Elderly perspectives regarding eHealth needs and
preferences in
the northern Dutch-German border region.
Cross-Border qualitative research
Deirdre Hummel
Student number: S3853853
Word count: 13519
Master Thesis
MSc. Business Administration Health Faculty of Economics and Business
University of Groningen
Supervisor
Dr E. Metting
Co-assessor
Dr M.A.G. van Offenbeek
Groningen, 19-07-2020
Abstract
Today’s healthcare system is facing challenges due to changes in Western society, including a growing number of elderly with chronic diseases resulting in an increasing healthcare demand. It is expected that digital innovations like eHealth have the opportunity of addressing the current challenges within healthcare. Moreover, eHealth projects introduce innovative technologies that enhance the cross-border collaboration and the level of health services for the population of border districts. New technology like eHealth can be promising but their full potential can only be reaped when it is fully accepted. Therefore, the main purpose of this study is to examine the perspective of elderly regarding eHealth in the Dutch-German cross-border region, which consist of an average older and less educated citizens. Due to this demographic structure, this population is more prone chronic diseases. 18 semi-structured interviews were held with elderly in the northern Netherlands and Germany. The results revealed the perspective of the elderly in both the Netherlands and Germany regarding eHealth, as well as the individual, technological and environmental barriers and facilitators they faced regarding eHealth in a region that is prone to (multiple) chronic conditions. This resulted in the following 10 barriers: cognition, accessibility, reduction personal contact, design does not fit the elderly needs, missing feedback, missing standards, privacy, problems with financing and no insight usage environment. Furthermore 9 facilitators were identified: independence, disease awareness, efficiency, user involvement, personal assistance, role of the GP & doctor, Covid-19, support environment, cross-border care. It is therefore suggested that eHealth and its implementation should be tailored to these barriers and facilitators. The fact that the German participants had almost no prior knowledge of eHealth and valued their privacy more than the Dutch participants stood out significantly when comparing between the two countries. No other differences have been found between countries. Additionally, the findings of this study provide relevant information for initiatives that want to upscale eHealth adoption within this specific region or regions that are similar in demographic structure. Moreover, the findings could be taken into consideration when implementing eHealth policies for the deployment of cross-border healthcare and exchanges of health data.
Key words: eHealth acceptance, eHealth adoption, barriers and facilitators of e‐Health applications,
Inhoud
1. Introduction ... 1
2. Theoretical background ... 3
2.1 Cross-border healthcare ... 3
2.2. Dutch-German Cross border region ... 3
2.3. What is eHealth? ... 5
2.3 Enhancing self-management with the use of eHealth ... 6
2.4 The digital divide ... 7
2.5 eHealth literacy ... 7
2.6. User-centred design for elderly ... 8
2.7 eHealth acceptance and adoption ... 9
3. Methodology ... 11 3.1 Research approach ... 11 3.2 Data collection... 12 3.3 Data analysis ... 13 3.4 Ethical considerations ... 13 4. Results ... 13
4.1. Perspective towards eHealth ... 15
4.2 Individual barriers ... 18 4.3. Individual facilitators... 20 4.4. Technology barriers ... 21 4.5. Technology facilitator ... 22 4.6. Environmental barriers ... 23 4.7 Environmental facilitators ... 24
5. Discussion and conclusion ... 26
5.1 Main findings ... 26
5.2 Practical and theoretical implications ... 29
5.3 Limitations and future research ... 30
5.4 Conclusion... 30
References ... 32
Appendix 1 – Dutch invitation for participant recruitment ... 38
Appendix 2 – Interview protocol ... 39
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1. Introduction
Today’s healthcare system is facing challenges due to changes in Western society, including a growing number of elderly with chronic diseases resulting in an increasing care demand (Huygens, 2018).it Subsequently, the financial and resource pressures in healthcare are increasing (Rauwerdink, Kasteleyn, Haafkens, Chavannes, & Schijven, 2020). Simultaneously, digitalization is in full swing, changing and revolutionizing our world and daily lives including health care organization. Therefore, it is expected that digital innovations have the opportunity of addressing the current t challenges within healthcare. Currently, innovation led to the use of technologies to enhance health services and information delivery through the Internet and related technologies and facilitate communication and decision making within healthcare (Eysenbach, 2001; Pagliari et al., 2005). These technologies, among others, are grouped under the term eHealth. From a technical point of view, the opportunities are immense. eHealth services, such as online coaching, monitoring applications, smart phone apps and digital patients’ portals are rapidly being developed. These applications have the potential to increase quality, accessibility, effectivity and efficiency of healthcare deliveries and subsequently time and costs can be saved (Dumay, 2007; Freed et al., 2018).
New technology like eHealth can be promising but their full potential can only be reaped when it is fully accepted. Nevertheless, in everyday life the eventual decision to adopt and accept new technology is not always obvious. In the end, the true value and the advantages of new technologies lie in the actual acceptance by end-users (Masella & Zanaboni, 2008). To take into account any barriers and facilitators for the acceptance of IT in healthcare, it is necessary to gain more knowledge on the relevant factors that may foster or hinder the extent to which end-users are willing to accept technology in healthcare settings. Having a clear overview of the facilitators and barriers towards eHealth use is crucial for technology design and the development of a successful implementation strategy (Van Velsen et al., 2018).
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employment, income, and wealth have different kinds of influences on health behaviour (Pampel, Krueger, & Denney, 2010). For example, the study of Hanson & Chen (2007) showed that low SES was associated with poorer diets, less physical activity, and greater cigarette smoking. Furthermore, 85% of elderly have at least one chronic health condition and this may be increased by unhealthy behaviours linked to low SES (Marengoni, Winblad, Karp, & Fratiglioni, 2008).
Unfortunately, many studies have shown that especially patients who are older and/or with a lower socio-economic status have difficulties using eHealth (Reiners et al., 2019) and thereby obstructing the eHealth potential. Hence, considering elderly’s perspectives in the development of eHealth may promote their daily use. Involving elderly by exploring their needs may facilitate an in-depth understanding of aspects linked to feasibility, usability or practical aspects related to daily life. In addition, creating active involvement of elderly people in eHealth development allows improvements in handling and in the level of acceptance and therefore facilitates long-term usage of eHealth (Thilo, Bilger, Halfens, Schols, & Hahn, 2017) This is especially relevant in areas with high prevalence of elderly and people with low SES, such as the border area between Groningen and Lower Saxony. To evaluate this further, this paper will focus on the population of the border regions in the northern Netherlands and Germany, which consist of an average older and less educated citizens. Due to this demographic structure, this population is more prone to poor lifestyle and chronic diseases (Olshansky & Ault, 1986).
Additionally, the European union has launched INTERREG subsidy program with the goal to connect border regions in Europe. The main objective of the program is to increase collaboration and the innovative strength of border regions and to reduce the barrier effect of the border. For this purpose, the cross-border healthcare promotes collaboration between health providers across national borders as a means of improving access and quality to care where conditions require a collaboration of expertise or resources. In order to achieve this, eHealth can play an important role since eHealth projects introduce innovative technologies that enhance the cross-border collaboration and the level of health services for the population of border districts (Andersen, 2008). This also applies for the Dutch-German border. An overview and comparison of the elderly’s perspectives within this venerable cross-border region has never been done before and is important as it shows what elderly need in order to use eHealth and what the possible gaps between the two countries are. As such, this exploratory paper focuses on the elderly perspective regarding eHealth needs and preferences to identify the barriers and facilitators in the cross-border region of the Netherlands and Germany. This lead to the following research question: What are
the elderly perspectives regarding eHealth in the northern Dutch-German cross-border region? This
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the theoretical dimensions of the research. Second, the methodology will be discussed. Thirdly, the results of the data analysis are provided followed by a discussion and a conclusion
2. Theoretical background
This chapter presents the theoretical background for this study and starts with an explanation of the cross-border initiative and the researched region. Afterwards, eHealth, self-management, the digital divide and eHealth literacy will be introduced. In the last two subsections an user-centred approach and the research model are introduced.
2.1 Cross-border healthcare
In European countries, there is an increasing demand for healthcare as a consequence to an ageing population and hence an increasing population with (multiple) chronic diseases. This coincides with a reduction in public budgets, posing challenges in providing health services of sufficient quality across Europe (Beenkens, 2011; Fredriksen, Martinez, Moe, & Thygesen, 2020). In light of the challenges posed by an ageing population and tighter public budgets, the European Union is seeking innovative ways of improving health service delivery. Currently, the European union has set the objective to connect the border regions in Europe. The EU is stimulating collaboration by providing support through funding and platforms where EU countries can collaborate on eHealth related issues (European commission, 2020a). Additionally, The Commission Communication on the Transformation of Digital Health and Care aims to strengthen the digitalisation of the healthcare sectors. The commission identified 3 pillars around which activities will be based: (1) secure data access and sharing, (2) connecting and sharing health data for research faster diagnosis and improved health and (3) strengthening citizen empowerment and individual care through digital services (European Commission, 2018). The main goal therefore is to increase collaboration and the innovative strength of border region and to reduce the barrier effect of the border. To support cross-border collaboration, the EU created the Interregional (INTERREG) program. Within the INTERREG programme, which is aimed at improving cross-border collaboration within the so-called Euregios, healthcare-related initiatives have been set up. They are dedicated to find solutions to complex challenges and to leverage on interregional cooperation opportunities to potentially generate breakthrough innovations in the health sector (Interreg Europe, 2020).
2.2. Dutch-German Cross border region
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bottlenecks at an early stage. However, there is no digital system that transfers (patient) information, making it increasingly difficult to provide the right type of care (European commission, 2020b).
Figure 1 - Dutch-German border research focus area.
Over the past few years, several events, activities and efforts have been made to improve bilateral relations between Germany and The Netherlands in the field of eHealth and elderly care. As the EU tries to stimulate cross-border collaboration it is important to consider that these two countries have different healthcare systems and policies but also differ in their perspectives (Vroomen & Zweifel, 2011). For example, the comparative study by van Der Schee, Braun, Calnan, Schnee, & Groenewegen (2007) showed that the people in Germany have less trust in healthcare than people in The Netherlands. Cultural differences between the Netherlands and Germany are an important source of differences. This must therefore be considered if border information exchange takes place.
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the extent of the issue becomes visible. The Netherland have with 89,4% significantly more data digitized (Task Force Health Care, 2019).
Figure 2 - Comparison between IT Budget in German and Dutch Hospitals showing that the Dutch hospitals use more budget on IT than German hospitals (Deloitte, 2018).
Furthermore, when comparing internet usage, the Netherlands scores higher (98%) in comparison with Germany (93%) (CBS, 2018). However, the statistical data of Eurocat showed that within both countries the household internet usage is growing (Eurocat, 2018) and with that the opportunities of eHealth.
2.3. What is eHealth?
eHealth is a broad term which has many definitions and includes a diverse range of technical innovations in health care. As far back as 2005, a total of 51 unique definitions for eHealth have been identified in a systematic review of the published definitions of this term, with most definitions related to use of communication technologies and networked information (Pagliari et al., 2005). At that time (and to date), the most cited definition was Eysenbach’s. Eysenbach defined eHealth not as an technical innovation but as 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 (Eysenbach, 2001). In addition Eysenbach (2001) pointed out that the "e" in e-health does not only stand for "electronic," but also implies efficiency, enhancing quality, evidence based, empowerment, encouragement, education, enabling, extending, ethics and equity. Added to that, according to Ossebaard & Van Gemert-Pijnen (2016), eHealth can be seen as an umbrella concept which includes associated terms as telemedicine, mHealth, care, ePublic health, eMental health, and tele-health.
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care. These days eHealth technologies are on a rapid course of growth and acceptance by mainstream medicine, particularly in situations where physical or functional distance separates the patient and the provider. Moreover, in the past the traditional patient role has been somewhat passive as a recipient of healthcare services, however the modern patient is more willing and able to assume a more proactive role in health-seeking behaviour by through the ever-present Internet and mobile electronic devices (Bujnowska-Fedak & Pirogowicz, 2014). To meet the growing expectations of patients, numerous websites and platforms now provide patients with useful medical information. In addition, medical centres and primary healthcare facilities are gradually providing remote online services, such as access to electronic patient health records and personal health records, online health services such as e-registration and e-prescribing, short message service (SMS) reminders for appointments and prescribed medicines, and, clinical applications such as teleconsultation/diagnosis as well as telemonitoring of the electrocardiogram, blood pressure, blood glucose levels, and other parameters (Bujnowska-Fedak & Pirogowicz, 2014). eHealth has the ability to strengthen communication and information exchange between healthcare professionals, and between patients and healthcare professionals. Furthermore, eHealth may also empower and influence individuals positively, providing opportunities for self-management (Hallberg & Salimi, 2020). Therefore self-self-management will be addressed in the following section. Against the background of an aging society, where more healthcare is needed and healthcare expenditures are increasing, self-management gains more and more importance (Bodenheimer, Lorig, Holman, & Grumbach, 2002) as self-management support has the potential to improve the efficiency of health services by reducing other forms of utilisation (Panagioti et al., 2014).
2.3 Enhancing self-management with the use of eHealth
Self-management is considered as an essential component of chronic care by professionals (Huygens, 2016). This concept is currently widely the topic of interventions to improve health outcomes and quality of life among chronically sick patients (Talboom-Kamp, Verdijk, Kasteleyn, Numans, & Chavannes, 2018). Furthermore, self-management is valued for its contribution to the healthcare efficiency, but also for its enhancement of the independence and autonomy of a patient (Schermer, 2009). The paper by Barlow et al. (2002) defined it as “the individual’s ability to manage the symptoms, treatment, physical
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pressure and weight and communicate this data with their care provider (Reiners et al., 2019). Unfortunately, as stated in the introduction, studies have shown that especially patients who are older and/or with a lower socio-economic status, thus an increased change of having chronic diseases, have difficulties with using eHealth (Reiners et al., 2019). Literature describes it as the “digital divide” between those who use digital technology to self-manage their disease and those who do not use digital technology (Graetz, Gordon, Fung, Hamity, & Reed, 2016). In order to have the most benefit of eHealth applications and their ability to support the self-management of patients, all citizens must be able to use and access eHealth systems (Calvillo, Roman, & Roa, 2015; Showell, 2017).
2.4 The digital divide
Challenges arise when considering the actual possibilities of applying eHealth. One of these challenges is the digital divide, commonly defined as the gap between those who have and do not have access to computers and the Internet (Van Dijk, 2006). However, the digital divide has grown to include issues with usability and information and communication technology (ICT) skills rather than mere access to Internet (Neter & Brainin, 2012). As expected, the younger generation is more adept at using ICT in daily life compared to the older generation, who tend to be more reluctant to learning new ways of doing things (Bujnowska-Fedak & Pirogowicz, 2014). In addition, Romano et al. (2015) highlight that individuals that suffer from chronic disease are predominantly elderly people, and it is therefore crucial to gain a better knowledge of the current digital divide situation, in order to understand the possible barriers and the ICT-acceptance. It is therefore important to stress the presence of a considerable digital divide in the use of the targeted population for eHealth applications. Given the increasingly important role of eHealth in healthcare, it is important to develop an understanding of the digital divide.
2.5 eHealth literacy
eHealth literacy is an important dimension of the digital divide, i.e., those who use versus those who do not use eHealth (Choi & DiNitto, 2013). Because what if we developed eHealth initiatives to improve health and deliver healthcare that were inaccessible to more than half of the population to whom they were intended? Consumer-directed eHealth tools, from informational websites to digital interventions, require the ability to read text, use information technology, and evaluate the content of these tools to make health decisions (Norman & Skinner, 2006). According to Choi & DiNitto (2013) eHealth literacy is: “the ability to seek, find, understand and appraise health information from electronic sources and
apply knowledge gained to addressing or solving a health problem”. There are many barriers to digital
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successful implementation of eHealth in three domains: cognitive (health knowledge/information gathering), instrumental (self-management of health needs and health behaviours), and interpersonal (e.g., interactions with physicians) (Choi & DiNitto, 2013). If eHealth is to realize its potential for improving the health of the public, the gap between what is provided and what individuals can access must be acknowledged and where possible solved (Norman & Skinner, 2006). Research in literacy and information technology use found that as literacy skill levels rise, the perceived usefulness of computers, diversity and intensity of Internet use, and use of computers for task-oriented purposes rise with it, even when factors such as age, income, and education levels are taken into account (Veenhof, Clermont, & Sciadas, 2005). This also applies for health literacy which is concerned with the knowledge and competences of persons to meet the complex demands of health in modern society. Health literacy can be defined as “people’s knowledge, motivation and competences to access, understand, appraise, and
apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion” (Sørensen et al., 2012). Individuals with limited
literacy skills have less knowledge of disease management and health promoting behaviours, report poorer health status, and are less likely to use preventive services than those with average or above average literacy skills (Kindig, Panzer, & Nielsen-Bohlman, 2004). For that reason the research focus is especially relevant as the cross-border region demographic structure consist of average older and lower educated citizens and is therefore more prone to chronic illnesses and hence an increased possibility on eHealth literacy and a digital divide in the region. Hence, a user-centred eHealth design is essential for eHealth adoption within this population.
2.6. User-centred design for elderly
According to Van Gemert-Pijnen et al. (2011) “Many eHealth technologies are not successful in
realizing sustainable innovations in health care practices. One of the reasons for this is that the current development of eHealth technology often disregards the interdependencies between technology, human characteristics, and the socioeconomic environment, resulting in technology that has a low impact in healthcare practices.” Hence collecting data on what the prospective user wants and needs, and
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should be given to people with less education and to those who have not used the Internet before. Their research found that higher age, female gender or a lower educational level were indicators of less intention to use eHealth (de Veer et al., 2015). Elderly who believed that eHealth apps were easy to use and that applications would enable them to be more inclined to use Internet applications in the future. However, the elderly who did not believe in the advantages and thought eHealth would be difficult to use, were less inclined to use eHealth (de Veer et al., 2015; Venkatesh, Morris, Davis, & Davis, 2003).
2.7 eHealth acceptance and adoption
Considering elderly’s perspectives in the development of eHealth may promote their acceptance (Thilo et al., 2017). Over the last several decades, an excess amount of theoretical models have been proposed and used to examine ICT acceptance and usage (Dwivedi, Rana, Jeyaraj, Clement, & Williams, 2019). Davis (1985) proposed his Technology Acceptance Model (TAM) in order to predict the use of technology in business settings (Davis, 1986). The Technology Acceptance Model defined use as predicted by an attitude towards use, which is a function of perceived usefulness and perceived ease of use, both of which are value judgments (Harst, Lantzsch, & Scheibe, 2019). These constructs are fragments that reflect the behavioural intention of a person to use technology like eHealth (Sezgin & Yıldırım, 2014). It was observed that TAM theory has been successfully applied in variety of health information studies. The work by Davis and associates therefore inspired a vast research into the technology acceptance. The most ambitious attempt is the Unified Theory of Acceptance and Use of Technology (UTAUT) developed by Venkatesh et al. (2003). According to UTAUT, four main factors influence intention to use, whereby intention to use is defined as the degree to which a person has formulated conscious plans to perform or not perform some specified future behaviour (de Veer et al., 2015)
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As displayed in figure 1 the UTAUT is based on four core determinants of intention and usage in combination with four specific moderators (gender, age, experience and voluntariness of use) that may influence behavioural intention and observable use behaviour (Venkatesh et al., 2003).
Performance expectancy The degree to which an individual believes that using the system will help him or her.
Effort expectancy The degree of ease associated with the use of the system .
Social influence The degree to which an individual perceives that important others believe he or she should use the new system
Facilitating conditions The degree to which an individual believes that an organizational and technical infrastructure exist to support use of the system
However, Beenkens (2011) review of the literature, suggest that the UTAUT model is mainly applied on the technology acceptance and use by healthcare professionals and is not often utilized to investigate patient acceptance of eHealth services. Most research into accepting technology in healthcare settings has largely ignored the patient. This is unfortunate, because the dynamics surrounding technology acceptance of the patient may well be different from that of the healthcare professional. If healthcare designers knew more about patients’ health-related preferences, care would most likely be more cost-effective and closer to the individuals’ desires and hence give rise to their acceptance (Brennan & Strombom, 1998). Furthermore, neither the TAM nor the UTAUT specifically refers to the adoption of e-health services. Therefore, the study by Griebel et al. (2013) combined the Unified UTAUT and the eHealth literacy concept and enhanced the resulting model with additional factors. Apart from the UTAUT variables and eHealth literacy, this research identified 10 additional factors: anxiety, trust, attitude toward using, computer self-efficacy, perceived system quality, search strategy, user's condition, health specific knowledge, Internet dependency and satisfaction with medical care. In addition demographics like age, gender, or socio-economic status were identified as being relevant to explain the usage behaviours of intended users of e-health services (Griebel, Sedlmayr, Prokosch, Criegee-Rieck, & Sedlmayr, 2013). In later research Griebel, Pobiruchin, & Wiesner (2015) identified three main barrier and facilitating categories for eHealth service adoption: (1) individual (2) technical and (3) environmental.
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Figure 4 – Research model for this study focussing on the three main categories that could influence eHealth adoption.
These three categories and the previously identified factors were used as a baseline for this study (see Figure 4) in order to reach this study objectives, which are: (1) investigate the actual perspective and intention of elderly toward using eHealth in the north Dutch-German cross-border (2) to get insight into barriers and facilitators that influence the intention to use eHealth and (3) to assess the differences and similarities between the Netherland and Germany and with that provide relevant information for the cross-border collaboration. The research model focusses on three specific areas and with that connect the elderly’s perspectives and experiences with potential barriers and facilitators. It is used to answer the main research question is: What are the elderly’s perspectives regarding eHealth in northern Dutch-German cross-border region? Additionally, the two sub questions are (1) what are the barriers and facilitators (2) and do they differ between the Netherlands and Germany?
3. Methodology
In this section, an overview of the methodology for this study is given. Methodology concerning research approach, data collection, data analysis and ethical considerations are presented within this chapter.
3.1 Research approach
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3.2 Data collection
Primary data was used to answer the research question, using semi-structured interviews. S emi-structured interviews consist of several key questions that help to define the areas to be explored, and allowed the interviewer or interviewee to diverge in order to pursue an issue related to the question in more detail (Boeije, 2010; Gill, Stewart, Treasure, & Chadwick, 2008; Lewin, Glenton, & Oxman, 2009). Only essential baseline characteristics and data required to answer the research question(s) were collected. Semi-structured in-depth interviews were conducted using an interview protocol (Appendix 2). The interview questions have been constructed around existing theory: the individual, technical and environmental categories were used as a baseline for the interview protocol. This resulted in the following interview topics: view on technology, usage technology in environment, cross-border region, finance, and privacy. These main themes were chosen to assess elderly perspectives and with that identify the barriers and facilitators of eHealth usage. The interview protocol was made in collaboration with another master student of the faculty of economics and business of the University of Groningen.
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3.3 Data analysis
First of all, the transcript data gathered by the interviews was imported in AtlasTi and were made anonymous by removing any names or information that can directly be linked to the participant. The coding process started with a deductive approach which involved a top-down approach to sort out different data fragments. These fragments were often aligned with the topics in the semi-structured interview schedule. These topics stem from the determinants of the UTAUT and the factors Griebel et al. (2013) identified to gain more insights in the acceptance and adoption of elderly. Furthermore, an inductive approach (codes that are derived from the data) which involved a bottom-up approach was used. These codes were built and modified throughout the coding process (read, code, and interpret the interviews). While inductive and deductive approaches to research seem quite different, they can actually be rather complementary (Fereday & Muir-Cochrane, 2006). Afterwards, through axial coding, the codes were placed into the inductive sub-categories which were then described and placed into the pre-defined, deductive categories (figure 4) (Boeije, 2010). The relevance of these sub-categories was determined in alignment and accordance to this study research goals. After the coding process was carried out per country, the codes and quotes were compared alongside each other to find any differences and similarities. The whole data analysis and coding process was done by the Dutch student.
3.4 Ethical considerations
This study was approved by the METc, UMCG and the University of Groningen. Since this study was performed in a healthcare setting the data privacy and security provisions for safeguarding medical information (anonymity and confidentiality) is an important ethical consideration which needed to be considered. Therefore, the software and procedures used for collecting, processing, analysing, and storing data was compliant with the UMCG policy and Standard Operating Procedures in the UMCG Research Toolbox. Digital data is archived on the UMCG network complying with strict UMCG security and back-up policy. Additionally, each participant completed an informed consent prior to participation in order to inform them about their rights and what to expect. All participation was voluntary, and the data was anonymised during data collection. Indirect and direct identifiable information was minimized and only collected for the purpose of this study. Direct identifiable information (e.g. contact details, code list/encryption key/subject identification log) was stored separately from pseudonymized data in a secure environment.
4. Results
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differing ages were interviewed on their knowledge, opinion, attitude, and expectations of eHealth services. As outlined in Table 2 the mean age was 72 years (range 66–85 years). All participants lived in their own homes within the cross-border region. All except one Dutch and one German participant had a chronic disease. The participants had varying experience with ICT. All participants mentioned having computers except one Dutch (9%) and two German participants (33%).The usage of smartphones and tablets were less common among the participants. Participants used these technologies in varying degrees and for different purposes: some mentioned using the Internet to search for health-related information, while others expressed disinterest in ICT and extremely limited use of it. A few Dutch participants and none of the German participants had prior eHealth experience, and in general, participants had a very narrow understanding of the term “eHealth” until examples were given. Participants expressed different expectations about using eHealth, with two major perspectives emerging in the analysis: (1) eHealth as something that makes things easier, and (2) eHealth as something that takes too much effort and is undesirable. Their perspective revealed the barriers and facilitators elderly face.
Table 2 - Demographics participants elderly
Characteristics Dutch German Total
Gender Female n=6 n=5 65% Male n=5 n=1 35% Age M=70,2 (66-81) M=82,5 (79-85) M=72,1 (66-85)
Living situation Live together/married n=7 n=0 41%
Living alone/single or widow n=4 n=6 59%
Internet usage Has an internet connection n=10 n=4 82%
Does not have an internet connection
n=1 n=2 18%
Used Internet in the past 7 days
n=10 N=4 82%
Chronic Disease Yes n=10 n=5 88%
No n=1 n=1 12%
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perspective of the elderly will be discussed. Second, per category the needs and expectations of elderly are presented with the use of the identified sub-categories and topics (see table 3).
4.1. Perspective towards eHealth
Overall most of the participants did see the value for eHealth usage: “In principle I think that it is really
good because healthcare is getting more intensive and people are getting older, and yes now I am part of that group. So, I can imagine that it would become a problem. During analysis it became visible that
there were no significant differences in opinions between the German participants and Dutch participants regarding eHealth. One German participant cited that: “It is a relieve. That you can talk to
your doctor via video especially for patients that are older and cannot easily go to the doctor or who live in a small town. There are many places where there is no doctor at all” Other participants stated
the following: “You want to stay healthy for a long time and if eHealth could support that than why
not?” “Well I do not see any disadvantage. There is a lot of pressure on healthcare and we should change that. Both costs and pressure for doctors in hospitals. A lot of things you can look up for yourself.” Participants also cited that when you get older there is an increasing motivation: “in fact you should not need motivation if it is for your health. You must do everything for it and everything that you need can be tackled. I think so. You just must do that. Your health is so important. Especially when you get older you must be careful. So, I would just tackle anything that is possible. I am there for that. And then you should not put your head in the ground. From now on I worry about it. When you get older health becomes particularly important. However, about three quarters of the participants expressed a
current disinterest in eHealth technologies, which they considered of limited value at this point in time as they did not view that they needed eHealth: “My kids say that it would be beneficial if I would use it.
But I just feel too good for it now.” They generally assumed that they currently could not benefit from
eHealth, perceiving its capabilities and functionalities as unnecessary. Confident in their own self- management routines, they saw no need for self-management tools: “No that would not count for me.
Maybe if I were to get something like diabetes or those things. Then I would use it. I don’t need anything except this in care.” Added to that one German participant highlighted that being severely ill would be
the one and only motivation to use eHealth. In addition, a few Dutch participants mentioned a dislike for eHealth: “I think it is outrageous because I also know about the elderly, my father of 85 is quite
reasonable with the computers, but this is going too far. All those buttons and all other things. No that's too complicated.” “It is not my world. I do however really like for example that I succeeded in video calling. I really found that scary. But then I did succeed. I am good at computers but not with anything that could support my health.” Furthermore, most of the participants acknowledged that it would be
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4.2 Individual barriers regarding eHealth
4.2.1 Cognition of elderly
All participants – both German and Dutch - mentioned that people should be able to use eHealth tools however, participants expressed their worries regarding the declining cognitive function of elderly and the usage of eHealth tools. Two Dutch participants cited that they just found it too difficult to learn how to use eHealth: “You shouldn't start with me because I just don't understand it.” Other participants cited that the capability to learn new things regarding IT is demanding and will cause elderly to reject the new technology: “There are simply people that refuse to use technology. There are people who do not want
anything to do with it. It is too tiring for them or they don’t understand it.” Participants highlighted that
those people had missed the boat and that this generation gap is not something that can be bridged: “Especially for the elderly that did not experience the whole change with informatica. They have missed
the boat.” Several participants explained how this is just something that needs to be waited out until the
new generation: “In this day and age, this generation, my generation, may not participate. That would
probably hit the next generation more.”
To bridge this gap, some participants cited that learning IT knowledge should begin early in order to re ap the benefits later: “My uncle of 80 would have been really good at it if he had learned it 10 years
ago. And now he says that he should have done it.” Added to that participants highlight how especially
the younger elderly group should be stimulated in time so they will be able to keep up: “I would really
stimulate the elderly from 70-80 years now. There are enough elderly of our age that do not know about it. They do not do anything with the computer. Even the 60-70 I would strongly advice to start.” In
addition, participants cited that it costs a lot of effort and you need to have the motivation and ability to keep up with all the new developments: “Something is new and strange. I think if you would do
something every day than it will stick but if you would do it once in a while then it is hard for elderly to remember how it works.” Other participants found that there will always be a group having trouble with
it: “I think it just a generation we have to bridge. Leave that behind. But then again there will be a new
gap... the less educated people or the less developed people, they will always have more trouble with it.” Also, language barrier and lower education level were mentioned as a barrier for eHealth use: “You first have to learn how to read and write otherwise you cannot use it. Also, it is extremely difficult to reach these people.”
4.2.2 Anxiety caused by eHealth usage
It was often mentioned by participants that eHealth could cause anxiety: “I do think it can make people
very anxious. I think it can evoke hypochondria. I am not an advocate for that.” To meet the needs of
the elderly, eHealth education is important: “If the data deteriorate, he can panic, it only makes sense if
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eHealth might cause elderly to feel depressed when they are constant reminded about their disease through eHealth: “Maybe someone can be down or a little depressed and then it is like God I have this
and I have that. Then it would completely turn the wrong way.” Furthermore, participants pointed out
that self-measurements at home has benefits, but they do have insecurities. Participants are insecure about how to perform a measurement and self-interpret the results, and they are anxious about the accuracy of the product. Some participants cited to have a lack of trust with eHealth and found that good and reliable information about it is a necessity. One German participant added that one should have reliable information about eHealth for trust. He stated that there is almost no information given about eHealth in Germany. Creating a source for distrust and anxiety for the German elderly. Furthermore, participants expressed that elderly are afraid of the unknown which in their case is the usage of IT resulting in resistance towards eHealth. One participant mentioned as disadvantage: “you are playing
your own doctor and that is scary’
4.2.3 Accessibility of eHealth
The analysis showed that some Dutch participants had experienced frustration with the healthcare system, because of poor coordination between different healthcare providers and difficulty accessing eHealth when they needed it. Furthermore, it became clear during the interviews that all Dutch participants had very limited knowledge about eHealth; perceptions varied of its capabilities and functionalities, as well as their understanding of the strategy or vision behind using eHealth in the healthcare sector. All of the German participants were unfamiliar to eHealth and had no insights into the options: “Well most people of my generation didn’t have that much contact with it. Some of them don’t
even know about it.” It is therefore hard for patients to access eHealth without any prior information
about it: “A patient need enlightenment. The patient would have to be informed to decide whether he
wants this technology. In some cases, it is necessary to be informed about which technologies exist.”
Furthermore, participants expressed that when someone is not familiar with IT usage it is really difficult to reach them as this is often done electronically: “But yes how do you reach them? That is often as done
through the Internet.” This group therefore has limited access and limited knowledge of the eHealth
possibilities.
4.2.4 Reduction of personal contact
One of the other most mentioned barriers for both German and Dutch participants was the reduction of personal contact. Participant highlighted how the use of eHealth might reduce personal contact which they viewed as something necessary: “I do not want it to be all computer. I would not like that at all.
The human aspect has to stay!” Also, participants feared that eHealth might enhance loneliness with
elderly as it might replace home care nurses: “When eHealth is replacing nurses and doctors, it makes
people lonely. They are alone and waiting for someone to come visit.” It is further highlighted that the
use of eHealth might come with communication issues: “Look, we 're old-fashioned and I think things
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someone means. I think that is a disadvantage.” In addition, participants reported that patients who use
eHealth should also be given the opportunity to receive regular and personal care; “eHealth should
support care, but not replace personal care.” The participants were vocal that the human aspects need
to stay and should never be replaced by anything. In addition, some Dutch participants that were positive about eHealth and its promise highlighted that the use of AI and robots would be going too far: I find it
a repulsive form of contempt for elderly. I find it horrible. That people can think of something like that. I am negative about this. It is not how you treat people.”
4.3. Individual facilitators
4.3.1 Independence increase through eHealth
In general, the majority of participants mentioned that independence was an important benefit of eHealth. There was no difference when comparing the response of the Dutch participants and the German participants. Both nationalities agreed on eHealth’s ability to support independence through the self-management applications it can offer: “I think it is a good feeling to have your own independence
with your health. You must stand up for yourself. You cannot be dependent, because then you will be overlooked.” One participant highlighted that: “It gives me a feeling of being in control. I can manage it myself and I can do it at my own time” Furthermore, many participants have experienced that the use
of eHealth will improve their awareness of their own body, resulting in enhanced independence.. For example, one participant stated: “That way you get to know your own body a little bit. Ailments and
things that belong to you. Something that you don't have to be afraid of.” Furthermore, according to the
participants this independence can also facilitates a fast response “The advantage is that you can do it
yourself and of course you do it regularly. Yes, you will immediately notice whether something is wrong”. Additionally, another participant talked about how he was able to do more things at home.
“You can do more things at home and research them yourself. And I already do that, and I regularly
measure my heart rate and such and my blood pressure.” Another participant also viewed that the ability
to do it at home was beneficial: “I think everyone is best in their own environment.” Especially with the current trend of the aging population and the wish and requirement of the state to stay longer at home. “I mean yes if we have to stay home longer. And I think it is a great thing. But it must remain responsible. And if that can be supported by technology. Why not?”
In contrast one Dutch participants mentioned that they did not see how eHealth would improve independence: “How could people be more independent for longer if they use computer? Because when
you are dependent it is often not possible to get out of bed alone or taking the right medication. So personal care has nothing to do with technology.” In addition, one German participant stated that he
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whether or not to use it ensuring that the patient is the one who decides and with that also chooses independently.”
4.3.2 Efficiency of healthcare
Despite their limited knowledge of eHealth, most participants were optimistic about its capabilities and functionalities, seeing it as something of value that could help to address some of the healthcare challenges: “Healthcare is under enormous pressure and we have to do something about it. You can do
a lot of things on your own. Looking certain things up yourself.” Participants found that eHealth
functionalities could increase healthcare’s efficiency: “First of all, the patient no longer has to go to the
doctor, which is exhausting at a certain age. Second it does not take up the doctor’s time and third it would also save costs. Furthermore, the participants saw how eHealth could also be efficient for
themselves: “You immediately see the results and it save travel time.” One participant also mentioned how it is efficient for supervision: “People can get supervision when they are at home. When you are in
a situation where you might fall or something like that. I think I will use that in a few years” Furthermore,
a majority of the participants also reported that speed is a huge advantage of eHealth: “The advantages
of these developments are that you can act faster.” Also, it was participants mentioned how it could be
time saving: “People do not have to go to the doctor. They can do it themselves at home. That saves a
lot of time for both the patient and the people who must assess it. These are of course enormous advantages which saves a lot of time, but also money”
4.3.3. Disease awareness in patients
Another facilitator that was often mentioned was how eHealth creates disease awareness: “I think
someone will be more aware of their health and then also deal with it more consciously.” Participants
mentioned that eHealth, when actively used, gives a person more grip on their own well-being and is supports a better-informed patient. “I think people are becoming more aware. Sometimes the doctor
tells them what to do and other times they just look it up. So, I Think that this awareness increases.”
When presented the case (see Appendix 2) participants found that one advantage was that the case subject would become more aware of his own disease: “Become more aware of his health and therefore
deal with it more consciously when he starts measuring and registering it himself.” 4.4. Technology barriers
4.4.1. Design does not fit the elderly needs
One frequently mentioned barrier was that the developed eHealth technology did not consider the elderly’s needs. Participants mentioned that eHealth applications should not be too complicated: “It
needs to be simple. That might give elderly more trust.” It was further mentioned that the developers
need to consider that some elderly suffer from physical and visibility disabilities: “Well the font are
often ridiculously small. And eHealth is not always accessible. And I just find it a hassle.” Another
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visual impairments. So, my friend has a visual impairment and she is told all the time: ‘oh you have to go to that website’ but she can’t see that!”
4.4.2. Missing feedback from physicians
Another technical barrier mentioned was that the applications did not give feedback to the patient: “Well
if I send something, I do not know what happens with it on the other side. I do not know if they received it correctly and how they will handle the provided information. You cannot see that. There can be mistakes made with it. So that will always be an aspect.” It was highlighted that regular feedback on
things would be perceived as soothing: “It is important to just have contact occasionally to say that
everything is okay. Just a signal or whatever.”
4.4.3. Missing standards in eHealth design
Another mentioned barrier for technology was that there was no standard eHealth application or applications that have the same instructions. Different health institutions have different eHealth applications and therefore also different ways of working. One participant reported an annoyance with all the different programs: “Every program is different, it makes it really difficult” Added to that, one German participant found that the data within systems is usually poor. It did not work well. Furthermore, it was highlighted by a few Dutch participants that with self-monitoring good standardization is important and healthcare needs to take precautions: “I think you should be careful with it. Because with
self-monitored people send their own results. Is that not dangerous? That things will be interpret wrong. And the patient does not even notice that he/she does it wrong.”
4.5. Technology facilitator
4.5.1. User involvement
Many participants responded that eHealth should be easy to use, and should require as few actions as possible, in particular for older people who are not familiar with the Internet or modern technologies. User involvement was something all participants valued as beneficial for creating an easy to use eHealth application. Most of the Dutch and German participants reported that they would like to be involved in the development of eHealth: “You can provide a little bit of experience with the development of
technology.” A Dutch participant highlighted that when you involve elderly, you might reduce their fear
for it as the information will become clearer, resulting in faster convinced elderly who could become enthusiastic. Some other participants found themselves too old for them and would have liked to participate if they were younger.
4.5.2. Personal assistance
Personal assistance was also a frequently mentioned facilitator: “They first need to have good guidance.
How they should do it. Because there are elderly that you will be able to convince.” Another participant
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be introduced and offered, elderly people preferred a health professional to explain precisely how it can be used. “The home care should provide personal assistance. I would like that they check if people are
doing it correctly. That you supervise this extra.” 4.6. Environmental barriers
4.6.1. No insight usage environment
All German and Dutch participants cited that they did not have any insights into the usage of their environment: “I have no insight into that now, I have to honestly say that I do not know whether they
use it” “It is not something I discuss with my friends” Most of the participants did not mind that they
did not know. However, this resulted in a limited knowledge of eHealth’s possibilities for the participants. Furthermore, Dutch participants mentioned that their region would be a difficult region to motivate: The rural mentality is something that starts to bother me. I did not mind it for over 20 years.
But probably because I am getting older, I notice there is more negativism. I do not want to be confronted with that. I think there is a big difference in attitude for eHealth usage if you live in the city or here. The interest is less here. Their world is smaller. So, you must do your best to motivate them. Added to that
another Dutch participant reported that it is therefore really important to educate this region: “You would
have to educate them first. There are always those who oppose it. Even my own sister, who is 7 years younger, can hardly use a computer.” The German participants did not discuss anything about their
region and the difficulty of motivating their environment. This could be due to the fact that no German participant had any previous knowledge of eHealth and thus could not provide information on this particular subject.
4.6.2 Problems with financing
Financial problems in care were frequently mentioned topics with all participants. Most participants – both German and Dutch - had mixed feelings on how eHealth should be financed. Most participants reported that every stakeholder should play a role: “I think everyone should, the state, patient and health
insurance.” Several participants mentioned that they expected that costs would increase because of the
implementation of eHealth: “Will it be put on the plate of the state of the health insurance? Then the
premiums will go up and that is a disadvantage of the people.” All participants expected that the health
insurance companies should play a role with eHealth distribution. Additionally, most participants would be willing to pay a percentage for eHealth if they had the funds for it. However, they found that it should be equal for everyone because not everyone has the funds. Especially in this specific region: “The state
cannot stand for everything, but it also depends on the patient. If it is someone with a very small income, then it should be supported”
4.6.4 Privacy
A well-discussed topic was privacy. Most Dutch participants were less concerned with their privacy than the German participants. One Dutch participant reported the following: “What could someone do
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that people are so frantic about it. Look, I am not an advocate but if someone read my file and it was noted that I broke my arm and I had a hart infarct. So what? What is the problem? If I have my arm in a swing people also can see that I broke it.” Another Dutch participant viewed it differently: I believe that GP’s and healthcare providers do their absolute best to keep it save. I think this data could harm if the healthcare insurances would be able to use it. The world of insurance than would look different.
One Dutch participant found it a scary but was not to concerned about it. “You hear from hackers right.
That all your stuff is open on the internet. I sometimes find that a scary thought. However, I’m like what can do with it?” Another participant was more cautious about it: I do not like it. When they can hack stuff. That all my medical data is on the street.” In general, when compared, the German participants
were somewhat more concerned for their privacy than the Dutch participants: If my data is recorded
than someone can take advantage of it. Practice has shown it, data that is collected will be used and you just don’t know for what.” Added to that another German participant remarked: “The technological requirements are extremely complex and to what extent is my data secured? One cannot judge whether my data is secured in individual cases. In all possible situations there is a risk of being hacked.” 4.7 Environmental facilitators
4.7.1 Role of the general practitioner (GP) & Physician
The GP has a prominent role especially in the Netherlands. All Dutch participants cited that the GP should be the one to approach them with an eHealth initiative. “You have to involve the GP as it is the
most trusted person for most people.” Emphasizing how the GP should play a big role for eHealth
adoption. Some Dutch participants added that another healthcare provider would also be someone they would listen to. “My preference would be the healthcare provider. Not anyone else.” Furthermore, one German participant talked about how she never received a recommendation from the physician for eHealth. She stated that “If the physician would suggest something that could be done if I was sick. It
would have to come from the physician to convince me of it. One German participant cited that he did
not really gave it a thought before: “I don't really think about it at my age. It is unnecessary.”
4.7.2 Support from family
Using the help and knowledge of relatives was frequently reported by participants. Some participants had family members who were motivating them to use technology: “I am really motivated. Yes,
especially with regard to my grandchildren.” Other participants had family members who reminded
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Several participants highlighted how the community plays an important role as a facilitator for elderly: “A little advertisement in the paper is not enough. The community can play a bigger role. That your
direct environment says: we are starting with a course for healthcare IT. So that people get more stimulated. Not a broad computer course but more focused because I think a lot of people are afraid of computers.” When asked to consider what would be the best way to approach and support the elderly,
it was suggested that the local associations would be an active mediator.: “We live in a village and have
a local association. If you were to set up an initiative to ask the community what they would like to know about technology and health. And you would also ask someone of the local GP’s to participate. Then you will reach way more people than just an advertisement in the paper. Because you’re asking people to walk into a room where things are unfamiliar and that is scary.” Another participant added that a
collaboration with the local GP and community creates a trusted environment which reduces some of the barriers elderly face: “A trusted environment to get acquainted with the use of technology.” Some participants also suggested that it might be helpful if the courses were offered by someone in their own age group: “Elderly teaching elderly, I think that might reduce the barriers as well.”
4.7.4 Cross-border care
Regarding cross-border care, none of the participants had any knowledge of the cross-border program, but did see the value of it: “Yes why not? Helping each other is something I definitely support.” Furthermore, none of the participants believed that the Netherlands and Germany were significantly different. Added to that one participant reported that he would like to see it throughout the whole of Europe: “I will definitely find it useful. Especially now since everything is a little different. With the
current COVID-19 virus, we see how different the countries are and how they all have different measures.”
4.7.5 Covid-19
Another frequently discussed issue was the Covid-19 virus, which was in full swing during the interviews. Participants reported that the Covid-19 will affect the current way of providing healthcare and will be a huge facilitator for eHealth adoption: “I think we need to take advantage of the situation
and that, after COVID-19, we will have learned that you can do a lot more effectively and that it is a stronger form of support than with the traditional method.” However, some participants mentioned that
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5. Discussion and conclusion
This study is, to our knowledge, the first to explore the perspective of elderly toward eHealth in Germany and the Netherlands, in a time when fast technology development and high degree of digitalization in the population might facilitate new forms of organizing and financing health care. The goal of this study was to assess perspectives of elderly in the cross-border region and discover the barriers and facilitators they face for using eHealth. Twenty-four subcategories were derived from the interviews which resulted in an overview of the barriers and facilitators within the cross-border region. In the next section the main findings will be discussed, followed by the theoretical and practical implications. Furthermore, the limitations and future research will be discussed in this chapter.
345.1 Main findings
The results of this study indicate that elderly in the cross-border region vary in their perspective, however this disparity was not found in between the two countries. The two main perspectives participants had were (1) eHealth as something that makes things easier, and (2) eHealth as something that takes too much effort for elderly and is undesirable.
5.1.1 Experiences with eHealth
The results indicate that most of the participants had a lack of understanding and experience with eHealth. Research showed that, even though patients are willing to use eHealth services, these services are in the end not frequently used. This may be related to the fact that many patients are not aware of the eHealth services offered (Huygens, et al., 2015) . When eHealth services were introduced, most of the participants were optimistic about eHealth 's capabilities. However, most of the elderly did not see the current value for themselves but they did see value for their elderly fellow citizens. This could be due to the fact that participants had well-controlled conditions, fewer interactions with healthcare, and less physical restrictions. The findings indicate that the elderly acknowledged that eHealth has the ability to improve healthcare.
5.1.2 The digital divide and eHealth literacy
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Germany found that 66.4% of elderly showed limited perceived health literacy (Berens, Vogt, Messer, Hurrelmann, & Schaeffer, 2016). Moreover, prominent cognitive barriers such as a decline in working memory may further impede elderly in fully benefiting from eHealth. If an interface is cluttered and complex, elderly experience difficulties in navigating through the application and in interpreting the subsequent system feedback. Research suggests a negative association between age and (e)health literacy which might be attributable to an age related decline of the ability to perform cognitive tasks that require information processing (van der Heide et al., 2013). eHealth may therefore be difficult to understand and learn, inefficient to use, induce user errors, and frustrate the elderly user. This hinders efficient use of eHealth and increases the risk of user errors and failure to notice important user interaction tasks, resulting in either dangerous use or non-adoption of eHealth by older adults. Furthermore, various papers have been published that advocates matching eHealth technology to the eHealth literacy of the intended user (Best, Souders, Charness, Mitzner, & Rogers, 2015; Kontos et al., 2014; Watkins & Xie, 2014). Not to mention, participants cited that individual barriers, such as trust in one’s own ability to use eHealth, likewise may limit effective and satisfying use of eHealth. For example, elderly tend to be afraid to experiment with eHealth, because they fear they might do it wrong. Literature adds that, as healthcare systems increasingly rely on Internet technology to manage patients’ records, communicate with them, and provide care, it will be necessary for patients who want greater involvement in their healthcare to become proficient in using eHealth (Choi & DiNitto, 2013). It is further cited that eHealth literacy interventions can provide older adults with the skills and knowledge necessary to benefit from eHealth resources (Watkins & Xie, 2014). Participants pointed out that user involvement and an user-centred design is highly necessary for the elderly. Therefore, it is recommended that developers of eHealth services should use an user-centred design and take into account the digital divide, eHealth literacy and the cognitive functions of elderly.
5.1.3 eHealth’s impact on self-management
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clearly inform and show patients how to use eHealth and how to interpret the results. This finding is supported by the research literature which suggests that patients may require self-management support from healthcare professionals, such as nursing staff (Slev et al., 2017). Added to that, the study by Gordon & Hornbrook (2018) showed that elderly who have less experience performing a variety of online tasks relevant to engagement with eHealth, will also be less likely to be interested in using eHealth education resources. This implies that, without support and assistance, segments of the elderly population who are already more vulnerable to chronic health conditions and experience obstacles to access to healthcare, are unlikely to benefit from eHealth (Gordon & Hornbrook, 2018). However, other literature on self-management showed that a more proactive self-management role is being promoted rather than a healthcare professional giving instructions and hoping the patient will adhere to them. Furthermore, it has been recognized that people living with a long term illness develop expertise and wisdom about their condition and want to play a part in making decisions about their own health (Soar, 2011). This should therefore be considered when providing eHealth education about self-management. 5.1.4. Financial and privacy issues
Moreover, several participants associated the implementation of eHealth with financial challenges as to who will fund it and what is required of patients in terms of funding eHealth. Most participants were willing to finance a part if it would help their situation but did mention that this would be a main barrier for people with a low-income. Research showed that offering low-income persons technology subsidies/allowances may help them join the digital age (Choi & DiNitto, 2013). Added to that, financing strategies adopted at national as well regional levels will widely affect eHealth long‐term sustainability (De Rosis & Nuti, 2018). Furthermore, some participants expected that the usage of eHealth would be limit their privacy. This finding is in line with the study by (Arief, Hai, & Saranto, 2013) which showed that eHealth’s main threats include data protection, privacy and the digital divide. Current research is looking for ways to ensure the privacy and data protection. For example, the study by Azeez & Van der Vyver (2019) proposed a secured and dependable architecture for eHealth that could guarantee efficiency, reliability and regulated access framework to health information. The architecture, though is currently under implementation, will guarantee absolute security and privacy between healthcare providers and the patients (Azeez & Van der Vyver, 2019).
5.1.5 Providing the right information
