Determinants of the intention to use e-Health by community dwelling older people

Elderly's Attitude towards the Selected Types of e-Health

This current study was sought to explore how older adults’ adaptation of information and communication technology (ICT) devices was associated with their preference for e-Health services. A total of 224 Czech older adults aged 60+ were analyzed for the study. The sample comprised 21% male and 79% female. A self-reported survey questionnaire was employed to assess the prevalence of the use of ICT devices and the Internet and general preference for e-Health services. A series of t-tests were performed between and within two groups divided into e-Health supporters and non-supporters. The results indicated that nearly half of the respondents preferred to use the Internet for searching for health-related information. We found that older adults’ use of ICT devices and educational level was significantly associated with the selection of the e-Health services. However, gender, household type, and the place for a residence did not count additional variance for the preferred e-Health services. For those who express willingness to receive the e-Health service, the preferred e-Health services should be implemented across relevant health domains. To do so, health professionals ought to provide the necessary equipment and educational programs that help older adults better access and adapt to e-Health services.

Examining Users' Adoption of Precision Medicine: The Moderating Role of Medical Technical Knowledge

Precision medical technologies have received a great deal of attention, but promoting such technologies remains a problem for enterprises and medical institutions. Adopting the unified theory of acceptance and use of technology (UTAUT) model and the health belief model (HBM), this study investigated the key factors affecting users' willingness to adopt precision medicine (PM) in terms of technical factors and external stimuli. Based on 415 questionnaires, performance expectancy, price value, social influence, and perceived threat of disease were found to significantly increase users willingness to adopt PM; meanwhile, privacy risks had the opposite effect. Knowledge about PM was found to strengthen the positive effect of performance expectancy, price value, social influence, and perceived threat of disease on willingness to adopt PM and weaken the negative effect of privacy risk. This study demonstrates the successful application of UTAUT to the medical field while also providing guidance for the promotion of PM.

Adoption intention and usage behavior of mHealth services in Bangladesh and China

Purpose

The purpose of this paper was to explore the comparative influential factors affecting the behavioral intention and actual usage of mHealth services in two distinct national environments, i.e. China and Bangladesh, in relation to the international expansion of mHealth services.

Design/methodology/approach

In this study, widely accepted Unified Theory of Acceptance and Use of Technology (UTAUT) with two additional variables, i.e. Perceived Reliability and Price Value have been selected as a theoretical framework. Primary data were collected from existing mHealth users among generation Y in both China and Bangladesh. A total of 296 and 250 questionnaires were deemed as usable for data analysis for Bangladesh and China, respectively.

Findings

Performance expectancy and social influence had significant impact on the adoption intention of mHealth services for both countries. Effort expectancy and price value were insignificant factors for Bangladesh, whereas facilitating condition and perceived reliability were insignificant for China.

Practical implications

The insights from this study could benefit mHealth services providers and those policymakers who seek to enter the Chinese and the Bangladeshi healthcare market. The dimensions identified in the study are based on a full assessment of mHealth usages experiences. Global service providers can use the dimensions identified by the paper to better assess their service performance on an international level.

Originality/value

The paper is unique in that it is one of the first cross-country examinations of influential factors affecting the adoption of mHealth services in two different countries. This study confirms the applicability of extended UTAUT model in the context of mHealth services among the generation Y in developing countries such as China and Bangladesh.

An Empirical Study on Patients' Acceptance of Physician-Patient Interaction in Online Health Communities

In China, the utilization of medical resources is contentious, and a large of hospitals are seriously congested because of the huge population and uneven distribution of medical resources. Online health communities (OHCs) provide patients with platforms to interact with physicians and to get professional suggestions and emotional support. This study adopted the unified theory of acceptance and use of technology to identify factors influencing patients’ behavioral intention and usage behavior when interacting with physicians in OHCs. An investigation involving 378 valid responses was conducted through several Chinese OHCs to collect data. Confirmatory factor analysis and structural equation modelling were utilized to test hypotheses. Both the reliability and validity of the scales were acceptable. All five hypotheses were supported, and behavioral intention played a significant mediating role between independent variables and dependent variables. This study clarified the mechanism by which performance expectancy, effort expectancy, social influence and attitude toward using technology affect usage behavior through the mediation of behavioral intention in OHCs. These findings suggest that OHCs can change the actions of websites such as adopting some incentives to promote patients’ intention of interaction. Physicians should understand patients’ actual attitudes toward OHCs and try to guide patients in their interactions, improving the quality of physician–patient interaction.

Aging and eye tracking: in the quest for objective biomarkers

Recent applications of eye tracking for diagnosis, prognosis and follow-up of therapy in age-related neurological or psychological deficits have been reviewed. The review is focused on active aging, neurodegeneration and cognitive impairments. The potential impacts and current limitations of using characterizing features of eye movements and pupillary responses (oculometrics) as objective biomarkers in the context of aging are discussed. A closer look into the findings, especially with respect to cognitive impairments, suggests that eye tracking is an invaluable technique to study hidden aspects of aging that have not been revealed using any other noninvasive tool. Future research should involve a wider variety of oculometrics, in addition to saccadic metrics and pupillary responses, including nonlinear and combinatorial features as well as blink- and fixation-related metrics to develop biomarkers to trace age-related irregularities associated with cognitive and neural deficits.

Determinants of access to eHealth services in regional Australia

BACKGROUND

Australia has a universal public healthcare system, but access to eHealth services (i.e. use of the Internet and related technologies for healthcare services) remains a remarkable challenge, particularly in regional, rural and remote communities. Similar to many other countries, Australia faces the challenges of an ageing population and chronic disease management as well as balancing the supply of and the demand for quality healthcare and advanced medical procedures. The prima facie case for inequality in accessing eHealth services across geographical settings is widely acknowledged. However, regional residents' perceptions on access to eHealth services lack empirical evidence. Therefore, this study empirically investigates the current state and predictors of eHealth service access in regional Australia.

METHODS

A cross-sectional questionnaire-based household survey was conducted within a total of 390 randomly selected adults from the Western Downs Region in Southeast Queensland, Australia. Bivariate analysis was conducted to examine the relationship between eHealth access and respondents' characteristics. A multivariate logistic regression model was also performed to identify the significant predictors of eHealth service access in regional Australia.

RESULTS

Approximately 78% of the households have access to eHealth services. However, access to eHealth services in socioeconomically disadvantaged households was lower (19%) than that of their advantaged counterparts (25%). Factors that significantly increased the likelihood of accessing eHealth services included middle age (odds ratio [OR] = 2.75, 95% confidence interval [CI]: 1.84, 8.66), household size (three to four members) (OR = 2.29, 95% CI: 1.19, 4.73), broadband Internet access (OR = 1.67, 95% CI: 1.15, 2.90) and digital literacy (OR = 2.39, 95% CI: 1.23, 4.59). Factors that negatively influenced access to eHealth services were low educational levels (OR = 0.28, 95% CI: 0.09, 0.61), low socioeconomic status (OR = 0.65, 95% CI: 0.28, 0.83) and remote locations (OR = 0.66, 95% CI: 0.23, 0.80).

CONCLUSION

Emerging universal eHealth access provides immense societal benefits in regional settings. The findings of this study could assist policy makers and healthcare practitioners in identifying factors that influence eHealth access and thereby formulate effective health policies to optimise healthcare utilisation in regional Australia.

A Web-Based and Print-Delivered Computer-Tailored Physical Activity Intervention for Older Adults: Pretest-Posttest Intervention Study Comparing Delivery Mode Preference and Attrition

BACKGROUND

Web-based interventions can play an important role in promoting physical activity (PA) behavior among older adults. Although the effectiveness of these interventions is promising, they are often characterized by low reach and high attrition, which considerably hampers their potential impact on public health.

OBJECTIVE

The aim of this study was to identify the participant characteristics associated with the preference for a Web-based or a printed delivery mode and to determine whether an association exists between delivery modes or participant characteristics and attrition in an intervention. This knowledge may enhance implementation, sustainability of participation, and effectiveness of future interventions for older adults.

METHODS

A real-life pretest-posttest intervention study was performed (N=409) among community-living single adults who were older than 65 years, with physical impairments caused by chronic diseases. Measurements were taken at baseline and 3 months after the start of the intervention. Hierarchical logistic regression was used to assess demographic and behavioral characteristics (age, gender, body mass index, educational attainment, degree of loneliness, and PA level), as well as psychosocial characteristics (social support for PA, modeling, self-efficacy, attitude, and intention) related to delivery mode preference at baseline and attrition after 3 months.

RESULTS

The printed delivery mode achieved higher participation (58.9%, 241/409) than the Web-based delivery mode (41.1%, 168/409). Participation in the Web-based delivery mode was associated with younger age (B=-0.10; SE 0.02; Exp (B)=0.91; P<.001) and higher levels of social support for PA (B=0.38; SE 0.14; Exp (B)=1.46; P=.01); attrition was associated with participation in the Web-based delivery mode (B=1.28; SE 0.28; Exp (B)=3.58; P<.001) and low educational attainment (B=-0.53; SE 0.28; Exp (B)=0.59; P=.049).

CONCLUSIONS

A total of 41% of the participants chose the Web-based delivery mode, thus demonstrating a potential interest of single older adults with physical impairments in Web-based delivered interventions. However, attrition was demonstrated to be higher in the Web-based delivery mode, and lower educational attainment was found to be a predictor for attrition. Characteristics predicting a preference for the printed delivery mode included being older and receiving less social support. Although Web-based delivery modes are generally less expensive and easier to distribute, it may be advisable to offer a printed delivery mode alongside a Web-based delivery mode to prevent exclusion of a large part of the target population.

TRIAL REGISTRATION

Netherlands Trial Register NTR2297; https://www.trialregister.nl/trial/2173.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-DOI: 10.2196/resprot.8093.

Factors Influencing Patients' Intentions to Use Diabetes Management Apps Based on an Extended Unified Theory of Acceptance and Use of Technology Model: Web-Based Survey

BACKGROUND

Diabetes poses heavy social and economic burdens worldwide. Diabetes management apps show great potential for diabetes self-management. However, the adoption of diabetes management apps by diabetes patients is poor. The factors influencing patients' intention to use these apps are unclear. Understanding the patients' behavioral intention is necessary to support the development and promotion of diabetes app use.

OBJECTIVE

This study aimed to identify the determinants of patients' intention to use diabetes management apps based on an integrated theoretical model.

METHODS

The hypotheses of our research model were developed based on an extended Unified Theory of Acceptance and Use of Technology (UTAUT). From April 20 to May 20, 2019, adult patients with diabetes across China, who were familiar with diabetes management apps, were surveyed using the Web-based survey tool Sojump. Structural equation modeling was used to analyze the data.

RESULTS

A total of 746 participants who met the inclusion criteria completed the survey. The fitness indices suggested that the collected data fit well with the research model. The model explained 62.6% of the variance in performance expectancy and 57.1% of the variance in behavioral intention. Performance expectancy and social influence had the strongest total effects on behavioral intention (β=0.482; P=.001). Performance expectancy (β=0.482; P=.001), social influence (β=0.223; P=.003), facilitating conditions (β=0.17; P=.006), perceived disease threat (β=0.073; P=.005), and perceived privacy risk (β=-0.073; P=.012) had direct effects on behavioral intention. Additionally, social influence, effort expectancy, and facilitating conditions had indirect effects on behavioral intention that were mediated by performance expectancy. Social influence had the highest indirect effects among the three constructs (β=0.259; P=.001).

CONCLUSIONS

Performance expectancy and social influence are the most important determinants of the intention to use diabetes management apps. Health care technology companies should improve the usefulness of apps and carry out research to provide clinical evidence for the apps' effectiveness, which will benefit the promotion of these apps. Facilitating conditions and perceived privacy risk also have an impact on behavioral intention. Therefore, it is necessary to improve facilitating conditions and provide solid privacy protection. Our study supports the use of UTAUT in explaining patients' intention to use diabetes management apps. Context-related determinants should also be taken into consideration.

Factors Affecting Patients' Use of Electronic Personal Health Records in England: Cross-Sectional Study

Background

Electronic personal health records (ePHRs) are secure Web-based tools that enable individuals to access, manage, and share their medical records. England recently introduced a nationwide ePHR called Patient Online. As with ePHRs in other countries, adoption rates of Patient Online remain low. Understanding factors affecting patients’ ePHR use is important to increase adoption rates and improve the implementation success of ePHRs.

Objective

This study aimed to examine factors associated with patients’ use of ePHRs in England.

Methods

The unified theory of acceptance and use of technology was adapted to the use of ePHRs. To empirically examine the adapted model, a cross-sectional survey of a convenience sample was carried out in 4 general practices in West Yorkshire, England. Factors associated with the use of ePHRs were explored using structural equation modeling.

Results

Of 800 eligible patients invited to take part in the survey, 624 (78.0%) returned a valid questionnaire. Behavioral intention (BI) was significantly influenced by performance expectancy (PE; beta=.57, P<.001), effort expectancy (EE; beta=.16, P<.001), and perceived privacy and security (PPS; beta=.24, P<.001). The path from social influence to BI was not significant (beta=.03, P=.18). Facilitating conditions (FC) and BI significantly influenced use behavior (UB; beta=.25, P<.001 and beta=.53, P<.001, respectively). PE significantly mediated the effect of EE and PPS on BI (beta=.19, P<.001 and beta=.28, P=.001, respectively). Age significantly moderated 3 paths: PE→BI, EE→BI, and FC→UB. Sex significantly moderated only the relationship between PE and BI. A total of 2 paths were significantly moderated by education and internet access: EE→BI and FC→UB. Income moderated the relationship between FC and UB. The adapted model accounted for 51% of the variance in PE, 76% of the variance in BI, and 48% of the variance in UB.

Conclusions

This study identified the main factors that affect patients’ use of ePHRs in England, which should be taken into account for the successful implementation of these systems. For example, developers of ePHRs should involve patients in the process of designing the system to consider functions and features that fit patients’ preferences and skills to ensure systems are useful and easy to use. The proposed model accounted for 48% of the variance in UB, indicating the existence of other, as yet unidentified, factors that influence the adoption of ePHRs. Future studies should confirm the effect of the factors included in this model and identify additional factors.

Digital brief interventions for risky drinkers are not the panacea: A pilot study exploring barriers for its implementation according to professionals' perceptions

Digital brief interventions have emerged as an instrument to improve the implementation of Screening, Brief Intervention and Referral to Treatment programs for risky drinkers. However, trials in Catalonia have been unsuccessful. This study was aimed at researching professionals' perceptions regarding the usefulness of digital brief interventions in overcoming traditional barriers of face-to-face Screening, Brief Intervention and Referral to Treatment and new barriers posed by the use of digital brief interventions. Professionals who participated in the Effectiveness of primary care based Facilitated Access to alcohol Reduction website (EFAR)digital brief intervention clinical trial were surveyed on April 2017 on the following areas: (1) satisfaction, (2) usefulness, (3) perceived ability of digital interventions on overcoming traditional barriers and (4) perceived new barriers of digital interventions. Sixty-eight professionals completed the survey. Univariate and multivariate analyses were performed using the level of professional engagement with the project as the dependent variable, barriers as independent variables and socio-demographic characteristics as covariables. Of all professionals, 79.4 percent were satisfied with their participation in the project, but only 26.5 percent perceived the website as useful. Low engagement was associated with the perceived lack of feedback (0.22; 95% confidence interval: 0.05 -0.88), perception that it was difficult to use among the elderly(0.22; 95 confidence interval: 0.05 -0.091) and among low socioeconomic population (0.14; 95% confidence interval: 0.03 -0.64). The majority of the participants indicated that digital brief intervention for risky drinkers succeeded in overcoming most of the traditional barriers. However, new barriers emerged as difficulties for implementing digital brief interventions in the Catalan Primary Health Care System. Usefulness perception is a key factor, which must be addressed in any proposed intervention in primary care.

Technology acceptance of older persons living in residential care

The social, psychological, physical, and financial benefits of digital inclusion are of increasing importance for older persons. However, older persons are often less inclined to utilise technological communication with reports of perceived poor technology acceptance. In this context, a study was conducted to investigate communication technology acceptance in older persons living in residential care. A cross sectional survey of residents (≥60 yrs) of four inner city residences in Durban, South Africa was conducted to assess communication technology access and technology acceptance defined as Usage Behaviour. A researcher-administered questionnaire was based on the Senior Technology Acceptance Model (STAM). Descriptive statistics of STAM factors and structural equation model (SEM) were conducted to test this model, to quantify the importance of various technology acceptance factors on Usage Behaviour among older persons living in residential care. The survey had a 72.1% response rate (n=277). Most of the respondents owned mobile phones (87.6%), although there was low smartphone ownership. Family desire to communicate and ease of use motivated mobile phone acquisition. Behaviour Intention, Facilitating Conditions, Attitude to Life and Satisfaction and education level were significantly associated with Usage Behaviour. Gerontechnology Anxiety and Age showed significant negative associations with Usage Behaviour. The acceptance of communication technology in this setting was low and predominantly influenced by Attitudinal and Technological Context factors together with age and education.

Dementia awareness and risk perception in middle-aged and older individuals: baseline results of the MijnBreincoach survey on the association between lifestyle and brain health

BACKGROUND

The total number of people with dementia is increasing worldwide, due to our aging society. Without a disease-modifying drug available, risk reduction strategies are to date the only promising way to reduce dementia incidence in the future. Substantial evidence exists that lifestyle factors contribute to the risk of dementia, such as physical exercise, mental activity and (non-)smoking. Still, most people seem unaware of a relationship between lifestyle and brain health. This paper investigates dementia literacy and knowledge of modifiable risk and protective factors of dementia in a Dutch population-based sample.

METHODS

An online-survey was carried out among 590 community-dwelling people between 40 and 75 years old in the Province of Limburg, the Netherlands. The total group comprises both of a provincial sample (n = 381) and a sample of three specific districts within the province (n = 209). Dementia awareness and knowledge about 12 risk and protective factors was assessed with items derived from the British Social Attitudes (BSA) survey, supplemented with custom items developed by the research team.

RESULTS

The majority of participants (56%) were unaware of a relationship between lifestyle and dementia risk. Most individuals identified low cognitive activity, physical inactivity and unhealthy diet as dementia risk factors. Particular gaps in knowledge existed with regard to major cardiovascular risk factors such as hypertension, hypercholesterolemia and coronary heart disease. Although the level of awareness varied by age and level of education, most people (70%) were eager to learn more about the topic of brain health, and indicated to be interested in using eHealth (54%) to measure or improve brain health.

CONCLUSIONS

Most people still are unaware of the relation between lifestyle and brain health, indicating the need for public health campaigns. Increasing awareness in the general population about the presence of modifiable dementia risk and protective factors is a crucial first step prior to implementation of preventative measures. Targeting specific subgroups, such as individuals with low socioeconomic status and low health literacy, is essential for the reach and effect of a prevention campaign. Outcome of this study was the rationale for an awareness campaign in The Netherlands, called "MijnBreincoach" ("MyBraincoach").

Theories Predicting End-User Acceptance of Telemedicine Use: Systematic Review

BACKGROUND

Only a few telemedicine applications have made their way into regular care. One reason is the lack of acceptance of telemedicine by potential end users.

OBJECTIVE

The aim of this systematic review was to identify theoretical predictors that influence the acceptance of telemedicine.

METHODS

An electronic search was conducted in PubMed and PsycINFO in June 2018 and supplemented by a hand search. Articles were identified using predefined inclusion and exclusion criteria. In total, two reviewers independently assessed the title, abstract, and full-text screening and then individually performed a quality assessment of all included studies.

RESULTS

Out of 5917 potentially relevant titles (duplicates excluded), 24 studies were included. The Axis Tool for quality assessment of cross-sectional studies revealed a high risk of bias for all studies except for one study. The most commonly used models were the Technology Acceptance Model (n=11) and the Unified Theory of Acceptance and Use of Technology (n=9). The main significant predictors of acceptance were perceived usefulness (n=11), social influences (n=6), and attitude (n=6). The results show a superiority of technology acceptance versus original behavioral models.

CONCLUSIONS

The main finding of this review is the applicability of technology acceptance models and theories on telemedicine adoption. Characteristics of the technology, such as its usefulness, as well as attributes of the individual, such as his or her need for social support, inform end-user acceptance. Therefore, in the future, requirements of the target group and the group's social environment should already be taken into account when planning telemedicine applications. The results support the importance of theory-guided user-centered design approaches to telemedicine development.

Older Adults' Attitudes Toward Ambulatory Technology to Support Monitoring and Coaching of Healthy Behaviors: Qualitative Study

Background

Prevention of functional decline demands a holistic perspective of health management. Older adults are becoming avid users of technology; however, technology is not yet largely used in supporting self-management of health in daily life. Previous research suggests that the low adherence to these technologies is likely to be associated with the fact that opinions and wishes of the older population are not always taken into consideration when designing new technology.

Objective

The aim of this study was to investigate the attitudes of older adults living independently regarding technology to support healthy behaviors, addressing nutrition, physical and cognitive function, and well-being.

Methods

In-depth semistructured interviews were performed with 12 older adults addressing 4 themes: (1) current practices in health management, (2) attitudes toward using technology to support health management, (3) wishes from technology, and (4) change in attitudes after actual use of technology. The fourth theme was investigated with a follow-up interview after participants had used a step counter, a smart scale, and a mobile app for 1 month. Data collected were analyzed using inductive thematic analysis.

Results

Participants were active in self-managing their health and foresaw an added value on using technology to support them in adopting healthier behaviors in everyday life. Attitudes and wishes differed considerably per health domain, with cognitive function being the most sensitive topic. Fears from technology mentioned were attention theft, replacement of human touch, and disuse of existing abilities. Poststudy interviews suggest that attitudes toward technology improve after a short period of use.

Conclusions

Technology to support aging in place must target health literacy, allow personalization in the design but also in the use of the technology, and tackle existing fears concerning technology. Further research should investigate the effect of these strategies on the adherence to technology to be used in daily life. We outline a set of recommendations of interest to those involved in developing and implementing technology to support aging in place, focusing on acceptance, barriers, and ethical concerns.

A Tablet App- and Sensor-Based Assistive Technology Intervention for Informal Caregivers to Manage the Challenging Behavior of People With Dementia (the insideDEM Study): Protocol for a Feasibility Study

Background

Despite the enormous number of assistive technologies (ATs) in dementia care, the management of challenging behavior (CB) of persons with dementia (PwD) by informal caregivers in home care is widely disregarded. The first-line strategy to manage CB is to support the understanding of the underlying causes of CB to formulate individualized nonpharmacological interventions. App- and sensor-based approaches combining multimodal sensors (actimetry and other modalities) and caregiver information are innovative ways to support the understanding of CB for family caregivers.

Objective

The main aim of this study is to describe the design of a feasibility study consisting of an outcome and a process evaluation of a newly developed app- and sensor-based intervention to manage CB of PwD for family caregivers at home.

Methods

In this feasibility study, we perform an outcome and a process evaluation with a pre-post descriptive design over an 8-week intervention period. The Medical Research Council framework guides the design of this feasibility study. The data on 20 dyads (primary caregiver and PwD) are gathered through standardized questionnaires, protocols, and log files as well as semistructured qualitative interviews. The outcome measures (neuropsychiatric inventory and Cohen-Mansfield agitation inventory) are analyzed by using descriptive statistics and statistical tests relevant to the individual assessments (eg, chi-square test and Wilcoxon signed-rank test). For the analysis of the process data, the Unified Theory of Acceptance and Use of Technology is used. Log files are analyzed by using descriptive statistics, protocols are analyzed by using documentary analysis, and semistructured interviews are analyzed deductively using content analysis.

Results

The newly developed app- and sensor-based AT has been developed and was evaluated until July in 2018. The recruitment of dyads started in September 2017 and was concluded in March 2018. The data collection was completed at the end of July 2018.

Conclusions

This study presents the protocol of the first feasibility study to encompass an outcome and process evaluation to assess a complex app- and sensor-based AT combining multimodal actimetry sensors for informal caregivers to manage CB. The feasibility study will provide in-depth information about the study procedure and on how to optimize the design of the intervention and its delivery.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11630

Patient Adherence to a Mobile Phone-Based Heart Failure Telemonitoring Program: A Longitudinal Mixed-Methods Study

BACKGROUND

Telemonitoring (TM) can improve heart failure (HF) outcomes by facilitating patient self-care and clinical decision support. However, these outcomes are only possible if patients consistently adhere to taking prescribed home readings.

OBJECTIVE

The objectives of this study were to (1) quantify the degree to which patients adhered to taking prescribed home readings in the context of a mobile phone-based TM program and (2) explain longitudinal adherence rates based on the duration of program enrollment, patient characteristics, and patient perceptions of the TM program.

METHODS

A mixed-methods explanatory sequential design was used to meet the 2 research objectives, and all explanatory methods were guided by the unified theory of acceptance and use of technology 2 (UTAUT2). Overall adherence rates were calculated as the proportion of days patients took weight, blood pressure, heart rate, and symptom readings over the total number of days they were enrolled in the program up to 1 year. Monthly adherence rates were also calculated as the proportion of days patients took the same 4 readings over each 30-day period following program enrollment. Next, simple and multivariate regressions were performed to determine the influence of time, age, sex, and disease severity on adherence rates. Additional explanatory methods included questionnaires at 6 and 12 months probing patients on the perceived benefits and ease of use of the TM program, an analysis of reasons for patients leaving the program, and semistructured interviews conducted with a purposeful sampling of patients (n=24) with a range of adherence rates and demographics.

RESULTS

Overall average adherence was 73.6% (SD 25.0) with average adherence rates declining over time at a rate of 1.4% per month (P<.001). The multivariate regressions found no significant effect of sex and disease severity on adherence rates. When grouping patients' ages by decade, age was a significant predictor (P=.04) whereby older patients had higher adherence rates over time. Adherence rates were further explained by patients' perceptions with regard to the themes of (1) performance expectancy (improvements in HF management and peace of mind), (2) effort expectancy (ease of use and technical issues), (3) facilitating conditions (availability of technical support and automated adherence calls), (4) social influence (support from family, friends, and trusted clinicians), and (5) habit (degree to which taking readings became automatic).

CONCLUSIONS

The decline in adherence rates over time is consistent with findings from other studies. However, this study also found adherence to be the highest and most consistent over time in older age groups and progressively lower over time for younger age groups. These findings can inform the design and implementation of TM interventions that maximize patient adherence, which will enable a more accurate evaluation of impact and optimization of resources.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/resprot.9911.

Implementation of a multicomponent telemonitoring intervention to improve nutritional status of community-dwelling older adults: a process evaluation

OBJECTIVE

The present study aimed to conduct a process evaluation of a multicomponent nutritional telemonitoring intervention implemented among Dutch community-dwelling older adults.

DESIGN

A mixed-methods approach was employed, guided by the process evaluation framework of the Medical Research Council and the Unified Theory of Acceptance and Use of Technology. The process indicators reach, dose, fidelity and acceptability were measured at several time points within the 6-month intervention among participants and/or nurses.

SETTING

The intervention was implemented in the context of two care organisations in the Netherlands.

SUBJECTS

In total, ninety-seven participants (average age 78 years) participated in the intervention and eight nurses were involved in implementation.

RESULTS

About 80 % of participants completed the intervention. Dropouts were significantly older, had worse cognitive and physical functioning, and were more care-dependent. The intervention was largely implemented as intended and received well by participants (satisfaction score 4·1, scale 1-5), but less well by nurses (satisfaction score 3·5, scale 1-5). Participants adhered better to weight telemonitoring than to telemonitoring by means of questionnaires, for which half the participants needed help. Intention to use the intervention was predicted by performance expectancy (β=0·40; 95 % CI 0·13, 0·67) and social influence (β=0·17; 95 % CI 0·00, 0·34). No association between process indicators and intervention outcomes was found.

CONCLUSIONS

This process evaluation showed that nutritional telemonitoring among older adults is feasible and accepted by older adults, but nurses' satisfaction should be improved. The study provided relevant insights for future development and implementation of eHealth interventions among older adults.

Relationship Between Internet Behaviors and Social Engagement in Middle-Aged and Older Adults in Taiwan

Aim: To examine older adults’ Internet use patterns and its relationship with social engagement. Methods: Telephonic interview data of older Internet users from two urban and two rural areas were analyzed (N = 248). Cluster analysis was used to identify their Internet use patterns. Multinomial logistic regression identified characteristics associated with the Internet usage groups, and the multiple regression was used to examine if the Internet usage pattern was associated with social engagement in real life. Results: The majority of older adults in Taiwan using the Internet were considered Leisure users (32%). Others were Sporadic (26%), Instrumental (21%), and Eager users (21%). Leisure and Eager users, but not Instrumental users, had significantly higher scores on social engagement compared with Sporadic users after controlling for sociodemographic and behavioral covariates. Eager Internet users were associated with 22.8% increase in the social engagement level, and Leisure users were associated with 31.2% increase in the social engagement level. Conclusions: Older adults with different Internet behaviors were associated with distinct sociodemographic and social engagement behaviors. Causal relationship is warranted for further investigation.

Expectations regarding eHealth among women with stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) is a common condition with a major impact on quality of life (QoL). Various factors prevent women from seeking help. However, eHealth (Internet-based therapy) with pelvic floor muscle training (PFMT) is an effective and satisfying intervention for these women. We hypothesize that women with symptoms after regular therapy will profit from eHealth. This study explores the expectations regarding an eHealth intervention among women who still suffer from SUI despite treatment.

METHODS

A qualitative study with semistructured interviews was conducted using a grounded theory approach. The study included women with SUI who had ever sought help for their condition.

RESULTS

Thirteen women were interviewed, most whom had experience with PFMT and still suffered from moderate-to-severe incontinence. Two themes emerged from data analysis: the need to meet, and eHealth as a tool to bridge obstacles. Women greatly emphasized that a healthcare professional, preferably one they know, should be available with eHealth. Several women indicated that the absence of personal contact caused lack of trust in success. However, several women were willing to use eHealth because its anonymity and flexibility could overcome obstacles in regular care.

CONCLUSIONS

eHealth based on PFMT is currently not a preferable treatment modality for women who still suffer from SUI despite treatment. eHealth cannot act as a substitute for their positive experience with personal contact. Some women are willing to use eHealth because of its advantages over regular care. Future experiences with eHealth might enable women with SUI to trust digital care.

User-Centered Adaptation of an Existing Heart Failure Telemonitoring Program to Ensure Sustainability and Scalability: Qualitative Study

BACKGROUND

Telemonitoring interventions for the management of heart failure have seen limited adoption in Canadian health systems, but isolated examples of telemonitoring programs do exist. An example of such a program was launched in a specialty heart failure clinic in Toronto, Canada, and a recent implementation evaluation concluded that reducing the cost of delivering the program is necessary to ensure its sustainability and scalability.

OBJECTIVE

The objectives of this study were to (1) understand which components of the telemonitoring program could be modified to reduce costs and adapted to other contexts while maintaining program fidelity and (2) describe the changes made to the telemonitoring program to enable its sustainability within the initial implementation site and scalability to other health organizations.

METHODS

Semistructured interviews probed the experiences of patients (n=23) and clinicians (n=8) involved in the telemonitoring program to identify opportunities for cost reduction and resource optimization. Ideas for adapting the program were informed by the interview results and prioritized based on (1) potential impact for sustainability and scalability, (2) feasibility, and (3) perceived risks to negatively impacting the program's ability to yield desired health outcomes.

RESULTS

A total of 5 themes representing opportunities for cost reduction were discussed, including (1) Bring Your Own Device (BYOD), (2) technical support, (3) clinician role, (4) duration of enrollment, and (5) intensity of monitoring. The hardware used for the telemonitoring system and the modalities of providing technical support were found to be highly adaptable, which supported the decision to implement a BYOD model, whereby patients used their own smartphone, weight scale, and blood pressure cuff. Changes also included the development of a website aimed at reducing the burden on a technical support telehealth analyst. In addition, the interviews suggested that although it is important to have a clinician who is part of a patient's circle of care monitoring telemonitoring alerts, the skill level and experience were moderately adaptable. Thus, a registered nurse was determined to be more cost-effective and was hired to replace the existing nurse practitioners in the frontline management of telemonitoring alerts and take over the technical support role from a telehealth analyst.

CONCLUSIONS

This study provides a user-centered example of how necessary cost-reduction actions can be taken to ensure the sustainability and scalability of telemonitoring programs. In addition, the findings offer insights into what components of a telemonitoring program can be safely adapted to ensure its integration in various clinical settings.

eHealth for people with multimorbidity: Results from the ICARE4EU project and insights from the "10 e's" by Gunther Eysenbach

Background

People with multimorbidity, especially older people, have complex health and social needs, and require an integrated care approach. In this respect, eHealth could be of support. This paper aims to describe the implementation of eHealth technologies in integrated care programs for people with multimorbidity in Europe, and to analyse related benefits and barriers according to outcomes from ICARE4EU study and within the more general conceptual framework of the “10 e's” in eHealth by Gunther Eysenbach.

Methods

In 2014, ICARE4EU project identified 101 integrated care programs in 24 European countries. Expert organizations and managers of the programs completed an on-line questionnaire addressing several aspects including the adoption of eHealth. Findings from this questionnaire were analyzed, by linking in particular benefits and barriers of eHealth with the “10 e's” by Eysenbach (Efficiency, Enhancing, Evidence-based, Empowerment, Encouragement, Education, Enabling, Extending, Ethics, and Equity).

Results

Out of 101 programs, 85 adopted eHealth tools, of which 42 focused explicitly on older people. eHealth could improve care integration/management, quality of care/life and cost-efficiency, whereas inadequate funding represents a major barrier. The “10 e's” by Eysenbach seem to show contact points with ICARE4EU findings, in particular when referring to positive aspects of eHealth such as Efficiency and Enhancing quality of care/life, although Empowerment/Education of patients, care Equity and Ethics issues seem crucial in this respect. Encouragement of a new relationship patient-health professional, and Enabling standardized exchange of electronic information, represent further aspects impacting integration/management of care.

Conclusions

Aspects of eHealth, which emerged as benefits and barriers impacting integration/management of care, as well as cost-efficiency and quality of care/life, can be identified on the basis of both ICARE4EU findings and the “10 e's” in eHealth by Eysenbach. They could represent objectives of new policies for supporting the deployment of eHealth technologies within integrated care across Europe.

A systematic diagnostic evaluation combined with an internet-based self-management support system for patients with asthma or COPD

Introduction

An (inter)national systematic approach for patients with asthma COPD referred to secondary care is lacking. Therefore, a novel systematic approach was designed and tested in clinical practice.

Methods

This was a retrospective observational study of data from the electronic record system of the Leiden University Medical Center. Asthma and COPD patients were included if they were evaluated with a novel systematic approach or if they had a new record for asthma or COPD and received usual care. The novel systematic approach consisted of a predefined diagnostic evaluation combined with an optional internet-based self-management support system. Diagnostic tests, final diagnosis, lifestyle advices, symptoms and individual care plans in the electronic records, number of patients referred back to primary care, and time to referral back to primary care were compared between the systematic approach and usual care groups using t-tests and chi-squared tests.

Results

A total of 125 patients were included, of which 22 (21.4%) were evaluated with the systematic approach. Mean (±SD) age was 48.8 (±18.4) years and 59.2% were women. Mean (±SD) number of diagnostic tests was higher in the systematic approach group compared with the usual care group (7.6±1.0 vs 5.5±1.8, P<0.001). Similarly, in the systematic approach group, more lifestyle advices (81.8% vs 29.1%), symptom scores (95.5% vs 21.4%), and individual care plans (50.0% vs 7.8%) were electronically recorded (P<0.001), and more patients were referred back to primary care (81.8% vs 56.3%, P=0.03). There were no differences in the final diagnoses and time to referral back.

Conclusion

Our study suggested that not all tests that were included in the systematic approach are regularly needed in the diagnostic work-up. In addition, a designated systematic approach stimulates physicians to record lifestyle advices, symptoms, and individual care plans. Thus, this approach could increase the number of patients referred back to primary care.

Patient factors associated with the initiation of telehealth services among heart failure patients at home

Telehealth is an intervention that can assist patients with heart failure to manage their symptoms at home. However, it is reported that between 24-70% of eligible patients do not receive telehealth. This study aimed to explore factors associated with the initiation of telehealth among home care patients with heart failure using the Outcome and Assessment Information Set data (N = 2,832). The findings indicate patients who received high-risk drugs education by visiting nurses had an 80% increase in the odds of receiving telehealth, and patients who received no assistance from caregivers had a 46% decrease in odds compared to those who were assisted at least daily.

A prospective evaluation of telemonitoring use by seniors with chronic heart failure: Adoption, self-care, and empowerment

Telemonitoring leverages technology for the follow-up of patients with heart failure. Limited evidence exists on how telemonitoring influences senior patients’ attitudes and self-care practices. This study examines telemonitoring impacts on patient empowerment and self-care, and explores adoption factors among senior patients. A longitudinal study design was used, involving three surveys of elderly with chronic heart failure (n = 23) 1 week, 3 months, and 6 months after beginning telemonitoring use. Self-care, patient empowerment, and adoption factors were assessed using existing scales. The patients involved in this study perceived value of using telemonitoring, did not expect it to be difficult to use, and did not encounter adoption barriers. There was a significant improvement in patients’ confidence in their ability to evaluate their symptoms, address them, and evaluate the effectiveness of the measures taken to address these symptoms. Yet, patients performed less self-care maintenance activities, and the capability of involvement in the decision-making related to their condition decreased. Telemonitoring can improve seniors’ confidence in evaluating and addressing their symptoms in relation to heart failure. This patient management approach should be coupled with targeted education geared toward self-maintenance and self-management practices.

Reducing patient and provider knowledge gaps: An evaluation of a community informed hepatitis C online course

OBJECTIVES

Hepatitis C (HCV) knowledge gaps are associated with lower levels of engagement in (HCV) care which contributes to HCV-related morbidity and mortality. Knowledge gaps may be exacerbated by rapid changes in HCV care/treatment. Cost-effective, timely and easy-to-implement education is needed to address knowledge gaps and foster HCV engagement.

METHODS

We developed a free, one-hour, online course for patients and providers. Online and facilitated course events were evaluated. Outcome measures included: pre/post-scores, perceived knowledge gains and increased capacity to educate/encourage engagement in HCV care.

RESULTS

Total pre-post-test gains were significant (p < .001) across groups. Over 50% of participants reported: perceived knowledge gains of "A lot" or higher; the course increased their capacity to educate and encourage client engagement in care by "A lot" or higher.

CONCLUSIONS

The evaluation confirmed ongoing patient and provider HCV knowledge gaps, significantly reduced those gaps, and increased provider's capacity to educate and encourage client engagement in HCV care.

PRACTICE IMPLICATIONS

The course is an effective tool to address knowledge gaps that might lower engagement in care. It is available to patients to use in the privacy of their own home or for providers for their personal use, to use with individuals or patient groups.

Rural-Urban Comparison of Telehome Monitoring for Patients with Chronic Heart Failure

INTRODUCTION

Rural geographic isolation may act as a promoting or restraining variable to the diffusion of technology and healthy aging in the community. Telehome monitoring (TM) leverages technology to support seniors living in the community with chronic conditions. To date, limited research has investigated the utilization of TM in rural settings. This study assesses the comparative utilization of TM for patients with heart failure in rural versus urban environments.

MATERIALS AND METHODS

We conducted a cross-sectional study involving chart reviews of all patients enrolled in the TM program at the University of Ottawa Heart Institute during 2014. Data were extracted on urban/rural status, demographic characteristics, and process and outcomes of care. Descriptive, bivariate, and multivariate analyses were conducted.

RESULTS

More rural patients did not have a documented reason for emergency room visits compared to urban patients. There was no significant association between the urban/rural status and the process and outcome measures at the multivariate level. Being followed-up regularly by a family physician and a specialist, as opposed to a specialist or general practitioner only, was associated with significantly longer TM period and a higher number of diuretic adjustments and calls made by nurses.

DISCUSSION

Although more urban patients were older and living alone, their profile did not affect their utilization of TM. The difference in diagnosis between urban and rural patients also did not contribute to such differences. Hence, there is no variation in the process and outcome measures associated with the utilization of TM between urban and rural environments.

CONCLUSIONS

Rural patients may not be perceived as extensive users of resources nor patients who represent challenges in terms of feasibility of TM use.

Understanding Older People's Readiness for Receiving Telehealth: Mixed-Method Study

Background

The Dutch Ministry of Health has formulated ambitious goals concerning the use of telehealth, leading to subsequent changes compared with the current health care situation, in which 93% of care is delivered face-to-face. Since most care is delivered to older people, the prospect of telehealth raises the question of whether this population is ready for this new way of receiving care. To study this, we created a theoretical framework consisting of 6 factors associated with older people’s intention to use technology.

Objective

The objective of this study was to understand community-dwelling older people’s readiness for receiving telehealth by studying their intention to use videoconferencing and capacities for using digital technology in daily life as indicators.

Methods

A mixed-method triangulation design was used. First, a cross-sectional survey study was performed to investigate older people’s intention to use videoconferencing, by testing our theoretical framework with a multilevel path analysis (phase 1). Second, for deeper understanding of older people’s actual use of digital technology, qualitative observations of older people executing technological tasks (eg, on a computer, cell phone) were conducted at their homes (phase 2).

Results

In phase 1, a total of 256 people aged 65 years or older participated in the survey study (50.0% male; median age, 70 years; Q1-Q3: 67-76). Using a significance level of .05, we found seven significant associations regarding older people’s perception of videoconferencing. Older people’s (1) intention to use videoconferencing was predicted by their performance expectancy (odds ratio [OR] 1.26, 95% CI 1.13-1.39), effort expectancy (OR 1.23, 95% CI 1.07-1.39), and perceived privacy and security (OR 1.30, 95% CI 1.17-1.43); (2) their performance expectancy was predicted by their effort expectancy (OR 1.38, 95% CI 1.24-1.52); and (3) their effort expectancy was predicted by their self-efficacy (OR 1.55, 95% CI 1.42-1.68). In phase 2, a total of 6 men and 9 women aged between 65 and 87 years participated in the qualitative observation study. Of the primary themes, 5 themes were identified that could provide greater understanding of older people’s capacities and incapacities in using digital technology: (1) “self-efficacy and digital literacy,” (2) “obstacles to using technology,” (3) “prior experience and frequency of use,” (4) “sources of support and facilitating conditions,” and (5) “performance expectancy.” These 5 themes recurred in all 15 observations.

Conclusions

Performance expectancy, effort expectancy, and perceived privacy and security are direct predictors of older people’s intention to use videoconferencing. Self-efficacy appeared to play a role in both older people’s intention to use, as well as their actual use of technology. The path analysis revealed that self-efficacy was significantly associated with older people’s effort expectancy. Furthermore, self-efficacy and digital literacy appeared to play a major role in older people’s capacities to make use of digital technology.

Examining Internet and eHealth Practices and Preferences: Survey Study of Australian Older Adults With Subjective Memory Complaints, Mild Cognitive Impairment, or Dementia

Background

Interest in electronic health (eHealth) technologies to screen for and treat a variety of medical and mental health problems is growing exponentially. However, no studies to date have investigated the feasibility of using such e-tools for older adults with mild cognitive impairment (MCI) or dementia.

Objective

The objective of this study was to describe patterns of Internet use, as well as interest in and preferences for eHealth technologies among older adults with varying degrees of cognitive impairment.

Methods

A total of 221 participants (mean age=67.6 years) attending the Healthy Brain Ageing Clinic at the University of Sydney, a specialist mood and memory clinic for adults ≥50 years of age, underwent comprehensive clinical and neuropsychological assessment and completed a 20-item self-report survey investigating current technology use and interest in eHealth technologies. Descriptive statistics and Fisher exact tests were used to characterize the findings, including variability in the results based on demographic and diagnostic factors, with diagnoses including subjective cognitive impairment (SCI), MCI, and dementia.

Results

The sample comprised 27.6% (61/221) SCI, 62.0% (137/221) MCI, and 10.4% (23/221) dementia (mean Mini-Mental State Examination=28.2). The majority of participants reported using mobile phones (201/220, 91.4%) and computers (167/194, 86.1%) routinely, with most respondents having access to the Internet at home (204/220, 92.6%). Variability was evident in the use of computers, mobile phones, and health-related websites in relation to sociodemographic factors, with younger, employed respondents with higher levels of education being more likely to utilize these technologies. Whereas most respondents used email (196/217, 90.3%), the use of social media websites was relatively uncommon. The eHealth intervention of most interest to the broader sample was memory strategy training, with 82.7% (172/208) of participants reporting they would utilize this form of intervention. Preferences for other eHealth interventions varied in relation to educational level, with university-educated participants expressing greater interest in interventions related to mood (P=.01), socialization (P=.02), memory (P=.01), and computer-based exercises (P=.046). eHealth preferences also varied in association, with diagnosis for interventions targeting sleep (P=.01), nutrition (P=.004), vascular risk factors (P=.03), and memory (P=.02).

Conclusions

Technology use is pervasive among older adults with cognitive impairment, though variability was noted in relation to age, education, vocational status, and diagnosis. There is also significant interest in Web-based interventions targeting cognition and memory, as well as other risk factors for cognitive decline, highlighting the urgent need for the development, implementation, and study of eHealth technologies tailored specifically to older adults, including those with MCI and early dementia. Strategies to promote eHealth use among older adults who are retired or have lower levels of education will also need to be considered.

Perceived value of eHealth among people living with multimorbidity: a qualitative study

Background

The prevalence of multimorbidity is increasing, creating challenges for patients, healthcare professionals, and healthcare systems. Given that chronic disease management increasingly involves eHealth, it is useful to assess its perceived value among people with multimorbidity.

Objective

To explore challenges related to multimorbidity and patients’ perspectives on eHealth.

Design

Ten semi-structured interviews with adults, living with multimorbidity in Copenhagen, Denmark. Interviews focused on patient-experienced challenges, from challenges related to self-management to challenges experienced in the healthcare sector, as well as perceptions of eHealth. During interviews, participants were presented with pictures of different eHealth technologies. Data analysis followed the systematic text condensation approach.

Results

Participants experienced challenges in their daily lives, e.g. when practicing self-management activities, when navigating the healthcare sector, and when interacting with healthcare professionals. Patient-perceived value of eHealth varied, depending on their burden of illness and treatment: those with a greater burden had more positive perceptions of eHealth, and expressed more intention to use it. Participants with less complex disease patterns and less burdensome treatment regimens were more likely to perceive eHealth as something worthless and undesirable. Participants stressed that eHealth should only be introduced as an optional supplement.

Conclusions

eHealth can potentially address some patient-experienced challenges related to multimorbidity by promoting self-management, patient-centeredness, and access. However, patients’ needs and preferences vary and eHealth cannot substitute the personal interaction between patient and healthcare professionals. Our findings point to the importance of patient assessment and stratification to ensure appropriate use of eHealth.

A Large-Scale Initiative Inviting Patients to Share Personal Fitness Tracker Data with Their Providers: Initial Results

Background

Personal fitness trackers (PFT) have substantial potential to improve healthcare.

Objective

To quantify and characterize early adopters who shared their PFT data with providers.

Methods

We used bivariate statistics and logistic regression to compare patients who shared any PFT data vs. patients who did not.

Results

A patient portal was used to invite 79,953 registered portal users to share their data. Of 66,105 users included in our analysis, 499 (0.8%) uploaded data during an initial 37-day study period. Bivariate and regression analysis showed that early adopters were more likely than non-adopters to be younger, male, white, health system employees, and to have higher BMIs. Neither comorbidities nor utilization predicted adoption.

Conclusion

Our results demonstrate that patients had little intrinsic desire to share PFT data with their providers, and suggest that patients most at risk for poor health outcomes are least likely to share PFT data. Marketing, incentives, and/or cultural change may be needed to induce such data-sharing.

Use of the Internet as a prevention tool against cognitive decline in normal aging

Recent demographic trends indicate that older people appear to be one of the fastest growing population groups worldwide. In the year 2000, people older than 65 years represented 12.4% of the population. This number is expected to rise to 19% by 2030, particularly in developed countries. Therefore, there is sustained effort at both national and international levels to prolong the active life of these people as long as possible. Since the present older generation at the age of 55 years is already digitally literate, the use of technologies is one of the solutions. The purpose of this study is to discuss the role of the Internet in the prevention of cognitive decline in normal aging. The author examines clinical studies that exploit the use of the Internet, including online training programs, in the prevention of cognitive decline in healthy older individuals. The findings of the clinical studies indicate that the use of the Internet, especially online cognitive training programs, may have a positive effect on the improvement of cognitive functions in healthy older adults. Nevertheless, larger sample longitudinal randomized controlled clinical trials aimed at the prevention of cognitive decline among healthy older adults are needed.

Analyzing older users' home telehealth services acceptance behavior-applying an Extended UTAUT model

BACKGROUND

Although telehealth offers an improved approach to providing healthcare services, its adoption by end users remains slow. With an older population as the main target, these traditionally conservative users pose a big challenge to the successful implementation of innovative telehealth services.

OBJECTIVES

The objective of this study was to develop and empirically test a model for predicting the factors affecting older users' acceptance of Home Telehealth Services (HTS).

METHODS

A survey instrument was administered to 400 participants aged 50 years and above from both rural and urban environments in Slovenia. Structural equation modeling was applied to analyze the causal effect of seven hypothesized predicting factors. HTS were introduced as a bundle of functionalities, representing future services that currently do not exist. This enabled users' perceptions to be measured on the conceptual level, rather than attitudes to a specific technical solution.

RESULTS

Six relevant predictors were confirmed in older users' HTS acceptance behavior, with Performance Expectancy (r=0.30), Effort Expectancy (r=0.49), Facilitating Conditions (r=0.12), and Perceived Security (r=0.16) having a direct impact on behavioral intention to use HTS. In addition, Computer Anxiety is positioned as an antecedent of Effort Expectancy with a strong negative influence (r=-0.61), and Doctor's Opinion influence showed a strong impact on Performance Expectancy (r=0.31). The results also indicate Social Influence as an irrelevant predictor of acceptance behavior. The model of six predictors yielded 77% of the total variance explained in the final measured Behavioral Intention to Use HTS by older adults.

CONCLUSION

The level at which HTS are perceived as easy to use and manage is the leading acceptance predictor in older users' HTS acceptance. Together with Perceived Usefulness and Perceived Security, these three factors represent the key influence on older people's HTS acceptance behavior. When promoting HTS, interventions should focus to portray it as secure. Marketing interventions should focus also on promoting HTS among health professionals, using them as social agents to frame the services as useful and beneficial. The important role of computer anxiety may result in a need to use different equipment such as a tablet computer to access HTS. Finally, this paper introduces important methodological guidelines for measuring perceptions on a conceptual level of future services that currently do not exist.