging peer influence, promoting extracurricular activities, and enhancing schoolwork to be more meaningful.