Educational Gerontology

ISSN: 0360-1277 (Print) 1521-0472 (Online) Journal homepage: https://www.tandfonline.com/loi/uedg20

Examining the role of Filipino elderly attitudes

toward computer and internet on their behavioral
intention for telehealth participation

Allan B. de Guzman & Michael Joseph S. Diño

To cite this article: Allan B. de Guzman & Michael Joseph S. Diño (2020): Examining the role of
Filipino elderly attitudes toward computer and internet on their behavioral intention for telehealth
participation, Educational Gerontology, DOI: 10.1080/03601277.2020.1715589

To link to this article: https://doi.org/10.1080/03601277.2020.1715589

Published online: 20 Jan 2020.

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EDUCATIONAL GERONTOLOGY
https://doi.org/10.1080/03601277.2020.1715589

ARTICLE

Examining the role of Filipino elderly attitudes toward computer

and internet on their behavioral intention for telehealth
participation
a
Allan B. de Guzman and Michael Joseph S. Diñob
a
The Graduate School and Research Center for Social Sciences and Education, University of Santo Tomas, Manila,
Philippines; bUniversity of Santo Tomas Graduate School, Research Development and Innovation Center, Our Lady of
Fatima University, Valenzuela City, The Philippines

ABSTRACT
Health technologies like computers and the internet are considered as
essential tools in addressing various health problems of various age groups
including the elderly. Through a multi-aspect survey questionnaire, this
study examined the role of attitudes toward computer and internet on
the behavioral intention for telehealth participation among a select group
of Filipino elderly who underwent a basic computer and internet training
for Telehealth program. Using regression analysis, results showed favorable
attitude toward computers (x = 6.23) and internet (x = 6.40) among the
elderly respondents after a computer literacy training. Their behavioral
intention to use telehealth was greatly influenced by ‘computer confidence’
(β = 0.24) and ‘web usefulness’ (β = 0.24). Results of this study highlight the
importance of telehealth literacy program in ensuring compliance and
engagement among the older adults.

Telehealth is the use of communication technology to support clinicians and patients at a distance
(Durrani & Khoja, 2009) and to enhance health care, public health, and health education delivery
and support Hsiao and Tsai (2009) through exchange of information (Sanders et al., 2012) education
and treatment of health-related conditions (Ferguson, Craig, & Dounavi, 2019). According to Woo
and Dowding (2018), a multitude of factors may affect the adoption of telehealth which include
concerns over equipment or technology, concerns over service change, ease-of-use, knowledge of the
benefits of telehealth, access to care, cost, and privacy. Of these factors, the use of computers and the
internet are indispensable components of Telehealth interventions (Kim, 2008). These technologies
enable healthcare providers to virtually connect to their distant patients for care and consultation.
Adewale (2004), Milligan, Roberts, and Mort (2011), for their part, believed that Telehealth pro-
grams that use such technologies are commendable solutions to augment the health service dispa-
rities among population groups including the senior cohort. Health technologies like computers and
the internet are adjudged to be the backbone of all health systems and are considered to be essential
tools in solving various health problem including the elderly’s (National Academy of Engineering &
Institute of Medicine, 2005).
In the Philippines, maintaining equal access to healthcare is a challenge to healthcare providers.
Filipino seniors are mostly dispersed due to the country’s archipelagic feature and have low mobility
prospect (Ogena, 2006). Further, the ratio and misdistribution of healthcare providers, which are mostly
concentrated in rural areas may hinder the attainment of universal healthcare among the Filipino elderly.
In such cases, the acceptance and utilization of Telehealth technologies such as computers and the

CONTACT Allan B. de Guzman abdeguzman@ust.edu.ph; doc_allan@yahoo.com Research Center for Social Sciences and
Education, University of Santo Tomas, Manila, Philippines
© 2020 Taylor & Francis Group, LLC
2 A. B. DE GUZMAN AND M. J. S. DIÑO

internet by an older population grow to be increasingly important (Broady, Chan, & Caputi, 2010;
Greenwald, Stern, Clark, & Sharma, 2018)
Though computer and internet seem to create significant health delivery benefits for the aging
population, a number of seniors may still not ready to enjoy its benefits. Research findings showed
that seniors’ perceived computer complexity (Carpenter & Buday, 2007; Heinz et al., 2013), lack of access
(Peacock and Kunemund, 2007), cost (Saunders, 2004), physical limitations (Carpenter & Buday, 2007),
and fear of hardware being outdated quickly (Saunders, 2004) are contributing factors to computer and
internet nonuse. Predominantly, elderly lack of interest and motivation in using the computer (Morris,
Goodman, & Brading, 2006; Peacock & Künemund, 2007) is a primary concern, since a heap of studies
established the inverse relationship between age and attitude toward technology. That is, the older the
individual, the less technology knowledge and interest they are likely to possess (Ellis & Allaire, 1999;
Karavidas, Lim, & Katsikas, 2005; Wagner, Hassanein, & Head, 2010). From a classical viewpoint, Ajzen
and Fishbein (1977) averred that a person’s positive attitude toward a target strongly predicts his
intention for the behavior. As a result, the stronger the person’s intention to perform a behavior, the
higher the possibility that the behavior will recur and be performed (Venkatesh & Davis, 2000).
Unfortunately, the specific link between attitude toward technology and intention to participate in
Telehealth among the elderly as subjects is yet to be clearly understood.
Henceforth, this study purports to examine the extent to which attitude toward technological devices
can be an effective predictor of Telehealth program participation among a select group of Filipino elderly.
Study outcomes are envisioned to inform and support the development of training and implementation
policies for possible enhancement of Telehealth initiatives specific for the elderly.

Theoretical background
Theoretical framework
Rogers (1995) Diffusion of Innovation provided the theoretical background for the present study. In
this theory, Rogers shared that awareness, interest, evaluation, trial, and adoption are the crucial
predictors of a person’s willingness to use an innovation. He further explained that innovation
diffusion is composed of five stages, namely: (1) knowledge, (2) persuasion, (3) decision, (4)
implementation and (5) confirmation. The stages suggest that an adopter’s acceptance of an
innovation starts with learning its purpose and ends with the decision to accept or reject such
innovation. Rogers (1995) explicated that diffusion of innovation has four (4) main elements,
namely: (1) innovation, (2) communication channels, (3) time, and (4) the social system. Using
these stages and elements in the context of the present study, elderly participants’ behavioral
intention to use Telehealth may be influenced by their understanding and positive attitude toward
computers and the internet as an outcome of effective instructor-driven technology orientation and
effective literacy training environment.

Literature review
Computers, internet, and the elderly
In recent years, a comparable growth between population aging, technology, and related-researches
has been noted. As the number of seniors increase, the presence of computers in various disciplines
becomes more apparent. A number of researches on the interesting association between the elderly
and computer use correspondingly showed that the internet milieu appears to be the most promising
area of inquiry. Older adults are reported to be one of the fastest growing internet users group
(Adams, Oye, & Parker, 2003; Nahm, Resnick, & Gaines, 2004). Notably, the negative stereotypes
attributed to them as being avoidant of technology have become an outdated notion (Broady et al.,
2010). Heterogeneity among senior users and benefits for users is revealed in the study of Cresci,
Yarandi, and Morrell (2010). In contrast with other senescent groups, Internet- inclined elderly or
 EDUCATIONAL GERONTOLOGY 3

Pro-Nets were revealed to be physically younger and have greater optimism with lesser chance of
acquiring lifestyle-related diseases.
The elderly group is viewed as having the potential to be equally effective in using computers and
becoming computer literate as younger age groups with proper encouragement and clear explanation
of potential benefits (Broady et al., 2010). Previous studies (see Cresci et al., 2010; Kim, 2008)
underscored the need for developing social interventions that would address non-computer users to
become engaged in technology. Notable examples are the provision of formalized computer training,
internet-accessible educational materials, online social support, and computer-mediated information
(Carpenter & Buday, 2007; Gatto & Tak, 2008). While evidence on learning by trial and error is
observed among the elderly, accepting the challenge of learning a new skill gives them a sense of
accomplishment and feelings of confidence after computer training (Gatto & Tak, 2008).
Interestingly, Carpenter and Buday (2007) mapped the way on how the elderly population uses
computers and internet into two (2) broad dimensions, namely: (1) solitary-social, and (2) obliga-
tory-discretionary. On the one hand, they viewed that solitary-social dimension reflects the degree to
which computer use involves maintaining contact with other people. Solitary activities are self-
focused undertakings such as playing games and managing finances while social activities are visible
when the elderly compose letters and send electronic mail. On the other hand, computer activities
that are more purely pragmatic and functional are referred to as obligatory-discretionary. At the
obligatory end, tasks include using computers for work and shopping, whereas discretionary
activities consist of using the computer and do travel-related research.
Personal computers and Internet are indeed seen as having the potential to improve the quality of life and
social well-being of older adults in a variety of ways (Dickinson & Gregor, 2006). They provide a neutral
plateau where individuals can engage in topics that interest them (Karavidas et al., 2005). An extensive
review by Wagner et al. (2010) further substantiate this concept when the five (5) interesting themes on
reasons why older adults use computers were revealed, namely: (1) communication and social support
(Alexy, 2000; Mann, Belchior, Tomita, & Kemp, 2005; McMellon & Schiffman, 2000; Morrell, Mayhorn, &
Bennett, 2000; Opalinski, 2001; Thayer & Ray, 2006), (2) leisure and entertainment (Campbell, 2008;
McMellon & Schiffman, 2000; Opalinski, 2001), (3) information-seeking help (Campbell, 2008; Flynn,
Smith, & Freese, 2006; Macias & McMillan, 2008; Tak & Hong, 2005), (4) information-seeking education
(Dorin, 2007; McMellon & Schiffman, 2000; Opalinski, 2001), and (5) productivity (White & Campbell,
2008; Weatherall, 2000). Internet communication tools such as electronic mail, instant messaging, and video
conferencing, as promising tools for Telehealth, remains to be unexplored.

Attitude toward computers and the internet

Considering the pervasiveness of computer with its associated technologies in the society, it is likely
that most individuals have developed some attitudes toward these machines (Shaft, Sharfman, & Wu,
2004). Understanding users’ attitude toward computer and the Internet is crucial to the success of
internet-based computer interventions like Telehealth. In fact, Dinesen, Nonnecke, and Nesbitt
(2016) averred that it will be increasingly important to develop a strong evidence base of successful,
innovative telehealth solutions that can lead to scalable and sustainable telehealth programs.
A positive attitude toward computers is linked to the development of computer literacy, acceptance,
and satisfaction with computer-based information systems (Kinzie, Delcourt, & Powers, 1994; Shaft
et al., 2004). Shaft et al. (2004) reviewed and discovered three (3) related concepts related to attitude
toward computers: (1) computer anxiety, (2) user information satisfaction, and (3) technology
acceptance. The most related construct pertains to computer anxiety. He also posited that attitude
is a trait rather than state variable. However, evidence suggests that it intervenes between demo-
graphic and attitudes toward computers (Igbaria & Parasuraman, 1989) and therefore these two are
considered as distinct constructs.
Numerous instruments have been developed to assess quantitatively individual attitudes toward
computer which operate at different levels with specific focus across disciplines (e.g. Gattiker &
Hlavka, 1992; Jay & Willis, 1992; Young, 2000). These research tools have emerged after the
4 A. B. DE GUZMAN AND M. J. S. DIÑO

theoretical link between attitude and behavior become well accepted (Ajzen & Fishbein, 1977 cited in
Shaft et al., 2004). Though a heap of these tools was valid and reliable for the general population, few
research applications were implemented in context of the elderly.
Based on the foregoing discussions, this study advanced the following hypotheses:

H1: Filipino elderly attitude toward computer is positively associated with their intention to
participate in Telehealth sessions.

H2: Filipino elderly attitude toward the Internet is positively associated with their intention to
participate in Telehealth sessions.

Method
Research design
The study adopted the descriptive-correlational design. Multiple correlations involving computer and
internet attitudes as predictors of intent to telehealth participation among the elderly were investigated.

Study site, participants, and procedure

The study was conducted in an urban community from a local government in the Philippines approxi-
mately 10 kilometers from the National Capital Region. Its local government maintains an active senior
citizen group through the Office of Senior Citizens Affairs making it easily accessible for researchers.
Healthcare services were provided by a private hospital, a government hospital, and a healthcare center,
while household internet connections are offered by four (4) private data service line companies.
Eighty-two (82) seniors were available and qualified to proceed with the survey based on the
inclusion criteria set as follows: (a) physically-able, (b) non-cognitively impaired using Mini-Mental
State Examination – Filipino Version (MMSE-F), Clock Drawing Test (CDT) and Geriatric
Depression Scale (GDS), (c) normal eye functioning or at most with corrective lenses, and (d)
willingness to participate in the program with signed informed consent. The participants underwent
basic computer and internet training for Telehealth program in the nearby state college.

Instrumentation and data collection

Web/internet attitude scale (WAS) or attitude toward the internet scale (ATIS)
Recently, the popularity of the internet in both developed and developing countries has prompted
researchers (e.g. Anderson, 2005; Liaw, 2002; Zhang, 2007) to develop a need for a reliable and valid
tool for assessing attitude toward it. The ATIS (Morse, Gullekson, Morris, & Popovich, 2011) was
developed with strict compliance to scale development identified by Clark and Watson (1995), and
passed a three-study sequence to establish its psychometric properties and applicability for a variety
of domains. It consists of 17 items with a 1–7 Likert type response scale with anchors ranging from
strongly disagree to strongly agree. Two (2) items were removed with prior approval from the
authors for its applicability in the current setting.

Computer attitude scale (CAS)

The CAS was developed by Loyd and Loyd (1985), consisted of 16 items that can be measured
similar to the scales used in ATIS. It highlights pieces related to anxiety, confidence, liking, and
computer usefulness that are deemed necessary in assessing attitude toward an object (Ajzen &
Fishbein, 1977). In a study by Liaw (2002), CAS yielded a commendable Chronbach’s alpha score
of 0.90.
 EDUCATIONAL GERONTOLOGY 5

Survey form on the factors affecting behavioral intention to participate in telehealth sessions
This self-report questionnaire contains 12 items designed to measure the constructs and relation-
ships contained in the research model. Previously developed and validated item was used, primarily
from those employed by Venkatesh and Davis (2000) in their development of UTAUT. It has been
slightly modified with the inclusion of terminologies relating to Telehealth sessions. These items
were rated using a 7-point Likert scale ranging from 1 – strongly disagree to 7 – strongly agree.

Data analysis
All statistical procedures were performed using SPSS version 21. The data results obtained from the
CAS and WAS were descriptively processed using mean, standard deviation and skewness. This
procedure facilitated a better understanding of the elderly attitudes toward computer technologies
through ranking of the attributes under both scales. Meanwhile, the regression analyses using
varying methods (i.e. enter, forward, and stepwise) inferred the causal relationship existed among
the attributes of CAS and WAS to the behavioral intention of the elderly in telehealth participation
in developing parsimonious model on the determinants of their behavioral intentions.

Results
Perceived attitude toward computer (CAS) and internet (WAS)
Table 1 shows the dimensions of the Filipino elderly’s perceived attitude toward computer (CAS)
and internet (WAS) scales. Among the dimensions of CAS, usefulness in using the computer ranked
highest (x = 6.32, SD = 0.78, S = −2.70) with skewness of −2.7. This was followed by liking (x = 6.30,
SD = 0.84, S = −3.56), serenity (x = 6.22, SD = 0.79, S = −2.46) and confidence (x = 6.09; SD = 0.85,
S = -2.02). A similar ranking was observed under the dimensions of WAS for usefulness (x = 6.61,
SD = 0.42, S = −0.61), liking (x = 6.53, SD = 0.43, S = −0.41), serenity (x = 6.32, SD = 0.61, S = −1.28)
and confidence (x = 6.15, SD = 0.76, S = −1.23).

Fit indices of regression models showing effect of attitude toward computer and internet on
behavioral intentions
Regression analyses provided relevant and critical information on the predictors of behavioral
intentions to participate in Telehealth sessions among the Filipino elderly respondents. This involved
the specific dimensions of CAS and WAS, namely: confidence, liking, serenity, and confidence.
Subsequently, the SPSS version 17 yielded five (5) significant regression models using enter, forward
and stepwise methods as summarized in Table 2.
Using the enter method, Model 1 generates a Pearson correlation coefficient of 0.47. This shows
the extent to which the identified predictors relate to the behavioral intention. Additionally, based on
the adjusted R2 value, confidence, liking, and serenity in using the computer accounts for the 13%
variability of behavioral intentions.
The forward method generated two regression models. Model 3 seems to have better statistical
inference than Model 2. The former (r = 0.29) considered only the perceived internet usefulness,

Table 1. Descriptive statistics of Filipino elderly’s perceived attitude toward computer and internet (n = 82).
Computer attitude scale (CAS) Web attitude scale (WAS)
Dimensions x s.d. Rank Skewness x s. d. Rank Skewness
Usefulness 6.32 0.78 1 −2.7 6.61 0.42 1 −0.61
Liking 6.30 0.84 2 −3.56 6.53 0.43 2 −0.41
Serenity 6.22 0.79 3 −2.46 6.32 0.61 3 −1.28
Confidence 6.09 0.85 4 −2.02 6.15 0.76 4 −1.23
6 A. B. DE GUZMAN AND M. J. S. DIÑO

Table 2. Fit indices of regression models showing effect of attitude toward computer (CAS) and internet (WAS) on behavioral
intentions.
Model 1 Model 2 Model 3 Model 4 Model 5
Method Enter Forward Forward Stepwise Stepwise
Criterion Variable Behavioral intention Behavioral Behavioral Behavioral Behavioral
intention intention intention intention
Predictor CAS: Confidence, Liking, WAS: Usefulness WAS: Usefulness WAS: Usefulness WAS: Usefulness
Serenity (β = 0.243) (β = 0.243)
CAS: Confidence CAS: Confidence
(β = 0.239) (β = 0.2439)
R 0.47 0.29 0.37 0.29 0.37
R2 0.22 0.08 0.14 0.08 0.14
Adjusted R2 0.13 0.07 0.12 0.07 0.12
P-value 0.02 0.01 0.00 0.01 0.00

which comprises the 7% variability of behavioral intention. Meanwhile, the latter (r = 0.37) added
the perceived confidence in using the computer as another predictor resulting to 12% in its
variability.
The last two (2) models underwent the most refined analysis through stepwise method. Model 4 (r =
0.29) shows that perceived internet usefulness influences 7% of the variability of behavioral intention. The
R2 value from model 5 showed that 12% of the variability of behavioral intention could be explained by
perceived internet usefulness and confidence in using the computer.
Drawing the strengths of these regression analyses, both Models 3 and 5 offer a similar parsimo-
nious model in predicting behavioral intention in telehealth participation. Figure 1 depicts the two
(2) predictor variables: (a) confidence in using the computer, and (b) perceived usefulness of the
internet. These predictors delivered a significant impact (β = 0.24) to behavioral intention (Figure 2).
This implies that confidence in using computers and perception of the internet usefulness con-
tributes to some degree of influences over their behavioral intention to participate in telehealth
sessions.

Discussion
Perceived attitude toward computer (CAS) and the internet (WAS)
In this study, a positive attitude toward computer use and the internet was found among a select
group of Filipino elderly. This finding may be attributed to elderly awareness and recognition of the
outcome benefits of a computer and internet training program. As previously observed, seniors’
completion of a technology training gives them a sense of accomplishment and feelings of con-
fidence (Gatto & Tak, 2008), which may foster positive impression toward computers and the
internet. Shaft et al. (2004), for their part, explained that a positive attitude toward these technologies

Figure 1. The hypothesized model.

 EDUCATIONAL GERONTOLOGY 7

Figure 2. Regression model of behavioral intention for telehealth participation.

is linked to the development of computer literacy, satisfaction, and acceptance of computer-based

information systems. Far from expectations, a lot of adults are still struggling with the use of
computers (Redsell & Nycyk, 2010), and senior training opportunities are scarce (Cresci et al.,
2010; Morrell et al., 2000). Dickinson and Gregor (2006) believed that older adults are usually
dependent on external assistance to achieve basic computer tasks. If industry key players will invest
on training program for seniors, more elders will become skillful in using computer and internet and
develop more positive attitude toward these technologies. Notably, the attributes of computer and
web attitude scales were rated by the elderly participants similarly. This may be explained by the
positive significant relationship between the two measures (Broady, Chan, & Caputi, 2010).
Therefore, it is implied that CAS and WAS can be used interchangeably in assessing the attitude
toward Telehealth technologies.

Fit indices of regression models showing effect of attitude toward computer and internet on
behavioral intentions
Findings of this study suggest that confidence in using the computer and perceived usefulness of the
internet, among others, are positively associated with Filipino elderly’s intention to participate in
Telehealth sessions. On the one hand, the elderly respondents consider confidence in using the computer
a predictor of their behavioral intention for Telehealth use. This may be explained by the distinguishing
nature of Filipino seniors as being cautious rather than risk-takers. That is, Filipino elderly considers the
importance of learning how to use computers as a primary requisite for Telehealth use. This finding
concurs with classical studies explaining that behavioral intention is strongest when the individual is
capable and skilled in performing the behavior (Igbaria, Pavri, & Huff, 1989; Winter, Chudoba, & Gutek,
1998). DelliFraine and Dansky (2008), for his part, averred that the lack of technology skills is
a significant barrier for older people to adopt Telehealth. Therefore, implementation of Telehealth
program for seniors must initially include computer literacy sessions specific for the learning needs of
the elderly to ensure their intention for use. Previous studies suggest that instruction must be multi-
sensory (Lin & Hsieh, 2006) and may include step-by-step directives with minimal explanation to avoid
working memory overload (Clarke, Ayres, & Sweller, 2005). On the other hand, perceived usefulness of
the internet was also seen to have a positive impact on elderly behavioral intention to use Telehealth. The
communication-related internet benefits of a Telehealth system appear to be appealing to senior users.
A prior study (James Kehoe et al., 2009) revealed that novice seniors have a profound interest on the
internet, because of its potential for social engagement among seniors (Carpenter & Buday, 2007;
Karavidas et al., 2005; Morrell et al., 2000; Thayer & Ray, 2006), which may further alleviate loneliness
and alienation that are both common to seniorhood (Karavidas et al., 2005). Hence, it appears that the
opportunity for socialization and communication with the healthcare provider is a vendable feature of
8 A. B. DE GUZMAN AND M. J. S. DIÑO

Telehealth. Maintaining sociable yet therapeutic bonds to enhance the patient–provider relationship in
virtual environments like that of Telehealth is vital to healthcare providers.

Conclusion
Gerontologic Telehealth primarily introduces the use of computer and internet technologies. This
study investigated the attitudes of a select group of Filipino elderly toward computer and internet,
and made an effort to predict the factors influencing their behavioral intentions to engage in
Telehealth using regression analysis. Study outcomes revealed that senior participants have
a positive attitude toward computer and internet after undergoing computer literacy training.
Their behavioral intention to use Telehealth was basically influenced by their confidence in using
the computer and positive perception on the internet benefits. These findings have shown the
importance of ‘computer and internet’ literacy session as an indispensable component of
a successful Telehealth program. Through this, seniors can effectively learn how to use computers
and the internet, and understand its relevance to foster their intentions to use Telehealth.
Results of this study may serve as a guide for practitioners, policymakers, and future researchers.
Healthcare providers involved in Telehealth need to validate the technology competence of their clients as
a primary eligibility criterion for seniors, who will undergo such initiatives. This practice may further be
translated into a standard practice guideline to ensure compliance and reduce possible disengagement
among seniors while on Telehealth mode of delivery. Future researchers could embark on investigations
that would result in the development of technology literacy modules suited for older adults, and exploration
of other possible factors as latent predictors of intent to use Telehealth among the elderly. Similar studies
with wider samples at varying geographical and cultural areas of interest are highly recommended.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by the Philippine Commission on Higher Education (CHED).

ORCID
Allan B. de Guzman http://orcid.org/0000-0002-3611-4013

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