The Impact of User's Perceived Ability on Online Health Information Acceptance

Abstract

The purpose of this study was to explain how perceived ability affects users' acceptance of online health information in Korea. Data were collected by a Web-based survey, and, in total, 449 samples were used for final analysis. The hypothetical model of this study was based on the Technology Acceptance Model. A structural equation modeling was used to evaluate the relationship between the included variables. The final model with appropriate relations exhibited an adequate fit to the data. This study provides evidence that perceived ease of use, perceived usefulness, and perceived credibility significantly affect how individuals use health information from the Internet. The subjective health knowledge and Internet efficacy exerted strong indirect effects on users' attitude and intention to use the online health information via the mediators of perceived ease of use, perceived usefulness, and perceived credibility. This study supports the hypothesis that the perceived ability of users is related to their acceptance of online health information. Users' perceived ability, including subjective health knowledge and Internet efficacy, was confirmed as a prerequisite for their health information use on the Internet. The results demonstrated that perceived ease of use, perceived usefulness, and perceived credibility are substantive mediators. Future research should consider a wider array of characteristics of health information and users and incorporate these characteristics for the provision of more useful, user-centered health information.

Introduction

As the standard of living is improved by socioeconomic development, there is a gradual increase in people's wish to live higher-quality lives. To pursue the quality of life, individuals are acting more actively to find useful information. The Internet is recognized as a representative medium through which people can easily acquire a variety of information.

In telecommunications, Korea ranked as the world's leader in availability of high-speed Internet services. Korea's Internet penetration rate passed the 77% mark as of 2010, with 36.5 million of the country's 48 million people over the age of 4 years having online access.¹ Furthermore, the Internet has become an essential resource for healthcare users as well. Ryu et al.² found that 84.4% of Internet users in Korea had used the Internet to access health information and considered the Internet as a valuable resource for health information. That is, the continuing developments in information technology are increasing the acceptance of Internet use among the general population, and in turn the “digital divide” related to differences in approaching the Internet is decreasing in Korea. Considering that most technical obstacles related to accessibility are gradually being eliminated, it is therefore important to understand how people encounter the possibility of using online health information.

Unlike off-line environments, the Internet requires more cognitive capability of the users relative to appropriate information searching and technical use. Therefore, in this study, users' perceived ability, including subjective health information knowledge and Internet efficacy, was considered to explain their health information-seeking behaviors on the Internet.

To explain the effect of users' perceived ability on their health information use on the Internet, the Technology Acceptance Model (TAM) was used to provide a conceptual framework for this study.³ TAM studies have produced useful insights into the cognitive, emotional, affective, and behavioral reactions of individuals to technology, as well as into the external parameters that influence technology acceptance.⁴ The TAM has also been modified and applied in various contexts of technology and received empirical support and has even used to explain the acceptance of technology in the health sector.^4,5

In this study, we particularly focused the online health information users' perceived ability requiring information searching on and using the Internet. We assumed that individuals' subjective appraisal of performance and effort in relation with using health information on the Internet would affect their behavioral intention. We adopted the TAM and extended it by adding external and mediating variables. Our model suggests that the extended TAM belief variables mediate the relationship between the user's perceived ability and attitude toward use of the Internet.

This study extended the TAM in two ways. First, it focused on the abilities of users that are necessary for them to use health information on the Internet, adding these as external variables to the TAM. The modified TAM model included two external variables related to users: Internet efficacy and subjective health knowledge.

Materials and Methods

Hypotheses

The hypothetical relationships of our model include the typical relationships of TAM. Taking into consideration that user's perceived ability influences the use of health information on the Internet; the following relationships were tested in the present study:

H1. Internet efficacy will have a positive effect on perceived ease of use.

H2. Internet efficacy will have a positive effect on perceived credibility.

H3. Subjective health knowledge will have a positive effect on perceived credibility.

H4. Perceived ease of use will have a positive effect on perceived usefulness.

H5. Perceived ease of use will have a positive effect on attitude.

H6. Perceived credibility will have a positive effect on perceived usefulness.

H7. Perceived credibility will have a positive effect on attitude.

H8. Perceived usefulness will have a positive effect on attitude.

H9. Attitude will have a positive effect on intention to use.

Study Design and Data Collection

This study used a descriptive and correlational cross-sectional survey. The questionnaire was prefaced with a page that explained the objectives of the study and assured respondents of the anonymity and confidentiality of their responses.

The target population of this study was Internet users who had ever searched for health information on the Internet within the previous 6 months. Data were collected by a Web-based survey using a structured self-administered questionnaire in 2010. The exclusion of 56 incomplete and invalid responses resulted in 449 questionnaires from the two Web sites being available for analysis.

Descriptive statistics of the sample are presented in Table 1. More males (n=267, 59.5%) than females (n=182, 40.5%) participated in the study. The subjects were 20–29 years old (n=166, 37.1%), 30–39 years old (n=220, 49%), 40–49 years old (n=48, 10.7%), and 50–59 years old (n=15, 3.2%), and 72 (16.0%) of them were high school graduates or less well educated, 152 (23.8%) were junior college graduates, 184 (41%) were university graduates, and 41 (9.1%) were educated more than university graduates. One hundred ninety-two (42.8%) were office workers, 93 (20.7%) were housewives, 65 (14.5%) were professional workers, and 42 (9.4%) were students, with the remaining subjects being self-employed, industry workers, government workers, etc.

Table 1.

General Characteristics of Respondents (n=449)

CHARACTERISTIC	N (%)
Gender
Male	267 (59.5)
Female	182 (40.5)
Age (years)
20–29	166 (37.1)
30–39	220 (49.0)
40–49	48 (10.7)
50–59	15 (3.2)
Education
High school graduate or below	72 (16.0)
Junior college graduate	152 (23.8)
University graduate	184 (41.0)
Above university graduate	41 (9.1)
Occupation
Student	42 (9.4)
Office worker	192 (42.8)
Industry worker	12 (2.7)
Professional worker	65 (14.5)
Government worker	10 (2.2)
Housewife	93 (20.7)
Self-employed	18 (4.0)
Others	17 (3.7)

Structural equation analysis was used to identify the relationship between the interdependent multiple variables affecting the use of health information on the Internet by users. The software used was LISREL version 8.1 (SSI, Lincolnwood, IL), and the variance–covariance matrix was used in the analysis.

Instruments

The instruments used in the study were chosen from previous relevant literature and suitably modified for users of health information. All instruments were comprehensively reviewed by two nursing professors. A pilot test was conducted to test their validity and reliability. Exploratory factor analysis with varimax rotation was performed to examine the interrelationships within a set of variables. The properties of the studied variables were assessed for reliability based on Cronbach's alpha coefficient and the item-to-total correlation. All scales had reliability coefficients ranging from 0.80 to 0.92, which indicates satisfactory internal consistency given that they exceeded the usual cutoff of 0.50.⁶

The subjective health knowledge was assessed by a modified version of the self-assessed knowledge instrument developed by Park et al.⁷ It has a three-item, 7-point Likert format for scoring. Possible scores are 7–21. Cronbach's alpha for subjective health knowledge was 0.80 in this study.

The Internet efficacy was measured using modified versions of the computer-efficacy instrument of Compeau and Higgins⁸ and the Internet-knowledge instrument of Potosky.⁹ Scores could range from 1 to 7, with higher scores indicating a higher health-information Web site efficacy. Cronbach's alpha for user subjective health knowledge was 0.87 in this study.

The scales for perceived ease of use, perceived usefulness, attitude to the Web site, and future intention to use were adapted from Davis.³ The scales were rated from 1 (“strongly disagree”) to 7 (“strongly agree”). The scale for measuring perceived ease of use represented the degree to which the user believed that the use of health information on the Internet would be free of physical and mental effort. Cronbach's alpha for perceived ease of use was 0.90 in this study. The scale for measuring perceived usefulness represented the degree to which the user believed that the use of health information on the Internet would enhance his or her health. Cronbach's alpha for perceived usefulness was 0.88 in this study. The scale for measuring attitude represented the degree to which the user was satisfied with the use of health information on the Internet. Cronbach's alpha for attitude was 0.92 in this study. The scale for measuring the intention to use represents the future intention of a user to use the Internet to obtain health information. Cronbach's alpha for intention to use was 0.87 in this study.

The scale for measuring the perceived credibility attempted to represent the perceived authority and truthfulness of the health information on the Internet. The perceived credibility was measured using a modified version of the Information Credibility Scale tested by West.¹⁰ Scores could range from 1 to 7, with higher scores indicating a higher perceived credibility. Cronbach's alpha for perceived credibility was 0.89 in this study.

Results

Model Fit

Based on the results of the correlation analysis, the proposed model was assessed using structural equation modeling with LISREL version 8.1. Maximum likelihood estimation was used to estimate the model parameters. The various goodness-of-fit statistics are listed in Table 2. The chi-squared value was 805.59, with 297 degrees of freedom (p<0.001). The chi-squared of the final trimmed model was not considered to be a good approximation (p<0.001), but the relative likelihood ratio—which is the ratio of the chi-squared to the number of degrees of freedom (=2.71)—was considered indicative of an acceptable fit. The goodness-of-fit index (GFI), the comparative fit index (CFI), the normed fit index (NFI), the nonnormed fit index (NNFI), and the root-mean-square error of approximation (RMSEA) were used to assess the fit of the model to the data using the recommended cutoffs of close to 0.9 for GFI, CFI, and NNFI and 0.05–0.08 for RMSEA.⁶ The values of these indices in this study—GFI=0.89, CFI=0.98, NFI=0.97, NNFI=0.98, and RMSEA=0.06—indicate the acceptable fit of the model. Figure 1 presents the model.

Fig. 1.

Conceptual model of the use of health information on the Internet by consumers. H, hypothesis.

Table 2.

Model Evaluation Overall Fit Measurement

FIT INDICES	RECOMMENDED VALUE	VALUE
Chi-squared	NA	805.59
Degrees of freedom	NA	297
Chi-squared/degrees of freedom	≤3.00	2.87
GFI	≥0.9	0.89
NFI	≥0.9	0.97
NNFI	≥0.9	0.98
CFI	≥0.9	0.98
RMSEA	≤0.08	0.06

CFI, comparative fit index; GFI, goodness-of-fit index; NA, not applicable; NFI, normed fit index; NNFI, non-normed fit index; RMSEA, root-mean-square error of approximation.

Hypotheses Test

Path coefficient estimates were estimated to test the hypothesized relationships among the variables of the model. Figure 2 shows that all the path coefficients except that for Hypothesis H5 were statistically significant, with t values from 2.05 to 17.22. The user's Internet efficacy exerted an extremely strong effect on perceived ease of use (β=0.57, p<0.01) and perceived credibility (β=0.35, p<0.01), supporting Hypotheses H1 and H2. The user subjective health knowledge exerted a direct and positive effect on perceived credibility (β=0.08, p<0.05), supporting Hypothesis H3. Perceived ease of use directly and positively influenced both perceived usefulness (β=0.42, p<0.01) but did not significantly affect the attitude (β=0.01), supporting Hypothesis H4 but not Hypothesis H5. Perceived credibility directly and positively influenced both perceived usefulness (β=0.40, p<0.01) and attitude (β=0.51, p<0.01), supporting Hypotheses H6 and H7. Perceived usefulness significant affected attitude (β=0.50, p<0.01), supporting Hypothesis H8. The attitude to using the Internet had a significant impact on the intention to use it (β=0.95, p<0.01), supporting Hypothesis H9.

Fig. 2.

Results of hypothesis (H) testing. Paths that are significant are indicated at the *0.05 and **0.01 levels. The dotted line indicates the path is not significant at the 0.05 level. Data are β values with t values in parentheses.

Discussion and Implications

We extended the basic TAM by adding the users' subjective health knowledge and Internet efficacy as external variables and perceived credibility as a mediating belief to test the effects of users' perceived ability on the acceptance of online health information. The effect of variables on health information usage on the Internet was focused on the perspectives of users, which will help to guide the development of nursing intervention using more useful user-centered health-information. This approach relates to the Diffusion of Innovations Theory, which indicates that relative advantage, compatibility, and complexity can affect an individual's adoption in technological products and services.^11,12

Cognitive ability is the level of mental activities involved in acquiring and processing information.¹³ Because we focused health information-seeking behavior on the Internet and not other forms of information services (e.g., book, person, and media), one of the key questions was on the information-acquiring competency: how users perceive their ability on technical use and how it further influences their belief and behavior. Therefore, users' efficacy in using the Internet was included in the conceptual model used in this study as one of the main factors affecting the acceptance behavior of health information on the Internet. The Internet efficacy was defined as the skill or capacity to find whatever a user is looking for,¹⁴ and this has been identified as a significant factor predicting users' Internet use.¹⁵

When confronted with a potentially life-threatening illness, information may provide needed knowledge about the disease, treatment, and self-care management.¹⁶ Moreover, it requires a user's cognitive capability to select relevant and credible information among them. In information search and processing, an individual's knowledge is central to understanding his or her behavior. Knowledge includes two categories: objective knowledge and subjective knowledge.^17,18 Objective knowledge is actual information about the product that is stored in long-term memory.¹⁸ Subjective knowledge, referred to as self-assessed knowledge, is a person's perception of how much he or she knows about a product.¹⁹ Previous research revealed that the mechanisms through these two types of knowledge, objective and subjective, affect search and information processing may be different.²⁰ Park et al.⁷ pointed out that the nature of an object might lead to a different effect between objective knowledge and self-assessed knowledge. In relation to health context, Sonnenberg¹⁴ presented the proposal that most people have difficulty in distinguishing the quality of health information, even more educated people who are believed to have more objective knowledge. Thus, we predict that subjective health knowledge should be correlated with the users' reliance on health information seeking rather than objective knowledge. Hence, it was assumed that users with sufficient subjective health knowledge would be highly involved in the task and would therefore actively engage in using health information from the Internet.

Second, perceived credibility was included as a mediating belief to explain how users use health information on the Internet. Apart from other technology acceptance, the hypothetical model of this study was developed based on the assumption that an Internet health information service would be selected and evaluated by users' perceived ability. Therefore, in order to consider both technical and informational contexts of health information Web sites, credibility was included as a mediating belief along with perceived ease of use and perceived usefulness in this hypothetical model. Credibility has been identified as a significant criterion that the user uses to evaluate the quality of the health information found on the Internet.²¹

The results of model testing indicated that the Internet efficacy affected both the ease of use (H1) and credibility (H2) of the obtained information perceived by users. This is consistent with the study by Eastin and LaRose,²² which demonstrated that self-efficacy in using the Internet is directly associated with outcome expectations related to obtaining information, including procuring information that is perceived to be trustworthy. Compeau and Higgins⁸ also found that individuals with lower self-efficacy in using the Internet will have lower expectations of finding credible online information.

The subjective health knowledge of users was also found to exert significant effects on perceived credibility (H3). In general, individuals with more education report more sufficient knowledge, but even they (with the exception of healthcare professionals) expressed difficulty in distinguishing the quality of health information and using it to make better decisions.¹⁴ The study results support the presence of relationships between the perceived abilities of users and their acceptance of health information obtained on the Internet. That is, users with higher perceptions of their capabilities to use the obtained information are more likely to accept the Internet as a source of health information.²³ The results of this study imply that the efficacy in using the Internet to obtain health information and the subjective health knowledge of users should be considered as the significant antecedents of the acceptance to use the Internet and must be taken into account when developing and implementing user-centered health-information Web sites.

The results of this study show that perceived ease of use has a significant positive effect on the perceived usefulness (H4). This supports the findings of earlier research on the TAM.³ The perceived credibility was also confirmed to have a significant impact on perceived usefulness (H6). This is consistent with previous studies, which indicated that reliability and accuracy of the health information presented to the user positively influenced that user's decision-making and satisfaction.²¹

The perceived ease of use did not significantly affect the attitude toward using the Internet (H5). This finding is contrary to typical outcomes of previous studies that have tested the TAM,¹⁴ but is consistent with the findings of Chang and Kim.⁵ In this study, this can be explained because ease of use was not regarded as strongly as perceived credibility or usefulness in relation with the acceptance of the Internet as a resource of health information. This finding has important implications for the development and provision of health information via the Internet, especially in terms of characteristics that are distinct from those of other types of information available on the Internet. Additionally, we found that attitude is affected more by perceived credibility (H7) than by perceived usefulness (H8). This indicates the importance of the contextual aspect of health information on the Internet in mediating the motivation and practical acceptance of users who use the Internet in this way. This finding has important implications for the development of health information on the Internet because it suggests that methods for improving both the user's understanding and the presentation of information should be used.

The results of this study show that users' attitude has a significant positive effect on their intention to use of Internet as a health information resource (H9). This finding is similar to those of previous investigations testing of the TAM. They revealed that users with a more positive attitude toward a technology system are likely to be more satisfied with the system and have positive behavioral intention.²⁴

The findings of this study will help health professionals to understand users' online health information-seeking behaviors from the perspective of users. This in turn will help them to develop better provision of the health information. In addition, this will help online health information providers to predict and identify the factors that promote users' appropriate use of health information on the Internet. Based on the results of this study, it could be suggested that enhancement of users' compatibility and improvement of information quality will guide the path to effective use of Internet health information, rather than simply eliminating infrastructure obstacles in Korea.

Conclusions and Limitations

It is certainly supported by this study that users' perceived ability, including subjective health knowledge and Internet efficacy, was confirmed as a prerequisite for their health information use on the Internet. We found that the three belief variables of our extended TAM of perceived ease of use, perceived usefulness, and perceived credibility are relevant to two external variables and mediated the relationships between external variables and attitude toward the usage of the Internet. The results demonstrated that perceived ease of use, perceived usefulness, and perceived credibility are substantive mediators. However, this study emphasized only a limited set of constructs from users' perspective, which is relatively small considering the variety of those studies in other investigations. Therefore, future research should consider a greater variety of users' characteristics regarding psychosocial aspects as well as environmental factors and incorporate these in the development of effective user-centered health information provision.

Footnotes

Disclosure Statement

No competing financial interests exist.

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