Technological Forecasting & Social Change 167 (2021) 120688

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Technological Forecasting & Social Change

journal homepage: www.elsevier.com/locate/techfore

The role of trust in intention to use the IoT in eHealth: Application of the
modified UTAUT in a consumer context
Wissal Ben Arfi a, *, Imed Ben Nasr b, Galina Kondrateva c, Lubica Hikkerova d
a
Strategy and Innovation, EDC Paris Business School, Department of Entrepreneurship and Digital Transformation, CRE - Observatory and Research Center on
Entrepreneurship, France
b
Master of Science in, Digital Marketing and Collaborative Strategies, La Rochelle Business School, Excelia Group, France
c
Marketing, EDC Paris Business School, Department of Digital Marketing, CRE - Observatory and Research Center on Entrepreneurship, France
d
Management, IPAG Business School, France

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

Keywords: The Internet of Things (IoT) has emerged over the last few decades in many fields, and healthcare can signifi­
Internet of Things cantly benefit from the IoT. This study aims to examine factors influencing patients’ adoption of the IoT for
Healthcare eHealth. To reach this objective, a research framework was developed that applies the United Theory of
Risk
Acceptance and Use of Technology (UTAUT) model and includes the risk− trust relationship to predicting
Trust
intention to use IoT in the medical context. Partial Least Approach - Structural Equation Modeling was conducted
UTAUT
with a sample of 267 French users. The findings highlight the key role of the risk− trust relationship for IoT
adoption. An unexpected result indicates that performance expectancy has no impact on intention to use the IoT
for eHealth. The contributions of this study can enable developers, medical professionals, and marketers to
improve the design of connected devices, optimize patient communication, and target potential users more
accurately, respectively.

1. Introduction
Healthcare presents a large field for innovative technologies. The
implementation of new devices, processes, data analysis methods and
other developments have enabled innovative technologies, such as the
Internet of Things (IoT), to enable innovative services that are vital to
people’s lives. More specifically, IoT devices are becoming more
accessible and easier to use, including connected medical devices
(Caputo et al., 2018; Mital et al., 2018). The IoT concept was introduced
in 2005 (Yang et al., 2013), and refers to a system of interconnected
devices; it includes hardware, software, and networks. The system
consists of a sensing device, a routing and communicating device, and a
cloud-based application (Solima et al., 2016). Recent trends in IoT
research appear to be driven by broad applications and the need for
consolidation (Gubbi et al., 2013). The device networks can lead to
many smart and autonomous applications and services that can bring
significant personal, professional, and economic benefits (Brasseal,
2015). IoT is nowadays recognized as the technology which has un­
doubtedly engendered the most disruption and the most significant
opportunities (Burrus et al., 2013). Such technologies currently use the
Internet to exchange information, achieve smart identification, and
conduct IoT operations (Wang and Hsieh, 2018).
Furthermore, the main strength of the IoT is its large impact on
different aspects of people’s daily lives. The effects of the IoT on user
behaviors have recently become an area of significant research interest.
IoT devices can make decisions autonomously or disseminate informa­
tion to users so they can make optimal decisions (Castro et al., 2016;
Maksimović and Vujović, 2017). Researchers have studied several areas

Abbreviations: ATU, attitudes towards use; AVE, average variance extracted; BI, behavioral intention; EE, effort expectancy; EFA, exploratory factor analysis; FC,
facilitating conditions; HIT, health information technology; IoT, Internet of things; IoHT, Internet of Healthcare Things; IoMT, Internet of Medical Things; PLS-SEM,
partial least approach - structural equation modeling; PEOU, perceived ease of use; PT, perceived trust; PU, perceived usefulness; PE, performance expectancy; PHS,
personalized healthcare system; SI, social influence; SWH, smart wearable health devices; TAM, technology acceptance model; TPB, theory of planned behavior; TRA,
theory of reasoned action; UTAUT, unified theory of acceptance and use of technology.
This article belongs to the special section on Technological Innovations to Ensure Confidence in the Digital World.
* Corresponding author.
E-mail address: wbenarfi@edcparis.com (W.B. Arfi).

https://doi.org/10.1016/j.techfore.2021.120688
Received 3 April 2020; Received in revised form 17 February 2021; Accepted 19 February 2021
Available online 25 February 2021
0040-1625/© 2021 Elsevier Inc. All rights reserved.
W.B. Arfi et al.
in which IoT technologies can be applied, such as the smart industry,
transportation, logistics, healthcare, people’s everyday life, and smart
cities (Kim and Kim, 2016; Metallo et al., 2018; Papa et al., 2020).
Currently, healthcare has a clear opportunity to seize the potential
benefits of IoT technology. The global Internet of Things in healthcare
market was valued at $113.75 billion in 2019 and is expected to reach
$332.67 billion by 2027, registering a CAGR of 13.20% from 2020 to
2027.1
E-Health is one area in which the IoT can be applied with potential
relevant economic and social impact (Martínez-Caro et al., 2018).
E-health refers to healthcare services that use the Internet and includes
technologies such as connected devices, computers, mobile phones,
websites, and applications (Lepore et al., 2018; Pagliari et al., 2005).
E-Health has made healthcare systems more accessible from anywhere
and at any time, in line with the dynamic lifestyle of the 21st century.
Today, significant technological improvements in both hardware and
software have been developed for consistent, safe, effective, timely,
flexible, patient-centered, and power-efficient healthcare systems
(Bhattacharya et al., 2017; Gao and Bai, 2014; Martínez-Caro et al.,
2018). With the introduction of connected devices and smartphones,
various IoT-based technologies have helped to modify and advance
traditional healthcare systems to become smarter and more customized
(Farahani et al., 2018; Mital et al., 2018; Tuli et al., 2020). The
healthcare industry utilizes the IoT, such as through the Internet of
Healthcare Things (IoHT) or the Internet of Medical Things. Moreover,
this innovative technology can help ensure that patients are monitored.
For example, the IoHT was used during the COVID-19 pandemic to trace
infected people and to replace traditional medical consultation with
teleconsultation and remote patient treatment (Singh et al., 2020).
Researchers have increasingly focused on the IoT for e-Health. Most
of these studies have examined the adoption of connected objects by
people with disabilities or chronic diseases or on connected homes that
enable healthcare monitoring for older adults (Cimperman et al., 2016;
Deshkar et al., 2017; Farahani et al., 2018). Several studies have also
highlighted how IoT-based technologies can enable services in the
medical field, such as locating patients in large hospitals, monitoring
vital signs, and tracking staff and equipment (Jang et al., 2016; Kim and
Kim, 2016).
Furthermore, research on technology acceptance and use in health­
care has focused on widely applied theoretical frameworks. Notably,
Holden and Karsh (2010) compared the Technology Acceptance Model
(TAM) for Health Information Technology with other frameworks. The
Unified Theory of Acceptance and Use of Technology (UTAUT) has been
used to analyze analysis u-healthcare services (e.g., Jang et al., 2016)
and healthcare wearable devices (Wang et al., 2020), and the UTAUT2,
an extension of the UTAUT, explains the acceptance of medical telecabin
(e.g., Baudier et al., 2020) or wearable healthcare technology (e.g.,
Talukder et al., 2020). Although the central concept, behavioral inten­
tion (BI) or intention to use, remains essential in technology adoption
models as it explains decision-making processes and precedes actual
adoption, researchers are nevertheless always examining new aspects of
technology adoption. Trust, privacy, security concerns, regulation is­
sues, identification, and semantic interoperability have all been identi­
fied as significant factors related to IoT adoption in eHealth (AlHogail
and AlShahrani, 2018; Martínez-Caro et al., 2018; Williams and
McCauley, 2016).
The concept of trust in Information and Communication Technolo­
gies (ICT) studies is associated with e-commerce (Gefen et al., 2003; Luo
et al., 2020) or digital payments (Singh et al., 2020). For example, the
trust− risk relationship is involved when users disclose personal data,
such as their credit card information. With its origins in relationship
1
https://www.alliedmarketresearch.com/iothealthcaremarket#:~:text=The
%20global%20internet%20of%20things,13.20%25%20from%202020%20to%
202027
2
Technological Forecasting & Social Change 167 (2021) 120688
management (Sirdeshmukh et al., 2002; Vivek et al., 2012), this concept
has since been applied to explain the human− technology relationship
(Alaiad and Zhou, 2014). In the healthcare context, trust significantly
influences decision-making related to e-health service use (Nisha et al.,
2019; Zhao et al., 2018). Nord et al. (2019) highlighted the significance
of trust for the IoT in that interactions among different IoT elements (e.
g., among connected devices) are on one side and users’ trust in tech­
nology is on the other. In eHealth services, developing a climate of trust
is believed to be an essential task that can boost the success of tech­
nology implementation. However, although IoT adoption in the
healthcare sector has been recognized, several topics are still theoreti­
cally and empirically underexplored. Considering this gap, the current
study’s objective is to examine the role of the trust− risk relationship for
personal IoT use in the medical context. This objective leads to the
following question:
What is the role of trust− risk relationship in the intention to use IoT
by patients in the healthcare context?
The UTAUT model (Venkatesh et al., 2003), with an extension of the
trust− risk relationship, can help to answer this question. A
non-probability convenience sample was collected of 267 French pa­
tients, and the data were then processed using Partial Least Approach -
Structural Equation Modeling (PLS-SEM). This method was chosen for
three reasons: (1) for the possibility to analyze data of different sample
sizes, (2) to conduct subgroup analysis, and (3) to analyze complex
structural models with numerous constructs.
The remainder of this article first reviews the current literature on
(1) the IoT in a modern context, and how it is implemented in the
eHealth sector specifically, and (2) technology acceptance and adoption
theories with a focus on the UTAUT model. Following this, the research
model, together with hypotheses, are proposed. The research method­
ology is outlined in Section 3, and the results are presented in Section 4.
Section 5 includes a discussion of the findings. Finally, Section 6 con­
cludes the paper by providing the implications, limitations, and future
research directions.
2. Theoretical background
2.1. The Internet of Things
The IoT is a relatively new paradigm "that connects real-world ob­
jects to the Internet, allowing objects to collect, process and communi­
cate data without human intervention" (Pattar et al., 2018, p.2101).
Various IoT-based devices are changing the healthcare system and
human habits, driving a shift toward what is becoming known as the
Personalized Healthcare System (PHS). Furthermore, IoT objects can
potentially enable a reduction in overall health costs and enhance sus­
tainability with patient-centered practices, such as with the considerable
efforts researchers have made to develop "Smart Wearable Health De­
vices" (SWH; Chan et al., 2012). Thus, the concept of IoT has captured
the interest and curiosity of academics and practitioners alike, as IoT has
the potential to provide innovative services and applications (Lu et al.,
2018).
Several studies highlighted how the IoT impacts both businesses and
society (Li et al., 2015; Solima et al., 2016). It introduces new services
and business models in line with this challenge (Shin, 2014; Stankovic,
2014). More specifically, researchers have highlighted how IoT impli­
cations have emerged over the last two decades as a new topic in the
healthcare industry. Thus, the healthcare system has moved toward
becoming smarter and more personalized, as various wearable devices
and smartphones have been developed (Laplante and Laplante, 2016;
Zheng et al., 2013).
In the current study, we focused on the IoHT and considered all IoT-
based devices with multiple potential applications, from remote moni­
toring to medical device integration (Lu et al., 2018). There are several
IoT application domains in healthcare (Ahmadi et al., 2019; Yousuf and
Mir, 2019), such as home healthcare, mobile health (m-Health),
W.B. Arfi et al.
electronic health (e-Health), and hospital management (Akkaş et al.,
2020). Considering these domains, the IoHT can enable real-time patient
monitoring for collecting, transferring, and storing medical data.
Furthermore, the IoHT can use available connectivity protocols (e.g.,
Bluetooth, Wi-Fi) to facilitate information exchange and enable
healthcare professionals to transform the way they detect diseases and
innovate in patient care. For healthcare providers, collecting, classi­
fying, and comparing data from multiple devices appear to be crucial.
The IoHT can perform these classifications and analyses in real-time and
also help to generate reports. For patients, IoHT solutions and connected
medical devices enhance them to be more engaged in monitoring their
health and improve their customer experience.
For professionals, IoHT offers solutions for better management of
medicines, ensuring that they are correctly prescribed and that in­
structions are well understood. Moreover, IoHT devices have demon­
strated their efficiency in minimizing errors and saving time. In
addition, IoHT devices have proven their effectiveness in minimizing
errors and saving time. Furthermore, these devices can help hospital
staff, such as with monitoring patients and cutting unnecessary hospital
visits and stays (Yousuf and Mir, 2019).
Overall, the present literature review highlighted that research on
IoT adoption in healthcare is growing in two main ways: by investi­
gating new opportunities to improve conventional models, and
exploring new approaches based on consumer behavior, the human­
− technology relationship, and understanding consumers’ experience.
Researchers have also suggested a need for further studies on IoT
adoption to provide a better understanding of how it can be facilitated
and supported in a healthcare context.
However, despite the growing number of studies highlighting the
main determinants of IoT adoption for eHealth and the proliferation of
conceptual and empirical research in this field, several issues remain
unexplored (Zhao et al., 2018). Consistent with previous researchers
who highlighted these critical gaps (Arfi et al., 2021; Goad et al., 2020;
Nicolazzo et al., 2020), in the present study we considered privacy, data
protection, and trust to critical factors for facilitating end users’ expe­
riences with connected healthcare devices.
The IoT provides healthcare establishments with the possibility to
collect and treat large amounts of data (Younan et al., 2020). However, a
perceived lack of confidentiality can lead to patients being resistant to
disclosing personal information. To overcome this reluctance, connected
medical devices should enable the trustworthy storage and treatment of
data. Thus, trust and perceived risk (PR) of data misuse are essential for
understanding user behavior. Therefore, this study examined the impact
of the trust− risk relationship on IoT adoption to explain user-related
factors.
2.2. Technology acceptance and use theories
The first theories to explain technology adoption and acceptance
were the Theory of Reasoned Action (TRA), Theory of Planned Behavior
(TPB), and Diffusion of Innovations Theory. The notion of intention in
these theories explains technology acceptance and the notion of
behavior explains the actual usage of the given technology (Gücin and
Berk, 2015). The TRA regards attitudes and subjective norms as de­
terminants of behavior (Ajzen and Fishbein, 1977). In turn, the TPB
extends the TRA by adding the variable of perceived control (Ajzen,
1991). The Diffusion of Innovations Theory proposes features of in­
novations (Rogers, 2003). For the diffusion of medical innovation, there
are such features as social-normative pressures, medical expert knowl­
edge, network performance effects, professional autonomy or individ­
ualism, and scientific evidence (e.g., Borracci and Giorgi, 2018).
Nevertheless, one of the most used healthcare models is the TAM,
which was developed by Davis (1989). It is based on the concepts of
perceived usefulness (PU), perceived ease of use (PEOU), and attitudes
toward use (ATU) to explain and predict the adoption of technology
(Davis, 1989). For example, the TAM has been used to understand the
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Technological Forecasting & Social Change 167 (2021) 120688
acceptance of technology by medical staff (e.g., Egea and González,
2011; Pai and Huang, 2011), as well as patients’ use of different tech­
nologies, such as preventive intervention programs (e.g., mobile appli­
cations related to nutrition and weight management; Gücin and Berk,
2015), eHealthcare systems (Holden and Karsh, 2010), and wearable
technologies (Dutot et al., 2019; Karahoca et al., 2018). The most
frequent criticism of the TAM relates to its simplicity (Shachak et al.,
2019). The sequel model, the UTAUT (Venkatesh et al., 2003), has the
following advantages over other theories: (1) it was developed by
considering previously developed models (some of which are presented
above; Venkatesh et al., 2003); (2) the model tested in healthcare set­
tings explained 70% of the variance in BI and about 50% in actual use
(Cimperman et al., 2016; Duarte and Pinho, 2019; Holden and Karsh,
2010); and (3) it was adapted to measure the technology used in by
clinicians and hospitals (Bawack and Kamdjoug, 2018; Shiferaw and
Mehari, 2019) and consumers or patients (Cimperman et al., 2016;
Jewer, 2018; Wang et al., 2020). Regarding the advantages of UTAUT,
this model was considered for investigation of the IoT in healthcare
adoption for this study.
2.3. UTAUT framework in healthcare
The UTAUT has been used to explain the adoption of diverse tech­
nology in healthcare by both target audiences – professionals and con­
sumers. Table 1 presents an overview of the studies that used the UTAUT
theoretical frameworks to assess technology adoption in healthcare.
The UTAUT includes three variables that directly predict
BI—performance expectancy (PE), effort expectancy (EE), and social
influence (SI)—and one that has a direct relation to actual usa­
ge—facilitating conditions (FC). Age, gender, experience, and volun­
tariness moderate all relationships in the model (Venkatesh et al., 2003).
Some researchers have demonstrated a direct relationship between FC
and BI (e.g., Boontarig, 2016; Jewer, 2018) in the medical context;
however, this research has often focused on BI rather than actual usage
(e.g., de Veer et al., 2015; Kohnke et al., 2014; Wang et al., 2020). This
focus highlights the decision-making process; thus, investigating
different variables proposes the prediction of technology adoption.
Accordingly, this study aimed to analyze the factors that influence BI
rather than the actual usage of connected healthcare devices.
Except for variables of the initial UTAUT (PE, EE, SI, and FC), re­
searchers examined diverse additional factors affecting BI in healthcare.
All those factors can be conditionally divided into those that are related
to users’ (1) personal traits, (2) knowledge of technology, or (3)
disclosure of data.
Some variables consider users’ level of knowledge about or previous
experiences with technology. For example, medical equipment users are
often older adults; thus, anxiety, including computer anxiety and resis­
tance to change, can predict the acceptance of new devices (Cimperman
et al., 2016; Hoque and Sorwar, 2017). In some countries, digital literacy
(Hsu et al., 2013) or accessibility (Lee and Rho, 2013) can impact
healthcare technology use healthcare. These variables, along with many
others, are important for understanding users’ BI. Nevertheless, IoT
technology in healthcare is generally used with a high level of profes­
sional supervision, even if it is for personal use. Factors related more to
personal traits than the technology itself can explain users’ adoption of
an information system. A relevant and often-discussed factor is
self-efficacy, or computer self-efficacy (de Veer et al., 2015; Kohnke
et al., 2014; Shiferaw and Mehari, 2019). However, high FC can provide
the necessary support for technology acceptance; therefore, the concept
of self-efficacy might have a moderating effect (Kohnke et al., 2014).
Other researchers analyzed the impact of personal innovativeness
(Nisha et al., 2019) on BI, while Boontarig (2016) examined psycho­
logical traits as predictors of BI.
Finally, many authors have studied issues emerging due to the use of
digital technology in healthcare, which requires personal data to be
recorded. Regarding non-professional acceptance of technology in a
W.B. Arfi et al. Technological Forecasting & Social Change 167 (2021) 120688

Table 1
UTAUT in healthcare.
Authors Year Users (professionals for Extension variables/ Framework Technology Key findings/Validated relationships
the organizational use and variables
patients for the consumer
use)

Venkatesh, Morris, 2003 Professionals Original model Computer BI: predictors PE, EE, SI
Davis., & Davis Use behavior: predictor FC
The primary moderators of the model are
gender, age, experience, and voluntariness
of use.
Griebel, Sedlmayr, 2013 ALL target audiences UTAUT Literature review Personalized e-health UTAUT (performance expectancy, effort
Prokosch, services expectancy, social influence and facilitating
Criegee-Rieck, & conditions) researchers examined ten
Sedlmayr, additional factors affecting the BI: (1)
Anxiety, (2) trust, (3) attitude toward using
technology, (4) computer self-efficacy, (5)
perceived system quality, (6) search
strategy, (7) user’s condition, (8) health
specific knowledge, (9) Internet
dependency, and (10) satisfaction with
medical care. Demographics as moderators
like age, gender, or socioeconomic status
were relevant.
Lee & Rho 2013 Patients UTAUT: BI + communication, Telemedicine Two subgroups: the users and the non-users.
accessibility, intimacy, and service risk. Gender as a moderator.

Hsu, Lee, & Su 2013 Patients UTAUT + perceived security, information Privacy-enhanced BI is influenced by PE, SI, FC, and perceived
security literacy healthcare security. But no direct effect of EE and
information system information security literacy on the BI.
Alaiad, Zhou, & 2014 Patients and professionals UTAUT + perceived security Home healthcare only BI, no actual use.
Koru robots EE no direct effect but an indirect effect
through PE on BI
The negative effect of perceived security.
Among the four UTAUT factors, PE was the
most potent predicting factor.
Kohnke, Cole, & 2014 patients, clinicians, and UTAUT + Attitude, Anxiety, and Self- Telemedicine Relations confirmed. The relations with
Bush agency personnel Efficacy as Moderators e-Home Health Care actual use were not tested.
Telehealth equipment
Alaiad & Zhou 2014 Patients + professionals UTAUT + trust, privacy concerns, ethical Home healthcare The strongest predictor is SI. PE confirmed,
concerns, legal concerns robots but was not found to be the strongest
predictor, as shown in the original study of
Venkatesh et al.EE – no effect.
The finding on the effect of trust on BI is
confirmed. SI and privacy concerns also have
indirect effects on BI.
de Veer et al. 2015 Patients UTAUT: PE, EE, SI + self efficacy E-health (telecare) Correlations between BI, PE, EE, SI, and self-
efficacy were moderately strong. The
relations with actual use were not tested.

Cimperman, 2016 Patients UTAUT + Perceived Security, Home Telehealth The variables of the extended UTAUT are
Brenčič, & Computer Anxiety, Doctor’s Opinion Services confirmed except SI, namely: EE, PE and FC,
Trkman Influence and added Perceived Security, Computer
Anxiety and Doctors’ Opinion.
Jang, Kim, & Lee 2016 Professionals UTAUT: BI, SI, PE, EE + Connectivity, Ubiquitous healthcare Relationships were confirmed
compatibility, complexity, perceived
benefit, perceived trust to PE
Bozan, Parker,& 2016 Patients UTAUT: Social influence based on Electronic health Institutional theory: understanding of social
Davey institutional theory: and includes records (EHR), factors in the UTAUT model. The study
coercive, normative, and mimetic forces patients portals found that normative and mimetic forces
have a significant effect on BI and use
behavior of patient portals among the
elderly.
Boontarig 2016 Patients UTAUT+ perceived value, + Adoption of health The findings indicate that FC and perceived
psychological traits related information value had significant effect on BI. The
via online social relations with actual use were not tested.
networks.
Hoque & Sorwar 2017 Patients UTAUT + Technology Anxiety, mHealth For the initial model:
Resistance to Change Relationships were confirmed. Technology
anxiety and resistance to change had a
significant but negative effect on BI

Bawack & 2018 Professionals UAUT + Self-efficacy, Cost-effectiveness Health information The research confirmed the direct relation
Kamdjoug systems between FC and BI in medical context. Only
age was a significant moderator in UTAU,
and SI had the most significant effect.
2018 Patients UTAUT + perceived credibility m-Health
(continued on next page)

4
W.B. Arfi et al.
Table 1 (continued )
Authors Year Users (professionals for Extension variables/ Framework
the organizational use and variables
patients for the consumer
use)
Quaosar, Hoque, &
Bao
Jewer 2018 Patients UTAUT but with FC to BI
Shiferaw & Mehari 2019 Professionals UTAUT + Self-efficacy; attitude; change
of relations inside of the original model
Nisha, Iqbal, & Rifat 2019 Patients UTAUT + trust, Perceived Credibility;
Health Care Knowledge
Perceived Financial Cost; Perceived Self-
Efficacy; Anxiety; Personal
Innovativeness; responsiveness,
assurance and empathy; Information
Quality; system quality
Wang, Tao, Yu, & 2020 Patients UTAUT and Task-Technology Fit
Qu
medical context, all security types are essential, such as perceived se­
curity and information security (Alaiad et al., 2014; Cimperman et al.,
2016; Hsu et al., 2013). Data disclosure also raises service risks (Lee and
Rho, 2013) and privacy concerns (Alaiad and Zhou, 2014). Therefore, as
PR and perceived trust (PT) are relevant predictors of BI in a medical
context (Nisha et al., 2019), the current study focused on the role of trust
in BI.
2.4. Trust and the trust− risk relationship
Regarding the IoT, the authors assumed that smart connected devices
are human-carried or human-related devices (Sicari et al., 2015). The
concept of trust includes important IoT aspects, such as the trust man­
agement protocol, trustworthiness evaluation, the reputation-based
trust mechanism, and trusted nodes (Sicari et al., 2015) used by de­
velopers. In this context, trust, or PT, can be defined as an individual’s
confidence in information systems (e.g., Jang et al., 2016). Trust appears
to relate positively intention to perform transactions via the Internet.
Numerous studies validated the strong impact of trust on BI (e.g., Alam
et al., 2020; Egea and González, 2011; Jang et al., 2016; Papa et al.,
2020; Pavlou, 2003). When smart connected devices are used to provide
healthcare, they can collect, manage, monitor, and analyze individuals’
health data. More specifically, this raises significant security and trust
issues highlighted in the current literature and may affect users’ adop­
tion of these smart objects.
In the IoT context, the ubiquity of smart devices and risk of tech­
nology misuse make the protection of private data essential. Moreover,
patients can have opposing viewpoints regarding the security aspect of
health information technology (Or and Karsh, 2009). For the medical
establishment, it is critical to inform patients, how, by whom, and what
kind of data will be used (Hengstler et al., 2016). For instance, we
considered a healthcare scenario in which hospital employees must have
access to patient data for administrative purposes (e.g., producing sta­
tistics, registering patients, invoicing, obtaining information on age,
gender), but are not allowed to know the details of patients’ medical
conditions. Data protection aims to guarantee adequate access rights for
medical staff without revealing patients’ confidential information. In
achieving this, patients can trust connected devices to monitor their
health conditions without compromising their privacy.
However, in using the IoT, people have no choice but to disclosure
their data, thus placing those data in danger of being exposed. By adding
trust in IoT adoption, AlHogail and AlShahrani (2018) found various
5
Technological Forecasting & Social Change 167 (2021) 120688
Technology Key findings/Validated relationships
Regarding UTAUT variables, PE, EE, and SI
had significant influence on BI. FC and
elderly’s BI and actual use of m-health
services are not confirmed.
Emergency The study provided empirical support for the
Department (ED) wait- UTAUT and direct relations between FC and
times website BI in the patient context!
EE was not significant.
Healthcare; electronic Predictors of BI: PE, SI, Attitude. Predictors
medical record (EMR) of use: EE, FC, and self-efficacy.
mHealth UTAUT model confirmed: FC is found as the
strongest direct determinant of BI.
Trust is another strong predictor of BI.
Healthcare wearable Results: PE, EE, FC, SI, and task-technology
devices fit positively affected consumers’ behavioral
intention
factors affecting trust, including PR. Initially, PR was defined in the
literature only in terms of fraud, but today, the definition has shifted to
include the potential for loss in the pursuit of a desired outcome when
using an e-service (Featherman and Pavlou, 2003; Martins et al., 2014;).
In the IoT context, PR can be defined as patients’ perceptions of the
potential outcomes of action due to their degree of uncertainty about the
use of health-related connected devices. People want to avoid loss as
much as possible when making decisions in risky situations, which can
be achieved through specific actions (Sung and Jo, 2018). PR in the IoT
is significant, due to the nature of this technology, such as Internet use,
data transmission, and complicated technology that might be not clear
to users (AlHogail and AlShahrani, 2018).
In the current study, risk was mainly defined based on its perceived
levels in unknown situations when patients use health-related devices.
Potential issues related to the privacy and confidentiality of data and
medical records decrease patients’ intention to share this information
and, therefore, their intentions to use a device. Several studies have
demonstrated how the PR of using connected devices is likely to influ­
ence decision-making and, ultimately, BI (Benson et al., 2015; George,
2004; Hansen et al., 2004; Liu et al., 2005; Saridakis et al., 2015).
2.5. Research model and hypotheses
2.5.1. Behavioral intention
The model’s central concept is BI. As mentioned above, many re­
searchers do not consider actual technology usage in their studies, but
rather the intention to use that technology. BI can be defined depending
on the context; however, it always refers to the degree to which a
technology is intended to be used (Venkatesh et al., 2003). Four UTAUT
components (PE, EE, SI, and FC) predict BI.
2.5.2. Performance expectancy
Adapting the initial definition of PE according to the present context,
we defined this factor as the degree to which individuals believe that
using the IoT will help them perform a specific task (Cimperman et al.,
2016; de Veer et al., 2015; Wang et al., 2020). In the context of wearable
medical devices, PE can be viewed as the extent to which the device can
assist users in monitoring their daily physical condition, making
self-care plans, and minimizing health threats (Wang et al., 2020). Thus,
an increase in patients’ PE for connected healthcare devices, such as the
perception of more effective health management, better access to
healthcare services, and better overall quality of life, will positively
W.B. Arfi et al. Technological Forecasting & Social Change 167 (2021) 120688

affect BI to use connected healthcare devices. PE has been identified in 2.6. Moderation effects
prior literature as a strong predictor of BI to use healthcare technology
(Cimperman et al., 2016; Quaosar et al., 2018). Thus, we hypothesized The initial model of Venkatesh et al. (2003) tested the effects of four
the following: moderators on different variables. In applying the model, the re­
searchers proposed the moderators related to the context and the tech­
H1. PE will positively impact BI.
nology’s importance. In the medical context, the most frequent and
significant moderator is age (Cimperman et al., 2016; Hoque and Sor­
2.5.3. Effort expectancy
war, 2017), as older patients could have difficulties with technology use.
In the initial use of technology, the level of ease associated with using
Demographics as moderators, such as age, gender, or socioeconomic
that technology strongly affects the acceptance behavior (Cimperman
status, have been found to be relevant in predicting technology adoption
et al., 2016). EE refers to "the degree of ease associated with using the
(Griebel et al., 2013). Lee and Rho (2013) found the moderation effect of
system" (Venkatesh et al., 2003, p.450). Furthermore, in the context of
gender in the adoption of IoHT. In this research, we applied to gender
patient use of connected healthcare devices, EE is associated with an
and age as moderators.
increase in the perception of technology as beneficial and useful. As a
result, higher EE refers to the energy required to manage the system (Or H6. Age and gender will moderate the effects of PE, EE, SI, and FC on
et al., 2011). EE is a strong predictor of BI in the medical context (Alaiad BI for IoT use in eHealth.
et al., 2014; Quaosar et al., 2018). Thus, we formulated the following
Fig. 1 presents the research model:
hypotheses:
H2. EE will positively impact BI. 3. Materials and methods

2.5.4. Social influence 3.1. Data collection

Several studies have highlighted the complex role of SI in the
acceptance of new technologies (Bhattacherjee and Hikmet, 2008;
Bozan et al., 2016; Mital et al., 2018; Sicari et al., 2015). SI is defined as
the degree to which individuals perceive that important others agree
with their specific behaviors or, in the context of this study, with the
adoption of connected devices for healthcare needs (Alam et al., 2020;
Venkatesh et al., 2003; Wang et al., 2020). Those patients can consider
to be important others include their family members or physicians
(Cimperman et al., 2016). In the context of health-related technology
use, SI has shown strong predictive power (Bozan et al., 2016; Hoque
and Sorwar, 2017). We therefore proposed the following hypothesis:
H3. SI will positively impact BI.
For the sampling strategy, the authors used a non-probability con­
venience sample collected in cooperation with French hospitals, dis­
tributors of connected healthcare devices, and pharmacies in large cities
in France. To reach users of healthcare devices, we used a self-
administered online survey and face-to-face interviews. Out of 298 re­
spondents, we retained 267 validated and complete answers. Of the
sample, 49% were younger than 20 years old, 28% were between 20 and
30 years old, and 22% were between 31 and 40 years old. Additionally,
37% of the respondents were male and 62% were female (Table 2).
3.2. Measurements

A five-point Likert scale (strongly agree to strongly disagree) and a

2.5.5. Facilitating conditions
five-point frequency scale (never to several times per week) were used
For patients to use health-related devices, technological or organi­
measured the variables in the present study. The questionnaire con­
zational support is needed. The availability of specialized resources and
structs were operationalized using measurement scales adapted from the
technical infrastructure can be considered FC. Several studies have
literature (Table 3). PE, EE, SI, and FC were measured with a scale
investigated the impact of FC on consumer PEOU (Jahangir and Begum,
proposed by Venkatesh and Zhang (2010) and validated by Foon and
2008; Mital et al., 2018; Sicari et al., 2015). In the context of connected
Fah (2011) and Sripalawat et al. (2011). Perceived risk (PR) was
devices, CE enables users to understand the resources and supporting
measured with a scale developed by Stone and Gronhaug (1993), and
facilities, such as their own abilities, knowledge of how to use tech­
perceived trust (PT) was measured using a scale was measured using a
nology (Alaiad and Zhou, 2014), and support and guidance from med­
scale developed by Thompson et al. (1991) and used by Cheng et al.
ical or technology professionals (Wang et al., 2020). In this case, the
(2006) and Pal et al. (2018).
patient develops BI to use the technology (Nisha et al., 2019). Thus, we
BI was measured using a single item adapted from Venkatesh and
hypothesized the following:
Zhang (2010). According to Rossiter (2003) and Bergkvist and Rossiter
H4. FC will positively impact BI. (2007), a unidimensional reflective attribute uses a single-item measure
or multiple synonymous items held to the same results. Rossiter (2003)
All four primary factors of the UTAUT were tested and validated by
argued that a single-item measurement is sufficient if the construct’s
various studies, including healthcare studies concerning patients’ tech­
object is easily and uniformly imagined. These conditions are present for
nology use (e.g., Alaiad and Zhou, 2014; de Veer et al. 2015; Jewer,
the concept of BI; therefore, a single-item measure was appropriate in
2018; Nisha et al., 2019; Wang et al., 2020).
the present study.
2.5.6. Trust− risk relationship
4. Results
Several studies have included risk as a critical component of trust
models and examined the trust− risk relationship (Bugshan and Attar,
We chose the PLS-SEM approach and used xlstat-PLSPM software to
2020; Hansen et al., 2018; Mou et al., 2017; Radaelli et al., 2017). To
test the empirical model. This approach is recommended as an appro­
some extent, risk might increase the importance of trust’s predictive
priate method to test causal models within small samples (Chin, 1998),
power (Egea and González, 2011). Nevertheless, the higher the level of
handle constructs with single and multi-item measures, (Hair et al.,
risk, the less likely it is users will develop trust toward a technology.
2016) and overcome the potential limit of the normal distribution of the
Therefore, we hypothesized the following:
measures (Esposito Vinzi et al., 2010). The primary PLS-SEM algorithm
H5. PR will mediate the positive impact of PT on BI. follows a two-stage approach. In the first stage, the latent variables are
estimated by scores of observed variables, proxies for structural model
relationships among the latent variables, scores of latent variables, and
coefficients in the measurement model. The second stage calculates the

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W.B. Arfi et al. Technological Forecasting & Social Change 167 (2021) 120688

Fig. 1. Framework Model of the determinants of behavioral intentions relating to IoT healthcare devices.

recommendations of Hair et al. (2016). The measurements’ convergent

Table 2 and discriminant validity were verified using the
Sample description.
Multitrait-Multimethod Matrix method proposed by Campbell and Fiske
Variables Categories Frequency per Rel. frequency (1959) and recommended by Bagozzi (1994). The correlation matrix
category per category [%)
presented in Table 5 shows that every item presents a high correlation
A. Age [17, 20] 133,000 49,813 coefficient (greater than 0.8) in relation to the concept it measures,
[21,30] 75,000 28,090 indicating satisfactory convergent validity. This also showed that the
[31,40] 59,000 22,097
B. Gender Male 99,000 37,079
item− construct correlation was higher than the same item’s squared
Female 168,000 62,921 correlation to the other concepts, which confirmed the measurements’
Socio- 1. Students 112,000 41,948 discriminant validity (5). This assertion is supported by the constructs’
professional squared correlation matrix, which indicates that the inter-construct
status
correlations are smaller than their mean communalities (Table 6).
2. Retired 7000 2622
3. Employees and 69,000 25,843
Workers 4.2. Structural model
4. Intermediate 15,000 5618
professions A test of the independent variables’ contributions to IoT users’ BI
5. Farmer 5000 1873
6. Artisans, 13,000 4869
provided mixed results (Table 7). The results indicate four variables, EE,
shopkeepers, CEOs SI, PR, and FC, influences BI to use the IoT for e-Health (Table 7). SI (B =
7. Executives and 46,000 17,228 0.335; t = 6.313) and FC (B = 0.309; t = 5.264) made an essential
intellectual contribution to BI, followed by EE, which had a less important influence
professionals
(B = 0.170; t = 2.298). These results supported H2, H3, and H4 about
the positive contribution of EE, SI, and FC to BI for IoT use. Furthermore,
final estimation of the outer weights and loadings and the structural the results showed that PT (B = − 0.341; t= − 5.905) had a significantly
model’s path coefficient (Chin, 1998; Hair et al., 2016). The boot­ negative influence on PR, and that PR made a significantly negative
strapping procedure was also adopted to analyze the inner (measure­ contribution to BI (B = − 0.124; t = − 2.104). This indicated that PT
ment) and outer (structural) models. According to Wong (2013), the contributes positively and indirectly to BI to use the IoT for health de­
bootstrap method proposes approximate t-values for significance testing vices, as reduced by the PR a user associates with this technology. This
of the structural path and a standard bootstrap error that appreciates the finding supported H5. However, contradictory to the research model, PE
indices’ reliability. made no significant contribution to BI to use the IoT in a health context
(B = 0.076; t = 0.058); thus, H2 was rejected.
The validated model of the determinants of BI to use the IoT for
4.1. Outer model
healthcare devices is shown in Fig. 2.
Regarding the causal model’s adjustment indices, the goodness of fit
To test the reliability and the validity of the measurement model, an
index of the absolute model (Gof_A = 0.512) was similar to the bootstrap
exploratory factor analysis (EFA) was conducted for the measurement
estimation (Gof_Aboot = 0.512). The goodness of fit of the measurement
scales (Table 4). The EFA results indicated that the average variance
and the inner models were superior to 0.9 (Gof_O = 0.997; Gof_I =
extracted (AVE) was satisfactory for all constructs, exceeding the 60%
0.944), indicating a satisfactory adjustment of the measurement vari­
limit recommended by Hair et al. (2016). However, items FC3 and FC4
ables and the causal model to the empirical data. This appeared to be
related to the measurement of FC, and TR3 related to the measure of PT,
supported by the bootstrap estimation of the good fit indexes which are
were deleted due to factor loadings below 0.6. The reliability and the
similar to the indexes of the model (Gof_Oboot= 0.993; Gof_Iboot= 0.912;
validity of the measurement items were considered using the indices of
Table 8).
Cronbach’s alpha and Dillon− Goldstein’s rho, which were greater than
0.7 and 0.8, respectively, in the present study. This was in line with the

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W.B. Arfi et al. Technological Forecasting & Social Change 167 (2021) 120688

Table 3 Table 4
Measurement items. Psychometric properties of the measurement scales.
Variables Measurement items References Latent variable Dimensions Factor Cronbach’s D.G. AVE
Loading alpha Rho
Performance [PE1] Using IoT products for Luarn and Lin [2005],
[PCA]
Expectancy healthcare would improve my Venkatesh and Zhang
performance [2010], Foon and Fah [2011] Performance PE1 0,899 0,897 0,928 0,763
[PE2] Using IoT products for Expectancy
healthcare would save my time PE2 0,832
[PE3] I would use IoT products PE3 0,906
for healthcare anyplace PE4 0,856
[PE4] I would find IoT products Effort EE1 0,851 0,915 0,940 0,796
for healthcare useful expectancy
Effort [EE1] Learning to use IoT Luarn and Lin [2005], EE2 0,924
expectancy products for healthcare is easy Venkatesh and Zhang EE3 0,910
for me [2010], Foon and Fah EE4 0,881
[EE2] Becoming skillful at using [2011], Sripalawat et al., Social Influence SI1 0,905 0,897 0,929 0,761
mobile banking is easy for me [2011] SI2 0,931
[EE3] Interaction with IoT SI3 0,802
products for healthcare is easy SI4 0,846
for me Perceived Risk PR1 0,762 0,880 0,926 0,751
[EE4] I would find IoT products PR2 0,979
for healthcare is easy to use PR3 0,845
Social Influence [SI1] People who are important Venkatesh et al., [2003], Facilitating FC1 0,930 0,883 0,945 0,893
to me think that I should use IoT Venkatesh and Zhang conditions
products for my healthcare [2010], Foon and Fah FC2 0,960
[SI2] People who are familiar [2011], Perceived trust TR1 0,967 0,772 0,898 0,792
with me think that I should use TR2 0,806
IoT products for my healthcare Behavioral BI – – – –
[SI3] People who influence my Intention
behavior think that I should use
Iot products for my healthcare
[SI4] Most people surrounding − 2.333), and FC (B = 0.213; t = 2.815) significantly influenced BI. For
with me use IoT products for
women, SI (B = 0.342; t = 4.158) and FC (B = 0.528; t = 5.575) were the
their healthcare
Perceived Risk Using Iot products for my Stone and Gronhaug (1993)
main influencers of BI. These results supported H6. Additionally, BI in
healthcare is risky women was found to be less affected by PR and EE than BI in men.
I feel that using Iot products for Regarding the moderating role of age, the results of the empirical
my healthcare would cause me model indicated that SI significantly contributed to BI in all age groups
a lot of trouble if something
(Table). There were no significant differences among the three age
went wrong.
Basically, I’m sure I would groups (i.e., 20 years or less, 21 to 30 years, and more than 30 years) in
make a mistake if I use IoT the importance they placed on SI when determining their BI. However,
products for my healthcare* as indicated by the path coefficients, this contribution seemed to in­
Facilitating [FC1] My living environment Venkatesh et al., [2003], crease with age, from 0.253 for those 20 years and younger, to 0.352 for
conditions supports me to use IoT products Venkatesh and Zhang
for my healthcare [2010], Sripalawat et al.,
those aged between 21 and 30 years, and finally 0.453 for those older
[FC2] My working environment [2011] than 30.
supports me to use IoT products Moreover, the results of the empirical model indicated between-
for my healthcare group differences in the contribution of PR and FC to BI. FC showed
[FC3] Using Iot products for my
an important impact on BI only in those in the 20 years and younger
healthcare is compatible with
my life group (B = 0.349; t = 3.839); it had significant role in the age categories.
[FC4] Help is available when I PR contributed mainly to the BI of those in the 21 to 30 years old group
get problem in using IoT (B = − 0.303) but seemed to not have a significant impact on the other
products for my healthcare age groups. However, this negative contribution could not be considered
Perceived Trust [TR1] I fear to use Iot products Thompson et al. (1991),
for my healthcare due to loss of Cheng et al. (2006), Pal et al.
as a moderating effect because PT did not influence PR in this age group
my personal data and privacy (2018) (Table 10).
[TR2] Iot products for For those who were older than 30 years, neither FC (t = 1.298) nor
healthcare offers a secure PR (t = − 0.957) impacted their BI (Table 10). Their BI to use the IoT for
medium which sensitive
health technology was defined exclusively by SI (B = 0.435; t = 3.873).
personal information can be
send confidentially These results partially support H6.
[TR3] I find Risky to disclose
my personal details and health 5. Discussion
information to the smart home
service providers
Behavioral [BI] I intend to use Iot products Venkatesh and Zhang
This study aimed to examine the roles of trust and the trust− risk
Intention for my healthcare [2010], relationship in the personal use of IoT in a medical context to address
issues of personal data disclosure (trust− risk relationship). The impact
of the UTAUT variables of PE, EE, SI, and FC on BI was examined by
4.3. Moderating roles of gender and age extending the model with the trust− risk relationship, in order to answer
the study’s research question. Out of five hypotheses, only one (H1) was
Regarding the moderating role of gender, a multigroup analysis of not supported (Table 11).
the causal model was conducted. Table 9 shows the main differences The present findings supported most of the hypothesized relation­
between men and women in BI to use the IoT for health. For men, EE (B ships among the UTAUT variables (H2, H3, H4). Thus, the strongest
= 0.218; t = 2.207), SI (B = 0.306; t = 4.530), PR (B = − 0.177; t = predictors of patients’ BI to use connected devices in healthcare were

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W.B. Arfi et al. Technological Forecasting & Social Change 167 (2021) 120688

Table 5
Correlation matrix of the measures.
Performance Expectancy Effort Expectancy Social Influence Perceived Risk Facilitating Conditions Trust Behavioral Intention

PE1 0,899 0,354 0,585 − 0,231 0,187 0,053 0,412

PE2 0,832 0,411 0,370 − 0,294 0,301 0,092 0,332
PE3 0,906 0,447 0,516 − 0,306 0,306 0,123 0,470
PE4 0,856 0,335 0,602 − 0,253 0,198 0,044 0,436
EE1 0,486 0,851 0,310 − 0,542 0,563 0,342 0,586
EE2 0,419 0,924 0,188 − 0,641 0,657 0,354 0,498
EE3 0,349 0,910 0,172 − 0,681 0,639 0,363 0,522
EE4 0,293 0,881 0,094 − 0,631 0,613 0,306 0,433
SI1 0,531 0,158 0,905 − 0,150 0,134 0,077 0,453
SI2 0,609 0,227 0,931 − 0,169 0,129 0,095 0,540
SI3 0,454 0,163 0,802 − 0,078 0,162 0,057 0,331
SI4 0,474 0,234 0,846 − 0,122 0,197 0,107 0,327
PR1 − 0,274 − 0,543 − 0,232 0,801 − 0,426 − 0,284 − 0,361
PR2 − 0,285 − 0,554 − 0,070 0,863 − 0,381 − 0,300 − 0,422
PR3 − 0,220 − 0,661 − 0,098 0,856 − 0,481 − 0,276 − 0,413
FC1 0,314 0,633 0,228 − 0,403 0,930 0,318 0,455
FC2 0,231 0,672 0,112 − 0,542 0,960 0,342 0,602
TR1 0,067 0,273 0,088 − 0,275 0,211 0,881 0,328
TR2 0,092 0,409 0,086 − 0,335 0,403 0,921 0,375
BI 0,478 0,579 0,491 − 0,475 0,569 0,392 1000

Table 6
Squared correlation matrix of the constructs of the structural model.
Performance Expectancy Effort Expectancy Social Influence Perceived Risk Facilitating Conditions Trust

Performance Expectancy 0,763*

Effort Expectancy 0,195 0,796*
Social Influence 0,361 0,050 0,761*
Perceived Risk 0,095 0,486 0,024 0,707*
Facilitating Conditions 0,079 0,479 0,029 0,259 0,893*
Perceived trust 0,008 0,148 0,009 0,116 0,123 0,813*
Behavioral Intention 0,228 0,335 0,241 0,226 0,323 0,154
*
Mean communalities.

Table 7
Contributions of the independent variables to behavioral intention.
Model Mediating and Independent Standardized Path Standard Error Critical Pr > |t| (5% Bootstrap Interval
Adjustement dependent variables coefficient (coef. with (coef. with ratio (CR) risk of error) Lower Upper
variables bootstrap) bootstrap) bound bound
− 95% (95%)

R2=0.116 Perceived Risk Perceived trust ¡0,341 0,058 ¡5905 0,000 ¡0,447 ¡0,238
F = 34,874 (¡0,353) 0,057
R2=0.557 Behavioral Performance 0,076 0,058 1320 0,188 − 0,051 0,175
F = 54,461 Intention Expectancy (0.081) (0.054)
Effort 0,170 (0.176) 0,074 (0.078) 2298 0,022 0,006 0,380
Expectancy
Social Influence 0,335 (0.342) 0,053 (0.043) 6313 0,000 0,254 0,444
Perceived Risk ¡0,124 0,059 (0.059) ¡2104 0,036 ¡0,255 0,011
(¡0.121)
Facilitating 0,309 (0.295) 0,059 (0.064) 5264 0,000 0,168 0,429
Conditions

found to be SI and FC. SI is often the most important predictor of
technology acceptance in the medical context, as many previous re­
searchers have confirmed in studies conducted with professional medi­
cal staff (Alazzam et al., 2016; Hennemann et al., 2017; van der Vaart
et al., 2016) and patients (e.g., Moon and Hwang, 2016; Okumus et al.,
2018; Tavares and Oliveira, 2017). Health is a personal matter; how­
ever, as people are often not experts in many health-related issues, they
are impacted by the important others in their social groups, such as their
family members physicians (e.g., Hsieh, 2016; Moon and Hwang, 2016;
Okumus et al., 2018; Tavares and Oliveira, 2017). However, FC is usu­
ally having a less powerful effect on BI, because users need technical
support during this stage of use. Nevertheless, many studies confirmed
that FC can have a substantial impact on BI (e.g., Duarte and Pinho,
2019; Hsieh, 2016; Shareef et al., 2015; van der Vaart et al., 2016).
Moreover, many studies did not consider actual use when testing the
UTAUT (e.g., Boontarig, 2016; de Veer et al., 2015; Jewer, 2018;
Kohnke et al., 2014; Wang et al., 2020). Hence, IoT is a disruptive
technology that is not well-known by ordinary users. The BI to use this
technology could depend on the specific device (Gao et al., 2015). Some
of these devices could require more technical support, while some could
require less. In any case, the medical context increases the necessity of
FC; thus, this factor showed greater significance in the current study
than in previous research.
As in many previous studies, EE in healthcare TAMs predicted BI (e.
g., Gao et al., 2015; Hsieh, 2016; Jianbin and Jiaojiao, 2013; Okumus
et al., 2018; van der Vaart et al., 2016), although this effect was less
strong than that of SI or FC in the present study. In fact, personal efforts
to use connected devices do not concern the patients because of

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W.B. Arfi et al. Technological Forecasting & Social Change 167 (2021) 120688

Fig. 2. Model of the determinants of behavioral intention relating to the IoT for healthcare devices.

Table 8
Goodness of fit index (Monofactorial manifest variables).
GoF GoF (Bootstrap) Standard error
Absolute 0,512 0,512 0,037
Relative 0,941 0,905 0,037
Outer model 0,997 0,993 0,025
Inner model 0,944 0,912 0,028
physicians’ social impact and conviction to receive technical support.
Unexpectedly, this study did not validate the effects of PE on BI. PE is
often conceptualized as the strongest predictor of BI (e.g., Reyes-Mer­
cado, 2018; Tavares and Oliveira, 2017; van der Vaart et al., 2016;
Venkatesh et al., 2003), as people are generally interested in knowing
the benefits of technology for their performance. PE might be critical for
the technology choice (Reyes-Mercado, 2018; Tavares and Oliveira,
2017; van der Vaart et al., 2016). However, Garavand et al. (2019)
found no effect of PE on students’ BI to use mobile health applications.
Further, PE was not found to predict the adoption of smartphone fitness
applications (Dhiman et al., 2019) or wearable healthcare technology
within a fitness subgroup (Gao et al., 2015). Ramtohul (2015) proposed
that a patient’s decision to adopt a particular technology might depend
on their physician’s attitude toward that technology; thus, patients are
influenced by this attitude. Together with the strong effect of SI and the
weaker influence of EE, the rejection of PE in the present study high­
lights the relevance of the trust− risk relationship. This study’s findings
indicate that PT and PR are related to the prediction of BI. Both are
relevant in influencing patients’ BI to use healthcare connected devices,
which is consistent with previous studies (e.g., Alazzam et al., 2016;
Caputo et al., 2018; Cody-Allen and Kishore, 2006; Goad et al., 2020;
Zhao et al., 2018). Our analysis answered the question of the role of the
trust− risk relationship in the decision to adopt the IoT in a medical
context by providing explanations for patient behavior.
6. Conclusion
The IoT is a globally used technology that has spread to many
different domains due to its multiple benefits (Brasseal, 2015).
Increasing research has focused on healthcare to offer the best solutions
for patients. E-Health is one such topic involving the IoT that has huge
potential (Martínez-Caro et al., 2018).
Thus, the results of the current study are significant, with both
theoretical research and practical implications, as discussed below.
6.1. Theoretical implications
First, the theoretical contributions include identifying the role of the
trust− risk relationship in a medical context for IoT use. The current
findings enrich the existing research by adding the constructs of PT and
PR, and the importance of use in a medical context is highlighted. This is
one of only a few studies on technology adoption models in which PE
was not supported, providing a new area for the further investigation of
the users’ characteristics and circumstances of use, particularly within a
medical context. As the IoT includes the adoption of a wide range of
devices, the type of product used might influence performance percep­
tion. The current research shows that this condition affects patients’ BI
toward eHealth devices.

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W.B. Arfi et al. Technological Forecasting & Social Change 167 (2021) 120688

Table 9
Moderating effect of gender on the relationships of the causal model.
Dependent variable Independent Standardized Path coefficient Standard Error (error value T Pr > |t| (5% risk Bootstrap Interval
variable (coef. with bootstrap) of bootstrap) of error) Lower Limit Upper limit
(95%) (95%)

Male Performance 0,098 0,075 1294 0,198 − 0,111 0,244

R2=0.537 Expectancy (0,088) (0,087)
R2 (bootstrap) Effort Expectancy 0,218 0,099 2207 0,029 ¡0,069 0,447
=0.551 (0,211) (0,110)
Social Influence 0,316 0,070 4530 0,000 0,171 0,530
(0,322) (0,074)
Perceived Risk ¡0,177 0,076 ¡2333 0,021 ¡0,361 ¡0,040
(¡0,195) (0,075)
Facilitating 0,213 0,076 2815 0,005 0,011 0,346
Conditions (0,211) (0,079)
Female Performance 0,083 0,091 0,913 0,364 − 0,083 0,214
R2=0.580 Expectancy (0,068) (0,077)
R2 (bootstrap) Effort Expectancy 0,079 0,111 0,711 0,479 − 0,185 0,334
=0.595 (0,075) (0,129)
Social Influence 0,342 0,082 4158 0,000 0,194 0,529
(0,352) (0,086)
Perceived Risk 0,033 0,093 0,355 0,723 − 0,347 0,171
(0,002) (0,098)
Facilitating 0,528 0,095 5575 0,000 0,202 0,700
Conditions (0,497) (0,111)

Table 10
Moderating effect of age on the relationships of the causal model.
Dependent variable Independent Standardized Path Standard Error (error value of T Pr > |t| (5% risk of Lower Limit Upper limit
variable coefficient bootstrap) error) (95%) (95%)

20 years and less Performance 0,153 0,101 1516 0,132 − 0,045 0,358
R2=0.150 Expectancy (0,154) (0,108)
R2 (bootstrap) Effort Expectancy 0,136 0,124 1096 0,275 − 0,067 0,393
=0.159 (0,131) (0,113)
Social Influence 0,253 0,087 2917 0,004 0,060 0,452
(0,260) (0,119)
Perceived Risk − 0,060 0,084 − 0,718 0,474 − 0,218 0,11
(− 0,064) (0,079)
Facilitating 0,349 0,091 3839 0,000 0,109 0,520
Conditions (0,338) (0,102)
21 to 30 years old Performance 0,035 0,093 0,382 0,703 − 0,197 0,215
R2=0.549 Expectancy (0,033) (0,132)
R2 (bootstrap) Effort Expectancy 0,218 0,118 1849 0,069 − 0,049 0,447
=0.586 (0,225) (0,189)
Social Influence 0,352 0,094 3759 0,000 0,201 0,560
(0,375) (0,100)
Perceived Risk ¡0,303 0,106 ¡2856 0,006 ¡0,415 ¡0,116
(¡0,276) (0,079)
Facilitating 0,214 0,112 1912 0,060 − 0,004 0,439
Conditions (0,215) (0,102)
More than 30 years Performance − 0,066 0,127 − 0,517 0,607 − 0,324 0,372
old Expectancy (− 0,044) (0,132)
R2=0.189 Effort Expectancy 0,263 0,171 1540 0,129 − 0,191 0,675
R2 (bootstrap) (0,265) (0,189)
=0.216 Social Influence 0,435 0,112 3873 0,000 0,233 0,681
(0,431) (0,100)
Perceived Risk − 0,169 0,177 − 0,957 0,343 − 0,496 0,104
(− 0,155) (0,130)
Facilitating 0,160 0,123 1298 0,200 − 0,193 0,488
Conditions (0,158) (0,137)

6.2. Practical implications

Table 11
Results of hypothesis testing.
Following the empirical results, several managerial implications can
Hypothesis Results be proposed. Initially, all connected devices used in a medical context
H1 PE impacts positively the BI. Rejected should be divided into groups according to their functionality: whether
H2 EE impacts positively the BI. Validated they are essential for the patient’s health and whether they require a
H3 SI impacts positively the BI. Validated prescription. This suggests that currently, connected e-Health devices
H4 FC impacts positively BI. Validated
H5 PR mediates the positive impact of PT on BI Validated
and online healthcare systems must take this factor into account to
H6 Age and Gender moderate the effects of PE, EE, SI, FC and PR on Validated better meet patients’ needs and expectations.
BI There are three groups of professionals interested in IoT adoption in
eHealth: providers of the technology/or developers of devices,

11
W.B. Arfi et al.
marketers, and medical staff. This research can be useful for all three
groups. First, IoT developers and experts can use the findings to improve
the adoption of such sophisticated and innovative devices by integrating
the factors that help trust develop in the design and new product
development stage. More specifically, adoption can be increased
through factors such as by intuitive usability, easy connection with
smartphones, and availability of instructions. Second, marketing pro­
fessionals should consider the differentiation of devices based on the
targeting of two different groups (patients who have a prescription and
potential users who adopt the IoHT without a prescription), the sales
channel (through pharmacies or direct), functional specifics (mandatory
use or not) regarding IoT features, functionality, expectancy, and ben­
efits. Depending on these aspects, it is recommended for IoT providers to
issue (in digital or real form) training on IoT use, manuals, and trials.
Advertising and other promotional activities can also help patients using
IoT for e-Health to perceive these new services as useful and effortless.
Third, healthcare managers and medical staff can improve health ser­
vices by promoting the advantages of the IoT. Therefore, they must
provide information for their patients (users with a prescription),
motivate them, and explain the health benefits of using connected de­
vices. The findings reveal that the design, promotion, and management
of IoT products should be based on improving the customer experience
(Chang et al., 2014)—in this case, the patients. Thus, managers need to
ensure that these technologies make patients more responsible, leading
to trust in healthcare services and ultimately fostering greater patient
satisfaction.
6.3. Limitations and directions for future research
Nevertheless, the study is not without limitations, which present
opportunities for further research. The construct of PT was used to
measure the relationship between user confidence and technology. Trust
has been examined in many previous studies and has been defined
differently depending on the research context. Thus, this construct could
be redefined in future work; for example, to better understand trust in
the IoT, it is recommended to apply trusting beliefs (McKnight et al.,
2002) or other theoretical models.
The context of IoT adoption itself served to the research. Likely, the
constructs that are typically significant for IoT use (PE, EE) decrease
their influence based on eHealth’s general adoption (trust in medicine or
medical advice, knowledge of the physician) because patients are not
aware of them. It is complicated or not possible to obtain this knowledge
in a short period of time. Nevertheless, in further research, it will be
essential to test these effects in greater depth, to identify which have the
most considerable impact in an eHeatlh context. Finally, this research
was conducted among the French population only, and its size limits the
generalization of the findings. Therefore, in future research, it would be
useful to increase the sample size and collect data in other countries to
be able to perform cross-cultural comparisons. Furthermore, as the data
were collected before the COVID-19 pandemic, we invite researchers to
explore these factors and test them within this specific context, allowing
patients to use connected devices to monitor their health status.
This study’s main objective was to highlight the importance of
confidence in BI to use the IoT for eHealth. The findings confirmed that
the IoT proposes building new relationships between patients and the
healthcare system. These relations require users to develop a high level
of trust and new knowledge. The influence of physicians is essential;
thus, healthcare authorities should offer a high level of professionalism
and security to encourage patients to use the IoT in a medical context.
The IoT has the potential to promote vital progress in the eHealth
industry. From the strengths and weaknesses of the results discussed
above, it can be concluded that the adoption of increasingly sophisti­
cated technology, such as the IoT, can require a new research on the
population, circumstances, and context.
12
Technological Forecasting & Social Change 167 (2021) 120688
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
None.
Acknowledgments
The authors would like to express their great appreciation to all
patients who agreed to answer the questionnaire and provided infor­
mation for the current study. In particular, the authors would like to
thank the guest editor and the reviewers for their insightful and
constructive comments.
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W.B. Arfi et al.
Dr. Wissal BEN ARFI, Associate-Professor at EDC Paris Business School (France) and
member of the OCRE - Observatory and Research Center on Entrepreneurship. PhD. in
Strategic Management, graduated from the University of Grenoble-Alpes (France). She
taught at the University of Auvergne, INSA Lyon, the University of Bordeaux, KEDGE
Business School and IDRAC Business School. Her main topics are in Digital Innovation,
Digital Innovation Platforms, Entrepreneurship, Machine Learning and Knowledge
Sharing. She published in Small Business Economics, Technological Forecasting and Social
Change, Journal of Organizational Change Management, Canadian Journal of Adminis­
trative Sciences and other international ranked journals.
Dr. Imed BEN NASR, Associate Professor of Marketing at La Rochelle Business School -
Excelia Group and Director of the MSc of Digital Marketing and Collaborative Strategies.
His-main research topics are related to Digital Marketing and specifically the Psycholog­
ical Perspective of the Consumer’s Digital Experiences. He published in French ranked
journal as “Recherches et Applications en Marketing” (RAM) and “Revue Management et
Avenir”. He contributes also to Academic books related to Digital Transformation.
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Technological Forecasting & Social Change 167 (2021) 120688
Galina Kondrateva has a Ph.D. in Business Management obtained at Paris-Saclay Uni­
versity. Today Dr. Kondrateva is an associate professor at EDC Paris Business School
(France), a member of OCRE (Observatory and Research Center on Entrepreneurship). Her
research interests are in the marketing and the adoption of technologies, with a big part of
cross-cultural comparison. Her research topics comprise analysis of users’ behavior in the
usage of mobile applications, telemedicine, blockchain, and Artificial Intelligence,
including comparison across cultures. Before starting her academic career, she worked for
ten years as an executive director in a marketing agency in Russia.
Lubica Hikkerova is professor at IPAG Business School, Paris. She obtained her PhD at
Matej Bel University in Banska Bystrica, Slovakia (ISO 9001 certified). Her main research
fields are summed up in two axes: marketing of services on the one hand, the development
of entrepreneurship and small businesses on the other. She has already published in in­
ternational top ranked journals such as Journal of Business Research, Small Business Eco­
nomics, and Technological Forecasting and Social Change.