THE STUDY OF INTERNET OF THINGS (IOT)-BASED

HEALTHCARE ACCEPTANCE IN PAKISTAN

Zulfiqar Ali Solangi Dr. Madihah S. Abd. Aziz Prof. Dr. Asadullah
Kulliyah of Information & Communication Kulliyah of Information & Communication Kulliyah of Information & Communication
Technology, International Islamic University Technology, International Islamic University Technology, International Islamic University
Malaysia, 53100 Kuala Lumpur, Malaysia Malaysia 53100 Kuala Lumpur, Malaysia Malaysia 53100 Kuala Lumpur, Malaysia
zulfs@hotmail.com madihahs@iium.edu.my asadullah@iium.edu.my

Abstract— The Future technology Internet of Things (IoT) has infrastructure would be heterogeneous anyone would connect
immense prospects to improve future health care and its related to any service, any network, any service, and anywhere. This
issues to delivery, management, and development. IoT is a network future network of things would provide smart solutions in
founded on the use of sensors, actuators, beams, RFID devices and development and implementation of smart homes, smart cities,
software in things that can transform the future healthcare into smart traffic, and smart health [2].
pervasive healthcare. IoT-based healthcare can improve the
One of the major applications of ICT is Electronic Health (e-
delivery of healthcare services efficiently and innovatively by
growing huge volume of patients’ data (big data) that can invoke health). So as to enhance efficiency, effectiveness, quality of
proactive, predictive decisions and insights in future healthcare of medical and business process of the health care, the health
Pakistan. The health sector in Pakistan is confronting a number of organizations and practitioners have been accepting ICT in
challenges, including rising steeply costs; amplified aged healthcare known as e-health. In particular, to access online
population; chronic disease due to contemporary lifestyle; a health records is one of the utmost communal services along
growing incidence of medical errors, inadequate technical staffing,
and lack of coverage and medical professionals in rural and
underserved areas. The research paper intends to contribute to the
community, medical professionals (doctors, support staff, health
administrator) and end-users of proposed system with the
development of ubiquitous healthcare framework specifically in
rural and underserved areas of Pakistan. The purpose of this
paper is to evaluate the acceptance and use of IoT in the healthcare
system by medical professionals, clinicians and patients in
Pakistan in the precision of the Unified Theory of Acceptance and
Use of Technology model (UTAUT), and Health Belief Model
(HBM). This paper extends the existing research to study IoT-
based healthcare acceptance, HBM will be contextualized with the
assimilation of UTAUT model constructs to assess the acceptance
study in general health sector of Pakistan. It is also expected that
this research study will help in providing solutions to improve
prevailing healthcare conditions of rural and underserved areas in
Pakistan. In this research study triangulation, which is mix mode
of research methodology involves both quantitative and
qualitative research, will be used to achieve all the research
objectives and test the research hypothesis. This research will be
using cluster sampling for data collection. Figure 1 Body Sensor Connected Healthcare Model [8]

Keywords—Internet of Things, UTAUT, HBM, Smart with many other services of e-health. Whereas IoT predicted
Healthcare, Internet of everything that future healthcare would consist of all this plus would
produce lots of smart health devices with health sensors to
I. INTRODUCTION assess, assist and treat millions of patients by providing them
advance diabetic care, cardiac care, drug delivery, and general
Each second number of sensors, smarts home appliances,
health and wellness. IoT in the healthcare, for example in figure
electronic devices, or gadgets are connecting to the internet via
1, Physician, embeds biological sensors in the body of the
public/private cloud or information and communication
patient to measure blood pressure (BP), electrocardiogram
technology (ICT) to access services that structures the network
(ECG), heartbeat, and oxygen saturation in order to better
of smart things so-called internet of things (IoT). IoT and its
determine cardiac patient condition remotely and react before
potential can provide new solutions to almost every aspect of
some vulnerabilities appear. It is clear that their purpose is to
daily activity, the IoT is the perfect storm of advanced sensors,
enable better healthcare. One can then easily extend IoT
real-time networks, and massive data centers [1]. In future IoT
technology to a patient monitoring system [3].
Since we live in an age where increasingly everything attaches chronic and life-style-related diseases; increasing number of
itself to the network, so IoT healthcare can expand the medical errors and a very limited medical coverage to remotely
perspective of being reactive to proactive. In order to know, and located areas. Having limited resources and lack of medical
therefore predict, emergency proactively, you must be in the infrastructure in remote areas, the healthcare sector is too
network. The ground on which IoT walks is being in the overburdened to provide better services in underserved areas of
network intelligently, gathering real-time information about the Pakistan.
patient in a network and transmit it back to health monitoring
system. The increasing business demand to enhance operation However, one proposed solution is to bring ubiquitous
efficiency and improved patient care will make IoT a dominant computing not only at home based level but also at work or
model for health care industry in the future [4]. The IoT-based anywhere the patient may be. IoT can enhance information
healthcare or the networked biosensors world offer the technology to evolve general healthcare into smart healthcare
possibility of a perfect future patients’ healthcare where patient to ensure better, quick and effective patient’s assessment,
monitoring system seems to access, assist and treat the patients assistance and treatment in developing countries like Pakistan.
itself. There are many challenges involved in the design of IoT-based
health systems that use such technologies, particularly since the
II. BACKGROUND available sensing possibilities enable the development of very
Pakistan has a population of 188 million, a Gross National new experiences that are not readily comparable to the existing
Product (GNP) per capita of $1429 and Pakistan’ Pakistan’s healthcare scenarios that patients or medical professionals are
total expenditure of health sector is 2.61% of Gross Domestic familiar with in Pakistan. Therefore, it increases necessity to
Product (GDP) in the year 2014. “The population and health explore and investigate the technological acceptance,
facilities ratio worked out 1,073 persons per doctors, 12,447 development, delivery and management and the impact of
persons per dentist and 1,593 persons per hospital bed”[5]. technology within future healthcare systems in Pakistan.
Pakistan is a developing nation with the greater part of its Furthermore, the research study is involved in developing a
populace situated in rustic zones. These territories neither have framework for the design of IoT systems, investigating user-
adequate social insurance or healthcare workplaces nor a solid driven healthcare with empirical study intensively on home care
framework that can address the wellbeing needs of the general in rural and underserved areas of Pakistan.
population[6]. These rustic zones are lacking in assets to meet
medical needs or emergency of expanding populace of Pakistan IV. LITERATURE REVIEW
[7]. According to Global Competitiveness Index (GCI) 2015-
2016 the potential of technological readiness in Pakistan is not According to researchers future medical systems specifically e-
sufficiently equipped right to use IoT-based healthcare health, would be embedded with IoT to provide advanced
specifically and remains low at 127th position in GCI health medical services with more secure and efficient authentication
key indicator. In Pakistan, the major barriers to the deployment for users [8]. The Technology Acceptance Model (TAM)
of technologically up-to-date healthcare lack of awareness of, depends on ideas from social psychology research and is an
limited proof of the cost viability of modern medical devices or instrument for characterizing and testing the goals of individual
services, the absence of trust in modern health solutions by end-clients to utilize new innovation. Moreover, the end-client's
patients as well as medical professionals [7]. Henceforth, the goal to utilize medicinal data innovation can be evaluated by
research study intends to elaborate the essence of IoT in using the Unified Theory of Acceptance and Use of
healthcare systems and then change the way healthcare is Technology[9]–[11].
delivered. The research study will highlight the growth,
acceptance, instigating perception about IoT-based healthcare A. Unified theory of acceptance and ue of technology
to improve the public health sector which is providing health (UTAUT)
services to 22 percent of the population and the rest of the UTAUT is more extensive hypothetical model when contrasted
population is served by private healthcare organizations at very with different models as it has consolidated every one of the
high cost. factors found in the current models like (TRA, TPB, TAM,
MM, C-TPB-TAM, MPCU, IDT, and SCT) with four
III. PROBLEM STATEMENT determinants, (i) Performance Expectancy, (ii) Effort
Internet of Things (IoT) revolution is reshaping health care to Expectancy, (iii) Social Influence, and (iv) Facilitating
deliver better care more efficiently. IoT-based healthcare Conditions [12]. Thus, UTAUT has been found more
system enables the transformation of healthcare IT to let productive using a combination of moderating factors over
medical professionals securely access resources they need technology acceptance model (TAM) and others. Respectively,
wherever they are on whatever device best suits their need to Viswanath, Morris, and Davis have verified UTAUT to be
access, assist and treat the patient. The future doctor-patient convenient in measuring behavioral intention to use the
care model depends on self-monitoring; IoT sensors in patients’ technology and actual use. Therefore, proposed study intends to
body increasingly allow to look after patients remotely. use UTAUT model with two external constructs to measure
behavioral intention to use the technology and actual use.
Healthcare in Pakistan is facing the challenges of rising steeply Several studies have been conducted using UTAUT in context
costs an increasingly elderly population, increasing a number of of healthcare systems worldwide to assess the acceptance
behavior of medical professionals, like [11], [13]–[15]. In all to action to use behavior of IoT systems in healthcare. Both
these studies UTAUT model theory was contextualized to Unified Theory of Acceptance and use of Technology
predict the intention of medical professionals and adoption of (UTAUT) and Health Belief Model (HBM) theories will be
information technology in healthcare systems. This model applied as foundation to use IoT-based framework in
theory will be used in this research study to assess acceptance technological context and health context respectively, and two
of Internet of Things (IoT)-based healthcare in Pakistan. Figure external constructs (trust and doctor-patient relation) will be
2 is summarizing UTAUT model. used to measure trust and doctor-patient relationship as
individual context for medical professionals and general public.

Figure 2 UTAUT Model (Viswanath Venkatesh et al., 2003)

B. Health Belief Model (HBM)

Health Belief Model was originally developed in the early Figure 4 Proposed Research Model
1950s by social psychologists to describe and foresee health A. Cues To Action/Behavioral Intention
behaviors, to know the relationship of health behaviors, and Cues to action defines the “strategies to activate readiness" [17].
utilize health services and practices systematically. Later, HBM “An individual's perception of the levels of susceptibility and
was reviewed to identify and distinguish sickness or disease seriousness provide the force to act” [18]. Benefits fewer
susceptibility and illness severity from health behavior by obstructions give the way of behavioral intention (Cues to
including general health motivation. Thus, many researchers action), it may require a behavioral change due to perceived
have verified HBM, as the furthermost used model for health risk which consists of perceived susceptibility and
determining and foreseeing preemptive health behavior [16], perceived severity of desired behavior. Cues to action is used in
[17]. HBM is summarized in figure 3. place of behavioral intention of UTAUT theory which shows
the inclination of individuals’ behavior to use desired behavior
indicated[12] as a trigger to respond to health behavior when
proper beliefs are detained. In Rosenstock's unique detailing,
Cues to action may incorporate outer prompts, for example, a
social and electronic media, social impact, or inward prompts,
for example, a negative change in real state or impression of
side effects. All the more, by and large, Cues to action may be
triggered by occasions, individuals, or things that goad
individuals to change their use behavior (Rosenstock, 1966).
Figure 3 Health Belief Model (HBM) (Cao, Chen, & Wang, 2014;
Desai, Shah, Rahim, Yin, & Lonie, 2014) Hypothesized as:
H1. Cues to action will have a significant positive effect on
Use Behavior of IoT-based healthcare
V. PROPOSED RESEARCH MODEL AND HYPOTHESES: B. Trust:
Proposed hypothetical model in figure 4.0 shows the Population intention to sue healthcare services is highly
relationship amongst various constructs affecting behavioral influenced by the trust. Individual’s trust may increase intention
intention and use behavior in IoT-based healthcare acceptance. to use the healthcare services [19]. Trust is a feeling of
This research study will use two widely appreciated research someone’s reliance on ability or confidence to do something
theories to identify use behavior and actual use of technology. suitably [20]. Trust is a sociocultural factor affecting the
There are three groups of factors: technological context, health significantly on behavior intention to use the system. It is
context, and individual context, in which factors relate to Cues hypothesized as:
 H2. Trust will have positive effect on Cues-to-Action of new system as concluded by many researchers that it is
straightly influencing performance expectancy and effort
C. Doctor-patient relationship: expectancy that causes positive impact on use behavior [12].
The doctor-patient relationship has been complying as the Hypothesized:
foundation of care like a medium in which data is gathered, H7. Facilitating condition will have a positive effect on
identification of diseases or problems, their causes and their Cues to action
proper follow-up in curative stimulation of action and support H. PERCEIVED HEALTH RISK:
are provided [21]. According to (Bertelsmann Stiftung, 2005), In this research study perceived health risk consisted of two
more than 60% of patients are influenced by their personal factors perceived susceptibility and perceived severity. Both
physicians to be ready for any kind of clinical treatment or factors show the vulnerability and seriousness of the disease
consultation. It is a sociological, philosophical and literary and kind of helplessness or threat perception are build up for an
relationship to guide decision making in a health plan between individual to intend the use behavior of proposed system [29].
doctor and patient. The doctor-patient relationship is a Hypothesized as:
sociocultural factor affecting the significantly on behavior H8. Perceived Health Risk raised with perceived
intention to use the system. It is hypothesized as follows: susceptibility and perceived severity will have positive effect
H3.The doctor-patient relationship will have a positive effect on Use Behavior
on Cues-to-action

D. Performance Expectancy: VI. CONCLUSION

Performance expectancy is confident anticipation of someone The goal of this research is to study IoT-based healthcare
about practicing technology or system would support increase acceptance. An integrated hypothetical research model is
his or her performance [12], [22]. This construct is common proposed based on UTAUT and HBM with two external factors
from different constructs of several theories as perceived (trust and doctor-patient relation) where UTAUT is to analyze
usefulness like TAM, TPB, C-TAM [23], [24]. technological context, HBM is to analyze health context and
H4. Performance expectancy will have a positive effect on two external factors are to analyze individual context to assess
Cues-to-action technological acceptance and adoption of IoT-based healthcare
systems in Pakistan. The outcome of reviewed literature finds
E. Effort Expectancy: that there are many challenges involved in the design of
Effort Expectancy is characterized as the level of healthcare systems which use the IoT technologies because it is
straightforwardness, easiness, and openness related to the very new experience and technology that is not readily
utilization of the proposed framework[22], [23], [25], [26]. This comparable to healthcare scenarios specifically in the context
construct is common from different constructs of several of this research study there is sure gap to be filled, so this study
theories as ease of use like TAM, TAM2 from [23], [24] and will focus to develop standard framework for medical
ease of use from IDT [22]. All of them have more or less have professionals and individuals to accept and use future IoT-
verified that effort expectancy has a significant impact on user based healthcare systems proficiently.
behavior, so it is hypothesized here in the context that: This research study will explore and investigate an effective
H5. Effort Expectancy will have a positive effect on Cues to response to the challenges currently faced by healthcare
action systems and other agents (medical professionals, clinicians,
F. Social Influence: patients) in meeting the requirements of the principles
Social influence has an ability to effect on the character or underpinning the every hospital healthcare system in Pakistan.
behavior of someone. Social influence is “an extent of an It is intended that research findings will contribute to the
individual perception about how important others including his development of a framework to support health professionals,
family, friends, and colleagues believe he or she should use the clinicians or patients in the delivery of the IoT- based healthcare
new system” [27], [28]. This factor has a straight impact on system in Pakistan. More, the research study will review
behavior and characterized as the subjective norm by many prospects of Internet of Things broadly in current healthcare as
researchers [23], [24]. Social influences and pressures will be a changer for current healthcare systems and service delivery
significant in determining technology acceptance decisions. both in urban and rural remote situated areas of Pakistan. The
Hypothesized: outcome of the research study will be inclusively committed to
H6. Social Influence will have a positive effect on Cues to proposing patients’ healthcare monitoring system to assess,
action. assist and treatment of the patients itself, and reduce the cost of
G. Facilitating Conditions: healthcare in future.
Facilitating conditions are defined as “the degree to which an
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