See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/318562026

Investigation of Physicians' Awareness and Use of mHealth Apps: A Mixed

Method Study

Article  in  Health Policy and Technology · July 2017

DOI: 10.1016/j.hlpt.2017.07.007

CITATIONS READS
8 567

3 authors, including:

Soner Yildirim
Middle East Technical University
96 PUBLICATIONS   1,390 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Nomophobia View project

The roadmap of transition to independence: A patient-centered research on teens with chronic conditions View project

All content following this page was uploaded by Emre Sezgin on 25 February 2020.

The user has requested enhancement of the downloaded file.

Author’s Accepted Manuscript

Investigation of Physicians' Awareness and Use of

mHealth Apps: A Mixed Method Study

Emre Sezgin, Sevgi Özkan-Yildirim, Soner

Yildirim

www.elsevier.com/locate/hlpt

PII: S2211-8837(17)30053-9
DOI: http://dx.doi.org/10.1016/j.hlpt.2017.07.007
Reference: HLPT247
To appear in: Health Policy and Technology
Cite this article as: Emre Sezgin, Sevgi Özkan-Yildirim and Soner Yildirim,
Investigation of Physicians' Awareness and Use of mHealth Apps: A Mixed
Method Study, Health Policy and Technology,
http://dx.doi.org/10.1016/j.hlpt.2017.07.007
This is a PDF file of an unedited manuscript that has been accepted for
publication. As a service to our customers we are providing this early version of
the manuscript. The manuscript will undergo copyediting, typesetting, and
review of the resulting galley proof before it is published in its final citable form.
Please note that during the production process errors may be discovered which
could affect the content, and all legal disclaimers that apply to the journal pertain.
Health Policy and Technology (2017) 6, 251–267

Available online at www.sciencedirect.com

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

Investigation of physicians' awareness and use

of mHealth apps: A mixed method study
Emre Sezgina,b,n, Sevgi Özkan-Yildirimb, Soner Yildirimc

a
Nationwide Children's Hospital, The Research Institute, 43215 Columbus, OH, USA
b
Middle East Technical University, School of Informatics, 06800 Çankaya, Ankara, Turkey
c
Middle East Technical University, Department of Computer Education & Instructional Technology, 06800
Çankaya, Ankara, Turkey

Available online 19 July 2017

KEYWORDS Abstract
Information Objective: The study aims to understand physicians’ awareness of mobile health (mHealth)
technology; apps and their intentions to use these apps in medical practice.
Healthcare; Method: Mobile Health Technology Acceptance Model (M-TAM) was tested employing the sequential
Mobile health; explanatory mixed method. An online survey and focus group interviews were conducted for data
Technology
collection. Physicians were invited to participate in the survey. Structural Equation Modeling (SEM)
acceptance;
was used in quantitative data analysis. Qualitative data were analyzed using coding, memo, and
Physicians;
Application use contextual analyses.
Results: 151 physicians participated in the survey, representing a 15% response rate. The model was
able to explain physicians’ intention to use mHealth apps by explaining 59% of the total variance.
Performance Expectancy, Mobile Anxiety, Perceived Service Availability and Personal Innovativeness
were major influencing factors of Behavioral Intention. Qualitative codes outlined that information
gathering and communication purposes were the major enablers in mHealth app usage. In that
regard, Communication and Consulting, Clinical Decision Making, Reference and Information
Gathering, and Information Management are the most popular app categories. On the other hand,
lack of knowledge and lack of investment were seen as the major barriers to mHealth app usage.
Conclusions: User perception and intentions are important factors in technology use. Thus, the
preferences, expectations, and characteristics of physicians which were outlined in this research
could be significant inputs for researchers, app developers, managers and policymakers.
& 2017 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.

Corresponding author at: Nationwide Children's Hospital, The Research Institute, 43215 Columbus, OH, USA.
n

E-mail addresses: emre.sezgin@nationwidechildrens.org (E. Sezgin), sevgiozk@metu.edu.tr (S. Özkan-Yildirim),

soner@metu.edu.tr (S. Yildirim).

http://dx.doi.org/10.1016/j.hlpt.2017.07.007
2211-8837/& 2017 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.
252
Introduction
The healthcare information technology market is expanding
globally. Reports reveal trajectories support the prolifera-
tion of mobile technology use in delivering healthcare
services is becoming the norm [1]. McKinsey's report pre-
sented that the tablet PC and smartphones market will
expand by up to 30% by 2018 [2]. On the software side, the
number of mobile apps has reached more than one hundred
thousand in approximately three years [3].
In parallel to this, studies investigating the effects of
mobile technology usage and apps in healthcare services are
also increasing. The studies underlined the significant global
impact of mHealth and in particular, the importance of
mHealth technologies in developing countries for accessing
healthcare and for patient monitoring [4,5]. However,
common concerns for the technology remain with regard
to sustainability, scalability, security, and privacy, which
may subsequently lead to problems in service quality [6]. On
the other hand, Healthcare Providers (HCP) report that
locational constraints, needs for interoperability, profes-
sional control and effective management for chronic condi-
tions are their particular concerns with regard to using
mHealth in healthcare delivery [7].
The actual use of mHealth requires in-depth investigation
in order to understand the true impact on its end users.
Significant escalation in smartphone usage might have
increased app usage in healthcare services, yet, its utiliza-
tion has not reached an acceptable level in practice [8].
Studies have demonstrated that acceptance issues for mobile
healthcare services need to be resolved to assure better
healthcare delivery [9,10]. In that regard, the use of mHealth
apps and the attitudes of healthcare providers remain
questionable and therefore in need of investigation [11].
In Turkey, the Ministry of Health reports over 135
thousand physicians actively practice medicine [12]. The
number of patients per physician is around 600, and each
hospital physician sees more than 4600 patients per year.
Thus, there is an excessive workload for physicians. To
maintain quality in healthcare delivery, assistive technolo-
gies were predicted to help physicians, such as mHealth
apps [13]. However, there is a gap in practical knowledge.
The current state of mHealth app use in most developing
countries is barely known, with few studies providing insight
about mHealth use in developing, low and mid-income
countries [14].
This current study investigates physicians’ mHealth app
usage in Turkey. A Mobile Health Acceptance Model (M-TAM)
was proposed and tested as a means to understanding the
influencing factors in mHealth app usage. Furthermore, the
study presents a social validation retrieving a collective
meaning among individuals through focus group interviews
in order to understand expectations and characteristics of
mHealth app use.
mHealth overview
Clinical use of mobile apps and devices is increasing.
Clinicians report that mHealth apps will become an impor-
tant tool for health management in the near future [15]. A
Wolters Kluwer Health report stated that eight out of ten
E. Sezgin et al.
healthcare professionals use smartphones in daily practice,
and that six out of ten are using tablet PCs [16]. The
literature demonstrated that mHealth is located in a posi-
tion that provides a promising technology integration
opportunity among healthcare services. It provides a plat-
form (-1-) to increase healthcare quality, productivity and
efficiency [17], (-2-) to improve accuracy and data conve-
nience as well as decision-making processes [7,18], and (-3-)
to enhance access to healthcare services [19]. There have
been several core fields for the use of mHealth which have
been identified and categorized in the literature (Table 1).
In these studies, the most common categories were com-
munication, decision support, education, tracking, and
monitoring. These categories also summarize the primary
purpose of using mHealth in practice.
Amongst them, Ventola [17] proposed an eight-group
categorization for mHealth apps (Table 2). The categories
outline the common field of mHealth app usage by health-
care providers, and helps to identify physicians’ preferences
of mHealth app use in this study.
The literature reports a number of new opportunities and
challenges that have emerged with mHealth. As an oppor-
tunity, mHealth was emphasized as an effective tool for
healthcare delivery in developing countries [13], and
mHealth was also argued as an improvement to commu-
nication among doctors [20–22]. In this context, the use of
auto-notification, tele-consultation, and digital X-ray image
apps have been demonstrated in medical practice [23].
Further, clinical image storing at clinics has enabled quicker
access and the ability to share high-quality images [24]. On
the other side, the public use of mHealth apps would
provide more insight into patient health history which aids
the diagnostic process. Studies revealed that self-monitor-
ing apps were the most used mHealth apps [25], including
apps for diabetes, asthma, and depression control [26],
fitness and training [25,27], and diet and physical activities
[28,29]. Furthermore, mobile intervention methods were
also widely adopted in healthcare services, and SMS remin-
der was one of the effective and most frequently used
methods [6,30].
As the challenges, technological, psychological, and
regulatory barriers in mHealth app use were considered
the major challenges, which could potentially lead to the
underutilization of mobile technologies [18]. Collaboration
was seen as another challenge to overcome. Interventions
and collaborations among systems developers, behavioral
experts, healthcare professionals, and patients need more
investment and development in order to promote the use of
the mobile health systems [18,28]. However, sharing perso-
nal health information with mobile apps raised concerns
about their privacy [6,31,32]. In the work environment,
perceptions about interruption from the use of technology
in routine tasks, the required extra efforts in multitasking,
perceived increase in workload within limited work time
and perceptions about weakening relationships were dis-
couraging elements for the use mHealth technologies as
seen by healthcare providers [7,20,21,33,34]. In addition,
incompetent use of healthcare technologies, trusting the
technology and a lack of awareness about their potential
and their functions were some of the personal challenges
[33]. Developers also demonstrated lack of awareness about
the needs in mobile health, and it was also considered a
Investigation of physicians' awareness and use of mHealth apps
Table 1 mHealth categorization.
Research
Status and trends of mobile-health applications for iOS devices: A ! Drug or medical information database
developer's perspective [29]
Mobile Health (mHealth) Approaches and Lessons for Increased Perfor-
mance and Retention of Community Health Workers in Low- and
Middle-Income Countries: A Review [8]
Mobile devices and apps for health care professionals: uses and benefits
[27]
The smartphone in medicine: A review of current and potential use
among physicians and students [30]
Mobile Technologies and Geographic Information Systems to Improve
Health Care Systems: A Literature Review [31]
barrier to the development of useful apps [25]. In develop-
ing countries, cultural, social, and educational barriers also
affect mHealth dissemination [7,34].
The literature showed that mHealth still needs develop-
ment. From a technical perspective, multiplatform devel-
opment for mHealth requires compatibility across mobile
apps and hospital systems [7,18,35]. Similarly, mobile
infrastructure is required to reduce system-level barriers
in accessibility [7,36], as well as increased security for
health records, and new standards and regulations [6,35].
Above all, there is a need for reliable and trustworthy apps
in the market [14,18,22,32], and to overcome sustainability
issues, such as short battery life and delays in mobile
processing [35]. Table 3 summarizes the challenges seen in
the use of mHealth.
Methodology
Research model
In order to assess physicians’ perceptions and attitudes
toward mHealth apps, a technology acceptance model was
253
Categories
! Medical information reference
! Decision support
! Educational tools
! Tracking tools
! Medical calculator
! Others
! Education and awareness
! Data access
! Monitoring and compliance
! Disease and emergency tracking
! Health information systems
! Diagnosis and consultation
! Information management
! Time management
! Health record maintenance and access
! Communications and consulting
! Reference and information gathering
! Clinical decision making
! Patient monitoring
! Medical education and training
! Patient care and monitoring
! Health apps for the layperson
! Communication, education and research
! Physician/Student reference apps
! Treatment and disease management
! Data collection and disease surveillance
! Health support systems
! Health promotion and disease prevention
! Communication between patients and health care
providers or among providers
! Medical education
proposed, named as the Mobile Health Technology Accep-
tance Model, or M-TAM. The model was developed based on
the findings of an in-depth literature review on technology
acceptance, and the consensus of experts. A group of
scholars (Ph.D. level of knowledge in behavioral science or
healthcare) were informed about the purpose of the study
and the literature findings. A consensus was reached about
the theories and constructs to be employed in the study.
Technology Acceptance Model (TAM) [37], Unified Theory of
Acceptance and Use of Technology (UTAUT) [38], Theory of
Planned Behavior (TPB) [39], and Innovation Diffusion
Theory (IDT) [40] were the theories selected for the model's
development. Table 4 presents the theories, constructs, and
definitions. Computer anxiety and computer self-efficacy
constructs were used as mobile anxiety and mobile self-
efficacy respectively in this study.
Figure 1 demonstrates the conceptual model. The rela-
tionships among the constructs (arrows) represent the
hypotheses. The hypotheses of the research were formu-
lated addressing the research question: “What are the
factors influencing physicians’ intention to use mHealth
apps?” In that regard, constructs’ influence on the beha-
vioral intention was hypothesized. Following that, another
254 E. Sezgin et al.

Table 2 Use of mHealth devices and apps by health-
care professionals [17].
Information management
■ Write notes
■ Dictate notes
■ Record audio
■ Take photographs
■ Organize information
and images
■ Use e-book reader
■ Access cloud service time
Time management
■ Schedule appointments
■ Schedule meetings
■ Record call schedule
Health record maintenance Patient monitoring
and access
■ Access EHRs and EMRs
■ Access images and scans
■ Electronic prescribing
■ Coding and billing
Communications and
consulting
■ Voice calling
■ Video calling
■ Texting
■ E-mail
■ Multimedia messaging
■ Video conferencing
■ Social networking
Reference and information
gathering
■ Medical textbooks
■ Medical journals
■ Medical literature
■ Literature search portals
■ Drug reference guides
■ Medical news
Clinical decision-making
■ Clinical decision support
systems
■ Clinical treatment
guidelines
■ Disease diagnosis aids
■ Differential diagnosis aids
■ Medical calculators
■ Laboratory test ordering
& interpretation
■ Medical exams
■ Monitor patient health
■ Monitor patient location
■ Monitor patient
rehabilitation
■ Collect clinical data
■ Monitor heart function
Medical education and
training
■ Continuing medical
education
■ Knowledge assessment
tests
■ Board exam preparation
■ Case studies
■ E-learning and teaching
■ Surgical simulation
■ Skill assessment tests
Table 3 Challenges in use of mHealth.
Challenges Reference
Need of collaboration and intervention [18,28,36]
Privacy [6,31,32]
Interruptions & multitasking requirements [7,34]
Increased workloads & Time constraints [20,21,33]
Cultural, social and educational barriers [7,34]
Lacks in skills and awareness [25,33]
Lack of trust in quality [28]
Weakened interpersonal relationships [22]
Multiplatform development [7,18,35]
Security [6,35]
Standards and regulations [14,18,22,32]
Delays [35]
Battery life [35]
Infrastructure [7,36]
Convenience sampling was used, and the data was collected
using online survey application (www.qualtrics.com). The
target sample was physicians using mobile health apps and
who were actively working in health institutions in Turkey. The
ethics board of the University approved the survey prior to
application. The questionnaire was tested for item integrity
and understandability with a pre-test study applied to a small
subset of the sample. The survey was announced via the
institution web page. Participants were invited via online posts
on social network groups and via e-mails sent to mailing lists.
In addition, a paper-based questionnaire was distributed to
physicians in the province. The invitation for online participa
tion reached approximately one thousand physicians, and
paper-based questionnaires were delivered to 53 physicians.
In the data analysis phase, the normality of the data and
internal consistency were tested using SPSS software. Linear
and casual models were then tested using Structural
Equation Modeling (SEM), which provided a multivariate
approach to observe latent relationships among the con-
structs [55]. Partial Least Squares (PLS) test was then
completed with a component-based approach employing
SmartPLS software [56].

Focus group interview procedure and analysis

set of hypotheses were formulated to seek influence of
constructs in use over performance expectancy and effort
expectancy (see Appendix A for hypotheses).
Quantitative data collection and analysis
A cross-sectional survey method was used in the data
collection. A structured questionnaire was developed to
test the hypotheses. A five-point, Likert-type scale was used
(“1: Strongly disagree”, “2: Disagree”, “3: Neutral”, “4:
Agree” and “5: Strongly agree”) [54]. The survey consisted
of three parts. The first part included an introduction about
mHealth apps, information about the purpose of study and a
consent form. The second part included demographic ques-
tions, and the third and final part was close-ended survey
questions.
The focus group interviews were administered by two
researchers, with one acting as a moderator/researcher
and the other as an observer. The researchers informed
participants about the purpose of the study, the procedure,
confidentiality of the information, and voluntary nature of
their participation. Verbal consent was sought before each
focus group interview. Focus Group 1 (FG1), Focus Group 2
(FG2) and Focus Group 3 (FG3) consisted of three, four and
three physicians respectively. The participants were physi-
cians using mHealth apps and working in health institutions
in Turkey. Each focus group was from a different hospital.
The informants were grouped considering demographic
characteristics (gender, age, specialty, and experience in
their profession) in order to create heterogeneity and
diversity of responses within the group. Snowball approach
Investigation of physicians' awareness and use of mHealth apps 255

Table 4 Constructs, definitions and references.

Constructs Definition Theories References

Behavioral intention (BI) “the degree to which a person has formulated conscious UTAUT [38]
plans to perform or not perform some specified future
behavior”
Effort expectancy (EE) “the degree of ease associated with the use of the system.” [38,41]
Performance expectancy (PE) “the degree to which an individual believes that using the [38,41]
system will help him or her to attain gains in job
performance”
Habit (HB) “constitutes the level of routinization of behavior, i.e. the [42,43]
frequency of its occurrence” (UTAUT 2)
Technical support and training “the technical support and the amount of training provided [11,38,44]
(TT) by individuals of knowledge”
Perceived service availability “the degree to which an innovation is perceived as being [38,45]
(PS) able to support pervasive and timely usage”
Personal innovativeness in the “the willingness of an individual to try out any new IT, plays IDT [40,46–48]
domain of IT (PI) an important role in determining the outcomes of user
acceptance of technology”
Compatibility (CO) “the degree to which an innovation is perceived as being [11,40,49,50]
consistent with the existing practices, values, needs and
experiences of the health care professional”
Result demonstrability (RD) “the extent to which the tangible results of using an TAM [46,51]
innovation can be observable and communicable” (TAM2)
Computer Self- efficacy “the degree to which an individual beliefs that he or she has [44,49,52]
the ability to perform specific task/job using computer”
(TAM3)
Computer anxiety “the degree of an individual's apprehension, or even fear, [44,49,52]
when she/he is faced with the possibility of using computers”
(TAM3)
Social influence(SI) “the degree to which an individual perceives that important TPB (and [38,41,53]
others believe he or she should use the new system” UTAUT)

was used in recruitment. Details about each group are
provided in Table 5. Each focus group interview lasted
approximately one hour. The responses were recorded and
observational notes were taken during the interviews.
During the sessions, an interview protocol was followed.
The methods of memoing, coding [57,58] and contextual
analysis [59] were employed. In the process of analysis, the
raw data, audio recordings, and notes were transcribed as a
first step (QDA Miner software was used in the transcribing
and coding). The data was then read through to ensure the
accuracy of the information. Then, the codes and themes
were created, and the meaning of these themes was
interpreted. The process of reading and the interpretation
continued until all relevant information was grouped with
codes and themes. During the procedure of transcription, a
colleague assisted in order to mitigate the risk of researcher
bias and potential misunderstandings. Additionally, peer
debriefing [60] was utilized, in which the researcher was
assisted by a colleague impartial to the study. Recker's [58]
key elements (Dependability, Credibility, Confirmability,
Transferability) were considered in the process of qualita-
tive data evaluation.
The questions of qualitative approach were developed
based on the quantitative findings of the study. This
approach helped to identify significant and non-significant
elements in the mHealth use of physicians. During the
interviews, the questions were directed in a deductive
setting.
Results
After the data collection process, 151 physicians completed the
questionnaire, which represented a 15% response rate. Incomplete
responses were then removed, and 137 complete responses were
used in the testing of the hypotheses.
Demographics
As can be seen in Table 6, the demographic data shows that the
majority of participants were young adults (53%) and male (56%).
Three out of four participants were specialist medical practitioners
(74%). Smartphones were the mostly used mobile device (98%), and
participants had one to five years of experience in using mobile
devices (69%). Competency in mobile device use was reported
mostly at the “good” level (63%). Most of the participants were
using mHealth apps more than once a week (54%), and mostly used
mHealth apps for one to two years (53%). Participants reportedly
used mHealth apps voluntarily (98%). The majority of participants
were practicing healthcare services in public hospitals (43%) and
training and research hospitals (33%). Specialist medical practi-
tioners (74%) were physicians from Pulmonology (15%), Cardiology
(8%), Pediatrics (7%), Surgery (7%), Primary Care (6%), Anesthesia
(6%), Internal Medicine (5%), Ophthalmology (5%), Dentistry (5%),
256
Figure 1 The conceptual model: M-TAM.
Gynecology (5%), Psychiatry (5%), Otorhinolaryngology (4%), Oncol-
ogy (4%), Emergency Medical Services (4%), Urology (4%), Orthope-
dics (4%), Pathology (3%) and Neurology (3%).
Mobile app use
The participants of the survey reported the names of mobile apps
they used in healthcare delivery or medical practice. Some of the
reported apps were not designed specifically for mHealth, but due
to their purpose of use, they were included in the study. The apps
were categorized by their field of use employing Ventola's [17]
categorization. Results showed that most of the apps were used for
communication and consulting. This was followed by clinical
decision making, reference and information gathering, information
management, medical education and training, time management,
and health records, maintenance and access. The least used apps
were in the category of patient monitoring (Figure 2). In total, 764
mHealth apps were reported, and were grouped under one of eight
categories. Categorization of apps was completed with the assis-
tance of academic and medical experts. Figure 2 shows the ratio of
apps in each category to the total number of apps.
The results presented that text and multimedia messaging apps
(e.g. WhatsApp, Google Hangout) are the popular apps in the
communications and consulting category. In total, 162 apps were
reported for communication and consulting, and almost half of the
participants in this category (50% and 43%) reported using WhatsApp
E. Sezgin et al.
and Google Hangout in their medical communications. In clinical
decision making, 144 apps were reported. Medical calculators (e.g.
Medcalc, Das28) (44%) and diagnostic assistance tools (e.g. Prognosis,
Dxsaurus) (43%) were the most used apps. Drug referencing apps
(Cepilaç) are the most used out of 137 reference and information
gathering apps (62%), followed by referencing (14%), cases and
guidelines (Nature, Uptodate) (14%) and dictionary (Eponyms) (10%)
apps. For information management, 117 apps were noted, and
mostly default mobile apps were reported as being used in this
category. Google Notes, e-book reader, Evernote and Photo apps
were used for reading and keeping notes. For medical education and
training, 74 apps were reported. Physicians were highly interested in
commonly used medical education and information apps (e.g.
Medscape) (62%) and visual training apps (e.g. OrthoApp, Vcell)
(27%). Public health training apps (11%) were also in focus. For time
management, out of 63 reported apps, Google Calendar was the most
used app (68%). It was followed by default mobile calendar tools
(16%) and an appointment app developed by the Health Ministry,
known as MHRS (16%). For health record maintenance and access,
Enlil, a national hospital management information system, was
reported as the most used app (52%). It was followed by other
medical health recording systems as Meddata (16%), E-nabiz (16%),
PACSapp (8%), and Acibadem (8%). For the patient monitoring
category, 17 apps were reported. This category had the least number
of apps reported. Pedometer (24%), calorie tracker (24%), heart rate
and information tracker tools (cardiograph) (18%), Apple health
Investigation of physicians' awareness and use of mHealth apps 257

Table 5 Focus group characteristics.

Focus group 1 Focus group 2 Focus group 3

Identifier FG1.a FG1.b FG1.c FG2.a FG2.b FG2.c FG2.d FG3.a FG3.b FG3.c
Gender Male Male Female Female Female Female Male Male Male Female
Age 39 29 33 28 31 35 40 26 24 24
Specialty Cardiology Pulmonology Gynecology Anesthesiology Urology Practitioner
Experience in Smart- 10 7 3 5 4 8 2 5 6 4
mobile device use
(years)
Experience in job 15 4 7 4 8 12 18 3 1 1
(years)
Institution City State Hospital University Research and Application Hospital Private Hospital
Interview duration 57 min 52 min 1 h 3 min

(18%), Instant health rate (12%) and Fitwell (6%) were the reported identifying ‘misspecified’ models, and PLS-SEM counts on measures
apps. The tracking apps were assumed to have been used by patients about the predictive capabilities of the model in order to assess the
and shared with physicians. quality of the model [68].

Descriptive results
Descriptive results outlined the distribution of the data. As given in
Table 7, the mean values provided the central tendency of
responses. Except for the mobile anxiety (MA) and technical support
and training (TT), the responses were clustered at the favorable
side (above 3) with standard deviations between 0.38 and 0.95. The
data presented negative Skewness and positive Kurtosis, and the
data was acceptable (71.5) to proceed to structural equation
modeling [55]. Shapiro-Wilk test was conducted to test the normal-
ity of the data [61], and the data were not normally distributed
(po0.05) (Table 7). During the analysis, list-wise deletion approach
was used to handle missing data. Cronbach's Alpha test was
conducted to assess internal consistency of the model. Alpha values
of constructs and the overall reliability (0.796) were acceptable
[62].
Structural equation modeling
Measurement model
Convergent validity and discriminant validity were tested to ensure
construct validity of the model. In the first phase, Fornell and
Larcker's [63] procedure was followed to test convergent validity
(Table 8). Item reliability test was then conducted by extracting
square values of item loadings, and they were expected to be above
0.4 [64]. Following that, composite reliability was tested and
resulted between 0.7 and 0.92, which was acceptable with above
0.60 [65]. At the final phase, convergent validity test was con-
ducted. AVE values of each construct were expected to be above
0.50 [66]. As given in Table 8, AVE values of the constructs met the
requirement with the values between 0.53 and 0.85. The model
met the requirements for convergent validity, except for items SI3
and TT2, which were removed from m-Health users due to low item
loadings.
Following the convergent validity, discriminant validity was
tested in order to measure divergence within constructs [67].
Discriminant validity test was conducted by calculating the square
roots of AVE values and analyzing the correlation (Table 9). The
square root of AVE was expected to be greater than the constructs’
correlation values (the diagonal path of the discriminant validity)
[64]. Fit indices for PLS-SEM (Goodness-to-fit) were excluded from
the analysis. Literature suggests that the measure was not fit for
Structural model
Since the items of model constructs can be identified as inter-
changeable among the constructs as well as having high correla-
tions, reflective measurement scale was employed in the PLS
modeling [64]. Literature suggests that if the PLS algorithm
converges before the maximum iteration limit (set to 300), it
ensures the stability of estimation [69], and convergence of the
algorithm completed at nine iterations. Estimating the normality of
the data, bootstrapping method was employed using 5000 resam-
pling. Table 10 outlines the approved and rejected hypotheses
providing path coefficients, t-statistics, and multicollinearity of the
data. For the approved hypotheses, path coefficient values were
suggested to be above 1.0, and t-statistics values were suggested to
be above 1.96 at the significance level of po0.05 [68]. Multi-
collinearity values of the data were non-problematic with the
variance inflation factor (VIF) value below five for each hypothesis
[70].
Results suggested that nine of the hypotheses were approved for
the model. According to the test results., for mHealth app users,
mobile anxiety (β=-0.160, po0.05), performance expectancy
(β=0.359, po0.001), personal innovativeness (β =0.139, po 0.05)
and perceived service availability (β=0.120, po0.05) had a sig-
nificant influence on behavioral intention. In addition, compatibility
(β =0.383, po0.001), personal innovativeness (β =0.284, po 0.001)
and result demonstrability (β=0.196, po0.05) had significant
influence on performance expectancy. Mobile self-efficacy and
perceived service availability had influence on effort expectancy
(β=0.365, po0.001 and β=0.175, po0.05). However, compatibil-
ity, effort expectancy, habit, mobile self-efficacy, social influence
and technical support and training had no influence on behavioral
intention. The remaining hypotheses were not supported as well.
The determinants of behavioral intention (MA, PE, PI, and PS)
accounted for 59% of the total variance explained for the intention
to use mHealth apps. In addition, the determinants of effort
expectancy explained 51% of the variance, and the determinants
of performance expectancy explained 51% of the variance
(Table 10, Figure 3).
Findings of focus group study
Three focus group interviews were finalized as the rich data was
obtained, and the researchers agreed that saturation was achieved
[71]. After coding of the transcripts, themes were created as
258 E. Sezgin et al.

also included sub-codes, which were identified as items influencing

Table 6 Demographic characteristics.
the actual use of mHealth apps. Response counts and percentages
are given in Table 11.
Demographics Percentages
Observational notes showed that the physicians had to fulfill
1. Gender their duties within a tight schedule and limited time, and the
hospital management expect them to work at their maximum limits
Female 44%
while providing healthcare services. Hospitals were equipped with
Male 56% mostly non-mobile devices and equipment, such as desktop PCs,
2. Age 25–35 (53%) X-ray devices. There was limited mobile equipment, such as mobile
36–45 (36%) electrocardiograph (ECG) and ultrasound devices, but they were
46–66 (11%) made available for particular healthcare services. Physicians and
3. Education Level other healthcare providers have an open and continuous commu-
General Practitioners 26% nication in their routine.
Specialist medical practitioners 74% Interviews demonstrated that, within the limited time to deliver
Specialist medical practitioners with 8% healthcare services, the physicians should be able to reach the
PhD degree information quickly when needed. Existing information and com-
munication technologies (e.g. Hospital management systems, SMS,
4. Mobile device preferences Smart Phone 98%
and e-mail) have been used in medical services and communica-
Tablet PC 61% tions, but to a limited level. Personal smartphones grant faster
5. Experience in mobile device use access to information, especially for communication among peers.
None – Web browsers and search engines were also used for medical
Less than 1 year 2% information searches, sometimes outperforming the mHealth apps.
1–5 years 69% Observations and interviews showed that mHealth apps have not
6–10 years 19% yet reached maturity due to its low effectiveness and lack of
More than 10 years 10% extensive use in the hospital system, limited development and the
6. Perceived competency in Mobile deficiency of standards and regulations. The informal use of mobile
device use communication apps in medical practice, lack of interoperability,
security, and control over apps would also support the low maturity
Excellent 18%
in mHealth.
Good 63%
Moderate 19%
Bad – Discussion
7. What is your mobile health appli-
cation use frequency? The literature argued that healthcare providers are aware
None 1% of mHealth technologies, and they acknowledge the bene-
More than once in a Month 28% fits of mHealth in clinical communication and healthcare
More than once in a Week 54% delivery [20,72]. This study supports this argument, out-
Everyday 17% lining a variety of evidence regarding physicians’ intentions
8. Do you use the mHealth applica- toward using mHealth apps.
tions on voluntary basis?
Yes 98%
No 2% mHealth Apps
9. How long have you been using the
mobile health applications? The self-reported mHealth apps outlined the common
None 1% trajectory in app preferences. Communication and consult-
Less than one year 20% ing, clinical decision making, reference and information
1–2 years 53% gathering and information management apps constituted
3–4 years 22% the popular categories in mHealth app use. For instance, a
5 years and above 4% physician may have WhatsApp, Medcalc, Epocrates, Up-to-
10. How can you define the type of date and Evernote in their mobile device as essential apps
your health institution? being used during the delivery of healthcare services. Web-
Public hospital 43% based searches and default mobile apps were also used by
Training and research hospital 33% physicians, such as Evernote, Google Drive or voice recor-
Health research center 7% der. Thus, each physician group may have their own “app
Community clinic 5% ecosystem”. These ecosystems may help developers to
Private hospital 12% identify the needs of physicians in medical practice and to
On-site medical services – develop specific apps to meet the demand.
The least preferred categories of apps were health record
maintenance and access and patient monitoring. Unlike the
other categories, these require a certain level of involve-
“enablers” (elements that enable or influence physicians to use
mHealth apps), “barriers” (elements of limiting or disabling physi-
ment of patients and network access to patient health
cians to use mHealth apps) and “enablers and barriers” (elements records. Thus, the possible reason would be mainly the need
that may either affect to use or not to use mHealth apps). Codes for mobile hardware, insufficient apps, lacking infrastruc-
were grouped as “personal” and “organizational” in order to ture as well as the regulations. These have been already
categorize according to personal and external influences. The codes regarded as issues for developing countries in the literature
Investigation of physicians' awareness and use of mHealth apps 259

Figure 2 mHealth app categories with usage rates.

Table 7 Descriptive statistics and reliability test.

Mean Std. deviation Skewness Kurtosis Shapiro-Wilk Cronbach's alpha

BI 4.2600 0.51613 "0.605 0.910 0.000 0.769

EE 3.9416 0.45696 "0.026 0.467 0.000 0.767
PE 4.1191 0.40583 "0.068 0.695 0.000 0.768
MA 1.7591 0.59440 0.689 0.841 0.000 0.856
MS 3.9295 0.47900 "0.073 "0.045 0.000 0.759
PI 3.6349 0.59647 "0.073 "0.170 0.000 0.767
HB 3.1752 0.95408 0.034 "1.068 0.000 0.759
SI 3.3186 0.67873 "0.752 0.238 0.000 0.783
CO 3.7104 0.52783 "0.263 "0.472 0.000 0.760
TT 2.6884 0.66311 0.509 ".012 0.000 0.796
RD 3.9635 0.38651 "0.455 1.229 0.000 0.779
PS 3.9126 0.48688 "0.796 1.137 0.000 0.780

[7]. Thus, there is a need for interconnected mobile devices
and apps for physicians as well as patients to create a
network for keeping health records, accessing and monitor-
ing patients in real time. In that regard, the authorities
should consider investing in service infrastructure, giving
priority to mobile healthcare services.
Research model
M-TAM was able to explain behavioral intention (BI) to use
mHealth apps with 51% of total variance. In that regard,
performance expectancy (PE) was one of the factors
significantly influencing BI. In the study, it was observed
that PE was more effective in explaining BI than effort
expectancy (EE). The significant effect of PE indicated that
physicians had beliefs about mHealth apps that would be
helpful in their job routines. The literature has already
provided that PE is one of the important indicators of the
adoption of health information systems [20,73,74], thus,
the findings supported the impact of PE. On the other hand,
the influence of PE on BI was an expected outcome from the
developing countries’ perspective [20]. In that regard, one
of the primary concerns of physicians can be stated as the
practical benefit of the mHealth apps, especially while
practicing within a tight schedule [75]. Focus group inter-
views supported this argument, as one participant stated
that, physicians have to be quick to fulfill their tasks in
seconds. Access to information in a timely manner is crucial
during the physicians’ routine [76]. PE was also influenced
by compatibility (CO), personal innovativeness (PI) and
result demonstrability (RD), which means the consistency
and integrity of mHealth apps, the degree of willingness to
use mHealth and availability of demonstrable results also
260 E. Sezgin et al.

influenced the perception of physicians about their job the expectations of physicians from mHealth apps was the
performances [46,47,77]. ability for pervasive and timely use. This finding supported
Perceived service availability (PS) was found as another Venkatesh's [38] argument that facilitating conditions are
significant factor influencing intention to use. Thus, one of influential in explaining the use of technology. In that
regard, service availability for specialty-specific mHealth
Table 8 Convergent validity (Item reliability, Compo- apps was a challenge, yet regarding the user interface,
site reliability, and AVE). language support was seen as expected by the physicians.
The physicians reported that use of mHealth apps was not
Constructs Items Item Composite AVE vitally important at the current level, however, when they
reliability reliability need to use it, they expect to have language support for
better access.
BI BI1 0.552 0.858 0.670 Similarly, PI was another factor that had a significant
BI2 0.701 influence on BI. Physicians were found to have a certain
BI3 0.755 level of willingness to use new technologies which even-
CO CO1 0.601 0.823 0.609 tually positively affect their attitudes toward using mHealth
CO2 0.493 apps [47]. In the focus groups, the physicians were observed
CO3 0.733 to have no barriers to new technologies, especially to
EE EE1 0.696 0.811 0.590 smartphones and mobile apps. They also stated that all
EE2 0.546 physicians around them own a smartphone and use mobile
EE3 0.527 apps, which would facilitate the process of technology
HB HB1 0.862 0.919 0.850 adoption.
HB2 0.838 On the other side, Mobile anxiety (MA) was identified to
MA MA1 0.462 0.730 0.578 have a negative influence on BI. Perceived intimidation,
MA2 0.693 hesitation or apprehension would negatively affect physi-
MS MS1 0.654 0.810 0.587 cians’ intention to use. In that regard, lack of initiatives and
MS2 0.538 perceived ability may increase physicians’ anxiety as well as
MS3 0.571 reducing their intention to use mHealth apps [20,49]. In the
PE PE1 0.544 0.775 0.535 interviews, as a disabler, anxiety was observed to have less
PE2 0.458 impact on physicians. The reason can be connected to a
PE3 0.602 couple of factors, such as existing trust with informally used
PI PI1 0.643 0.860 0.673 apps and the low level of importance of mHealth in common
PI2 0.652 practice. It was observed that, at the initial phases, validity
PI3 0.724 and reliability issues may create apprehension in terms of
PS PS1 0.672 0.820 0.607 using medical apps, but they were overcome by routine use.
PS2 0.405 Physicians’ perceptions toward consistency of mHealth
PS3 0.743 apps with the tasks and practices (HP4: CO to BI) and
RD RD1 0.617 0.810 0.681 physicians’ perceived abilities in performing daily task with
RD2 0.746 mHealth apps (HP9: MS to BI) did not have a significant
SI SI1 0.852 0.903 0.824 relationship with BI. Even though the literature states
SI2 0.796 otherwise [50,78], a lacking in routine practices with
TT TT1 0.526 0.830 0.713 mHealth and job conditions (as in a developing country)
TT3 0.900 would be effective drivers for this result [20]. The inter-
views revealed a certain level of compatibility issued among

Table 9 Discriminant validity.

BI CO EE HB MA MS PE PI PS RD SI TT

BI 0.818
CO 0.447 0.780
EE 0.563 0.528 0.768
HB 0.543 0.621 0.535 0.922
MA " 0.538 " 0.256 " 0.349 "0.422 0.760
MS 0.566 0.600 0.653 0.546 "0.375 0.766
PE 0.667 0.622 0.577 0.602 "0.483 0.562 0.731
PI 0.529 0.478 0.504 0.596 "0.367 0.588 0.540 0.820
PS 0.441 0.349 0.459 0.339 "0.335 0.463 0.354 0.229 0.779
RD 0.450 0.453 0.405 0.333 "0.254 0.470 0.494 0.337 0.516 0.825
SI 0.221 0.227 0.205 0.248 "0.172 0.223 0.160 0.020 0.365 0.214 0.908
TT 0.027 0.166 0.129 0.207 0.260 0.231 0.093 0.167 0.126 0.054 0.277 0.844
Investigation of physicians' awareness and use of mHealth apps
Figure 3
mHealth apps and hospital information systems. However,
since there is no active implementation of mHealth or use of
mHealth apps within an organized official capacity, there
may not be a perception about compatibility in behavioral
intention, simply due to lack of practice [79,80]. Similarly,
mobile self-efficacy (MS) was observed to exist; however,
the conceptualization of mHealth use in practice might be
ambiguous due to limited apps for each specialty. The
physicians reported the need for apps for their own speci-
alty. For instance, Gynecologist informants stated that
there are many popular apps for pregnancy monitoring;
however, there are few apps for use by physicians. Thus,
self-efficacy might not have been assessed due to lack of
specialty-specific mHealth apps, which require further
development [76].
For similar reasons, the insignificant relationship of
technical support and training (TT) and BI can be explained.
Since there is no formal use or regulations for mHealth apps,
voluntary use resulted in low motivation toward the needs
of technical support and training [43]. Interview findings
supported this argument. The physicians reported having a
busy schedule and low-level willingness to participate in any
training program or to have technical support. Instead, they
prefer to use the internet for support and training. One of
the physicians reported that she used web blogs to search
for new mHealth apps and also for ratings of their
261
Path analysis.
usefulness. In this case, technical support and training could
be perceived as insignificant to physicians.
Habit (HB) and social influence (SI) were not found
influential on BI, which is consistent with the literature
[42,81]. Here, the argument was that mHealth app usage
had not reached a sufficient level of routine usage to be
considered habitual. Considering the interview findings,
there is a certain level of use of mobile apps which can be
considered as a habit (e.g. Communication apps), yet it is
not applicable for the use of other mHealth apps. On the
other hand, the insignificant effect of social influence could
be the result of time constraints, lack of interest and
awareness of using mobile health apps [33]. In addition,
physicians reported that they prefer searching for apps
themselves, and do not engage in conversations about
mHealth apps very often. In cases where they were unable
to find a particular app, they may ask a colleague. One
participant reported that he always uses web sources for all
apps he downloads.
Unexpectedly, effort expectancy (EE) had no influence on
BI. The influence of EE had been repeatedly justified in
many studies [73,74,82]. However, the findings suggest that
perceived ease of using mHealth apps had not reached a
certain level of maturity. Interview findings supported that
the insignificant impact could have been a result of the
frequency of app use in daily practice or using substitute
262 E. Sezgin et al.

Table 10 Results of hypothesis testing.

Hypotheses Relationship Path coefficients T Statistics p-Values VIF Status

HP1 PE-BI 0.359nn 4.072 0.000 2.334 Supported

HP6 PS-BI 0.120n 1.997 0.045 1.531
HP8 MA-BI " 0.160n 2.001 0.046 1.872
HP10 PI-BI 0.139n 1.996 0.047 2.051
HP22 CO-PE 0.383nn 4.536 0.000 1.521
HP15 PI-PE 0.284nn 3.548 0.000 1.344
HP19 RD-PE 0.196n 2.457 0.014 1.585
HP12 MS-EE 0.365nn 3.348 0.001 2.301
HP17 PS-EE 0.175n 2.007 0.041 1.613
HP4 CO-BI " 0.105 1.267 0.205 2.253 Not supported
HP23 CO-EE 0.103 1.347 0.178 2.061
HP2 EE-BI 0.106 1.475 0.140 2.139
HP7 HB-BI 0.077 0.905 0.366 2.360
HP14 HB-EE 0.146 1.505 0.132 2.278
HP11 MA-EE " 0.011 0.202 0.840 1.678
HP9 MS-BI 0.118 1.411 0.159 2.547
HP13 PI-EE 0.112 1.481 0.139 1.912
HP16 PS-PE 0.059 1.076 0.282 1.412
HP18 RD-EE 0.009 0.176 0.860 1.611
HP3 SI-BI 0.063 1.432 0.153 1.357
HP5 TT-BI " 0.06 1.204 0.229 1.463
HP21 TT-EE " 0.041 0.643 0.520 1.340
HP20 TT-PE -0.036 0.741 0.459 1.050
n
p o 0.05.
nn
po 0.001.

Table 11 Themes and codes of focus group interviews.

Themes Codes Sub-codes Count % Codes

Enablers Personal enablers Information gathering 27 12%

Communication 25 12%
Urgency 16 7%
Accessibility 10 5%
Interest in new technologies 9 4%
Education 8 4%
Ease of use 7 3%
Expectations 7 3%
Social sharing 5 2%
Leisure time 5 2%
Organizational enablers Compatibility 16 7%
Performance 13 6%
Assistance 6 3%
Barriers Personal barriers Lack of knowledge and interest 11 5%
Software problems 7 3%
Anxiety 5 2%
Organizational barriers Lack of investment 17 8%
Lack of control 15 7%
Enablers and barriers Habits 8 4%

apps or technologies (e.g. using web applications and desk-
top PCs in the visits). These might have created ambiguity in
perceiving the ease of use and intention to use.
In addition, even though the mediating and direct effect
of EE was not significant in the study, MS and PS had a
significant effect on EE. Here, it can be argued that ease of
use of mHealth apps would be influenced by the physicians’
ability and the availability of technology [44,45]. On the
other hand, effort expectancy of physicians was found to
have no influence by HB, CO, MA, PI, RD, and TT. Since the
Investigation of physicians' awareness and use of mHealth apps
influence of EE on BI was not significant, its mediating effect
for the aforementioned factors remained redundant. Simi-
larly, the PS and TT had no influence on performance
expectancy. Unlike Wu et al.’s [45] suggestion, PS showed
no encouraging indication to use mHealth by physicians. In
fact, its impact could have been disregarded due to the lack
of conceptualization of the construct in real life. In a similar
manner, the perception of TT might not have been identi-
fied by physicians due to lack of practice in mHealth
support. Thus, the direct effect of TT on performance
expectancy remained insignificant [11].
Practical and managerial implications
Communication, decision making, and information gather-
ing are the primary aims of physicians using mHealth apps in
healthcare services. This finding was supported by Franko
and Tirrell's study [83], which outlined that commonly used
apps among physicians were drug guides and medical
calculators, and the requested apps were about reference
materials, treatment guides, and general medical knowl-
edge. Thus, information gathering and communication
needs were the primary app choices of the physicians.
Blending these empirical results with the factors influen-
cing behavioral intention to use the technology, the evi-
dence demonstrated that practical benefits are the key
elements in the actual use of mHealth apps (significant
effect of PE, PS, and CO). In that regard, developers of
mHealth apps should primarily focus on the practicality of
apps more than focusing on the details [19,25]. In addition,
availability for timely use is another important element.
Even though the apps were available on the mobile plat-
form, time is an important constraint, especially for physi-
cians working to a tight scheduled [33]. Thus, high
responsiveness and effectiveness would be an important
benefit. Here, the optimization of mHealth apps specific to
medical specialties would enhance the usability.
In the broader perspective, these needs require infra-
structure development, focusing on compatibility and inter-
operability among mHealth apps, mobile healthcare
devices, and hospital management systems. In that regard,
government incentives would be influential to increase
investments in mHealth infrastructure and to increase the
number of specialty-specific mHealth apps. Promoting the
use of mHealth apps could also positively affect job
performance, which would increase efficiency as well as
the quality of doctor-patient time [76].
Physicians’ willingness to use new technology should be
nurtured in order to promote mHealth app use. The trust in
mobile apps and the interest in new technologies are
positive attitudes which reduce the resistance toward new
apps, but increase the vulnerability to possible malicious
content. Physicians’ reports in this study have already
raised some concerns about the lack of mHealth apps in
the domain [13] and privacy issues about health records
[84]. Thus, the authorities should consider promoting the
formal use of mHealth apps by controlling the content and
distribution. Authorities should supply apps considering the
preferences of physicians in each specialty. Providing stan-
dards and regulations would also help to address security
263
and privacy issues, and also to promote standardization in
mHealth app development [18].
Policymakers and managers need to consider the afore-
mentioned implications in procedure and policy develop-
ment in order to improve healthcare services for society.
There is a need for alignment between mHealth apps and
healthcare services to create an interoperable and control-
lable working environment for physicians [3]. In that regard,
it is important to note that mHealth apps need to be
checked for reliability and consistency to ensure the main-
tenance of healthcare quality [32]. In the process of
mHealth platform development, costs, increasing workloads
and unscheduled tasks [20], trust, security [28], privacy
[31], standards and regulations [18,32] should be recognized
and considered as major challenges. On-the-job training and
operational support were commonly suggested for the use
of mHealth apps in order to enhance physicians’ ability to
perform their daily tasks. However, the physicians’ interest
in new technologies could be a leverage for promoting
training programs and to reduce their reluctance to use
mHealth apps. For instance, mobile game-based training
could be effective since physicians reported not to prefer
on-site training programs [85].
Limitations
A self-reported and cross-sectional survey may have caused
the study to suffer from self-reporting biases. In addition,
the quantitative design limited the collection of all relevant
data within a scale in the research. Since TAM might have
presented low predictive power in the study [86], the
authors developed an integrated model, yet it might be
unable to explain the latent facts and relationships. On the
other hand, the sample size was another limitation. Even
though the sample size met the requirements to conduct
the analyses [87], the data was limited in representing the
population. The sample size also limited the study to
capture differences among different specialties of physi-
cians. The constructs were adopted from previous studies
which were designed to assess new technologies (e.g.
computers, handheld devices), but they were not specific
to mobile apps. This may be a reason for the unexplained
variance in the study. Thus, the unexplained physician
behaviors may require further research in order to reveal
other factors in mHealth app usage. In the focus group
interviews, the risk of collecting information from acquain-
tance physicians (as a result of the snowball approach),
reluctant behaviors of informants, and the researchers’
experiences and approach may have limited the depth of
information gathered.
Conclusion
This study contributed to the literature in terms of provid-
ing a new model to explain the acceptance of mHealth apps
by healthcare providers. In addition to that, providing a
dataset from a developing country depicted an alternative
outlook to influencing factors in using mHealth apps.
Furthermore, this study extended prior research about the
perceptions and preferences on mobile healthcare apps
[36,76,88]. The authors would suggest further studying of
264
mHealth apps in order to increase the depth of the current
study. In that regard, expanding the sample size and target
group including different specialties would be a promising
step. A longitudinal approach is also suggested to report
behavioral changes on mHealth app use over time.
Author contribution
This research study is out of a PhD thesis work of the first
author Mr. Emre Sezgin, who has completed his thesis work.
Emre Sezgin will defend his thesis in the next couple of
months. The second and third authors Associate professor
Dr. Sevgi Ozkan-Yildirim and professor Soner Yildirim are
supervisors of him and they have initiated, directed and
critically contributed to the research and the paper.
Author statements
Funding
There is no direct funding for his research. However the
authors have been receiving grants from TUBITAK (The
Turkish Scientific and Research Council) for doing this
research.
Conflict of interest
Up to the authors' knowledge, there is no conflict of
interest. The survey conducted has been accomplished
voluntarily by the participating physicians' willing and
consent. The survey participants were informed about the
research they are involved and they accepted the terms and
conditions on the interpretation of the results of the
research.
Ethical approval
Not required.
Acknowledgements
This study was supported by The Scientific and Technological
Research Council of Turkey (TUBITAK) with 2211C doctoral
research scholarship program.
Appendix A. Supporting information
Supplementary data associated with this article can be found
in the online version at http://dx.doi.org/10.1016/j.hlpt.
2017.07.007.
References
[1] World Health Organization. European health report- Targets
beyond reaching new frontiers in evidence; 2015.
E. Sezgin et al.
[2] Atluri V, Rao S, Rajah T, Schneider J, Thibaut M, Varanasi S. ,
et al. Unlocking digital health: opportunities for the mobile
value chain; 2015.
[3] OECD. OECD Digital Economy Outlook 2015 [Internet]; 2015.
Available from: 〈http://ec.europa.eu/eurostat/documents/
42577/3222224/Digital+economy+outlook+2015/
dbdec3c6-ca38-432c-82f2-1e330d9d6a24〉.
[4] Istepanian RSH, Laxminarayan S, Pattichis CS. M-Health: emerging
mobile health systems [Internet]. In: Istepanian OSH, Laxminarayan
S, Pattichis CS, editors. MHealth. London: Springer-Verlag; 2010.
p. 133–270. http://dx.doi.org/10.1007/b137697.
[5] Hampton T. Recent advances in mobile technology benefit
global health, research, and care. Am Med Assoc 2012;307
(19):2013–4.
[6] Källander K, Tibenderana JK, Akpogheneta OJ, Strachan DL,
Hill Z, ten Asbroek AH, et al. Mobile health (mHealth)
approaches and lessons for increased performance and reten-
tion of community health workers in low- and middle-income
countries: a review. J Med Internet Res 2013;15(1):e17.
Available from: 〈http://www.jmir.org/2013/1/e17/〉.
[7] Varshney U. Mobile health: four emerging themes of research.
Decis Support Syst 2014;66:20–35. Available from: 〈http://
linkinghub.elsevier.com/retrieve/pii/S0167923614001754〉.
[8] Rai A, Chen L, Pye J, Baird A. Understanding determinants of
consumer mobile health usage intentions, assimilation, and channel
preferences. J Med Internet Res [Internet] 2013;15(8):e149. Avail-
able from: 〈http://www.pubmedcentral.nih.gov/articlerender.fcgi?
artid=3742412&tool=pmcentrez&rendertype=abstract〉.
[9] Hung M-C, Jen W-Y. The adoption of mobile health manage-
ment services: an empirical study. [cited 2012 Mar 21]. J Med
Syst [Internet] 2010;36:1381–8. Available from: http://www.
ncbi.nlm.nih.gov/pubmed/20878452.
[10] Wu I, Li J, Fu C, Wu S. The acceptance of wireless healthcare
for individuals : an integrative view. Proc 12th Int Conf Enterp
Inf Syst 5; 2010. p.1–6.
[11] Wu J-H, Wang S-C, Lin L-M. Mobile computing acceptance
factors in the healthcare industry: a structural equation
model. [cited 2012 Mar 21]. Int J Med Inform [Internet]
2007;76(1):66–77. Available from: http://www.ncbi.nlm.nih.
gov/pubmed/16901749.
[12] Number of physicians, number of persons per physician and
number of patient hospital visits per physician- 2009–2014
[Internet]. Ankara; 2015. Available from: 〈www.tuik.gov.tr/
PreIstatistikTablo.do?Istab_id=1612〉.
[13] Kahn J, Yang J, Kahn J. Mobile health needs and opportunities
in developing countries. Health Aff [Internet] 2010;29
(2):252–8. Available from: 〈http://content.healthaffairs.org/
content/29/2/252.short〉.
[14] Chib A, van Velthoven MH, Car J. mHealth adoption in low-
resource environments: a review of the use of mobile health-
care in developing countries. J Health Commun [Internet]
2015;20(1):4–34. Available from: 〈http://www.ncbi.nlm.nih.
gov/pubmed/24673171〉.
[15] PwC Health Research Institute. Top health industry issues of
2015 [Internet]; 2014. Available from: 〈http://www.pwc.com/
en_US/us/health-industries/top-health-industry-issues/down
load.jhtml〉.
[16] Wolters Kluwer Health 2013 Physician Outlook Survey [Inter-
net]; 2013. Available from: 〈http://www.wolterskluwerhealth.
com/News/Pages/latestnews.aspx〉.
[17] Ventola CL. Mobile devices and apps for health care profes-
sionals: uses and benefits. [cited 2015 Feb 10]. Pharm Ther
[Internet] 2014;39(5):356–64. Available from: http://www.
pubmedcentral.nih.gov/articlerender.fcgi?artid=4029126&
tool =pmcentrez&rendertype=abstract.
Investigation of physicians' awareness and use of mHealth apps
[18] Becker S, Miron-Shatz T, Schumacher N, Krocza J, Diamantidis
C, Albrecht U-V. mHealth 2.0: experiences, possibilities, and
perspectives. JMIR mHealth uHealth [Internet] 2014;2(2):e24.
Available from: 〈http://mhealth.jmir.org/2014/2/e24/〉.
[19] Liu C, Zhu Q, Holroyd K a, Seng EK. Status and trends of
mobile-health applications for iOS devices: a developer's
perspective. Available from:. J Syst Softw [Internet] 2011;84
(11):2022–33. http://dx.doi.org/10.1016/j.jss.2011.06.049.
[20] Gagnon M-P, Ngangue P, Payne-Gagnon J, Desmartis M. m-Health
adoption by healthcare professionals: a systematic review. J Am
Med Inform Assoc [Internet] 2015:1–10. Available from: 〈http://
jamia.oxfordjournals.org/cgi/doi/10.1093/jamia/ocv052〉.
[21] Steven R, Steinhubl M. Can mobile health technologies transform
health care? JAMA [Internet] 2013;310(22):2395–6. Available
from: 〈http://list.umassmed.edu/read/attachment/136612/1/
Steinhubl_JAMA_MHTTransformHealthCare_2013.pdf〉.
[22] Ozdalga E, Ozdalga A, Ahuja N. The smartphone in medicine: a
review of current and potential use among physicians and
students. J Med Internet Res 2012;14(5):1–14.
[23] Nhavoto JA, Grönlund Å. Mobile technologies and geographic
information systems to improve health care systems: a litera-
ture review. JMIR mHealth uHealth [Internet] 2014;2(2):e21.
Available from: 〈http://mhealth.jmir.org/2014/2/e21/〉.
[24] Zwart CM, He M, Wu T, Demaerschalk BM, Mitchell JR, Hara AK.
Selection and pilot implementation of a mobile image viewer: a
case study. JMIR mHealth uHealth [Internet] 2015;3(2):e45. Avail-
able from: 〈http://www.pubmedcentral.nih.gov/articlerender.
fcgi?artid=4463772&tool=pmcentrez&rendertype=abstract〉.
[25] Sama PR, Eapen ZJ, Weinfurt KP, Shah BR, Schulman K a. An
Evaluation of Mobile Health Application Tools. JMIR mHealth
uHealth [Internet]. 2014;2(2):e19. Available from: 〈http://
mhealth.jmir.org/2014/2/e19/〉.
[26] Fiordelli M, Diviani N, Schulz PJ. Mapping mHealth research: a
decade of evolution. J Med Internet Res [Internet] 2013;15(5):
e95. Available from: 〈http://www.jmir.org/2013/5/e95/〉.
[27] Xu W, Liu Y. mHealthApps: a repository and database of mobile
health apps. JMIR Mhealth Uhealth [Internet] 2015;3(1):e28.
Available from: 〈http://mhealth.jmir.org/2015/1/e28/〉.
[28] Hale K, Capra S, Bauer J. A framework to assist health
professionals in recommending high-quality apps for support-
ing chronic disease self-management: illustrative assessment
of type 2 diabetes apps. JMIR mHealth uHealth [Internet]
2015;3(3):e87. Available from: 〈http://www.ncbi.nlm.nih.
gov/pubmed/26369346〉.
[29] Burke LE, Ma J, Azar KMJ, Bennett GG, Peterson ED, Zheng Y,
et al. Current science on consumer use of mobile health for
cardiovascular disease prevention: a scientific statement from
the American heart association. Circulation. 2015;132.
[30] Free C, Phillips G, Watson L, Galli L, Felix L, Edwards P, et al.
The effectiveness of mobile-health technologies to improve
health care service delivery processes: a systematic review
and meta-analysis. PLoS Med [Internet] 2013;10(1):e1001363.
Available from: 〈http://www.scopus.com/inward/record.url?
eid=2-s2.0-84873845389&partnerID=40&md5=7caa0d7bae3b
9ede6a8d2a11803011ce〉.
[31] Kumar S, Nilsen WJ, Abernethy A, Atienza A, Patrick K, Pavel
M, et al. Mobile health technology evaluation: the mHealth
evidence workshop. Am J Prev Med [Internet] 2013;45
(2):228–36. Available from: 〈http://www.ncbi.nlm.nih.gov/
pubmed/23867031〉.
[32] Barton AJ. The regulation of mobile health applications. BMC
Med [Internet] 2012;10(1):46. Available from 〈http://www.
biomedcentral.com/1741-7015/10/46〉.
[33] [ur] Rehman S, Ramzy V. Awareness and use of electronic
information resources at the health sciences center of Kuwait
265
University. Libr Rev [Internet] 2004;53(3):150–6. [Available
from] 〈http://www.emeraldinsight.com/doi/abs/10.1108/00
242530410526556〉.
[34] Solvoll T, Scholl J, Hartvigsen G. Physicians interrupted by
mobile devices in hospitals: understanding the interaction
between devices, roles, and duties. J Med Internet Res
2013;15(3):1–12.
[35] Jersak LC, Costa AC, Callegari Da, Jersak LC, Adriana C,
Callegari DA. A Systematic Review on Mobile Health Care;
2013.
[36] Praveen D, Patel A, Raghu A, Clifford GD, Maulik PK, Moham-
mad Abdul A, et al. SMARTHealth India: development and field
evaluation of a mobile clinical decision support system for
cardiovascular diseases in rural India. JMIR mHealth uHealth
[Internet] 2014;2(4):e54. Available from: 〈http://www.ncbi.
nlm.nih.gov/pubmed/25487047〉.
[37] Davis FD. Perceived usefulness, perceived ease of use, and
user acceptance of information technology. Manag Inf Syst
1989;13(3):319–40.
[38] Venkatesh V, Morris MG, Davis GB, Davis FD. User acceptance
of information technology: toward a unified view. MIS Q
2003;27(3):425–78.
[39] Fishbein M, Ajzen I. In: Park DC, Liu LL, editors. Belief, attitude,
intention and behaviour: An introduction to theory and research
[Internet]. Reading MA AddisonWesley. MA: Addison-Wesley; 1975.
p. 480. Available from: 〈http://www.people.umass.edu/aizen/
f&a1975.html〉.
[40] Rogers EM. Diffusion of Innovations [Internet]. In: Salwen MB,
Stacks DW, editors. An integrated approach to communication
theory and research. NY: Free Press; 1995. p. 519. (Health
Behavior and Health Education: Theory, Research, and Practice;
vol. 65) Available from: 〈http://books.google.com/books?
hl=en&lr=&id=v1ii4QsB7jIC&pgis=1〉.
[41] Kijsanayotin B, Pannarunothai S, Speedie SM. Factors influen-
cing health information technology adoption in Thailand's
community health centers: applying the UTAUT model. Int J
Med Inform 2009;78:404–16.
[42] Gagnon M-P, Godin G, Gagné C, Fortin J-P, Lamothe L,
Reinharz D. An adaptation of the theory of interpersonal
behaviour to the study of telemedicine adoption by physicians.
[cited 2012 Mar 26]. International J Med Inform [Internet]
2003;71(2-3). Available from: http://linkinghub.elsevier.com/
retrieve/pii/S1386505603000947.
[43] Venkatesh V, Thong JYL, Xu X. Consumer acceptance and use
of information technology: extending the unified theory of
acceptance and use of technology. MIS Q [Internet] 2012;36
(1):157–78. Available from: 〈http://papers.ssrn.com/sol3/
papers.cfm?abstract_id=2002388〉.
[44] Aggelidis VP, Chatzoglou PD. Using a modified technology
acceptance model in hospitals. Int J Med Inform, 78; 115–26.
[45] Wu I-L, Li J-Y, Fu C-Y. The adoption of mobile healthcare by
hospital’s professionals: An integrative perspective. [cited
2012 Mar 1]. Decis Support Syst [Internet] 2011;51(3):587–96.
Available from: http://linkinghub.elsevier.com/retrieve/pii/
S0167923611000911.
[46] Yi MY, Jackson JD, Park JS, Probst JC. Understanding informa-
tion technology acceptance by individual professionals:
Toward an integrative view. [cited 2012 Mar 9]. Inf Manag
[Internet] 2006;43:350–63. Available from: http://linkinghub.
elsevier.com/retrieve/pii/S0378720605000716.
[47] Hung S-Y, Ku Y-C, Chien J-C. Understanding physicians’
acceptance of the Medline system for practicing evidence-
based medicine: a decomposed TPB model. [cited 2012 Mar
28]. Int J Med Inform [Internet] 2012;81(2):130–42. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/22047627.
266
[48] Agarwal R, Prasad J. A conceptual and operational definition of
personal innovativeness in the domain of information technol-
ogy. Inf Syst Res 1998;9(2):204–15.
[49] Schaper LK, Pervan GP. ICT and OTs: a model of information
and communication technology acceptance and utilisation by
occupational therapists. Int J Med Inform [Internet] 2007;76
(1):212–21. Available from: http://www.ncbi.nlm.nih.gov/
pubmed/16828335.
[50] Chen J, Park Y, Putzer GJ. An examination of the components
that increase acceptance of smartphones among healthcare
professionals. Electron J Heal Inform 2010;5(2):1–12.
[51] Venkatesh V, Davis FD. A theoretical extension of the technol-
ogy acceptance model: four longitudinal field studies. Manag
Sci 2000;46(2):186–204.
[52] Venkatesh V, Bala H. Technology acceptance model 3 and a
research agenda on interventions. Decis Sci [Internet]., 39;
273–315. http://dx.doi.org/10.1111/j.1540-5915.2008.00192.x.
[53] Ajzen I. The theory of planned behavior. Organ Behav Hum
Decis Process 1991;50:179–211.
[54] Allen I, Seaman C. Likert scales and data analyses. Qual Prog
2007;7:64–5.
[55] Kline RB. Principles and practice of structural equation
modeling. Struct Equ Model 2010;156:427.
[56] Ringle C, Wende S, Will A. Smart-PLS Version 2.0 M3 [Internet].
University of Hamburg; 2005. [cited 2015 Oct 2][. Available
from]〈www.smartpls.de〉.
[57] Glaser BG, Strauss AL The discovery of grounded theory:
strategies for qualitative research [Internet]. Vol. 3, Sociology
The Journal of The British Sociological Association. Aldine;
1967. 269-270 p. Available from: http://dx.doi.org/http://
soc.sagepub.com/cgi/doi/10.1177/003803856900300233.
[58] Recker J Scientific research in information systems: a beginner’s
guide [Internet]. 2012 [cited 2015 Jan 15]. Available from: 〈http://
books.google.com/books?Hl=en&lr=&id=LzGbLKxjKHAC&oi=
fnd&pg=PR3&dq=Scientific+Research+in+Information+Systems
+A+Beginner%25E2%2580%2599s+Guide&ots=1fj_sF8jGf&sig=
VHAw-vGPiubS1OXmvln4FnNRrz0〉.
[59] Mishler EG. Research Interviewing: context and Narrative
[Internet]. Harvard University Press; 1991. [cited 2012 Jun 13]
[. 206 p. Available from]〈http://www.amazon.com/Research-In
terviewing-Narrative-Elliot-Mishler/dp/0674764617〉.
[60] Spall S. Peer debriefing in qualitative research: emerging
operational models. [Available from: 〈http://qix.sagepub.
com/cgi/doi/〉. Qual Inq [Internet] 1998;4(2):280–92. http:
//dx.doi.org/10.1177/107780049800400208.
[61] Ghasemi A, Zahediasl S. Normality tests for statistical analysis:
a guide for non-statisticians. [cited 2014 Jul 13]. Int J
Endocrinol Metab [Internet] 2012;10(2):486–9. Available from:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?
artid =3693611&tool=pmcentrez&rendertype=abstract.
[62] Steel RGD, Torrie JH, Dickey DA. Principles and procedures of
statistics: a biometrical approach. New York: McGraw-Hill;
352–401.
[63] Fornell C, Larcker D. Evaluating structural equation models
with unobservable variables and measurement error. [cited
2015 Sep 30]. J Mark Res [Internet] 1981. Available from:
http://www.jstor.org/stable/3151312.
[64] Hair J, Black W, Babib B, Anderson R, Tatham R. Multivariate
data analysis [Internet]. 7th ed. Analysis. NJ: Prentice Hall;
2009. p. 816. Available from: 〈http://www.lavoisier.fr/livre/
notice.asp?ouvrage=1086590〉.
[65] Nunnally J, Bernstein I. Psychometric theory. 3rd ed. New
York. NY: McGraw-Hill; 701.
[66] Segars AH. Assessing the unidimensionality of measurement: a
paradigm and illustration within the context of information
systems research. [cited 2015 Sep 30]. Omega [Internet]
1997;25(1):107–21. Available from: http://www.sciencedir
ect.com/science/article/pii/S0305048396000515.
E. Sezgin et al.
[67] Tabachnick BG, Fidell LS. Using multivariate statistics. Boston:
Pearson Education; 983.
[68] F. Hair Jr J, Sarstedt M, Hopkins L, G. Kuppelwieser V. Partial
least squares structural equation modeling (PLS-SEM). Eur Bus
Rev [Internet] 2014;26(2):106–21. [Available from]〈http://www.
emeraldinsight.com/doi/abs/10.1108/EBR-10-2013-0128〉.
[69] Wong KK. Partial least squares structural equation modeling
(PLS-SEM) techniques using smartPLS. Mark Bull [Internet]
2013;24:1–32. Available from: 〈http://marketing-bulletin.mas
sey.ac.nz/v24/mb_v24_t1_wong.pdf〉.
[70] Grewal R, Cote JA, Baumgartner H. Multicollinearity and
measurement error in structural equation models: implications
for theory testing. Available from:. Mark Sci [Internet] 2004;23
(4):519–29. http://dx.doi.org/10.1287/mksc.1040.0070.
http://pubsonline.informs.org/doi/.
[71] Fusch PI, Ness LR. Are we there yet? Data saturation in
qualitative research Qual Rep [Internet] 2015;20(9):1408–16.
Available from: http://tqr.nova.edu/wp-content/uploads/
2015/09/fusch1.pdf.
[72] Vital Wave Consulting. mHealth for development: the oppor-
tunity of mobile technology for healthcare in the developing
world. Washington, D.C. and Berkshire, UK; 2009.
[73] Sezgin E, Özkan-Yildirim S. A literature review on attitudes of
health professionals towards health information systems: from
e-Health to m-Health. [cited 2015 Jun 2]. Procedia Technol
[Internet] 2014;16:1317–26. Available from: http://www.scien
cedirect.com/science/article/pii/S2212017314003752.
[74] Holden RJ, Karsh B-T. The technology acceptance model: its past
and its future in health care. [cited 2012 Mar 4]. J Biomed Inform
[Internet] 2010;43(1):159–72. Available from: http://www.pub
medcentral.nih.gov/articlerender.fcgi?artid=2814963&tool=
pmcentrez&rendertype=abstract.
[75] Chau PYKP, Hu PJ. Investigating healthcare professionals’
decisions to accept telemedicine technology: an empirical
test of competing theories. [cited 2012 Jun 11]. Inf Manag
[Internet] 2002;39:297–311. Available from: http://www.scien
cedirect.com/science/article/pii/S0378720601000982.
[76] Duhm J, Fleischmann R, Schmidt S, Hupperts H, Brandt SA.
Mobile electronic medical records promote workflow: physi-
cians’ perspective from a survey. [cited 2016 Jul 5]. JMIR
mHealth uHealth [Internet] 2016;4(2):e70. Available from:
http://mhealth.jmir.org/2016/2/e70/.
[77] Ducey AJ, Coovert MD. Predicting tablet computer use: an
extended technology acceptance model. Heal Policy Technol
[Internet] 2016;5(3):268–84. http://dx.doi.org/10.1016/j.
hlpt.2016.03.010.
[78] Wu J, Wang S, Lin L. What drives mobile health care ? An
empirical evaluation of technology acceptance. In: Proc 38th
Hawaii Int Conf onf Syst Sci; 2005. p. 1–9.
[79] Embi PJ, Yackel TR, Logan JR, Bowen JL, Cooney TG, Gorman
PN. Impacts of computerized physician documentation in a
teaching hospital: perceptions of faculty and resident physi-
cians. J Am Med Inform Assoc 2004;11(4):300–9.
[80] Georgiou A, Ampt A, Creswick N, Westbrook JI, Braithwaite J.
Computerized Provider Order Entry–what are health profes-
sionals concerned about? A qualitative study in an Australian
hospital [cited 2011 Aug 1]. Int J Med Inform [Internet]
2009;78(1):60–70. Available from: http://www.ncbi.nlm.nih.
gov/pubmed/19010728.
[81] Yu P, Li H, Gagnon MP. Health IT acceptance factors in long-
term care facilities: a cross-sectional survey. [cited 2012 Mar
28]. Int J Med Inform [Internet] 2009;78(4):219–29. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/18768345.
[82] Hsiao C-H, Tang K-Y, Liu JS. Citation-based analysis of
literature: a case study of technology acceptance research.
Scientometrics [Internet], 105; 1091–110. Available from:
〈http://link.springer.com/10.1007/s11192-015-1749-5〉.
 Investigation of physicians' awareness and use of mHealth apps
[83] Franko OI, Tirrell TF. Smartphone app use among medical
providers in ACGME training programs. J Med Syst 2012;36
(5):3135–9.
[84] Kessel KA, Vogel MM, Schmidt-Graf F, Combs SE. Mobile apps in
oncology: a survey on health care professionals' attitude
toward telemedicine, mhealth, and oncological apps. J Med
Internet Res [Internet] 2016;18(11):e312. Available from:
〈http://www.jmir.org/2016/11/e312/〉.
[85] Edwards EA, Lumsden J, Rivas C, Steed L, Edwards LA,
Thiyagarajan A, et al. Gamification for health promotion:
systematic review of behaviour change techniques in smart-
phone apps. BMJ Open [Internet] 2016;6(10):e012447. [Avail-
able from]〈http://www.ncbi.nlm.nih.gov/pubmed/27707829〉.
View publication stats
267
[86] Ward R. The application of technology acceptance and diffu-
sion of innovation models in healthcare informatics. [cited
2013 Aug 29]. Heal Policy Technol [Internet] 2013;2(4):222–8.
Available from: http://linkinghub.elsevier.com/retrieve/pii/
S2211883713000543.
[87] Goodhue DL, Lewis W, Thompson R, Does PLS. have advantage
for small sample size or non-normal data? MIS Q 2012;36
(3):1–16.
[88] Hao H, Padman R, Telang R Physician’s usage of mobile clinical
applications in a community hospital: a longitudinal analysis of
adoption behavior [Internet]. UK Academy for Information
Systems Conference Proceedings; 2013. [cited 2016 Apr 8].
Available from: 〈http://aisel.aisnet.org/ukais2013/11〉.