We used a grounded theory approach in this study. Data were analyzed using Glaser’s inductive grounded theory approach. We decided to apply a methodology proposed by the grounded theory approach because we found grounded theory useful in getting to understand the rehabilitees’ subjective experiences for generating a substantive theory in a relatively new research area [24]. The focus was on finding out the rehabilitees’ experiences and attitudes toward technology prior to using remote technology. The rehabilitees described in qualitative interviews their experiences with computer use, social media, and other applications of modern technology.

The interviews were conducted in 2015 and 2016 in Rehabilitation Centre Peurunka, Finland, where the Social Insurance Institution of Finland arranges regular cardiac rehabilitation courses. The study is a part of a remote technology in cardiac rehabilitation study registered at the ISRCTN Registry [ISRCTN61225589]. The Ethics Committee of the Central Finland Health Care District approved the study.

The participants were 39 rehabilitees (10 women and 29 men); 82% (32/39) of them had undergone coronary angioplasty and 10% (4/39) had undergone coronary artery bypass about 3 to 12 months prior to rehabilitation. Most subjects had a computer (23/27, 85%) and used the internet (25/27, 92%). Many had mobile phones (16/27, 59%) and tablets (10/27, 37%), and several used wrist activity trackers (10/27, 37%). These statistics are similar to those obtained during the testing of other European cardiac patient populations [25]. According to Glaser’s inductive grounded theory approach, baseline information and characteristics of the subjects were collated later for this paper and were not taken into account in the analysis [24] (Table 1).

The total duration of rehabilitation was 15 days spread between three 5-day periods over a time span of 12 months. Rehabilitation took place in a rehabilitation center [26]. Qualitative interviews were conducted at the beginning of rehabilitation in 4 focus group discussions, each interview lasting 30 to 60 minutes, overall 156 minutes. The interviews were conducted by the same interviewer and they were informal and semistructured. The questions were mostly unplanned and spontaneous, but the interviewer also presented the same series of open-ended questions to all subjects. They were asked questions like, “Tell me about your experience with modern technology,” and “What are your expectations of remote counseling?” The interviews were audio-recorded and transcribed for analysis. The transcripts were imported into ATLAS.ti (ATLAS.ti Scientific Software Development GmbH) computer software, which enables data storage, organization, and retrieval for analysis. The number of subjects was determined according to data saturation, which is a point at which no more new experiences of the topic could be elicited [24].

The constant comparative model guided the data collection process. Data were collected through 4 informal interviews and analyzed using the constant comparative model. We collected and analyzed data concurrently, and as the analysis progressed the research question became more focused. First, we started substantive coding [24,27]. Subcategories were created in open coding. We analyzed incidents and compared them with other incidents, looking for similarities and differences and creating as many concepts as possible, coding substantively. Being theoretically sensitive, data were closely read and questioned. Next, we identified the properties and dimensions of each subcategory. Finally, we grouped the concept into subcategories creating as many subcategories as possible and then integrated the subcategories into the category. During this constant comparative model process, we recorded our ideas and notions, which helped us process the data. Data analysis was continued until the category was theoretically saturated [24].

The following example describes the creation of the “being uninterested” subcategory. The analysis began with open coding. We analyzed data on the diversity of the rehabilitees’ experiences of technology use as well as their attitudes toward, and expectations for, remote counseling. This perspective expanded from their responses and debates. Constant comparison convinced us that all codes essentially described or explained how each rehabilitee used technology or what their attitude toward technology was. Next we named properties (1) using technology occasionally, (2) limiting to use, (3) challenging problem-free technology, and (4) activating empowerment counseling. We named the subcategory for this experience as “being uninterested.” Textbox 1 shows an example of the process.

The constant comparison of properties resulted in hypotheses about relationships between the subcategories [28]. We continued to collect and analyze data until no new subcategories emerged and the subcategories were saturated; a category was thereby created and named “rehabilitees identifying e-usage in the process of behavior change.”

The study shows that the diversity of the rehabilitees as technology users and their different needs for technology should be taken into account in rehabilitation planning. The four subcategories are “feeling outsider,” “being uninterested,” “reflecting benefit,” and “enthusiastic using” (Figure 2). Some rehabilitees whose e-role is “outsider” or “occasionally using” need face-to-face communication for a large part of rehabilitation, while individuals whose e-role is “usefully” or “diversely” need incrementally less face-to-face interaction and feel that Web-based behavior change coaching will provide sufficient support for their rehabilitation. However, all rehabilitees hope that technology would be simple, flexible, and easy to use and learn, which would enable participation in an e-process. Participation in a remote rehabilitation program, as in this research, requires skills in areas such as Web-based log-ins and in reading and responding to tasks and messages. Activity self-monitoring requires downloading an activity tracker program to the computer and synchronizing the program with the computer.

The rehabilitees in the “feeling outsider” subcategory have a positive attitude toward technology, yet they do not see technology important for themselves. Their mindset supports previous research results that positive attitudes toward technology is a prerequisite for the uptake of technology [29,30] and eHealth [19]. At the beginning of remote rehabilitation, it is important to encourage rehabilitees’ abilities to use various devices, since these abilities will make them more receptive to the use of technology [31] and enable participation in remote rehabilitation. Studies have also found that even though the digital skills of senior citizens have improved, they are still insufficient [32]. Rehabilitees’ ability to use technology is also ensured by adequate internet technology support in remote rehabilitation [33]. Finally, it is important that apps and instructions are available in the user’s own language.

The rehabilitees in the “being uninterested” subcategory were not interested in technology and eschewed its use. They felt that easy-to-use technology encourages technology use while technology that does not work frustrates, and they felt constant communication in social media irritating. They expect coach contact to maintain motivation during remote rehabilitation. However, when their expectations of technology are exceeded, the resulting experience is positive and pleasant [34,35] and maintains motivation [35], which has also been shown in previous research.

The rehabilitees in the “feeling outsider” and “being uninterested” subcategories need more face-to-face counseling during remote rehabilitation. The rehabilitees in the “feeling outsider” subcategory need supportive guidance in technology use, while the individuals in the “being uninterested” subcategory need to be motivated in order to create positive experiences. Maintaining a spark of interest and motivation requires a motivator and a coach who gives feedback, weekly assignments, and regular reminders [36]. Previous research has shown that interventions based on the behavior change theory may motivate more than those lacking a theoretical basis, but studies conducted on mobile cardiac rehabilitation have not specifically addressed behavior change strategies. Web-based interventions may provide an opportunity for real-time coaching [37,38], motivation, and engagement, allowing rehabilitees to achieve a meaningful behavior change [18]. The rehabilitees feel that they need an external motivator, and the importance of the behavior change theory should therefore be given an adequate emphasis in the planning of remote rehabilitation.

The rehabilitees in the “reflecting benefit” subcategory use technology daily, and technology challenges they encounter stem from technical problems and attitudes. They expect apps to be easy to use, secure, and in their own language. The perceived ease of technology use influences perceived usefulness and together these bolster their intention to use technology for a real purpose (usage behavior) [39]. The technology acceptance model has also been applied in the health care context [34,35]. In addition, perceived usefulness with a perceived value plays a role in the acceptance of technology [40]; for example, it provides personalized information, support, monitoring, and feedback [21,22]. The minimization of application risks increases trust in systems [21,33,35]. These rehabilitees’ acceptance of technology increases when applications are easy to use and interactive, which has also been shown in previous qualitative studies.

Remote rehabilitation should enable social participation, such as peer group discussion and personalized feedback. These rehabilitees use social media as a means of communication and appreciate the possibility to interact. Social media, such as Facebook, Twitter, Pinterest, and Instagram, is part of their day-to-day life [41]. Social participation should be used in remote rehabilitation by granting them access to a peer group [16,17] and enabling problem-free peer group discussion on matters regarding the rehabilitation process. Health care rehabilitation applications allow users to receive information and interact since rehabilitees can receive assignments, record and review data, receive automated feedback, and connect with peers or health care professionals. All of these have been found to be important Web-based user experiences in previous studies [20-22,38]. These rehabilitees’ experiences show little need for other services than automated feedback in the form of mainly interactive coaching, which gives a little push and supports a lifestyle change.

The rehabilitees in the “enthusiastic using” subcategory accept technology as an integral part of their everyday life. Statistics show that mobile phone use is increasing [42], and these rehabilitees use mobile phones actively. Mobile health apps are increasingly popular, and mobile phone users have downloaded mobile health apps [43]. They are keen users of sufficiently coach-supported Web-based intervention apps to boost motivation for physical activity [14,44,45]. Recent studies show that participants appreciate professional Web-based support [20]. The subjects of these studies had participated in Web-based e-rehabilitation, which reduces face-to-face interactions [45,46] and is particularly suited to an active user who adequately masters technology and is interest in it. Easy-to-use and smoothly functioning technology allows extensive personal activity and body function monitoring—in other words, self-tracking. The recently termed quantified self notion has emerged to promote self-knowledge through numbers [9]. Health change coaching is based on the behavior change theory, motivational strategies, and communication techniques [20,46].

The rehabilitees’ experiences with and attitudes toward technology provide information on how to implement a counseling theory and methods for the planning of remote rehabilitation. A coach should conduct individual risk factor assessment and management, exercise training, and self-management of modifiable risk factors and provide education and psychosocial support [38]. Professional health coaches can help rehabilitees increase self-direction, set specific goals, and take action to achieve and sustain health-supporting behaviors [38,47-49]. In addition to self-monitoring, an easy-to-use interface is a desirable feature in mobile apps for promoting physical activity. Examples of these interfaces are the integration of biosensors that collect information from body and life systems such as electrocardiogram, physical activity, heart rate, blood pressure, and blood glucose measurement [50]. Digital stethoscopes, thermometers, and weight scales [9] can also be used in remote rehabilitation.

The topic is important because remote rehabilitation is already being implemented and will continue to be implemented in the future due to increasing digitization [46,47]. Technology-related studies have shown that remote technology is most successful when it is simple and designed for easy understanding and easy use [30]. Easy-to-use technology also produces positive and successful experiences [49]. As rehabilitees’ skills develop, they gain self-esteem and are empowered to expect positive, successful experiences [29,32]. Remote rehabilitation must take into account the abilities of each rehabilitee in learning, cognition, and motor and perceptual skills [29,33,51] and allow an individual ample time to master new skills [29]. In the future, the recognized needs and concerns of the subjects in the “feeling outsider,” “being uninterested,” “reflecting benefit,” and “enthusiastic using” categories should be combined with previous research and taken into account. In this way, the acceptance and use of remote technology could be upped for more meaningful and effective rehabilitation. The results of this study can also be used in designing remote rehabilitation and health coach training programs. There is a lack of quality research on the experiences of coronary disease patients, and a need exists for mixed-methods research for the development of easy-to-use effective and meaningful welfare technology.

There are weakness that need to be considered when interpreting the findings of this study. The subjects discussed their experiences of technology at the beginning of rehabilitation, and everyone was given the opportunity to share his or her experiences. The interviewer created an accepting atmosphere and encouraged silent participants. Despite this, it is possible that the participants were trying to please the group when answering the questions. On the other hands, there are advantages. The results have attracted interest and their relevance, credibility, and usefulness have been identified as important when implementing remote rehabilitation. They have been also used in comparative rehabilitation groups, in musculoskeletal system reconditioning, and in work ability rehabilitation.

The aim of this study was to explore in detail rehabilitees’ experiences and attitudes toward technology. The results are the rehabilitees’ technology experiences described as “feeling outsider,” “being uninterested,” “reflecting benefit,” and “enthusiastic using,” which relate to their e-usage. The results help providers and health workers to identify different technology users among potential rehabilitees and determine what use levels must be taken into account when developing remote rehabilitation. The category formed into four subcategories which define the rehabilitees’ technology experience and attitude. The results can also be used more widely in different contexts of social and health care for the planning of and training in remote rehabilitation/e-rehabilitation counseling and education.