with the rapid aging of the population and the abrupt increase in the number of people needing care , the ability of a family to provide care has become relatively insufficient . nowadays , the nuclear family is unable to support the care for family members , and the employment rate for women , who are traditionally the caretakers , is growing . as there lacks the understanding of telecare , and the government has limited funding to invest in related services , the amount of manpower providing care can not meet the demands of the market . telecare refers to the utilization of distance communication techniques that link the user end and the service end to provide continuous , instant , and accessible care services . telecare can be used not only in disease monitoring but also in health promotion and disease prevention . its main clinical applications are in patients with chronic diseases , as well as the elderly or young patients . it has been shown to be especially effective in helping patients with chronic diseases ( e.g. , diabetes , coronary heart disease , and asthma ) [ 13 ] . although related industries are aggressively seeking cooperation with medical care industries and institutions , the technical maturity of related products needs to be continuously improved . in addition , the patients ' needs must be taken into consideration during the design of practical products in order to increase the rate of telecare use . the health belief model ( figure 1 ) [ 4 , 5 ] focuses on the four components , which are as follows : perceived benefits ( pbs ) : it refers to an individual 's perception of the benefits gained from reducing disease risk and other unhealthy status;perceived disease threats ( pdts ) : it refers to an individual 's subjective perception of the possibility of having a specific disease and the severity of the influence of the disease on the individual;perceived barriers of taking action ( pbta ) : it refers to an individual 's perception of the negative influences created by taking the action of caring for the individual , such as high cost , inconvenience , time consumption , bodily pain , and side effects;the individual 's cues to actions ( cues ) : it refers to the process change due to the introduction of certain factors such as the internal factor of physiological condition and the external factors of mass media education , advice from friends and relatives , and the urging of medical professionals for the implementation of behaviors that promote health . perceived benefits ( pbs ) : it refers to an individual 's perception of the benefits gained from reducing disease risk and other unhealthy status ; perceived disease threats ( pdts ) : it refers to an individual 's subjective perception of the possibility of having a specific disease and the severity of the influence of the disease on the individual ; perceived barriers of taking action ( pbta ) : it refers to an individual 's perception of the negative influences created by taking the action of caring for the individual , such as high cost , inconvenience , time consumption , bodily pain , and side effects ; the individual 's cues to actions ( cues ) : it refers to the process change due to the introduction of certain factors such as the internal factor of physiological condition and the external factors of mass media education , advice from friends and relatives , and the urging of medical professionals for the implementation of behaviors that promote health . hbm is commonly used in health behavior research and is applicable in explaining or predicting health related behaviors [ 7 , 8 ] . therefore , this study used hbm to understand the intention to use telecare in patients with chronic diseases . a large medical institute in taiwan was used as an example , and the findings could provide an important reference for future managers , policy makers , and researchers in related fields . many theoretical and empirical studies have shown that there is a strong and significant causal relationship between the behavioral intention ( bi ) to use and the use of technology . moreover , it has been found that intention predicts the actual use of technology [ 9 , 10 ] . based on agarwal and prasad 's   argument ( that behavioral intention is more appropriate than actual use as a measure of belief ) , this study used bi rather than actual use , because telecare in taiwan is in its early stage , and there are very few actual users available for study . bi was , therefore , considered an independent measure that was more in line with actual needs . this study proposed the following hypotheses ( 1 to 5 ) based on hbm related researches [ 4 , 5 , 7 , 8].(h1 ) there is a positive correlation between individuals ' attitudes toward using ( att ) and the behavioral intention to use telecare.(h2 ) individuals with higher perceived benefits of telecare will have a higher positive attitude to use telecare.(h3 ) individuals with higher perceived disease threats ( i.e. , higher perceived susceptibility and severity ) will have a higher positive attitude to use telecare . ( h4 ) individuals with higher perceived barriers of taking action will have a lower positive attitude to use telecare.(h5 ) individuals with higher cues to action will have a higher positive attitude to use telecare.(h5a ) individuals with higher external cues to action ( ecues ) will have a higher positive attitude to use telecare.(h5b ) individuals with higher internal cues to action ( icues ) will have a higher positive attitude to use telecare . there is a positive correlation between individuals ' attitudes toward using ( att ) and the behavioral intention to use telecare . individuals with higher perceived benefits of telecare will have a higher positive attitude to use telecare . individuals with higher perceived disease threats ( i.e. , higher perceived susceptibility and severity ) will have a higher positive attitude to use telecare . individuals with higher perceived barriers of taking action will have a lower positive attitude to use telecare . individuals with higher cues to action will have a higher positive attitude to use telecare . ( h5a ) individuals with higher external cues to action ( ecues ) will have a higher positive attitude to use telecare.(h5b ) individuals with higher internal cues to action ( icues ) will have a higher positive attitude to use telecare .   individuals with higher external cues to action ( ecues ) will have a higher positive attitude to use telecare . individuals with higher internal cues to action ( icues ) will have a higher positive attitude to use telecare . this study chose patients with chronic diseases as study subjects , in order to respond aggressively to the pressing issues of a rapid aging population , including the abrupt increase in the percentage of the population needing care , insufficient governmental funding and manpower preparation , the long - term occupation of hospital beds by patients with chronic diseases , the rising cost of hospice care , and the need to promote life quality in patients with chronic diseases . patients older than 20 years who had chronic diseases ( such as diabetes , heart disease , and asthma ) were surveyed using convenience sampling and a structural questionnaire , and a total of 500 valid questionnaires were collected . of the respondents , 55.8% are females , and most are aged 45 to 54 years old ( 20.8% ) , followed by above 65 years old and 35 to 44 years old ( 19.8% and 17.4% , resp . ) . most of the respondents are high school educated ( 29.1% ) followed by a college education level ( 28.9% ) . most of the respondents ' monthly incomes are 20,001 ~ 50,000  ntd ( 37.2% ) followed by 50,001 ~ 80,000  ntd ( 29.3% ) ( us$1  nt$29.54 ) . this study was based on the definition and the constructs related to hbm [ 4 , 5 ] . hbm is comprised of seven constructs : pb , pdt , pbta , ecue , icue , att , and bi . the operationalization and sources of the measurement items used in this study are shown in table 1 . the evaluation items employed a five - point likert - type scale for measurement , ranging from 1 ( strongly disagree ) to 5 ( strongly agree ) . confirmatory factor analysis ( cfa ) was employed to examine the reliability and validity of the measurement model . furthermore , the structural equation modeling ( sem ) technique was employed to interpret the causal model , and lisrel 8.7 was used for information analysis . the model 's overall appropriateness of fit was evaluated using the following indicators : goodness of fit index ( gfi ) , adjusted goodness of fit index ( agfi ) , normalized fit index ( nfi ) , non - normed fit index ( nnfi ) , incremental fit index ( ifi ) , relative fit index ( rfi ) , comparative fit index ( cfi ) , parsimony goodness of fit index ( pgfi ) , root mean square residual ( rmr ) , and the root mean square error of approximation ( rmsea ) . in this study , the measurement model included 23 indicators describing seven latent constructs ( pb , pdt , pbta , ecue , icue , att , and bi ) . as suggested by hu and bentler , the overall model fit was assessed using ten goodness - of - fit indices : gfi , agfi , nfi , nnfi , ifi , rfi , cfi , pgfi , rmr , and rmsea . eight fit indicators ( nfi , nnfi , rfi , ifi , cfi , pgfi , rmsea , and rmr ) all reached the suggested standards , and the other fit indicators ( gfi and agfi ) were slightly lower than the required standards ( 0.81 and 0.75 , resp . ) . the structural equation analysis ( sem ) by baumgartner and homburg   of 184 papers published between 1977 to 1994 in four journals ( i.e. , the journal of marketing , journal of marketing research , international journal of research in marketing , and journal of consumer research ) showed that 24% and 48% of the published papers reported that gfi and agfi fit indicators lower than the suggested standards could still be considered as acceptable . therefore , this study concluded that the fit indicators of this study were within an acceptable range . the reliability and validity of the measurement model were examined using confirmatory factor analysis ( cfa ) . cronbach 's alpha value and the construct reliability value were used to measure the internal consistency of the measurement model ( see table 3 ) . the construct reliability was between 0.853 ~ 0.990 , and cronbach 's alpha was between 0.851 ~ 0.990 . both were higher than the standard of 0.6 suggested by bagozzi and yi . the results showed a high internal consistency of the research variables and indicated the good reliability of the latent variables used in this research . convergent validity refers to the high degree of correlation of different measurement methods used to measure the same dimension . the standardized factor loading of all measurement variables in this study was between 0.67 ~ 0.98 ( see table 3 ) , which was all above the suggested value of 0.5   and indicated good convergent validity of the measurement model in this study . discriminant validity refers to a low degree of correlation of the measurement methods ( either different or the same ) used to measure two different dimensions . the chi - square difference test was used to measure the change in the chi - square value assuming the correlation of two dimensions as 1 . the results showed that the chi - square value  was higher than the critical value of 3.84 , indicating good discriminant validity for the measurement tools . table 2 shows the model fit indicators . after comparing all the fit indicators with the suggested standards , in addition , hypotheses 1 , 2 , 5a , and 5b were supported based on the structural model shown in figure 2 . specifically , the attitude toward using ( att ) was found to positively influence the behavioral intention to use ( bi ) significantly ( the standardized path coefficient of ( h1 ) = 0.97 ) , while the perceived benefits ( pbs ) were found to positively influence the attitude toward using ( att ) significantly ( the standardized path coefficient of ( h2 ) = 0.71 ) . external cues to action ( ecue ) positively and significantly influences attitude toward using ( att ) ( the standardized path coefficient of ( h5a ) = 0.12 ) , and internal cues to action ( icue ) positively and significantly influences attitude toward using ( att ) ( the standardized path coefficient of ( h5b ) = 0.25 ) . neither the perceived disease threat ( pdt ) nor the perceived barriers to taking action ( pbta ) had a statistically significant influence on attitude toward using ( att ) ; therefore , hypotheses 1 , 2 , 5a , and 5b were supported , while hypotheses 3 and 4 were not supported by the analysis . furthermore , the r value for behavioral intention to use ( bi ) was 0.972 , which was larger than 0.5 , indicating that a high degree of variation could be explained by the model . this study aimed to use hbm to predict the intention to use telecare in patients with chronic diseases . structural equation modeling showed that the perceived benefits ( pbs ) , external cues to action ( ecus ) , and internal cues to action ( icue ) all had significant and positive influences on the attitude toward using ( att ) telecare in patients with chronic diseases . the results were consistent with related researches that found pb having a positive and significant influence on att [ 4 , 5 , 12 , 16 ] but were different from huang and lin   results , in which icue and ecue did not have a significant level of influence on att . this study concluded that while promoting the use of telecare , priority may be given to promotion of the users ' perceived benefits ( pbs ) . furthermore , this study did not find significant influences of the perceived disease threat ( pdt ) and perceived barriers of taking action ( pbta ) on the attitude toward using ( att ) . this result was different from the conclusions of other studies adopting hbm , in which the general findings showed a significant positive influence of pdt on behavioral intention [ 4 , 5 , 16 , 17 ] and a significant negative influence of pbta on att [ 4 , 5 , 16 ] . in addition , this study found a significant positive correlation between attitude toward using and the behavioral intention to use telecare . this result was consistent with previous findings in related researches [ 9 , 1821 ] . in summary , this study found that the attitude toward using should be strengthened and that the priority should be placed on promoting the patients ' perceived benefits , in order to promote the behavioral intention to use telecare in patients with chronic diseases . the patients ' pb could be promoted by strengthening the health monitoring functions of telecare , thereby increasing the convenience of receiving medical care through the use of telecare , making the patients feel safer , and giving them an elevated quality of life . another focus could be on providing external cues to action , such as increasing the influence of important people ( medical personnel , media , relatives , friends , and family members ) . in doing so , the multiple advantages of telecare could be reached in regards to the welfare of patients with chronic diseases . their results differed from the findings in this study , which found that the perceived benefits were the major factor influencing the attitude toward using , followed by the perceived barriers of taking action ( a significantly negative correlation ) , and the perceived disease threat ( a significantly positive correlation ) . neither external nor internal cues to action reached statistical significance . based on the differences in the results of this study and that of huang and lin , the factors influencing the intention to use telecare may be different for the general public and for patients with chronic diseases . the perceived benefits are the major influencing factor for both populations ; however , in patients with chronic diseases , internal and external cues to action have higher influences , while in the general public , the perceived barriers of taking action and the perceived disease threat are more influential . therefore , based on the findings of this study , it was proposed that different methods should be used to promote the attitude toward using and the actual usage of telecare , according to the different demographic characteristics of the subjects . when promoting the use of telecare in patients with chronic diseases , priority should be placed on the perceived benefits , with a secondary focus on external cues to action . first , the findings demonstrated that patients with chronic diseases use telecare differently from the general public . the main contribution of this study was to explore the intention of patients with chronic diseases to use telecare . second , different methods should be used to promote the attitude toward using and the actual usage of telecare according to the different demographic characteristics of the subjects . to promote the use of telecare in patients with chronic diseases , priority should be placed on promoting the perceived benefits , with a secondary focus on external cues to action , such as promoting the influences of important people on the patients ( medical personnel , media , family members , relatives , and friends ) . third , when promoting the use and acceptance of telecare in patients with chronic diseases , technology developers should prioritize the promotion of the usefulness of telecare . policy makers can also strengthen the marketing of media and medical personnel to increase the acceptance of telecare by patients with chronic diseases . this approach could be used as an important reference for policy makers to use in promoting telecare for patients with chronic diseases and as a reference for related healthcare information technology industries . first , the results could assist telecare related technological industries in their further development and in the enhancement of their competitiveness to develop products meeting the patients ' needs . second , the results could assist in the understanding of the predictions for the use of telecare by patients with chronic diseases , in order to avoid the waste of medical resources and to suppress rising health care costs . the results of this study have great reference value for taiwan , where telecare development is still at its early stage . this study could provide references pertaining to the predictions of important variables influencing the use of telecare and the relationship among these variables for researchers in related fields , technology developers , and policy makers [ 2224 ] .
objective . this study chose patients with chronic diseases as study subjects to investigate their intention to use telecare . methods . 
 a large medical institute in taiwan was used as the sample unit . 
 patients older than 20 years , who had chronic diseases , were sampled by convenience sampling and surveyed with a structural questionnaire , and a total of 500 valid questionnaires were collected . 
 model construction was based on the health belief model . 
 the reliability and validity of the measurement model were tested using confirmatory factor analysis ( cfa ) , and the causal model was explained by structural equation modeling ( sem ) . results 
 . the priority should be on promoting the perceived benefits of telecare , with a secondary focus on the external cues to action , such as promoting the influences of important people on the patients . 
 conclusion . 
 the findings demonstrated that patients with chronic diseases use telecare differently from the general public . to promote the use and acceptance of telecare in patients with chronic diseases 
 , technology developers should prioritize the promotion of the usefulness of telecare . 
 in addition , policy makers can strengthen the marketing from media and medical personnel , in order to increase the acceptance of telecare by patients with chronic diseases .