Computers in Biology and Medicine 43 (2013) 281–286

Contents lists available at SciVerse ScienceDirect

Computers in Biology and Medicine

journal homepage: www.elsevier.com/locate/cbm

Innovative health care delivery system—A questionnaire survey to

evaluate the influence of behavioral factors on individuals’
acceptance of telecare
Jui-Chen Huang n
Department of Health Business Administration, Hungkuang University, No.1018, Sec.6, Taiwan Blvd., Shalu Dist., Taichung City 43302, Taiwan, R.O.C

a r t i c l e i n f o abstract

Article history: The purpose of this research is to explore people’s intention to use telecare and evaluate the degree of
Received 29 June 2011 influence that behavioral factors on individuals’ acceptance of telecare. The subjects are residents of
Accepted 27 December 2012 Taiwan. The Structural Equation Modeling (SEM) technique was used to analyze the forecasting model
applied to telecare. The results show that this model has good explanatory power for the behavioral
Keywords: intentions of using telecare. Among factors influencing the behavioral intentions of using telecare, the
Telecare strongest factor is attitude, followed by the perceived usefulness, the perceived ease of use, subjective
Technology acceptance model norms, and personal innovativeness, respectively. The findings of this study may serve as a reference to
TAM future studies.
Innovation
& 2013 Elsevier Ltd. All rights reserved.

1. Introduction On the other hand, the implementation of telecare may be

An aging population structure leads to a considerable demand for
health care, in turn, increases the medical care expenses. The
demand for long-term care services is expected to increase from
48.7% to 59.9% over the next 10 years [47,60]; hence, it is important
to integrate medical care resources to achieve resource sharing. Care
devices based on information and communication technologies
(ICTs) include real-time visual and auditory contacts and relation-
ships between caregivers and users, clothing and household furnish-
ings that monitor patients inside and outside their homes, and
electronic bracelets that keep track of patients’ symptoms [11].
Telecare can be used in home health care, and to prevent and
monitor illness [34]. In particular, the use of telecare on chronic
ailments has been confirmed highly effective [8,10,30,35,39,46], and
is able to reduce the expanding medical expenses [6,29,39,45,61].
Organizational and societal changes, such as cost reduction policies
and an aging population, are the main driving forces for the
development of telecare [9]. Patients are generally satisfied with
telecare, but they prefer a combination of telecare with conventional
health care service [10]. Even though telecare offers many benefits
[70], there are organizational, ethical, legal, design, usability and
other matters that need to be resolved before it becomes prevalent
[10]. Evers and Loey [25] indicated that telecare has been regarded
as a potential solution for many years but has yet to be accepted,
due to legal, technical and ethical problems. Horton [32] pointed out
that many telecare devices are not user-friendly and bulky.
associated with user resistance [42,12]. Ignoring the user side of
such technological innovation may limit its usefulness and inter-
fere with user intentions [51]. Or and Karsh [48] performed a
systematic literature review to identify the variables promoting
consumer health information technology (CHIT) acceptance
among patients. They suggested that future research guided by
technology acceptance theories should improve the understand-
ing of patients’ CHIT acceptance, which in turn could lead to
better CHIT design and implementation. Koch and Hägglund [40]
suggested that health informatics in elderly care is an expanding
field of interest, but there is still a lack of knowledge concerning
the elderly technological needs and the optimal design. There are
scanty evaluation studies on telecare, particularly those with an
evaluation framework of the integrated model. In comparison
with studies in other countries, relevant studies in Asian area are
insufficient [39].
Acknowledging the advantages of telecommunication technol-
ogy and medical care, the Taiwanese government in 2008
included telecare as a development project in the emerging
service industry. Therefore, it is important to explore and forecast
the public’s willingness to use telecare, which is the motive of
this study.
2. Prior research and theoretical background
2.1. Technology acceptance model (TAM)

n
Tel./fax: þ886 3 5502 347. The technology acceptance model (TAM) proposed by Davis
E-mail address: juichen@ms17.hinet.net [20] has been supported by numerous studies, and has been well

0010-4825/$ - see front matter & 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.compbiomed.2012.12.011
282 J.-C. Huang / Computers in Biology and Medicine 43 (2013) 281–286
researched in the area of information systems for nearly two
decades. It has been successfully applied to predict the usage
intention for a variety of new technologies [13,37]. TAM [20,21] is
comprised of five constructs: perceived ease of use (PEOU),
perceived usefulness (PU), attitude toward using (ATT), beha-
vioral intention to use (BI), and actual system use (AU). Of these,
BI is modeled as a function of ATT and PU, and it determines the
actual use. ATT is determined by a function of PU and PEOU. PEOU
affects PU, and ATT affects BI directly. PU is defined as ‘‘the degree
to which a person believes that using a particular system would
enhance his or her job performance’’, and PEOU as ‘‘the degree to
which a person believes that using a particular system would be
free from effort’’ [20]. ATT is defined as positive or negative
feelings toward the information technology (IT). BI is defined as
‘‘a person’s subjective probability that he will perform some
behavior’’ [26] Substantial empirical evidences have accumulated
to support the notion that attitude mediates PU and BI in using
information systems [38,24,62].
Relevant studies [62,63] have suggested that TAM should
integrate other theories of acceptance in order to incorporate
relevant human and social factors, and facilitate its predictive and
explanatory power. In addition, the number of studies on TAM in
the field of health care, particularly in medical informatics, is
rather limited. As a result, the development of TAM has been
considered from an aspect of providing greater empirical health
care [15,16,36,50,69]. Wilson and Lankton [65] indicated that
future research should consider using other methods or con-
structs in order to develop a better model. Holden and Karsh [31]
reviewed over 20 studies using health IT for patient care, all of
which had been published on or before July 2008. They suggested
that TAM can predict a substantial portion of the use or accep-
tance of health IT, but that the theory may benefit from several
additions and modifications, indicating that there is a need to
continue exploring new theoretically motivated variables and
relationships that can be added to TAM. Djamasbi, Strong, and
Dishaw [22] pointed out that TAM does not always adequately
explain user behavior. Based on the above studies, this study
suggests that future studies should investigate the important
factors that influence the acceptance of e-health by patients.
Thus, the following hypotheses are proposed:
H1a. Perceived ease of use (PEOU) has a direct effect on the
attitude toward using (ATT) of telecare.
H1b. Perceived ease of use (PEOU) has a direct effect on per-
ceived usefulness (PU).
H2a. Perceived usefulness (PU) has a direct effect on the attitude
toward using (ATT) of telecare.
H2b. Perceived usefulness (PU) has a direct effect on behavioral
intention to use (BI).
2.2. Innovativeness
Goldsmith and Hofacker [27] defined innovativeness as ‘‘the
relative willingness of a person to try a new product or service’’.
Rogers [54] referred to innovativeness as ‘‘the degree to which an
individual or other unit of adoption is relatively earlier in
adopting new ideas than other members of the social system’’.
There is no consensus in the definition of innovativeness [53].
Agarwal and Prasad [1], and Chang, Cheung, and Lai [14] indicated
that the perceptions of an innovation are a key independent
variable of information technology adoption.
Schillewaert, Ahearne, Frambach and Moenaert [58] pointed
out that individual innovativeness directly affects technology
adoption, positively affects perceived ease of use (PEOU) [38,49],
and affects adoption indirectly through the usefulness and ease of
use. Referring to the definition proposed by Rogers [54], this
study developed the following hypotheses:
H3a. Innovativeness positively affects perceived ease of use
(PEOU).
H3b. Innovativeness positively affects perceived usefulness (PU).
2.3. Subjective norm
The subjective norm (SN) is the person’s perception that most
people who are important to him think he should or should not
perform the behavior in question [26]. Holden and Karsh [31]
indicated a number of studies that had tested potentially impor-
tant relationships not specified in the original TAM [66], such as
the effect of the subjective norm [15,16,17,19,23,52,55,56,67]. In
most cases, the subjective norm is directly and significantly
related to a person’s intention to use the system and
the perceived usefulness (PU) [17,23,41,43,52,55,56,57,67,68].
The following hypotheses are thus proposed:
H4a. Subjective norm (SN) has a direct effect on perceived
usefulness (PU).
H4b. Subjective norm (SN) has a direct effect on behavioral
intention to use (BI).
As many previous theories and studies have indicated, BI and
the usage of technology share a strong and significant causal
relationship, and this can be used to predict the actual usage
[18,44,59,64]. Agarwal and Prasad [2] argued that for a survey-
based research design, behavioral intention is more appropriate
than actual usage, as ‘‘it is measured contemporaneously with
beliefs’’. Ajzen [3] proposed TPB (the theory of planned behavior).
He regarded behavioral intention to use (BI) as a prerequisite for
action, and that the use of attitude toward using (ATT) only
cannot directly predict behavior. In contrast, only behavioral
intention to use (BI) can enable accurate predictions [3–5].
The research model of this study is as shown in Fig. 1.
The theory of reasoned action (TRA) proposed by Fishbein and
Ajzen [26] suggests that if the attitude of an individual toward
behavior is more positive, the individuals’ behavioral intention to
use (BI) will be relatively stronger. Thus, the following hypothesis
is proposed:
H5. An individual’s attitude toward using (ATT) and behavioral
intention to use (BI), with respect to telecare, are positively
associated.
3. Materials and methods
3.1. Research design and data collection procedures
The questionnaire was pre-tested to verify the appropriateness
of the questionnaire content. Content validity was ensured
through an extensive literature review of academic and practical
journals, as well as discussions with eight experts in this domain.
Since telecare is in its incipient stages in Taiwan, a convenience
sample was used in order to deal with the fact that most people
had little knowledge of telecare, which could undermine the
effectiveness of the questionnaire. Therefore, this study selected
individuals aged 15 years and older, and who had visited the
Taiwan International Senior Lifestyle and Health Care Exhibition,
as the subjects. A detailed telecare description was provided to
the subjects. A total of 369 valid samples were retrieved, with
females accounting for 53% of the respondents. Most of the
respondents are in the 35–44 age group (34%), followed by the
 J.-C. Huang / Computers in Biology and Medicine 43 (2013) 281–286 283

H4b

H4a
SN PU H2b
H2a

H3b
H1b ATT BI
H5

H1a
Innovativeness PEOU
H3a

Fig. 1. The research model. Note: perceived ease of use (PEOU), perceived usefulness (PU), Subjective norm (SN), attitude toward using (ATT), behavioral intention to
use (BI).

45–54 age group (30%); 53% of the respondents have university or Table 1
graduate education; their average monthly income ranged The demographic characteristics of the participants.
between NT$50,000 and NT$80,000 (US$1ENT$28.92) (see
Characteristics of the participants Number of Percentage of
Table 1). participants participants (%)

3.2. Measures of the constructs Gender

Male 173 47
Female 196 53
The contents of the questionnaire was based on the definition
Age (years old)
and constructs of TAM [20,21], innovativeness [54], and subjec-
15  24 16 4
tive norm (SN) [26]. Four constructs, namely perceived ease of use 25  34 43 12
(PEOU), perceived usefulness (PU), attitude toward using (ATT), 35  44 125 34
and behavioral intention to use (BI), were included. The oper- 45  54 109 30
ationalization and sources of the questionnaire items in this study 55  64 48 13
4 65 28 8
are shown in Table 3. The measurement was based on a five-point
Likert-type scale, ranging from 5 (strongly agree) to 1 (strongly Marital status
Married 185 50
disagree).
Single 184 50
Education
3.3. Data analysis methods Junior high school or below 28 8
Senior high (vocational) school 67 18
Junior College 80 22
Confirmatory factor analysis (CFA) was conducted to examine
University 129 35
the reliability and validity of the measurement model, and the Master degree or above 65 18
structural equation modeling (SEM) was employed to interpret the
Monthly household income (US$1 ENT$28.92)
causal model, using LISREL 8.7 as the instrument of information o NT $20,000 8 2
analysis. Each of the impact coefficients was estimated using the NT$ 20,001 50,000 98 27
maximum likelihood estimates method, while the model’s overall NT$ 50,001 80,000 196 53
goodness of fit was evaluated using the following seven indicators: NT$ 80,001 120,000 61 17
4 NT$ 120,001 6 2
the chi-square statistic/degree of freedom, the goodness-of-fit index
(GFI), the adjusted goodness-of-fit index (AGFI), the normed fit
index (NFI), the comparative fit index (CFI), the root mean square
residual (RMR), and the root mean square error of approximation Table 2
(RMSEA). Fit indices for measurement and structural models.

Fit indices Recommended value Measurement model Structural model

4. Results
GFI Z 0.9 0.91 0.90
AGFI Z 0.8 0.88 0.87
4.1. Reliability and validity of the measurement model NFI Z 0.9 0.99 0.99
CFI Z 0.9 0.99 0.99
In this study, the measurement model included 21 indicators RMSEA r 0.1 0.06 0.06
RMR r 0.05 0.03 0.04
describing six latent constructs (PEOU, PU, Innovativeness, SN, ATT, w2/d.f. r3 2.12 2.33
and BI). As suggested by Hu and Bentler [33], the overall model fit
was assessed by several goodness-of-fit indices: the chi-square
statistic/degree of freedom, GFI, AGFI, NFI, CFI, RMR, and RMSEA. model was assessed using Cronbach’s alpha and construct reliability
The results of the CFA are presented in Table 2. The goodness-of-fit (see Table 3). The construct reliabilities (ranging from 0.83 to 0.92)
indices suggested that the measurement model was a good fit to the and alpha coefficients (ranging from 0.82 to 0.92) for all of the six
data. Therefore, this study further evaluated the psychometric proper- constructs were higher than the benchmark of 0.6, as suggested by
ties of the measurement model in terms of its reliability, convergent Bagozzi and Yi [7]. This demonstrated high internal consistency, and
validity, and discriminant validity. in turn, the reliability of each construct.
CFA was used to examine the reliability and validity of the The construct validity included convergent and discriminant
measurement model. The internal consistency of the measurement validities. The results of the test of convergent validity are presented
284 J.-C. Huang / Computers in Biology and Medicine 43 (2013) 281–286

in Table 3. The results revealed that most of the standardized factor
loadings of the indicators in each construct were higher than the
suggested level of 0.50 [28]. Furthermore, they were statistically
significant, at po0.01. Hence, the convergent validity of the
measurement indicators was supported. In addition, a discriminant
validity test was performed to establish the distinction among the
constructs used in this study. This study followed the method
suggested by Hair et al. [28] to pair these two latent constructs
and subject them to two models of CFA. The first model allowed the
correlation between the two constructs to be estimated (uncon-
strained), while in the other model, the correlation between the two
constructs was set at 1 (constrained). The chi-square difference test
was then employed to compare the two models. All of the
chi-square difference values were statistically significant, at
po0.01. Hence, the discriminant validity was confirmed.

Table 3
Reliability and validity results. 4.2. Structural model

Categories
Perceived ease of use (0.91, 0.91)a [20,21]
I find that using the telecare is simple.
I find that the telecare is easy to learn.
I find that the telecare is easily understandable and clear.
Overall, I find that using the telecare is convenient.
Perceived usefulness (0.91, 0.91)a [20,21]
I find that using the telecare is helpful in monitoring health. 0.85
Telecare can enhance my level of convenience in accessing 0.89
medical care service.
Overall, I find the telecare highly useful.
Innovativeness (0.83, 0.82)a [54]
I’m the first to try new technology among the surrounding
people.
I like to try new technology.
I’m open to new ideas.
Subjective norm (0.83, 0.84)a [26]
Relatives encourage and support me to use the telecare.
Friends encourage and support me to use the telecare.
Medical care personnel encourage and support me to use the
telecare.
Media endorses the use of the telecare.
Attitude toward using (0.89, 0.89)a [62]
I like using the telecare.
Overall, I consider the telecare to be just right.
In my old age, using the telecare would be ideal.
Behavioral intention to use (0.92, 0.92)a [62]
Overall, I am highly willing to use the telecare.
If necessary, I would use the telecare often.
In my old age, I am willing to use the telecare.
In my old age, I would use the telecare often.
Standardized The SEM technique was used to interpret the causal model.
factor loading The structural model was a good fit to the data (see Table 2), and
the variance explained that with respect to the structural model,
0.83 the R2 value of the behavioral intention to take action was 0.80
0.85 (higher than 0.5). This implied that the structural model had
0.87 adequate favorable explanatory power.
0.84
Fig. 2 indicates the relationship of the structural model, and
demonstrates the standardized path coefficients of the significant
structural relationships among the tested variables. Perceived ease of
use (PEOU, standardized path coefficient¼ 0.39) was found to
significantly and positively affect attitude toward using (ATT); there-
0.88 fore, Hypothesis 1a was supported. Perceived ease of use (PEOU,
standardized path coefficient¼0.77) was found to significantly and
positively affect perceived usefulness (PU); therefore, Hypothesis 1b
0.77 was supported. Perceived usefulness (PU, standardized path
coefficient¼0.60) was found to significantly and positively affect
0.84
0.75
attitude toward using (ATT); therefore, Hypothesis 2a was supported.
Innovativeness (standardized path coefficient¼0.91) was found to
significantly and positively affect perceived ease of use (PEOU);
0.59 therefore, Hypothesis 3a was supported. SN (standardized path
0.73 coefficients¼0.28 and 0.22, respectively) was found to significantly
0.80 and positively affect both perceived usefulness (PU) and behavioral
intention to use (BI); therefore, Hypotheses 4a and 4b were sup-
0.86
ported. Attitude toward using (ATT, standardized path
coefficient¼0.99) was found to significantly and positively affect
behavioral intention to use (BI); therefore, Hypothesis 5 was sup-
0.88
0.84 ported. As the impact of perceived usefulness (PU) on behavioral
0.84 intention to use (BI) and the impact of Innovativeness on perceived
usefulness (PU) were not statistically significant, it was supposed
that Hypotheses 2b and 3b were not supported.
0.90
0.84
0.89
5. Discussion
0.82

a
Values in parentheses for constructs indicate construct reliability and The purpose of this research was to explore people’s intention to
Cronbach’s alpha, respectively. use telecare and evaluate the degree of influence that behavioral

H4b: 0.22*

H4a: 0.28*
SN PU (R2=0.97)
H2b: n.s.
H2a: 0.60*

H3b: n.s.
H1b: 0.77* ATT (R2=0.83) BI (R2=0.80)

H5: 0.99*
H1a: 0.39*
Innovativeness PEOU (R2=0.82)
H3a: 0.91*

Fig. 2. Hypotheses testing results. Note: perceived ease of use (PEOU), perceived usefulness (PU), Subjective norm (SN), attitude toward using (ATT), behavioral intention to
use (BI). *Path coefficient is significant at the 0.05 level. n.s. insignificant at the 0.05 level.
 J.-C. Huang / Computers in Biology and Medicine 43 (2013) 281–286
factors on individuals’ acceptance of telecare. The results indicated
that the forecasting model of telecare, based on the perceived ease of
use (PEOU), perceived usefulness (PU), personal innovativeness,
subjective norms, attitudes, and intention, could be accepted. Further-
more, the explanatory power of the willingness to use telecare
achieved 80%, indicating that the forecasting model of telecare could
effectively forecast and explain people’s willingness of use.
The model showed good fit, and thus, it is a useful reference for
future studies. This study made a number of important findings.
First, the perceived ease of use (PEOU) has a significant positive
effect on the perceived usefulness (PU), indicating that the ease of
use of the system affects the perceived usefulness (PU). To enhance
the perceived ease of use (PEOU), it is suggested to create operating
interfaces that are user-friendlier, and to provide a demonstration
system for practice, in order to make users feel more comfortable to
use the system. In addition, education is important for users’ ease of
use, as the users could realize that telecare is a useful, convenient,
and accessible service. The perceived usefulness (PU) has a signifi-
cant positive effect on the users’ attitude, indicating that the attitude
toward using (ATT) is positively affected when people find the
system to be helpful. This could mean that users will adopt a new IT
system if they perceive the system as useful, even if they dislike it.
The acceptance of innovation has a significant positive effect on the
perceived ease of use (PEOU) of telecare; in other words, users with
higher acceptance of innovation will regard the system as easy to
use. For users with low acceptance toward innovation, it is sug-
gested to find ways reduce their anxiety toward new technology
and increase their willingness to use. For those with higher
acceptance of innovation, it is suggested to increase the variety of
telecare access to meet their needs. The findings of this study
suggested that when developing user training programs, reducing
users’ anxiety will be helpful. Another suggestion is to develop
multi-functional accessories, such as multi-language accessories
with touch screens. This study found that individual innovativeness
could enhance attitudes toward using telecare. Updating and chan-
ging users’ ideas regarding telecare may influence others’ acceptance
of innovativeness, thereby achieving the acceptance and adoption of
telecare. The acceptance of innovation has no significant effect on
the perceived usefulness (PU), suggesting that users will not find a
system to be helpful when the acceptance of innovation is high. The
subjective norms have both direct and indirect effects on the
behavioral intention of use (BI), indicating that the intention of
use will be affected by the support of friends and family. The
subjective norms have a significant and positive effect on the
perceived usefulness (PU) of telecare, indicating that users will find
telecare helpful when they are supported by their friends and
families. It is suggested that hospitals could host medical care
seminars to provide useful information to the public, and use the
media to enhance the willingness of use. Attitude has a positive
effect on the behavioral intention of using telecare, indicating that a
higher attitude of use will lead to a higher willingness of use.
Therefore, the willingness of use can be enhanced by increasing the
users’ attitude of use, as the willingness of use will increase when
users have a positive attitude toward the use of telecare.
6. Conclusion
According to the degree of influence of the behavior intentions,
the strongest factor was attitude toward using (ATT), followed by
the perceived usefulness (PU), the perceived ease of use (PEOU), the
subjective norms and personal innovativeness, respectively. This
study was conducted from the viewpoint of users in order to
ascertain the critical factors that affect telecare usage, in order to
create a more comprehensive evaluation system. This research
supplemented relevant studies by pointing out that there are
285
insufficient studies on telecare evaluation, especially in Asia. For
industries, this may accelerate the development of the digital health
industry and help to effectively integrate information communica-
tion with the technology industry, the generic service industry and
the health care industry, in order to improve people’s lives.
The research model showed a good fit, and thus, is a useful
reference for future studies, developers of technology, and policy
makers. The results were consistent with Wilson and Lankton
[65], who indicated that future research should consider using
other methods or constructs in order to develop an improved
model. On the other hand, the findings of this research suggested
that telecare innovativeness and subjective norm are likely to be
important constructs in users’ acceptance of telecare. Therefore,
this study proposed that these two factors should be included in
future telecare acceptance models. More research on telecare and
its effects needs to be conducted, in order to provide evidence for
optimizing the use of this promising technique.
There were a number of research limitations of this study.
Telecare is a technology in Taiwan; therefore, the general public
has limited knowledge of it. The analysis on the formation of the
model from the perspective of the general public may have
affected the accuracy of this study, and it was difficult to collect
data. Consequently, this study selected representative audiences
attending an international exhibition as the subjects. Although
this method could solve the predicament, the subjects might have
been those who were interested in such a topic or those with a
higher level of education. As a result, in addition to conducting a
pre-test and testing expert content validity during the distribu-
tion of questionnaires, this study used convenience sampling to
select 60 subjects who did not attend the exhibition, in order to
investigate the cognitive difference between them and those who
attended the exhibition. The result showed that there was no
statistically significant difference. Therefore, the reliability, valid-
ity, and representativeness of this study were all acceptable.
However, in the future, it is advised to conduct large-scale studies
where a larger sample size of subjects can be selected, in order to
strengthen the investigation on this important issue.
Conflict of interest statement
No competing financial interests.
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Jui-Chen Huang is an assistant professor in the Department of Health Business
Administration, Hungkuang University, Taiwan. She received her Ph.D. degree in
Technology Management from Chung-Hua University, Taiwan, as well as an MS in
Public Health from Kaohsiung Medical University, Taiwan. Her current Ph.D.
research interests include healthcare information management, technology man-
agement, artificial intelligence techniques, technology acceptance, innovation
evaluation, long-term care management, and marketing. She has many papers
published in SSCI, SCI and EI journals, and she is a reviewer of many SCI, SSCI and
EI journals. She is listed in Marquis Who’s Who in Science and Engineering (2011–
2012), Marquis Who’s Who in Medicine and Healthcare (2011–2012), and Marquis
Who’s Who in Asia (2012).