Digital Health Acceptability Questionnaire (DHAQ)

Abstract

The Digital Health Acceptability Questionnaire (DHAQ) (Haydon et al., 2023) is a psychometrically validated self-report instrument engineered to measure health consumers’ acceptability of telehealth consultations across two primary operational modalities: synchronous telephone consultations and videoconference appointments. Developed through a rigorous deductive approach grounded in the Theoretical Framework of Acceptability (TFA) articulated by Sekhon, Cartwright, and Francis (2017), the DHAQ translates theoretical tenets of healthcare intervention evaluation into an empirically robust clinical assessment tool. An initial pool of 19 candidate items was subjected to empirical testing using a nationally representative sample of Australian adults who had actively engaged with telehealth services within the preceding 12 months. Exploratory factor analyses (EFA) employing oblique (Oblimin) rotation demonstrated a clean, stable two-factor structure across both delivery modalities, paring the instrument down to a refined 10-item scale (configured as two distinct 5-item subscales: Attitude toward the Service and Individual Capacity and Effort to Use Telehealth). The DHAQ demonstrates exceptional internal consistency, yielding a Cronbach’s alpha of α = 0.91 for the telephone iteration and α = 0.92 for the videoconference version, with the extracted factors accounting for 70.36% and 67.31% of the total variance, respectively. Respondents rate items using a 5-point Likert response scale ranging from “strongly disagree” to “strongly agree.” The DHAQ provides health services researchers, digital health developers, and healthcare administrators with a standardized, theory-driven metric to isolate modifiable consumer perceptions, systematically mitigate digital health disparities, and evaluate patient-centered acceptability across diverse clinical domains.

Keywords

Attitude toward the Service, Consumer Attitudes, Digital Health Acceptability, Digital Health Acceptability Questionnaire, Individual Capacity and Effort to Use Telehealth, Patient-Reported Outcome Measures, Psychometrics, Telehealth, Telemedicine, Telephone Consultation, Theoretical Framework of Acceptability, Videoconference Consultation

Authors

The Digital Health Acceptability Questionnaire was conceptualized, designed, and psychometrically validated by an interdisciplinary team of digital health researchers and clinical implementation scientists affiliated with the Centre for Online Health at The University of Queensland, Brisbane, Queensland, Australia:

• Helen M. Haydon — Centre for Online Health, The University of Queensland, Woolloongabba, Queensland, Australia (Corresponding Author; Email: [email protected]).
• Taylor Major — Centre for Online Health, The University of Queensland (ORCID: 0000-0002-2531-8221).
• Jaimon T. Kelly — Centre for Online Health, The University of Queensland (ORCID: 0000-0003-0232-5848).
• Soraia de C. Catapan — Centre for Online Health, The University of Queensland.
• Liam J. Caffery — Centre for Online Health, The University of Queensland (ORCID: 0000-0003-1899-7534).
• Anthony C. Smith — Centre for Online Health, The University of Queensland (ORCID: 0000-0002-7756-5136).
• Victor Gallegos-Rejas — Centre for Online Health, The University of Queensland (ORCID: 0000-0001-9856-4848).
• Emma E. Thomas — Centre for Online Health, The University of Queensland.
• Annie Banbury — Centre for Online Health, The University of Queensland (ORCID: 0000-0001-8841-1215).
• Centaine L. Snoswell — Centre for Online Health, The University of Queensland (ORCID: 0000-0002-4298-9369).

Purpose

The global healthcare landscape underwent an unprecedented structural transformation following the rapid, reactive scale-up of digital healthcare delivery models during the COVID-19 pandemic. While remote care modalities transitioned from peripheral clinical novelties into mainstream clinical workflows, post-implementation sustainability hinges not merely on technical deployment, but on sustained consumer acceptability. Historically, healthcare organizations evaluated remote services using generic customer satisfaction metrics or modified technology adoption inventories borrowed from industrial settings. However, general patient satisfaction surveys suffer from severe ceiling effects and lack theoretical specificity, frequently conflating satisfaction with interpersonal bedside manner, access convenience, or the clinical outcome itself.

The primary purpose of the Digital Health Acceptability Questionnaire (DHAQ) is to establish a rigorous, standardized, theoretically grounded, and psychometrically validated instrument capable of assessing consumers’ post-experience acceptability of telehealth services. Importantly, the instrument addresses a critical gap in health services research by differentiating between two widespread, yet functionally divergent, remote delivery channels: voice-only telephone consultations and audiovisual videoconference appointments. Telephone consultations represent a low-barrier, ubiquitous channel with minimal hardware demands, whereas videoconferencing introduces distinct visual affordances alongside complex cognitive burdens, user interface frictions, and varying hardware dependencies. The DHAQ provides distinct parallel forms for both modalities to enable comparative evaluative research.

In clinical practice and healthcare delivery administration, the DHAQ serves multiple operational purposes:

• Service Improvement and Quality Assurance: Identifying specific system friction points (e.g., disproportionate cognitive burden, perceived misalignment with personal healthcare goals) across ambulatory clinics transitioning to hybrid service models.
• Digital Health Equity Screening: Uncovering disparities in digital self-efficacy and perceived effort among vulnerable, rural, or geriatric cohorts who may find videoconferencing excessively burdensome relative to traditional telephone care.
• Comparative Effectiveness and Hybrid Trial Research: Functioning as a validated patient-reported outcome measure (PROM) in randomized controlled trials and implementation science studies evaluating novel digital care pathways against face-to-face standards of care.
• Resource Allocation and Infrastructure Strategy: Guiding health system leadership in discerning whether specific clinical specialty consultations (e.g., follow-up chronic disease management versus initial diagnostic triage) achieve acceptable consumer alignment via telephone or necessitate dedicated videoconference portals.

Psychological Construct

The core psychological construct measured by the DHAQ is digital health acceptability, defined as a multi-faceted cognitive and affective appraisal formed by healthcare consumers regarding the appropriateness, personal fit, cognitive effort, and burden of engaging in remote clinical consultations. Rather than treating acceptability as a passive, unidimensional affective response (e.g., “liking” or “being satisfied with” care), the construct reflects an integrative cognitive processing of whether a technological healthcare medium successfully aligns with an individual’s personal care philosophies, values, self-efficacy, and resource constraints.

Through empirical exploratory factor analysis, the construct bifurcates into two distinct, correlated latent dimensions:

1. Attitude toward the Service

This subscale captures the individual’s global evaluative appraisal, affective orientation, and perceived coherence of the digital delivery modality relative to their intrinsic healthcare standards. It encompasses:

• Affective Attitude: Positive emotional feelings and general contentment experienced when utilizing the modality (e.g., items reflecting enjoyment and liking the service modality).
• Intervention Coherence and Ethicality: The extent to which the remote medium fits into the consumer’s fundamental conceptual model of what constitutes safe, ethical, and high-quality healthcare delivery (e.g., evaluating whether remote care conforms to their personal ideal of good clinical care).
• Perceived Effectiveness and Goal Congruence: The user’s cognitive conviction that the consultation medium successfully met their acute clinical demands and advanced their personal health objectives without compromising clinical efficacy.

2. Individual Capacity and Effort to Use Telehealth

This subscale operationalizes the cognitive, temporal, and logistical expenditures required by the patient to successfully access, navigate, and participate in the consultation. It encompasses:

• Perceived Burden: The subjective tax on personal resources, cognitive overhead, or emotional strain imposed by engaging in the remote appointment (e.g., items measuring whether attending the visit felt burdensome or demanding).
• Self-Efficacy: The consumer’s confidence in their digital competence, logistical readiness, and capability to successfully set up, troubleshoot, and execute the appointment across the specified technology channel.
• Effort and Usability: The degree of operational simplicity experienced during setup and execution, including the perceived conservation of personal time and procedural efficiency relative to traditional in-person transit and waiting rooms.

Theoretical Framework

The architectural foundation of the DHAQ is explicitly anchored in the Theoretical Framework of Acceptability (TFA) formulated by Sekhon, Cartwright, and Francis (2017). Prior to the publication of the TFA, acceptability in healthcare implementation literature suffered from profound conceptual ambiguity, frequently defined interchangeably with feasibility, usability, client satisfaction, or adoption rates. Sekhon and colleagues resolved this paradigm deficit by synthesizing systematic literature into a cohesive, multi-component theoretical model defining acceptability as:

“A multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention.”

The TFA delineates seven distinct component constructs:

1. Affective Attitude: How an individual feels about the intervention.
2. Burden: The perceived amount of effort required to participate.
3. Ethicality: The extent to which the intervention fits with an individual’s value system.
4. Intervention Coherence: The extent to which the participant understands the intervention and how it works.
5. Opportunity Costs: The extent to which benefits, profits, or values must be surrendered to engage in the intervention.
6. Perceived Effectiveness: The likelihood that the intervention will achieve its intended purpose.
7. Self-Efficacy: The participant’s confidence that they can perform the behaviors required to participate.

The development of the DHAQ utilized a deductive methodology, systematically drafting candidate test items mapped directly onto these seven theoretical facets. While classic technology acceptance models—such as the Technology Acceptance Model (TAM; Davis, 1989) and the Unified Theory of Acceptance and Use of Technology (UTAUT; Venkatesh et al., 2003)—emphasize generic technology attributes such as Perceived Usefulness (PU) and Perceived Ease of Use (PEOU) in commercial or organizational settings, the TFA framework centers upon the deeply sensitive personal dynamics of healthcare interactions. By leveraging the TFA, the DHAQ accounts for healthcare-specific values, clinical goal achievement, relational safety, and emotional burden, yielding a specialized instrument attuned to the realities of healthcare delivery.

Validity

The psychometric validation of the DHAQ followed contemporary psychometric guidelines, providing robust empirical support across several facets of construct and measurement validity:

Content and Face Validity

Items were deductively generated by clinical and digital health implementation experts to ensure comprehensive coverage of the Theoretical Framework of Acceptability. The resulting draft items underwent iterative refinement, linguistic optimization, and expert evaluation at the Centre for Online Health to confirm clear reading ease, semantic fidelity to digital consultation workflows, and clinical face validity across both telephone and video contexts.

Construct Validity

Construct validity was evaluated using a nationwide cross-sectional validation cohort in Australia (comprising adults who had completed a remote consultation within the prior year). Exploratory Factor Analysis (EFA) demonstrated that the retained 10 items cleanly loaded onto two theoretically coherent latent constructs in both delivery versions:

• Telephone Consultation Scale: The two-factor solution accounted for an exceptional 70.355% of the total variance, confirming that the questionnaire captures the core underlying dimensions of telephone care acceptability.
• Videoconference Consultation Scale: The identical two-factor structure emerged cleanly, accounting for 67.312% of the total variance, demonstrating structural stability across distinct digital media types.

Convergent and Discriminant Directions

Item loadings onto their assigned primary factors were exceptionally strong (predominantly exceeding 0.70 to 0.85), with minimal cross-loadings, demonstrating robust within-factor convergence and clear discriminant divergence between the affective evaluation of the service and the operational self-efficacy/burden dimension. Authors highlighted ongoing research agendas evaluating convergent validity via bivariate correlations with legacy measures such as the TAM-21 (Davis, 1989), the Telehealth Usability Questionnaire (TUQ), and standardized healthcare consumer satisfaction indices (e.g., CSQ-8), hypothesizing moderate-to-high convergent associations alongside distinct factor divergence reflecting healthcare-specific ethicality and burden.

Reliability

The reliability of the DHAQ was thoroughly evaluated through internal consistency analyses across both consultation modalities:

• DHAQ-Telephone Consultation Scale (Full 10 Items): Demonstrated outstanding internal consistency, achieving a Cronbach’s alpha coefficient of α = 0.91.
• DHAQ-Videoconference Consultation Scale (Full 10 Items): Yielded an equally superior Cronbach’s alpha coefficient of α = 0.92.

These coefficients significantly exceed standard psychometric benchmarks (α ≥ 0.70 for research, α ≥ 0.80 for diagnostic and clinical monitoring instruments), demonstrating high item homogeneity and minimal measurement error. Furthermore, split-factor analyses of the two individual 5-item subscales demonstrated high internal consistency within each factor (alphas ranging from 0.85 to 0.91), confirming that both the Attitude toward the Service and Individual Capacity and Effort to Use Telehealth dimensions function reliably as independent subscales or when combined into an omnibus digital health acceptability score.

Factor Analysis

To ascertain the empirical structural composition of the DHAQ, exploratory factor analyses (EFA) were performed on the candidate items across both administration modalities:

Methodological Parameters

• Extraction Method: Principal Axis Factoring / Maximum Likelihood extraction.
• Rotation Method: Oblique rotation (Direct Oblimin), selected based on the theoretical premise that affective consumer attitudes toward a clinical service correlate with an individual’s personal capability and perceived effort in using the delivery technology.
• Retention Criteria: Kaiser-Guttman criterion (eigenvalues > 1.0), inspection of the scree plot inflection points, parallel analysis, and interpretability against the underlying TFA framework.

Factor Architecture & Variance Explained

The factor analytical investigations revealed identical two-factor latent architectures across both modalities, paring down initial items into two balanced 5-item dimensions:

• Telephone Appointment Model: The two-factor model accounted for 70.355% of the total cumulative variance. Factor 1 (Attitude toward the Service) captured items reflecting clinical goal attainment, healthcare ideal alignment, and affective enjoyment. Factor 2 (Individual Capacity and Effort to Use Telehealth) consolidated items reflecting minimal personal burden, operational ease, time savings, and setup self-efficacy.
• Videoconference Appointment Model: The parallel two-factor solution accounted for 67.312% of the total cumulative variance, exhibiting comparable factor loadings and item-to-factor mapping.

All retained items demonstrated primary factor pattern coefficients well above the standard 0.40 threshold (most exceeding 0.70), with negligible cross-loadings (< 0.30), validating the multidimensionality of the scale while preserving theoretical parsimony.

Instrument / Measurement Tool

• Instrument Name: Digital Health Acceptability Questionnaire (DHAQ)
• Alternative Titles: DHAQ-Telephone Appointments; DHAQ-Videoconference Appointments
• Test Type: Original psychometric self-report questionnaire / Patient-Reported Outcome Measure (PROM)
• Administration Modality: Self-administered; executable via digital surveys (online portals, SMS-delivered links, patient portal integration) or paper-and-pencil formats
• Completion Time: Approximately 2 to 4 minutes
• Target Population: Adult healthcare consumers (aged 18 years and older) who have participated in a remote clinical consultation within a defined recall window (typically within the past 12 months)
• Number of Items: 10 items (configured across two 5-item subscales)
• Subscale Structure:
  • Factor 1: Attitude toward the Service (5 items: Items 1, 2, 5, 9, 10)
  • Factor 2: Individual Capacity and Effort to Use Telehealth (5 items: Items 3, 4, 6, 7, 8)
• Item Phrasing Adaptation: Items are instantiated according to the consultation modality under review by inserting “phone” or “video” into the bracketed prompts (e.g., [phone/video]).
• Response Format: 5-point Likert rating scale:
  • 1 = Strongly disagree
  • 2 = Somewhat disagree
  • 3 = Neither agree nor disagree
  • 4 = Somewhat agree
  • 5 = Strongly agree
• Scoring Procedures:
  • All 10 items are positively phrased relative to high acceptability, low burden, and high self-efficacy (no reverse-scoring required for standard administration).
  • Total Acceptability Score: Computed as either the sum score (range: 10 to 50) or the mean score (range: 1.0 to 5.0) across all 10 items, where higher scores signify greater overall acceptability.
  • Subscale Scores: Computed by calculating the mean score (range: 1.0 to 5.0) of the corresponding 5 items for Attitude toward the Service and Individual Capacity and Effort to Use Telehealth, respectively. Mean scores > 4.0 indicate high acceptability and favorable service onboarding.

Permissions & Fee and Test Year

• Year of Formal Publication: 2023
• Copyright & Authorship: Helen M. Haydon, Taylor Major, Jaimon T. Kelly, Soraia de C. Catapan, Liam J. Caffery, Anthony C. Smith, Victor Gallegos-Rejas, Emma E. Thomas, Annie Banbury, and Centaine L. Snoswell (Centre for Online Health, The University of Queensland).
• Licensing and Research Permissions: The DHAQ is an open-access psychometric instrument available free of charge for non-commercial academic research, educational instruction, and institutional quality improvement initiatives.
• Commercial Use: Commercial exploitation, re-licensing, or integration into proprietary fee-for-service enterprise software platforms requires formal written authorization from the authors and The University of Queensland.
• Correspondence & Author Inquiries: Inquiries regarding test implementation or translation permissions should be addressed to Dr. Helen M. Haydon at [email protected] (Centre for Online Health, Princess Alexandra Hospital, Building 33, Woolloongabba, QLD 4102, Australia).

References

• Davis, F. D. (1989). Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Quarterly, 13(3), 319–340. https://doi.org/10.2307/249008
• Haydon, H. M., Major, T., Kelly, J. T., Catapan, S. d. C., Caffery, L. J., Smith, A. C., Gallegos-Rejas, V., Thomas, E. E., Banbury, A., & Snoswell, C. L. (2023). Development and validation of the Digital Health Acceptability Questionnaire. Journal of Telemedicine and Telecare, 29(10, Suppl), 8S–15S. https://doi.org/10.1177/1357633X231202279
• Sekhon, M., Cartwright, M., & Francis, J. J. (2017). Acceptability of healthcare interventions: An overview of reviews and development of a new theoretical framework. BMC Health Services Research, 17(1), Article 88. https://doi.org/10.1186/s12913-017-2031-8
• Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. D. (2003). User acceptance of information technology: Toward a unified view. MIS Quarterly, 27(3), 425–478. https://doi.org/10.2307/30036540

Items of the Scale