Framework analysis on the adoption of digital healthcare services among senior citizens by using the extended technology acceptance model (ETAM)

Development of digital healthcare in Malaysia

Digital healthcare in Malaysia has been growing rapidly in recent years, (Alashhab et al., 2021), driven by technological advancements, rising healthcare costs (He and Tang, 2021), and increasing demand for more convenient and accessible healthcare services (Jeffree et al., 2020). Digital healthcare in Malaysia refers to the use of technology to provide healthcare services and manage health information. It encompasses a wide range of technologies and solutions, including telemedicine, electronic health records, mobile health applications, wearable devices, and remote monitoring systems (Baudier et al., 2023). These are a few of the key developments in digital healthcare in Malaysia based on different studies (AlQudah, 2021).

According to Manzoor et al. (2022), telemedicine is one of element of digital healthcare, focused on audio or video connections conferencing with doctors, that is becoming increasingly popular in Malaysia, particularly in rural areas where access to healthcare services is limited. The Malaysian government has also been promoting telemedicine to improve healthcare access and reduce costs (Bouziane et al., 2022). In recent years, Malaysia has been increasingly embracing digital healthcare to improve the quality and accessibility of healthcare services for its citizens. Based on literature by Jembai et al. (2022), the government has implemented several initiatives aimed at promoting the use of technology in healthcare, including the launch of the Malaysia Health Data Warehouse and the introduction of the Telemedicine Act in 2018. The development of Mobile health (mHealth) has meant that the use of mobile devices to deliver healthcare services and information is also gaining popularity in Malaysia (Shrestha et al., 2022). Kc et al. (2021) have stated that many healthcare providers in Malaysia have launched their own mobile applications to provide patients with access to medical advice, appointment scheduling, and prescription refills. However, several studies highlighted that there was a scarcity in studies that evaluated all the performance and impact of these devices, application and policies proposed created by government and non-government agencies (Chowdhury et al., 2021).

As reported by Enaizan et al. (2020) and Zakaria (2022), many healthcare facilities in Malaysia are now using electronic medical records (EMRs) to store and manage patient information. Hira et al. (2022) mentioned this allows for more efficient sharing of medical records among healthcare providers and reduces the risk of medical errors. Additionally, the Malaysian government launched the national health information exchange (HIE) called MyHEalthXchange which allows healthcare providers to share patient data securely and efficiently (Bazel et al., 2022). Additionally, research has shown most users are young citizens and the participation among senior citizens is lower but should be increasing progressively along with the development of technology advancement in healthcare (Seven et al., 2021). According to Puri et al. (2022), the use of health wearables, such as fitness trackers and smart watches, is also growing in Malaysia. These devices allow individuals to monitor their health and wellness and provide valuable data to healthcare providers for diagnosis and treatment (Al-Turjman et al., 2020). Past literatures argued the usage of digital healthcare among senior citizens and the degree of their understanding on the device functions and usage, is still shallow (Lee and Lee, 2020).

Hariharan, (2021) stated that digital healthcare solutions have been particularly important in Malaysia during the COVID-19 pandemic, as they have enabled healthcare providers to deliver care remotely and reduce the risk of transmission of the virus. Telemedicine services have seen a significant increase in demand (Galen Centre for Health and Social Policy, 2018), as patients have sought to avoid in-person visits to hospitals and clinics. Based on Wong and Hazley (2020) study, digital healthcare in Malaysia is on the rise and is expected to continue to grow in the coming years. However, there are still challenges to be addressed, such as ensuring data privacy and security, and addressing the digital divide in rural areas, but the country has the potential to transform the healthcare landscape in Malaysia, improving access to care, reducing costs, and ultimately improving health outcomes for the population (Jamil, 2021).

Senior citizen adoption and challenges of digital healthcare in Malaysia

Adoption of digital healthcare in Malaysian has been steadily increasing in recent years (Putri et al., 2020). According to Salleh, et al. (2021) and Bile et al. (2022) this can be attributed to several factors, such as the growing availability of digital healthcare services, the convenience of accessing healthcare from home, and the increasing familiarity of seniors with digital technology. Nevertheless, previous studies show that the adoption of digital healthcare among senior citizens in Malaysia has been slow, potentially due to various reasons such as lack of awareness, limited access to technology, and concerns about data privacy and security (Malarvizhi and Manzoor, 2020; Ahadzadeh et al., 2021). According to Tawalbeh et al. (2020), to address concerns about data privacy and security, healthcare providers must ensure that they have robust security measures in place to protect sensitive information. There should be a clear and concise information on data privacy policies to reassure senior citizens that their information is safe (Kulyk et al., 2023). Additionally, Malaysia is a multicultural and multilingual country, and not all seniors may be fluent in the language used on digital healthcare platforms. The non-familiarity of the language featured in digital application could potentially make it difficult for them to understand and navigate these platforms (Lee et al., 2021). Similarly, there could be difficulty for senior citizens to use digital devices because of poor eyesight, limited mobility or hearing impairments that could potentially make accessibility difficult for them (Wilson et al., 2021, Banskota et al., 2020). The cost of digital healthcare services and devices could also be a barrier for some, especially those on a fixed income or retirement (Wilson et al., 2021). As a minimum, users will need to own a digital gadget such as smart phone, laptop, tablet or any other gadget before being able to access to digital healthcare services.

Past studies also suggested way to increase adoption is to educate and raise awareness among senior citizens about the benefits of digital healthcare (Yuan, and Cheah, 2020). It was advised for awareness to be raised through community outreach programs and workshops that highlight the advantages of using technology in healthcare, such as remote consultations, online appointment scheduling, and easy access to medical records (Caballero et al., 2021; Visvesvaran et al., 2021). In addition, Godinho et al. (2020) state that it is essential to address the issues of limited access to technology by providing affordable and accessible digital healthcare solutions where potentially can be achieved by partnering with technology companies and telecommunication providers to offer low-cost devices and internet access to seniors (Lousado et al., 2021). Yet, there is a lack of studies focused on investigate the attitude, and behavioral towards technology that could help on understand better the extent of technology adoption and usage (Zhong et al., 2021).

The extended technology acceptance model (ETAM)

A model called the technology acceptance model (TAM) was created to show the relationship of one’s adoption towards technology based on perceive usefulness, perceive ease of use, and actual use of system (Zin et al. 2023). Over the years, this model has been improved and now includes external variables, attitude, and behavioral intention as additional factors of technology adoption (Liu et al., 2022). ETAM is derived from the TAM that was initiated by Davis et al. 1989 and originated to discuss the adoption of technology (Zin et al. 2023, Yang, C. C., Yang, S. Y., and Chang, Y. C. 2023). Various studies have referred to TAM as theoretical starting points for studying technology adoption and usage (Yang, C. C., Yang, S. Y., and Chang, Y. C. 2023). The ETAM was developed by Venkatesh and Davis (2000) and highlights the importance for researchers to understand the driving factors of perceived usefulness. These determinants have changed over time and the variable is not only limited to subjective norms. Past literature quoted these determinants including: image, job relevance, output quality, results demonstrability, experience, and voluntariness (Prasetyo et al., 2021, Kim, et al., 2022, Tsai et al., 2021, Velicia-Martin et al., 2021, Zhao and Wang, 2020). The ETAM is the most appropriate theoretical model to measure user perceived usefulness, perceived ease of use, acceptance and adoption of technology, as well as the actual usage of the application. It is also the basis to several studies that are pertinent to technology adoption and usage of senior citizens (Zin et al. 2023, Liu, D., Li, Q., and Han, S., 2022).

In this context of research, external variables are hypothesized to be determinants of perceived usefulness and perceived ease of use. This is followed by perceived usefulness and perceived ease of use driving the variable “attitude toward using”. These variables measure the senior citizen’s positive or negative feelings toward using digital healthcare. This model posits that perceived usefulness permits organizations to strategize on growing user acceptance and usage (Zin et al., 2023, Liu, D., Li, Q., and Han, S., 2022).

This research will review the utilization of the ETAM from past studies that derive from the TAM. The aim is to discover the relationship and way to assess the adoption of digital healthcare services among senior citizens. The flow of ETAM can be seen in Figure 1.

Figure 1. ETAM’s theoretical framework.

(Y., Trianita, M., & Dharma, S. (2019) adapted from Venkatesh, V., and Davis, F. D. (2000).

Familiarization

Data familiarization provides an initial understanding as the first step of the analysis. The major themes will depend on the items found related to the research questions and the data familiarization step will continue until the researchers arrive at reasonable variation within past literatures. Two researchers were assigned for the data familiarization and they first review past literature that utilized ETAM as a tool to measure the challenges in adopting technologies. It was considered to be even better if the key ideas are related to healthcare or senior citizens as the users. However, as long as the literature uses ETAM approach to assess technology adoption, the data is accepted for familiarization process. Several relevant questions that occur during this process revolve around how users perceive the technology, how users use it, what are their opinions about it, and how external factors could affect the way they use technology. All of these were taken into consideration before generating the themes in the next step.

Identifying framework

From the familiarization of data, the next step is to have a more concrete descriptions by identifying relevant themes. These themes were derived from items that were gathered during the familiarization step and it was grouped and ordered in a way that assist the researchers to gather common attributes of items into relevant groups and concepts; perceived usefulness, perceived ease of use, actual use, external variables, attitude and behavioral intention. Through discussion, the same two researchers that perform data familiarization will code the major themes for the data to be more manageable and refined. The refinements include naming the themes, identifying items for each theme, and collapsing irrelevant items. From this process, the main themes that were identified and coded are perceived usefulness, perceived ease of use, actual use, external variables, attitude and behavioral intention. Generating these themes was absolutely crucial before the indexing process takes place as it requires researchers to interpret the common meaning across all found items that were sub-categorized in each theme.

Indexing

The process of indexing is to link the sub-categorized items in each theme and to code the commonalities that were found across the themes. All researchers gather to discuss the identified themes and negotiate the meaning for each theme before linking them to the items. Within each theme, the generated code will be based on the common meaning to represent the linked sub-category. The indexing step also provides opportunity to revise the themes, sub-categories, or unit that was identified especially if there is a need to accommodate new concept or new variation. This is where the researchers may encounter coded items that are not relevant and the process will continue in an iterative way until all data are appropriately indexed. For this study, at the end of the indexing steps, two commonalities were found among the coded themes and thus, two categories were identified which are viewpoint (perceived usefulness, perceived ease of use, behavioral intention), and impact (attitude and actual use). One last theme, external variable was treated as a stand-alone factor as it does not have any commonality with other coded themes and it will go through charting process where all nine codes or items within the theme will be examined with possible data abstraction if it was found necessary.

Charting

In this step, the researchers look at the order of units and components to make sure it is relevant to the objective; which is to review the findings based on senior citizens’ perspective. The researchers revisit most of the units that were assigned under the external variable theme and develop further analysis to ensure it fits the key characteristics of senior citizens’ perception of challenges. Upon studying the unit within this theme, it is now coded into a new category called factor. As there were no abstraction done in the previous step, the abstraction of unit happens to occur at this step whereby five codes were removed from the external variable theme. The removed codes were system quality, social interaction, computer self-efficacy, relevance, and user interface. The final list of codes remains inside the external variable theme include information quality, privacy and security, trust, and health literacy.

Mapping and interpretation

The final step in framework analysis is mapping and interpretation where it is to review and combine the data following the meaning and relationship across all categories, themes and items. It is ultimately for researchers to present a connection to showcase the relationship across all units and how the whole data were structured. Upon the process of the final mapping, the generated framework consists of three main categories; viewpoint, impact, and factors. Viewpoints consist of perceived usefulness, perceived ease of use, and behavioral intention. Impact consists of attitude and actual use. Factors consist of information quality, privacy and security, trust, and health literacy.

The generated framework explains further the ability for ETAM to be utilized to measure the adoption of digital healthcare among senior citizens. Summary of the framework analysis can be seen in Table 1.

What are the type of users’ technology adoption study can be measured by using ETAM?

Past researchers have utilized the ETAM to conduct research that is related to users’ adoption towards technology. For this research, five different models from five different research project were selected for framework analysis as seen in Table 3.

Table 3. Existing framework utilizing ETAM.

No	Description of the model
1	Framework diagram
	Aim and scope	To determine the factors affecting the acceptance of e-learning platform during COVID-19.
	External variables	Information quality, system quality and user interface.
	Citation	(Prasetyo et al., 2021)
2	Framework diagram
	Aim and scope	To study the quality characteristics and acceptance intention for healthcare kiosks covering the elders’ perception from South Korea.
	External variables	Service quality, system quality, and information quality.
	Citation	(Kim, Chung and Park, 2022)
3	Framework diagram
	Aim and scope	To assess the deployment of masks to combat the COVID-19 Pandemic in Taiwan through web-based cross-sectional study.
	External variables	Health literacy, privacy and security, and computer self-efficacy.
	Citation	(Tsai et al., 2021)
4	Framework diagram
	Aim and scope	To study the acceptance of COVID-19 tracing application
	External variables	Privacy concern, trust
	Citation	(Velicia-Martin et al., 2021)
5	Framework diagram
	Aim and scope	To measure users’ attitude on the health-related short video advertising on social media
	External variables	Social interaction, intrusiveness, in formativeness, and relevance
	Citation	(Figure reproduced with permission from Zhao and Wang, 2020)

As seen in Table 3, the first reviewed model was developed to study the factors affecting students’ acceptance towards e-learning platform. This study by Prasetyo et al. (2021) showcases how perceived usefulness is connected to information quality while perceived ease of use is connected to system quality and user interface. It also shows that the external variable does not have a direct effect on behavioral intention which then will determine the actual use.

The second reviewed model was used to study the acceptance of healthcare kiosks among the elderly in Korea (Kim, Chung and Park, 2022). Even though this study does utilize the ETAM by having external variables, it connects the perceived usefulness and perceived ease of use direct to the technology acceptance among users. The external variables utilized in this study consist of service quality, system quality, and information quality.

The third reviewed model is to look into assessing the use of masks to combat COVID-19 through web-based sectional study (Tsai et al., 2021). Across all other models review, the model utilized in this study is one of the closest to the original model of ETAM that was created by Venkatesh and Davis (2000). As for the external variables, this study investigates health literacy, privacy and security, and computer self-efficacy.

The fourth reviewed model is to study the acceptance of COVID-19 tracing application by looking at privacy concern and trust issue among users (Velicia-Martin et al., 2021). Additionally, the fifth reviewed model is used to measure users’ attitude on health-related social media video advertising with external variable of social interaction, intrusiveness, in formativeness, and relevance (Zhao and Wang, 2020).

Therefore, from all the reviews above, the researchers found several types of studies that utilize ETAM model in relation to digital healthcare adoption. Key similarities found in the discussion of external variables that associated with human and devices characteristics. For instance, users look for healthcare application interface, security and privacy. Additionally, users would consider self-literacy, social interaction, self-efficacy as factors that contribute to willingness and trust to use digital healthcare.

What are the challenges for senior citizens to adopt digital healthcare services?

Upon reviewing past literature, external factors that drive or impede senior citizens’ technology adoption vary according to the study subject and context. Similar findings from studies that were conducted particularly for senior citizens, digital adoption that covers different age of users summarize in Table 4. Table 4 illustrates the findings of the potential challenges for senior citizens to adopt digital healthcare services and these external variables were generated from the framework analysis charting process.

Studies by Prasetyo et al. (2021); Zin, et al. (2023); Zhao and Wang (2020); and Lee, et al. (2021) agreed that information quality is one of the key external barriers to technology adoption. These studies stressed how important information quality is to the users that attract and motivate them to use the application. Senior citizens considered as mature users will consider how useful the information in digital healthcare that could be used for their health monitoring etc. Information quality is one of key factor that ascertain the information performance and how successful the e-learning environment.

The second barrier found is privacy and security. This finding is not only applicable to senior citizens but to most users from different age groups (Kim, Chung and Park, 2022). This is because the results from various studies confirmed that regardless of culture or background users’ views on privacy and security are consistent. People tend to consider information privacy, psychological privacy, and social privacy towards digital adoption.

The third external variable found to be trust. Trust refers to the faith, level of confidence, and expectation of senior citizens that digital healthcare services will benefit them in many ways. Prior studies have applied trust to the TAM and discovered roles of trust in increasing usefulness (Tsai et al., 2021). These studies propose more research emphasis on examine trust with the ETAM. Trust measures users view toward the digital healthcare is either is well protected, reliable and secured.

The final barrier is health literacy, studies by Yu et al. (2021) and Brackstone et al. (2022) found that the extent of health literacy can contribute to users’ willingness to technology adoption. This factor assesses the ability of senior citizens to understand and process the health information provided in digital healthcare that led to their decision making.

How to utilize ETAM to measure the adoption of digital healthcare services among senior citizens?

Based on the framework analysis, ETAM could be one of the more accurate models to measure the adoption of digital healthcare services among senior citizens. Various studies from multiple research areas covering management, communication, psychology and technology, have verified in their findings of users’ perceived usefulness, users’ perceived ease of use, and how it affects users’ attitude that will then lead to their behavior and intention to use. In addition, the external variables could also affect users’ behavior and intention. The external variables found in this study are information quality, privacy and security, trust, and health literacy which formulated from past validated studies (Prasetyo et al., 2021, Kim et al., 2022, Tsai et al., 2021, Velicia-Martin et al., 2021, Zhao and Wang, 2020). The development of framework mapping from the framework analysis can be seen in Table 2. Further explanation of the selected external variables is as follows:

The study by Wang et al. (2023), applied the ETAM model to investigate the factors that affect the adoption of mobile health services among older adults in China. The results showed that information quality, privacy and security, and trust significantly influence the intention to use mobile health services among senior citizens. Similarly, a study by Zhou et al. (2019) applied the ETAM to investigate the factors that influence the adoption of telehealth services among senior citizen study China. The results showed that information quality, privacy and security, and trust significantly affect the adoption of the services.

Overall, the ETAM model derived from Venkatesh and Davis (2000) was used to develop framework in Figure 2 and has proven to be effective in measuring the adoption of digital healthcare services among senior citizens by incorporating important factors such as information quality, privacy and security, trust, and health literacy. By considering these factors, healthcare providers can design and implement digital healthcare services that meet the needs and preferences of senior citizens and improve their health outcomes.

Figure 2. Framework model to assess senior citizens’ adoption of digital healthcare.