Digital and Remote Health for Older Adults in Rural or Underserved Settings: Systematic Review of Clinical, Behavioral, and Implementation Outcomes

Background: Older adults in rural or underserved settings face persistent access barriers. Digital and remote health interventions may mitigate these gaps. Objective: The aim of this study is to assess technologies, effectiveness, and implementation challenges of digital or remote health interventions for adults ≥60 years old in rural or underserved contexts. Methods: A systematic search was conducted in 4 electronic databases, such as PubMed, Scopus, Web of Science, and Embase (inception: April 2025), under dual screening by 2 reviewers. The tool Cochrane Risk of Bias 2.0 was used to assess the risk of bias for randomized trials, and Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I) was used for nonrandomized trials. For observational studies, we used the National Institutes of Health quality assessment tool, and a narrative synthesis was performed. Results: Fourteen studies met the inclusion criteria (randomized and nonrandomized designs; median follow-up ~12 mo). Ten of 14 (71%) reported significant improvements in at least 1 clinical end point (eg, hemoglobin A1c, blood pressure, and weight), 11 of 14 (79%) improved behavioral or psychosocial outcomes, and 5 of 9 (56%) reduced hospitalizations or acute episodes. Risk-of-bias concerns most frequently related to missing data and selective reporting. Digital literacy and broadband access were the most consistent barriers, while multicomponent, nurse-supported models achieved higher adherence. Equity-related dimensions (place, gender, and socioeconomic status) were variably reported, with limited attention to language, cultural tailoring, or social capital. No study included a formal cost-effectiveness analysis. Conclusions: Digital and remote health interventions can benefit older adults in rural and underserved settings by improving selected clinical and behavioral outcomes. However, heterogeneity, small sample sizes, and the absence of economic evaluations temper certainty. Importantly, gaps in equity reporting and persistent barriers to digital inclusion highlight the need for future trials to integrate PROGRESS-Plus (place of residence, race/ethnicity, occupation, gender, religion, education, socioeconomic status, social capital, plus other context-specific determinants of health equity) dimensions, embed cost-effectiveness assessments, and design interventions that are both sustainable and accessible to the most underserved populations.