Technology in Society 60 (2020) 101212

Contents lists available at ScienceDirect

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

Investigating acceptance of telemedicine services through an extended

technology acceptance model (TAM)
Syeda Ayesha Kamal a, Muhammad Shafiq a, c, *, Priyanka Kakria b
a
Department of Industrial Engineering, University of Engineering and Technology Taxila, 47080, Taxila, Pakistan
b
Department of Industrial Engineering, Institute of Quality and Technology Management, University of the Punjab, Pakistan
c
School of Engineering and Technology, Asian Institute of Technology, Thailand

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

Keywords: Background: Developing countries around the globe are striving continuously to provide free access to health care
Telemedicine services. Telemedicine services represent a significantly increasing form of an adequate health care delivery
Technology acceptance mechanism in developing countries.
Usage intention
Research objective: This research study was aimed at investigating the factors influencing the acceptance of
TAM
Developing countries
telemedicine services among the rural population of Pakistan. Technology Acceptance Model (TAM) was used as
PLS a theoretical framework for this research, with the inclusion of several other antecedents.
Research method: A face-to-face survey method was used to collect research data from 275 participants. The data
were analyzed using Partial Least Squares (PLS) method.
Results: The findings suggest that usage intention of telemedicine services is a function of perceived ease of use,
technological anxiety, social influence, perceived ease of usefulness, trust, facilitating conditions, perceived risk,
and resistance to technology.
Conclusions: This research study confirms the applicability of TAM with the inclusion of additional variables to
model the adoption of telemedicine services in developing countries. The study offers valuable information for
policymakers and health service providers for understanding the facilitators and inhibitors influencing the large
scale implementation of telemedicine services. The research findings regarding factors including perceived risk,
trust, facilitating conditions and resistance to change can aid in the design and adequate provision of tele­
medicine services in developing countries.

1. Introduction depression, and cancer [6,7].

Pakistan ranks as the sixth most populated country in the world.
Recent evidence suggests that over the past few years, information Healthcare system in rural areas of developing countries including
and communication technologies (ICT) have brought tremendous Pakistan is generally marred by the lack of access to even basic primary
changes to the traditional environment of healthcare services [1,2]. health services [8]. Approximately 64% of its population is located in
Research studies have shown that telemedicine is gradually becoming rural areas and only 30% of its rural population has access to basic
the most prominent service of ICT with remarkable effects on the health facilities. Despite some notable improvement in certain health
traditional mechanism of health care services [3]. Around the globe, indicators over the last decades, rural health care system of Pakistan
telemedicine services are enhancing the efficacy of physicians, reducing continues to be dominated by a high escalation in population growth,
medical costs and improving the access to health care services [4,5]. maternal mortality rates and increasing burden of chronic diseases.
Telemedicine services allow health-care professionals to monitor, di­ According to the health statistics of 2017, the infant mortality rate in
agnose and offer medical treatment at great distances using telecom­ rural areas of Pakistan was 61.27 per thousand births and maternal
munication technologies. Research studies have also advocated mortality was 261 per ten thousand births [9,10]. Akin to the settings of
telemedicine services as a promising solution to improve several chronic other developing countries, ease of access to health care facilities is also
medical conditions including hypertension, obesity, diabetes, poorly disseminated in rural areas of Pakistan. The financially deprived,

* Corresponding author.
E-mail addresses: [email protected] (S.A. Kamal), [email protected] (M. Shafiq), [email protected] (P. Kakria).

https://doi.org/10.1016/j.techsoc.2019.101212
Received 3 March 2019; Received in revised form 8 September 2019; Accepted 15 November 2019
Available online 18 November 2019
0160-791X/© 2019 Elsevier Ltd. All rights reserved.
S.A. Kamal et al. Technology in Society 60 (2020) 101212

resource-constrained rural population is often unable to access timely Records remain uniformly insignificant in rural hospital settings and
efficient medical information [10]. People living in rural areas have to clinical practices [12]. Although various research studies suggest posi­
spend a huge amount of money on traveling and bear considerably large tive outcomes for the adoption of telemedicine services yet the will­
expenditures for various medical treatments [9]. ingness of patients/users of rural areas to adopt telemedicine and their
Nonetheless, the recent remarkable growth in modern information respective satisfaction with these services demands further research [18,
and communication technology (ICT) and potential of telemedicine 19]. In spite of the rising interest in health informatics studies [18],
services has paved new ways for reaching out to the rural population of limited information is available regarding the patient’s willingness to
Pakistan for improving its access to health care services. Telemedicine adopt and utilize telemedicine services in the perspective of developing
services represent a promising future for addressing the critical lack of countries [17]. Patients represent the principal users of telemedicine
access to manage several health-related issues, especially in rural areas services and their willingness to adopt telemedicine services has a
of Pakistan [11]. Current medical evidence also advocates for tele­ remarkable impact on its successful implementation. Research studies
medicine as a powerful tool to improve the accessibility of existing have shown that there exists a distinct paucity of literature describing
health-care facilities particularly for people living in rural areas [12,13]. how telemedicine services can be utilized in the rural environment of
Despite its acknowledged benefits, telemedicine will be a useful Pakistan to medically equip an economically marginalized population
health service only when people will begin to utilize it. Therefore, the [20]. Patients’ resistance is a very common phenomenon whenever
general attitude of end-users towards acceptance of telemedicine ser­ changes are introduced into traditional systems of medical care [21].
vices will play a significant role. To foster the adoption of telemedicine Rural Pakistani patients may exhibit reluctance to utilize telemedi­
services among people, it is initially very important to analyze the fac­ cine services. Although telemedicine systems offer to open up new av­
tors influencing their perception. The aim of this study is, therefore, to enues for accessing medical services, it will not be easy to radically
develop a research model using the Technology Acceptance Model transform the current landscape of rural health care if people are not
(TAM) as the main theoretical framework. The research model is focused willing to utilize these services [20,21]. Therefore, a prior understand­
on investigating the key facilitators and inhibitors of telemedicine ser­ ing of factors influencing the acceptance of telemedicine services among
vices in the perspective of a developing country by using a face-to-face rural population is necessary. The wide-scale implementation of tele­
questionnaire-based survey. Based on the research findings and data medicine services in rural areas requires an overwhelming acceptance
analysis using Partial least squares (PLS), the empirical validation of and active participation from local communities. The benefits of tele­
proposed research model is carried out. medicine can be manifested only if patients are ready to use it proac­
The remainder of the paper is structured as follows. Section 2 de­ tively. Therefore the investigation of attitude and acceptance of patients
scribes the research background for determination of factors influencing towards telemedicine services become integral for its effective utiliza­
usage intention of respondents towards telemedicine services. Section 3 tion [22,23]. Furthermore, various studies have already established the
highlights the hypotheses development and section 4 represents the importance of understanding the resistance of users and how they can be
research methodology. Results obtained from data analysis are pre­ successfully managed [24]. However, the theoretical explanation of
sented in section 5. Section 6 highlights discussions in light of data rural users’ resistance towards telemedicine is in dire need of further
analysis. Conclusions and recommendation drawn from the research exploration. The limitation of empirical evidence, suggests the need to
findings are presented in section 7. Limitations of the current research develop a generalized model for analyzing the acceptance and resistance
study are presented in section 8. of users towards telemedicine services in the ongoing stream of research.
The following research query is undertaken by this study:
2. Research background What are the major drivers and barriers influencing the intention of
patients to use telemedicine services in a developing country like
In Pakistan, telemedicine services were first introduced in 1998 by Pakistan?
Elixir Technologies in collaboration with Holy Family Hospital Raw­ The prime objective of this research is, therefore, to focus on inves­
alpindi [14]. Afterward, a telemedicine project in Sakurdu was launched tigating the factors influencing patients’ willingness to accept telemed­
with the collaboration of Stanford University and Physician Association icine services. To analyze the key factors influencing the adoption of
of North in 2006 [15]. Another project called “Pakistan Telemedicine” telemedicine, a theoretical model (Telemedicine service acceptance
was launched by the collaborative efforts of the United States and model) based on the extension of TAM (Technology Acceptance Model)
Pakistan in 2007. This project was aimed at providing better health care has been proposed which contains few variables from the original TAM.
facilities at Holy Family Hospital Rawalpindi and also at Spoke hospital The outcomes of this study are expected to benefit government, poli­
in Attock. The project offered medical consultation in a variety of do­ cymakers and healthcare providers for successful development of tele­
mains including cardiology, radiology, surgery and infectious diseases medicine services.
[14]. Pakistan Space and Upper Atmosphere Research Commission
(SUPARCO) also launched a satellite-based telemedicine project. The 2.1. Technology acceptance model (TAM)
project was aimed at connecting the remotely located hospital at Shi­
karpur with Jinnah Medical Centre in Karachi via Paksat-1 satellite for The choice of an individual to voluntarily accept new technology is
the provision of medical consultations [16]. Another successful venture known as technology acceptance. For successful implementation and
of telemedicine was the startup known as “Telesehat’’ started by a utilization of technology, users’ willingness is a crucial factor [25].
telephone company “Comcept”. The founders of this project collabo­ During the last few decades, researchers have developed several models
rated with doctors across Pakistan to design and develop various soft­ to understand the attributes of technology acceptance among users.
ware systems and interfaces for medical products. Some other notable These models have been verified multiple times to determine their
initiatives of telemedicine were “Jaroka’’ and “Sehat-first”. More than effectiveness for many information technology-based applications [26].
2000 patients were treated with the help of these initiatives [16]. However, the technology acceptance model TAM by Davis so far rep­
Despite the implementation of above-mentioned projects, acknowl­ resents the most established and substantial foundation of technology
edgment of potential benefits of telemedicine services and the agreed acceptance [26]. TAM, which originated from the fields of sociology and
consensus on its reliability and accuracy, telemedicine services have yet psychology, is the most frequently used model in various research
to become a fundamental part of rural health care system of Pakistan. studies. The major goal of TAM is to forecast the adoption of new
Research studies identify this low adoption of telemedicine technology technology among users and to highlight the design problems of the
among developing countries as a common pattern [17]. The utilization information system before its usage becomes prevalent among people
of eHealth applications including telemedicine and Electronic Medical [27]. TAM consists of two main constructs: perceived ease of usefulness

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and perceived ease of use which are used in numerous technological important factor of patients’ acceptance [39–41]. Due to its central role
contexts [27–29]. in facilitating various social interactions among members of society,
Nonetheless, several research studies have expressed concerns trust becomes an integral condition for maintaining successful inter­
regarding the usage of TAM with its original constructs to explain users’ personal relations [42]. In the context of online medical services, trust
intention towards health information technologies. For a specific user has been defined in many ways; various authors consider it to be one
context such as the adoption of telemedicine services, the usage inten­ dimensional while others perceive it as two dimensional. Whereas in the
tion of respondents cannot be sufficiently explained with few variables context of research investigating the acceptance of telemedicine ser­
only. The specific utilization of telemedicine services among people is vices, the importance of trust is further enhanced for engaging in ac­
dependent on multiple social and behavioral factors which are not tivities such as medical prescription or purchasing medicine [43].
present in the TAM model. Research studies have highlighted that the Within the context of this research, we perceive trust as faith in the
intertwined effect of various social factors such as social influence and adoption of a new technology that end-users/patients place in it with
facilitating conditions can significantly alter the user behavior towards regards to the services this technology can provide. Based on that, for
acceptance of new technology. Telemedicine services represent an the current study, it is recommended that the perception of users
improved alternative for health care services in developing countries; regarding placing their trust in the technological infrastructure and
hence it is pertinent to focus on inclusion of additional social variables procedural guarantees should also enhance their intention to use
(with their underlying effect as inhibitor/facilitator) in TAM model and telemedicine.
how these variables can influence the perception of users? Therefore,
this research study has included variables such as social influence, 3.1.2. Perceived usefulness and perceived ease of use (PU and PEOU)
facilitating conditions, trust, privacy, perceived risk, technological Based on the review of empirical results of TAM in the context of
anxiety and resistance towards technology to gain a better insight into health care research, we decided to operationalize the most common
user’s perception. constructs of TAM in health-related studies.
Hence, perceived usefulness, perceived ease of use, facilitating con­
3. Research model and hypotheses development ditions and usage intention are selected for this research study. In the
initial research of TAM, perceived usefulness and perceived ease of use
3.1. Technology acceptance and resistance are the most common and significant determinants of technology
acceptance [44–48]. Perceived usefulness is generally defined as the
Despite the acknowledged potential of information technology (IT) extent to which a person believes that using a system will help in
in health care systems for improving the quality of medical care and enhancing his/her performance. In the context of this study, PU had to
safety of patients, the majority of IT-based health systems encounter be redefined because the usefulness of a system for patients has some­
resistance from users or fail altogether. Users have a general tendency to what altered meaning from previously included definitions of PU. Pa­
exhibit resistance whenever any new innovative technology is imple­ tients feel that adopting to telemedicine services will be useful only if it
mented based on their pre-conceived evaluation of change. Resistance will lead to faster delivery of health care services with the low-cost of
can significantly alter the decision of a user to adopt or discard a new medical inspection, improved documentation and reduced service time
technology, hence, the failure and problems of many IT-based health of health care [49]. PEOU is defined as the degree as to which a person
systems can be tracked to user’s resistance because of the inclusion of believes that using technology will bear minimum effort on his/her
hard influence tactics [30]. In many health informatics based ventures, expense [24,50]. Based on that, we expect that patients will prefer to
resistance is mostly overlooked because of its probable effects on the accept and use telemedicine services only when they feel that using
sustainability of the system. Also, the primary purpose of designing a these services will lead to better results.
new system is to enable the user and not to minimize the consideration
of resistance from the perspective of the user. Hence, the probable ef­ 3.1.3. Social influence (SI)
fects of resistance are often overlooked in IT-based health care system. Social influence is the degree or the extent to which a person believes
According to early research studies on organizational resistance, some that others, especially, his/her acquaintances and friends believe that
researchers deem it as a change which is the direct product of unfreezing he/she should use a new system [29]. Studies have confirmed that social
the equilibrium of the established dynamics of the system before the influence has a noteworthy effect on the intention of users to accept a
change can impart any significant contribution [31]. new technology [51,52]. Moreover, in developing countries, people
In the context of information and communication technologies, often live in joint family systems and are dependent on each other in
resistance is generally defined as the social inertia towards a change multiple social and economic contexts. The usage of telemedicine ser­
which is possibly brought by the new technology [32]. Resistance can’t vices in such an environment will not only be visible to their
be termed equivalent of non-usage of the system because non-usage may family-members/neighbors/acquaintances but the opinion of these
imply that users are still evaluating the new system or they simply people can also encourage the end-users to utilize telemedicine services.
exhibit a lack of awareness about the existing system, whereas, resis­ Hence it is very important to examine the effect of this construct upon
tance implies the complete rejection of technology by the users. Hence, acceptance of telemedicine services. In the context of this research, we
resistance can’t be merely called a lack of change rather it is a define social influence to be the attribute which encourages or prevents
comprehensive opposition towards a change, a cognitive force which people to use telemedicine.
arises when status quo is endangered due to any form of change [33].
Therefore, it becomes necessary to examine the effects of resistance 3.1.4. Facilitating conditions (FC)
within a technology acceptance model to understand how resistance can Another direct determinant of behavioral intention to accept tech­
become a barrier in the adoption of telemedicine services [34,35]. nology is facilitating conditions. This determinant is not included in the
original TAM [27]. Facilitating conditions is defined as the existence of
3.1.1. Trust (T) adequate organizational and technical infrastructure for a user’s support
Over time, various studies have supported the inclusion of factors to adopt a new technology [53]. Facilitating conditions combine three
such as risk and trust in theoretical models of TAM for explaining the basic constructs: perceived behavioral control, facilitating conditions,
acceptance and integration of IT-based medical care technologies [36, and compatibility [54,55]. The successful usage of telemedicine services
37]. Trust has been widely regarded as an important determinant in the is significantly dependent upon the presence of adequate technological
assessment for the acceptance of new eHealth services [38]. This also infrastructure. Moreover, the usage of telemedicine services also re­
holds for telemedicine services where trust is considered as an equally quires a continuous connection between health care professionals,

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service providers, and end-users, located in distant areas. 3.1.8. Privacy (P)
The capability of a medical health professional to monitor and offer Generally, privacy can be described as the state to be left alone [69].
medical feedback using adequate health care infrastructure is a pre- Privacy can be categorized into four major types. However, in the
requisite for fostering the adoption of telemedicine services among context of health care information systems privacy stands out. Review­
people. Hence, this research study extends the original TAM by the in­ ing the definition of information privacy, it can be interpreted as the lack
clusion of facilitating conditions as a facilitator for the adoption of of control a person experiences about his/her personal information once
telemedicine services. Literature has also widely acknowledged the they have adapted themselves to a new system. Privacy can be perceived
significant effect of facilitating conditions on usage intention [56,57]. as the sense of establishing a user’s faith into a system such that he/she
will feel secure enough to share personal health information. The
3.1.5. Technological anxiety (TA) importance of privacy, when it comes to exchanging medical informa­
In this study, we have expanded the basic TAM model with some tion within the health care system, can’t be denied. Previous studies
additional variables including technological anxiety, resistance to have acknowledged the importance of privacy as an important deter­
change and privacy concerns. With the advancement in science and minant for technology acceptance. If a user believes his/her information
technology, it becomes critical to explore and understand the willing­ is not being kept safe in an online health care program, it will reduce the
ness of users to adopt new technologies [58]. Technological anxiety can adoption of new technological initiatives [70,71]. Similarly, in the
be described as the fear or apprehension that people experience when context of health care studies, privacy concerns are shown to reduce the
they begin to consider using or start using a computer-based technology usage intention for the adoption of electronic health records and various
they have not used before [59]. web-based health care interventions [72,73]. Hence, users with high
Technological anxiety is a negative emotional response and a nega­ privacy concerns regarding the exchange of information within a tele­
tive relationship exists between using a new system and TA. Similarly, in medicine system might become reluctant to adopt it.
the context of telemedicine, people might feel anxious to utilize these The technological (acceptance of telemedicine) and geographical
services. Hence, it is important to investigate the effect this factor can context (Pakistan) of this research study points towards an early stage of
impart on usage intention. implementation. Hence, we propose that usage intention of patients
towards telemedicine services is primarily comprised of five prime en­
3.1.6. Resistance to use (RC) ablers which are: perceived ease of use, perceived ease of usefulness,
Studies have also verified that resistance towards technology de­ social influence, trust and facilitating conditions. The inhibitors of usage
creases the intention of users to utilize a new technology [60]. The in­ intention in the current study include technological anxiety, perceived
clusion or introduction of a new technological system usually endangers risk, resistance to use, and privacy.
the established working setting of the users. In extreme conditions Based on the above discussion, the following hypotheses are pro­
where users are compelled to utilize telemedicine services in absence of posed in Table 1 as listed below.
any alternative to accomplish the health-related task or they may start
using the system voluntarily, however, they will stop using it after some 4. Research methodology
time. Contributing to the resistance of users towards telemedicine,
another factor could be the prior experience of a user with a system. If The research aim of this study is to analyze and explore the factors,
the prior usage of the system has left the user uncomfortable or it has shaping and influencing patients’ attitude towards telemedicine. Fig. 1
failed to provide the necessary information, users will not tend to use it represents the research model of this study where “Intention to use
again [61,62]. Telemedicine” is considered as a dependent variable. The targeted
population for this research was patients in hospitals and ambulatory
3.1.7. Perceived risk (PR) care. It should be noted as there would be larger variations among this
The importance of risk as a key predictor of human behavior can’t be group; hence, it can’t be considered homogenous. Also, possible support
denied. Perceived risk is defined as the perception of a person if he/she of IT in the treatment of one patient significantly differs from the rest. To
decides to undertake an action or activity [63]. The effects of risk and ensure the validity of all measures, the individual constructs of de­
uncertainty can’t be mitigated in the domain of health and information terminants were adopted from previous studies, the details of which are
communication technologies, Nevertheless, the sources of variation of provided in Appendix A.
risk and uncertainties concerning usage of IT vary significantly among
patients and doctors [64,65]. Previous studies have identified various
Table 1
aspects of the risk, dividing into six types: performance, financial, social,
List of Proposed hypotheses for research constructs.
psychological, safety, social, and opportunity/time [66]. In the context
of uncertainty and task-related problems with online services, research Factors Abbreviation Hypothesis
has indicated further seven facets of risk which include: time, perfor­ Trust (T) H1: Trust positively influences the intention to
mance, financial, social, physiological, privacy, and overall risk. Build­ use telemedicine services.
ing on that, in this research study we define perceived risk for patients in Perceived (PU) H2: Perceived usefulness positively influence
usefulness the intention to use telemedicine services.
terms of psychological, financial and performance risk. Performance Perceived ease of (PEOU) H3: Perceived ease of use positively influences
risk: the probabilistic perception of a telemedicine system harming the use the intention to use telemedicine services.
patients because of the unavailability of adequate information. Psy­ Social Influence (SI) H4: Social influence positively influences the
chological risk: the perceived threat based on the perception that the use intention to use telemedicine services.
Facilitating (FC) H5: Facilitating conditions positively
of telemedicine services won’t yield any mental satisfaction, resulting in
Conditions influences the intention to use telemedicine
psychological discomfort. Financial risk may be defined as the inability services.
to incur the cost associated with the usage of telemedicine services in Technological (TA) H6: Technological anxiety negatively
time. For general consumers where individual decisions are integral to Anxiety influences the intention to use telemedicine
utilize or purchase telemedicine services, it becomes important for them services.
Resistance to Use (RC) H7: User’s resistance negatively influences the
to consider the financial and time-loss aspects of risk as well. Hence, for intention to use telemedicine services.
this study, the perceived risk becomes a critical variable for assessment Perceived Risk (PR) H8: Perceived risk negatively influences the
of patients’ acceptance. It is identified in the literature that perceived intention to use telemedicine services.
risk contributes to the expectations of destructive consequences, thus, Privacy (P) H9: Privacy negatively influences the
intention to use telemedicine services.
imparting a negative effect on usage intention [35,67,68].

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Fig. 1. Research model.

4.1. Research instrument and data collection proposed model and to validate the hypothesized relationship of de­
terminants. PLS is being commonly used in multiple fields including
This research study was officially and ethically approved by the accounting, marketing, sociology, business, and health care informatics.
Board of Post Graduate studies at the University of Engineering and PLS model primarily consists of structural and measurement models.
Technology Taxila, Pakistan. Initial questionnaire for this study was Analysis of the structural model is carried out using measures of internal
developed in English and was later translated into a local language reliability and validity. Once the structural model is analyzed, the PLS
(Urdu) by a linguistic expert at University of Engineering and Tech­ algorithm then utilizes t-testing and path values for hypothesis verifi­
nology Taxila who was already well familiar with telemedicine. It was cation. Based on the proposed research model, this study has also uti­
ensured that both questionnaires reflected the same meaning in terms of lized the PLS model for analyzing the factors influencing usage intention
perception. of users towards telemedicine services.
The questionnaire consisted of two sections: part A comprised the
basic demographic characteristics of the participants, including infor­ 5. Results
mation regarding gender, age, qualification, access to internet, income,
and the number of visits to the doctor. Part B contained questions for Out of 275 distributed questionnaires, 226 were selected for data
various factors presented in the research model (Fig. 1). Likert scale of analysis and the rest were discarded as they were incomplete.
point-5 was used that oscillated between strongly disagree (1) to Table 2 summarizes the demographic characteristics of participants.
strongly agree (5). To validate the effectiveness of the questionnaire, a As shown in Table 2, 64.6% of the total participants were males. The age
pilot study was conducted at the University of Engineering and Tech­ of respondents varied in the range of 20 years–50 years; maximum
nology, Taxila, for which 15 professors and 10 postgraduate students frequency of respondents was observed in the age group of 20–30 years.
were recruited. The participants were chosen because of their technical The academic qualification of participants was observed mainly for the
competencies and thorough understanding of Telemedicine. Question­ bachelor’s category (58.4%). 60.2% of participants belonged to the rural
naires collected from the pilot study assisted in improving its effec­ environment and 39.8% belonged to the urban environment. Partici­
tiveness with some specific adjustments in terms of its context. pant’s monthly income was observed mostly in the income range of
The target study population primarily consisted of patients who 10–20 thousand. 59.3% of the participants visited hospitals once every 6
visited “Christian Hospital” and “District Head Quarter Hospital”, months. Moreover, 51.3% of the participants reported they had access to
Taxila. The recruitment of participants from these hospitals had several internet services.
reasons: firstly, these hospitals have access to network coverage, For statistical analysis, data follows normality characteristics. The
providing the patients with access to tele-consultation, and secondly, value of skewness for all the variables lie in the range of þ1 to 1
these hospitals are visited not only by the locals of Taxila city but also exhibiting that distribution of data was normal. Moreover, the results for
people residing in rural areas. The research project began in November kurtosis of all the determinants lie in the range of 2.58 to þ2.58
2018 and was completed in December 2018 in terms of data collection. indicating that distribution of data was normal.
All the participants were informed regarding the purpose of this research Once normality of the data was confirmed, the next step was to
study and consent of every participant was ensured by asking them to determine the internal reliability, convergent validity and discriminant
sign a consent form. validity of the model. To measure the internal reliability of the data,
Cronbach alpha was evaluated against the standard threshold of 0.7, the
criterion for acceptable internal consistency of data [75,76].
4.2. Data analysis Convergent validity was calculated using Average Variance Extrac­
ted (AVE), Composite Reliability (CR), and item loadings, such that
The data collected from respondents were analyzed using Partial minimum 0.50 of AVE exists for construct validity. As clearly depicted
Least Squares (PLS), a statistical technique embodied in structural by Table 3, the calculated values of Cronbach alpha ranged from 0.73 to
equation modeling (SEM) [74]. PLS was employed to empirically test the

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Table 2 level, hence, the required criterion for convergent validity is also
Demographic analysis. fulfilled.
Variable Frequency Percent (%) To measure the discriminant validity of data, cross-loading matrix
along with the square root of AVE was determined. It is to be noted that
Gender
Male 146 64.6 for discriminant validity, the square root of AVE of a determinant must
Female 80 35.4 surpass the correlation it exhibits with other constructs [53]. Also, the
Age entries present in corresponding columns and rows of correlation matrix
Less than 20 years 2 0.9 must be less than the diagonal element [53]. Results presented in Table 4
Between 20 and 30 years 146 64.6
Between 30 and 40 years 62 27.4
confirm the discriminant validity of this data.
Between 40 and 50 years 10 4.4 Table 5 represents a summary of the structural model, developed to
50 years or above 6 2.7 determine the relationship between various factors in the model. The
Qualification theoretical model was tested by using a standardized path coefficient
Matriculation 18 8
and t-statistics with the help of the bootstrapping method. It can be seen
Bachelors 132 58.4
Masters 68 30.1 from the table below that positive influence of perceived usefulness,
Doctorate 8 3.5 perceived ease of use, social influence, facilitating conditions and trust is
Living Environment supported by hypothesis testing.
Urban 90 39.8 It can also be seen that negative influence of technological anxiety,
Rural 136 60.2
Monthly Income
perceived risk and resistance to technology is also validated by hy­
Between 10 and 20 thousand 136 60.17 pothesis testing. However, the proposed negative effect of privacy was
Between 20 and 30 thousand 62 27.43 rejected by hypothesis testing.
Between 30 and 40 thousand 28 12.38
Health Incentives
6. Discussions
Yes 104 46
No 122 54
Do you have any access to Internet facilities? This research study developed a theoretical model based on TAM to
Yes 110 48.7 determine the usage intention for telemedicine among rural patients.
No 116 51.3
From Fig. 2 drawn below, it can also be seen that overall 62.45% of the
No of Visits
Once every 6 months 134 59.3
variance in usage intention towards telemedicine services is explained
Once every 3 months 36 15.9 by this research model. The research aim of this study was to determine
Once a month 10 4.4 the drivers and barriers influencing usage intention of telemedicine
Which chronic disease do you suffer from? services among people. Based on the research findings, it can be seen
Cardiac 65 28.76
that constructs including perceived usefulness, social influence, trust,
Hypertension 71 31.41
Diabetes 90 39.82 perceived ease of use and facilitating conditions represent the drivers
influencing usage intention of telemedicine services. Research findings
also indicate that technological anxiety, resistance towards technology,
0.878, composite reliability varied in the range of 0.815–0.942. As the and perceived risk act as the significant barriers influencing the usage
calculated indices were all above the recommended threshold [77], intention of telemedicine services.
strong internal reliability of data was supported. The individual item It can be seen that perceived usefulness (t ¼ 4.428, β ¼ 0.313), and
loadings of constructs oscillated between 0.818 and 0.973, whereas, the perceived ease of use (β ¼ 0.148, t ¼ 2.207) are important drivers for
values for AVE ranged from 0.638 to 0.803, exceeding the recommended acceptance of telemedicine services in the context of a developing
country. This result is in line with previous research studies [3,6,78].
Therefore, these factors are significant in the health care context of
Table 3
Measurement model.
Pakistan as has been found elsewhere. The more people view telemed­
icine as an easy to use technology, the more they will be motivated to
Constructs Items Loadings AVEa CRb Cronbach’s alpha
utilize these services. Consequently, telemedicine services must be
T T1 0.892 0.803 0.891 0.755 designed according to patients’ acceptance level of technology. In this
T2 0.901 way, people will not have to spend a tremendous amount of time and
PU PU1 0.834 0.663 0.854 0.745
PU2 0.882
effort to utilize these services. Therefore, telemedicine service providers
PU3 0.818 must focus on the clinical needs and rural health care environment of
PEOU PEOU1 0.872 0.709 0.879 0.715 end-users for its effective utilization.
PEOU2 0.899 Social influence (t ¼ 2.629, β ¼ 0.161) was also found out to be an
PEOU3 0.848
influential determinant of usage intention, which is consistent with the
SI SI1 0.941 0.891 0.942 0.878
SI2 0.947 findings of previous studies [5,79]. Patients and medical professionals
FC FC1 0.815 0.638 0.840 0.715 living in joint family settings are likely to form dependent evaluations of
FC2 0.835 the telemedicine system. People will be more likely to utilize telemed­
FC3 0.842 icine services if their family members and acquaintances view these
TA TA1 0.936 0.844 0.815 0.817
TA2 0.901
services as effective for improving health care conditions. For this pur­
RC RC1 0.88 0.779 0.876 0.716 pose, prominent community members, health workers and, local reli­
RC2 0.877 gious figures must be engaged in research discourse regarding
PR PR1 0.827 0.780 0.876 0.732 telemedicine services which can lead to more positive results. Moreover,
PR2 0.936
the service providers of telemedicine should focus on the provision of
P P1 0.747 0.752 0.856 0.728
P2 0.973 various incentives among rural communities which will encourage them
UI UI1 0.833 0.697 0.873 0.782 to promote this technology as well.
UI2 0.856 The research results for trust (t ¼ 2.401, β ¼ 0.145) indicate its
UI3 0.815 significance for large scale implementation of telemedicine services and
a
AVE ¼ Average variance extracted. confirm the findings of previous studies [80,81]. Trust signifies the faith
b
CR¼ Composite Reliability. users place in telemedicine services for acquiring better health services

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S.A. Kamal et al. Technology in Society 60 (2020) 101212

Table 4
Correlation analysis.
Constructs T PU PEOU SI FC TA RC PR P UI

T 1
PU 0.454 1
PEOU 0.567 0.650 1
S1 0.542 0.556 0.611 1
FC 0.511 0.544 0.579 0.687 1
TA 0.256 0.356 0.455 0.627 0.410 1
RC 0.249 0.464 0.405 0.599 0.394 0.378 1
PR 0.443 0.454 0.507 0.634 0.396 0.384 0.393 1
P 0.029 0.042 0.029 0.150 0.157 0.108 0.488 0.081 1
UI 0.559 0.674 0.509 0.524 0.687 0.627 0.599 0.634 0.150 1

programs where affordability of end-users is carefully gauged. Eventu­

Table 5
ally, a cost-effective recovery mechanism will encourage both physi­
Analysis of the model.
cians and patients to adopt telemedicine services.
Hypothesis Path T-values Conclusion According to findings of this study, it was identified that resistance to
Coefficients
technology (β ¼ 0.158, t ¼ 3.091), and technological anxiety (β ¼ -
H1: Trust positively influences the 0.145 2.401 > Supported 0.242, t ¼ 5.053), had a significantly negative relationship with the
intention to use telemedicine 1.96
usage intention. It is because that in a developing country like Pakistan
services.
H2: Perceived usefulness positively 0.313 4.428 > Supported
where people don’t have frequent access to doctors, most of the people
influence the intention to use 1.96 prefer a face-to-face meeting with doctors instead of relying on remote
telemedicine services. modes of communication and diagnosis. Although, it can be seen from
H3: Perceived ease of use positively 0.148 2.207 > Supported the demographic characteristics that nearly 48% of the total respondents
influences the intention to use 1.96
had access to the internet. However, the idea of using the internet or
telemedicine services.
H4: Social influence positively 0.161 2.629 > Supported mobile services for health care procedures is still relevantly new for
influences the intention to use 1.96 them to adopt. Therefore, awareness campaigns and programs need to
telemedicine services. be designed in rural areas for public awareness as it will help to reduce
H5: Facilitating conditions positively 0.126 2.190 > Supported the resistance towards the acceptance of telemedicine services.
influence the intention to use 1.96
telemedicine services.
Perceived risk (β ¼ - 0.160, t ¼ 2.996) is also seen as a major barrier
H6: Technological anxiety negatively - 0.242 5.053 > Supported for acceptance of telemedicine services, confirming its effect on usage
influences the intention to use 1.96 intention in the context of health care studies [78,85]. Due to meager
telemedicine services. health resources, people of a developing country like Pakistan associate
H7: User’s resistance negatively - 0.158 3.091 > Supported
a perceived sense of risk with the adoption of new technology. Not to
influences the intention to use 1.96
telemedicine services. forget the digital barrier and limited technical competencies further
H8: Perceived risk negatively - 0.160 2.996 > Supported increase the resistance to adopt Telemedicine. On the other hand, ac­
influences the intention to use 1.96 cording to findings of this study, facilitating people with adequate
telemedicine services. infrastructure will aid them in adapting telemedicine, which is the need
H9: Privacy negatively influences the 0.035 1.281 < Not
intention to use telemedicine 1.96 Supported
of the hour and consistent with the previous studies of TAM.
services. It is also important to note that another prime factor for enhancing
the awareness regarding telemedicine services among the public is the
Significant at p-value (p < 0.05); Arrows exhibit the direct relationship between
formulation of viable policies and regulations, the responsibility of
the independent and dependent variable.
which solely lies on the government. Unfortunately, Pakistan lacks any
formal policy regarding implementation of telemedicine, encouraging
in the future. If people living in rural areas start believing that tele­
and guiding service providers, health care professionals, and users to
medicine services are effectively reliable, then they will have fewer
utilize these services. Hence, the government should place a strong
doubts about using these services. Therefore, service providers of tele­
emphasize on devising policies and mechanisms to effectively commu­
medicine services should work on establishing trust among users. This
nicate the clinical utility of telemedicine among service providers and
can be accomplished if users are provided with multiple service offers
users.
and ubiquitous access.
Based on the results of hypotheses testing, it can be seen that facil­
7. Conclusions and recommendations
itating conditions (β ¼ 0.126, t ¼ 2.190) are highlighted as significant
drivers for acceptance of telemedicine services. These research findings
Telemedicine in Pakistan has a great potential to serve the country’s
are in line with the findings of previous studies [82–84]. People living in
declining health care system. Telemedicine services can serve as an in­
rural areas fully comprehend the importance of adequate technical
tegral building block of the existing traditional health set up in Pakistan.
infrastructure and its subsequent impact upon usage intention. There­
The research study developed a theoretical model based on TAM to
fore, the government of Pakistan actively needs to collaborate with
investigate factors influencing the acceptance of telemedicine service.
stakeholders to launch health care incentives and interventions for
This research study explored the drivers and barriers influencing the
telemedicine services. For instance, the government of Pakistan can
willingness of patients to utilize telemedicine services. The research
collaborate with telecommunication companies to provide easy access
findings highlight that perceived usefulness, perceived ease of use, social
to internet facilities to residents of rural areas. It can also launch ini­
influence, facilitating conditions, and trust are main drivers influencing
tiatives by engaging primary health care providers, doctors, and physi­
the acceptance of telemedicine services. However, technological anxi­
cians in the research stream of telemedicine services. Tele-care units
ety, resistance to technology and perceived risk can inhibit the accep­
should be established in remote areas of Pakistan and must be given
tance of telemedicine services. Privacy was found to be an insignificant
complete financial support so that monetary concerns do not discourage
determinant of usage intention and there was no significant correlation
people. Such initiatives can lead to the design and development of

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S.A. Kamal et al. Technology in Society 60 (2020) 101212

Fig. 2. Research model.

between privacy and intention to utilize telemedicine services. facilitating conditions, social influence, technological anxiety and,
Regardless of the substantial influence of facilitating conditions and perceived risk; telemedicine service providers, planners, and policy­
social influence on the acceptance of telemedicine services, it can be makers can design better strategies for the successful implementation
seen that people of Pakistan are not provided with adequate opportu­ and adoption of these services in a developing country. Because of the
nities to utilize telemedicine services. It was identified that trust is an empirical approach of this study, the research findings can be easily
essential determinant for acceptance of telemedicine services. Thus a applied to the health care settings of other developing countries for the
higher level of trust in telemedicine systems can significantly enhance uptake of telemedicine services.
the usage intention of patients.
It is also suggested that new education-support programs and 8. Limitations
development initiatives should be introduced to encourage people for
the acceptance of telemedicine services. However, the focus of these The end-participants of this study were mainly patients, despite the
support programs shouldn’t be restricted to develop evidence-based involvement of multiple other entities in the health care system. Firstly,
telemedicine interventions and the formulation of recommendations the research study population primarily consisted of a mixed sample
and guidelines. Instead, the focus should also be on increasing the (rural and urban). Hence it is recommended for future studies to explore
awareness and acceptance of telemedicine services not only among the the acceptance of telemedicine services using the research sample which
users but among all the stakeholders of the health care system as well. is more representative of the survey population. Further studies are
The findings of this study contribute to the existing body of knowl­ essentially required to explore the other substantial antecedents in the
edge regarding the design and development of telemedicine services. health care system for the acceptance of telemedicine services among
The research findings also highlight how this entire process can be made people nationwide including psychological parameters such as price
more effective for the adoption of telemedicine services among the value, hedonic motivation, self-efficacy and, habit. Additional con­
people of developing countries. This research represents the first structs such as personal motivation, innovativeness and, cultural con­
empirical study identifying barriers and drivers of telemedicine services structs should also be examined to unveil more reliable findings of the
from patients’ perspective in Pakistan based on the extension of TAM proposed model for the adoption of telemedicine services in a devel­
with additional constructs. Based on the identified factors including oping country.

Appendix A

Constructs Definitions References

Perceived Usefulness (PU) PU1: Using Telemedicine would improve the quality of my health care. [29,86,87]
PU2: Using telemedicine would improve my access to healthcare services.
PU3: Using Telemedicine would be useful in my daily routine.
Perceived ease of use (PEOU) PEOU1: I would find learning to use telemedicine would not be very difficult for me. [88,89]
PEOU2: I would find it easy for myself to interact with doctors using telemedicine.
PEOU3: Interacting with telemedicine systems would be clear and understandable for me.
Resistance to use (RC) RC1: I wouldn’t want the telemedicine to alter my traditional way of using health care services. [35]
RC2: I wouldn’t want the telemedicine to interfere or change the way I interact with doctors.
RC3: I don’t want telemedicine services to change the way I deal with my health problems and choices.
Trust (T) T1: Telemedicine services would be trustworthy for improving my health care routine [90]
T2: Telemedicine systems will require me to be cautious with this technology.
T3: I feel satisfied and confident that I will be able to rely on the benefits of telemedicine
Technology Anxiety (TA) TA1: Using telemedicine would make me feel nervous. [91,92]
TA2: Using telemedicine would make me confused and uncomfortable
(continued on next page)

8
S.A. Kamal et al. Technology in Society 60 (2020) 101212

(continued )
Constructs Definitions References

Facilitating conditions (FC) FC1: I would be able to have all the necessary resources for using the telemedicine services [93,94]
FC2: I would acquire sufficient knowledge for using telemedicine service
FC3: Telemedicine will suite well with my health care routine
Social Influence (SI) SI1: People around me who mean to me a lot would prefer if I would use telemedicine services [53,95]
SI2: People who significantly influence my behavior would prefer if I use telemedicine services.
Perceived Risk (PR) PR1: Learning how to use telemedicine services and adapting it would be a loss of my time. [90,96]
PR2: Using telemedicine systems would be a loss of money and resources.
PR3: Using telemedicine wouldn’t be compatible with my moral values and image
Usage Intention (UI) Assuming that I was given the chance to access telemedicine, I intend to use telemedicine services. [91]
Whenever I would need remote medical care from professionals, I would gladly use telemedicine services.
I intend on informing my relatives and friends about telemedicine

Appendix B. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.techsoc.2019.101212.

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