Perceived e-health literacy (PEHL)
The term 'health literacy' was initially used in 1974 in the United States to indicate guidelines for health education among students. It refers to a person's capacity to acquire, process, and understand essential health information and services required for making informed health-related choices (Berkman, Davis and McCormack, 2010). A research study introduced an e-health literacy model, which defines e-health literacy as the skill to search, locate, understand, and evaluate health information obtained from electronic sources (Norman and Skinner, 2006).
Perceived e-health literacy (PEHL) emerges as a crucial variable influencing users' engagement with MHAs. PEHL encompasses users' perceived aptitude in effectively utilizing health technologies to enhance their health outcomes. Individuals with greater levels of PEHL are more inclined to actively engage with MHAs, perceive them as valuable and user-friendly, and ultimately demonstrate stronger intentions to continue using these platforms. In the contemporary healthcare landscape, digital technologies have ushered in a new era of patient empowerment and engagement. At the forefront of this revolution are mobile health applications (MHAs), offering users unprecedented access to health information, resources, and services (Mbunge et al., 2021). As the adoption and utilization of MHAs continue to rise, understanding the factors influencing users' interactions with these platforms becomes increasingly paramount. PEHL is a crucial dimension in this evolving paradigm, encapsulating users' subjective perceptions of their ability to navigate, comprehend, and utilize eHealth resources effectively. Rooted in the broader framework of health literacy, PEHL extends beyond traditional literacy skills to encompass digital competencies essential for engaging with online health information and services.
Despite its inherent significance, the concept of PEHL remains relatively underexplored within the context of MHAs. As users increasingly rely on these platforms for health-related information and support, understanding the role of PEHL in shaping their experiences and behaviors becomes imperative. By elucidating the nuances of PEHL and its impact on users' engagement with MHAs, researchers can inform the development of tailored interventions that address users' unique literacy needs and preferences. The importance of PEHL lies in its profound implications for users' health behaviors, outcomes, and experiences with eHealth platforms. Individuals with higher levels of PEHL are better equipped to engage with eHealth resources effectively, resulting in improved health knowledge, self-management abilities, and decision-making skills.
Trust
Trust is considered a key enabler in adoption, primarily because of its significance in addressing two pivotal aspects of digital technologies: vulnerability and uncertainty (Belanche, Casaló and Flavián, 2012). It is "the readiness of one party to expose themselves to the actions of another party, with the anticipation that the latter will carry out a specific action that is deemed important by the trusting party, regardless of the ability to oversee or regulate the actions of the other party (Mayer, Davis and Schoorman, 1995)." In the virtual world, building trust is vital to reduce transaction costs, enhance consumer purchase rates, and alleviate uncertainties and risks faced by online shoppers. In developing countries, trust plays exerts a notable impact on shaping consumer behavior (Zaidi et al., 2019). In a research article by (Zhou et al., 2023), it was mentioned that trust is an essential psychological characteristic to check prior and during the initial phases of adoption, particularly in urban regions where a great deal of the population have not yet been accustomed to chronic encounters with the given behavior. This can be applied in the later phase of after initial use to determine if such adoption will continue. Therefore, in conditions of uncertainty, trust plays a crucial role in reducing vulnerability and satisfying the human desire to comprehend the social context of interactions, involving the aspects of what, when, why, and how individuals behave (Gefen, Karahanna, and Straub, 2003; AlHogail and AlShahrani, 2019). This could explain the significance of trust as a critical factor in research focusing on online transactions, particularly within online services, as illustrated in this study. Various features relevant to the provision of electronic services, such as the dynamic nature of the environment, the user's skill level, and absence of physical communication, have underscored the critical role of trust in e-environment interactions.
2.2 Theoretical background and research hypotheses
Technology Acceptance Model
This Model provides a theoretical framework for understanding users' acceptance and adoption of technology (Davis, 1989). TAM posits that perceived usefulness and perceived ease of use come out as key determinants of users' intention to use a technology, this influences their usage behavior. While TAM has been used to numerous technology adoption contexts, the inclusion of PEHL as a critical antecedent to perceived usefulness and perceived ease of use represents a novel extension of the model in the context of mobile healthcare. TAM clarifies and forecasts the user's inclination towards technology-oriented information systems or computer-based applications, such as e-commerce. Furthermore, specific research endeavors have even formulated more comprehensive factors encompassing many systems that do not rely on particular circumstances (Davis, 1989; Koufaris, 2002). The TAM suggests a direct correlation between how useful individuals perceive a technology to be and their intention to use it. Therefore, a technology's perceived level of usefulness correlates positively with the intention to embrace it.
Perceived Usefulness (PU):
At the heart of TAM lies the concept of PU, which pertains to how much a person believes a specific technology will improve their performance and productivity in achieving tasks or goals (Michels, Wever and Musshoff, 2023). In simpler terms, it's about whether users perceive the technology as beneficial or advantageous to them. For instance, if individuals believe that using a mobile health application (MHA) will help them manage their health more effectively by providing easy access to medical information and resources, the probability of viewing it as useful is higher.
Perceived Ease of Use:
Perceived ease of use, second pillar in the TAM, revolves around the notion of how easy or straightforward individuals view the technology in terms of its usability and accessibility. Essentially, it assesses whether users find the technology convenient and user-friendly enough to interact with. For example, if individuals perceive that using a particular social media platform requires minimal effort and is intuitive in navigation, they are more likely to perceive it as easy to use.
User Attitudes and Behavioral Intentions:
According to Technology Acceptance Model (TAM), users' views regarding the usefulness and ease of use have a direct impact on their attitudes towards embracing and utilizing the technology (Baki, Birgoren and Aktepe, 2018). If individuals perceive a technology to be both useful and easy to use, they are more likely to develop a positive attitude towards it, fostering their intention to adopt and use the service. On the contrary, if individuals view the technology as not being useful or challenging to use, they will not feel the need to embrace it.
2.3 Research hypotheses
The concept of PEHL referring to the skill to search, locate, understand, and evaluate health information obtained from electronic sources. Users with higher levels of PEHL are better equipped to comprehend and navigate mobile health applications (MHAs), leading to enhanced trust in the reliability and effectiveness of these platforms. The PEHL of individuals significantly influences their perception of the usefulness and ease of using mobile health applications for managing health and wellness. Individuals possessing higher levels of PEHL are more inclined to recognize the benefits and functionalities of MHAs, leading to greater PU and PEOU of these applications as they are better equipped to navigate and utilize MHAs effectively, leading to a perception of greater ease of use. Thus, it is hypothesized that
H1
PEHL positively influences users' trust in continuance intention of MHA
H2
PEHL positively influences users' PU of MHA
H3
PEHL positively affects users' PEOU of MHA
Users will only embrace new technologies and intend to continue using if they provide a distinct advantage compared to current options (Bandinelli et al., 2023). This perspective is present in the TAM's concept of Perceived Usefulness, which measures a person's belief in the potential of a system to enhance their overall well-being (Davis, 1989). Hence, the following hypothesis is proposed
H4
Users' PU of MHAs positively influences their trust in MHAs
H5
Users' PU of MHAs positively influences their intention to continue using these apps.
Perceived ease of use refers to how easy a person perceives it would be to use a particular system (Liu and Ye, 2021). As per TAM, the PEOU has been demonstrated to greatly influence behavior and intention regarding the adoption of various technologies. Research indicates that individuals are more inclined to embrace a novel technology if it proves user-friendly or at least not excessively complicated. Thus, the subsequent hypothesis is put forth
H6
Users' PEOU of MHAs positively influences their trust in MHAs
H7
Users' PEOU of MHAs positively influences their continuance intention of these apps
Trust encompasses 3 fundamental principles: capability, uprightness, and goodwill. Researchers view trust as an intricate human belief shaped by interactions among human and technological environment, affected by various factors (Gefen, 2000; Alrawad et al., 2023). Consequently, numerous researchers have proposed that trust has an effect on people's need to utilize, embrace, welcome new technologies like e-commerce, mobile applications, etc, (Almaiah et al., 2022; Wu and Tang, 2022). Trust is crucial in fostering adoption and interactions between humans and technology (Adnan et al., 2018). Hence, the decision to continue engaging with a particular technology hinges on trust. Research have been conducted on the correlation between trust and intention to continue. According to a research, trust has the potential to influence repeat purchase habits, with this connection being influenced by routine (Hsu, Chang and Chuang, 2015). (Zhou, 2012) also suggested that trust could impact continuance usage directly and indirectly by encountering resistance to change. Therefore, it is widely acknowledged that trust serves as a precursor to the intention to continue. Within the realm of e-health, trust reflects users' perceptions towards both the MHA they utilize and its provider. Furthermore, the heightened emphasis on privacy further underscores the significance of trust in influencing continuance intention. Users are more likely to trust Mobile Health Applications when they have a positive perception of PU and PEOU. We propose the following hypothesis
H8
Trust has a positive influence on users' intention to continue using MHAs
H9
Trust mediates the relationship between PEHL and users' intention to continue using MHAs.
H10
Trust mediates the relationship between PU of MHAs and users' intention to continue using these apps.
H11
Trust mediates the relationship between PEOU of MHAs and users' intention to continue using these apps.