A Two-Stage Analysis of Internet Access and E-Health Adoption among Italian Older Adults

Population ageing and the digital transformation of healthcare place older adults at the centre of telemedicine policy, yet e-Health services can only benefit those who are first able to access and then willing to use digital tools. This study identifies the determinants of the potential use of online health services among people aged 65 years and over in Italy, disentangling digital access from e-Health adoption. We analysed cross-sectional data from the 2024 wave of the ISTAT “Aspetti della Vita Quotidiana” (AVQ) survey, restricted to 11,705 respondents aged ≥65 years. A two-stage design was adopted to avoid circularity: Stage 1 modelled Internet access in the whole elderly sample, while Stage 2 modelled the use of at least one online health service among the 5841 elderly Internet users. Weighted binomial generalized linear models (logit link) with HC1 robust standard errors were fitted; discrimination, calibration and fit were assessed through the area under the ROC curve (AUC), the Brier score and the Cox-Snell pseudo-R². Overall, 33.1% of people aged ≥65 years and 65.3% of elderly Internet users had used at least one online health service in the previous three months. Educational attainment was the strongest determinant in both stages (Stage 2 adjusted OR for a university degree versus primary education = 5.50, 95% CI: 4.48 - 6.76). A marked North-South geographic gradient (Stage 2 OR = 1.54, 95% CI: 1.37 - 1.72), advancing age (OR = 0.77 for ≥75 years) and health-care need proxied by specialist visits (OR = 1.58, 95% CI: 1.41 - 1.78) were consistently associated with e-Health adoption. Female sex was a barrier to digital access (Stage 1 OR = 0.81) but not to e-Health adoption (Stage 2 OR = 1.03, ns). The Stage 1 model showed excellent discrimination (AUC = 0.884), whereas the Stage 2 model was more modest (AUC = 0.691). The potential use of telemedicine among Italian older adults is structured by a two-layered social gradient: education, geography and age shape both physical access to the Internet and the subsequent adoption of health services online. Policies implementing the digital-health objectives of the Italian National Recovery and Resilience Plan (Mission 6) should couple infrastructure investment with targeted digital-literacy interventions for the least-educated, oldest and southern older adults to prevent telemedicine from widening existing health inequalities.