International Journal of Information Management 49 (2019) 58–68

Contents lists available at ScienceDirect

International Journal of Information Management

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

Mobile technology identity and self-efficacy: Implications for the adoption T

of clinically supported mobile health apps
⁎
Ali Balapoura, Iris Reychavb, , Rajiv Sabherwala, Joseph Azuric
a
Department of Information Systems, Sam M. Walton College of Business, University of Arkansas, Fayetteville, AR, 72701, USA
b
Department of Industrial Engineering & Management, Ariel University, P.O.B 40700, Ariel, Israel
c
Sackler Faculty of Medicine, Tel Aviv University and Maccabi Healthcare Services, Israel

A R T I C LE I N FO A B S T R A C T

Keywords: Despite smartphone applications (apps) being key enablers of telemedicine, telehealth, and self-monitoring,
mHealth apps adoption issues persist for mobile healthcare (mHealth) apps. This study diverged from the traditional adoption
IT identity approach and drew on more innovative theories to predict the intentions of patients for adopting apps supported
Self-efficacy by clinics. More specifically, technology identity literature was explored to make this prediction and the study
Mobile technology identity (MTI)
surveyed 292 patients who were seated in the waiting room of a local clinic. The results suggested that perceived
Mobile apps
mobile technology identity (MTI), perceived related IT experience, and perceived self-efficacy positively influ-
ences patients’ perceived intentions to adopt mHealth apps provided by clinics or hospitals. Furthermore, the
results suggested that perceived related IT experience positively influences users perceived self-efficacy and
perceived MTI. However, education was found to negatively influence patients’ perceived intentions to use
mHealth apps. This study contributes to the growing literature on the use of these apps in trying to elevate the
quality of patients’ lives. Moreover, there are implications for mHealth-app designers who are trying to make
healthcare services accessible via smartphones.

1. Introduction and self-monitoring (Reychav et al., 2019; Weinstein et al., 2014). The
majority of healthcare providers lack the time to provide patients with
Mobile devices are contributing greatly to the improvement of the continuous care necessary to manage chronic diseases (Quinn et al.,
people’s lifestyles and healthcare delivery (Faiola, Papautsky, & Isola, 2008), so mHealth apps can potentially compensate for this issue
2018). This significant change has taken place for two reasons: first, (Deng, Hong, Ren, Zhang, & Xiang, 2018). By extension, clinics can use
smartphone use has become much more widespread as a result of being mHealth apps for direct monitoring of patients, drug-referencing, de-
affordable and accessible to many classes of society; second, their cision support, electronic health records, medical education, and so
computational power has improved so significantly that many apps can forth (Boulos, Brewer, Karimkhani, Buller, & Dellavalle, 2014). For
now be developed and offered to enhance healthcare delivery to pa- example, apps such as InpharmD, which is adopted by some physicians,
tients (Kaphle, Chaturvedi, Chaudhuri, Krishnan, & Lesh, 2015; will help practitioners to make quicker pharmacological decisions,
Petrovčič, Rogelj, & Dolničar, 2018). Therefore, it can easily be ob- particularly in complex cases where they must spend a lot of time
served that over 325,000 mHealth apps are available at all major app searching for answers to technical questions about drugs in order to
stores (Research2Guidance, 2017) in several health-related categories avoid prescribing the incorrect medication or dosage (Wicklung, 2018).
such as fitness, cardiology, diabetes, obesity, smoking cessation, and Similarly, mHealth apps that are designed for self-monitoring can save
chronic diseases (Silva et al., 2015). The benefits of using such apps are patients from visiting clinics and also save physicians’ time with un-
many for both patients and healthcare providers: for delivering care necessary checkups which can instead be done through mobile-enabled
and monitoring patients remotely, saving time, and reducing costs computing (Mendiola, Kalnicki, & Lindenauer, 2015). As previously
(Reychav, Kumi, Sabherwal, & Azuri, 2016; Shin, Lee, & Hwang, 2017; stated, there are thousands of healthcare apps available online which
Silva et al., 2015). are attempting to push for improvements in the current state of
Smartphone apps are unrivaled enablers of telemedicine, telehealth, healthcare (Veríssimo, 2018). Nevertheless, the issue regarding

⁎
Corresponding author.
E-mail addresses: [email protected] (A. Balapour), [email protected] (I. Reychav), [email protected] (R. Sabherwal),
[email protected] (J. Azuri).

https://doi.org/10.1016/j.ijinfomgt.2019.03.005
Received 20 October 2018; Received in revised form 14 March 2019; Accepted 14 March 2019
0268-4012/ © 2019 Elsevier Ltd. All rights reserved.
A. Balapour, et al. International Journal of Information Management 49 (2019) 58–68

adoption in mHealth apps persists (Kwon, Mun, Lee, McLeod, & information technology identity, and self-efficacy; (2) articulate the
D’Angelo, 2017). hypotheses and present the research model; (3) outline the research
The adoption literature, even though widely discussed, falls behind method, analysis, and results; (4) discuss the results and highlight their
in representing and predicting the adoption of these apps, as a phe- implications for theory and practice and; (5) finally, explore the study’s
nomenon, for two reasons. First, it could be argued that adoption limitations and possible future directions as well as provide a conclu-
models in the mHealth context have relied heavily on traditional sion.
adoption theories such as Theory of Reasoned Action (TRA; Fishbein &
Ajzen, 1975; Zhang, Guo, Lai, Guo, & Li, 2014), Technology Acceptance 2. Literature review
Model (TAM; Davis, 1989; Deng et al., 2018; Dou et al., 2017) and
Unified Theory of Acceptance and Use of Technology (UTAUT; Hoque & This section will summarize the existing literature on mHealth apps
Sorwar, 2017; Venkatesh, Morris, Davis, & Davis, 2003) with minimal and self-tracking, technology identity, and self-efficacy. Next, the im-
modification to the original framework in the form of introducing new portance of these concepts in the mobile healthcare context will be
contextual variables (for example: Kwon et al., 2017; Lee & Cho, 2017; discussed and, lastly, the way in which the aforementioned concepts
Lee, Han, & Jo, 2017; Quaosar, Hoque, & Bao, 2018; Yuan, Ma, informed the research design and helped to address the proposed re-
Kanthawala, & Peng, 2015). Meanwhile, users’ internet behavior, in- search questions will be discussed.
formation consumption, and digital media use have shifted significantly
(Beaunoyer, Arsenault, Lomanowska, & Guitton, 2017). Second, some 2.1. Mobile healthcare adoption
studies on mHealth apps have collected samples that are not re-
presentative of the target population, including students or occasional The contemporary studies on adoption of mobile apps and services
app users who may or may not be patients (Kwon et al., 2017; Lee & relied on variety of theories such as TAM, UTUAT, TRA, and IS Success
Cho, 2017; Lee et al., 2017; Quaosar et al., 2018; Yuan et al., 2015). model to predict adoption of mobile apps by users (Alalwan, Dwivedi,
While traditional literature can explain patients’ intentions to adopt Rana, & Williams, 2016; Alalwan, Dwivedi, & Rana, 2017; Baabdullah,
mHealth apps, there are other overarching concepts that may play a Alalwan, Rana, Kizgin, & Patil, 2019; Malaquias & Hwang, 2019;
role, especially in the mobile context, such as technology identity Shareef, Dwivedi, Kumar, & Kumar, 2017; Shaw & Sergueeva, 2019;
theory (Carter & Grover, 2015). The purpose of this study, therefore, Wang, Ou, & Chen, 2019). For example, in the mobile banking context,
was to address these gaps. Alalwan et al. (2017) found that hedonic motivation, performance ex-
Against this backdrop, the above issues will be discussed and an pectancy, effort expectancy, price value, and trust are main predictors
adoption model for mHealth apps will be proposed that is clinically of users’ intention to adopt mobile apps. Baabdullah et al. (2019) ex-
supported and which connects patients with clinics and physicians tended Alalwan et al. (2017) by combining the IS success model with
using IT identity theory (Carter & Grover, 2015) and self-efficacy UTAUT2 and found that habit, service quality, and system quality will
(Compeau & Higgins, 1995). Mobile technology is becoming an integral play an important role in the adoption of apps. In addition, there are
part of the individual’s self-identity and such a phenomenon is affecting studies that identified factors such as trust and user satisfaction as the
people’s daily lives, decisions, and behavior (Alahmad, Carter, Pierce, & main driver of adoption (Fox & Connolly, 2018; Shareef et al., 2017;
Robert, 2018; Carter & Grover, 2015; Carter, Grover, & Thatcher, Wang et al., 2019). On the other hand, there is an established niche that
2016). Recent works show that MTI theory which builds on IT identity specifically focused on the adoption of mHealth apps.
theory is a relevant lens through which to explain the interaction of Mobile apps in healthcare can be recognized as both emerging and
patients with mHealth apps (Reychav et al., 2019). In thus study, MTI enabling technologies that are in use in many countries. These apps can
refers to the extent to which an individual views use of mobile tech- reduce the number of hospital or clinic visits and atomize the mon-
nology as integral to his or her sense of self (Carter & Grover, 2015). itoring process of patients by physicians. This facilitating technology
Thus, creating opportunities for further application of this theory in not only helps patients but also physicians and hospital staff who can
mHealth studies. In short, an attempt will be made to find an answer to benefit from wearable and mobile app devices (Wu, Wang, & Lin, 2007;
the following research questions: Wu, Li, & Fu, 2011). Nowadays, smartphones are easily accessible and
offer unique processing powers that allow for complex apps to run, such
(1) What are the effects of mobile technology identity and self-efficacy on as those that provide health services. Reasonably, self-tracking devices
the adoption intentions of patients with regard to telehealth apps? (for example, the Fitbit) are particularly designed for tracking patients’
(2) What is the effect of prior experience on adoption intention, perceived health, but they are not as widespread and accessible as mobile apps on
self-efficacy, and perceived mobile technology identity? smartphones. Thus, mHealth apps remain the most accessible form of
affordable healthcare services for patients and can even be used for
By addressing these questions, this study contributes to mHealth tracking health status (via measures of blood pressure and weight, for
literature and practice. By utilizing a new theory – that is, MTI – the instance) through self-reports. Furthermore, there is a wide range of
literature will be extended beyond the traditional adoption models. In apps available related to fitness, cardiology, diabetes, obesity, smoking
particular, MTI affects individuals’ behavior (Carter et al., 2016) and cessation, and chronic disease tracking for all age ranges (Lim & Noh,
has become an integral aspect of self-identity. In using such a novel 2017; Silva et al., 2015).
approach, it is hoped that: (a) future researchers will be motivated to Adoption of general mHealth apps has been studied through mul-
adopt MTI theory in their study of mobile apps within and beyond tiple lenses such as extrinsic/ intrinsic motivation, ease of use, useful-
healthcare settings; (b) this emerging theory, which is in its early ness, privacy concerns, risk beliefs, self-efficacy, autonomy, and control
stages, will be contextualized. Without such contextualization and ap- (Fox & Connolly, 2018; Liu, Ngai, & Ju, 2019; Zhao, Ni, & Zhou, 2018).
plication, the generalizability of theories is not achievable; thus, an- However, there is a paucity of research dedicated to the adoption of
other contribution of this study will be the application of IT identity focused mHealth apps which are designed, supported, and sponsored by
theory in the mHealth context (Johns, 2006; Hong, Chan, Thong, clinics and hospitals for the purpose of tracking their own visiting pa-
Chasalow, & Dhillon, 2013). Furthermore, developers who have been tients and which this study attempted to address. The purpose of these
working to produce apps for patients’ continuous use can attempt to apps is to reduce the frequency of visits and track patients with special
manipulate and benefit from or its sub-dimensions (Dependency, Re- needs. There are two elements at play here: one is the acceptance of
levance, and Emotional Energy; Carter & Grover, 2015) so as to de- these apps by physicians and healthcare professionals (Chen, Lieffers,
termine the success of their apps. This paper will do the following: (1) Bauman, Hanning, & Allman‐Farinelli, 2017) prior to authorization for
review and discuss the existing literature on mobile healthcare, patient use; as well as patients’ own willingness to use these apps. Wu

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et al. (2007) and Wu et al. (2011) studied the former whilst this study Emotional energy refers to “an individual’s enduring feelings of
addressed the acceptance of such apps by their target patients. emotional attachment and enthusiasm in relation to an IT or class of
ITs” (Carter, 2012, p. 115). The result of continuous and long-term
2.2. Information technology identity interaction with an IT device is a feeling of confidence, energy, and
enthusiasm in relation to the self. In fact, a lack of these emotions
Individuals identify themselves through self-categorization and so- among individuals creates negative feelings such as boredom
cial comparison. People see themselves as members of organizations, (Hackbarth, Grover, & Mun, 2003). For example: “The phone is a means
religions, families, and so forth (Ashforth & Mael, 1989). Self-categor- to inform and empower us. It can be something as simple as avoiding
ization in nature serves two functions: for individuals to put the social traffic or checking the price of an item at different stores. Either way,
environment into order and also so that they may understand and you have the power and the control… you live by your schedule and
perceive the identity of their peers within the environment (Stets & don’t have to wait for others. Your self-esteem is then fuelled by that
Burke, 2000). How individuals perceive and understand categories, power, so you feel more secure.” (Carter, 2012, p. 22). The impact of
classifications and roles are predominantly affected by the cultural the device in terms of emotional dependency varies based on individual
characteristics, values, and norms that make his or her identity unique. beliefs and personality (Clayton & Opotow, 2003). For some, the ab-
Similarly, individuals perceive others in comparison to themselves sence of a mobile phone that holds their personal information, mem-
based on the same elements of personality, cultural norms, and values. ories, and documentation of their emotions (such as photos and videos)
As a result, an individual’s identity is subjective. It should also be re- in relation to previous interactions of the individual with the device
minded that the aggregation of parallel categorizations builds an in- (Vincent, 2006) can cause emotional trauma.
dividual’s identity so that they do not experience conflict (Carter & The last dimension, relatedness, refers to “a blurring of boundaries
Grover, 2015). For example, being a wife and mother together form a between notions of the self and an IT experienced as feelings of con-
female’s identity without contradiction. This combination of categories nectedness with an IT or class of ITs” (Carter, 2012, p. 114). This di-
contributes to the consistency and integrity of a person’s identity, dis- mension reflects the fact that individuals incorporate resources and the
ruption of which could lead to an identity crisis and the beginning of characteristics of their devices within their individual self-concept; as a
the self-re-identification route. Individuals develop self-identity which, consequence, they feel intimately connected to these IT devices.
over time, continuously develops and stabilizes through loops of feed- Clayton and Opotow (2003) claimed that relatedness is the most
back and change. sought-after component of the perceived personal identity. Carter et al.
An embodiment of self-categorization is seeing IT (the object of (2013) showed that the level of significance which individuals assign to
attention) as integral to the sense of self. Therefore, IT identity is de- the use of mobile phones affects their feeling of relatedness to the de-
fined as “the extent to which a person views use of IT as integral to his vice. People who use their phones more for communication and as a
or her sense of self” (Carter & Grover, 2015, p. 938). Traditionally, the means of connecting with their surroundings tend to identify them-
role of IT has been to enhance and overcome humans’ neuro- and selves more with relatedness than other dimensions. Loss of a device for
physio-logical limitations (Bakos & Treacy, 1986). IT has empowered these individuals tends to cause severe feelings of detachment from
individuals to the extent that without it the individual would feel their surroundings.
something of the self is missing. The wide application of IT becomes In the healthcare setting, recent literature proposed that the use of
part of the individual and the daily roles they maintain. For example, wearable fitness devices at the workplace could affect users’ IT identity.
young people’s engagement with their mobile phones is related to their In particular, businesses are promoting the use of such devices, which
self-concept (Walsh, White, & Young, 2010) and the sense of empow- are becoming integral to individuals’ identity owing to the frequency of
erment an individual feels as a result of using IT devices (e.g. smart- interaction and on which they are developing am emotional de-
phones and tablets) pushes the demand for access to them in everyday pendency (Giddens, Gonzalez, & Leidner, 2016). Savoli and Bhatt
life. Consequently, IT becomes so embedded in individuals’ lives that it (2017) proposed that IT identity directly influences emotion relating to
becomes ensnared with their identity and personality in different si- IT which, in turn, affects patients’ decisions on whether or not to adopt
tuations (Carter, 2012). The existing literature on identity theory does healthcare outlets (e.g. devices, apps, and so on). Carter et al. (2013)
not explore the relationship with objects as part of one’s identity per- also found that mobile devices are becoming part of an individual’s
ception (Clayton & Opotow, 2003; Stets & Biga, 2003). However, the identity. Accordingly, this study adopted IT identity and its dimension
“embeddedness” of IT with oneself takes the concept of identity to to predict users’ adoption of healthcare mobile apps used for self-
another level – that is, the individual now has IT-enabled identities (e.g. tracking.
being a better employee, mother, or wife) and IT identity (seeing IT as
an inseparable part of the self). 2.3. Self-efficacy
Carter (2012) proposed three dimensions for IT identity that re-
present an individual’s self-perception in relation to IT: Dependency, Self-efficacy refers to an individual’s judgments of their ability to
emotional energy, and relatedness. Dependency refers to “the degree of organize and execute courses of action required to attain designated
reliance a person feels on a particular IT or class of ITs as a source of types of performance (Bandura, 1986). This concept has been adopted
personal well-being” (Carter, 2012, p. 115). IT is so prevalent and in- and applied to Information System (IS) research by Compeau and
tuitive that businesses, the social environment, and personal lives de- Higgins (1995). When using a device such as a computer, higher self-
pend upon it, so it constitutes individuals’ identity. As such, individuals efficacy leads to easier use and lower resistance. In this context, the
express the feeling of a great need for IT devices and rely on them. For computer may simply be replaced with an mHealth app, which was
example: “The one day of not having my phone available for use made done in the study outlined in this paper as an adopted measure to obtain
me realize how dependent I have become on it…. My phone is like a subjectivity regarding how users believe in their capabilities to use
lifeline to me.” (Carter et al., 2016, p. 1438). The frequency of IT usage mHealth apps.
directly affects an individual’s dependency on a device for conducting Contemporary studies showed that self-efficacy affects behavioral
social relationships, resolving work-related issues, and pursuing leisure intention to adopt e-government, e-commerce, and mobile apps and
and fun (Carter, Grover, & Thatcher, 2013, 2016). In a high-de- services both directly and indirectly (Irani, Dwivedi, & Williams, 2009;
pendency situation, if a device malfunctions, the user experiences in- Alalwan, Dwivedi, Rana, Lal, & Williams, 2015, 2016; Fox & Connolly,
convenience. However, in the absence of said device, the user becomes 2018; Rana & Dwivedi, 2015; Rana, Dwivedi, & Williams, 2015;
vulnerable and instead experiences emotional tension, panic, anxiety, Shareef, Kumar, Kumar, & Dwivedi, 2011; Shaw & Sergueeva, 2019).
and fear. Lim and Noh (2017) studied the adoption of fitness apps and found that

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Fig. 1. Research model.

self-efficacy promotes healthy behavior and adoption of such apps. Si- 2014). Consistently, this paper argues that users who have experience
milarly, Fox and Connolly (2018) found that mHealth self-efficacy po- using mHealth apps are more inclined to adopt a particular mHealth
sitively influences the mHealth adoption intentions. However, there are app designed to facilitate their care delivery. Evidently, this prior ex-
some contradictory findings with respect to its effect in the mHealth perience removes cognitive barriers or users’ resistance toward adop-
context (Rana et al., 2015). On the contrary, Asimakopoulos, tion of these apps. Thus:
Asimakopoulos, and Spillers, (2017) found that neither general self-
H1. Perceived related IT experience positively influences perceived
efficacy nor computer self-efficacy have any effect on participants’ at-
intention to use mHealth apps.
titudes toward mobile fitness-tracking health technology. Surprisingly,
empirical results also show that computer self-efficacy can negatively It is argued that prior experience also affects self-efficacy.
influence the intention of patients to adopt mHealth (Bhatnagar, Knowledge of using similar apps and smartphones, in general, is likely
Madden, & Levy, 2017). Theoretically, this concept should be a relevant to affect users’ judgment of their own abilities to use a specific mHealth
and well-established predictor of mHealth adoption, but empirical re- app for reporting their health status or for other medical services
sults are conflicting. As such, this study will further investigate the (Zhang et al., 2016). In particular, the way in which knowledge re-
effect of this construct. moves barriers to learning and adoption has been discussed and how
this alters users’ perceptions in assessing his/her abilities to use
mHealth apps. As such, advanced prior IT experience positively influ-
3. Hypothesis development
ences self-efficacy. Thus:

In this section, we develop hypotheses and a theoretical model H2. Perceived related IT experience positively influences perceived self-
based on adoption, technology identity, and self-efficacy literature. efficacy.
Fig. 1 summarizes the proposed research model. In short, it is suggested
Experience of mobile devices increases as a result of day-to-day use
that related IT experience affects self-efficacy, MTI, and adoption in-
of mobile apps. The more experience gained as a result of regularly
tentions; further, it is argued that self-efficacy and mobile identity are
checking the mHealth app the more dependency on the mobile device
the predictors of adoption intentions.
grows (Carter et al., 2016). Carter and Grover (2015) suggested that
The first three hypotheses deal with the effects of prior IT experi-
dependency is a dimension of IT identity and they emphasized the
ence on self-efficacy, MTI and adoption intentions. Prior IT experience
functional features that come with the device (e.g. email, alarm clock,
specifically refers to users’ previous experience of mHealth apps. In the
group messaging system, social media, and mHealth apps). They also
mid-nineties, Taylor and Todd (1995) published a paper in MIS Quar-
gave examples of how these practical features increase user interaction
terly highlighting the sole role of prior IT experience in IT usage. The
with the device. This could include mHealth apps which require the
underlying logic of prior experience is that “knowledge gained from
user to (a) report their health status frequently during the week; (b)
past behavior shape human intentions because experience makes
pose questions to physicians through the app; (c) make appointments;
knowledge more accessible in memory” (Taylor & Todd, 1995). A sig-
(d) receive dietary plans or reminders to take medication, and so forth.
nificant body of research suggests that without direct experience of
Consequently, as knowledge of how to use mobile apps and smart-
interaction with objects (mobile apps in this case), users’ acceptance of
phones increases, dependency on these devices grows. Similarly, prior
it is the mere result of group norms or peer pressure, which can lead to
studies have discussed this effect by showing that proficiency with
failure (Venkatesh & Morris, 2000). Users’ experience of software pro-
devices through continued use increases dependency on the device it-
ducts is valuable to developers because knowledge barriers and high
self (Lin, Chiang, & Jiang, 2015; Park, Kim, Shon, & Shim, 2013).
learning needs in relation to newly developed software can impose
Moreover, mHealth apps that are specifically designed to foster the
considerable unfavorable costs on providers (Mellarkod, Appan, Jones,
relationship between clinics and patients make users feel empowered to
& Sherif, 2007). However, when users have prior experience with such
achieve things they could not achieve otherwise, as discussed. For in-
apps they are more prone to adopt them. This effect on adoption in-
stance, an enormous advantage for users is that their frequency of visits
tentions has been studied and the results suggest that it is an important
to clinics can be reduced through the use of these apps thus saving time.
factor which has both direct and indirect effects on shaping users’ at-
Emotional energy (another dimension of IT identity devised by Carter &
titudes toward IT usage (Al-Qeisi, Dennis, Alamanos, & Jayawardhena,

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Grover, 2015) refers to the feelings of empowerment, excitement, se- mHealth apps supported by clinicians and targeted to facilitate the re-
curity, and energy as the result of using IT. One extremely useful feature lationship between health clinics and patients. Given that prior studies
of mHealth apps is that they empower users and elevate their emotional have emphasized how clinicians’ own self-efficacy and approval of
energy which makes them identify themselves with using a mobile mHealth apps can impact patient uptake of such apps (Chen & Allman-
device. Users’ knowledge and prior experience with these apps can Farinelli, 2018), an attempt was made to factor this into the study de-
elevate this emotional energy by awakening its potentials within the sign, as explained in the following sub-section.
user, making them more efficient in using their smartphones as a result
of gaining experience through daily use. Hence, it was hypothesized
that: 4.1. Study setting and participants
H3. Perceived related IT experience positively influences perceived
The participants in this study were adults who made use of
mobile technology identity.
healthcare services at a clinic in the center of Israel, one of the main
Self-efficacy becomes important in this context because patients branches of the National Health Fund. While patients were in the
must use it for reporting their status. If they believe they cannot use clinic’s waiting room during their visit, they were asked to use an app
their mobile device for this purpose, the whole idea of developing an on their smartphones or tablets to report their health status (height,
app for monitoring patients at clinics becomes fruitless. Computer self- weight, blood pressure etc.) and to complete a short online ques-
efficacy was found to be a precursor to computer use by Compeau and tionnaire via the same device. At the very beginning of the process, the
Higgins (1995). In particular, believing in one’s ability to use IT devices patients were informed that participation in the study was voluntary
is expected to motivate use when necessary. While it has been studied and that their personal information would remain confidential. They
widely in internet and mobile contexts (Alalwan et al., 2015, 2016; were additionally assured that participation would have no influence
Irani et al., 2009;), the self-efficacy has been found to affect adoption in on their treatment. The entire process – from distribution of the ques-
the healthcare information system by indirectly (Rana & Dwivedi, tionnaire to the taking of measurements – was conducted at the health
2015) or directly (Fox & Connolly, 2018) affecting behavioral intention clinic by a research team of nurses who had received appropriate
to adopt. Following the above rationale as discussed by Compeau and training and were authorized by the management of the health care
Higgins (1995) it was hypothesized that: provider and the branch administration. Furthermore, the branch em-
ployees and medical staff were provided with an explanation of the
H4. Perceived self-efficacy positively influences perceived intention to
study's purposes and objectives in order to facilitate the process of data
use mobile for reporting health status.
collection and collaboration if patients had questions. To operationalize
Carter and Grover (2015) listed three behavioral consequences of IT the constructs in this study, scales from the existing literature were
identity: device feature use behavior, enhanced use, and resistance used. The constructs were measured along a five-point Likert scale (1 =
behavior and claim that MTI can lead to both resistance and adoption. Strongly agree; 2 = Agree; 3 = Neutral; 4 = Disagree; 5 = Strongly
In a group setting, members’ identity is defined in terms of complying disagree); the items and sources are shown in Appendix A.
with the affective, cognitive, relational, and evaluative components of Overall, 292 subjects participated in the study. A number of in-
the group which reinforces identity. This includes IS-usage behavior for dividuals did not answer all the demographic questions (e.g. 19 did not
participating and engaging with the community as one form of com- report their age and one person did not report on education), but it was
pliance (Pan, Lu, Wang, & Chau, 2017). Self-identification with IT is decided that their responses would be retained as they had completed
recognized as the extent to which the use of a particular technology is all the measurement questions. This process provided 266 useful re-
an integral part of the self (Alahmad et al., 2018). Prior studies have sponses. Table 1 summarizes the descriptive statistics of the clinical
examined the effect of social identity on IS-usage behavior, yet tech- patients who volunteered to participate in this study.
nology identity, which is a recently developed concept, has not been
very well explored in the context of usage behavior, even though it is
inherently linked to adoption (Pan et al., 2017). This paper argues that 4.2. Survey analysis
higher levels of MTI lead to higher motivation to adopt a specific
mHealth app because high MTI means the individual is highly depen- The constructs were tested for reliability and validity. The
dent on the device and very enthusiastic about using it and, subse- Cronbach’s alpha for Dependence, Emotional Energy, Related IT ex-
quently, feels a sense of connection with it. As such, this sense of en- perience, Intention to Use and Self-efficacy were above the suggested
thusiasm regarding the device may increase the individual’s motivation value of 0.70 (Hair, Anderson, Tatham, & Black, 2006). The relatedness
to adopt mHealth apps. Similarly, when feelings of dependence or re- dimension of identity was excluded due to reliability and validity is-
latedness to the device are high, individuals are more motivated to sues. In addition, one or two items from the dimensions of identity were
adopt mHealth apps because they can elevate these feelings as dimen- removed in the analysis process due to not meeting the same reliability
sions of identity, according to Carter and Grover (2015). Therefore: or validity requirements in the confirmatory factor analysis process
(Hair et al., 2006). The results of the principal component analysis
H5. perceived mobile technology identity positively influences
suggested that the items met the threshold of 0.40 in terms of their
perceived intention to use mobile apps for reporting health status.
reciprocal factors (Table 2). Next, common method variance tests were
This study outlined in this paper also included age, gender, and performed (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003).
education as the control variables since existing literature on adoption Harmon’s one-factor test was carried out by allowing all items to
suggests that these elements affect behavioral intentions either directly load on a single factor. The emerging factor explained 40 percent of the
or indirectly (Venkatesh et al., 2003; Venkatesh, Thong, & Xu, 2012). total variance; given that this number was under 50 the common
Consequently, these factors were included in the proposed model in the method bias was not a concern. After this, an unmeasured latent-factor
hope that it would enrich understanding of the adoption of mHealth method was employed in conjunction with a measurement model by
apps by patients for self-monitoring. adding a common factor, fixing its variance to ‘one’ and adding paths
from this factor to all observed variables in the model, fixing the
4. Method loadings so as to render these paths equal. The estimated coefficient for
this path was 0.42 and the square of this value produced the common
To test the proposed research model, a study was conducted in a variance, which was about 17 percent, thus the common method bias
medical setting in order to capture actual patients’ thoughts about those was not a concern in this sample (Podsakoff et al., 2003).

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Table 1 & Larcker, 1981). All composite reliabilities exceed 0.70. In summary,
Descriptive statistics. these results show convergent and discriminant validities of the mea-
Variables Frequency Percent sures.

Age: 5. Results
18–30 59 22.18
31–60 123 46.24
61+ 65 24.44
Given that the structural model includes demographics as the con-
NA 19 7.14 trols and, as discussed, a few respondents did not fully complete this
Gender: information (see Table 1), a “missing value" estimation was included in
Male 91 31.12 the analysis of the structural model using maximum likelihood for the
Female 175 59.31
missing values in STATA. The results of the structural model are pre-
NA 26 8.9
Education: sented in Fig. 2. The fit indices for the structural model met the re-
Academic 150 51.36 commended values according to prior studies (Gefen et al., 2000):
Non-academic 115 39.38 RMSEA = 0.05; CFI = 0.96; TLI = 0.95; χ2/degree of freedom =
NA 27 9.24
204.64 (d.f. = 117; p < 0.001); N = 266. Fig. 2 suggests that related
BMI groups*:
Underweight (0-18.49) 4 1.36
past experience with IT positively influenced intention to use mHealth
Normal (18.5 – 24.99) 103 35.27 apps for self-report of health status by patients (β = 0.23, p < 0.01),
Overweight (25 – 29.99) 88 30.13 thus H1 was supported. Relevant past experience also positively af-
Obese (30 or more) 39 13.35 fected perceived self-efficacy among patients (β = 0.46, p < 0.01) and
NA 58 19.86
perceived MTI (β = 0.49, p < 0.01); therefore, H2 and H3 were sup-
Systolic blood pressure*:
Low (Under 90) 5 1.71 ported. Furthermore, the results suggested that perceived self-efficacy
Normal (91-120) 141 48.29 positively influenced intention to use (β = 0.54, p < 0.01), so H4 was
Pre-high (121-140) 90 30.82 supported. Similarly, it was found that perceived MTI positively influ-
High (141 and above) 56 19.18 enced intention to use (β = 0.16, p < 0.05), supporting H5 as well. A
Diastolic blood pressure*:
Low (under 60) 21 7.19
mixed result, however, was found regarding the effects of the control
Normal (61-80) 174 59.58 variables. In particular, it was noted that the effects of age (β = 0.07,
Pre-high (81-90) 45 15.41 p = 0.17) and gender (β = -0.06, p = 0.16) were not statistically sig-
High (91 and above) 42 14.38 nificant on intention to use mHealth apps, but education level nega-
NA 10 3.42
tively influenced this intention (β = -0.09, p < 0.10).
NA = No access (not reported by the patient).
* Based on CDC.gov standards. 6. Discussion

Table 2 MHealth apps are rapidly changing the landscape of healthcare

Principle component analysis. delivery. Thousands of healthcare apps are available online which at-
tempt to push for improvements in the current state of healthcare
Variable Comp1 Comp2 Comp3 Comp4 Comp5 Unexplained
(Veríssimo, 2018). However, the adoption and diffusion of these apps is
IntUse1 0.5735 −0.0192 −0.03 0.0201 0.066 0.139 an issue that the literature is trying to address (Kwon et al., 2017). The
IntUse2 0.5955 −0.0016 −0.0676 0.0096 0.0611 0.1357 study in this paper diverged from the traditional adoption approach
IntUse3 0.4473 0.051 0.1138 −0.0286 −0.1045 0.3172 used in mHealth literature (Kwon et al., 2017; Lee & Cho, 2017; Lee
IDep1 −0.1328 0.5522 0.0856 0.0383 0.0493 0.2358
et al., 2017; Quaosar et al., 2018; Yuan et al., 2015) and used the more
IDep2 0.0948 0.6156 −0.0859 −0.0737 −0.0675 0.2589
IDep3 0.0011 0.5126 −0.0477 0.0437 0.052 0.3461 innovative MTI theory. Moreover, the study focused on those apps that
SelfEff1 0.0303 0.0004 0.5397 0.0177 0.0062 0.2657 would facilitate the relationship between patients and physicians or
SelfEff3 −0.0831 −0.0474 0.67 −0.031 0.005 0.2214 clinics which has been raised as a challenge for health research
SelfEff3 0.2228 0.0261 0.4023 0.0066 −0.0875 0.235
(Chandwani, De, & Dwivedi, 2018). Many mHealth apps are very
Pex1 −0.011 0.0613 0.007 0.607 −0.0498 0.1502
Pex2 0.0001 −0.1373 −0.0728 0.6081 0.1344 0.2424
general and are used without the supervision of the individual’s family
Pex3 0.0462 0.096 0.0762 0.4929 −0.1513 0.2733 doctors. However, when these apps are offered by clinics, the use of
IEng1 −0.1456 0.0873 0.1989 0.0646 0.4307 0.4108 such apps becomes very important because patient interaction with the
IEng2 0.0836 0.0653 0.0621 −0.0538 0.5477 0.2554 app is monitored by the clinic and family doctors. As such, this study
IEng3 0.0431 −0.0613 −0.0895 0.0172 0.6593 0.2667
attempted to shed light on the factors that affect patients’ attitudes
IntUse = Intention to use; IDep = Dependence (MTI dimension); toward the adoption of mHealth apps offered by healthcare providers
IEng = Emotional energy (MTI dimension); SelfEff = Self-efficacy; for close monitoring of their health status. The theories of technology
Pex = Related IT experience. identity (Carter & Grover, 2015) and self-efficacy (Compeau & Higgins,
1995) were relied upon to predict individuals’ intention to use such
4.3. Measurement model mobile apps. To test the hypotheses, patients were surveyed in the
clinic waiting room. In particular, it was found that self-efficacy posi-
The examined measurement model met the recommended fit indices tively influenced patients’ intentions to use mobile apps for reporting
(Fornell & Larcker, 1981; Gefen, Straub, & Boudreau, 2000; Hair et al., their health status along measures such as weight, and systolic and
2006; Hu & Bentler, 1999): The indices were as follows: RMSEA = 0.05; diastolic blood pressure. Compeau and Higgins (1995) contextualized
CFI = 0.96; TLI = 0.95; χ2/degree of freedom = 199.29 (d.f. = 113; self-efficacy in information systems and introduced computer self-effi-
p < 0.001), all of which are within the threshold of good-fit models. cacy. This concept is applicable to other IS-related contexts such as
Table 3 shows the internal consistency and discriminant validity of mHealth apps. Likewise, Zhang et al. (2016) reported a positive effect
constructs. The diagonal represents the average variance extracted of self-efficacy on adoption intentions. The study herein similarly
(AVE) for each construct and the other cells in the discriminant validity concluded that patients’ confidence in their own ability to complete and
section show the correlations. All AVEs are above 0.5 and the square submit their own medical reports directly affected their intentions to
root of each AVE exceeds all correlations among the constructs (Fornell use such mobile apps (Hypothesis 4).
Furthermore, the results showed that MTI positively influenced the

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Table 3
Reliability and Validity.
Construct Mean Std. dev. Cronbach’s alpha CR 1 2 3 4 5 6 7

1.Education 0.56 0.49 – – – –

2.Gender 1.65 0.47 – – – –
3.Age 46.71 18.06 – – – −0.05 –
4.Identity 3.14 0.94 0.82 0.84 – 0.13* −0.33*** 0.85
5.Self-efficacy 3.85 1.07 0.83 0.82 – 0.05 −0.21*** 0.39*** 0.78
6.Related IT experience 2.67 1.30 0.82 0.84 – 0.01 −0.30*** 0.38*** 0.46*** 0.72
7.Intention to use 3.74 1.17 0.88 0.83 – 0.07 −0.16** 0.39*** 0.67*** 0.50*** 0.77

Diagonal = Square root of AVE; St.d. = Standard deviation; CR = Composite Reliability.

* p < 0.05.
** p < 0.01.
*** p < 0.001.

Fig. 2. Results of the SEM model.

intentions to adopt mHealth apps (Hypothesis 5). Social identity theory experience refers to an individual’s knowledge of how to leverage
is used to explain aspects of individuals’ behavioral responses in a technology and its features to achieve a goal; thus, the greater the
particular environment, which means that behavior is affected by in- knowledge an individual possesses the greater his or her confidence in
dividuals’ sense of social identity (Stets & Biga, 2003). Technology using mHealth apps because of an expectation that the experience will
identity theory (Carter & Grover, 2015), which is based on social be familiar. Lastly, patients’ background knowledge in using similar
identity, posits that behavior manifests in forms of feature use, en- mHealth apps will contribute to their dependency on such apps and also
hanced use, and resistance in relation to IT. Carter et al. (2016) theo- create a feeling of empowerment (emotional energy; Carter & Grover,
rized that mobile phone identity affects behavior (i.e. adoption). The 2015). For instance, if a patient has used mHealth apps in the past for
MTI dimensions of emotional energy and dependence that were applied help with taking medicine on time, she or he will feel empowered and
in this study correlated well with intentions to adopt mHealth apps dependent on his or her mobile device. Without the device and app, the
provided by clinics. In particular, being confident, enthusiastic, and individual might not remember to take the pills on time. In accordance
inspired by mobile phones creates a positive attitude toward its features with prior studies, the results demonstrated that background knowl-
(one of which is mHealth apps); hence, patients are more prone to edge of an app’s capability and what it can accomplish on behalf of a
adopt such apps when offered by clinics. In a similar vein, patients’ patient affects the individual’s self-identification with mobile tech-
dependency on their phones occurs as a result of their reliance on the nology (Carter et al., 2016).
benefits they provide, such as communication, support, health man- Surprisingly, the results showed that age and gender had no effect
agement, entertainment, and so on. Therefore, dependency contributes on the intention to adopt mHealth apps. The existing literature on
to patients’ intention to adopt mHealth apps. adoption emphasizes the roles of age and gender which directly or in-
Conversely, the results showed that related IT experience positively directly influence attitude and behavioral intentions (Venkatesh et al.,
influenced the intention to adopt mHealth apps (Hypothesis 1), self- 2003, 2012); however, the results of this study did not support this
efficacy (Hypothesis 2), and MTI (hypothesis 3). By extension, the role notion. Perhaps this is because the prevalence of smartphones among
of prior IT experience has been highlighted in adoption literature and is all classes of society make it easy for individuals to use them for dif-
well-established (Al-Qeisi et al., 2014; Mellarkod et al., 2007; Taylor & ferent tasks; thus, the same behavioral intentions exist across different
Todd, 1995; Venkatesh & Morris, 2000). As such, the findings in this genders and ages. In a study of mobile banking adoption, Malaquias and
paper regarding the effects of related IT experience on the intention to Hwang (2019) also found no support for the effect of age and gender on
use mobile apps is consistent with previous studies. IT-related adoption intentions. This indeed could be different for other

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technologies (for instance, tablets or desktop computers) because establishing the background knowledge in how to use smartphones
smartphones are much more widely used in developed countries before teaching the users how to use the mHealth app. Or if the
(Anderson, 2015). This study also found that education negatively in- mHealth app is used for tracking young adults with depression, then the
fluences intention to use mHealth apps, which means that intention is provider and designer should consider that these individuals have more
greater amongst patients who are less well-educated. Logically, it might background experience with mobile use, thus more complex designs
be expected that individuals with academic degrees would show a would not bother them.
stronger intention to use mHealth apps for self-monitoring but the re- Lastly, it was found that patients holding an academic degree were
sults were contradictory. In fact, it could be that patients who are for- already using some mHealth apps or had experience using them, yet
mally educated are more skeptical about the safety and quality of these they showed less interest in adopting new ones. Perhaps this is because
apps compared to patients who are not. there are thousands of mHealth apps and the majority do not effectively
help patients. This is both a positive and negative signal for mHealth
6.1. Theoretical contribution app developers: positive in the sense that if clinics design an mHealth
app that is supervised by physicians and professional app developers,
This study makes several contributions to the mobile healthcare the quality of the app will make it stand out in a mass of impractical and
literature. First, it adds to the adoption and diffusion literature, which useless mHealth apps (Chen, Lieffers, Bauman, Hanning, & Allman-
promotes mHealth-app use for enabling healthy lifestyle management Farinelli, 2017); and negative in the sense that offering a new mHealth
by delivering health education, self-monitoring, and patient-provider app and trying to make it diffuse quickly will be challenging.
collaboration (Faiola et al., 2018). By extension, mHealth services have
not been successful even though there are many apps available for 7. Conclusion
smartphones (Lee et al., 2017) for reasons such as poor accountability
(Chen, Cade, & Allman-Farinelli, 2015) and there have been several In conclusion, this study attempted to predict the factors affecting
attempts to endorse and promote the adoption and diffusion of all types the adoption of mHealth apps provided by clinics and hospitals. To do
of mHealth apps. This literature has been extended by proposing a so, a deviation was made from traditional adoption predictors, such as
conceptual model which leverages self-efficacy and MTI as the pre- ease of use and usefulness (Davis, 1989); instead, MTI, self-efficacy, and
dictors of mHealth-app adoption. The focus here was on mHealth apps prior experience were taken as the main predictors of intention to use
that are either developed or supported by clinicians because without mHealth apps offered by healthcare providers. Surprisingly, education
clinicians’ own mHealth-app self-efficacy, the adoption of mHealth apps was negatively associated with adoption intention among patients.
by patients is less likely (Chen & Allman-Farinelli, 2018). Second, by Hospitals and clinics can leverage the findings of this study to promote
surveying real clinical patients instead of randomly surveying students their mHealth apps.
(Kwon et al., 2017; Lee & Cho, 2017) or app users (Lee et al., 2017), the
applicability and generalizability of the proposed model was enhanced. 7.1. Limitations and future research
mHealth apps should also seek to serve the appropriate target popula-
tion and, for this reason, patients were surveyed in this study in order to Despite the discussed implications, this study has limitations like
capture the essential elements that affect their adoption. Third, the many others. In the first instance, data were collected via a ques-
existing technology identity literature was extended by testing this re- tionnaire that presented issues such as high measurement errors
cently developed construct within a nomological network of causes and (Podsakoff et al., 2003). Using archival data of actual mHealth-app use
consequences (Carter & Grover, 2015). Carter et al. (2016) proposed may compensate for such limitations. Second, the data were also col-
that MTI affects behavior but their model was based on a qualitative lected in a setting where it was not possible to place too much pressure
study. The study outlined in this paper complemented their work by on patients to complete all the questions. As such, they were permitted
empirically testing the causes and consequences of MTI. to complete the survey if they felt so inclined. This resulted, therefore,
in some missing data values that slightly affected prior predictions. This
6.2. Implications for practice was compensated for by estimating the structural model using the
“missing value” option in STATA. Third, the study was conducted in
Moreover, this study has implications for practice. First of all, based one context, precluding any examination of potential cultural or con-
on the results, developers and clinics can focus on promoting self-effi- textual effects. Lastly, on data source was relied upon, although it is
cacy and educating patients on how physician-approved mHealth apps recommended that researchers use more than one sample – or even
(Chen, Lieffers, Bauman, Hanning, Allman‐Farinelli et al., 2017) could multiple sources – of data collection in order to better predict and ex-
be used to improve their health. For example, professionals can direct plain phenomena (Orlikowski & Baroudi, 1991).
patients to educational programs in community centers and universities This study recommends that future researchers investigate the role
(Fox & Connolly, 2018). On-site training is another approach that can of hedonic factors in the adoption of mHealth apps. Gamification is
improve patients’ capabilities in using mHealth apps, especially when becoming a trend among all non-entertainment apps (Hamari &
the clinicians are in favor of such apps (Alalwan et al., 2015). Altering Koivisto, 2015; Seaborn & Fels, 2015); for example, Lee et al. (2017)
patients’ attitudes will mitigate subsequent resistance behaviors. studied the effect of enjoyment on intentions to use mHealth apps but
Second, developers should actively participate in finding ways to as- did not find any correlation. As such, there is a need for further in-
sociate designed mHealth apps with patients’ MTI. That means focusing vestigation in this field. Furthermore, this paper recommends future
on the emotional energy (if not dependency) dimension of MTI so as to studies to consider factors that stimulate or affect resistance behavior
make the experience of using apps more energizing and exciting. One among mHealth-app users. It was found that education negatively in-
way of achieving this is to rely on the gamification of mHealth apps fluenced the intention to adopt such apps. This finding has implications
(Seaborn & Fels, 2015). for resistance behavior and it is suggested that future researchers in-
Third, the results of this study suggest that individuals background vestigate these factors in greater detail. Carter and Grover (2015) in-
experience in IT use can significantly change the equation in favor of troduced MTI as a reflective construct with three dimensions but the
the adoption of mHealth apps, which is good news for providers and study herein did not find a case for the reliability of relatedness (one of
designers if in early stages they identify their target users. For example, the dimensions), so it was abandoned. It is further recommended that
mHealth app targeted for elderly people with limited prior knowledge future researchers adopt MTI with all its three dimensions in different
of IT use, should consider these individuals will have low confidence in contexts and contribute to the refinement of this theory. In addition,
their mobile use abilities, so the provider should spend more time on longitudinal study designs may shed light on adoption of mHealth apps.

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MTI is one such longitudinal concept in nature and denotes the idea
that, over time, technology identity increases with continued use.

Appendix A

Measurement items

Items λ Mean St.d. Cronbach's alpha

Mobile Technology Identity : 1

– 3.14 0.94 0.82
Dependence 0.93 3.56 1.16 0.79
1 Thinking about myself in relation to a mobile device, I feel dependent on mobile device. 0.83 3.42 1.50
2 Thinking about myself in relation to a mobile device, I feel needing the device. 0.69 4.00 1.24
3 Thinking about myself in relation to a mobile device, I feel reliant on the device. 0.72 3.26 1.40
4 Thinking about myself in relation to a mobile device, I feel counting on the device.* – 3.74 1.25
Emotional Energy 0.77 2.73 0.97 0.74
1 Thinking about myself in relation to a mobile device, I feel energized. 0.63 3.15 1.12
2 Thinking about myself in relation to a mobile device, I feel enthusiastic about the device. 0.84 2.89 1.28
3 Thinking about myself in relation to a mobile device, I feel pumped up. 0.64 2.13 1.18
4 Thinking about myself in relation to a mobile device, I feel confident.* – 3.73 1.03
Self-efficacy2: – 3.85 1.07 0.82
1 I believe I can complete this medical report using mobile technology if there was no one around to tell me what to do. 0.78 3.93 1.20
2 I believe I can complete this medical report using mobile technology even if I have never used a similar technology before. 0.68 3.70 1.27
3 I am confident that I can effectively report medical information using mobile technology. 0.88 3.92 1.24
Related IT experience3: – 2.67 1.3 0.82
1 To what extent do you use applications related to health on a mobile device? 0.85 2.75 1.52
2 To what extent do you use monitoring options on a mobile device? 0.56 2.23 1.41
3 To what extent do you use the Maccabi application on a mobile device? 0.84 3.03 1.58
Intention to use4: – 3.74 1.17 0.87
1 I intend to use a mobile device app in order to maintain my health. 0.81 3.64 1.33
2 I believe I will continue using clinical mobile apps in order to maintain my health. 0.78 3.59 1.32
3 .If any health care provider will ask me to report personal health data using a mobile device app, I will do so. 0.77 4.01 1.26

1. Adopted from: Carter (2012), Carter and Grover (2015), Carter et al. (2013).
2. Adopted from: Davis (1985), Liao, Palvia, and Chen, (2009).
3. Adopted from: Compeau, Higgins, and Huff, (1999), Liao et al. (2009).
4. Adopted from: Goodhue and Thompson (1995)
* Dropped.

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