Trust in Public and Private Providers of Health Apps and Usage Intentions

Binze , Bjö n; Kendzio a, Jenni e ; Wi e, Anne-Ka in; Winkle , Till J.
A icle — Published Ve sion
T us in Public and P i a e P o ide s o Heal h Apps and
Usage In en ions
Business & In o ma ion Sys ems Enginee ing
P o ided in Coope a ion wi h:
Sp inge Na u e
Sugges ed Ci a ion: Binze , Bjö n; Kendzio a, Jenni e ; Wi e, Anne-Ka in; Winkle , Till J. (2024) :
T us in Public and P i a e P o ide s o Heal h Apps and Usage In en ions, Business & In o ma ion
Sys ems Enginee ing, ISSN 1867-0202, Sp inge Fachmedien Wiesbaden GmbH, Wiesbaden, Vol. 66,
Iss. 3, pp. 273-297,
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RESEARCH PAPER
T us in Public and P i a e P o ide s o Heal h Apps and Usage
In en ions
A Sec o al P i acy Calculus and Con ol Pe spec i e
Bjo
¨ n Binze •Jenni e Kendzio a •Anne-Ka in Wi e •Till J. Winkle
Recei ed: 1 July 2023 / Accep ed: 2 Ap il 2024 / Published online: 11 June 2024
ÓThe Au ho (s) 2024
Abs ac Mobile heal h apps, pa icula ly pe sonal heal h
eco ds (PHRs), play a i al ole in heal hca e digi aliza-
ion. Howe e , he a ying go e nance app oaches o
p o iding PHR pla o ms ha e led o a g owing deba e on
he adequa e egula ion o heal h echnology wi h ega d o
hei adop ion. This a icle in es iga es how p o ide
go e nance, whe he public o p i a e, in luences use s’
in en ions o use and decisions o download a PHR app.
D awing on ins i u ional us , p i acy calculus, and p i-
acy con ol amewo ks, he s udy de elops hypo heses
abou how p o ide go e nance a ec s he pa hways
h ough which us in luences use s’ in en ions o adop he
app. Da a acqui ed om an online expe imen in he Ge -
man ma ke e eals ha use s exhibi a highe le el o us
in public p o ide s compa ed o he same app p o ided by
p i a e companies. Fu he mo e, p o ide go e nance sig-
ni ican ly al e s he pa hs in how us in luences usage
in en ions h ough pe cei ed bene i s, pe cei ed isks, and
p i acy con ol. These indings con ibu e o he de elop-
men o a sec o al heo y o p i acy calculus and p i acy
con ol in In o ma ion Sys ems (IS). Mo eo e , hey o e
p ac ical insigh s o heal hca e egula o s and heal h app
p o ide s wi h he aim o p omo ing he accep ance and
usage o PHRs and o he mobile heal h apps.
Keywo ds Mobile heal h Digi al heal h Pe sonal heal h
eco ds Adop ion Usage in en ion P i acy calculus 
P i acy con ol
1 In oduc ion
Mobile heal h apps such as pe sonal heal h eco ds (PHR)
a e conside ed c ucial o heal hca e digi aliza ion as hey
enable indi iduals o manage hei pe sonal heal h e ec-
i ely (A che e al. 2011; Geo ge and Kohnke 2018).
PHRs assis use s in accessing, in eg a ing, and o ganizing
hei pe sonal heal h in o ma ion, he eby enhancing
communica ion be ween pa ien s and heal hca e p o ide s
(Abd-al azaq e al. 2019; Niazkhani e al. 2020; Tang e al.
2006). Howe e , na ional heal h sys ems employ a ying
go e nance app oaches o p o iding PHR pla o ms (Lee
e al. 2021) and he e is a small, bu g owing deba e as o
which le el o egula ion, e.g., o p i acy in heal h
in o ma ion exchange, is adequa e o d i e heal h ech-
nology adop ion (e.g., Adje id e al. 2016; Mille and
Tucke 2009; Te ulino e al. 2023).
Ce ain coun ies, such as he Scandina ian coun ies
and F ance, o e cen alized PHR pla o ms h ough public
heal h au ho i ies (e.g., Appenzelle 2020; Jensen e al.
2017). Simila ly, Ge many has enac ed legisla ion equi -
ing i s public heal h insu ances o p o ide and ac i a e
PHRs o hei insu ed indi iduals by 2025, while he e is
Bjo
¨ n Binze and Jenni e Kendzio a ha e con ibu ed equally o his
wo k.
Accep ed a e one e ision by he edi o s o he Special Issue.
B. Binze (&)J. Kendzio a (&)A.-K. Wi e T. J. Winkle
Facul y o Business Adminis a ion and Economics, Chai o
In o ma ion Managemen , Uni e si y o Hagen, Hagen,
Ge many
e-mail: [email p o ec ed]
J. Kendzio a
e-mail: [email p o ec ed]
T. J. Winkle
e-mail: [email p o ec ed]
T. J. Winkle
Depa men o Digi aliza ion, Copenhagen Business School,
F ede iksbe g, Denma k
123
Bus In Sys Eng 66(3):273–297 (2024)
h ps://doi.o g/10.1007/s12599-024-00869-4
also a g owing ma ke o heal h apps om p i a e p o i-
de s (Re iene 2022; Sch ahe 2021). O he coun ies wi h
plu alis ic heal hca e sys ems, such as he U.S., p ima ily
ely on he p i a e ma ke o he de elopmen o heal h
apps. A p ominen example is Google ha is ying o en e
and pene a e he heal hca e ma ke wi h se e al digi al
o e ings (Je cich 2021), such as he Ca e S udio pla o m
ha o e s heal hca e p o essionals an in eg a ed pe spec-
i e o pa ien eco ds (Balasub amanian 2022; Google
Heal h 2023). These examples illus a e ha PHR adop ion
con ex s a y conside ably ac oss coun ies.
Fu he mo e, a g owing numbe o compe ing heal h
apps wi h simila unc ionali ies is being o e ed by bo h
public and p i a e p o ide s, e en wi hin a single ma ke .
Fo ins ance, in Ge many, he s a up XO Li e in eg a es a
medica ion checke in o hei MedWa che app o au o-
ma ed es ing o d ug he apy sa e y (MedWa che 2023).
This unc ionali y is also pa o he oadmap o he
‘elek onische Pa ien enak e’ (ePA), he PHR p o ided by
public insu ance companies in Ge many, as ou lined in he
ecen digi al s a egy o he ede al minis y o heal h
(Bundesminis e ium u
¨ Gesundhei 2023). While he p o-
ision o he ePA will be manda o y o public insu e s by
2025, use s ha e he possibili y o op ou o i s ac i a ion.
This legally p esc ibed p o ision, bu olun a y use o PHR
apps on he ma ke aises he legi ima e need o app
p o ide s and heal hca e egula o s o be e unde s and
how p o ide go e nance (i.e., whe he public o p i a e)
i sel a ec s use s’ in en ions o use heal h apps.
Among he many exis ing mobile heal h apps, PHRs
ace pa icula ly complex challenges ac oss mos na ions
(Roeh s e al. 2017). Despi e pe inen p i acy egula ions
such as GDPR in Eu ope, us in PHR p o ide s emains a
majo issue, which has hinde ed he widesp ead adop ion
among consume s (Spil and Klein 2015). Resea che s om
di e en ields ha e obse ed an ins i u ional us pa adox:
al hough public ins i u ions ely on people’s us o
e ec i ely ac as hei agen s (Ro hs ein and S olle 2008),
consume s in many coun ies end o us p i a e compa-
nies and hei b ands mo e han hei go e nmen s (Pesce
2020; Wa d e al. 2016). Howe e , i emains o be seen
whe he his us pa adox ex ends o he domain o
heal hca e and he s o ing o sensi i e heal h da a in PHRs.
P e ious esea ch has ex ensi ely s udied he ac o s
ha in luence he accep ance o in o ma ion echnologies,
highligh ing he ole o p i acy- ela ed ac o s, such as
us (e.g., Ca e and Be
´lange 2005; Connolly e al. 2023;
Lin e al. 2021), p i acy conce ns (e.g., Dine and Ha
2005; Eh a i e al. 2020; Malho a e al. 2004), and p i acy
con ol (e.g., Dine e al. 2016; Li e al. 2014). T us ,
p i acy con ol, and pe cei ed bene i s ha e consis en ly
been ound o ha e a posi i e impac on he in en ion o use
an app, while pe cep ions o p i acy and secu i y isks end
o dec ease i . Howe e , he e is a lack o heo e ical
de elopmen ega ding he in luence o he app p o ide s’
go e nance on he use ’s beha io al in en ion o use a
heal h app. This p esen s a majo gap in ou knowledge,
conside ing ha p e ious esea ch has demons a ed a y-
ing le els o us in di e en ins i u ions (Wa d e al.
2016). Unde s anding he impac o p o ide go e nance
on people’s us pe cep ions, usage in en ions, and deci-
sions o ul ima ely download and use a heal h app could be
a key o add ess he pe sis en us challenges associa ed
wi h PHRs in heal hca e. Consequen ly, his s udy aims o
answe he ollowing ques ion: How does p o ide go e -
nance in luence he beha io al in en ion o use and he
decision o download a mobile heal h app?
Taking ou an age poin in an ins i u ional us pe -
spec i e, we i s hypo hesize ha di e en go e nance
ypes (public: heal h au ho i y and public insu ance; p i-
a e: big company and s a up) in luence us in he app
p o ide . Ex ending he p e alen p i acy calculus and
p i acy con ol pe spec i es, we hen p opose h ee di -
e en ial e ec s by which p o ide go e nance may a ec
he pa hways o us on in en ions o use h ough pe cei ed
bene i s, pe cei ed isks, and pe cei ed p i acy con ol. To
es hese hypo heses, we conduc ed an online expe imen
in he Ge man ma ke , aming i as a use s udy o a eal
PHR app in de elopmen . Pa icipan s we e andomly
assigned o one o ou p o ide go e nance scena ios and
asked o e alua e he simula ed app.
Con a y o he public/p i a e us pa adox, ou esul s
demons a e ha use s ha e highe us in a public heal h
app p o ide compa ed o he same heal h app p o ided by
a p i a e company, e en hough public p o ide s a e
a es ed o ha e lowe abili ies. Fu he mo e, u ilizing
pa ial leas squa es (PLS) mul ig oup analysis me hods,
we ind ha p o ide go e nance signi ican ly al e s he
pa hways h ough which us in luences in en ions o use
he app. This is pa icula ly he case wi h ega d o pe -
cei ed bene i s, pe cei ed isks, and pe cei ed con ol.
Usage in en ions, in u n, signi ican ly p edic he decision
o download he app. Ou indings sugges ha p i a e
heal h app p o ide s, despi e gene ally enjoying lowe
le els o us , can in luence usage in en ions and down-
loads mo e s ongly by le e aging bene i pe cep ions and
p i acy con ols compa ed o public p o ide s. Con a y o
ou hypo hesis, public p o ide s can in luence he in en ion
o use and download decision o a highe deg ee han p i-
a e ones by mi iga ing he pe cei ed isks.
Ou s udy con ibu es a sec o al heo y o p i acy cal-
culus and p i acy con ol o esea ch in In o ma ion Sys-
ems (IS) by accoun ing o he di e en o ms o
go e nance among us ed ins i u ions. In addi ion, ou
esul s also call in o ques ion he widesp ead concep ual-
iza ion o abili y as a us componen . On a p ac ical le el,
123
274 B. Binze e al.: T us in Public and P i a e P o ide s..., Bus In Sys Eng 66(3):273–297 (2024)
ou indings o e insigh s o heal h app p o ide s and
heal hca e egula o s o enhance he adop ion and usage o
PHRs and o he heal h apps. In he ollowing sec ions, we
de elop he esea ch hypo heses, desc ibe he me hods
employed, p esen he esul s, and discuss he heo e ical
and p ac ical implica ions.
2 Rela ed Wo k and Hypo hesis De elopmen
This sec ion akes i s an age poin in he ins i u ional us
pe spec i e whe eby we hypo hesize he in luence o p o-
ide go e nance on us in heal h app p o ide s. We hen
in oduce he p i acy calculus (i.e., pe cei ed bene i s and
pe cei ed isks) and pe cei ed con ol o explain how us
ansla es in o usage in en ions, and de elop ou hypo he-
ses o how p o ide go e nance al e s hese pa hways in
he con ex o PHR apps.
2.1 An Ins i u ional Pe spec i e on T us
in he P o ide
The cons uc o us has mo i a ed many schola s om
a ious disciplines such as psychology, ma ke ing, and IS
o explo e i s a ious aspec s and peculia i ies (Ebe
2009). A mul i ude o concep ualiza ions, measu es, and
an eceden s o us ha e eme ged in he li e a u e (So
¨llne
and Leimeis e 2013). In his s udy, we ollow an adap ed
e sion o he widely ci ed de ini ion p oposed by Maye
e al. (1995) and de ine us as he willingness o a us o
o be ulne able o he ac ions o a us ee based on he
expec a ion ha he us ee will pe o m a pa icula ac ion
ele an and impo an o he us o , i espec i e o he
abili y o moni o he espec i e us ee (So
¨llne and
Leimeis e 2013). A us ee’s speci ic cha ac e is ics a e o
g ea ele ance in his ela ionship, as he us o s’ will-
ingness o us is based on hei assessmen o hese
cha ac e is ics (So
¨llne e al. 2016a).
P e ious esea ch concep ualized h ee impo an com-
ponen s o us ing belie s: a us ee’s abili y, bene olence,
and in eg i y (Maye e al. 1995). Abili y e lec s he us-
o ’s pe cep ion ha he us ee’s compe encies, skills, and
ask- ela ed ac i i ies demons a e expe ise and enable he
us ee o succeed in a speci ic domain (Maye e al. 1995;
So
¨llne 2020). Bene olence e lec s he us o ’s pe cep ion
ha he us ee demons a es an o e all posi i e o ien a ion
owa ds he us o and wan s o do good o he us o
(Maye e al. 1995;So
¨llne 2020). In eg i y e lec s he
us o ’s pe cep ion ha he us ee adhe es o a se o
p inciples, alues, and ideals ha a e accep able o he
us o (Maye e al. 1995;So
¨llne 2020). This s udy con-
side s hese componen s as sepa a e cons uc s in addi ion
o o e all us in he p o ide .
While p io esea ch has iden i ied mul iple us ela-
ionships and us a ge s ha a e ele an o IS esea ch
(So
¨llne e al. 2016b), his s udy speci ically examines us
in he p o ide o a mobile heal h app. In his con ex , he
app use assumes he ole o he us o , while he app
p o ide cons i u es as he us ee. The impo ance o use s’
us in he p o ide o an in o ma ion echnology o he
accep ance has been demons a ed by nume ous s udies
(e.g., Mi endo 2017; Robin and Dandis 2021;So
¨llne
2020). Howe e , mos o he exis ing esea ch has ocused
on a single p o ide and hus neglec ed possible di e ences
in he indi iduals’ pe cep ions o di e en p o ide ypes.
Only a limi ed numbe o s udies ha e placed emphasis
on po en ial di e ences be ween p o ide s. Fo ins ance, in
an e-comme ce con ex , Ja enpaa e al. (2000) es ed in an
expe imen how us pe cep ions di e be ween online
s o e ypes (e.g., online books o es and online a el si es)
and ound signi ican di e ences. Bansal e al. (2016) used
a con olled lab expe imen in which hey p esen ed use s
wi h websi e s imuli om con ex s wi h di e en mone a y
sensi i i y (i.e., inancial, heal h, and e-comme ce web-
si es) and concluded ha con ex is a salien ac o o us
o ma ion which is c i ical o disclosing pe sonal in o -
ma ion online. In a heal hca e con ex , Ande son and
Aga wal (2011) explo ed an indi idual’s us and decision
o disclose pe sonal heal h in o ma ion o di e en s ake-
holde s. The s udy ound signi ican di e ences in he
willingness o disclose in o ma ion o hospi als compa ed
o go e nmen al agencies, bu no be ween pha maceu ical
companies and go e nmen al agencies.
Gi en he g owing deba e on he heal hca e echnology
egula ion, his s udy ocuses on he go e nance be ween
public and p i a e o ms as an essen ial p o ide cha ac-
e is ic. Speci ically, we conside wo possible ypes o
public p o ide s o heal hca e apps ha play a key ole in
di e en heal hca e sys em con ex s: heal h au ho i ies and
public insu ances. Heal h au ho i ies a e go e nmen al
bodies esponsible o heal h policy-making which p o ide
o e sigh o he heal h sec o . By de ini ion, heal h
au ho i ies a e public ins i u ions whose ope a ions a e
inanced by ax e enues. Coun ies like Denma k and
F ance exempli y he p o ision o PHR in as uc u es by
heal h au ho i ies (Appenzelle 2020; Jensen e al. 2017).
On he o he hand, public insu ances a e, in he con ex o
his s udy, classi ied as co po a ions unde public law ha
play a i al ole in ul illing public in e es asks such as
heal hca e se ice eimbu semen . Thus, hey a e highly
egula ed, bu legally independen en i ies. In Ge many, o
ins ance, he e a e cu en ly 96 s a u o y (i.e., public)
heal h insu ances co e ing app oxima ely 90% o he
popula ion (GKV Spi zen e band 2023).
In addi ion, ou s udy conside s wo ypes o p i a e
p o ide s o PHR apps ha ep esen opposi e ends o he
123
B. Binze e al.: T us in Public and P i a e P o ide s..., Bus In Sys Eng 66(3):273–297 (2024) 275
ma u i y spec um: big companies and s a ups. Big com-
panies a e concep ualized as la ge co po a ions and cha -
ac e ized by hei well-es ablished b ands and di e si ied
ope a ions, which may include in ol emen in he heal h-
ca e ma ke . These companies a e subjec o co po a e laws
and a e held accoun able no only inancially, bu also in
e ms o social esponsibili y. Examples o big companies
in Ge many p o iding heal h apps (amongs o he se ices)
include i ms like Siemens and SAP SE. S a up companies
a e smalle i ms ocusing on de eloping inno a i e mobile
heal h solu ions, such as PHR apps. No able ci ies like
Bos on and Be lin boas dynamic s a up ecosys ems e -
en ly engaged in he bu geoning digi al heal h ma ke
(Judah e al. 2020). Bo h, big companies and s a ups, a e
keenly in ol ed in he mobile heal h sec o . Fo ins ance,
he global so wa e ma ke o PHRs is p ojec ed o su pass
15 billion US dolla s by 2030 (Zion Ma ke Resea ch
2023). Table 1p esen s an o e iew o he key a ibu es o
hese ou p o ide ypes.
Because a us ee’s cha ac e is ics a e ele an o he
us o s’ willingness o us , we p opose ha he le el o
us depends on he dis inc ion be ween public and p i a e
heal h app p o ide s. A ecen su ey on mobile apps o
pandemic esea ch di e en ia ed be ween go e nmen al
and p i a e o ganiza ions, e ealing ha his dis inc ion
was signi ican o he le el o us ha use s placed in he
apps (Buh e al. 2022). Public ins i u ions, by de ini ion,
ha e he manda e o se e and ake ca e o he popula ion
(Ro hs ein and S olle 2008), wi h heal hca e being a pa o
hei esponsibili ies in mos coun ies. Hence, he e is a
high deg ee o cohe ence be ween he mission o public
ins i u ions o se e he public good (Rainey e al. 2021)
and he ask o p ese e he highly sensi i e heal h da a.
Thei high deg ee o accoun abili y o he public makes
heal h au ho i ies a gene ally us ed p o ide o heal h
echnologies, including PHR apps. P i a e ins i u ions such
as companies, in con as , ha e inhe en ly di e en objec-
i es. While many companies conside social esponsibili y
as a pa o hei mission, hei p ima y ocus is on gen-
e a ing p o i s. This aises conce ns ha p i a e p o ide s
may p io i ize p o i oppo uni ies o e use s’ p i acy
(Ande son and Aga wal 2011). Fo ins ance, a s udy ela ed
o ea s o heal h da a sha ing e ealed ha wo o ou
conce ns we e explici ly associa ed wi h po en ial da a
exploi a ion by p i a e companies (Lounsbu y e al. 2021).
The e o e, we hypo hesize:
Hypo hesis 1 T us and i s componen s (abili y, bene o-
lence, in eg i y) will be highe o public p o ide s o
heal h apps and lowe o p i a e p o ide s.
2.2 P o ide Go e nance Al e ing he T us -Usage
In en ion Pa hways
P io IS esea ch has consis en ly demons a ed a ela-
ionship be ween us and usage in en ions. Fo example,
us in luences he in ended use o a B2C websi e in
ecomme ce (Ge en and S aub 2003) and he in en ions o
use an e-go e nmen sys em (Ca e and Be
´lange 2005). In
he ollowing, we d aw on p i acy calculus and p i acy
con ol pe spec i es o explica e he di e en pa hways ha
explain he us -usage ela ionship. Linking back o ou
p o ide go e nance concep ualiza ion, we hen de elop
h ee hypo heses o how p o ide go e nance al e s hese
pa hways. Figu e 1displays ou esea ch model and
hypo heses.
Conside ing ha he s o ing o sensi i e heal h da a in
mobile apps may exace ba e people’s conce ns abou
po en ial misuse o hei heal h da a, he in en ion o use a
heal h app in ol es a p i acy calculus (Li e al. 2014). The
p i acy calculus is a widely accep ed model which posi s
ha indi iduals make p i acy decisions based on a p ocess
o weighing he an icipa ed bene i s and isks o his
decision (Culnan and Bies 2003; Lau e and Wol e 1977).
This implies ha indi iduals, when con on ed wi h he
choice o using a heal h app ha necessi a es he disclosu e
o pe sonal in o ma ion, e alua e he an icipa ed bene i s
and po en ial isks associa ed wi h he echnology, which
ul ima ely impac s hei decision-making p ocess ega ding
adop ion. In his con ex , i is impo an o acknowledge he
complex in e play be ween pe cei ed isks, bene i s, and
he o en opaque na u e o da a usage. Consequen ly, i is
Table 1 P o ide go e nance and p o ide ype concep ualiza ion
Go e nance Public go e nance P i a e go e nance
Type Heal h au ho i y Public insu ance Big company S a up company
Owne ship Public ins i u ion Public law company Publicly lis ed company P i a e company
Regula ion Regula o Highly egula ed Conside ably egula ed Mode a ely egula ed
Economy Tax inanced Membe ship inanced P o i -based Ven u e unding
Compe ence Policy & o e sigh Reimbu semen Se ices a scale Inno a ion
123
276 B. Binze e al.: T us in Public and P i a e P o ide s..., Bus In Sys Eng 66(3):273–297 (2024)

c ucial o conside he incomple e in o ma ion use s o en
ha e abou how hei da a been used (o en pe cei ed as
‘black box’) and he beha io al biases ha may in luence
hei decision-making.
Fu he mo e, when esea ching p i acy decisions, i is
essen ial o conside he con ex (Acquis i e al. 2015; Yun
e al. 2019). Smi h e al. (2011) iden i ied ou con ex ual
o ces ela ed o p i acy belie s: he ype o collec ed
in o ma ion, he use o in o ma ion by sec o , he echno-
logical applica ions, and he poli ical con ex . In he con-
ex o ou s udy, we e e o pe sonal heal h da a such as
i al pa ame e s, diagnoses, es esul s, and medica ion
plans. This da a can be used o enhance ca e p ocesses,
imp o e clinical ou comes, and d i e ad ancemen o
esea ch wi hin he heal hca e sec o . The echnological
applica ion is a PHR, a digi al pla o m ha enables indi-
iduals o access, manage, and sha e hei pe sonal heal h
in o ma ion wi h heal hca e p o essionals wi hin a p i a e,
secu e, and con iden ial en i onmen (Tang e al. 2006).
The poli ical con ex o ou s udy is Ge many, a coun y
wi h high p i acy sensi i i y (Bellman e al. 2004) ha has
no ye achie ed widesp ead adop ion o any PHR pla o m
(Sch ahe 2021). In he ollowing, we concep ualize he
pe cei ed bene i s and pe cei ed isks o PHRs o he
con ex o his s udy and elabo a e on pe cei ed con ol.
2.2.1 Pe cei ed Bene i s Pa hway and P o ide
Go e nance
As pa ien s o en ecei e ca e om many di e en
heal hca e p o ide s, hei heal h da a a e commonly dis-
pe sed o e a ious acili ies and s o ed in di e en analog
and digi al o ma s. In gene al, PHRs a e seen as a majo
de elopmen owa ds he digi iza ion o heal hca e sys-
ems, wi h he pu pose o imp o ing quali y and lowe ing
he cos s o heal hca e (Bandyopadhyay e al. 2012),
leading o a ious ypes o bene i s a PHR app may p o ide
o i s use s. The ex en o pe cei ed bene i s o an app
posi i ely in luences use s’ in en ions o download i (Eling
e al. 2013; Ha is e al. 2016) and also a ec s hei will-
ingness o sha e pe sonal in o ma ion wi h he app (Wo -
ich e al. 2018). P io wo ks ha e emphasized di e en
bene i s o PHRs.
Fo example, PHRs enable imely and loca ion-inde-
penden access o a wide a ay o pe sonal heal h in o -
ma ion (Tang e al. 2006). Such heal h in o ma ion can
s em om di e en sys ems used by ca egi e s and heal h
p o essionals au ho ized by he pa ien (Tang e al. 2006).
Access o hei in o ma ion helps pa ien s o manage hei
heal h and moni o diseases mo e e ec i ely in conjunc-
ion wi h hei heal hca e p o ide s. In addi ion, PHRs can
s eng hen he heal h li e acy o pa ien s by p o iding hem
wi h knowledge abou hei own ca e. This esul s in
pa ien s’ enhanced abili y o mo e e ec i e heal hca e
managemen . PHRs gi e pa ien s con ol o e hei heal h
eco ds and da a and empowe hem o become ac i e
pa icipan s in hei own ca e (Tang e al. 2006). Fu he -
mo e, PHRs can imp o e heal hca e quali y due o ea lie
iden i ica ion o ad e se e en s, de ined as inju ies ha a e
caused by medical managemen , such as medica ion e o s
(Bandyopadhyay e al. 2012) and a oidance o duplica e
examina ions. In ol ing pa ien s in hei own ca e h ough
a PHR can p omo e p e en ion and mo e imely in e en-
ions and hus disbu den he heal hca e sys em. Las ly,
PHRs can enhance he communica ion be ween pa ien s
and physicians when hey a e collabo a i ely acking he
pa ien ’s heal h. This can help o e come in o ma ion
asymme ies and educe communica ion ba ie s. PHRs
may e en change physician encoun e s om episodic o
Pe cei ed
bene i s
In en ion o use
T us in he p o ide
Con ols
P i acy awa eness
P i acy conce ns
Willingness o disclose heal h da
Gende
Age
F equency o heal h app use
Insu ance s a us
Educa ion
Decision o
download
>
Public P i a e
P o ide go e nance
H1
Disc e e
cons uc
Con inuous
cons uc
Di ec e ec
Legend:
Pe cei ed
con ol
Pe cei ed
isks
Indi ec e ec
H4:
<
H3:
<
H2:
<
Fig. 1 Resea ch model
123
B. Binze e al.: T us in Public and P i a e P o ide s..., Bus In Sys Eng 66(3):273–297 (2024) 277
con inuous, which should make i easie o he pa ien s o
ask ques ions (Tang e al. 2006).
Despi e he common ea u es o a PHR, each indi idual
will e alua e hese bene i s depending on he espec i e
con ex (Smi h e al. 2011). T us in he p o ide in luences
an indi idual’s pe cep ion o an in o ma ion sys em o e ed
by ha p o ide , including i s pe cei ed use ulness and
bene i s (So
¨llne e al. 2016b). The in luence o us on
pe cei ed bene i s has been subs an ia ed in o he con ex s
such as e-commence (Kim e al. 2009) and e-se ices (Mou
and Cohen 2014). Fu he mo e, in line wi h p e ious
esea ch (e.g., Gong e al. 2019; Li e al. 2014), pe cei ed
bene i s likely inc ease an indi idual’s usage in en ion o a
PHR app. Fo example, Gong e al. (2019) highligh ed he
impo ance o pe cei ed bene i s on he in en ions o use an
online heal h consul a ion se ice; Li e al. (2014) ound a
s ongly posi i e e ec o bene i s on he in en ion o use a
s andalone PHR app. Agains his backg ound, we expec
o ind a pa hway in which us posi i ely in luences he
pe cei ed bene i s o a mobile heal h app and pe cei ed
bene i s, in u n, posi i ely in luence he in en ion o use.
Wha is unknown, howe e , is whe he he cha ac e is-
ics o he o ganiza ion handling pe sonal heal h in o ma-
ion, speci ically he p o ide ’s go e nance, will in luence
his pa hway. Such in luence could a ise om he dis inc
economic and compe ence- ela ed cha ac e is ics ha di -
e en ia e hese ins i u ions (see Table 1). P i a e compa-
nies, d i en by ma ke -di e en ia ion, may ha e a g ea e
incen i e o p omo e hei p oduc s (e.g., mobile PHRs)
e en i hese do no ye ully sa is y he bene i expec a-
ions, leading o use suspicion. The e o e, use s ha do no
us a p i a e p o ide , will no expec he p omised
bene i s o ma e ialize. Low pe cei ed bene i s, in u n, will
be associa ed wi h low usage in en ions. Use s who do us
a p i a e p o ide , howe e , will likely ha e g ea bene i
expec a ions and also highe usage in en ions due o he
p i a e p o ide ’s p esumed compe ency in p o iding
inno a i e se ices a scale. Highe bene i s expec a ions
om he p i a ely p o ided app should also ansla e in o
high usage in en ions, as use s will an icipa e ha his
ma ke o e ing will e ec i ely mee hei speci ic needs. I
is, he e o e, a necessa y equi emen ha use s us he
p i a e p o ide and i s o e ing, be o e making a posi i e
bene i e alua ion and o ming hei usage in en ions.
Inno a ion and economic incen i es a e less p onounced
in he public sec o (A undel e al. 2019) and public p o-
ide s a e gene ally seen as ha ing less compe ence in
p o iding e ec i e solu ions han he p i a e sec o
(H idman 2019). Consequen ly, use s migh a he expec a
‘s anda d’ se ice om a public p o ide o a heal h app
ega dless o hei us in his public ins i u ion. In o he
wo ds, he e is likely less a ia ion in he pe cei ed ben-
e i s depending on us in public p o ide s compa ed o
p i a e p o ide s. Con e sely, use s’ in en ion o use a
publicly p o ided app may be less in luenced by expec a-
ions o bene i s. This is because public heal h apps migh
be iewed mo e as a socie al obliga ion o a common good
a he han a pe sonal consume choice (Gale si e al.
2023). Hence, o publicly p o ided apps, he usage
in en ions migh be less oo ed in bene i s expec a ions han
o p i a e p o ide s’ apps. In summa y, we sugges ha
bo h, he e ec o us in he p o ide on pe cei ed ben-
e i s and he e ec o pe cei ed bene i s on in en ion o use
di e be ween public and p i a e p o ide s. The e o e, we
pose:
Hypo hesis 2 The posi i e indi ec e ec o us on
in en ion o use ia pe cei ed bene i s will be s onge o
p i a e p o ide s and weake o public p o ide s.
2.2.2 Pe cei ed Risks Pa hway and P o ide Go e nance
The second componen o he p i acy calculus is he pe -
cep ion o isks associa ed wi h a p i acy- ela ed decision.
Pe cei ed isks can be de ined as ‘‘ he subjec i e belie ha
he e is some p obabili y o su e ing a loss in pu sui o a
desi ed ou come’’ (Pa lou and Ge en 2004). Unce ain y
abou possible consequences can nega i ely impac he ne
ou come o he p i acy calculus and, consequen ly, he
in en ion o use (Fea he man and Pa lou 2003; Fla ia
´n and
Guinalı
´u2006). Depending on he con ex , ce ain ypes o
isks can be mo e impo an han o he s. The heal hca e
domain is cha ac e ized by highly sensi i e in o ma ion
and a plu ali y o s akeholde s, hus leading o a b oad
ange o isks ha need o be conside ed (Ande son and
Aga wal 2011). Mo eo e , in ligh o po en ial haza ds
such as da a abuse o misuse, pa icula ly conce ning
sensi i e heal h in o ma ion, and conside ing he di e se
and pe haps unexpec ed uses o his da a, i ’s c ucial o
add ess he ‘black box’ na u e o PHR apps. Indi iduals
o en possess limi ed in o ma ion ega ding o ganiza ional
p ac ices o he implica ions o hei da a sha ing. This gap
in unde s anding can lead o an unawa eness o he ue
alue and po en ial consequences o sha ing pe sonal
in o ma ion (Deuke 2010). Such lack o awa eness ham-
pe s indi iduals’ abili y o accu a ely assess isks, hus
in luencing hei decision-making and bene i ealiza ion.
T us has been iden i ied as a signi ican an eceden o
pe cei ed isks (Culnan and A ms ong 1999). When us
in a p o ide is high, he subjec i e isks associa ed wi h
using he sys em seem lowe om a use pe spec i e (e.g.,
Kim e al. 2009; Mou and Cohen 2014). Pe cei ed isks, in
u n, nega i ely in luence he beha io al in en ions o use
in o ma ion sys ems (e.g., Li e al. 2014; Nicolaou and
McKnigh 2006). Fo ins ance, Li e al. (2014) showed ha
lowe pe cei ed isks o a s andalone PHR, such as
123
278 B. Binze e al.: T us in Public and P i a e P o ide s..., Bus In Sys Eng 66(3):273–297 (2024)
Mic oso Heal hVaul , inc ease he use s’ in en ions o use
his sys em. Pe cei ed isks o m he second pa o he
equa ion o he p i acy calculus. Taken oge he , we expec
o ind a second pa hway in which us in luences he
pe cei ed isks o a mobile heal h app, and pe cei ed isks,
in u n, in luence in en ion o use.
Open o in es iga ion is he po en ial ole ha p o ide
go e nance may play o his pa hway. The in luence o
us on pe cei ed isk migh di e be ween public and
p i a e p o ide s due o he economic and egula o y
cha ac e is ics ha dis inguish hese ins i u ions (see
Table 1). Use s may eel ha p o i -d i en companies ha e
an incen i e o exploi hei use s’ heal h da a (Ande son
and Aga wal 2011), especially conside ing po en ial egu-
la o y loopholes (Lounsbu y e al. 2021). The e o e, us in
he p o ide is likely a necessa y equi emen o mi iga e
isk pe cep ions wi h p i a e p o ide s. Fu he mo e, isk
pe cep ions wi h p i a e p o ide s can also be expec ed o
play a majo ole o usage in en ions. Due o he black box
na u e o PHR apps and he linge ing ea s o po en ial da a
exploi a ion by p i a e companies (Lounsbu y e al. 2021),
pe cei ed isks a e likely o ha e a g ea impac on usage
in en ions. The ailu e o Google Heal h, o example, was
la gely a ibu ed o Google’s inabili y o build us wi h
consume s (O’Ma a 2015).
Public p o ide s, in con as , a e subjec o s ic egu-
la ions and do no ope a e o p o i (Rainey e al. 2021). As
a esul , whe he use s us a public ins i u ion o no may
ha e a lowe impac on pe cei ed isks, as use s may ha e
con idence ha egula ions will p e en he misuse o hei
da a. Placing high us in a public ins i u ion will ha e
lesse impac on pe cei ed isks, oo, because use s migh
no assume nega i e in en ions o ha ins i u ion in he i s
place (Buh e al. 2022). In a simila ein, he s ong eg-
ula o y o e sigh and accoun abili y o public p o ide s
should gene ally ins ill mo e con idence in da a sa e y and
e hical handling. This is likely o lead o less emphasis on
pe cei ed isks in indi iduals’ decision-making on po en-
ial adop ion. In sum, we a gue ha he na u e o he p o-
ide impac s how pe cei ed isks in luence use
in en ions. We hypo hesize:
Hypo hesis 3 The posi i e indi ec e ec o us on
in en ion o use ia pe cei ed isks will be s onge o
p i a e p o ide s and weake o public p o ide s.
2.2.3 Pe cei ed Con ol Pa hway and P o ide
Go e nance
A cons uc equen ly men ioned in conjunc ion wi h he
p i acy calculus is pe cei ed (p i acy) con ol. Pe cei ed
con ol e e s o ‘‘ he indi idual’s pe cep ion o being able
o con ol access o and use o hei in o ma ion’’ (Ba ol
e al. 2022). While he ac ual con ol allows people o
choose wha and how much da a o e eal, i is o en he
pe cei ed le el o con ol which de e mines he (disclo-
su e) beha io (P inci and K a
¨me 2020). In p io s udies,
esea che s ha e ound a con ol pa adox. People who eel
in con ol o hei pe sonal da a end o e eal mo e
in o ma ion e en hough he objec i e isks may inc ease.
Con e sely, people who pe cei e a lowe le el o con ol
may disclose less in o ma ion, e en hough he ac ual isks
associa ed wi h disclosu e may be lowe (B andima e e al.
2013).
P i acy con ol has been ex ensi ely s udied in ela ion
o a ious ac o s, including pe cei ed isks, p i acy
conce ns, and us . Especially he ela ionship be ween
us and pe cei ed con ol has been explo ed om di -
e en pe spec i es and in di e se con ex s (e.g., Dine
e al. 2016; Fox e al. 2022; Li e al. 2014; Saengchai
e al. 2020). While us and pe cei ed con ol can be
conside ed as wo ac o s in he same nomological laye
in luencing p i acy conce ns (Dine e al. 2016) and
in en ion o use (Li e al. 2014), hey migh also in luence
each o he . Fo ins ance, Fox e al. (2022) in es iga ed
how pe cei ed con ol in luences he pe cei ed us wo -
hiness in online in e ac ions. Saengchai e al. (2020)
examined he media ing ole o pe cei ed con ol in he
ela ionship be ween ci izen us and he adop ion o
e-go e nmen se ices. Mo eo e , Robin and Dandis
(2021) ound ha a lack o us can be o se by he
p esence o pe cei ed con ol.
In he con ex o his s udy on a PHR app, we adop he
pe spec i e ha p o ide us is an an eceden o pe cei ed
con ol a he han an ou come. We assume ha indi iduals
al eady possess a ce ain le el o us in he p o ide
o ganiza ion, which subsequen ly in luences hei pe cep-
ion o hei abili y o con ol hei p i acy h ough he
PHR app. In ou expe imen , pa icipan s we e ini ially
in oduced o he p o ide o ganiza ion, allowing hei
us ing belie s o o m, be o e es ing he p o o ype app
and i s p i acy con ols (see Me hodology in Sec . 3).
The e o e, we expec o ind a hi d pa hway whe ein us
posi i ely in luences he pe cei ed con ol o a mobile
heal h app, and pe cei ed con ol, in u n, in luences
in en ion o use.
We en u e in o unexplo ed heo e ical e i o y by
hypo hesizing an e ec o p o ide go e nance on his
pa hway. The e a e compelling easons o belie e ha he
in luence o us on pe cei ed con ol di e s be ween
public and p i a e p o ide s, s emming om he dis inc i e
egula o y and compe ence- ela ed cha ac e is ics ha se
hese ins i u ions apa (see Table 1). Since indi iduals
may associa e p i a e o ganiza ions wi h he de elopmen
o be e solu ions, hose who possess high us in p i a e
p o ide s a e mo e likely o belie e ha hese companies
123
B. Binze e al.: T us in Public and P i a e P o ide s..., Bus In Sys Eng 66(3):273–297 (2024) 279
ac in he bes in e es o use s and hus know how o
p o ide supe io p i acy con ols. Con e sely, indi iduals
wi h low us a e likely o pe cei e a dea h o obus
p i acy con ols due o he lack o ele an egula ions ha
compel p i a e p o ide s o p o ide a minimum s anda d o
adequa e con ols. These di e ences in pe cei ed con ols
a e likely o ansla e in o g ea e a iance in he in en ions
o use ma ke -p o ided PHR app. When p i a e p o ide s
a e pe cei ed o o e ad anced da a handling ea u es ha
enhance he use s’ con ol o e hei own p i acy (Walke
2016), hen consume s will be mo e willing o adop hei
solu ions. P i a e p o ide s ha do no o e hese con ols,
howe e , a e unlikely o ind and g ow hei use base.
In con as , due o he egula ed en i onmen , us in
public p o ide s migh be a less o a decisi e c i e ion o
use s o base hei pe cep ions o p i acy con ols and
usage in en ions in. Indi iduals who ha e low us in
public ins i u ions can assume ha a minimum le el o
p i acy con ols will be ensu ed due o he egula ed
en i onmen . Use s who do us public ins i u ions may
likewise expec p i acy con ols ha mee s anda d
equi emen s a he han supe io ea u es, due o lowe
pe cei ed compe ence o public p o ide s in p o iding
ad anced p i acy ea u es (H idman 2019). In addi ion,
since public p o ide s a e gene ally pe cei ed as o e ing
mo e secu e and s anda dized p i acy p ac ices by de aul
(Dine e al. 2008), use s a e also less likely o base hei
usage in en ions in he pe cei ed con ols o public p o-
ide s han o p i a e p o ide s. In sum, we sugges ha
p o ide go e nance in luences he e ec o us on he
pe cei ed con ol and he e ec o pe cei ed con ol on he
in en ions o use o a mobile heal h app. We pose:
Hypo hesis 4 The posi i e indi ec e ec o us on
in en ion o use ia pe cei ed con ol will be s onge o
p i a e p o ide s and weake o public p o ide s.
2.2.4 In en ion o use and Ac ual Beha io
Unde s anding he connec ion be ween human in en ions
and ac ions is no simple unde aking. While a comp e-
hensi e app oach o echnology adop ion esea ch should
go beyond me e usage in en ions, di ec ly measu ing ac ual
adop ion o usage o a (hypo he ical) echnology is o en
di icul in p ac ice. As a esul , he in en ion o use a
echnology is commonly employed as a mo e quan i iable
p oxy o u u e usage (Venka esh e al. 2003). This
app oach is unde pinned by he belie ha he in en ion o
use a echnology e ec i ely o ecas s ac ual usage (Da is
e al. 1989) because i e lec s an indi idual’s mo i a ional
ac o s and eadiness o pe o m a speci ic ac ion (Ajzen
1985; Fishbein and Ajzen 1975).
Howe e , i is c ucial o acknowledge he ecognized
in en ion-beha io gap in his con ex (Ajzen 1991; Wu and
Du 2012). This gap highligh s he phenomenon whe e
indi iduals do no always ac on hei s a ed in en ions,
meaning ha in en ion can be a p ecu so bu does no
in a iably lead o beha io in o m o co esponding
ac ions (Webb and Shee an 2006). The e o e, echnology
adop ion migh be mo e accu a ely iewed as a p ocess
(Pa ma e al. 2022), whe e he in en ion o download an
app is an essen ial indica o o po en ial beha io , bu he
p og ession om hese in en ions o ac ual beha io
in ol es a ious ac o s and is no as s aigh o wa d as i
migh seem.
Despi e his gap, esea ch s ill unde sco es he c ucial
impo ance o in en ions as key psychological p edic o s o
beha io (Shee an 2002), signi ying hei p ima y ole in
o ecas ing ac ions. Building on his wi h es ablished
echnology accep ance amewo ks (Ajzen 1991; Da is
e al. 1989), nume ous s udies ha e shown ha an indi-
idual’s in en ions a e signi ican and eliable indica o s o
hei ac ual beha io (Pa lou 2003;Shin2009). This
unde sco es he no ion ha ini ial ac ions, such as down-
loading an app, a e d i en by he use ’s in en ion o u ilize
i s ea u es and unc ions (Gokgoz e al. 2021). In align-
men wi h his body o esea ch, we an icipa e ha he
in en ion o use a mobile heal h app in luences he decision
o download i .
Table 2summa izes he co e model a iables o his
esea ch. As con ol a iables, we conside a numbe o
gene al ai s ha can in luence an indi idual’s beha io al
in en ion o use a mobile heal h app: Fi s , p i acy
awa eness is included as indi iduals who possess a high
le el o awa eness o exis ing p i acy egula ions and
issues may ha e lowe usage in en ions due o hei pe -
sonal disposi ion o alue p i acy (Xu e al. 2008). Second,
p i acy conce ns a e commonly conside ed as a a iable
in luencing beha io al in en ions (Smi h e al. 2011). In
line wi h p io esea ch, all ou dimensions o p i acy
conce ns a e conside ed, including collec ion, e o s,
unau ho ized access, and seconda y use (Angs and Aga -
wal 2009; Smi h e al. 1996). Thi d, he gene al willingness
o disclose pe sonal heal h da a is included as i has e-
quen ly been in es iga ed as a dependen a iable in p i-
acy esea ch ha is closely ela ed o usage in en ions
(En eß-Fu
¨ s eneck e al. 2019). In addi ion, we conside as
con ol a iables a se o socio-demog aphic cha ac e is ics
o he use s, speci ically, gende , age, le el o educa ion,
equency o heal h app use, and insu ance s a us.
123
280 B. Binze e al.: T us in Public and P i a e P o ide s..., Bus In Sys Eng 66(3):273–297 (2024)
Table 5 Resul s o he model es s: main e ec s and o al (indi ec ) e ec s
Hypo hesis Pa h Full
sample
(n= 286)
Public
(n
1
= 151)
P i a e
(n
2
= 135)
G oup
di e ences
Resul s
- es
p
MGA
b
p
Di ec e ec s – T us ?Pe cei ed bene i s 0.54***
(10.55)
0.42***
(6.00)
0.67***
(12.31)
0.003 0.003 –
– T us ?Pe cei ed isks -0.65***
(13.84)
-0.65***
(12.45)
-0.68***
(8.93)
0.357 0.346 –
– T us ?Pe cei ed con ol 0.60***
(12.65)
0.48***
(6.64)
0.73***
(16.52)
0.002 0.001 –
– Pe cei ed bene i s ?In en ion o
use
0.46***
(6.86)
0.42***
(4.37)
0.52***
(6.37)
0.236 0.232 –
– Pe cei ed isks ?In en ion o use -0.16*
(2.22)
-0.27**
(3.05)
0.004
(0.04)
0.021 0.022 –
– Pe cei ed con ol ?In en ion o use 0.15**
(2.58)
0.05
(0.64)
0.27**
(3.20)
0.026 0.026 –
To al and indi ec
e ec s
– T us ?In en ion o use 0.44***
(8.92)
0.38***
(6.51)
0.55***
(7.64)
0.033 0.039 –
H2 ( ) T us ?Pe cei ed bene i s ?
In en ion o use
0.25***
(4.99)
0.18**
(3.03)
0.35***
(5.31)
0.029 0.031 Suppo ed
H3 ( ) T us ?Pe cei ed isks ?In en ion
o use
0.10*
(2.08)
0.18**
(2.81)
0.00
(0.04)
0.030 0.031 Re e sed
H4 ( ) T us ?Pe cei ed con ol ?
In en ion o use
0.09**
(2.42)
0.02
(0.63)
0.20**
(3.00)
0.009 0.009 Suppo ed
Pa hs (Con ols) – P i acy awa eness ?In en ion o
use
-0.06
(1.08)
-0.04
(0.40)
-0.05
(0.87)
0.434 0.440 –
– PC collec ion ?In en ion o use -0.02
(0.36)
-0.01
(0.06)
-0.04
(0.53)
0.373 0.373 –
– PC e o ?In en ion o use 0.00
(0.10)
0.03
(0.57)
-0.03
(0.45)
0.234 0.236 –
– PC unau h. access ?In en ion o use -0.04
(0.97)
-0.03
(0.43)
-0.05
(0.79)
0.430 0.430 –
– Willingness o disclose ?In en ion
o use
0.16*
(2.15)
0.21*
(1.85)
0.07
(0.66)
0.192 0.193 –
– Gende ?In en ion o use 0.01
(0.14)
0.06
(0.83)
-0.01
(0.13)
0.237 0.214 –
– Age ?In en ion o use -0.05
(0.91)
0.04
(0.68)
-0.13
(1.55)
0.047 0.048 –
Educa ion ?In en ion o use 0.02
(0.47)
0.06
(0.92)
0.00
(0.02)
0.247 0.247 –
– F equency o app use ?In en ion o
use
-0.01
(0.17)
0.00
(0.02)
0.01
(0.09)
0.486 0.488 –
– Insu ance ?In en ion o use -0.17
(0.93)
-0.03
(0.13)
-0.34
(1.01)
0.204 0.212 –
–R
2
(In en ion o use) 0.437 0.401 0.497 – – –
–R
2
adj. (In en ion o use) 0.431 0.389 0.485 – – –
n.s. no suppo ed;
b
MGA mul ig oup analysis (one-sided compa ison); *p .05; **p .01; ***p .001;
To adhe e o model sample size he con ol a iables we e es ed sepa a ely
123
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in bo h g oups. As expec ed, he e ec o us on pe cei ed
bene i s is signi ican ly s onge o p i a e p o ide s
(b= 0.67
***
, = 12.31) han o public p o ide s
(b= 0.42
***
, = 6.00, p= 0.003). The e ec o pe cei ed
bene i s on in en ion o use is also s onge o p i a e
p o ide s (b= 0.52
***
, = 6.37) han o public p o ide s
(b= 0.42
***
, = 4.37), al hough his di e ence is no
signi ican .
Conce ning he pa hway h ough pe cei ed isks, ou
esul s e eal a su p ising inding: The indi ec pa h o us
on in en ion o use ia pe cei ed isks is no only signi i-
can ly s onge o public p o ide s (b= 0.18
**
, = 2.81)
han o p i a e p o ide s (b= 0.00, = 0.04, p= 0.031),
bu his indi ec e ec is no signi ican a all o p i a e
p o ide s. While his p o ides e idence ha p o ide
go e nance al e s he pa hway in which us ansla es in o
usage in en ions ia pe cei ed isks, i is he opposi e o
wha we had hypo hesized. The e o e, he esul s do no
suppo hypo hesis H3. A close look a he di ec e ec s
be ween us Ýpe cei ed isks, and pe cei ed isksÝin-
en ion o use shows ha he nega i e e ec o us on
pe cei ed isks is signi ican o bo h, public p o ide s
(b= -0.65
***
, = 12.45) and p i a e p o ide s (b=-
0.68
***
, = 8.93), wi hou a signi ican g oup di e ence.
Howe e , he e ec o pe cei ed isks on in en ion o use is
only signi ican o he public g oup (b= -0.27
**
,
= 3.05), bu no o he p i a e g oup (b= 0.004,
= 0.04, p= 0.022).
Tu ning o pe cei ed con ol, we ind e idence ha he
indi ec pa h o us on in en ion o use is signi ican ly
s onge o p i a e p o ide s (b= 0.20
**
, = 3.00) han
o public p o ide s (b= 0.02, = 0.63, p= 0.009), o
which he indi ec e ec is absen . Thus, ou indings
suppo hypo hesis H4; p o ide go e nance al e s he
pa hway in which us ansla es in o usage in en ions ia
pe cei ed con ol. Looking a he di ec pa hs, he esul s
show ha he e ec o us on pe cei ed con ol is sig-
ni ican ly s onge o p i a e p o ide s (b= 0.73
***
,
= 16.52) han o public p o ide s (b= 0.48
***
, = 6.64,
p= 0.001). The e ec o pe cei ed con ol on in en ion o
use is no only signi ican ly s onge o p i a e p o ide s
(b= 0.27
**
, = 3.20), bu he e is no e ec a all o public
p o ide s (b= 0.05, = 0.64, p= 0.026).
The analysis o he o al e ec o us on in en ion o
use summa ize hese indings by showing ha he o al
e ec s a e signi ican ly s onge o p i a e p o ide s
(b= 0.55
***
, = 7.64) han o public p o ide s
(b= 0.38
***
, = 6.51, p= 0.039). As o con ol a iables,
we ind ha willingness o disclose had a signi ican e ec
on in en ion o use in he ull sample and o public p o-
ide s (b= 0.21
*
, = 1.85), al hough wi hou a signi ican
g oup di e ence. Rega ding g oup di e ences, only he
e ec o age on in en ion o use was signi ican ly di e en
be ween he public p o ide and p i a e p o ide g oups
(p= 0.048), bu nei he pa h was signi ican o ei he
g oup (public: b= 0.04; p i a e: b= -0.13). Fo all o he
con ol a iables, no signi ican pa hs o g oup di e ences
we e de ec ed.
4.4 Reg ession o Usage In en ions on Download
Decisions
Rega ding he download decision (whe he a pa icipan
wan ed o p oceed wi h he download o no ), we con-
duc ed a logis ic eg ession including he in en ion o use
and all con ol a iables as p edic o s. The esul s showed a
mode a e o s ong ela ionship o he model p edic o s
wi h he download decision, as indica ed by he Nagelke ke
and Cox-Snell pseudo R
2
alues o 0.509 and 0.375,
espec i ely. The in en ion o use eme ges as he s onges
and signi ican p edic o o he decision o download he
app (B = 1.577, Wald s a is ics = 49.827, p 0.001).
Examining he odds a ios, an inc ease o one s anda d
de ia ion in he in en ion o use made a use 4.84 imes
mo e likely o decide o download he PHR app in ou
expe imen (95% CI [3.13, 7.50]), ega dless o he p o-
ide ype. Fu he mo e, he willingness o disclose pe -
sonal da a also in luenced he download decision
(B = 0.536, Wald s a is ics = 5.590, p= 0.18) wi h an
odds a io o 1.709 (95% CI [1.10, 2.66]). The logis ic
eg ession model co ec ly p edic ed 85.7% o cases wi h a
posi i e download decision and 69.4% o cases wi h a
nega i e download decision, esul ing in an o e all p e-
dic ion accu acy o 79.4%.
1
4.5 Pos -hoc Media ion Analysis
Ou s uc u al model e ealed h ee indi ec e ec s o us
on in en ion o use, namely h ough pe cei ed bene-
i s, pe cei ed isks and pe cei ed con ol. Following Zhao
(2010), we also conduc ed a pos hoc media ion analysis o
unde s and he ex en o which hese indi ec e ec s
media e a possible di ec e ec o us on in en ion o use.
We es ima ed wo di e en models o es o possible
media ion. Fi s , we analyzed he h ee a iables in sepa-
a e models o ex ac he media ing e ec o each indi-
idual po en ial media o . The o al e ec o us on
in en ion o use was signi ican wi h a coe icien o
b= 0.578 ( = 11.859, p 0.001), and he di ec e ec s
we e b= 0.338 ( = 5.934, p 0.001) o he pa h ia
pe cei ed bene i s, b= 0.445 ( = 6.648, p 0.001) o
he pa h ia pe cei ed isks, and b= 0.462 ( = 8.195,
p 0.001) o he pa h ia pe cei ed con ol. Rega ding
he indi ec e ec s, all pa hs we e signi ican wi h
1
Mo e comp ehensi e esul s a e p o ided in online Appendix H.
123
288 B. Binze e al.: T us in Public and P i a e P o ide s..., Bus In Sys Eng 66(3):273–297 (2024)
b= 0.240 ( = 5.364, p 0.001), b= 0.132 ( = 2.591,
p= 0.005), and b= 0.116 ( = 3.219, p= 0.001) espec-
i ely. These esul s show ha when conside ed indi idu-
ally, all h ee cons uc s pa ially media e he e ec o us
on in en ion o use, pe cei ed bene i s media ing 42%,
pe cei ed isks 23%, and pe cei ed con ol 20% o he
o al e ec .
Second, we es ima ed a media ion model acco ding o
Hai e al. (2022) ha included all h ee po en ial media o s
simul aneously. He e, he o al e ec o us on in en ion
o use was signi ican wi h a coe icien o b= 0.589
( = 11.856, p 0.001) and he di ec e ec o us on
in en ion o use when including all h ee media o s was
signi ican wi h a coe icien o b= 0.284 ( = 4.301,
p 0.001). Rega ding he indi ec e ec s, pe cei ed ben-
e i s pa ially media ed he e ec o us on in en ion o
use (b= 0.224, = 4.888, p 0.001) wi h 39% o he o al
e ec , while he indi ec e ec s o pe cei ed isks and
pe cei ed con ol we e insigni ican (see Table 6). This
was as expec ed, because high co ela ions be ween he
media ing cons uc s lead o an omission o he compe ing
e ec s (see Table C1). Tha is, he p esence o mo e
media o s masks he e ec o o he po en ial media o s
when conside ed simul aneously (Hai e al. 2022).
4.6 Pos -hoc Analysis o T us and I s Componen s
We conduc ed a second pos -hoc analysis o in es iga e
how abili y,bene olence, and in eg i y in luence he
o e all us o indi iduals in an app p o ide , and analyzed
he ela ionships be ween he cons uc s mo e in dep h (see
Figu e I1 in online Appendix I). A e applying he con-
sis en PLS algo i hm, R
2
in us was 0.736 (adjus ed:
0.733), indica ing ha almos h ee qua e s o he a iance
in hese componen s is sha ed wi h us . Fo he ull
da ase , we ound ha he e ec s o bene olence on us
and hose o in eg i y on us we e s a is ically signi ican
(b= 0.39
***
, = 7.43 and b= 0.50
***
, = 9.33 espec-
i ely). The pa h coe icien o abili y on us was close o
ze o (b= 0.018) and lacked s a is ical signi icance (see
Table 7), sugges ing ha abili y does no con ibu e o us
in a heal h app p o ide in he con ex o his s udy. When
analyzing he public and p i a e da ase s sepa a ely, he
pa hs be ween bene olence and in eg i y on us a e sig-
ni ican o bo h g oups, and mul ig oup analyses e eal no
signi ican di e ence be ween hem. Howe e , he pa h o
abili y on us in he app p o ide becomes signi ican only
o he p i a e g oup (b= 0.13*, = 2.03), and no o he
public g oup, al hough mul ig oup analysis e eals ha his
di e ence is no signi ican .
5 Discussion
In he ligh o he ongoing deba e su ounding adequa e
go e nance app oaches o he digi aliza ion o heal hca e,
he objec i e o his esea ch was o examine whe he and
how p o ide go e nance has a bea ing on he beha io al
in en ion o use a mobile heal h app and he consequen
decision o consume s o download such an app. By means
o an online expe imen using he case o a newly de el-
oped PHR app, we ound ha whe he he p o ide o he
heal h app is a public o a p i a e ins i u ion ma e s no
only o he pe cei ed us wo hiness o his p o ide , bu
also o he in en ions o use he heal h app and hus, in
u n, o he decision o download i . D awing on p i acy
calculus and p i acy con ol pe spec i es, we de eloped
h ee hypo heses ha cap u e he di e en ial e ec s in he
s eng h o he pa hways by which us ansla es in o
usage in en ions h ough pe cei ed bene i s, pe cei ed
isks, and pe cei ed p i acy con ol.
Speci ically, we examined p o ide go e nance no only
as a di ec in luence on us (H1), bu also as a mode a o
o he e ec s o us on in en ion o use h ough pe cei ed
bene i s (H2), pe cei ed isks (H3), and pe cei ed p i acy
con ol (H4). Ou indings show ha , while us in p i a e
app p o ide s is signi ican ly lowe han in public p o ide s
p o iding he same app, us has a s onge posi i e o al
e ec on he in en ion use h ough pe cei ed bene i s and
pe cei ed con ol o p i a e p o ide s han o public
p o ide s. Con a y o H3, howe e , he e ec h ough
pe cei ed isks is s onge o public p o ide s han o
p i a e p o ide s. O e all, ou s udy holds wo impo an
implica ions o p i acy calculus heo y and heal hca e IS.
5.1 Implica ion 1: Towa ds a Sec o al Theo y
o P i acy Calculus and Con ol
Ou s udy ep esen s a i s s ep owa ds a sec o al heo y
o p i acy calculus and p i acy con ol ha accoun s o
he con ex ual di e ences in p i a e e sus public sec o s.
Ou esea ch hus subsc ibes o he calls ha con ex
ma e s in he s udy o us and p i acy phenomena (e.g.,
Acquis i e al. 2015; Bansal e al. 2016; Chong e al. 2022;
Yun e al. 2019). P i acy calculus heo y has ecei ed
widesp ead a en ion since he ea ly 2000s in he con ex o
e-comme ce esea ch. Since hen, i has been used in di -
e en a eas conce ning consume us in online in e ac-
ions wi h businesses, including social ne wo king (Yun
e al. 2019). I is he e o e no su p ising ha he o e -
whelming majo i y o p i acy s udies in IS ha e (implic-
i ly) aken a p i a e sec o con ex as a p emise. P i acy in
he highly egula ed ield o heal hca e, howe e , is a gu-
ably mo e complex han in he adi ional playing ield o
p i acy esea ch. This is because, depending on he
123
B. Binze e al.: T us in Public and P i a e P o ide s..., Bus In Sys Eng 66(3):273–297 (2024) 289
na ional heal h sys em con ex , in heal hca e he e a e
mul iple (public and p i a e) ins i u ions in ol ed in p o-
iding heal hca e se ices and p ocessing consume da a
(Dash e al. 2019). Mo eo e , his da a can ha e di e en
le els o sensi i i y (Rahman 2019). P e ious esea ch in
heal hca e has conside ed p i acy calculus in ei he p i a e
sec o (e.g., Li e al. 2014) o in public sec o (e.g., P inci
and K a
¨me 2020) con ex s. The di e ences be ween us
and p i acy in he in e ac ion wi h public ins i u ions and
p i a e companies, howe e , ha e o da e no been ade-
qua ely e lec ed in he heal hca e IS li e a u e. In his
spi i , ou s udy suppo s heo y po abili y o p i acy
calculus and p i acy con ol heo y o he ield o heal h-
ca e IS.
Ou suppo o he hypo hesis ha us has a signi i-
can ly s onge e ec on in en ion o use ia pe cei ed
bene i s when he p o ide is a p i a e company as opposed
o a public ins i u ion (H2) is a i s elemen o his sec o al
heo y. This inding means ha o p i a e p o ide s o
heal h apps, us is essen ial o suppo he pe cep ion o
consume bene i s, such as imp o ed access o heal h da a,
suppo o hei heal h li e acy, be e heal hca e quali y,
and imp o ed communica ion wi h physicians. Con e sely,
o a public app p o ide , consume s base hei
Table 6 Media ion analysis
To al e ec s
(T ?IU)
Di ec e ec
(T ?IU)
Indi ec e ec s
(T?IU)
Media ion
Coe icien
(T- alue)
p- alue Coe icien
(T- alue)
p- alue Pa h Coe icien
(T-Value)
p- alue Pe cen ile boo s ap
95% con idence in e al
5% lowe bound 95% uppe bound
0.578
(11.856)
0.000 0.338
(5.934)
0.000 T ?PB ?IU 0.240
(5.364)
0.000 0.169 0.317 Yes, pa ial
0.445
(6.648)
0.000 T ?PR ?IU 0.132
(2.591)
0.005 0.054 0.222 Yes, pa ial
0.462
(8.195)
0.000 T ?PC ?IU 0.116
(3.291)
0.001 0.062 0.177 Yes, pa ial
0.284
(4.301)
0.000 T ?PB ?IU 0.224
(4.888)
0.000 0.151 0.302 Yes, pa ial
T?PR ?IU 0.030
(0.633)
0.263 -0.042 0.112 No
T?PC ?IU 0.040
(1.156)
0.124 -0.016 0.099 No
Numbe s in I alics a e he esul s o simple media ion analyses
Table 7 Resul s o he pos -hoc analysis o us and i s componen s
Pa h Full sample
(n= 286)
Public
(n
1
= 151)
P i a e
(n
2
= 135)
Subg oup analysis
- es
p
MGA
b
p
Pa hs Abili y ?T us in he p o ide 0.02
(0.32)
0.01
(0.10)
0.13*
(2.03)
0.145 0.138
Bene olence ?T us in he p o ide 0.39***
(7.43)
0.35***
(5.52)
0.38***
(5.12)
0.391 0.385
In eg i y ?T us in he p o ide 0.50***
(9.33)
0.52***
(7.10)
0.45***
(5.41)
0.270 0.254
R
2
(T us in he p o ide ) 0.736 0.691 0.774 – –
R
2
adj. (T us in he p o ide ) 0.733 0.684 0.769 – –
b
MGA mul ig oup analysis (one-sided compa ison); *p 0.05; **p 0.01; ***p 0.001
123
290 B. Binze e al.: T us in Public and P i a e P o ide s..., Bus In Sys Eng 66(3):273–297 (2024)
expec a ions o bene i s o a much lesse ex en on hei
us in his p o ide . Ou heo e ical explana ion o his
sec o al di e ence is g ounded in ins i u ional us pe -
spec i e and a p oposed e ec o public egula ion as a
us -enhancing and us -subs i u ing mechanism. Du ing
he Co id-19 pandemic, o example, consume s adop ed
acing apps mo e widely when hey we e ecommended o
e en manda ed by go e nmen egula ion (Rieme e al.
2020). Ou da a show ha , while consume s pu g ea e
us in public p o ide s, hey ha e on a e age he same
le el o pe cei ed bene i s om he public p o ide ’s app
as hey do om he p i a e p o ide ’s app. Usage in en-
ions a e, again, signi ican ly lowe wi h he p i a e p o-
ide ’s app (Table 4). Ou sec o al esul s sugges ha ,
e en i consume s lose us in he public p o ide s, his
will ha dly ha m he bene i expec a ions and usage o he
app o he same ex en as i would o he p i a e p o ide .
I is hus likely ha consume s base hei bene i expec a-
ion o heal h apps by public p o ide s on o he belie s han
us , such as he belie in he p o ide ’s mission o con-
ibu e o he public good (Gale si e al. 2023; Lounsbu y
e al. 2021).
The second elemen o ou di e en ial heo y o p i acy
calculus and p i acy con ol can be seen in he indings
ega ding H4. T us has a signi ican ly s onge e ec on
in en ion o use ia pe cei ed con ol when he p o ide is
a p i a e company; he e ec is insigni ican when he
p o ide is public (Table 5). Pe cei ed con ol ela es o
he belie ha he indi idual can con ol which o he pa -
ies (e.g., physicians, insu ances, hi d pa ies) ob ain
access o he da a, and o which pu poses. The pe cep ion
ha consume s can con ol hei p i acy when in e ac ing
online has been con i med as an impo an c i e ion ha
d i es IS usage in en ions, including hose in a heal hca e
con ex (e.g., P inci and K a
¨me 2020). He e, we do no
only see an indica ion o public go e nance ac ing as a
us -subs i u ing, bu also as a con ol-subs i u ing mech-
anism. Fo p i a e p o ide s, consume s belie e o ha e
his con ol only i hey us he p o ide . Fo public
p o ide s, in con as , us is no a p e equisi e o he same
ex en . Mo e impo an , howe e , is he second leg o he
pa hway. Pe cei ed con ol does no seem o be a ele an
c i e ion o use s o ancho hei usage in en ions when he
p o ide is public. To pu i di e en ly, o public heal h
apps, consume s do no seem o p io i ize he p esence o
p i acy con ols in hei decision o adop he app, while
o p i a e heal h apps hey do. This sugges s ha public
p o ide s a e no expec ed o p o ide he same le el o
p i acy con ols as p i a e p o ide s.
The hi d and las elemen o a sec o al p i acy calculus
heo y is gi en by ou unexpec ed indings ega ding
hypo hesis H3: T us has a s onge e ec on in en ion o
use ia pe cei ed isks when he p o ide is public han
when i is p i a e; he e ec is insigni ican , when he
p o ide is p i a e. This inding is su p ising as one could
ha e expec ed he le el o egula ion inhe en o public
go e nance o ha e he same us subs i u ion e ec o
pe cei ed isks as o he pe cei ed bene i s and con ols.
Del ing deepe in o his pa h, i is e iden ha he lack o
signi icance obse ed o p i a e p o ide s can be a ib-
u ed o he insigni ican di ec e ec o pe cei ed isk on
in en ion o use (Table 5). In o he wo ds, o p i a e
p o ide s, p i acy isks did no ha e an e ec on in en ion
o use he heal h app e alua ed in ou s udy. On he one
hand, his inding con as s wi h he li e a u e ha has
ound pe cei ed isks as a cen al p edic o o usage
in en ions in p i a e sec o con ex s, including in heal h-
ca e (e.g., Li e al. 2014; Nicolaou and McKnigh 2006).
One possible explana ion could be ha he high isks
inhe en o he con ex o heal hca e da a a e al eady ac-
o ed in o use s’ in en ions, ega dless o he pe cep ion o
hese isks. An al e na i e explana ion could be ha in he
ligh o he compa a i ely high pe cei ed bene i s o
heal hca e apps om p i a e p o ide s, po en ial use s o
heal h apps base hei calculus solely on hese bene i s and
end o dis ega d he isks. Fu he esea ch is wa an ed o
explo e which o hese possible explana ions holds ue o
p i a e p o ide s o heal h apps. On he o he hand, he
p i acy isk pa o he calculus u ns ou o be highly
ele an o apps om public p o ide s. Hence, isk pe -
cep ions can appa en ly no be mi iga ed h ough egula ion
and public go e nance. I migh be oo ed in he psychol-
ogy o he indi idual ha ea s o da a loss and da a misuse
canno be mi iga ed by he ac ha he o he pa y is a
us ed and egula ed ins i u ion (Lounsbu y e al. 2021).
The pe cei ed lesse abili y o public p o ide s migh
imply ha use s may be pa icula ly conce ned abou hei
da a being comp omised by hi d pa ies i i is s o ed wi h
public p o ide s. O e all, ou H3 inding con ibu es o he
deba e on policy app oaches in heal hca e digi aliza ion by
easing ou a new bounda y o public go e nance o heal h
echnology adop ion. Use s appa en ly need o us public
ins i u ions as much as hey need o us p i a e ins i u-
ions o become con inced ha hei da a is secu ely and
p i a ely s o ed, and his pe cep ion is e en mo e c ucial
he e o hei usage in en ions han wi h p i a e p o ide s.
In sum, ou indings sugges ha p i a e p o ide s o
mobile heal h se ices can ansla e use s’ us in o usage
in en ions by s eng hening he bene i s and con ol pe -
cep ions o hei heal h apps. Public p o ide s, in con as ,
can p oac i ely s i e o a ac use s by add essing and
lowe ing he pe cei ed isks o hei o e ings. The o e -
a ching heo e ical implica ion is ha we p o ide a
nuanced pic u e o how p i acy calculus and p i acy
con ol heo y apply o public sec o heal hca e IS as
opposed o he p edominan ly s udied se ing in p i a e
123
B. Binze e al.: T us in Public and P i a e P o ide s..., Bus In Sys Eng 66(3):273–297 (2024) 291
sec o (i.e., business) con ex s. Public go e nance and
egula ion ac as pa ial subs i u es o us in ela ion o
he posi i e d i e s o usage in en ions while exace ba ing
he ole o pe cei ed isks, as ou sec o al p i acy calculus
and p i acy con ol pe spec i e sugges s.
5.2 Implica ion 2: Reconside ing Abili y as a T us
Componen
Second, ou s udy ques ions he no ion o abili y as a
necessa y componen o ins i u ional us , pa icula ly in
he con ex o heal hca e digi aliza ion. P e ious us
esea ch in IS has concep ualized abili y, de ined as he
compe encies, skills, and ask- ela ed ac i i ies ha enable
he us ee o succeed in a speci ic domain (Becke e al.
2014), as one o he h ee impo an componen s o ins i-
u ional us , nex o bene olence and in eg i y (Maye
e al. 1995). Al hough his ipa i e concep ualiza ion has
ecei ed wide ecogni ion, esea che s ha e also encoun-
e ed p oblems wi h i s ope a ionaliza ion. Fo example,
So
¨llne e al. (2010) ound ha in eg i y was no a signi -
ican us componen in he con ex o mobile phone se -
ices. In ou s udy o mobile heal h apps, abili y did no
p o e o be a signi ican componen o us in a mobile
heal h p o ide , al hough bo h cons uc s, us and abili y,
aken by hemsel es demons a ed psychome ic alidi y.
We a gue ha he non-signi icance o abili y in he
con ex o us in a mobile heal h app p o ide , as
demons a ed in ou pos -hoc analysis, is no a p oduc o
andomness o e o , bu indica i e o he dilemma we ace
in he heal hca e con ex , speci ically in he ma ke like he
one ha was s udied (Ge many). While consume s s ill
ha e ela i ely high us in public au ho i ies and belie e
in hei in eg i y and bene olence, hey ha e somewha los
ai h in he go e nmen ’s capabili y o e ec i ely deli e
mobile heal h se ices, such as a PHR, o all ci izens. This
sen imen is clea ly e lec ed in he subg oup means o H1,
whe e us in he public heal h au ho i y signi ican ly
su passes ha in bo h p i a e p o ide s, while pe cei ed
abili y o he public heal h au ho i y is signi ican ly lowe
han ha o bo h p i a e ypes (and also lowe han he
public insu ance ype, see Table 4). Ge many, in pa icula ,
has a his o y o slow p og ess in heal hca e digi aliza ion
wi h ega ds o publicly p o ided in as uc u e (Blu
¨mel
e al. 2020; Re iene 2022).
While abili y was no associa ed wi h us o public
p o ide s, we ound a weak associa ion o p i a e p o i-
de s (Table 7). The key heo e ical implica ion is ha
ins i u ional us and abili y a e no always and in any case
co ela ed. This challenges he assump ion ha ins i u ional
us can be uni e sally speci ied h ough he h ee com-
ponen s o abili y, in eg i y, and bene olence. Thus, he e
is a need o be awa e o he con ex when s udying he
componen s ha po en ially o m us in ins i u ions and
p o ide s o heal h IS se ices. In heal hca e digi aliza ion,
consume s may us ce ain pa ies al hough hey do no
conside hem as able (e.g., go e nmen s), while con-
e sely, hey migh dis us o he s (e.g., companies), whom
hey pe cei e as mo e compe en in deli e ing e ec i e
digi al heal h se ices. Thus, ou esea ch un eils a no el
us -abili y dilemma in he con ex o heal hca e digi al-
iza ion ha wa an s u u e explo a ion.
5.3 Limi a ions
The gene alizabili y o he esea ch implica ions is con-
s ained by he ollowing limi a ions. Fi s , since heal hca e
is an inhe en ly complex ield subjec o speci ic cul u al
and egula o y condi ions, we ocused on one speci ic
ma ke (Ge many) and one speci ic app (a PHR) o keep
hese condi ions cons an . T us in public e sus p i a e
o ganiza ions and i s ela i e e ec s on usage in en ions
migh be weighed di e en ly by use s om o he na ional
con ex s, depending on he speci ic mobile heal h app.
Second, we delibe a ely excluded heal hca e p o ide s as a
p o ide ype, since heal hca e p o ide s (e.g., hospi als)
a e unlikely o p o ide PHR apps in he ma ke ha was
s udied (Ge many). Thi d, al hough we included a se o
con ol a iables, he e is a possibili y ha addi ional
a iables ou side he scope o his s udy could ha e an
e ec on he in en ion o use a PHR.
Fou h, while ou sample was ai ly balanced in e ms o
gende , he a e age age o he pa icipan s was ela i ely
young, wi h 31.4 yea s. A mo e balanced sample in e ms
o age dis ibu ion may ha e yielded di e en esul s. Fi h,
o ope a ionalize he wo p o ide go e nance ypes o he
pu pose o ou online expe imen , we chose ou speci ic
en i ies and labels. Al hough we ha e a gued how and why
each o hese en i ies adequa ely ep esen s he wo go -
e nance ypes, i is possible ha pa icipan s o ou
expe imen s would ha e a ed he s udy a iables di e -
en ly, had we chosen o he en i ies and labels. Six h, ou
sample was acqui ed using he online pla o m P oli ic,
which may imply ce ain sel -selec ion biases o ou sam-
ple beyond he ac o s we we e able o con ol o .
Se en h, pa icipan s o ou s udy we e exposed o a
simula ed PHR app ha was p esen ed o hem as a genuine
app unde de elopmen , which may limi he ex e nal
alidi y o ou esea ch. Eigh h, ou s udy uses down-
loading as a p oxy o app usage, mainly highligh ing
ini ial adop ion o PHR apps and neglec ing o unde s and
long- e m usage. Fu u e esea ch should explo e wha
d i es bo h ini ial downloads and ongoing, e ec i e use o
PHR apps o (sensi i e) heal h da a managemen . Las ly,
ou c oss-sec ional use da a only asce ains s a is ical
123
292 B. Binze e al.: T us in Public and P i a e P o ide s..., Bus In Sys Eng 66(3):273–297 (2024)

associa ion, no he causali y ha is inhe en o ou heo-
izing and hypo heses.
5.4 P ac ical Implica ions
Simila o many o he coun ies, he ecen plans in Ge -
many o expand he na ionwide heal h in as uc u e
h ough PHRs ( he ePA) ha e spa ked ongoing deba es
conce ning he po en ial bene i s and isks, wi h adop ion
le els emaining minimal (Sch ahe 2021). The indings o
ou s udy ad oca e ha public s akeholde s s ep up hei
e o s o p omo e he implemen a ion and p o ision o
na ionwide PHRs h ough publicly go e ned digi al
in as uc u es. Despi e a equen ly no ed ins i u ional
us pa adox (Ro hs ein and S olle 2008), ou esea ch
demons a es ha use s in Ge many place signi ican ly
highe le els o us in public p o ide s o manage hei
pe sonal heal h da a compa ed o p i a e companies,
including big companies and s a ups. These indings
s a kly con as wi h s udies conduc ed in o he coun ies,
such as he US, ha ha e e idenced dis us owa d go -
e nmen in ol emen in he sha ing o heal h da a
(Ande son and Aga wal 2011). Hence, ou esea ch ein-
o ces he no ion ha in he sphe e o Eu opean heal hca e,
publicly egula ed p o ide s a e iewed as he mos eliable
s ewa ds o heal h da a.
Second, ou s udy in o ms public and p i a e p o ide s
abou he mechanisms h ough which hey can sus ain and
inc ease people’s in en ions o adop mobile heal h apps. In
pa icula , p i a e p o ide s should p io i ize he p omo ion
o he applica ion’s heal h managemen bene i s and i s
p i acy con ols. Con e sely, public p o ide s ough o
concen a e hei e o s on add essing he pe cei ed isks
associa ed wi h he applica ion. Rega ding he Ge man ePA
implemen a ion, i s ands o eason ha insu icien in o -
ma ion abou he measu es o mi iga e p i acy and secu i y
h ea s may ha e been one o he key ac o s ha hinde ed
he widesp ead accep ance o he PHR in Ge many in he
pas . In his sense, we hope ha ou s udy can p o ide an
impe us o s akeholde s o design mo e use -cen ic PHR
apps and complemen hese wi h e ec i e communica ion
s a egies o a posi i e change.
6 Conclusions
Mobile heal h apps play a c ucial ole in he u u e p o i-
sion o ca e, wi h a no able su ge in he numbe o publicly
and p i a ely go e ned apps en e ing he ma ke . In an
e o o in es iga e how app p o ide go e nance in lu-
ences PHR usage in en ions, his s udy de eloped a sec o al
heo y o p i acy calculus and pe cei ed con ol, which
was es ed in an online expe imen wi h a sample o
po en ial use s o a PHR app in Ge many. Ou esul s
p o ide e idence o a pa ially us -subs i u ing e ec in
public sec o : While public p o ide s exhibi highe le els
o us and lowe le els o abili y han p i a e p o ide s,
his us alone is no as c ucial o c ea ing pe cei ed
bene i and con ol expec a ions in use s as i is o p i a e
p o ide s. Howe e , us emains a mo e c i ical ac o o
mi iga ing pe cei ed p i acy and secu i y isks o public
p o ide s han o p i a e p o ide s. In addi ion o con-
ibu ing o he ongoing deba e ega ding he go e nance
o heal h echnology adop ion, ou esea ch also chal-
lenges he assump ion ha us is always associa ed wi h
abili y, pa icula ly in a public sec o con ex . Heal hca e
egula o s and app p o ide s can glean insigh s om ou
s udy ega ding he echnology and communica ion le e s
h ough which hey can e ec i ely enhance he widesp ead
accep ance and usage o hei mobile heal h o e ings.
Supplemen a y In o ma ion The online e sion con ains
supplemen a y ma e ial a ailable a h ps://doi.o g/10.1007/s12599-
024-00869-4.
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