Journal of

Information Systems Engineering

and Business Intelligence
Vol.10, No.1, February 2024
Available online at: http://e-journal.unair.ac.id/index.php/JISEBI

Patients’ Acceptance of Telemedicine Technology: The

Influence of User Behavior and Socio-Cultural Dimensions
Purno Tri Aji 1)* , Luthfi Ramadani 2)
1)Department of Electrical and Electronic Engineering, Universitas Negeri Yogyakarta, Yogyakarta, Indonesia
1)
purno.tri@uny.ac.id

2)Department of Information Systems, Telkom University, Bandung, Indonesia

2)
luthfi@telkomuniversity.ac.id

Abstract

Background: Over the years, the role of startups has experienced a significant increase in healthcare delivery, particularly in
telemedicine. However, there are still some inherent challenges, including cultural factors, lack of digital literacy, and uneven
internet network infrastructure that must be considered during implementation. Previous reports also showed that there was a
knowledge gap regarding the factors influencing acceptance of telemedicine.
Objective: This study aimed to introduce and investigate an adjusted model based on Technology Acceptance Model (TAM)
to assess the influence of user dimensions, technological aspects, and socio-cultural elements on the intention to adopt
telemedicine services.
Methods: The hypothesized relationships between latent variables were examined through Structural Equation Modeling
(SEM). In addition, data analysis was carried out using Partial Least Squares-Structural Equation Modeling (PLS-SEM).
Results: Self-efficacy (β=-0.272, P=0.013), perceived usefulness (β=0.355, P=0.000), facilitating conditions (β=0.425,
P=0.000), and cultural factors (β=0.421, P=0.001) were found to exert a significant influence on the intention to adopt
telemedicine services. Meanwhile, trust, the variables of perceived ease of use, and social influence had no significant influences.
Conclusion: This study emphasized the significance of comprehending the factors influencing the adoption of telemedicine
services. In addition, the results showed that the extended TAM was applicable in assessing acceptance of telemedicine services.

Keywords: acceptance, telemedicine, TAM, SEM, intention to use

Article history: Received 31 July 2023, first decision 4 December 2023, accepted 26 January 2024, available online 28 February 2024

I. INTRODUCTION
In recent years, the global pandemic has compelled a widespread digital transformation across various industries in
most countries around the world. This transformation has catalyzed substantial growth in the adoption of telehealth or
telemedicine in healthcare and IT sectors [1]. In addition, the development of Information and Communications
Technology (ICT) and telecommunications infrastructure plays an essential role as facilitators for the rise of digital
startups in healthcare sector. The synergy between technology and healthcare sector has yielded significant
advancements, with telemedicine emerging as a key player. Several studies reported the various benefits of
telemedicine, including improved healthcare maintenance and reduced healthcare costs, thereby altering the landscape
for patients. Accessing healthcare services has become more streamlined and convenient, reshaping individuals’
lifestyles in maintaining health [2].
Several studies explored the widespread adoption of telemedicine, such as Rouidi et al. [3] which conducted an in-
depth exploration of acceptance, focusing on physicians' perspectives. The report categorized the constructs employed
into 3 dimensions, including individual, technological, and organizational contexts. In addition, an extended Unified
Theory of Acceptance and Use of Technology (UTAUT) model was used with the incorporation of various variables,
including perceived incentive, level of IT use, and compatibility into the proposed framework. Kuo et al. [4] also
carried out a similar investigation, aiming to identify factors influencing physicians' perceptions of telemedicine
adoption using Theory of Planned Behavior (TPB). Moreover, Ly et al. [5] assessed the individual and contextual
determinants of telemedicine usage using a comprehensive framework spanning micro, meso, and macro levels,

*
Corresponding author

ISSN 2443-2555 (online) 2598-6333 (print) © 2024 The Authors. Published by Universitas Airlangga.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
doi: http://dx.doi.org/10.20473/jisebi.10.1.81-93
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adapted from the social-ecological framework. The descriptive study obtained insights from both physicians and
project managers, contributing valuable perspectives to the discourse.
Compared to previous studies, Song et al. [6] introduced a theoretical model, aiming to predict and elucidate
patients' intention to persist in using mobile health services for chronic condition self-management. In addition, a
hybrid model was tested by merging the information system continuance with the information system success model.
The results revealed that factors, such as health status, user satisfaction, and perceived usefulness significantly
influenced patients' intention to consistently use mobile health services. In another recent investigation, Zobair et al.
[7] explored the determinants of health seekers' acceptance and adoption of telemedicine services in a rural public
hospital setting in a growing economy. The study extended and adapted Technology Acceptance Model (TAM),
introducing new variables, such as privacy data security, and service quality. The results showed a significant influence
of these variables on patients’ behavioral intention (BI) to embrace telemedicine healthcare services in rural areas.
Furthermore, Alexandra et al. [8] conducted a comprehensive survey on acceptance model of hospital telemedicine,
examining the influence of user behavior and technological dimensions on user intention. A modified TAM was used,
which categorized variables into 2 dimensions, namely user and technological. Primary TAM variables in the proposed
model comprised perceived ease of use, perceived usefulness, behavioral intention, and actual use (AU). Although
this study introduced additional variables as part of the model modification, socio-cultural dimension, particularly
user perspective on the adoption of telemedicine service platforms was not considered.
Considering the gap in the literature, the primary objective of this current study is to enhance the comprehension of
acceptance of telemedicine service platforms. In addition, it was posited that exploring user intention towards using
telemedicine service platforms, with a focus on socio-cultural factors, represents a crucial avenue of investigation. In
the socio-cultural context of this study, the social influence exerted by user immediate environment to promote
telemedicine usage was explored. The influence of cultural norms or individuals' tendencies to consult with a doctor
in person was also assessed. Based on a previous study, a considerable number of individuals still prefer direct, face-
to-face consultations with a doctor. However, a cultural barrier arises from the degree of societal receptivity and
endorsement of innovative technology, such as telemedicine. To analyze acceptance of telemedicine, this study
adopted TAM. Furthermore, TAM has been extensively used in several studies to explore acceptance of telemedicine
and digital health [9][10]. For instance, in a comprehensive review, Garavand et al identified TAM and extended TAM
as the predominant models in previous reports [11]. The versatility of TAM is also evident, as it can be easily modified
to incorporate or expand upon other factors based on the current requirements. In addition, this study integrates specific
elements from Unified Theory of Acceptance and Use of Technology (UTAUT) model, particularly facilitating
conditions and social influence, which were expected to exert an influential role in shaping the behavioral intention to
adopt telemedicine.

II. LITERATURE REVIEW

A. Telemedicine
Telemedicine comprises leveraging information and communication technology to enhance patient outcomes
through expanded access to healthcare and medical information [12]. In addition, it provides remote health services
that engage health professionals, specifically doctors and patients [11]. According to previous studies, a total of 4
elements are related to telemedicine, including providing clinical support, useful for overcoming geographical and
distance barriers, aiming to improve public health, and comprising the use of a variety of information technology
devices. [12]. Previous studies categorized telemedicine into several types, including telemedicine services, tele-
consultation, mobile health, telerehabilitation, telehomecare, telemonitoring, and teleneonatology [11]. These terms
are in the context of digitizing healthcare which provides various benefits, such as enhancing community access to
health services, boosting the efficiency of human resources, elevating service quality, and lowering healthcare costs
[13].
In line with previous reports, telemedicine could be a solution to problems in today's healthcare sector, particularly
in developing countries, regarding accessibility, financial benefit, healthcare cost, and recent technology
advancements. In addition, it plays an essential role in the plan and is supported by governments across the country
[14]. Telemedicine can reach and distribute health services to a large portion of the population residing in both rural
and urban areas [15]. This indicates that it holds the potential to tackle diverse healthcare challenges and transform
public health significantly. Moreover, the introduction of telemedicine in developing nations is considered as a
significant innovation, comprising technological and social aspects in healthcare system.

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B. Hypotheses Development and the Proposed Model

TAM model is an extensively used framework for assessing perceptions and elements that influence the adoption
of emerging technology. In addition, it was first introduced by Davis in 1985 and identifies behavioral intention as a
key driver prompting users to embrace technology, a motivation shaped by the attitude. In the context of attitude
formation, the 2 principal factors influencing individuals’ willingness are perceived ease of use and perceived
usefulness [16]. TAM is also a fundamental and flexible model, which can be changed or expanded by combining it
with other models. Consequently, various modifications have emerged with the aim of analyzing telemedicine
technology. Several studies also explored the application to different environments and different contexts, with
acceptable results, such as reports on the hospital's teleconsultation application [8], acceptance of telehealth services
[17], and the adoption and use of telemedicine technology by healthcare professionals [3].
1) Trust (TR)
Several studies incorporated risk and trust factors into TAM model to elucidate acceptance of IT-based technology,
as demonstrated by Pavlou [18]. Trust is an essential factor that has been extensively used to comprehend technology
acceptance in healthcare sector [10]. In addition, it plays a crucial role in the ongoing intention to use mHealth services
[19]. According to Kamal et al., it positively influences the intention to adopt telemedicine services [20]. Ahlan et al.
expanded the model in developing country contexts, introducing trust, which directly contributed to the expected
usefulness (convenience) and expected ease of use of a self-diagnosis application [21]. Based on the results, this
current study suggests that user perceptions of trust in the technological infrastructure must enhance the intention to
use telemedicine. Consequently, the following hypothesis was formulated:
H1: Trust has a significant influence on Behavioral Intention.
2) Self-efficacy (SE)
Self-efficacy is related to individuals’ assessment of the ability to effectively use a system for a specific task. The
influence of this factor on behavioral intention can manifest through the perceived ease of use and perceived usefulness
of telemedicine [22]. Several studies revealed that computer self-efficacy plays a role in fostering acceptance of
telemedicine among both individuals and organizations [23][14]. Consequently, this study posits that self-efficacy
significantly influences acceptance of telemedicine.
H2: Self-efficacy has a significant influence on Behavioral Intention.
3) Perceived Usefulness (PU) and Perceived Ease of Use (PEOU)
Perceived usefulness and perceived ease of use are the two primary factors influencing user acceptance, as
postulated in Davis' study. Perceived usefulness refers to individuals’ confidence in a specific system enhancing the
job performance [16]. In the context of health technology and telemedicine, it was redefined by Kamal et al. as the
utility of the system for patients, acknowledging that its significance could differ from other studies. Patients perceive
telemedicine as useful when it offers quicker healthcare services at reduced costs, improved documentation, and a
decrease in service time [20]. Meanwhile, perceived ease of use is defined as the extent to which individuals believe
that using technology could minimize the effort and costs. Given this interpretation, it was assumed that patients
embraced and used telemedicine services more readily when the technology was expected to yield superior services
and outcomes. Consequently, the following hypotheses are posited:
H3: Perceived Usefulness has a significant influence on Behavioral Intention.
H4: Perceived Ease of Use has a significant influence on Behavioral Intention.
4) Facilitating Conditions (FC)
The facilitating conditions determinant is not part of the original TAM framework. In addition, this determinant is
described as individuals’ belief in the existence of organizational and technical support infrastructure for system usage
[23]. The presence of IT equipment, infrastructure, and knowledge of technology use plays an essential role in
supporting telemedicine use [24]. The effective use of these services is largely dependent on the availability of
adequate technological infrastructure. The successful integration of telemedicine comprises collaborative efforts
among healthcare professionals, service providers, and patients located in remote areas [20]. Consequently, this study
aims to verify whether there is a substantial correlation between facilitating conditions and user intention to adopt a
specific telemedicine application. Based on the results, the following hypothesis is posited:
H5: Facilitating conditions have a significant influence on Behavioral Intention.
5) Social Influence (SI)
Social influence is the degree to which individuals believe others expect them to use the new system [23]. Previous
studies have affirmed that social influence, expressed through subjective norms and images, directly contributes to the

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intention to adopt new technology [25]. Or and Karsh conducted a study predicting patient behavior concerning
acceptance or rejection of health information technology. The results showed that social factors, particularly the
influence of physicians, home care nurses, children, or grandchildren, played a crucial role [26]. In developing
countries, where individuals often reside in interdependent extended families, both socially and economically, the
opinions of those around them significantly influence the use of telemedicine services. Whether the influence is
encouraging or discouraging, it has a significant on the decision to use technology [20]. In the context of this study,
social influence was proposed to comprise factors that either promote or deter individuals from using telemedicine.
Therefore, the following hypothesis was formulated:
H6: Social Influence has a significant influence on Behavioral Intention.
6) Culture (CU)
Based on the results, there are limited studies examining culture as a factor in telemedicine acceptance. The work
of Mansouri-Rad [27] becomes relevant when culture is viewed as an indirect precursor to the successful adoption of
telemedicine. According to other studies, patients using telemedicine in rural areas believe that practitioners familiar
with culture are generally preferred [5]. In addition, Jang-Jaccard et al. stated that cultural factors were one of the
barriers to delivering telehealth in rural Australia [28]. Nwabueze et al. reported that cultural influences on users
influenced the adoption of telemedicine. However, cultural factors influence behavioral intention only for prospective
users and not for actual users [29]. Culture in this study is defined as individuals’ habits in consulting doctors and
considered to be closely related to user resistance towards new technology, such as telemedicine. Culture is also the
level of user acceptance of changes in health services from previously conventional to the use of telemedicine
applications, which is a new technology for consulting with doctors online. Therefore, the following hypothesis was
proposed:
H7: Culture has a significant influence on Behavioral Intention.
7) Behavioral Intention (BI)
Behavioral intention refers to a situation where individuals consciously intend to perform or abstain from a specific
behavior in the future [30]. In the context of this study, the behavioral intention to use denotes individuals’ intention
to utilize telemedicine services. According to TAM, the actual usage of a system is shaped by the behavioral intention
to use [31]. Furthermore, this factor can be characterized as the inclination to persist in applying technology [16].
Based on the results, the following hypothesis was formulated:
H8: Behavioral Intention has a significant influence on Actual Use.

User Dimension

Trust
H1

Self-Efficacy
H2

Technologycal Dimension
Perceived
H3
Usefulness

Perceived Ease of H4 Behavioral H8

Actual System Use
Use Intention to Use
H5
Facilitating
Condition

H6
Socio-cultural Dimension

Social Influence
H7

Culture

Fig. 1 The Proposed Model on User Acceptance of Telemedicine Service

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C. Conceptual Framework
This study examines acceptance of telemedicine technology among patients, specifically focusing on telemedicine
service platforms in Indonesia. Building upon insights from previous studies, the proposed model extends TAM by
incorporating additional variables. For the original TAM, variables of perceived usefulness, perceived ease of use,
and behavioral intention to use were included. This was because these variables garnered the highest level of support
in previous studies. Furthermore, recognizing the limited exploration of the relationship between the behavioral
intention to use telemedicine services platforms and socio-cultural factors in previous studies, the socio-cultural
dimension was introduced in the proposed model. This study formulated 8 hypotheses, outlined in the proposed model
illustrated in Fig. 1.
The current variables are categorized into 3 dimensions, namely user, technological, and socio-cultural dimensions.
The user dimension comprises aspects directly associated with telemedicine users, influenced by trust and self-
efficacy. The technological dimension included the existing technical infrastructure, such as hardware and software
to facilitate telemedicine use. This dimension is influenced by perceived ease of use, perceived usefulness, and
facilitating conditions. Meanwhile, socio-cultural dimension is an external factor influencing patient adoption of
telemedicine, comprising social influence and culture.

III. METHODS
A. Data Collection
This study used a quantitative method through an online questionnaire. The questionnaire to be shared was first
subjected to a readability test to ensure comprehension among respondents before the distribution as shown in Table
1. The sample population comprised individuals who were knowledgeable about or had previous experience with
telemedicine application. The readability test was carried out for one week with 10 respondents who provided critiques
or suggestions. The questionnaire received feedback on the use of standard language, consistency of terms,
identification of typos, and enhancements to sentence structure for improved respondent understanding by conducting
the readability test. Furthermore, the feedback served as a guide for refining the questionnaire.

TABLE 1
STUDY INSTRUMENTS
Latent Item Measurement Source
Variable
PU PU1 Employing telemedicine could enhance the quality of my healthcare. [20]
PU2 Using telemedicine could enhance my access to healthcare services. [20]
PU3 Incorporating telemedicine would be beneficial in my daily activities. [20]
PEU PEU1 I am confident that using telemedicine application is straightforward for me. [8][22]
PEU2 I am confident in my ability to easily engage with doctors through telemedicine application. [8]
PEU3 I am confident in my comprehension of how to interact with telemedicine application. [8]
FC FC1 I would have access to all essential resources for using telemedicine services. [20]
FC2 I possess IT proficiency to operate telemedicine application. [8]
FC3 In case of challenges with using telemedicine application, I can seek assistance from others. [8]
SE SE1 I could use telemedicine with previous experience in similar technologies. [14]
SE2 I could employ telemedicine after observing someone else using it before trying it myself. [14]
SE3 I could use telemedicine independently, even in the absence of guidance from others. [14]
SE4 I could operate telemedicine solely with manuals as references, even if there were no one around [14]
to guide me.
TR TR1 Telemedicine provider is dependable. [19]
TR2 Telemedicine provider provides information that can be relied upon. [19]
TR3 Telemedicine service provider upholds and fulfills promises and commitments. [19]
SI SI1 Individuals who hold considerable significance to me would appreciate my use of telemedicine [20]
services.
SI2 Those who have a substantial influence on my behavior would favor my adoption of telemedicine [20]
services.
CU CU1 I believe there are many advantages and benefits of using telemedicine applications. [29][32]
CU2 I am open to using new technologies such as telemedicine applications. [29][33]
CU3 I accept the change in health services from previously conventional to the use of telemedicine [29]
applications, because this is something new.
BI BI1 If provided with the opportunity to access telemedicine, I plan to avail telemedicine services. [20]
BI2 In the event of requiring remote medical care from professionals, I would willingly use [20]
telemedicine services.
BI3 I plan to communicate information about telemedicine to my relatives and friends. [20]
AU AU1 I frequently utilize telemedicine. [34]
AU2 I plan to continue using telemedicine for as long as it is necessary. [34]
AU3 I regularly make use of telemedicine. [34]

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In Partial Least Squares Structural Equation Modeling (PLS-SEM), determining the minimum sample size was an
essential consideration. The "10-times rule" method was widely employed in PLS-SEM based on the principle that
the sample size must exceed 10 times the highest number of inner or outer model links directed at any latent variable
[35]. Based on this guideline, the minimum sample size for this current study was set at 70 respondents. In addition,
data collection was carried out using an online survey created with Google Forms and distributed to a total of 105
respondents. In this study, respondents were selected randomly by selecting patients who had used telemedicine
applications, such as Halodoc, Alodokter, Good Doctor, and other similar variants. Halodoc, the prominent health tech
startup in Indonesia, was joined by others, including Alodokter and Klikdokter. These platforms offered a range of
services, including online consultations, pharmacy delivery, online drug purchases, doctor and hospital bookings,
fertility and pregnancy calendars, and a comprehensive directory of diseases and drugs [36]. Among the 105
questionnaires distributed, 70 were selected for data analysis, while the remaining incomplete variants were excluded.
Table 2 presents an overview of respondents’ demographics, such as gender, age, educational background,
employment status, and the types of telemedicine applications used.
B. Instrument Development
The survey was developed in the Indonesian language and comprised 2 sections. Part A focused on gathering basic
demographic information about respondents, including gender, age, education, and employment status. Meanwhile,
part B included questions related to various factors outlined in the proposed model. A six-point Likert scale, ranging
from "strongly disagree" to "strongly agree," was used in the questionnaire. The use of a six-point Likert scale was
designed to mitigate neutral response bias. This bias could occur when respondents opt for the midpoint without
careful consideration. The six-point scale encouraged a thoughtful consideration of each question and the selection of
option that leaned either positively or negatively. The questionnaire, consisting of 27 questions, incorporated items
from previously validated studies, modified to suit the context of this current study.

IV. RESULTS
PLS based on SEM was used to test the model, as it provided various valuable statistics and was considered a more
suitable approach for several reasons [37]. Data analysis was carried out using Smart PLS v.4.0.9.8 software. The
analysis process comprised 3 stages, and in the first, measurement model for all variables and indicators in the
questionnaire was evaluated to assess convergent validity, discriminant validity, and construct reliability. The second
stage comprised evaluating the structural model to ascertain the relationships between factors and elucidate causality,
while the final stage consisted of hypothesis testing.

TABLE 2
RESPONDENT DEMOGRAPHIC
Population Characteristic Classification Frequency Percentage
Gender Male 49 70.0
Female 21 30.0
Age 20-29 17 24.3
30-39 38 54.3
40-49 13 18.6
50-59 1 1.4
>59 1 1.4
Education Level Associate Degree 6 8.6
Bachelor 32 45.7
Master 28 40.0
Doctoral 4 5.7
Employee Status Student 4 5.7
Employee 58 82.9
Self-employed 8 11.4
Telemedicine Applications Halodoc 58 82.9
Alodokter 16 22.9
Good Doctor 1 1.4
Klikdokter 6 8.6
Tanyadok 2 2.9

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A. Respondent Demographics
This survey comprised the participation of 70 respondents with varying educational and professional backgrounds.
The majority of respondents were male, accounting for 70.0% of the total population. In addition, the age range varied
from 20 to over 59 years, with the highest proportion falling in the 30 to 39 years age group, constituting 54.3% of the
population. Based on the data, the majority of respondents were employees in companies/organizations/government.
A total of 82.9% of them used telemedicine application Halodoc, which was popularly used, followed by others, such
as Alodokter (22.9%), Good doctor (1.4%), Klikdokter (8.6%) and Tanyadok (2.9%).
B. Assessment of Measurement Model
In the examination of measurement model, the reliability and validity was evaluated, specifically convergent
validity, discriminant validity, and construct reliability. Convergent validity assessed the interconnectedness of
questions in a latent factor by verifying the factor loadings, adhering to the rule of thumb of 0.7. Through adjustments
to the indicators, all loading factor values were increased to surpass 0.7. In addition, convergent validity was assessed
using Average Variance Extracted (AVE), where AVE values exceeding 0.5 were considered acceptable. Discriminant
validity showed the distinctiveness of a given construct from other latent constructs. This validity was established
when the square root of AVE for each latent variable surpassed the correlations between latent variables [38]. Another
approach to confirm discriminant validity was by ensuring that an indicator's loading was higher than all of the cross-
loadings [35]. Meanwhile, construct reliability, indicating the internal consistency of the indicators forming a variable,
was evaluated through Cronbach’s alpha (CA) and composite reliability (CR). For reliability, both Cronbach's alpha
(CA) and composite reliability (CR) values must exceed 0.7.

TABLE 3
THE SQUARE ROOT OF AVE
AU BI CU FC PEU PU SE SI TR
AU 0.909
BI 0.734 0.909
CU 0.566 0.788 0.838
FC 0.471 0.720 0.698 0.828
PEU 0.578 0.726 0.788 0.659 0.877
PU 0.692 0.775 0.686 0.626 0.786 0.886
SE 0.460 0.584 0.662 0.813 0.751 0.601 0.742
SI 0.339 0.462 0.590 0.557 0.449 0.456 0.534 0.922
TR 0.510 0.639 0.749 0.578 0.723 0.656 0.591 0.589 0.930

TABLE 4
RELIABILITY & VALIDITY TEST
Latent Variable Item Loading Factors Average Variance Cronbach's Alpha Composite Reliability
Extracted (AVE) (CA) (CR)
CU CU1 0.873 0.702 0.788 0.876
CU2 0.784
CU3 0.855
FC FC1 0.919 0.842 0.813 0.914
FC2 0.917
PEU PEU1 0.863 0.768 0.850 0.909
PEU2 0.913
PEU3 0.853
PU PU1 0.898 0.784 0.863 0.916
PU2 0.886
PU3 0.873
SE SE3 0.912 0.866 0.847 0.928
SE4 0.949
SI SI1 0.931 0.850 0.824 0.919
SI2 0.913
TR TR1 0.926 0.866 0.923 0.951
TR2 0.936
TR3 0.930
BI BI1 0.919 0.826 0.894 0.934
BI2 0.907
BI3 0.900
AU AU1 0.937 0.827 0.897 0.935
AU2 0.888
AU3 0.903

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The convergent validity assessment revealed a robust correlation between the indicator and the relevant construct
or latent variable, with a minimum loading factor of 0.70, affirming that the indicator effectively measured the targeted
construct. This assertion was reinforced by an acceptable AVE value exceeding 0.5, indicating satisfactory convergent
validity. The discriminant validity test further validated the adequacy of measurement model. In addition, it was
asserted that the square root of AVE for each latent variable must surpass the correlations among the latent variables,
as shown in Table 3.
To assess the reliability of measurement model or construct reliability, the examination comprised evaluating the
parameter values of Cronbach's alpha and composite reliability, with a criterion of being equal to or greater than 0.70.
The test results indicated that both Cronbach's alpha and composite reliability in this study met these specified criteria,
as shown in Table 4. Consequently, it could be inferred that measurement model employed was both valid and reliable.
C. Assessment of the Structural Model
The evaluation of the structural model was dependent on the assessment of R-Squared (R²) and Q-squared (Q²)
values, which were both essential in determining the model's goodness of fit. R², a statistical metric in regression
models, assessed the proportion of variance in the dependent variable that the independent variable could account for,
with values ranging from 0 to 1. A higher R² indicated a greater extent of variability explained by the model.
Meanwhile, Q-squared (Q²) evaluated how effectively the observed values was consistent with the model and the
parameter estimates. A Q² value exceeding zero for a specific reflective endogenous latent variable indicated the path
model's predictive relevance for a particular dependent construct [39]. The R² and Q² values for behavioral intention
and actual use variables are presented in Table 5.

TABLE 5
STRUCTURAL MODEL MEASUREMENT
Parameter R2 Effect Size Q2
BI 0.790 strong 0.733
AU 0.539 moderate 0.398

Based on Table 5, the R² value for behavioral intention construct was 0.790, indicating a robust effect size, which
was classified as strong. This value indicated the capacity of exogenous constructs in this study to elucidate the
endogenous construct. The results showed that perceived usefulness, perceived ease of use, facilitating conditions,
self-efficacy, trust, social influence, and culture collectively accounted for 79.0% of the variance in behavioral
intention. Meanwhile, the R² value for actual use variable was 0.539, denoting a moderate effect size. All the Q² values
for the endogenous constructs exceeded zero, indicating the path model's predictive relevance for each specific
dependent construct. The results showed that the model could accurately forecast the values of the dependent variables
using the independent variables.

Fig. 2 Measurement Model

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D. Hypothesis Testing Result

The examination of hypothesis measurements was based on the assessment of the p-value. To ascertain the
significance of the hypotheses, a bootstrapping procedure was employed with a two-tailed t-distribution, and the
analysis was conducted at a significance level of 0.05. The results are presented in Fig. 2 and summarized in Table 6.
According to Table 6, a total of 5 hypotheses had been validated, specifically H2 (SE → BI), H3 (PU → BI), H5
(FC → BI), H7 (CU → BI), and H8 (BI → AU). Meanwhile, 3 hypotheses were refuted, namely H1 (TR → BI), H4
(PEU → BI), and H6 (SI → BI).

TABLE 6
STRUCTURAL MODEL MEASUREMENT
Hypotheses Relationship Original Sample Standard T P Status
Sample Mean Deviation Statistic Values
(O) (M) (STDEV)
H1 TRBI 0.029 0.027 0.100 0.291 0.771 Rejected
H2 SEBI -0.272 -0.270 0.110 2.481 0.013 Accepted
H3 PUBI 0.355 0.354 0.092 3.860 0.000 Accepted
H4 PEUBI 0.050 0.060 0.142 0.354 0.724 Rejected
H5 FCBI 0.425 0.424 0.116 3.649 0.000 Accepted
H6 SIBI -0.071 -0.061 0.082 0.873 0.383 Rejected
H7 CUBI 0.421 0.407 0.124 3.393 0.001 Accepted
H8 BIAU 0.734 0.733 0.050 14.534 0.000 Accepted

V. DISCUSSION
1) Hypothesis Measurement Results
In this study, self-efficacy (β= -0.272, P = 0.013) had a significant influence on individuals’ intention to use
telemedicine. The result was consistent with previous studies [10], [22], [40], where it played an essential role in
influencing acceptance of telemedicine services. In healthcare context, Garavand et al. [11] and Jung et al. [22]
identified self-efficacy as a key determinant influencing technology acceptance, particularly from the perspective of
healthcare professionals, such as physicians. According to previous studies, telemedicine is an emerging technology,
which requires a certain level of digital competency [41]. In this digital era, healthcare technologies are available to
make it easier for patients to access health facilities. The level of digital literacy ability greatly determined the use of
telemedicine applications by individuals. At present, Indonesians, specifically those in urban and suburban areas, were
more familiar with technology and frequently used digital devices and platforms to facilitate the daily activities [42].
Consequently, individuals were less likely to encounter problems when using digital technology. The results were
inconsistent with previous reports, which concluded that self-efficacy did not make substantial contributions to
predicting user behavioral intention regarding the adoption of telemedicine healthcare services [7].
The testing of hypothesis H3 yielded results indicating a significant relationship between perceived usefulness (β=
0.355, P = 0.000) and the prediction of behavioral intention. The result was in line with other studies by Zobair et al.
[7], Or et al. [43], and Jung et al. [22], highlighting the substantial influence of perceived usefulness in telemedicine
adoption. Furthermore, the significance of this influence could be attributed to patients' motivation to engage with
technology driven by the perceived convenience it offered. Patients anticipated that using telemedicine could enhance
the access to healthcare services, thereby contributing to an improved quality of life. This perspective was reinforced
by Song et al. [6] which found that the variable positively influenced participants' intention to continue using mobile
health services. Consequently, decision-makers must prioritize ensuring that telemedicine technology was in line with
the evolving needs of modern healthcare [15].
The outcomes of H5 indicated a significant influence of facilitating conditions (β= 0.425, P = 0.000) on behavioral
intention to adopt telemedicine. The result was consistent with a previous study by Binyamin et al., which obtained
similar results [34]. In the context of telemedicine, facilitating conditions assessed whether users possessed the
necessary resources for using telemedicine services. This factor was considered essential and had been validated as a
precursor to user behavior in accepting technology [34]. Facilitating conditions also ensured the availability of
resources, including time and financial means, along with technical resources, such as Internet connectivity and mobile
devices [24]. The prevalence of smartphone ownership and widespread internet access in Indonesia served as an
encouraging factor for the adoption of mobile health and telemedicine applications [42]. In addition, the development
of healthtech startups, specifically telemedicine in Indonesia, such as Halodoc and Alodoc, had changed the lifestyle
of modern society. Halodoc and Alodokter were two of Indonesian largest telemedicine application players [44].
Moreover, the digital literacy skills of most Indonesians were quite mature, indicating the absence of constraints by
technical problems in accessing these applications [45], [46]. Compared to previous studies by Kifle et al. [14] and

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Alviani et al. [47], concluded that facilitating conditions did not exert a significant influence on acceptance, this study
found a different trend. This suggests that not all regions within a country, particularly rural areas, benefited from
comprehensive internet coverage. Consequently, the limitation emerged as a hindering factor in the widespread
adoption of technology.
This study also revealed the significant influence of culture (β= 0.421, P = 0.001) on individuals' intentions to use
telemedicine. The result was consistent with the observations made in a recent report by Nwabueze et al. [29], asserting
that culture played a substantial role in shaping individuals' intentions to adopt new technology, particularly before
becoming accustomed. In the Indonesian context, one effective method of introducing new technologies comprised
promotion through the Internet and social media channels [48]. Indonesia has 191.4 million active social media users
[49], hence, leveraging these platforms becomes an essential strategy for technology adoption. Individuals were likely
to become interested by offering the benefits and advantages of telemedicine. Indonesians typically have an open
character, and easily accepted and followed new technology, indicating that this method was considered the most
effective way to get a response from the community. Meanwhile, Alajlani et al. [33] stated that lack of awareness was
a major barrier to acceptance of new technology, such as telemedicine. This was due to several factors, including the
resistance of people to telemedicine because of the lack of advocacy related to the great benefits. Based on these
results, it was important to increase public awareness regarding the use of new technology.
The results of the H8 test revealed a significant influence, with behavioral intention (β=0.734, P = 0.000)
significantly influencing actual use of telemedicine applications. This was consistent with the results of Alexandra et
al. [8], asserting the essential role of behavioral intention in the practical adoption of telemedicine in Indonesia. In line
with Manda and Salim [50], attitudes toward the use of Halodoc teleconsultation application significantly influenced
the actual usage. Abdool et al. [51] also demonstrated in a previous study that behavioral intention served as a robust
and significant predictor of the effective use of telemedicine. Furthermore, Hoque et al. [52] proposed that a positive
intention to use these applications had a favorable influence on the practical adoption.
Based on the results, study trust, perceived ease of use, and social influence did not exert significant influences on
behavioral intention in the proposed model (H1, H4, and H6 lack support). The results were consistent with previous
studies where constructs, such as social influence [8], [53], perceived ease of use [7],[43], and trust failed to
significantly contribute to predicting user behavioral intention in adopting telemedicine healthcare services. In a
previous investigation by Alexandra et al. [8], social influence associated with hospital telemedicine applications in
Indonesia did not have a significant influence. This assertion was also corroborated by Lestari and Rofianto [53] in
the results, where external cues to actions did not positively influence the intention to adopt mobile health. External
cues to actions were essentially interpreted as prompts or stimuli promoting individuals to embrace mobile health. In
essence, external cues to actions shared a similar meaning with social influence. Furthermore, Zobair et al. [7]
discovered that perceived ease of use did not make significant contributions to predicting user behavioral intention
regarding the use of telemedicine services. Furthermore, it was logically sound to conclude that trust did not exert
significant influences on behavioral intention. Trust could be understood as user belief in the capability of telemedicine
services to provide improved online health services in the future. In developing countries, such as Indonesia,
individuals still feel hesitant to use these services due to thoughts about the associated advantages. Therefore,
telemedicine providers must strive to build trust in users through the promotion of the services and benefits offered.
However, this outcome was inconsistent with previous studies that recognized trust, social influence, and ease of use
as key factors influencing the adoption of telemedicine [20], [47].
B. Contributions and Implications
This study made a valuable contribution to the existing body of literature on telemedicine acceptance. The results
explored the connections between various constructs and identified factors shaping individuals' decisions to engage
with virtual healthcare services. In addition, a significant theoretical contribution was made by introducing an
extensive set of dimensions to forecast the behavioral intention to adopt telemedicine using an extended TAM
framework for describing and predicting system usage. In terms of theoretical advancement, this study aimed to
innovate by incorporating a socio-cultural dimension into the framework, comprising social influence and culture as
2 distinct constructs. The results showed the influence of culture on intention to use telemedicine, with social influence
demonstrating no significant influences.
The results offered useful implications for telemedicine providers by identifying various factors that must be
considered. These providers must take several steps to persuade users to use telemedicine services. Ease of using the
application was a priority for patients during usage. Telemedicine providers could also promote the services by
offering convenience and various benefits when using the applications. This included furnishing thorough descriptions
of the benefits of the provided features and instructions on how to use the application [47]. Meanwhile, internet

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connections also required more attention because it was one of the key factors in accessing virtual healthcare services
[42].
C. Limitation and Future Study
This study had several limitations, including the sample size, which remained comparatively modest. The
population exclusively consisted of respondents from urban and suburban areas, and there was a sole concentration
on user or patient viewpoint. Future studies were advised to examine the prevalence of telemedicine services using
study samples that were more representative of the study population. Furthermore, there was a need to explore the
perspective of physicians or health professionals regarding the implementation of telemedicine services.

VI. CONCLUSIONS
In conclusion, this study formulated and scrutinized an extended TAM framework, showing the essential
understanding of factors influencing acceptance of telemedicine. The results indicated that self-efficacy, perceived
usefulness, facilitating conditions, and culture were crucial factors significantly influencing the intention to use
telemedicine services. Meanwhile, trust, perceived ease of use, and social influence did not yield significant
influences. The results suggested that in Indonesia, patients exhibited a heightened interest in employing telemedicine
applications as these platforms were perceived to enhance healthcare accessibility and improve overall health quality.
The burgeoning presence of numerous telemedicine startups offering convenient consultations with healthcare
professionals further propelled the increased use of the services. This study also showed the significant role of culture
in shaping individuals' intentions to embrace telemedicine, signifying a lack of resistance to new technology.
Furthermore, behavioral intention served as an essential predictor, significantly influencing the actual usage of
telemedicine applications. This supported the notion that the inclination to use telemedicine applications profoundly
influenced the practical use.

Author Contributions: Purno Tri Aji: Conceptualization, Methodology, Data Curation, Software, Writing Original
Draft, Editing, Supervision. Luthfi Ramadani: Investigation, Data Collection, Writing - Review.

Funding: This research received no specific grant from any funding agency.

Acknowledgments: The authors would like to thank all the participants for their responses to the questionnaire.

Conflicts of Interest: The authors declare no conflict of interest.

Data Availability: The corresponding author declared all types of data used in this study available for any
clarification. The author of this manuscript is prepared to provide justifications for the dataset. To gain access to the
data used in this study, interested parties should contact the email address provided. The profiles of the respondents
are kept completely confidential.

Informed Consent: Informed consent was obtained from all subjects involved in the study.

Animal Subjects: There were no animal subjects

ORCID:
Purno Tri Aji: https://orcid.org/0009-0005-1950-3729
Luthfi Ramadani: https://orcid.org/0000-0001-6489-3221

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