Stages of use: consideration, initiation, utilization, and outcomes of an internet-mediated intervention

Attrition, or nonuse of the intervention, is a significant problem in e-health. However, the reasons for this phenomenon are poorly understood. Building on Eysenbach's "Law of Attrition", this study aimed to explore the usage behavior of users of e-health services. We used two theoretical models, Andersen's Behavioral Model of Health Service Utilization and Venkatesh's Unified Theory of Acceptance and Use of Technology, to explore the factors associated with uptake and use of an internet-mediated intervention for caregivers taking care of a family member with dementia.

A multiphase, longitudinal design was used to follow a convenience sample of 46 family caregivers who received an e-health intervention. Applying the two theories, usage behavior was conceptualized to form four stages: consideration, initiation, utilization (attrition or continuation), and outcome. The variables and measurement scales were selected based on these theories to measure the sociodemographic context, technology aptitudes, and clinical needs of the caregivers.

In the Consideration Stage, caregivers who felt that the information communication technology (ICT)-mediated service was easy to use were more likely to consider participating in the study (p = 0.04). In the Initiation Stage, caregivers who showed greater technology acceptance were more likely to initiate service earlier (p = 0.02). In the Utilization Stage, the frequent users were those who had a more positive attitude toward technology (p = 0.04) and a lower perceived caregiver competence (p = 0.04) compared with nonusers. In the Outcome Stage, frequent users experienced a decline in perceived burden compared with an escalation of perceived burden by nonusers (p = 0.02).

We illustrate a methodological framework describing how to develop and expand a theory on attrition. The proposed framework highlighted the importance of conceptualizing e-health "use" and "adoption" as dynamic, continuous, longitudinal processes occurring in different stages, influenced by different factors to predict advancement to the next stage. Although usage behavior was influenced mainly by technological factors in the initial stages, both clinical and technological factors were equally important in the later stages. Frequency of use was associated with positive clinical outcomes. A plausible explanation was that intervention benefits motivated the caregivers to continue the service and regular use led to more positive clinical outcome.