Technology in Society 67 (2021) 101800

Contents lists available at ScienceDirect

Technology in Society
journal homepage: www.elsevier.com/locate/techsoc

An extension of technology acceptance model for mHealth user adoption

Manindra Rajak *, Krishnendu Shaw
Department of Management Studies, Indian Institute of Technology (ISM) Dhanbad, Jharkhand, 826004, India

A R T I C L E I N F O A B S T R A C T

Keywords: Providing health care services has become a challenge for the government, especially for emerging economies,
mHealth which face huge resource problems. mHealth (mobile health) has the potential to reduce health-related problems
Technology acceptance model significantly in the long run. It can be used as a preventive healthcare tool also. Despite the potential, minimal
Structural equation modelling
studies exist on the technology adoption of mHealth. There have been inadequate studies in the context of India.
Mobile health care
Social influence
To find out the domains where studies can be conducted and after a thorough literature review, the study
Behavioural intention employed the Technology Acceptance Model (TAM) for the smooth running of mobile health services.
As a theoretical contribution, this research is an extended version of the TAM, suggested by Davis, through
considering six additional variables such as social influence, technology anxiety, trust, perceived risk, perceived
physical condition, Resistance to change. To validate the linkages, a close-ended questionnaire was developed
after a thorough literature survey. The current study collected 289 valid responses from different mHealth
services users. The constructs of the model have been tested in Indian settings by conducting exploratory and
confirmatory factor analysis. Further, Structural equation modelling is ably employed to validate the model to
suit the Indian requirements. The adoption of mHealth was found to have had an enormous impact on social
influence, behavioural intention and trust. The empirical examination showed high predictive power for adop­
tion intention of mHealth services and the influential role of these important constructs. The implications for
academics and policymakers have been discussed in this study. Finally, the future scope and limitations of the
study have been discussed.

1. Introduction
After the advancement in Information and communication technol­
ogy (ICT), mobile health (mHealth) has become a possible alternative
system to deliver healthcare facilities [1]. It provides health care ser­
vices through mobile communication devices. The devices, which are
commonly used in mHealth, are mobile phones, smartphones, tablets,
laptops, sensors, and a notebook. These mobile gadgets have various
functionalities, and they help users in communicating in real-time mode,
accessing information, knowledge, and data sharing through various
applications [2]. mHealth works on different mobile-based platforms
like android, windows, iOS, etc. Mobile phones can be classified into two
categories regarding their capabilities: smartphones and basic mobile
phones [3]. Over a period of time, a revolution has happened in the
smartphone area. It is slowly progressing across the world. In terms of
business value, the global mHealth market has reached USD 46,048
million in the year, 2019; and it is estimated to reach USD 230,419
million by 2027 [4]. This is due to the reduction of technologies related
to cost and more accessibility to mobile data [5]. The mobile phone is
penetrating with significant speed both in developed as well as devel­
oping economies [6]. For example, in India, the number of smartphone
users was estimated to reach 760 million by the year 2021 [7]. India has
emerged as the next largest global smartphone market across the planet.
The smartphone has helped people to make their lives easier by
providing video calls, voice chat, text chat, real-time data sharing,
sharing of documents, etc. These functionalities of the smartphone can
be used for delivering health care services [8]. mHealth has enormous
potential to provide healthcare in a customised manner [9–11].
Although mHealth is a promising application in the 21st century, there is
a considerable challenge for adopting such an application/technique.
The research on mHealth can be broadly classified into two areas,
such as the development of new technology and the embracing of
technologies [12]. Actually, the Technology acceptance model (TAM)
was initially formulated by Davis to explore the relationships among the
elements like “perceived usefulness” (PU), “perceived ease of use”
(PEOU), Attitude (ATT), Behavioural Intention (BI) and actual use (AU)

* Corresponding author.
E-mail address: manindra213@gmail.com (M. Rajak).

https://doi.org/10.1016/j.techsoc.2021.101800
Received 22 September 2020; Received in revised form 26 October 2021; Accepted 28 October 2021
Available online 3 November 2021
0160-791X/© 2021 Elsevier Ltd. All rights reserved.
M. Rajak and K. Shaw
[13]. This model has been substantially used in several sectors to solve
different technology adoption problems [14–18]. However, it has been
inadequately used in adopting mHealth services, especially keeping
India in mind [1,19,20]. Hence, there is an urgent need to carry out an
empirical study in the context of India. Different researchers have
explored the efficacy of mHealth in the context of several nations across
the globe, but the rate of adoption has been found to be varying from
country to country. The mHealth technology adoption has been
observed significantly for North America, Southwest Asia, South
America and Bangladesh [21–23]. However, it was found low in Africa
[21,24,25]. The adoption of mHealth is in the infancy stage in India.
Recently different initiatives have been taken in various parts of India to
operationalise mHealth. For example, Madhya Pradesh has recently
come up with SMS based medical prescriptions due to the low avail­
ability of doctors in cities [26]. Nevertheless, the success of such a sys­
tem is dependent on the intention to adopt by medical practitioners and
users [27]. Various researchers observed that mHealth technologies
could effectively manage various diseases like type-1 diabetic Mellitus,
asthma, smoking, and many more [28–31]. It can also strengthen the
existing healthcare delivery system through the integration of
technologies.
According to a report of Berg insight AB, approximately 2.2 million
patients are currently using mHealth systems across the world [32].
Apparently, the intervention of mHealth looks very promising to handle
the diseases, but it has been found to fail after some time. It works well in
a small project while compared to a big project. For the victory of the
mHealth project, the users should be adopting the technologies with
ease. Minimal studies exist on the technology adoption of mHealth
projects in India.
The target behind this study is to propose a modified TAM for
capturing the intention for adopting mHealth services. In the process of
achieving the goal, the extended TAM has been formulated employing
structural equation modelling (SEM), and primary data garnered from
289 users across India. The sampling method chosen is Judgemental
sampling. In the next segment, the reviews of several constructs per­
taining to the traditional TAM have been elaborated. In addition, this
study also proposes some new factors in the traditional TAM to test its
effectiveness in the Indian context. A conceptual model will be shown in
Fig. 1. The study also makes an attempt to validate or justify the pro­
posed model after the collection of data from various regions in an
empirical manner. The last section deals with the discussion and
conclusion and comparative analysis of the study on the basis of liter­
ature review analysis and empirical findings.
2. The theoretical background of the study
The acquisition of mHealth services technology has been studied
from several aspects, and varied theories have been analysed. Various
researchers have coined significant insightful observations in the tech­
nology acceptance model. In literature, technology adoption was stud­
ied from the perspective of the organisation as well as the individual
Fig. 1. Conceptual framework.
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Technology in Society 67 (2021) 101800
[33]. The organisational point of view explores how technology pene­
trates across an organisation. Researchers like Rogers [34] observed the
penetration of innovative technologies across the organisation. The
authors amalgamated the variables from the “Technology acceptance
model” (TAM) and “Diffusion of Innovation theory” to articulate the
behavioural tendency of the users [35]. The “Diffusion of Innovations
theory” can be segregated into five parts- “relative advantage, compat­
ibility, complexity, trial ability and observables” [15].
The technology acceptance of the individual was explored from two
perspectives. Firstly, how do the traits of a user influence a particular
technology? Secondly, how do the functionalities of technology influ­
ence the users to adopt the same? [36]. Parasuraman [37] conducted
seminal work in the sphere of technology acceptance and formulated the
Technology Readiness Index (TRI). The theory explains how personal
liking and disliking often encourage using technology. On the other
hand, the TAM tries to explore how the perception of the individual
alters with respect to the technology will lead to the adoption of the
same.
In literature, “Theory of reasoned action” (TRA) [212] and “Theory
of Planned Behaviour” (TPB) [38] were suggested to explain the
behavioural aspects. To add to it, Davis [39] extracted a few elements
from these aforesaid theories and proposed a TAM for accepting various
types of technologies. Initial TAM, proposed by Davis [39]; has five
dimensions like “Perceived Usefulness (PU), Perceived Ease Of Use
(PEOU), Attitude (ATT), Behavioural Intention (BI), and Actual Use”.
The TAM was effectively executed in various contexts for adopting
different technologies [40]. A few examples are internet services,
healthcare applications etc. [41]. The TAM is relatively an established
and robust model as its constructs have been validated several times in
different contexts [14,16,42,43]. The model has the ability to explain
approximately 40% of the variability [40]. TAM as a theoretical base has
been substantially employed in adopting varied technological applica­
tions such as the education sector, electronic logistic information sys­
tem, clinical information system, mobile technology adoption,
physicians’ acceptance of electronic health care records (HER) systems,
adoption of software measures, Information technology adoption,
adoption of online tax, technology adoption among physicians, physi­
cian acceptance of telemedicine technology, and Understanding Aca­
demics’ Behavioural Intention [14,15,42–46]. In the above-given areas,
authors have added the external factors in the TAM model for their
perspective areas. However, the study on mHealth is relatively limited,
especially in the context of developing countries like India. The tradi­
tional TAM may not be enough to discuss the adoption behaviour of
mHealth [47].
To solve the problem, different other dimensions are incorporated in
the model taken from the archived literature to predict the mHealth
adoption behaviour of the users.
3. Technology acceptance model in health care
Acceptance of technology defines whether an individual is willing or
reluctant to use technology. The consistent surge in the utilisation of IT
in recent years has prompted the healthcare industry to adopt technol­
ogy for delivering quick services to patients. Thus, the diffusion of IT
into the healthcare system has intensified the high engagement of the
physicians as well as the medical seekers having knowledge of computer
technology. But despite these, it takes the acceptance and utilisation of
technology by an individual for the success in the implementation of IT
in the healthcare system.
Over the past two decades, many models relating to technology
acceptance were developed and tested and were primarily intended to
cover a broad spectrum of IT systems like electronic medical records and
personal digital assistants and so on [48,49]. Hoque and Bao [50] have
used TAM to provide an overview of mHealth practices in Bangladesh to
address the significant role of the application in improving healthcare
delivery, especially to the current generation who are adept in using
M. Rajak and K. Shaw
smart devices. Another study by Yu et al. [51] has developed a con­
ceptual framework by applying extended TAM 2. In the present frame­
work, authors have used Image, Subjective Norms, Job Role, and
Computer Level as an external Variable with the model TAM 2. The
results of this study have given the explanation for the caregivers’
acceptance of mHealth practices for long-lasting care. Dünnebeil et al.
[52] have further expanded the TAM for understanding the use of
mHealth in the ambulatory care setting.
Nistor et al. [53] incorporated the Theory of Acceptance and Use of
Technology for a sample size of 2866 in Germany and Romania through
the survey. The variables used are according to Hofstede’s [54] theo­
rems. The study investigated the acceptance of technology among
different cultures. The authors concluded that culture shapes the
learning environment of individuals. The study approved the Theory of
Hofstede and that culture plays a significant determinant in accepting
technology. Lin and Chang [55]; in their findings of the study, denoted
that the concept of Technology readiness (TR) is effective. The study
noted that in order to accept technologies, it is important that Techno­
logical readiness increases like innovation and positivity while reducing
the security issues. Sahin [56]; in their experimental design, employed
scales on the basis of Everett M. Rogers Diffusion of Innovations Theory
to analyse the variables like Preferred innovativeness, innovation per­
ceptions and innovation decisions regarding future usage of ICT. The
findings suggested that the teachers were interested in the innovation.
The case studies changed their perception of adopting computer-related
technology in their education, which had a positive increase. Thus the
role of technology in elementary teaching was accepted positively by the
teachers.
Maldonado et al. [57]; in their study using the Unified theory of
acceptance and use of technology (UTAUT), was adopted as the theo­
retical framework. The results denoted that there was a positive influ­
ence of technology among the schools with considerate motivation and
social influence. Therefore, self-worth is important for the students to
analyse their capabilities and positive growth for adopting technology
instead of traditional classrooms. In their study, Persico et al. [58] used
the acceptance of the technology for education has been analysed in this
study for an Italian online university keeping the Technology Accep­
tance Model as the framework. Adequate training to the staff along with
advanced technology will aid in the improvement of the learning process
with a long-lasting impact. Sawng et al. [59]; in their study, employed
the Information technology model to provide the framework to under­
stand why mobile phones are being used. Diffusion of Innovation The­
ory, Technology Acceptance Model, Task Technology Fit Model, Theory
of Perceived Risk has been studied and incorporated to understand the
reasons behind the usage of mobile and the benefits reaped. The factors
which are the reasons behind acceptance are the perceived usefulness,
perceived ease of use, perceived costs, perceived use, service-specific
benefits, economic benefits, cost risk, service risk, social benefits,
perceived network effects.
In their study, Dwivedi et al. [60] conducted an analysis of the re­
views that also revealed the usage of external variables. The zero-order
correlation was found significant and can be used for further studies on
technology adoption. Future studies can be done on other journals
which could not be accessed by the researchers and on the structural
relationship between UTAUT Constructs.
In their study, Shyu and Huang [61] focus on E-government learning
and analyse the citizens’ usefulness from the websites. The relevance of
the technology acceptance model is tested for the explanation of
e-government learning. The perceived usefulness led to a change in
attitude, behavioural intention and usage. E-government learning refers
to learning from government websites regarding anything pertaining to
the interest of the citizens. Sometimes, certificates are also offered after
the learning and certificates are offered, which can add value. The
limitations are the variables like self-efficacy, computer convenience,
learning goals, influence attitude and behavioural intention, which was
not analysed. In their study, Zarmpou et al. [62] analysed the role of
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Technology in Society 67 (2021) 101800
mobile phones using models like the Technology acceptance model,
Diffusion of Innovations, the Unified Theory of acceptance, and the Use
of technology. The variables to analyse the new variables are behav­
ioural intention, perceived ease of use, usefulness, trust, innovativeness,
relationship drivers, and functionality. The findings indicated that the
respondents liked to use the mobile services for ease of use like network,
speed, response time etc. Thus, the results denoted the emotional
connection of the users with mobile phones. The respondents were
motivated on their own to use the technology.
In their research, Heather Holden and Rada [63] analysed the usage
of the technology for educational purposes by the teachers. The active
methodology by conducting a survey upon 99 teachers of two rural
schools in Virginia. The variables are perceived ease of use, perceived
ease of use and usability, perceived usefulness and attitude towards
using AT. The results indicated that technology brought in positivity
along with other psychological variables like self-efficacy, demographic
factors, personality for the usage and adoption of technology. The
teachers have adopted technology for teaching, believed in the change,
and willingly integrated it into the classroom. Lee and Han [64]; in their
study, analysed the behaviour of adopting mHealth apps. The research
employed health behaviour as well as consumer value research to assess
health behaviour. 550 respondents were selected from Seoul, South
Korea and the data was analysed using the Structural Equation Model­
ling technique. The variables which worked for the respondents are
usefulness, value for money and ease of usage. Interestingly, in this
study, gender, income, and age did not significantly influence the data
and had nil impact. The researchers stated that this study brought the
positive impact of mHealth apps used by the respondents who required
health facilities in the vicinity of their homes. Hoque et al. [65] studied
the usage of mobile phones to access health information, especially
among the young age group. The Technology Acceptance Model is the
theory used for understanding the theoretical implications. The data
collected from young respondents were quantified using Partial Least
Square method. The respondents agreed to the usage of mHealth ser­
vices for the perceived usefulness rather than any other variables. The
authors suggested the use of mHealth services for accessing better health
facilities.
Zhang et al. [66]; in their study on 481 respondents, found gender
differences when it came to adopting mHealth. The results were sup­
ported using the theory of reasoned action (TRA) model and variables
like attitude and intention. The findings indicate that the conditions and
attitude form as the base for the adoption of mHealth services. The
gender difference was outright evident when the findings implied a
higher adoption among males than the females. Moreover, males had
“Edgeworth–Pareto substitutability” amongst attitude and subjective
norms for the adoption of mHealth and the intention behind it. There­
fore, when seen from a social psychology point of view, gender differ­
ences impact the usage and adoption of mHealth. In their study, Zhao
and Zhou [67] have reviewed 35 empirical studies that used
meta-analysis techniques to understand the significance of moderating
age in the adoption of mHealth. For the meta-analysis, the keywords like
“Mobile health”, “MHS”, “adoption”, “mHealth”, “Acceptance” were
used and searched in different databases like Google scholar Science
Direct, Springer link and so on. Correlation analysis and reliability sta­
tistics were employed for analysing the data. The findings indicated the
significance of variables like perceived ease of use, perceived usefulness,
perceived severity, perceived vulnerability, subjective norm, attitude
and trust towards adopting mHealth services. Middle-aged and older
people find it challenging to adopt new technology and lack efficiency
like the younger ones. The middle-aged and elderly were found to be
affected by perceived ease of use, perceived vulnerability and perceived
severity. In their study, Chib et al. [68] analyse the literature existing on
the adoption of mHealth in developing nations. A thorough review of the
articles has depicted that studies in developing nations mostly cater to a
deterministic approach, with few studies showcasing the research design
demonstrating outputs. The authors also found out that the studies had
M. Rajak and K. Shaw
less theoretical understanding and did not mention the probable health
outcomes using appropriate technology. The researchers have pointed
out that future studies should formulate new theories from a social
science perspective, which will benefit policymakers and bureaucrats.
In their research, Hoque and Sorwar [69] attempted to empirically
test the Unified Theory of Acceptance and Use of Technology (UTAUT)
to understand the intention of the elderlies towards mHealth services.
The study was conducted among 300 respondents aged above 60 years
in Dhaka, Bangladesh. The data were analysed employing Partial Least
Squares (PLS Method). The variables which had a higher impact upon
the respondents were “performance expectancy, effort expectancy, so­
cial influence, technology anxiety as well as resistance to change”. The
study indicated that the findings would help policymakers devise
appropriate techniques to enable the elderlies to access mHealth, espe­
cially in developing and underdeveloped nations. In their study, Jen and
Hung [70] analysed the problems faced by senior citizens in adopting
mHealth and the factors acting as the barrier. The study’s sample size
was 200 students who had an elderly in their family aged 65 years and
above. The theoretical framework included the Theory of Planned
Behaviour and the Technology Acceptance Model. The Partial Least
Square analysis depicted that attitude, perceived usefulness, perceived
ease of use influenced the elderly. Thus the research highlighted the
impact of attitude as well as gender disparities for adopting mHealth. In
their study, Faqih et al. [71] wanted to analyse the potential of the
mHealth services to render better services and the users perception to­
wards it. The study was conducted in developing nations using the
Technology Adoption Model as the theoretical construct. A survey of
366 respondents in Jordan was analysed using the PLS-SEM statistical
tool. The findings suggested that variables like trust, perceived useful­
ness, privacy, ease of use, and social influence had a profound effect on
the respondents. Besides that, gender and age have an impact upon the
people who adopt the technology. Deng et al. [72] have studied the
usage of mobile health services among the middle-aged and the older
citizens of China. A survey was conducted among 424 respondents using
Structural Equation Modelling to statistically analyse the data. The re­
sults indicated that attitude, resistance to change, perceived behavioural
control, and perceived values were the variables affecting the
middle-aged respondents. Whereas anxiety towards technology,
perceived value, self-actualisation, perceived behaviour control were
the factors amongst the senior citizens. Thus, the authors mentioned that
this study would help policymakers identify the loopholes and render
better healthcare facilities.
Kim et al. [73] stated that to understand the real intention behind
adopting new technology, it is important to comprehend the factors
using the unified theory of acceptance and use of technology (UTAUT)
and the Technology Acceptance Model (TAM). A survey was conducted
among 449 healthcare workers (primarily nurses and doctors) for two
weeks, and the data were analysed employing structural equation
modelling (SEM). The findings of the SEM Analysis were compared with
an electronic medical record log (EMR). It was found that the intention
to adopt any new technology was mainly due to the performance ex­
pectancy or attitude. Thus, performance is the prime reason for adopting
healthcare technologies. Zhang et al. [74] conducted an intensive study
amongst the 91 Canadian nurses employing Technology Acceptance
Model 2. The author has highlighted that despite the comfort and ease,
several mobile applications have faced several problems. The study
implied that the variables like the subjective norm and organisational
image played a significant factor in adopting any health care technology.
Cocosila and Archer [75] stated that the research examines the
reasons for adopting mHealth services. An experiment for a month was
conducted, revealing that motivation is the most significant factor and
not “multi-faceted overall risk” is the barrier for people to adopt it.
Besides mHealth services being attractive, it is also enjoyable for several
to adopt the technology.
In their research, Chong et al. [76] analysed the adoption of tech­
nology among 252 medical professionals. The study utilised the unified
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Technology in Society 67 (2021) 101800
theory of acceptance and use of technology (UTAUT) to comprehend
RFID adoption among the respondents. The variables taken up are
“performance expectancy, effort expectancy, facilitating conditions,
social influence”, as well as age and gender. Wanjau et al. [77] stated
that significant health issues like AIDS, Tuberculosis, Malaria and many
others have led to health ailments in Kenya since it gained its political
independence. The Kenyan government has come up with innovative
measures to tackle health and come up with several measures. The study
has depicted that Kenya spends 5.1% of its GDP on health services;
hence, mortality rates are still very high. Therefore, the researcher
claimed that Kenya needs to focus more on health and reaching Mil­
lennium Development Goals is still far-reaching.
Gagnon et al. [78] stated that 101 reviews were done for studies that
researched the adoption of ICT by healthcare workers. The positive
factor for adopting technology was perceived usefulness, whereas the
disadvantages were non-familiarity with ICT, design, technical glitches,
and time. The researchers indicated that strategies should be laid down
for the adoption of ICT by health workers in the near future. Yao et al.
[79] conducted a study on the response towards RFID in health care.
Several respondents found it highly efficient for getting updates on the
patient’s condition, whereas many experienced barriers like privacy is­
sues, technical glitches and costs. The researchers suggested the
manufacturing of low-cost RFID Systems so that all the flaws can be
addressed and better efficacy be ensured in the sphere of healthcare.
Deng [80] mentioned that mobile usage has considerably increased
among people. This study employed Technology Acceptance Model
(TAM) and Health Belief Model (HBM) as theoretical constructs. The
intention towards usage of mHealth services increased due to perceived
usefulness, perceived barriers, and the service’s availability. The author
suggested the marketing of mHealth services so that more people adopt
it and avail its benefits. Ryu [81]; in their study, analyses the role of
video UCC Services in aiding the elderly with health care. The sample
size of the respondents was 290, and the variables used for analysis are
perceived ease of use, perceived usefulness, perceived enjoyment, and
compatibility. The respondents were above the age of 50 years from
Korea using an online survey. Technology Acceptance Model (TAM),
Motivation Theory (MT), and the Innovation of Diffusion Theory were
used as theoretical constructs. The analysis of the data was conducted
using the Partial Least Squares (PLS) statistical tool. The findings indi­
cated that elderlies are not completely against adopting technology;
instead, a few criteria need to be met. Anxiety towards computers may
be reduced or eradicated if the technology user is confident enough and
there are no other conventional barriers like age and gender.
Egea and González [14] point out the technology’s acceptance, pri­
marily the electronic health care records (ECHR systems) by health
workers. The theoretical construct was based on the Technology
Acceptance Model (TAM). The attitudinal factors were the major factors
found for acceptance and perceived usefulness, perceived ease of use.
Ramola et al. [82]; in their study, analysed the different 3D Printing
techniques and how they can be cost-effective. The authors conducted a
thorough review of literature for 70 research papers from 2007 to 2018.
The results indicated that a handful of researchers had analysed the cost
factors in additive manufacturing. The 3D techniques aid in healthcare
systems and can assist in delivering customised healthcare facilities,
thereby improving our country’s health sector.
Tsai et al. [83] stated eHealth has huge potential in the healthcare
sector. The authors conducted a thorough review of 221 eHealth
research papers. The researchers have noted that there is a big need to
conduct in-depth studies for workflow and clinical processes. There is a
pressing need to improve the style of diagnosis, quality of services and
how the studies have highlighted care towards patients aided by tech­
nology. Kavandi and Jaana [84]; in this review, analysed the reviews of
studies conducted between December 2017 to February 2018. The
studies were chosen based on the HIT Adoption criterion. The reviews
were collected from databases like Web of Science, Scopus, Medline,
PubMed and CINAHL. A total of 41 studies were reviewed, and the
M. Rajak and K. Shaw
results showcased that senior citizens accept technologies as it is
perceived as useful, social influence, design and quality of the technol­
ogy. The authors suggested rigorous research so that other factors and
better healthcare facilities can be ensured. Alam et al. [23] studied the
factors behind the acceptance of mHealth services among generation Y
of Bangladesh. The study had a sample size of 296 respondents. The
study employed the extended Unified Theory of Acceptance and Use of
Technology (UTAUT) model. The data was statistically analysed using
Structural equation modelling (SEM) with a partial least squares
method. The results denoted that social influence, reliability and per­
formance expectancy were the factors behind acceptance of the mHealth
apps. The author pointed out that gender plays a significant role in the
adoption of technologies.
4. Inclusion of additional constructs in TAM
TAM is utilised in forecasting the behavioural pattern of the con­
sumers and is used in a varied range of domains. For instance, it is used
in the discipline of Library and Information Science (LIS) as well as
Education [85,86], sports [87], e-learning ([88], internet banking [89,
90], cloud computing [91], in operations management ( [92], and in the
adoption of Information Technology (IT) [93–95].
Moreover, the capacity of the Technology acceptance model (TAM)
is seen in the findings of Davis [39]; wherein he added that the theory
could be reformed by the addition of a few more variables as long as they
fit the research study. Liu et al. [45]; in their study to understand the
usage pattern of online learning, found that the model is very easily
predictable. On a similar note, Melas et al. [44] found the theory very
handy for their study on the information requirements among medical
staff. Taking the previous studies, this research has included Technology
Anxiety (TA), Social Influence (SI), Perceived Risk (PR), Trust (TR),
Resistance to change (RC), and Perceived Physical condition PPC) as
subsidiary variables for analysing the user’s intention in accepting
mHealth services.
This research has added TA as a significant component to compre­
hend the impact of technology anxiety. The previous studies have found
Technology Anxiety as a common variable. In a study by Williams [96];
the majority of American citizens were found to be technophobic.
Similarly, in Craig’s [97] study, it was found that one-third of the
college-going students [98] put up with technology-related anxiety. On
the other hand, Rosen and Maguire [99] found that a very minimal
percentage of the population suffers from severe technology anxiety.
Thus it is clear that technology anxiety is definitely a very crucial var­
iable in the study. [100]; Heinssen et al. [101] have classified technol­
ogy anxiety as a variable that influences the effectiveness of societal
computerization. Another variable, “Social Influence’’, has an impact on
mobile health (mHealth) adoption where the user perceives others
opinions on the adoption of the service. Mathieson [102]; Taylor and
Todd [103]; in their study, considered social influence as a significant
variable.
Limayem et al. [104]; Phau and Teah [105]; in their study, found out
that an individual’s family, friends and colleagues influence the
decision-making process as well as alter the behaviour. Kulviwat et al.
[106] mentioned that an individual is motivated to follow not just the
suggestions of the society but also follows the referent group’s norms. In
this context, as mHealth is a new technology and therefore, other’s ex­
periences will serve as a boon for the new user. Thus social influence is a
big factor that motivates new users to adopt the technology. The intent
to use new technology will increase manifold if there is an influence
from the society as well.
The third variable is Perceived Risk (PR), which includes the un­
certainty for the anticipated negative results after using the technology.
Bauer [107] has defined it as ‘‘a combination of uncertainty plus seri­
ousness of outcome involved’‘. It is measured utilising an
expectancy-value by the extent of the loss or the significance of the loss
or exposure.
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Technology in Society 67 (2021) 101800
Therefore, perceived risk is ‘‘the potential for loss in the pursuit of
the desired outcome of using a mHealth services’’. PR uses information
data like “(a) feelings of uncertainty, (b) discomfort [108], (c) conflict
aroused in the user [109], (d) concern, (e) psychological discomfort
[110], (f) making the consumer feel uncertain [111], and (g) cognitive
dissonance [112,234]”. The dissonance comes to light from the assess­
ment of the product, which has costs, risks, utility and benefits. In this
research study, the utility gains have increased the task performance,
and this increases the risks attached with it as well as the uncertainty
with the internet.
The fourth variable is Trust (TR). In this research, the Trust factor is
an added variable for checking the credibility of the users. Trust binds
social relationships [113] and therefore becomes a significant factor for
human communication [114]. Trust is also a pivotal element for any
business [115] for it to run smoothly. The existence of trust leads to a
business without any sort of issues [116]. [117] said that trust develops
over a period of time and with continuous interactions. Lippert [118]
said that trust is a measure for the healthy functioning of the individual,
organisation, group or culture. The object of trust can vary and be an
individual, object or any event [119]. Any organisation to carries out an
exchange of knowledge among its members through a certain amount of
trust [120].
The Fifth variable is Resistance to Change (RC) and is pivotal for a
diverse nation like India, where people from different communities are
situated in various parts of the country. This variable mentions that
sometimes people are unable to let go of their habits, ideas, beliefs and
the stress that they face adopting any new technology [121]. This is not a
major part of the TAM Theory, yet it finds a valuable place in several
research studies due to its relevance in the usage pattern of the users
[122]. Cheng et al. [123] said that Resistance to Change as a variable is
being studied and has been analysed in the medical discipline [121] and
organisational sciences [122].
The sixth variable is Perceived Physical condition (PPC), which
comprehends the adoption of innovation by the senior citizens and their
hesitance. Several research studies have considered chronological age as
a tool to analyse the adoption behaviour of old people. But it has been
found that chronological time has little significance in old age [124].
Mathur & Moschis [125]; Moschis [126] stated that ageing is a complex
and continuous process, and there arise gradual changes in the indi­
vidual. The changes have been identified into two
categories-bio-physical and psychosocial [126,127]. Biophysical
changes are the variations witnessed in the sensory and intellectual
functioning, reduced mobility as well as physical strength, etc. The
second one is psychosocial, wherein the individuals go through a mental
transformation and social transformation where others can understand
the change [126]. This gradual ageing undermines the elderly’s capacity
to adopt new changes both physically and cognitively [128]. The decline
in the functioning of the sensory and motor organs, more so due to the
usage of mobile phones, is prominent [129]. This indicates that elderly
people encounter more difficulties in using mobiles [128]. In this
research, perceived physical condition (PPC) implies the beliefs of an
individual’s physical difficulties of vision, hearing, and motion occur­
ring in everyday life. This can serve as internal controls or inhibiting
conditions that accelerate the anticipation to use an IS [130]. mHealth
needs visual and audio capacities and perception of the physical con­
dition, which facilitates an individual in engaging themselves in tech­
nology usage.
5. Theory and hypotheses
5.1. Technology anxiety (TA)
Technology anxiety can be defined as to “what extent an individual
feels problems while utilising a new technology” [72]; page no-900,
[131,132]. In the era of the 1960s and 1970s, a significant number of
studies were carried out to measure psychological reactions like anxiety
M. Rajak and K. Shaw
towards using computers through traditional measurement systems.
Technology anxiety can be measured through emotional factors such as
frustration, apprehension, fear [133], increased heart rate, and negative
thoughts [134–137]. It is a kind of negative response to using new
technology. Guo et al. [121] observed that technology anxiety often acts
as a hindrance in the way of using innovative technologies like newly
launched software or computer applications [138]. Various researchers
have observed that anxiety for using a computer has a negative effect on
PEOU and PU [40,139]. A similar type of study has also been conducted
for the teleconferencing system [140]. The finding of researchers was
similar to that of the application of the computer system. Technology
anxiety is also related to the age of the user. Technology anxiety
generally occurs when a person himself feels stressed from using the
application. Higher technology anxiety may lead to loss of performance.
Many researchers observed that older people suffer more from tech­
nology anxiety than the younger ones because they have the less tech­
nical knowledge and interest than youth [132,141]. Hence, the lack of
skills in new technology triggers frustration and stress. As a result, older
people are less interested in using innovative technology. The research
exponents have discovered a positive connection between the age of the
user and anxiety towards technology. Other researches related to older
people have anxiety due to technology generating huge hindrances for
the adoption of the new technology [142,143]. The anxiety of the user
often increases with the acceleration in the complex process of tech­
nology. The current study has harnessed the anxiety dimension from the
existing studies of computer-based anxiety. From the literature, the
following hypotheses can be conjectured.
H1a. Technology anxiety has a negative effect on PEOU towards using
mHealth services.
H1b. Technology anxiety has a negative effect on PU towards using
mHealth services.
5.2. Social influence (SI)
Social Influence is nothing but how the perception of a person is
affected by the liking and disliking of the surroundings [47,144]. Social
surroundings are crucial for understanding the importance of technol­
ogy in the day to day life. In spite of the importance, the factor has not
been well studied amalgamating in traditional TAM for measuring
mHealth technology acceptance.
Social influence from the perspective of mHealth can be con­
ceptualised as the level upon which the user or the patient understands
the importance of adopting mHealth services [145]. Various studies in
technology adoption have investigated that social influence affects the
decision towards adoption of the technology [42]. The influence of so­
ciety provides confidence to people for using technology, and it gives a
positive indication to adopt via perceived usefulness [146]. The ease and
comfortability in usage are dependent upon the user’s skill as well as the
technology; opinions from surrounding people may affect it. As inves­
tigated by Haaker et al. [147]; most people were using some services
after getting influenced by social circles. Attitude, perception, and
behaviour of a person are getting impacted by the information received
from the social network access. Social influence is an important factor
that shapes and alters the perception of an individual towards adopting
any technology. The future users may have a feeling that the adoption of
this service and technology does not require much effort if people
around them resonate with the ease in the usage [148,149]. The influ­
ence of social circles determines the behaviour towards adopting new
technology and has an indirect impact too.
We have expected that social influence would be especially very
crucial in our context. It may be conjectured that the user or patient can
adopt mHealth services very effortlessly under social influence. Social
influence is influencing positively to PEOU and PU [150,151]. Based on
all these, it is proposed:
6
Technology in Society 67 (2021) 101800
H2a. Social influence has a very positive impact on PEOU towards
using mHealth services.
H2b. Social influence has a very positive impact on PU towards using
mHealth services.
Social influence is directly linked with a person’s attitude towards
the usage of mHealth services, and it is based on personal innovation.
Personal innovativeness while using information technology is a quality
that reflects the users’ urge and interest to utilise the services of the new
technology [152]. Technology innovations create uncertainties
regarding the assumed outcomes, and the people who are not certain
about uncertainties can have an interaction with the social circle before
coming to a decision.
In general, the usage of innovative technology has been seen as
public consumption; it can be directly affected by the surrounding
people [42,153]. It has been found that the influence of society predicts
the behaviour and the intentions of inexperienced subjects [103]. Ven­
katesh & Davis [40] have expressed that “social influence has a crucial
impact upon the behavioural intention”. “Social influence is influencing
positive attitude and behavioural intention in various studies” [42,72,
154]. On the basis of the discussion, the following hypothesis has been
formulated that:
H2c. Social influence creates a very positive impact on the attitude of a
person for using mHealth services.
H2d. Social influence has a very positive effect on BI towards using
mHealth services.
5.3. Perceived risk (PR)
The perceived risk concept was introduced by researcher Bauer in
the year 1960. The author conceptualised the risk from the perspective
of uncertainty and consequences related to the end user’s actions. The
construct is useful for the adoption of any new element. Hence, it can be
applicable for mHealth application selection also. Consumer re­
searchers’ noted perceived risk as the uncertainty linked with purchas­
ing a new product [155]. Perceived risk is an outcome of various
uncertainties related to using information technology. It was reported in
various studies that people are concerned about different types of risks
associated with online activities [156]. When users are uncertain about
online services, they are more worried about the usefulness of technol­
ogy or problems associated with it [157]. The definition of perceived
risk has been found to be changing over a period of time. Various
scholars have suggested different definitions in the literature from
different perspectives. Earlier perceived risk was often perceived from
the context of fraud and product quality. Many studies on perceived risk
suggested different dimensions of risk [158–161]. In literature, the risk
is measured as a “multi-dimensional construct”. For consumer behav­
iour, the risk is quantified through the negative experiences of users in
uncertain conditions [162,163]. Perceived risk was broadly categorised
into two dimensions, such as performance and psychological [155].
Cunningham [155] further dissected the performance risk into three
segregations such as “economic, temporal, effort, and divided psycho­
social risk into two categories such as psychological and social”. In
consumer behaviour, risk has been identified as a “perceived possibility
of experiencing negative outcomes or losses in uncertain situations” (
Page no-184, [164,165]. The risk pertaining to using mHealth services
can be quantified, keeping the inherent level of uncertainty and
perceived level of the users in mind [16]. Users are also found not in
favour of using mHealth services if the requirement of time is high for
applying the technology [16]. The information technology adoption by
the users was found to be influenced by the risk of performance, privacy
and psychological risk [166–168]. Perceived risk was found as an
important determinant towards accepting mHealth services [169]. Since
intention to use mHealth services is uncertain; therefore, perceived risk
can be conjectured as the antecedent for the behavioural intention for
M. Rajak and K. Shaw
the utilisation of the service. Consequently, the following hypothesis has
been formulated:
H3. Perceived risk causes a negative effect on behavioural intention
towards using mHealth Services.
5.4. Trust (TR)
In literature, Rousseau et al. [170] has stated trust as “a psycholog­
ical state comprising the intention to accept vulnerability based upon
positive expectations or behaviour from others” (page no-395, [170].
Vulnerability is an essential factor of trust because trust always “exists in
uncertain environments” [171,172]. Trust construct has been used in
many situations to solve issues pertaining to uncertainty as well as risk
[173]. Trust allows a user to participate in risky activities which are not
controllable [174]. Trust is a mechanism to reduce the risk of losses by
keeping a person mentally strong with a high power of positive thinking.
Trust can be classified as knowledge-based, personality-based,
cognition-based, and Institution-based.
As per Luhmann [175]; trust can be developed on the basis of fa­
miliarity of behaviour among different parties. This phenomenon is
known as knowledge-based trust. It reduces the risk of social uncertainty
due to the improvement in manual understanding. The trust developed
from the first impression is known as Cognition-based trust. According
to Brewer and Silver [176]; cognitive-based trust is defined as individual
beliefs about reliability, dependability, and competence. The trust-based
on profit is known as calculative-based trust. This type of trust is
developed by giving profits to the stakeholders. Institution-based trust
can be measured through the guarantee and safety offered by an orga­
nisation. In addition, personality-based trust can be measured through
the belief of others whether to trust or not.
In mHealth, the construct trust may be useful in explaining the traits
of the patients and users who use the mHealth technology for buying
medicine or seeking health information [177,178]. Previous studies
have observed trust as “a multi-factor element consisting of competence,
integrity, and benevolence” [179,180]. Benevolence is defined as the
level to which mHealth service providers’ are concerned about the ad­
vantages of their users’. Also, competence is defined as the degree to
which mHealth service providers offer the best service. Whereas integ­
rity is the level to which a mHealth service provider can keep his
promise honestly [172].
The trust factor was used by various researchers to assess the tech­
nology adoption [181]. Various empirical studies have shown that users
are generally hesitant to use mHealth services due to being non-familiar
with the mHealth applications and unwilling to share personal infor­
mation [172]. Hence, Trust plays a significant role in accepting the
mHealth services [182]. Various studies have depicted a positive
connection between trust and PU and PEOU [183–186]. As mHealth
service is one of the new technologies, acceptance entails the trust fac­
tors. Nowadays, trust may act as a catalyst for adopting mHealth services
[163,184]. The trust in mHealth applications also depended on the
availability of the internet and the efficacy of software [186,187]. The
adoption of mHealth services by users and patients is subjected to
various uncertainties [188], which may be bridged by the trust over the
applications [163,186]. The uncertainties regarding the adoption of
mHealth vary greatly between healthcare professionals and the common
population [16,189].
H4a. Trust will have a positive effect on the Perceived Ease of Use
(PEOU) of using mHealth services.
H4b. There is a positive effect of trust on PU of using mHealth services.
5.5. Resistance to change (RC)
According to continuity theory, persons often try to maintain their
older activities [190]. This particular phenomenon is applicable for
7
Technology in Society 67 (2021) 101800
maintaining one’s lifestyle and habits. The aversion to change is a
crucial aspect for the acquiring of mHealth services [191]. As of now,
health services are generally delivered through visiting hospitals. There
are significant numbers of people who feel comfortable in taking face to
face consultations by visiting the health centre. As mHealth is a novel
concept with regard to India; hence, it is very imperative to incorporate
this factor in the model. Deng et al. [72]; in their research on mHealth
adoption with respect to China taking Resistance to change as one of the
important constructs. The factor has significance in the Indian context as
a paradigm shift of delivering health care services is slowly happening
across the country. Nowadays, health services can also be accessed
through mobile phones. For example, Jeeva Ayurveda is currently
operating health services through telephones.
Resistance to change for mHealth technology can be classified into
two segments like patients and medical service providers. The imple­
mentation of mHealth is not possible with Resistance to change of either
party. Deng et al. [72] observed a “negative relationship between
resistance to change and behavioural intention in the context of China”.
Few more studies also have found Resistance to change as a major
hindrance for the adoption of mHealth services [121,191,192]; Nov and
Ye, 2008; [193].
H5. Resistance to change is negatively associated with behavioural
intention to use mHealth services.
5.6. Perceived physical condition (PPC)
Ageing is considered to be quite a complex process, which cannot be
explained by normal psychological theory [125,126]. Ageing may be
transpired and related to the changes of biophysical and psychosocial
conditions. These conditions of human beings are changing with
increasing age [126,127]. Biophysical condition is related to the
changes in the organ’s sensory and intellectual function, decreased
mobility, and physical strength, whereas; psychosocial change alludes to
the transformation of mentality.
The changing of biological and psychosocial significantly affects the
cognitive and physical capabilities of elders, such as vision, hearing and
mentality. As a result, older people face more difficulty in using a
computer or recent mobile-based applications [128]. This can be used as
internal controls or as inhibiting conditions that increase their likeli­
hood of using an IS. As the application of mHealth services necessitates
strong audio and visual capabilities as well as an active participant, the
perception of the physical condition might also affect participation
intention [81]. Further, some studies state that elderly people are
traditionally thought to be hesitant to change, yet they may adopt new
technological applications if they believe they are appropriate and
simple to use [194]. This research argues that perceived physical con­
dition is a significant factor for mHealth technology adoption. Unfor­
tunately, very few studies have been carried out addressing perceived
physical condition in the context of India. In the literature, it was found
that perceived physical condition can decrease the intention of adopting
new technology [128]. Xue et al. [194] incorporated the perceived
physical condition construct in the study of mobile health informatics
with reference to Singapore. Ryu et al. [81] have used perceived phys­
ical condition in their study and found that perceived physical condition
has a direct negative effect on the intention to participate. The authors
found that PPC does not have a direct connection with the actual mobile
technology adoption. By critically analysing the literature, the hypoth­
esis formulated is as follows: .
H6. Perceived physical condition negatively related to behavioural
intention towards using mHealth services.
5.7. Perceived usefulness (PU)
“Perceived usefulness” (PU) is a major driver of any technology
adoption [195,196]. In the actual TAM, technology acceptance is
M. Rajak and K. Shaw
governed by perceived usefulness and attitude. It was found that PEOU
affects the PU of technology positively [52]. It is defined as “the degree
to which a person believes that using a particular system would improve
his or her job performance” (page no-985, [13]. Various researchers
have used the “perceived usefulness” factor for adopting various tech­
nologies. A few examples are e-ticketing [197]; mobile learning [198].
With reference to mHealth, it portrays how a user or healthcare pro­
fessional perceives the technology on their own [16,189,199]. The study
pointed out the positive influence of “Perceived usefulness” amongst the
attitude of users toward using actual technology [14,16,42,43]. In a
recent study Hoque [200] emphasised incorporating the perceived
usefulness factor for mHealth technology adoption. The hypotheses
proposed are as follows:
H7. Perceived usefulness (PU) is influencing positively on attitudes
toward using mHealth services.
5.8. Perceived ease of use (PEOU)
This research study defines “perceived ease of use as the degree to
which a user or a patient believes that using mHealth services requires a
minimum degree of effort”. In the earlier studies, a positive relationship
between the “perceived ease of use” and attitude towards using infor­
mation technology was found [201]. Similarly, “perceived ease of use
also positively influenced the perceived usefulness” [42,43,202]. The
relationship amongst “perceived ease of use” of the technology and
“behavioural intention” of the user is depended on various factors such
as the experience of the user with the system, mental characteristics, and
kind of work to be done with the help of technology (; [16,189,195,
202–205]. Earlier studies have shown that PEOU has a crucial role in
understanding and making predictions on the attitude and behaviour of
the users utilising digital resources [46,189,206].
In a nutshell, various empirical evidence exists between “perceived
usefulness” and “perceived ease of use” [15,17,45,207] and attitude
toward using information technology and between “perceived ease of
use” and “perceived usefulness” [102,195,208,209] of the system.
Especially to adopt mHealth services suggests that “perceived ease of
use” is significantly related to “perceived usefulness” and users’ attitude
toward using mHealth services.
H8a. Perceived ease of use (PEOU) is influencing attitudes positively
toward the use of mHealth services.
H8b. Perceived ease of use (PEOU) is influencing positively towards
Perceived usefulness (PU) for the use of mHealth services.
5.9. Attitude
Attitude is the positive as well as negative emotions connected with a
particular behaviour [210]. Tung et al. [15] viewed attitude as a
perceived behaviour control. The authors hypothesised that a high de­
gree of perceived behavioural control could lead to “behavioural
intention and actual use of a technology” [15]. The theory of reasoned
action (TRA) explained that the engagement of an individual person in a
particular matter could be related to subjective norms and attitudes
[211]. Attitude is a feeling of doing a specific job [211]. The effect of
attitude towards behavioural intention is a noteworthy aspect of the
TRA and the theory of planned behaviour [211,212]. Therefore, the
original TAM has included a positive direct linkage between attitude and
behavioural intention [13]. The connection between attitude behav­
ioural oral intention means that users are interested in utilising infor­
mation technology when they regard it in a positive way [13]. The link
between the attitude as well as behavioural intention is significant with
the time period. Furthermore, more empirical studies proved that atti­
tude towards using information technology mediates between salient
beliefs and behavioural Intention [213]. Previous studies also proved
the support between attitude and behavioural intention [189,214].
8
Technology in Society 67 (2021) 101800
Hence, positive attitudes should be nurtured for ensuring user adoption
of mHealth services.
H9. Attitude will have a direct positive effect on Behavioural Intention
to use mHealth services.
5.10. Behavioural intention
Behavioural intention refers to motivating aspects that affect a
certain activity, where the stronger the intention to conduct the
behaviour, the more likely it will be performed. Ajzen and Fishbein [38]
define behavioural intention as the agent’s subjective likelihood of
performing the behaviour. This concept initially emerged from the
Theory of Planned Behavior (TPB). According to the TPB, behavioural
intentions are determined by attitude toward the behaviour, subjective
norm for the behaviour, and perceived behavioural control. A favour­
able attitude and a supporting subjective norm give the motivation to
engage in the activity in the current formulation of the theory, but a
concrete intention to do so is generated only when perceived control
over the conduct is sufficiently strong [215]. The concept of behavioural
intention has been utilised in a variety of contexts with varied in­
terpretations. TAM also uses behavioural intention to measure the de­
gree of intention to adopt emerging technologies. In the present study,
Behavioural intention to adopt mHealth services has been con­
ceptualised as the outcome of attitude, social influence, perceived risk,
resistance to change and perceived physical conditions.
6. Research methodology
This research study was intended for investigating the in­
terrelationships among the various mHealth adoption factors. This study
has modified the traditional TAM incorporating different factors.
mHealth adoption in the context of India has been explored infre­
quently. To fill the gaps of the existing research, this study intends to
carry out a primary survey across India.
6.1. Questionnaire development
This research intends to modify the TAM to explore the adoption
intention of mHealth by Indian users. The traditional TAM has been
modified by amalgamating other factors like social influence, technol­
ogy anxiety, and perceived physical condition. The construct of
“perceived usefulness” and “perceived ease of use has been measured by
items suggested by Deng [80]. The construct of technology anxiety,
social influence, behavioural intention and attitude will be measured by
items suggested by Deng et al. [72]. Perceived physical condition,
Resistance to change, trust, and perceived risk constructs have been
measured by Hoque and Sorwar [69]; Egle et al. [216]; respectively.
During survey instrument development, the standard items are modified
in terms of mHealth. For example, the normal technology term has been
replaced by mHealth. A questionnaire, attached herewith appendix I,
was developed by adopting the standard constructs from existing liter­
ature. The standard construct often helps to make the study more
credible. As the constructs were developed in different contexts by
different researchers, therefore, it was very imperative to carry out a
factor analysis over the identified factors to find out the suitability of the
factors in the Indian context.
Apart from the construct, the survey also intended to collect data of
demographic details. For the survey instrument, the construct validity of
the questionnaire has been checked. After developing the questionnaire,
it has been pilot tested, taking respondents from academic experts,
medical experts, and PhD students. The intention of the pretesting of the
question is to remove the ambiguity before starting the final survey. A
total of 40 questionnaires were circulated for pilot testing. After con­
ducting the pilot testing, a few items rephrased and were dropped from
the questionnaire. The questions were developed to reduce general
M. Rajak and K. Shaw Technology in Society 67 (2021) 101800

biasness. For the questionnaire, a five-point Likert scale varying between Table 1
“strongly disagree” to “strongly agree” was adopted. Description of the sample (N = 289).
Demographic Profile of Respondents
6.2. Identification of respondents
Items Category Statistic Items Category Statistic
(%) (%)
Before conducting the primary survey, it was very important to
Gender Male 55.02 Occupation Student 53.98
determine the respondents of the survey. The respondents of this Female 44.98 Housewife 15.92
research work were selected on the grounds of the usage of android/ Personal 08.99
smartphone devices and having facilitated internet service in their business
phones. Further, the respondents were segregated based on their expe­ Public 07.96
Organisation
rience of using mHealth services. For example, a person who used to
Private 09.34
search health-related information and medical practitioners who often Organisation
use the mobile phone for medical data interchange. In addition, the age Others 03.81
of the respondents was given significant importance while choosing Age 18–28 52.25 Education Intermediate 9.00
respondents. The current study considered the respondent whose age level
was more than or equal to 18 years because below 18 years old children 29–39 24.22 Graduation level 34.95
are treated as minors in India, and mobile phones are not allowed to 40–50 14.88 Post-Graduation 39.79
level
them by their parents. The responses of the respondents more than 18
50+ 08.65 Others 16.26
years were considered stable as compared to responses of the minor
respondents. In addition, various medical practitioners are also consid­
ered as respondents of the study. The Kaiser-Meyer-Olkin Measure of Sampling 2 Adequacy (KMO)
was observed to check the proportion of variance in the variables. In this
6.3. Sampling frame design study, the KMO value was observed at 0.728, which is very close to 1.0.
The Bartlett test for sphericity was found significant for the sample (χ2
After deciding on the respondents, it was also important to choose = 3209.39; p < 0.000). This Bartlett Test implies the adequacy corre­
the proper sampling technique for the study. Choosing a proper sam­ lations among the variables. In this study, cross-loadings in a rotated
pling is important for reducing the requirement of resources and component matrix among variables were not observed. The total vari­
removing the biases from the study. The simple random technique is ance explained was 70.587%. Table 2 represents the factor loadings and
mostly preferred to collect the data. However, to implement the afore­
said sampling, it is also important to have an idea of the population Table 2
frame. However, a proper sampling frame is not available for such a Measurement items.
study. To avoid the problem, judgmental sampling was adopted in the
ITEM Factor loadings Cronbach’s Alpha
study.
RESISTANCE TO CHANGE 0.769
Resistance to Change 1 .754
6.4. Data collection Resistance to Change 2 .839
Resistance to Change 3 .870
For this research work, the data were collected across India using TECHNOLOGY ANXIETY 0.943
different instruments. The main challenge of conducting a survey is the Technology Anxiety 1 .950
Technology Anxiety 2 .945
response rate. To improve the response rate, three channels like e- Technology Anxiety 3 .930
questionnaire, a hard copy of the questionnaire and an in-person survey PERCEIVED USEFULNESS 0.740
were adopted. Since the online survey technique is often found to be Perceived Usefulness 1 .675
contributing a very low rate with regard to the developing country, the Perceived Usefulness 2 .837
Perceived Usefulness 3 .837
present research adopted in-person questionnaire surveys to maximise
SOCIAL INFLUENCE 0.763
the response rate. Total 1050 questions were circulated among the Social Influence 1 .767
possible respondents. Subsequently, only 317 questionnaires were Social Influence 2 .811
received, out of which 28 were rejected because of missing data. As a Social Influence 3 .819
result, 289 questionnaires were considered for further processing. The PERCEIVED PHYSICAL CONDITION 0.688
Perceived Physical Condition 1 .780
demographic details of the sample are depicted in Table 1. Perceived Physical Condition 2 .780
Initially, the collected data were screened to fulfil the norms of Perceived Physical Condition 3 .743
normality and outliers. For normality of the data, skewness and kurtosis TRUST 0.711
index measures were used. All the values of skewness and kurtosis for all Trust 1 .736
Trust 2 .780
constructs comes between three and ten, respectively. Therefore, the
Trust 3 .773
distribution of data according to the recommendation of Kline [217] can ATTITUDE 0.829
be considered to be normal. Attitude 1 .852
Attitude 2 .776
6.5. Assessment of measurement model Attitude 3 .853
PERCEIVED RISK 0.622
Perceived Risk 1 .693
Here, the constructs of modified TAM have been taken from the Perceived Risk 2 .743
literature. To validate the scale, it is imperative to carry out a factor Perceived Risk 3 .752
analysis on the identified factors. The present study adopted the SPSS BEHAVIOURAL INTENTION 0.766
Behavioural Intention 1 .793
21.0 software package for performing exploratory factor 2 analysis
Behavioural Intention 2 .829
(EFA). The principal component extraction method and varimax factor Behavioural Intention 3 .816
rotations were adopted for the EFA considering minimum factor loading PERCEIVED EASE OF USE 0.792
of 0.5. The minimum value of 0.5 has been taken in various studies for Perceived Ease Of Use 1 .847
conducting EFA. A minimum value was taken to avoid cross-loading Perceived Ease Of Use 2 .771
Perceived Ease Of Use 3 .844
among the items.

9
M. Rajak and K. Shaw
Cronbach’s alpha of various items. Initially, 33 items were subjected to
EFA, out of which three items were dropped for making the scale suit­
able for the Indian context. After conducting the EFA, the confirmatory
factor analysis was performed to further confirm the suitability of the
scale. In CFA, the goodness-of-fit (GOF) can be calculated by taking fit
statistics like chi-square test, normed fit index (NFI), comparative fit
index (CFI), Root 1 Mean Squared 1 Residual (SRMR), and Root Mean
Square Error of Approximation (RMSEA). For good model fit, Hu and
Bentler [214] recommended that CFI and NFI values should be nearer to
0.90. Similarly, RMSEA and SRR values should be lower than 0.05 and
0.08, respectively [214].
Fig. 2 depicts the pictorial view of the CFA having ten factors and 30
Fig. 2. CFA of the proposed model.
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Technology in Society 67 (2021) 101800
items. The following results were obtained in the CFA analysis like χ2/
df = 1.11, CFI = 0.986, NFI = 0.88, RMSEA = 0.020, and SRMR = 0.06.
Thus, the CFA of the present study has confirmed the EFA of the study.
While performing CFA, discriminant and convergent validity should
be tested to establish construct validity and reliability of the instrument
[218]. Fornell and Larcker [219] recommended that for convergent
validity, Composite Reliability (CR) and Average Variance Extracted
(AVE) of every construct should be more than 0.7 and 0.5, respectively.
Similarly, for discriminant validity, MSV (maximum shared variance)
and ASV (Average shared variance) should, in a lesser number, be less
than AVE. Table 3 shows the good data fit for construct validity and
reliability in the present study.
M. Rajak and K. Shaw Technology in Society 67 (2021) 101800

Table 3
Convergent and discriminant validity.
CR AVE MSV ASV RC TA PU SI PPC TR ATT PR BI PEOU

RC 0.837 0.642 0.214 0.072 0.801

TA 0.924 0.754 0.356 0.159 0.191 0.868
PU 0.861 0.611 0.368 0.161 0.212 0.384 0.782
SI 0.864 0.681 0.368 0.162 0.166 0.357 0.607 0.825
PPC 0.904 0.761 0.356 0.122 0.105 0.597 0.310 0.332 0.873
TR 0.864 0.682 0.214 0.080 0.463 0.129 0.334 0.307 0.158 0.826
ATT 0.856 0.603 0.367 0.226 0.388 0.552 0.566 0.567 0.512 0.418 0.776
PR 0.857 0.669 0.232 0.092 0.286 0.482 0.240 0.227 0.297 0.283 0.353 0.818
BI 0.842 0.641 0.164 0.077 0.070 0.296 0.316 0.344 0.372 0.203 0.405 0.136 0.801
PEOU 0.779 0.543 0.367 0.170 0.155 0.517 0.492 0.555 0.348 0.174 0.606 0.420 0.306 0.737
MEAN 4.020 3.361 3.802 3.433 4.236 4.096 2.901 4.025 2.885 3.614
S.D. 0.905 1.226 0.960 0.760 0.739 0.656 0.955 0.709 0.823 0.865

Note: Diagonal value: square root of AVE and non-diagonal value: correlation.

6.6. Assessment of structural model

Table 4
Standardised path coefficients, path significances, and variance.
Structural Equation Modelling (SEM) observes the causal relation­
ships among latent constructs. Fig. 3 shows the pictorial view of the Estimate P Hypothesis
SEM. In this study, the relationships among the factors were tested H1a Technology → Perceived − 0.106 0.041 Accepted
simultaneously using structural equation modelling in SPSS 21.0 soft­ Anxiety Ease of Use
ware. The fit indices of the structural model are as follows: χ2/df = H1b Technology → Perceived − 0.149 0.042 Accepted
Anxiety Usefulness
1.301, NFI = 0.848, CFI = 0.959, RMSEA = 0.032, RMR = 0.052. All fit H2a Social → Behavioural 0.216 0.017 Accepted
indices indicated suitability with the data. Table 4 depicts the stand­ Influence Intention
ardised path coefficients, path significance, as well as variance, H2b Social → Perceived 0.355 *** Accepted
explained (R2) by each path, all sustained by the path analysis results, Influence Ease of Use
H2c Social Attitude 0.514 *** Accepted
except H1a, H1b, H3, H5, and H6. →
Influence
H2d Social → Perceived 0.191 0.046 Accepted
7. Discussion and conclusion Influence Usefulness
H3 Perceived Risk → Behavioural − 0.151 0.042 Accepted
As per the results, TA is negatively influencing the PEOU (β = Intention
H4a Trust → Perceived 0.264 0.016 Accepted
− 0.106, p < 0.05) and PU (β = − 0.149, p < 0.05), respectively. The Ease of Use
outcome corroborates the findings of Park et al. [220]; Gelbrich and H4b Trust → Perceived 0.374 0.002 Accepted
Sattler [221]; and Yang and Forney [141]; which were reported in Usefulness
different contexts. In developing countries like India, technology anxiety H5 Resistance to → Behavioural − 0.121 0.003 Accepted
Change Intention
is often found high, which can trigger a lack of use of mHealth services.
H6 Perceived → Behavioural − 0.119 0.002 Accepted
Lack of technical knowledge may be a reason for higher anxiety and low Physical Intention
PEOU and PU. Sometimes privacy of the data may be a reason for Condition
technology anxiety. The mHealth user often feels that there is a possi­ H7 Perceived → Attitude 0.261 0.001 Accepted
bility of data leaking, which may affect the social status of the users. The Usefulness
H8a Perceived Ease → Attitude 0.258 0.004 Accepted
hypotheses H1a and H1b have been found to be significant. Further, SI is of Use
also found to be positively influencing the PU, PEOU, ATT and BI, H8b Perceived Ease → Perceived 0.210 0.015 Accepted
leading to the acceptance of H2a, H2b, H2c, H2d hypotheses, respec­ of Use Usefulness
tively. SI seems to be comparatively influencing more on ATT (β = H9 Attitude → Behavioural 0.223 0.002 Accepted
Intention

0.514, p < 0.05), followed by PEOU (β = 0.355, p < 0.05), BI (β = 0.216,

p < 0.05) and PU (β = 0.191, p < 0.05), respectively, in terms of using
mHealth services. The total aggregate of this study validates the findings
of Mun et al. [150]; Cheung and Vogel [151]; Sun and Zhang [154] and
López-Nicolás et al. [42]. In a developing country like India where
people prefer to live in a joint family and often get influenced by their
friends and social settings. Social influence acts as a referral medium to
penetrate a new technology. In the current study, PR, RC, and PPC were
found to be negatively influencing the BI, which led to the acceptance of
H3, H5, and H6. The results corroborate the findings of Safeena et al.
[222]; Martins et al. [159]; Featherman et al. [223]; Oreg [224]; Xue
et al. [194]; Ryu et al. [81]; and Deng [80]. Establishing the primary
belief, this research has indicated a negative relationship between
perceived risk and behavioural intention. It can be perceived that the
risk-averse users don’t want to use mHealth applications in place of
regular medical visits. In addition, the results also established that
people often don’t want to change their habits. Additionally, the result
also showed that a decrease in PPC has increased the intention to adopt
Fig. 3. Pictorial view of SEM model.

11
M. Rajak and K. Shaw
mHealth technology. For example, young people have greater com­
fortability in adopting new technology when a comparison is made with
old people. Moreover, TR was found to be positively influencing PEOU
and PU, which led to the acceptance of H4a and H4b. The study validates
the findings of Cho et al. [225]; Wu and Chen [17]. Further, PU was
found to be influencing the ATT (β = 0.261, p < 0.005) toward using
mHealth services. The results are in tune with the findings of AlSoufi and
Ali [226]; Succi and Walter [227]. Likewise, PEOU also positively im­
pacts the ATT (β = 0.258, p < 0.05) and PU (β = 0.210, p < 0.05). The
results corroborate the findings of AlSoufi and Ali [226]; Succi and
Walter [227]. The result manifested that ATT has a positive reverbera­
tion upon the BI towards acquiring the habit of using mHealth services.
Based on the results, hypotheses H7, H8a, H8b, and H9 can be accepted.
The findings are similar to Hsu and Chang [228]; Hsiao and Tang [229].
This study has attempted to extend the existing TAM for the adoption
of mHealth in the Indian context. In the basic TAM, five constructs such
as Perceived Ease of Use, Perceived Usefulness, Attitude, Behavioural
Intention and Actual Use are suggested. For assessing the users’ inten­
tion to adopt mHealth services, the current research work has consid­
ered another six additional variables as Technology Anxiety (TA), Social
Influence (SI), Perceived Risk (PR), Trust (TR), Resistance to Change
(RC), and Perceived Physical Condition (PPC) in the existing TAM.
For this research work, social influence has been found to be influ­
encing the Perceived Usefulness (PU), Attitude (ATT), Perceived Ease of
Use (PEOU), and Behavioural Intention (BI). In this research, it is
evident that society often plays a crucial role in convincing a user to­
wards adopting mHealth services. In a community-based structure,
people are getting influenced by their friends, relatives to adopt new
technology. People get updates about new technology from social
gatherings, and lack of knowledge about new technology may be
considered as backwardness in society. The respondents also felt that
due to this social influence, they developed a positive attitude for using
the services. The results corroborate the finding of Manda and Msosa
[230].
In India, increasing technology anxiety has significantly reduced the
“perceived usefulness” (PU) and “perceived ease of use” (PEOU). This
manifests that the respondents feel worried and less comfortable while
using mHealth services. Technology anxiety may be an outcome of a lack
of knowledge about the technology and the chance of leaking private
data. Users are more likely to adopt new technology with confidence
when their skill level or knowledge appears stable and mature. This
property may frequently obstruct the spread of mHealth services. As a
result, the current study found that recognising some technological,
organisational, and individual characteristics is critical in increasing the
behavioural intention of users to use mHealth services.
In the Indian context, trust showed a positive impact on the
“perceived usefulness” (PU) and “perceived ease of use” (PEOU). This
implies that the respondents’ are getting convinced by the benefits and
various functionalities provided by the mHealth services, which make
them confident of using the system.
In the current study, perceived risk (PR), resistance to change (RC),
and perceived physical condition (PPC) negatively impact behavioural
Intention (BI). The negative impact of PR on BI implies that there is a risk
of loss or misuse of users’ data deposited in the mHealth services, which
restricts the users from using such applications. There is a possibility of
hacking the data and misuse of personal information. Similarly, the
negative impact of RC on BI implies that the respondents are interested
in continuing the old practice of visiting health centres to avail of
medical facilities. The Resistance to change may happen due to the lack
of information about new technology and fear of using that. Lack of
knowledge about the basic internet can also trigger Resistance to
change. As mHealth is relatively a new technology, respondents were
not highly convinced about the efficacy of mHealth as compared to
traditional systems. In our study, old people often put high Resistance to
change as compared to young people.
Likewise, the negative impact of PPC on BI implies that as the users/
12
Technology in Society 67 (2021) 101800
patients grow old, their physical conditions gradually deteriorate, which
further affect their behavioural intention for adopting the mHealth
services. In other words, the changing of biological and psychological
state due to ageing affects cognitive and physical capabilities such as
vision, hearing, and mentality. As a result, aged people find difficulty in
using a computer or mobile-based applications. Thus it can be said that
the higher the PPC, the lower will be the behavioural intentions to adopt
new technology.
Previous studies on information technology acceptance in general
and mHealth services, in particular, has been focused on the general
components of TAM. This research considered the roles of system ser­
vices and personal traits in innovation acceptance. This is because
mHealth with wireless features is an emerging technology for users in
terms of high uncertainty in system services, great change of their work
styles, and real belief of its usefulness. These considerations are partic­
ularly important for the context of mHealth services. The authors have
approached this from a broader perspective in terms of considering
various perspectives, including the attributes of organizations, in­
dividuals, technology, system services, and psychological states. The
empirical findings have been confirmed to have higher predictive power
compared to previous studies. This will provide a new way of thinking
for theoretically defining the antecedents of behavioural intention to use
in the context of mHealth services.
8. Implications for the academic
This study has attempted to measure the adoption of mHealth by
Indian users. To fulfil the research objective, TAM has been used as a
foundation. The model has been stretched to incorporate factors like
Technology Anxiety (TA), Social Influence (SI), Perceived Risk (PR),
Trust (TR), Resistance to Change (RC), and Perceived Physical Condition
(PPC). The incorporation of these factors and followed by testing the
model in the Indian context has not been reported in the literature. From
the literature, it is clear that a considerable number of studies have been
conducted on e-Health. But mHealth is slightly different from e-Health
as this system ensures mobility and more flexibility as compared to e-
Health. The findings of our study have been compared with the findings
of similar studies conducted in different contexts. Our proposed model
can undergo tests in the study of developing countries. The model is
relatively different from recently published studies.
9. Implications for policymakers
In the digitisation era, technology has become an essential tool for
human beings. The huge networks can be used to provide healthcare
facilities to human beings [231]. The mHealth application can act as a
preliminary disease prevention medium, which can help the government
to save a huge amount of money on public health. Through this tech­
nology, the disease may be identified in the early stages. Through the
mHealth applications, a patient can be directly linked with the doctor
and get quality medical advice in a cost-effective manner. In India, tel­
ehealth services are operational at various places. Few examples are
global, Apollo telehealth and Jeeva clinics. However, a mobile-based
system ensures more flexibility in the system and disease can be moni­
tored on a real-time basis. Successful implementation will help the
government to reach remote locations in a cost-effective manner. In
developing countries where health budgets are limited, mHealth may
emerge as a future technology. Like other studies, this study also suffers
from a few limitations. In this study, judgmental sampling was adopted
to collect the data. Hence, there may be some bias in the response of the
respondents. In this study, a significant amount of respondents were
students who were comparatively using more technology than others.
Hence generalising the findings requires more data and more
experiments.
M. Rajak and K. Shaw Technology in Society 67 (2021) 101800

10. Future scope and limitations
Further, future research may be based on this foundation; 1st, while
the respondents of the present study have been identified by a new user
of technology, behaviour intention may vary in terms of user levels of
experience. 2nd, the present study develops a theoretical framework and
further validates with survey data. Further studies can be redesigned
with case studies to longitudinally observe the usefulness of this
research framework in practice. Furthermore, while mHealth in this
study is still in its early use, the authors’ focus is on exploring the
purpose of its use and type of tools from a more general perspective.
Finally, as the present study has produced some interesting results, a
number of limitations may be inherent in it. A number of studies have
reported that gender differences play a moderating role in the rela­
tionship between attitude, social influence and behavioural intention.
The present study showed that approximately 55.02% and 44.98% of
the respondents were male and female, respectively. The findings may
not appropriately reflect the population distribution of gander and cause
a bias against the current findings. However, no systematic non-response
bias was reported among the sample respondents in gender regards.

Appendix I

Items (Source) Abbreviation

Perceived Usefulness [80] PU

Using mobile health service would enhance my effectiveness in health PU1
I would find mobile health service useful in the healthcare practice PU2
I think mobile health services are useful for my job PU3
Perceived Ease of Use [80] PEOU
Learning to use mobile health service would be easy for me PEOU1
It would be easy for me to become skillful at using mobile health service PEOU2
Interacting with the mobile health system would not require a lot of my mental effort. PEOU3
Technology Anxiety [72] TA
Using mobile health services would make me very nervous. TA1
Using mobile health services make me worried TA2
Using mobile health services may make me feel uncomfortable. TA3
Social Influence [72] SI
If I use mobile health service, I can provide better health information to my friends and family SI1
People around me think it is a good idea for me to use mobile health services. SI2
People around me have encouraged me to use mobile health services. SI3
Behavioural Intention [72] BI
I have a high intention to use mobile health services. BI1
I plan to use mobile health services to manage my health. BI2
I have the resources, knowledge, and ability to use Mobile health service. BI3
Attitude [72] ATT
Using mobile health services is a good idea. ATT1
Using mobile health services will promote me to manage health more actively. ATT2
I like the idea of using mobile health services. ATT3
Perceived Physical Condition [81] PPC
Using mobile health services would require me to exert more effort to perform usual daily activities. PPC1
Using mobile health services would limit the kind of activities I can perform. PPC2
Using mobile health services would cause me to have difficulty in performing daily activities. PPC3
Resistance to Change [69] RC
I don’t want the mobile health services to change the way I deal with health-related problems. RC1
I don’t want the mobile health services to change the way I keep myself healthy. RC2
Overall, I don’t want the mobile health services to change the way I currently live. RC3
Trust [14] TR
I feel confident that I can rely on the benefits provided by the mobile health service. TR1
As I understand it, mobile health services provide very good functionalities. TR2
I believe that I can trust in the adequate functioning of the Mobile Health service. TR3
Perceived Risk [14] PR
Using the mobile health services would lead to a loss of privacy because the information handled could be used without my knowledge. PR1
Using the mobile health services would not fit in well with my personal values or self-image. PR2
Mobile health services may misuse the patient data. PR3

Credit author statement

Manindra Rajak: Writing – original draft, Data curation, Formal analysis, Methodology, Visualization, Software, Validation, Project administra­
tion, Visualization, Writing – review & editing, and Resources. Krishnendu Shaw: Conceptualization, Investigation, and Supervision.

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