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THE MODERATING EFFECT OF PSYCHOLOGICAL FACTORS TOWARDS THE DIFFUSION OF A WEB-BASED HEALTH INFORMATION SERVICE (WBHIS)

Siti Noraini Mohd Tobi Faculty of Business Management

Universiti Teknologi MARA snoraini7601@puncakalam.uitm.edu.my

Maslin Masrom

Razak School of Engineering and Advanced Technology Universiti Teknologi Malaysia

maslin.kl@utm.my

Azman Mohammed

Health Education Division Ministry of Health Malaysia azmanmohd@moh.gov.my

Mohd Nasir Abdullah

Malaysia Institute for Health Behavioural Research Ministry of Health Malaysia

mnasir_a@moh.gov.my

ABSTRACT

The use of the Internet to retrieve health information is increasingly common and becoming the centre from which an individual acquires knowledge to make informed decisions regarding his health. MyHEALTH Portal (MHP) is a web-based health information service (WBHIS) set up by the Ministry of Health Malaysia as one of the MSC Telehealth Flagship Application in 2005. It is a national initiative by the Malaysian Government to bring great advances to the country through the innovative use of Information and Communication Technology (ICT) aims to empower and encourage individuals to be responsible for their health by providing health information and education online. This study is intended to investigate the MHP’s usage and other related factors specifically the psychological factors that influnce its usability using a quantitative research approach. It helps to understand factors that might hinder users from using MHP and inhibit them from making informed decision regarding their health condition. The findings would significantly help relevant parties to analyze the changes that are necessary in order to promote MHP to the mass. A conceptual framework is also developed indicating the key determinants of individual intention to use MHP through the central tenets of Rogers’s Diffusion of Innovations (DoIs) to identify the key critical success factors that influence individuals’ attitude based on the Theory of Reasoned Action (TRA) moderated by a psychological factors using the Health Belief Model (HBM).

Keywords: Psychological, diffusion, web-based health information service (WBHIS).

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1. Introduction

The concept of eHealth has gained momentum within health care in recent years, but surprisingly little has addressed the issue of health promotion within eHealth. eHealth was described as tools or solutions for both health professionals and personalized health systems for health consumers including health information networks, telemedicine services, personal wearable and portable communicable system, electronic health records and health portals (Commission of the European Communities, 2004). Eng (2002) provides a more specific definition of eHealth as the use of emerging technologies and, in particular, the internet to enhance health and health care. eHealth is playing an increasingly large role in the lives of health consumers with the goals of the public health approach, which targets large population segments or an entire population. The approach of ehealth through the use of the internet to retrieve health information has becoming the center from which an individual acquires knowledge to make informed decisions regarding his health. Millions of consumers get health information from the internet and it becomes the gateway for an individual to gain access to his personalized health assessment from which he will be able to monitor his health status. Lee (2013) believed that the internet is more effective in the delivery of health information and can be easily accessed at large. Given the great number of published definitions of eHealth, surprisingly little reference is made to the use of these technologies in the health promotion field. It is defined as ‘‘the science and art of helping people change their lifestyle toward a state of optimal health (Am J, 1989). However, the absence of the term does not automatically imply that the technology has not been utilized in health promotion.

Meanwhile, health education is described as any combination of learning experiences designed to help individuals and communities to improve their health, by increasing their knowledge or influencing their attitudes (WHO, 2014). An effective ways of how to promote health education to the mass is with the support of technology using online health information service which is similarly the web-based health information service (WBHIS). WBHIS is an example of online health education under the pillars of ehealth. Marcus et al (2000) highlighed delivering effective and cost-effective interactive health promotion interventions would be greatly facilitated by increased reliance on eHealth applications and such in the case is the WBHIS.

It is made known the health sector is the primary supplier of health information. Some of the information is reliable and up to date; some is not. A way of how to identify whether the sources are good or bad is by considering the source whether it is a .gov, .com, .edu, or .org. Indisputably, governmental health portals and websites provide quality, reliable and trusted health information for its citizens to help them to make healthy and informed choices anywhere at any time. Likewise throughout these, an individual can quickly search for a topic, or look into specific areas accountably in more detail such as: managing conditions and diseases, coping with life stages and general advice on health and wellbeing.

2. MyHEALTH Portal (MHP)

MHP is a web-based health information service set up by the Ministry of Health Malaysia as one of the MSC Telehealth Flagship Application in 2005. This is a national initiative by the Malaysian Government to bring great advances to the country through the innovative use of Information and Communication Technology (ICT) which can also accelerate Malaysia´s growth towards becoming a fully developed nation by the year 2020. MSC Telehealth Flagship Application is envisaged to transform the Malaysian healthcare system to be more integrated, distributed and virtual with the aim of providing equitable, accessible and high quality healthcare services. This will help to realize

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the healthcare vision of the nation by emphasizing on life-long wellness wherein individuals, families and communities are empowered to play a major role in managing their health. The objectives of this portal are: to empower and encourage individuals to be responsible for their health by providing health information and education online as well as to provide reliable and quality health related information to specific target groups in a user friendly and easily accessible manner.

Through MHP the public will be able to access current health information and health advice easily via the internet. This portal carries certain health-related topics such as Health for Kids; Teenagers; Prime Years; Golden Years; Nutrition; Medication and You; Oral Health Alert; Frequently Asked Questions (FAQ) and also maintains a Health Forum. The number of hits for the portal at the end of August 2009 was 697,538. An average hits per day was 542 and the average weekly hits was 3,787. There are now 6,111 registered users and 7,210 people having interacted with health experts (10th Malaysia Health Plan, 2011).

All the information provided in the governments’ health websites or portals undergoes a quality assurance review process, and is sourced from a range of trusted partners including major health organizations in each country. The contents are developed using content governance framework, which also includes quality assessments of selected information partners.

3. Background of the Problem

In Malaysia, non-communicable diseases surpass the communicable diseases in terms of morbidity and mortality. Non-Communicable Disease (NCD) such as cardiovascular disease, diabetes and cancer are the major causes of admissions and deaths in government hospitals (Health Facts, 2012). The National Health Morbidity Surveys (NHMS) conducted in 1996 (NHMS II) and 2006 (NHMS III) showed that the prevalence of diabetes and hypertension are increasing in trend. The prevalence of Diabetes Mellitus has increased twofold in NHMS III (14.6%) as compared to NHMS II (8.3%) and higher prevalence in Hypertension and Cardiovascular Disease has also been observed in NHMS III.

By the year 2020, it is estimated that people of 60 years of age will contribute to 11.2% of the total population, with a consequent increase in morbidity (NHMS III, 2006). The expected increase in the number of elderly will result in a consequent increase in morbidity conditions which may consume a large portion of funds for health. It has been made aware that it is difficult to change and modify behaviors of individuals and communities. A lot of health messages and information has been disseminated to the public but these have yet to be translated into actions and behavioral changes. Clearly, there is still a wide gap between community’s knowledge and their behavior. Ultimately it is communities, families and individuals who must change their behavior in order to be healthier. It is obviously being aware that the community still does not take ownership of their health issues. Community empowerment thus becomes instrumental. Having access to any of the ehealth applications such as online health education services could enhance this. Community needs to participate in ehealth for their own health benefits. Their participation can be improved through developing their skills and abilities to build capacity. Therefore, there is an urgent need to create a high level of awareness within the public about health and wellness, for example; awareness on health risk assessment, prevention of disabilities and healthy ageing. These as mentioned earlier were provided in MHP. Likewise it is crucial to study individual’s attitude and behavioral intention towards health promotion and education as person's behavior is predicted by their attitude toward the particular behavior and how they think other people would view them if they did the actual behavior. Both of these factors determine a person's behavior intention, which leads to whether the

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actual behavior will be carried or not. Thus this proposed study tries to fill the gap and to investigate the factors that influence the use of WBHIS and the role of psychological influence that might have on the behavioral change activity towards encouraging Malaysian in applying MHP.

4. Research Objectives

The proposed study offers the following objectives to be investigated:

RO 1 : To examine whether there is a significant relationship between the diffusion aspect and health consumers’ attitudes in using MHP?

RO 2 : To investigate whether psychological factors influence the relationship between diffusion aspects and health consumers’ attitudes toward the use of MHP?

RO 3 : To examine whether there is a significant relationship between social factors and health consumer’s intention to use MHP?

RO 4 : To investigate whether psychological factors influence the relationship between social factors and health consumers’ intention toward the use of MHP?

5. Research Questions

RQ 1: What is the relationship between complexity, relative advantage and triability of MHP toward health consumers’ attitudes in using MHP?

RQ 2a: How do outcome expectations and cues to action influence the relationship between complexity and health consumers’ attitudes in using MHP?

RQ 2b: How do outcome expectations and cues to action influence the relationship between relative advantage and health consumers’ attitudes in using MHP?

RQ 2c: How do outcome expectations and cues to action influence the relationship between triability and health consumers’ attitudes in using MHP?

RQ 3: What is the relationship between attitude and subjective norms toward health consumer’s intention in using MHP?

RQ 4a: How do outcome expectations and cues to action influence the relationship between attitude and health consumers’ intention to use MHP?

RQ 4b: How do outcome expectations and cues to action influence the relationship between subjective norms and health consumers’ intention to use MHP?

6. Theoretical Framework

The theoretical approaches applied in this proposed study are seeking to understand user’s intention to use WBHIS in terms of the implementation process as well as to understand the psychological determinants of user acceptance at an individual level. Figure 1 explains the relationship between independent variables, dependent variables and moderators.

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Figure 1: Conceptual framework for the moderating effect of psychological factors towards the diffusion of MHP

7. Literature Review

7.1 eHealth and Telemedicine

The confluence of the internet's rapid growth with the increasing adoption of health information technology has led to the development of new types of ehealth information technologies. Eysenbach (2001) has proposed ehealth as the following; “ehealth is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. Ina broader sense, the term characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve healthcare locally, regionally, and worldwide by using information and communication technology.”

ehealth examples include internet discussions and support groups, internet-based disease management programs, general and disease-specific health information portals, patient-physician communication tools, patient portals, personal health records, and patient-accessible medical records. ehealth may be most beneficial in its ability to enable new means of care delivery that place an emphasis on patient self-management.

It also has been known so far there are several countries that have recognized the potential of telehealth applications in their healthcare settings. Telehealth can be defined as the use of information and communication technologies to support and provide health information to a variety of health professionals and consumers on variety of health topics and issues, which are from the clinical to the general aspects (Mohan & Yaacob, 2004). In Malaysia, Telehealth project was launched in 1999 to achieve the National Health Vision that is to have a healthy nation by next year 2020. The main goal is to keep people in the “wellness” paradigm. It is intended to empower people to greater access and increase knowledge in personal health management and well-being. Among the applications, Mass Customised Personalised Health Information & Education (MCPHIE) is using the web or Internet technologies as the key standard in search for and receipt of health information. The MCPHIE becomes the enabler for empowerment of the individual in order to achieve the national Health Vision of “promoting individual responsibility and community participation towards an

Complexity

Triability

Relative Advantage

Attitudes

Subjective Norms

Intention to

use MHP

Outcome Expectation

s

Outcome Expectation

s

Cues to Action

Cues to Action

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enhanced quality of life” and this can be achieved by allowing the public to access online health information (A. Hashim, 2004).

7.2 The Health Belief Model (HBM)

The Health Belief Model is a psychological health behavior change model developed to explain and predict health-related behaviors, particularly in regard to the uptake of health services (Robert, 1995). The health belief model was developed in the 1950s by social psychologists at the U.S. Public Health Service (Rosenstock, 1974) and is one of the most well-known and widely used theories in health behavior research. The HBM suggests that people's beliefs about health problems, perceived benefits of action and barriers to action; and self-efficacy explain engagement (or lack of engagement) in health-promoting behavior. A stimulus, or cue to action, must also be present in order to trigger the health-promoting behavior. The health belief model attempts to predict health-related behaviors by accounting for individual differences in beliefs and attitudes. Implicit in the conceptualisation of the health belief model (HBM) is the combination of perceived susceptibility with perceived seventy (to produce perceived threat), and perceived benefits with perceived barriers (to determine evaluation of the course of action taken). As such, health behaviour is more likely to be carried out if benefits can be derived from performing the behaviour; there are few barriers to performing the behaviour, or some combination of these. Similarly, if one is “health motivated”, behavioural enaction is more likely. Finally, cues to action such as symptom perception or health communication may also prompt performance of the behaviour. For this proposed study, behavioral intention of health consumers will only be moderated with outcome expectation constructs consist of perceived benefits and perceived barriers and; cues to action construct.

7.2.1 Outcome Expectations (Perceived Benefits vs Perceived Barriers)

Outcome expectation is comprised of perceived benefits and perceived barriers which are used together to determine evaluation of the course of action taken. As such, health behaviour is more likely to be carried out if benefits can be derived from performing the behaviour; there are few barriers to performing the behaviour, or some combination of these. Health-related behaviors are also influenced by the perceived benefits of taking action (Glanz, Rimer & Viswanath, 2008). Perceived benefits refer to an individual's assessment of the value or efficacy of engaging in a health-promoting behavior to decrease risk of disease (Janz & Becker, 1984). If an individual believes that a particular action will reduce susceptibility to a health problem or decrease its seriousness, then he or she is likely to engage in that behavior regardless of objective facts regarding the effectiveness of the action (Rosenstock, 1974). For example, individuals who believe that wearing sunscreen prevents skin cancer are more likely to wear sunscreen than individuals who believe that wearing sunscreen will not prevent the occurrence of skin cancer.

Health-related behaviors are also a function of perceived barriers to taking action (Glanz, Rimer & Viswanath, 2008). Perceived barriers refer to an individual's assessment of the obstacles to behavior change (Rosenstock, 1974a). Even if an individual perceives a health condition as threatening and believes that a particular action will effectively reduce the threat, barriers may prevent engagement in the health-promoting behavior. In other words, the perceived benefits must outweigh the perceived barriers in order for behavior change to occur (Janz & Becker, 1984 and Glanz, Rimer & Viswanath, 2008). Perceived barriers to taking action include the perceived inconvenience, expense, danger (e.g., side effects of a medical procedure) and discomfort (e.g., pain, emotional upset) involved in engaging in the behavior (Rosenstock, 1974a). For instance, lack of access to affordable

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health care and the perception that a flu vaccine shot will cause significant pain may act as barriers to receiving the flu vaccine.

7.2.2 Cues to Action

The HBM posits that a cue, or trigger, is necessary for prompting engagement in health-promoting behaviors (Rosenstock, 1974b). Cues to action can be internal or external. Physiological cues (e.g., pain, symptoms) are an example of internal cues to action. External cues include events or information from close others, the media, or health care providers promoting engagement in health-related behaviors. Examples of cues to action include a reminder postcard from a dentist, the illness of a friend or family member, and product health warning labels. Research assessing the contribution of cues to action in predicting health-related behaviors is limited (Janz & Becker, 1984; Rosenstock, 1974b; Carpenter, 2010 and Glanz, Rimer & Viswanath, 2008). Cues to action are often difficult to assess, limiting research in this area. For instance, individuals may not accurately report cues that prompted behavior change. Cues such as a public service announcement on television or on a billboard may be fleeting and individuals may not be aware of their significance in prompting them to engage in a health-related behavior.

7.3 Diffusion of Innovations (DoIs)

DoIs is one model used to predict information system usage. Rogers (2003) defined diffusion as the process by which an innovation is communicated through certain channels over time among the members of a social system and implemented. In diffusion theory, the adoption process is highlighted as inseparable from the diffusion process where diffusion is imposed of individual adoption. Indeed, diffusion describes the adoption process across a population over time. As of 2004, more than 5000 diffusion publications had referenced his theory (Rogers, 2004). Diffusion of Innovations has been applied to numerous contexts, including medical sociology, communications, marketing, development studies, health promotion, organizational studies, knowledge management, and complexity studies (Greenhalgh et al., 2005). In this theory, the adoption of innovation is modeled as a process of information gathering and uncertainty reduction with a view to evaluate the technology. The individual’s decision on whether to use the technology is based on perceptions of the technology such as relative advantage, compatibility, complexity, trialability and observability (Rogers, 1995). The objective of DoIs research is to explain or predict rates and patterns of innovation adoption over time and/or space. An outcome of DoIs research has been the identification of innovation attributes which ostensibly influence diffusion at the individual level (relative advantage, compatibility, complexity, trialability, and observability) (Rogers, 2003 & 2004).

However, Rogers’s perceptual measure, while valuable, is somewhat limited in its ability to explain the user’s initial attitude toward adopting innovations. In addition, the work of Rogers’ and all subsequent research employing his model leaves a critical gap in the existing knowledge of this important subject. That gap is precisely what to be addresses in this proposed research, namely identifying and empirically examining pre-adoptive behaviors toward technology adoption and usage through three DoIs measures; complexity, relative advantage and trialability. The three attributes from Rogers are selected as the most face valid constructs studied WBHIS intention to use by employing independent variables of complexity, relative advantage, and trialability from Rogers (Conrad, 2009) and using Davis’s behavioral intent to predict willingness to use. Behavioral intention is a function of both attitudes toward a behavior and subjective norms toward that behavior, which has been found to predict actual behavior. Rogers’s constructs of relative advantage and complexity

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have been demonstrated to be theoretically the same as Davis’s perceived usefulness and perceived ease of use. It is believed that the use of these variables will effectively explained willingness to use at the individual level.

7.4 Theory of Reasoned Action (TRA)

The theory of reasoned action (TRA) is a model for the prediction of behavioral intention, spanning predictions of attitude and predictions of behavior. TRA was developed by Martin Fishbein and Icek Ajzen (1980) and in the theory intention is defined as the motivation required to perform a particular behaviour. Therefore, the more one intends to perform a behavior, the more likely is its performance. Within this framework, intention is held to be determined by attitudes (general positive/negative evaluation of behaviour) and subjective norm (global perception of social pressure). The details of the two constructs are highlighted below.

7.4.1 Attitudes

Attitude refers to an individual’s positive and negative evaluations with regard to a behavior (Ajzen & Fishbein, 1980). Much of the research supports the view that attitudes and subjective norms, can significantly predict intention (Ajzen, 1991; Kim, 2009; Madden, et al., 1992; Pavlou & Fygenson, 2006; Venkatesh & Brown, 2001). Specifically, Ajzen and Fishbein (1980) found that an individual’s attitude toward a behavior is a predictor toward the intention toward that behavior. In other words, Ajzen and Fishbein (1980) found that if an individual has a positive attitude toward a behavior, he/she is more likely to engage in that particular behavior. In the contrary, a negative attitude would have a negative effect on intention.

In a study by Torres (2011), attitude was found as significantly affect users’ intentions to use patient health portal (PHPs). Previous studies also have shown that attitude is a strong predictor of intentions (Madden, et al., 1992; Mathieson, 1991; Norman & Conner, 1996; Taylor & Todd, 1995; Venkatesh & Brown, 2001).

7.4.2 Subjective Norms

Subjective norm refers to an individual’s perception of the people important to him/her and his/her thoughts regarding a particular behavior (Ajzen & Fishbein, 1980). In other words, an individual who believes that he/she should engage in a particular behavior based on the perceived social pressure may more likely intend to engage in the behavior (Ajzen, 1991a). On the other hand, if an individual believes that those who are important to him/her think that he/she should not engage in a particular behavior, he/she will less likely intend to engage in the behavior. Torres (2011) found that a subjective norm was significant towards users’ intentions to use patient health portal (PHPs). Other research studies also had found subjective norms to be a significant predictor of intentions (Madden, et al., 1992; Mathieson, 1991; Norman & Conner, 1996; Taylor & Todd, 1995; Venkatesh & Brown, 2001). Jian et al. (2012) also reported that subjective norms became one of the critical issues for the adoption of personal health records technology (PHRT) among health care users.

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8. Methodology

Participants will be recruited from a convenience sample of adults in the area of Klang Valley ranging from 18 to 56 years old and willing to participate in the survey. An open invitation will be made through placement of flyers in public area, through the electronic means (Facebook and email invitation) and by word of mouth. The survey instrument will include the background questionnaire, adopted Technology Adoption (Moore & Benbasat (1991); Rogers (1995), and Health-related Belief Questionnaire. The survey will be conducted in two phases. The first phase involved conducting a pretest of the survey instrument. The pretest is conducted to ensure that the initial survey items are significant to this study and to examine reliability of scales. Upon completion of the pretest analysis, the survey instrument will be finalized and administered to the sample population.

Based on an initial power calculation using the G-Power application, a minimum of 200 participants will be needed for this dissertation. G-power computes the effect size based on the number of parameters that are defined in a study (Erdfelder, Faul, & Buchner, 1996). Based on a specified number of parameters (dependent and independent variables), the system calculates the minimum number of participates needed in order to ensure that the results from the study are not a result of chance. Using the multivariate research requirement that asks for 25 observations (Hair et. al, 1998) for each variable, a minimum of 200 participants is needed for this dissertation.

9. Conclusion

The Ministry of Health Malaysia has launched MHP in 2005 but the intention to use MHP is known to be limited within the health consumers and within the Ministry as well. It has been known so far limited studies were conducted on exploring the users’ intention to use MHP though this new technology is said to empower users to make an informed decision regarding their health condition through trusted and reliable health information provided in the portal. While many can speculate the advantages offered by this WBHIS, it is of important to know the implementation particularly the intention and diffusion to use this portal among the health consumers. Thus there is a need for investigating the usability aspect of this technology and contribute to the body of knowledge regarding this particular WBHIS. This proposed study is intended to investigate the MHP usage and other related factors that influnce its usability using a quantitative approach. This research is practically imperative as it can help to understand some factors that might hinder users from using MHP and inhibit them from making an informed decision regarding their health condition. It is expected that the findings would significantly help relevant parties to analyze the changes that are necessary in order to promote MHP to the mass.

Acknowledgement

Most cordial thanks are due to the sponsorship, Universiti Teknologi MARA and Ministry of Higher Education for funding the research study. Authors would also like to extend appreciations to respective reviewers for their constructive comments and feedbacks which will benefits the study.

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