This study draws on the same formative ethnographic dataset described in our prior publication examining feasibility and practical implementation solutions for pharmacist video visits among older veterans [25]. This manuscript extends that work by focusing on how ethnographic methods can identify and disentangle age-related assumptions from technology familiarity in the design of technology-based clinical trials. The analytical focus and conceptual framing in this manuscript are distinct from those in the prior implementation publication.

This study was reviewed and approved by the VA Central Institutional Review Board (approval number 19-35). All participants provided informed consent prior to participation. Study staff explained the purpose of the study, procedures, potential risks, and voluntary nature of participation, and participants were informed of their right to withdraw at any time without consequences to their care. To protect participant privacy and confidentiality, all data were deidentified at the time of analysis. Field notes and observational data were stored on secure, VA-approved servers with access limited to authorized study personnel. No personally identifiable information is reported in this manuscript. Participants received a US $50 gift card as compensation for their time.

Potential participants were identified using an electronic health record–generated list of veterans aged ≥65 years who met the inclusion criteria (eg, ≥2 chronic conditions, no diagnosis of dementia, and at least 1 primary care visit in the prior year). Participants were recruited over approximately 10 months using a combination of mailed invitations and outbound telephone calls. In total, 316 invitation letters were mailed to veterans identified through the electronic health record as potentially eligible. Overall, 64 veterans responded to the mailed invitation; 41 indicated they were not interested in participating, and 23 initially agreed. Of these, 2 veterans subsequently declined enrollment due to personal reasons (ongoing cancer treatment and caregiving responsibilities) and 1 could not be scheduled within the recruitment window; recruitment stopped once the target sample size (n=20) was reached.

To supplement mailed invitations, the study staff conducted outbound telephone calls to veterans who did not respond to the letter. Across mail and telephone contact attempts, veterans either declined participation after learning more about the study or could not be reached (eg, disconnected phone numbers or no response after repeated attempts). In total, 17 veterans were determined to be ineligible due to no longer meeting the study criteria (eg, not currently taking ≥5 medications, recent diagnosis of cognitive decline, or enrollment in a VA satellite clinic). Recruitment ceased once the target sample size (N=20) was reached. All enrolled participants completed the observed telehealth visit.

Our ethnographic assessment used direct observation and structured field notes to capture the real-world experiences of older adults as they navigated a clinical video visit using the VA’s synchronous video platform VA Video Connect (VVC). An experienced anthropologist led this assessment by recruiting and enrolling participants and joining each participant at home before and during their virtual visit.

To participate, all veterans needed internet access at home and a device with a camera and microphone. For those lacking a video-capable device, the anthropologist arranged for the provision of a VA-loaned tablet. The VA’s tablet distribution program was instrumental in bridging the digital divide for veterans with limited access to video care. Veterans receiving a tablet were scheduled for a test visit with a local VA employee, while others received a demonstration from the anthropologist prior to their pharmacist video visit. Before the video visit, the anthropologist provided a video demonstration when needed. Subsequently, the participant and pharmacist connected via VVC.

Ethnographic methods in anthropology involve qualitative techniques—such as semistructured interviews and focus groups—with a unique emphasis on situating specific events within their broader real-life contexts [22,26,27]. Unlike surveys or post hoc interviews, ethnographic methods also rely on in-situ, real-time observations to capture sociocultural, behavioral, and technical challenges that participants may not articulate in interviews [27]. In this assessment, field notes and direct observation notes were critical in documenting the technical, logistical, and emotional dimensions of older adults’ virtual care experiences.

Field notes are detailed, descriptive records that researchers, particularly anthropologists and ethnographers, take during participant observation and interviews [28,29]. We designed a standardized field note form informed by a priori concepts from the Consolidated Framework for Implementation Research (CFIR) [30] and insights from experienced clinical pharmacists (Multimedia Appendix 1). Field notes are generally understood to be primary data collected in the field to document observations, interactions, and insights gained through immersive research methods [28]. Both the in-house anthropologist and the remote clinical pharmacist completed field notes for each participant. The anthropologist’s (in-house) and the clinical pharmacist’s (remote) field notes complemented each other by capturing a range of experiences and challenges, including the following:

Direct observation is an ethnographic method ideal for studies on naturally occurring behaviors, actions, or events [29]. For example, observation is particularly useful for understanding patients’ experiences because it provides an insider perspective and thus allows researchers to understand end users’ experiences of a problem. Direct observation was conducted before, during, and after the virtual visit session to fully understand the participant’s experience. Key components included the following (Figure 1):

This formative ethnographic assessment was not originally designed to study digital ageism as a primary construct. Rather, the study focused on understanding how older adults navigated real-time telehealth encounters to inform the implementation of a subsequent RCT. Because the study population consisted exclusively of older adults, we anticipated that age-related assumptions about technology, whether expressed by participants, embedded in clinical workflows, or reflected in research procedures, might emerge alongside structural and usability barriers. Data sources included structured field notes completed independently by the in-house anthropologist and the remote clinical pharmacist for each observed visit, as well as observational documentation of previsit preparation and postvisit reflections. All field notes were compiled and organized by participant and visit stage.

We analyzed the ethnographic data (structured field notes and direct observation summaries) using a qualitative rapid analysis approach commonly applied in health services and implementation research, emphasizing matrix-based summarization, team-based interpretation, and iterative refinement of themes [31,32]. This approach is consistent with pragmatic ethnographic methods, including Rapid Assessment Procedure–Informed Clinical Ethnography, which integrates ethnographic observation with rapid, implementation-focused analysis [33].

The rapid qualitative analytic process proceeded in 4 iterative steps. First, field notes were summarized using structured analytic matrices organized by participant; visit phase (previsit, during visit, and postvisit); and focal domains (eg, technical barriers, participant responses, environmental context, and caregiver involvement). This step allowed for systematic comparison across cases while preserving contextual detail. Second, 2 analysts (the anthropologist and the clinical pharmacist) independently reviewed matrix summaries to identify recurring patterns and salient observations. Preliminary themes were generated inductively, with attention to both anticipated implementation challenges (eg, technology access and usability) and emergent phenomena observed during visits.

Third, the 2 primary analysts met weekly over a 6-month period to compare interpretations, refine thematic definitions, and resolve discrepancies through discussion and reference back to the original field notes. These meetings focused on clarifying analytic boundaries, distinguishing overlapping concepts, and ensuring consistency across cases. Fourth, biweekly analytic meetings with a senior qualitative methodologist and a clinical subject matter expert provided an additional layer of review. These meetings were used to challenge emerging interpretations, assess analytic coherence, and confirm that themes were grounded in observational evidence.

Several strategies were used to enhance analytic rigor and credibility [34]. First, triangulation across data sources (anthropologist field notes, pharmacist field notes, and direct observation) allowed for cross-validation of findings. Second, team-based analysis and consensus discussions reduced reliance on a single analyst’s interpretation. Finally, analytic decisions were documented through iterative matrix revisions and meeting notes, creating an audit trail of theme development. This rapid, iterative analytic process enabled the identification of implementation-relevant insights while maintaining methodological transparency and rigor appropriate for ethnographic research embedded within clinical trial preparation.

We distinguished digital ageism from related but distinct phenomena, such as structural barriers to access (eg, broadband availability and device ownership) and usability or design limitations of telehealth platforms. We reserved the term “digital ageism” for age-related stereotypes, lowered expectations, and identity-based assumptions, whether externally imposed or internalized, that shaped participants’ perceptions of their own technological competence and their engagement with virtual care. Consequently, digital ageism was used as an interpretive lens during analysis, rather than as a priori coding framework or outcome.

Participants had a mean age of 74 (SD 3.18) years; of 20 participants, 18 (90%) were male, and 18 (90%) identified as White. In total, 11 (55%) participants had completed high school or a General Educational Development test, and 13 (65%) participants reported some prior experience with digital technology (eg, owning or using a smartphone, tablet, or computer). However, experience with video-based platforms was limited for many participants, and assistance was frequently required; 7 (35%) participants reported neither regular access to a video-capable device nor prior experience using such technology and required assistance both before and during the virtual visit. Additionally, 3 (15%) participants reported having access to a device and some experience with technology but nonetheless encountered technical difficulties during the visit that required real-time support.

This formative ethnographic study examined how older adults engaged with video-based telehealth encounters in real-world settings to inform recruitment and implementation strategies for a subsequent telepharmacy randomized clinical trial. Through in-home observation conducted before, during, and after pharmacist video visits, we identified a range of structural, technological, and sociocultural factors that shaped telehealth engagement. Through direct observation, we gained insight into the disconnect between technological design and user needs, highlighting where telehealth platforms fail to accommodate older adults and how digital ageism manifests in real-world health care settings. These insights directly informed the development of recruitment and technology troubleshooting methods for the subsequent RCT focused on pharmacist video visits for medication management among older adults. In addition, although digital ageism was not a core focus of our study, age-related assumptions emerged as an important interpretative factor that influenced how participants anticipated, experienced, and evaluated their own video visits.

Consistent with prior work, our findings underscore that telehealth engagement among older adults cannot be understood only in terms of individual technical skills or motivation [4-7,9-15]; our in-depth observational approach uniquely highlights both the facilitators and obstacles encountered before and during video visits. Structural barriers such as broadband access, device ownership, and email access intersect with sociocultural factors, including household layout, rurality, and caregiver presence. In-home observation allowed us to identify challenges that would not have been apparent through remote assessment alone, such as difficulty transporting devices within the home, concerns about privacy, and other physical limitations.

Family members frequently served as informal technology facilitators, assisting in device setup, account management, and troubleshooting. This finding highlights the importance of considering digital literacy programs tailored to older adults’ needs as potentially dyadic, including community-based initiatives and caregiver-led tutorials [25,35].

Age-related assumptions about technology surfaced during observation and participant interaction. Participants’ reluctance to engage with video visits was attributed to older age and lower technical experience. Although successful completion of video visits was frequently accompanied by expressions of surprise or pride, suggesting that telehealth encounters functioned as moments in which age-related self-perceptions were reinforced. These patterns can be further understood through a sociopsychological identity framework, which conceptualizes age and generational status as socially constructed identities rather than fixed deficits. As described by Lee and Hartanto [36], individuals’ engagement with technology is shaped not only by skills or access but also by identity-relevant meanings, stereotypes, and expectations associated with belonging to an age group. From this perspective, observed changes in confidence reflect changes in how participants interpreted their own age-related technological competence rather than simple resolution of usability barriers.

It is important to note that not all age-related considerations observed in this study should be interpreted as manifestations of ageism. Some adaptations, such as preparing for visual, hearing, or mobility limitations, enabled and supported successful participation in the study. These practices reflect responsive design rather than ageist assumptions. The analytical challenge lies in distinguishing between accommodations that enhance inclusion and assumptions that lower expectations or discourage engagement. Although similar technology challenges might arise in younger populations with limited technology exposure, the tendency to attribute difficulty to age identity and the meaning attached to this appeared to be specific to older adults’ experiences in this context.

Our findings suggest that incorporating ethnographic methods prior to trial implementation can surface otherwise overlooked barriers and facilitators to telehealth engagement among older adults. In-home observation provided actionable insights that informed protocol refinements, recruitment strategies, and support mechanisms for the subsequent randomized trial. Broadly, these methods may help ensure that technology-focused clinical research does not inadvertently exclude older adults by assuming access, skills, or comfort with digital tools.

As with most qualitative research, our findings are not broadly generalizable to populations at large. The sample size was small and drawn from veterans willing to participate in a formative telehealth study and thus does not reflect the demographics of older adults in the United States. Given the technology acceptance and uptake during the COVID pandemic, the individuals enrolled in our study likely had additional motivation to learn to use video technology and thus participate in our study. Additionally, as this was a formative qualitative study, findings reflect observed experiences and reported perceptions rather than measured intervention effects. Finally, our hands-on ethnographic approach to recruitment and participant engagement with technology may not be feasible for all studies, especially those that are larger and time limited.

We conducted a focused ethnographic assessment of 20 older individuals engaging in a virtual clinical visit. We illustrate that the application of ethnographic methods to identify and reduce critical barriers to participation and retention in complex health interventions among older adults can yield critical information to improve an RCT. We offered critical insights into how older adults experience telehealth encounters in everyday contexts and revealed the interplay of structural barriers, social support, and age-related self-perceptions. Although digital ageism was not an initial focus of this study, age-related assumptions about technology emerged as a factor shaping engagement with virtual care. Integrating ethnographic approaches and methods into telehealth research and implementation efforts may help improve inclusivity, feasibility, and responsiveness for older adult populations.