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The COVID-19 pandemic has been an international public health emergency, posing severe threats to lives and health care systems worldwide. In Hong Kong, the implementation of different preventive measures (eg, regulations for social distancing, reprioritization of hospital services) affected the lives of not only the general population but also individuals with chronic diseases. Being one of the most commonly diagnosed cancers in Hong Kong, breast cancer diagnosis and treatment delays occurred during the COVID-19 pandemic []. For example, the number of pathologic specimens for the 4 most common cancer regions in Hong Kong (including breast cancer) received by public laboratories and public hospitals for cancer diagnostic services reduced by 15.5% overall in 2020, compared with the prior 3-year average []. Another study suggested that breast cancer patients in Hong Kong needed to wait 3 weeks longer for their first specialist consultation during the COVID-19 crisis than before the pandemic [].
After completion of active treatments, many breast cancer survivors (BCS) still need supportive cancer care (SCC) and rehabilitation services to help with different cancer-related life aspects []. In the Netherlands, one-third of 1051 surveyed BCS reported difficulties contacting their general practitioner due to COVID-19 []. The COVID-19–related lockdowns in the United States and Germany also disrupted patients’ referrals to cancer survivorship programs [,]. To reduce the impact of COVID-19 on cancer care, alternative modes of SCC delivery are therefore important.
Acceptability of Telehealth for Cancer PatientsResearch suggests that COVID-19 might have catalyzed new models of health care (eg, telehealth) []. Telehealth is the use of technology to deliver health care, health information, or health education at a distance []. Telehealth technologies (including telephone, videoconferencing, and internet-based intervention) can bring services into the patient’s home and help them cope with their illness without the need to be physically present at a hospital or clinic []. A recent qualitative study in Australia reported that patients with hematological cancer considered telehealth an acceptable alternative during the pandemic []. However, some patients encountered difficulties using teledelivered cancer care services due to a lack of knowledge and skills, plus some preferred to see the doctor visually through a video call over other teledelivered options []. Another survey explored the prospect of using telemedicine for follow-up among Australian BCS and found that 70% of respondents had suitable devices to access telehealth but only 15% accepted the postoperation teleconsultation with their surgeon []. Given that relevant research is limited in the Hong Kong context, this study examined the level of acceptability of telehealth for BCS to access SCC and its associated factors amid the COVID-19 pandemic.
Telehealth-Related Perceptions as Determinants of Patients’ Intentions to Use Telehealth for SCCDifferent theoretical models have been applied to explore intentions to use telehealth among general healthy populations and patient populations outside the COVID-19 context []. Among the models, the unified theory of acceptance and use of technology (UTAUT) is one of the most influential theories to understand people’s acceptance of different types of information technologies including telehealth []. According to the UTAUT, performance expectancy (whether the individuals believe using the system would provide benefits), effort expectancy (whether the system is easy to use), social influence (perception of important others’ opinions about using the system), facilitating conditions (organizational and technical infrastructure supporting the use of the system), and technology anxiety (users’ negative emotional states related to learning to use technology [eg, nervousness, fear]) are the important determinants of people’s intentions to use technology []. Compared with other traditional behavioral theories (eg, Theory of Planned Behavior, Health Belief Model), the UTAUT seems to have stronger explanatory power for understanding people’s intentions to use telehealth [].
The model has been applied to people’s use of telehealth in different disease contexts. For example, higher performance expectancy, lower effort expectancy, more favorable social influences, less technology anxiety, and more facilitating factors have been associated with intention to use telehealth among Chinese populations (eg, older individuals in the community, individuals with chronic diseases) [,]. Performance expectancy and social influence were associated with higher intention to use telehealth service and treatment among patients with diabetes in Korea []. Similarly, among patients with type 2 diabetes in South Africa [], lower performance expectancy, lower effort expectancy, less social influence, and fewer facilitating conditions explained the generally lower intention to use telehealth services. To the best of our knowledge, research on examining cancer survivors’ intentions to use teledelivered SCC during the COVID-19 pandemic was limited. Therefore, this study aimed to examine how telehealth-related perceptions were associated with intentions to use telehealth for SCC among BCS in Hong Kong during the COVID-19 pandemic.
Individual Characteristics and Fear of COVID-19 as Potential Determinants of Intentions to Use Telehealth for Supportive Cancer Services Among BCSIn addition to telehealth-related perceptions, patients’ sociodemographic characteristics might also contribute to the acceptability of telehealth []. Factors like age, education, possession of smart device(s), the nature of the consultation (routine follow-up versus urgent need for physical examination), and experience with using technology could contribute to the acceptability of telehealth for cancer survivors []. Specific to the pandemic situation, recent studies found that fear of COVID-19 transmission was associated with higher intentions to use contact tracing apps among the general population in Germany [] and telehealth services among cancer patients in the United States []. Expecting the same phenomenon to apply to BCS in Hong Kong, we aimed to examine the roles of patients’ individual characteristics (eg, sociodemographic and clinical factors, fear of COVID-19) and prior experience with using technology in intentions to use telehealth for SCC.
Moderating Role of Education LevelDespite the wide use of the UTUAT to explain people’s intentions to use technology, whether the contribution of the variables in the theory differs based on people’s sociodemographic and individual characteristics has not been extensively examined. Prior studies have generally regarded sociodemographic variables as covariates for intentions or behavior, which fails to unpack the complex ways in which such characteristics might interact with beliefs to determine behavioral intention and actual behaviors (eg, [-]). Education level has been suggested as a potential moderator between perceptions about behaviors and intentions to engage in online behaviors. For example, studies measured the intention of individuals to use e-banking based on the UTAUT model in the United Kingdom and Jordon and found that education level had a positive moderating effect on performance expectancy, facilitating conditions [], and effort expectancy []. Another study in Indonesia also found that education level moderated the relationship between effort expectancy and intention to use e-money services []. Similar research on the intentions of BCS to use telehealth amid the COVID-19 pandemic was limited. Specifically, the role of education as a moderator between telehealth perceptions and BCS’ intentions to use teledelivered SCC were investigated in this study.
Purpose of the StudyThis study aimed to examine how telehealth-related perceptions contribute to the intention to use telehealth for cancer care among BCS in Hong Kong during the COVID-19 pandemic (). We hypothesized that favorable telehealth-related perceptions (higher performance expectancy, lower effort expectancy, more facilitating conditions, positive social influences), less technological anxiety, and greater fear of COVID-19 would be associated with higher intention to use telehealth for SCC. We also hypothesized that the associations between telehealth-related perceptions and intentions to use teledelivered SCC would be moderated by education level, such that associations between telehealth-related perceptions (higher performance expectancy, lower effort expectancy, more facilitating conditions, positive social influences, less technological anxiety) and intention to use teledelivered SCC would be stronger among those with a higher education level.
Figure 1. Conceptual model of the study. A cross-sectional study was conducted. BCS were eligible to participate if they (1) were older than 18 years, (2) had a confirmed diagnosis of Stage 0-III breast cancer since the outbreak of COVID-19 in Hong Kong (January 2020), (3) were receiving active treatment (eg, radiotherapy, chemotherapy), (4) could read Chinese to answer questionnaires and communicate in Cantonese, and (5) were able to provide meaningful informed consent. BCS were excluded if they had (1) a history of any psychiatric disorder, (2) metastatic brain disease, (3) any other type of cancer, or (4) recurrent breast cancer.
Prospective participants were recruited from the Hong Kong Breast Cancer Registry (HKBCR). The HKBCR has been the most comprehensive, representative local data collection and monitoring system for BCS in Hong Kong []. Upon approval, BCS who fulfilled the inclusion criteria based on the data in the HKBCR were invited to participate in the study through telephone calls. Of the 943 BCS contacted, 409 were not reachable, 23 were not eligible, and 227 were not interested in the study. With initial verbal consent via phone, those who were eligible and interested in the study (N=287) were asked to complete the cross-sectional survey. Participants received a cover letter explaining the study details, consent form, packet of questionnaires, stamped return envelope, thank you/reminder letter, and replacement packet via mail. After consent, participants completed the survey in the home setting. Telephone calls were used to remind individuals who had not returned the questionnaires. The study was conducted between June 2022 and December 2022 (amid the fifth wave of the COVID-19 pandemic in Hong Kong) []. A total of 209 completed surveys were returned (out of 287 sent), yielding a completion rate of 72.8%.
Ethical ConsiderationsEthics approvals were sought from the Joint Chinese University of Hong Kong - New Territories East Cluster Clinical Research Ethics Committee (CREC Ref. 2021.286) and Hong Kong Breast Cancer Foundation. We obtained informed consent before participation in the survey. Upon completion of the survey, participants received supermarket vouchers (worth HK$100; approximately US $12.80) to compensate them for their time. We guaranteed that the identity of the participants would not be revealed.
Sample Size PlanningThe dependent variable was the intention to use teledelivered SCC services. Based on prior studies on the acceptability of telehealth among Chinese populations [,], we expected a small to medium overall effect size (f2=0.10) in the association between telehealth-related perceptions and intentions to use telehealth services in the hierarchical regression analysis. To achieve a statistical power of .80 at α=.05, a minimum of 201 participants were needed (G*Power 3.1.2). The sample size (N=209) achieved via the recruitment strategy was expected to allow the detection of the expected effect size with sufficient statistical power.
MeasuresA written, closed-ended, anonymous, self-administered questionnaire was used in the study. To ensure that the questionnaire was readily comprehensible, a pilot test was conducted among 10 BCS who were eligible for the study. The study questionnaire was finalized based on feedback from the pilot test participants.
Intention to Use Telehealth for Future Supportive Cancer ServicesParticipants’ intentions to use telehealth for future supportive cancer services was measured using a SCC service utilization scale [] that was modified according to the local health care context. The checklist covered different categories of services, including psychological support (6 items; α=.91), medical consultation (5 items; α=.86), integrated or complementary care (6 items; α=.87), and peer support (2 items; α=.83). On a 4-point scale (1, no intention or not applicable; 2, low intention; 3, moderate intention; 4, high intention), participants were asked to indicate their intention to use telehealth for each SCC service (eg, “I intend to use telehealth for ‘psycho-oncology counseling.’”). The scale has been shown to be reliable and valid among Western cancer survivors [].
Perceptions About Telehealth for SCC ServicesWe used 4 subscales (performance expectancy [3 items], effort expectancy [4 items], social influence [3 items], and facilitating conditions [3 items]) to measure participants’ perceived usefulness, perceived ease, social influence, and facilitating conditions, respectively, for using telehealth in cancer care []. Sample items include “Using telehealth for cancer care is beneficial to my health.” (α=.83; performance expectancy), “It is easy for me to become skillful at using telehealth for cancer care service.” (α=.87; effort expectancy), ”People whose opinions that I value (eg, my doctors) think I should use telehealth for cancer care services.” (α=.86; social influence), and ”I have the resources necessary to use telehealth for cancer care services.”(α=.90; facilitating conditions). On a 5-point scale (1, strongly disagree; 5, strongly agree), higher mean item scores from the scales indicate higher levels of the corresponding constructs. The Chinese versions of these scales were shown to be reliable and valid among Chinese adults [].
Technology AnxietyA 3-item scale was adapted to measure participants’ technology anxiety while using telehealth services []. On a 5-point scale (1, strongly disagree; 5, strongly agree), a higher mean item score indicates a higher level of technology anxiety (eg, “I feel nervous about using telehealth.” α=.91). The Chinese version of the scale was shown to be reliable and valid among Chinese adults [].
Fear of COVID-19The Chinese version of the 7-item Fear of COVID-19 scale was adapted to measure participants’ fear of COVID-19 []. On a 5-point scale (1, strongly disagree; 5, strongly agree), a higher mean item score indicates a higher level of COVID-19 fear (eg, “It makes me uncomfortable to think about COVID-19.” α=.88). The scale has been shown to be reliable and valid in the Chinese population [].
Clinical and Sociodemographic CharacteristicsParticipants self-reported their (1) sociodemographic characteristics (eg, age, education level, employment status, marital status), (2) treatment-related variables (eg, surgeries undergone, treatments receiving or undergone, time since last treatment), (3) daily living variables (eg, access to the internet, use of electronic or mobile devices), and (4) breast cancer-related variables (eg, stage at diagnosis, time since diagnosis).
Cancer Care Experiences During COVID-19Participants were asked if they had participated in any telehealth online consultation sessions for SCC (including psychological support services, medical support services, integrated and complementary support services, spiritual support services, other support services; no=0, yes=1).
Statistical AnalysisDescriptive and bivariate Pearson correlation analyses were conducted. Hierarchical regression analyses were also conducted to examine factors associated with intentions to use telehealth for supportive cancer services. The sequence of entering independent variables followed suggestions from prior studies that examined factors associated with people’s health or health behavior outcomes and the interaction effects among those factors (eg, [,]). The process usually involves entering important sociodemographic and individual experience variables in the first block (as a statistical control for confounding variables), variables representing major theoretical constructs in the next block(s), and the interaction terms between the proposed moderating variable and the independent variables of interest in the last block. In our study, fear of COVID-19 and the sociodemographic and clinical variables that had significant bivariate correlations with the dependent variables were entered in block 1 of the regression model. Telehealth-related perceptions (ie, performance expectancy, effort expectancy, social influence, facilitating conditions, technology anxiety) were entered into block 2 of the regression model. In the last block, 5 interaction terms between telehealth-related perceptions and education level were entered into the model. To compute the interaction terms, the mean-centered scores of telehealth perceptions and education level (binary: college level versus below college level) were multiplied. All continuous independent variables were centered prior to the analyses. For statistically significant interactions, simple slopes analyses [] were conducted to examine how the main effects of telehealth perceptions on intentions to use teledelivered SCC varied at different education levels. Those with P≤.05 in the final regression model were considered statistically significant. These analyses were performed using SPSS version 26.0.
Among the 209 participants, 82 (39.2%) were 50 years or younger, 63 (30.1%) were 51 years to 60 years old, and 62 (29.7%) were at least 61 years old. In addition, of the 209 participants, 91 (43.5%) had a tertiary education, 72 (34.4%) worked full-time, 99 (47.4%) reported a religious affiliation, and 53 (25.4%) had a comorbid chronic illness. Regarding cancer-related characteristics, 10 (4.8%), 60 (28.7%), 86 (41.1%), and 53 (25.4%) of the 209 participants reported being diagnosed with Stage 0, Stage I, Stage II, and Stage III breast cancer, respectively, and 194 (94.3%) had undergone breast cancer surgery. The average time since diagnosis was 16.6 (SD 8.00) months. Regarding internet access, 204 of the 209 participants (97.6%) had a mobile phone with internet access ().
Table 1. Demographic characteristics of the participants (N=209).CharacteristicsResultsAge (years), n (%)Participants’ intentions to use different types of teledelivered SCC services are presented in . Almost all the teledelivered SCC services listed were accepted by most of the participants. The most accepted teledelivered SCC services in different categories were psychooncology counseling (140/209, 67%), nutrition consultation (165/209, 78.9%), movement and exercise activities (146/209, 69.9%), and patient support groups (131/209, 62.6%).
Table 2. Acceptability of teledelivered supportive cancer care services among breast cancer patients (N=209).Teledelivered supportive cancer care servicesReporting moderate or high intention to use, n (%)Psychosocial careThe correlation analysis results showed that the participants with a higher education level, prior telehealth experience, and more confidence using technology devices were more likely to report a higher intention to use telehealth (). Older age was associated with lower intentions to use 3 different types of teledelivered oncology services. Higher levels of performance expectancy, effort expectancy, facilitating conditions, and social influence were associated with higher intentions to use teledelivered oncology services. A higher level of technology anxiety was negatively correlated with intentions to use teledelivered oncology services. Contrary to the hypotheses, fear of COVID-19 was not associated with intentions to use teledelivered oncology services (). Other demographic characteristics (eg, marital status, P=.82; cancer stage, P=.83; time since diagnosis, P=.18; income, P=.10) were not correlated with the intention to use telehealth (data not tabulated).
Table 3. Correlations among major independent variables and intentions to use teledelivered supportive cancer care services (N=209).Independent variablesIntention to use psychosocial teledelivered supportive careIntention to use teledelivered medical consultationsIntention to use teledelivered complementary cancer careIntention to use teledelivered peer support groups1. Ageaa≤55 years (0); >55 years (1).
bHigh school or less (0); at least college (1).
cNo (0); Yes (1).
Hierarchical Regression AnalysisGiven that the independent variables were moderately correlated, the independent variables were checked for multicollinearity in the regression analysis. None of the variables had a variance inflation factor ≥5, which indicated the absence of multicollinearity problems.
In block 1, the background variables explained 16.4%, 14.9%, 13.4%, and 20.2% of the variance in the intentions to use teledelivered psychosocial care, medical consultation, complementary care, and peer support groups, respectively. Specifically, a higher education level was associated with higher intentions to use teledelivered complementary care and peer support groups, and greater confidence with using technological devices was associated with higher intentions to use all 4 types of teledelivered SCC services. Prior telehealth use was associated with greater intentions to use teledelivered medical consultation and peer support groups ( and ).
Table 4. Hierarchical regression analyses to explain intentions to use telehealth services (N=209).StepsIntentions to use teledelivered supportive cancer careaTotal R2: 0.336.
bTotal R2: 0.281.
c≤55 years (0); >55 years (1).
dHigh school or less (0); at least college (1).
eNo (0); Yes (1).
Table 5. Hierarchical regression analyses to explain intentions to use telehealth services (N=209).StepIntentions to use tele-delivered supportive cancer care
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