ORIGINAL RESEARCH
An Empirical Study of Adopting Mobile
Healthcare Service: The Family’s
Perspective on the Healthcare Needs
of Their Elderly Members
Wen-Yuan Jen, Ph.D.,1 and Ming-Chien Hung, Ph.D.2
1
National United University, Institute of Information and Society,
Miao-Li, Taiwan.
2
Department of Information Management, Nanhua University,
Chia-Yi, Taiwan.
Abstract
In an aging society, the issue of increased medical costs troubles both
government agencies and families with aging parents. Many elderly
people require long-term care, and the medical and financial prob-
lems associated with long-term care worry their entire family. Mobile
healthcare service (MHS) has been widely applied by medical
practitioners and researchers for years. Unfortunately, the elderly
often fear both the technology and the cost its use incurs; hence, they
seldom actively adopt MHS without the prompting and support of
other family members. This study highlights this issue of long-term
healthcare for the elderly and extracts the factors affecting their
family’s intentions in adopting MHS. Based on the integration of the
Theory of Planned Behavior and the Technology Acceptance Model,
the factors associated with the family’s intention of the aging people
toward MHS are explored. Data were collected from 200 students in
the ‘‘Job Master’’ track in a local ‘‘Executive Master of Business
Administration’’ program. Half of them had at least one immediate
family member who was older than 65 years of age. A partial least
squares (PLS) analysis shows that ‘‘attitude’’ significantly affected
the behavioral intention of adopting MHS, and ‘‘perceived useful-
ness’’ and ‘‘perceived ease-of-use’’ had an indirect effect via ‘‘atti-
tude.’’ The PLS model explains the variance in intention (64.1%),
DOI: 10.1089=tmj.2009.0093 ª M A R Y A N N L I E B E R T , I N C . . VOL. 16
attitude (58.1%), and perceived usefulness (33.8%). Overall, this
study shows that attitude was an important determinant of MHS
adoption. Gender also significantly affected the relationship between
attitude and behavioral intention to adopt MHS.
Key words: mobile healthcare service, aging people, theory of
planned behavior, technology acceptance model
Introduction
T
aiwan is currently facing a demographic dilemma; fewer
children are being born, and the overall population is aging.
At the same time, the cost of medical care is increasing
yearly.1 The issue of increased medical expenses for an
aging population is a thorny issue awaiting solution.2 A report on
healthcare for elderly Americans shows that 85% of people age 65
and older report at least one chronic condition; more than half report
at least two; and more than a quarter report three or more.3 Hence, we
have to work hard to provide effective healthcare resources for the
elderly. With increasing improvement in mobile technology, mobile
healthcare is becoming an increasingly effective and economical
approach for providing healthcare services to the elderly.
Chronically ill elderly require more long-term care than other
segments of the population. Providing healthcare for the elderly is an
increasingly heavy burden and an important issue for families with
elderly parents, insurers, and government agencies. Loera points out
that the elderly perceive that mobile healthcare service (MHS) might
positively improve their access to healthcare services.4 Although
Loera found the application of MHS was a convenient approach for
most elderly people, some of them might have difficulty using MHS
N O . 1 . J A N U A R Y=F E B R U A R Y 2 0 1 0 TELEMEDICINE and e-HEALTH 41
JEN AND HUNG
technology. Moreover, fear of increased financial burden may cause
the elderly to delay their use of MHS, thereby worrying family
members and endangering their own health.
Information provided by MHS is shared by patients, their families,
and medical care providers. However, past studies provide an in-
complete picture of a family’s intention to provide MHS for their
elderly. While identifying the benefits of innovative mobile service to
users is important,5 it is also important to investigate the factors
affecting the acceptance of mobile healthcare technology.6 As con-
cerned family members are the primary buyers of MHS services for
elderly patients, this study investigates MHS purchaser intention
(immediate family of elderly patients) rather than user intention
(elderly patients). Employing an intention-based approach, this study
examines the integrated model derived from Theory of Planned Be-
havior (TPB) and Technology Acceptance Model (TAM) to extract the
factors influencing a family’s intention of providing MHS services to
their elderly members.
TPB is grounded on the Theory of Reasoned Action (TRA),7,8 which
focuses on the behaviors of people who have incomplete volitional
control.8 TRA regarded behavior (B) as a direct function of behavioral
intention (BI) and represented the antecedents of BI through attitude
(A), which reflects the favorable or unfavorable feelings to perform
a behavior, and subjective norm (SN), which reflects individual per-
ceptions of social pressure to perform or not to perform the behavior.
As an extension of TRA, TPB adds the concept of perceived behavioral
control (PBC), which reflects the perceptions of ease or difficulty of
performing the behavior to address conditions in which the individual
does not have complete control over the performed behavior.8,9 In TPB,
behavior is determined by BI and PBC; BI is a weighted function of
attitude, subjective norm, and PBC. TPB can be formally stated below:
B ¼ w1 BI þ w2 PBC
BI ¼ w3 A þ w4 SN þ w5 PBC
where w is weight.
Using TRA and TPB, it is difficult to identify a stable set of belief
structures for attitude.9 Likewise, SN is difficult to draw out from the
mediator effort of attitude.8 TAM is a special case of TRA in which
two beliefs are specified: perceived usefulness (PU), which reflects
user’s subjective belief that using the technology will increase
her=his performance, and perceived ease-of-use (PEOU), which in-
dicates the degree to which the mobile health service technology is
easy to understand or operate. These factors comprise attitude and
exclude the roles of subjective norm9,10 and personal control factors
on behavior.9 TAM regards behavior as a direct function of BI, and BI
is modeled by attitude and PU. PEOU is a direct determinant of PU;
42 TELEMEDICINE and e-HEALTH J A N U A R Y=F E B R U A R Y 2 0 1 0
attitude mediates the link between intention and beliefs about PU and
PEOU. That is,
B ¼ BI ¼ w1 A þ w2 PU
A ¼ w3 PU þ w4 PEOU
PU ¼ w5 PEOU
In past studies, the explanatory power of TPB and TAM has been
inconsistent. While TAM focuses on the characteristics of system
design and is particularly useful as a guide to design efforts, TPB pays
more attention to normative and control factors so that organizations
can easily implement the system based on those characteristics.9 In
Chinese tradition, long-term healthcare of the family’s elderly is a
filial obligation. As perceived ability and control may be important
determinants of behavior,8,9 we used TPB as a direct predicting model
of behavior intention and regarded the PU and PEOU as determinants
of attitude that indirectly influence behavior intention. That is,
BI ¼ w1 A þ w2 SN þ w3 PBC
A ¼ w4 PU þ w5 PEOU
PU ¼ w6 PEOU
BI is the most important determinant of behavior for current
predicting models for information technology (IT) use,9 and the
formation of an intention to carry out a behavior is regarded as a
necessary precursor to behavior.8,9 As behavior can be predicted from
intention with considerable accuracy when behavior poses no serious
problems of control,8 selecting intention as the measurement of be-
havior is theoretically justifiable and pragmatically adequate for IT in
the early stages, especially because use is not yet widespread.6 This
article assessed the effects of attitude, SN, and PBC on BI, but it did
not directly measure behaviors. Additionally, attitude often plays a
major role in deciding IT use, and because personal demographics
(e.g., age, gender, education level, monthly salary, marital status, and
age and residency of parents) may influence attitudes toward IT, the
moderator effect of demographics should be further explored. Thus,
we modified the function of BI as below:
BI ¼ w1 A þ w2 SN þ w3 PBC þ w4 A
Demographics
The aim of this study is to explore the factors that affect the
family’s intention to adopt MHS for their elderly. In the following
pages, material and methods are briefly described, and an overview
of the survey results and discussion are presented.
Materials and Methods
TPB and TAM provided taxonomies of variables affecting the in-
tention to adopt innovative technology. Following the purpose of this
 EMPIRICAL STUDY OF ADOPTING MOBILE HEALTHCARE SERVICE
study, the research model and hypotheses are proposed (Fig. 1
presents the research model):
H1: Perceived ease-of-use is positively associated with perceived
usefulness.
H2: Perceived ease-of-use is positively associated with attitude.
H3: Perceived usefulness is positively associated with attitude.
H4: Perceived usefulness is positively associated with behavioral
intention of adopting MHS.
H5: Subjective norm is positively associated with behavioral in-
tention of adopting MHS.
H6: Perceived behavioral control is positively associated with
behavioral intention of adopting MHS.
H7: Attitude is positively associated with behavioral intention of
adopting MHS.
H8: Demographics have a moderating impact on the relationship
between attitude and behavioral intention of adopting MHS.
In Chinese society, the family is a very important source of sup-
port. The obligation to take care of one’s parents is especially em-
phasized, and this intergenerational transfer is a safeguard against
aging for the elders. Hence, providing long-term care for one’s family
elders is an age-old tradition that continues today. Today’s elderly
experienced post-World War II reconstruction and economic re-
cession; hence, they tend to be less well educated and less inclined
to learn new things, and to be generally more conservative in their
spending habits. In addition, some elderly are economically disad-
vantaged because they have already distributed their assets to their
children, another tradition. Influenced by these traditional values
and attitudes, most elderly will adopt innovative services=products
only at the urging and under the guidance of family members. Since
most elderly are not MHS primary purchasers, this study investigates
immediate family (purchaser) intention rather than the intention of
Subjective Norm
H5
Perceived
Behavioral Control H6
Perceived H4
Usefulness H7
H3
H1 Attitude H8
Perceived Ease
H2 Demographics
of Use
Fig. 1. Research model. MHS, mobile healthcare service.
ª M A R Y A N N L I E B E R T , I N C . . VOL. 16
family elders (end users). Questionnaires were distributed to students
enrolled in an Executive Master of Business Administration (EMBA)
program at a university in central Taiwan. Generally speaking, most
EMBA students are of good economic status, are strongly motivated
learners, and are open to adopting innovative services=products;
hence, this study invited EMBA students to be our sample.
The questionnaire consisted of two parts. The first part elicited
respondent demographics, including age, gender, education, marital
status, monthly salary, age of parents, and parent’s residency status.
The second part contained the questionnaire proper, which consisted
of 27 statements to which respondents were asked to indicate their
degree of agreement. All 27 statements of the instrument had been
validated by prior research.9 In order to assess the face validity of the
questionnaire, the help of 3 healthcare professionals and 2 mobile
service researchers was enlisted. After discussion, the initial ques-
tionnaire was revised to ensure that there was a good match between
the information the questionnaire elicited and the factors upon which
the intention to adopt MHS would be measured.
A review of the literature shows that partial least squares (PLS) is a
powerful second-generation multivariate technique for analyzing
causal models involving multiple constructs with multiple observed
items.11 The PLS analysis was used to assess associations between
factors and behavior intention. Both measurement and structural
model were run simultaneously using Visual PLS 1.04b. The detailed
descriptive analysis of demography was made by SPSS 13.0 (SPSS,
Inc., Chicago, IL).
Results
Of the 200 questionnaires distributed, 192 were returned. After
excluding incomplete questionnaires and questionnaires indicating
no elder family member, a total of 100 usable questionnaires re-
mained, a validation rate of 50%. The question items
for the abovementioned constructs are listed in the
Appendix. Respondents of valid questionnaires were
59% male; 49% were between the ages of 41 and 50;
and 72% of respondents’ parent’s residency status was
‘‘living with children.’’ All data are listed in Table 1. An
Behavioral analysis of the measurement model and structural
Intention of model based on those samples is presented below.
adopting MHS In the measurement model, convergent validity is
commonly used to assess construct validity.12 There
are three recommended criteria.13 First, factor load-
ings of all standardized items are suggested to be
higher than 0.5. Second, the composite reliability is
suggested to be higher than 0.6.14 Third, the average
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JEN AND HUNG

Table 1. Demographic Analysis (N ¼ 100) Table 1. Continued

ITEM % ITEM %
Gender Parent residency status

Male 59% Living alone 28%

Female 41% Living with children 72%

Age

<30 1%
variance extracted needs to be higher than 0.5. The results of con-
>31–40 39%
struct validity of the instrument are listed in Table 2 and showed good
41–50 49% construct validity. This means that the measurement model is ac-
51–60 9% ceptable in terms of construct validity. Overall, the results provided
empirical support for the instrument used to test our suggested model.
>60 2%
In the structural model, we use the BootStrap procedure15 to test the
Education significance for all paths. Figure 2 shows the relative strengths of each
College 61% path specified by the research model and the variance (R2) explained
by each path. First, as hypothesized, PEOU is significantly associated
Masters 39% with PU (b ¼ 0.582, t ¼ 8.942, p < 0.01) and R2 is 0.338. Second, PEOU
ITEM % is significantly associated with ATT (b ¼ 0.145, t ¼ 1.978, p < 0.05).
Month salary (USD) Third, PU is significantly associated with attitude (ATT) (b ¼ 0.668,
t ¼ 10.186, p < 0.01.) Collectively, PEOU and PU constructs account
<1,875 57%
for 58.1% of variance in ATT. Finally, among PU, SN, PBC, and ATT,
1,875–3,125 31% only ATT has significant impact on BI (b ¼ 0.547, t ¼ 5.744, p < 0.01)
>3,125 12%
and accounts for 64.1% of the variance in BI. In contrast, SN and PBC
are not significantly associated with the BI of adopting MHS. There-
Marital status fore, H1, H2, H3, and H7 are supported. The results indicate that the BI
Single 24% of adopting MHS is explained by PEOU, PU, and ATT.
Married 76%
In testing the moderator effect of demographics, the hierarchical
procedure was used to compare the R2 value for the interaction
Age of father models with the main effects model, which excluded the demo-
<65 years 1% graphic constructs. The difference of R2 value was used to judge the
overall effect value (f2) for the interaction where 0.02, 0.15, and 0.35
65–74 years 45%
had been suggested as small, moderate, and large effects, respec-
75–84 years 24% tively.16 As is shown in Table 3, gender and monthly salary moder-
>84 years 3% ated the relationship between attitude and behavior intention toward
MHS more greatly than in the main effect model and other interac-
ITEM %
tion effect models. Although the effect values for the moderated
Age of mother effects of gender and monthly salary were small (f2 ¼ 0.043 and
<65 years 1% 0.029), the effect of gender and monthly salary constructs still cannot
be ignored. Gender, specifically, has a significantly greater moder-
65–74 years 11%
ating effect than other demographics. The mean analysis for both
75–84 years 47% males and females toward MHS is listed in Table 4. Males demon-
>84 years 19% strate a greater intention to use MHS and have higher attitude scores
toward MHS than do females. With regard to the determinants of

44 TELEMEDICINE and e-HEALTH J A N U A R Y=F E B R U A R Y 2 0 1 0

 EMPIRICAL STUDY OF ADOPTING MOBILE HEALTHCARE SERVICE

Table 2. Descriptive Statistics and Psychometric Properties of Reflective Measures

CONSTRUCT CR AVE ITEM LOADING MEAN SD T-VALUE
SN 0.81 0.59 SN1 0.84 4.48 0.66 18.80

SN2 0.80 4.18 0.66 10.77

SN3 0.66 3.49 0.69 7.09

PBC 0.82 0.61 PBC1 0.52 3.40 1.02 3.25

PBC2 0.83 3.50 0.93 11.42

PBC3 0.93 3.60 0.77 26.90

ATT 0.94 0.81 ATT1 0.84 4.30 0.62 23.17

ATT2 0.92 4.10 0.72 49.26

ATT3 0.96 4.19 0.71 63.05

ATT4 0.89 4.18 0.63 31.29

PU 0.92 0.79 PU1 0.89 4.30 0.64 36.39

PU2 0.89 4.30 0.54 27.47

PU3 0.89 4.26 0.66 34.67

PEOU 0.78 0.54 PEOU1 0.82 4.18 0.72 13.16

PEOU2 0.68 3.89 0.68 7.77

PEOU3 0.68 3.86 0.84 8.46

BI 0.91 0.78 BI1 0.87 4.01 0.63 26.95

BI2 0.85 4.06 0.75 12.47

BI3 0.93 4.03 0.77 67.89

CR, composite reliability; AVE, average variance extracted; SD, standard deviation; SN, subjective norm; PBC, perceived behavioral control; ATT, attention; PU, perceived
usefulness; PEOU, perceived ease of use; BI, behavioral intention.

attitude, males place more emphasis on PU of MHS, while females
value ease-of-use.
Discussion
This study objective integrated TAM and TPB, and the research
model explains 64.1% of families’ intention to adopt MHS for their
elderly. The results indicated that attitude was the most important
factor in determining a family’s intention to accept MHS. Ad-
ditionally, while PEOU has a significant direct impact on PU of using
MHS, it also has an indirect effect on attitude of using MHS through
the mediator of PU. As PEOU has an indirect effect on ATT, we have to
focus on its impact. If an elderly patient’s family perceives MHS as
easy to use, they also perceive it as useful; they then adopt MHS and
help their elderly use the MHS technology. Similarly, Wu et al.17
pointed out that PU and PEOU significantly affected healthcare
professional BI in adopting the mobile healthcare information sys-
tem. Obviously, whether it be medical care professions or the family
of elderly patients, the primary factor in deciding to adopt MHS are
PU and PEOU. Hence, we may conclude that, to be successful, all
providers of mobile healthcare services and related products have to
simplify their service functions and interfaces. Ensuring that MHS
purchasers and users will readily perceive how easy MHS technology
is to use will also ensure future growth for the MHS industry.
Table 3 shows that both gender and monthly salary moderated the
relationship between attitude and behavior intention toward MHS.
This is an interesting issue that awaits researcher exploration. This

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JEN AND HUNG

cantly moderated the family’s attitude toward adopting

Subjective Norm MHS for use by their elderly family members.
(SN) In this study, we integrated TAM and TPB, and
explored whether normative and control factors affect

0.1 .841
a family’s intention to purchase MHS services for their
(1
59 )
Perceived

ns
elderly members. However, our findings indicated that
Behavioral Control
0.0 SN and PBC were not significantly associated with the
(PBC) (0. 55 ns
93 BI to adopt MHS. The study subjects, EMBA students,
2) Behavioral
Perceived
0.142ns Intention (BI) of had relatively high socio-economic status as well as
Usefulness (PU)
(1.913) Adopting MHS the competence and confidence to operate MHS
R2=0.338 2
0.6 .18

R =0.641
**
(1

technology. In Chinese society, long-term care for

68 6)

7
0

4
0.5 744)
**
0.582**
(8.942)

Attitude (ATT) ( 5. elders is provided for by the family. The subjective

R2=0.581 norm, a function of beliefs about the expectations of
(-2.202)
.9 *

-0.130*
(1 .145

important referent others, had no significant effect

)
78
0

Perceived Ease of
upon the subjects’ BI toward MHS. In other words, the
Use (PEOU) subjects did not consider these referents’ opinions;
Gender they cared only about the services and functions MHS
ns
non -significance
* p< 0.05 could provide. In sum, our findings indicated that
**p< 0.01 PEOU, PU, and ATT could efficiently explain and
predict family intention to purchase MHS services for
Fig. 2. Results of partial least-squares analysis. MHS, mobile healthcare service. their elderly members. During the present economic
recession, it is important that low-cost, effective long-
study extended prior research by theorizing and confirming a mod- term healthcare be provided for the elderly. As technology ad-
erator role of demographics in the link between attitude and behavior vances and more and more useful mobile healthcare services can
intention toward MHS. The results demonstrate that gender signifi- be conveniently provided18–20 for the elderly through easy-to-use

Table 3. Hierarchical Test

R2 **F 2 T-VALUE
Main effect model 0.625

Interaction effect model with gender of respondents 0.641 0.043 2.045*

Interaction effect model with monthly salary of respondents 0.636 0.029 1.442
(cut-off point ¼ $3,125 [USD])

Interaction effect model with education of respondents 0.632 0.019 1.288

Interaction effect model with age of respondents (cut-off point ¼ 40 years) 0.628 0.008 0.909

Interaction effect model with residency status of parents 0.628 0.008 0.316

Interaction effect model with marital status of respondents 0.626 0.003 0.663

Interaction effect model with age of parents (cut-off point ¼ 74 years) 0.625 0 0.958
*p < 0.05.
**f2 ¼ [R2 (interaction effect model)  R2 (main effect model)]=[1  R2 (main effect model)].

46 TELEMEDICINE and e-HEALTH J A N U A R Y=F E B R U A R Y 2 0 1 0

 EMPIRICAL STUDY OF ADOPTING MOBILE HEALTHCARE SERVICE

8. Ajzen I. The theory of planned behavior. Organiz Behav Hum Decision Process
Table 4. Means Analysis of Each Construct 1991;50:179–211.
PU EOU ATT PBC SN INT 9. Taylor S, Todd PA. Understanding information technology usage: A test of
Means Male 4.33 3.97 4.22 3.44 4.07 4.09 competing models. Inf Syst Res 1995;6:144–176.
10. Davis FD, Bagozzi RP, Warshaw PR. User acceptance of computer technology: A
Female 4.23 3.99 4.16 3.51 4.02 3.95 comparison of two theoretical models. Manage Sci 1989;35:982–1003.
PU, perceived usefulness; EOU, ease of use; ATT, attitude; PBC, perceived 11. Fornell C. A second generation of multivariate analysis, methods: Vol. 1. New
behavioral control; SN, subjective norm; INT, behavioral intention to adopt MHS. York: Praeger, 1982.
12. Sethi V, Carraher S. Developing measures for assessing the organizational
impact of information technology: A comment on Mahmood and Soon’s paper.
Decision Sci 1993;24:867–877.

interfaces, MHS will continue to contribute much to improving the
quality of long-term healthcare services for the elderly.
This research model is suitable for the areas of intergenerational
transfer cultures such as China, Japan, Taiwan, and other countries
whose social structures are based on Confucian values. However, this
research model will not necessarily be suitable for other cultures,
which is the limitation of this study. Finally, regardless of the local
culture, there is no doubt that family elders will benefit greatly from
the extended healthcare services mobile devices deliver if their
families purchase MHS services and guide them in their use.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Ming-Chien Hung, Ph.D.
Department of Information Management
Nanhua University
No. 55, Sec. 1, Nanhua Rd.
Zhongkeng, Dalin Township, Chia-Yi County 62248
Taiwan
E-mail: chemyhmc@gmail.com
Received: July 8, 2009
Revised: August 13, 2009
Accepted: August 13, 2009

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JEN AND HUNG

APPENDIX: Items of Instrument APPENDIX: Continued

CONSTRUCTS SCALES CONSTRUCTS SCALES
Subjective Norms (SN) Perceived Ease of Use (PEOU)

SN1 The experts who influence my behavior
would think that I should use the
mobile healthcare service for my
elderly family.
SN2 My family would think that I should
order the mobile healthcare service for
my elderly family.
SN3 My friends would think that I should
order the mobile healthcare service for
my elderly family.
PEOU1 Instructions for using equipment in the
mobile healthcare service will be easy
to follow.
PEOU2 It will be easy to learn how to use the
mobile healthcare service.
PEOU3 It will be easy for elderly people to
operate the equipment in the mobile
healthcare service
Behavior Intention (BI)

Perceived Behavioral Control (PBC) BI1 I am glad to introduce the mobile

healthcare service to my elderly family.
PBC1 I have knowledge and ability to operate
the mobile healthcare service for my BI2 I will adopt the mobile healthcare
elderly family. service for my elderly family.

PBC2 I think I can handle the mobile BI3 I will adopt the mobile healthcare
healthcare service for my elderly service based on my elderly family’s
family. necessity.

PBC3 Helping my elderly family to use the

mobile healthcare service is entirely
within my control.

Attitude (ATT)

ATT1 Using the mobile healthcare service

is a good idea for the families with
elderly people.

ATT2 The mobile healthcare service increases

the elderly family’s healthcare service
quality.

ATT3 Adopting the mobile healthcare service

improves the elderly family’s safety.

ATT4 The mobile healthcare service

is valuable.

Perceived Usefulness (PU)

PU1 The mobile healthcare service will be

beneficial to the care of elderly people.

PU2 Using the mobile healthcare service will

reduce psychological burden of family.

PU3 The advantages of the mobile

healthcare service will outweigh the
disadvantages.

48 TELEMEDICINE and e-HEALTH J A N U A R Y=F E B R U A R Y 2 0 1 0