Willingness factors on the level of telehealth adoption

to Use Telehealth


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obstructive pulmonary disease (COPD) is one of the major causes of morbidity
and mortality across the world 1. Pulmonary rehabilitation is recommended as part of
the treatment plan for COPD patients as it has been shown to improve functionality,
and quality of life 2. Pulmonary rehabilitation can reduce the cost of
health care by stabilizing or reversing systemic manifestation of the disease 3, and by reducing
emergency visits and days of admission for COPD patients 4. However, only 1-2 % of COPD patients receive
pulmonary rehabilitation services each year, despite its well-documented
benefits 5. Reasons for such low utilization rate include poor
access to a rehabilitation program and inconvenient timing of the program’s
services. Recently, tele-pulmonary rehabilitation, pulmonary rehabilitation
services through Internet, has been proposed as a solution for the current
problems of shortages in rehabilitation programs, low attendance rates among
COPD patients, and the high cost of the traditional methods of delivering
pulmonary rehabilitation services 6.

Using telehealth in pulmonary
rehabilitation is in its infancy. This situation highlights the need to
elucidate the intentions of potential users for this technology to identify
influencing factors on the level of telehealth adoption in rehabilitation
programs. The identification of users’ acceptance level of telehealth could be
of help to guarantee successful implementation, and positive outcomes of
forthcoming tele-pulmonary rehabilitation programs.



Chronic Pulmonary Diseases and
Pulmonary Rehabilitation

In the United States, chronic
respiratory diseases became the third leading cause of death in 2011 7. COPD can be defined as “a preventable and
treatable disease with some signi?cant extra pulmonary effects that may
contribute to the severity in individual patients. Its pulmonary component is
characterized by air?ow limitation that is not fully reversible. This air?ow limitation
is usually progressive and associated with an abnormal in?ammatory response of
the lungs to noxious particles or gases” 8. The number of newly diagnosed patients with COPD
is increasing as approximately 14 million cases of bronchitis and 2 million
cases of emphysema have been reported every year 9. Based on the increasing number of patients with
chronic pulmonary diseases and its consequences of individuals’ lives and on
health care system in general, there is more attention now toward recommending
pulmonary rehabilitation interventions to be part of any treatment plan for
patients with chronic pulmonary diseases.

Pulmonary rehabilitation is a
multidisciplinary intervention that includes disease related education,
cardiopulmonary and muscle strengthening exercises, and psychological support
designed to minimize disease symptoms and complications and to improve
individuals’ respiratory systems’ ability to function 10. Benefits of pulmonary
rehabilitation include optimizing functional status of the respiratory systems
and improving the quality of life in the four health-related quality of life
domains: dyspnea, fatigue, mental health and mastery over the disease 2. Pulmonary rehabilitation can reduce health-care
cost by stabilizing or reversing systemic effects of the disease 3, and by reducing
emergency visits and days of admission for COPD patients 4. Pulmonary rehabilitation services (PRS) can be
offered as in-patient hospital-based 11, or community-based out-patient
programs in-a group setting lasting usually for 8 to 12 weeks. Self-monitored,
home-based pulmonary rehabilitation is an alternative method that can be more
convenient, accessible, and cost-effective to deliver PRS compared to
in-patient programs 12 13.

Only 1-2 % of COPD
patients receive PR services each year, despite the well-documented benefits.
Reasons for such low utilization rate include: poor access to a rehabilitation
program, lack of transportation, and inconvenient timing of the program 5. Moreover, 34% of COPD patients who were referred
for pulmonary rehabilitation declined participation, and 36% were considered to
be non-adherent 14. Aiming to improve patients’
participation and adherence to pulmonary rehabilitation programs, additional
tools such as using Internet and telecommunication technology to supervise
patients at home just recently proposed. Remote real-time supervision using
telecommunication technology during home-based pulmonary rehabilitation
sessions has the potential to minimize patients’ anxiety during home exercising
sessions, provide accurate exercise prescriptions and aid patients’ recovery
progression 15.





Tele is Greek for “at a distance,” so
telehealth is the provision of health care at a distance 16. Telehealth defined as
the “use of electronic information and telecommunication technology to support
long-distance clinical health care, patients, and professional health-related
education, public health and health administration.”17 Telehealth technology has been
used successfully in different health care disciplines including: pathology,
radiology, psychiatry and dermatology, in addition to using telehealth to
provide home care or self-monitoring for patients with chronic diseases 18. According to The American
Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), telehealth
technology can be used also to advance the delivery of cardiac and PRS. Telehealth
technology can be used in rehabilitation programs as an adjunct to an existing
therapeutic modality, a method to improve the time frame of therapeutic
contact, or as an alternative tool when access to care is not available 19.


Technology acceptance can be
defined as the willingness of a user or a group of users to use information
technology that support their performance 20. Even though users’ actual
adoption may not match their intention to use the information technology,
measurements of technology acceptance can give the closest available prediction
of actual technology usage in the future. In the past, technology developers
and innovators relied on their authority to attract users to their products.
However, the availability of such technology alone did not motivate utilization
by patients. The pervasive expansion of information technology into every
aspect of life, in addition to the high cost of implementing new informational
technology systems, encouraged stakeholders in the health care system to seek more
understanding of the factors that would make their products more acceptable 20.

Statement of Problem

Using telehealth is a new field of health care practice.  Potential users’ uncertainty and
misperceptions regarding telehealth are barriers to its implementation 21.  To
successfully establish a new telehealth program, the human factor must be accounted for as well as software and
technology aspects.  Therefore, to
successfully implement a telerehabilitation program, level of acceptance need
to be assessed among potential users. Measuring telehealth acceptance
determinants will help telehealth developers design better systems that
consider patients’ and health care practitioners’ needs. 


This study aims to measure health care practitioners and
patients’ willingness to use telehealth. The prime objective of conducting the
research is to answer the following question: What is the acceptance (intention) level of using telehealth
among health care practitioners in comparison to patients?


The data collection method for this study was a
self-administered survey. The collected data involved measurement of the
intention to use telehealth



          Sample 1: the
first sample included health care practitioners working in rehabilitation
programs.  A convenience sample was recruited for participation from rehabilitation
programs.  Participants were eligible if
they: 1) read and write in English, and 2) health care practitioners working in
a rehabilitation center.  This group of
participants included all the health care professionals (physicians, nurses,
physical therapists, respiratory therapists, and occupational therapists) who
are involved or have participated in providing traditional face-to-face PR

Sample 2: this sample
included patients with respiratory conditions attending rehabilitation
programs.  A convenience sample was recruited for participation from the rehabilitation
programs. Participants were considered
eligible if they: 1) read and write in English, 2) are older than 18 years, and
3) are having a respiratory condition. 
This group of participants included all the patients with respiratory
conditions including patients with COPD, asthma, CF, bronchiectasis, and
Kyphoscoliosis who are attending PR programs. 
Patients with respiratory
deficiency or who underwent lung transplantation were also included in this study.


statistics (univariate descriptive) were performed to report the
characteristics of the sample, to identify means and standard deviations.

The hypothesis of this study was:
patients have more intention to use telehealth in comparison with healthcare
professionals. Independent T- test was conducted to test the hypothesis (table

 Table (1)


Characteristics of the

Sample 1: this sample
included health care practitioners working in rehabilitation   programs. 
The sample included physicians, nurses, respiratory therapists,
physiotherapists, occupational therapists, and exercise physiologists. A total
of 222 subjects completed the survey.                                       

  The second sample in this study included
patients with chronic respiratory diseases. A total of 134 subjects from
rehabilitation programs completed the survey. None of the participants in this
sample have used telehealth. 

Hypothesis Testing

To test the null hypothesis that
there is no difference between the groups; professional’s scores and patients’
scores an independent t-test was conducted using a sample of 222 of healthcare
professionals and 135 for patients. Since that the Sig value for Levene’s is less
than 0.05 (0.001), then we reject the null hypothesis that the variances of the
two samples are equal. That is, we do not assume equal variances.

mean of the number of the scores of the healthcare professionals was 2.9 with a
standard deviation (.69) and 2.66 with a standard deviation of (.80) for the
patients group. The independent t-test showed that there was a statistically
significant difference between the two samples, t (355) =4, p=0.00, however,
the effect size is small (r2 = 0.04). This indicates that 0.4% of the variance
in scores can be attributed to wither healthcare professionals or patients.
These results suggest that healthcare professionals may have more intention
than patients to use telehealth.Discussion


       Measuring telehealth acceptance of one
group of the potential users may provide a fragmentary picture of the situation
and partial road plan for future telehealth programs, which in return may
affect telehealth program outcomes and sustainability.  We sought to explore both health care
practitioners’ and patients’ perspectives on telehealth acceptance, which will
be useful in meeting their needs in future telehealth programs.  The involvement of patients, in addition to
health care practitioners, in our study is in accordance with the increasing
interest of involving patients in health care decisions 22. 

and telerehabilitation acceptance was measured in multiple studies 23-25. Studies that explored telehealth acceptance
included different telehealth technologies. 
The definitions of telehealth varied from one study to another, but most
of the studies defined telehealth as
the general use of the Internet by health care practitioners to monitor
patients’ vital signs and exercise data.

acceptance among both health care practitioners and patients within the same
context have not been explored to date. 
The literature includes one article similar to our research study.  Liu et al. (2015) utilized the unified theory
of acceptance and use of technology (UTAUT) to examine additional theoretical
factors that affect acceptance of new technologies for rehabilitation by
therapists 26. Liu and colleagues measured
only the health care practitioners’ acceptance of telerehabilitation.  In our study we measured telehealth
acceptance of both patients and health care practitioners, which provided
better understanding of telehealth acceptance.

A recent study explored the technology engagement level of
people attending PR and its effect on their intention to use telehealth 27.  Seidman and colleagues assessed the
participants’ demographics associated with the willingness to use telehealth.  Even though the main goal of Seidman et al.’s
study was to only assess the level of technology engagement and its effect on
the intention to use telehealth, it is a key study that examined how the demographics
of patients with chronic respiratory
diseases might affect their intentions to use telerehabilitation. Our finding
that the intention to use telehealth for patients is less could be  due to their old age and less exposer to
technology in comparison to the healthcare professionals where they use high
tech machines and computers on their daily basis, further research is needed to
support our findings.






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