Privacy Concerns and Continued Use Intention of Telemedicine During COVID-19

Introduction

Internet privacy concerns (IPCs) are one major barrier to adoption of digital technologies or online services,^1,2 a commonly observed phenomenon in commercial settings. The higher the privacy concerns consumers have, the lower the likelihood of using personalized services on ecommerce websites³ or the lower the intention to make online purchases.⁴

From the perspective of the privacy calculus theory, people may adopt online services if the benefits of mitigating risks outweigh the costs of potential privacy invasion.⁵ Kordzadeh and Warren found that as long as consumers believe that their information can benefit someone, they are willing to share personal health information in public virtual health community discussions.⁶ Anderson and Agarwal found that the negative association between privacy concerns and willingness to provide access to personal health information will be attenuated if the purpose is for patient care and if the information is requested by hospitals.⁷

In their national survey of 1,847 respondents, Dimitropoulos et al.⁸ found that 75% agreed that the benefits of electronic health records outweighed privacy risks. In the same survey, 60% of respondents reported willingness for their physicians to share their information for treatment, even if their privacy cannot be protected all the time.⁸

People tend to make decisions differently when facing risks. It is reasonable to question whether privacy still plays a predictive role in online technology adoption when people are facing immediate and potentially severe risks—both personal (e.g., illness) and environmental (e.g., pandemic). Patients may be willing to partake in virtual visits during a pandemic if their perceived benefits (e.g., safety and convenience of rapid access to health care services) outweigh perceived privacy risks. Although privacy effects on behavioral intention when people are relatively ill have been studied to some extent in literature,^9–12 the effects when people are under environmental risks are unexplored.

The outbreak of COVID-19 pushed health care providers to deploy virtual visits, which drastically expanded the landscape of virtual visits. Within about 1 month of the disease outbreak, virtual visits in a large health system in New York (NYU Langone Health) were found to have a 135% increase daily for urgent care and 4,345% increase daily for nonurgent care.¹³ Not surprisingly, 81.5% of virtual visit users during COVID-19 were first-timers, as found in our national survey for acute conditions.¹⁴

This unprecedented increase in the size of the telemedicine user pool provides us a unique opportunity to understand how privacy concerns are related to their behavior and continued use intention of virtual visits. The study during COVID-19 also allows us to understand the relationships when people are under both personal and environmental risks.

This article aims to understand telemedicine users’ information privacy concerns, usage satisfaction, and their association with continued use intention when people are experiencing acute health conditions (personal risks) during COVID-19 (environmental risks).

This study aims to answer 3 research questions. First, for people facing personal risks, are the levels of privacy concerns different between early adopters (nonfirst-timers during COVID-19) and late adopters (first-timers during COVID-19) of telemedicine? Second, is the negative association between privacy concerns and use intention that is prevalent in commercial settings also evident when people are facing both personal and environmental risks? Third, how does usage satisfaction during COVID-19 associate with future use intention?

Methods

Patients who used virtual visits for acute conditions during COVID-19 were surveyed in June 2020, and some results were reported elsewhere.¹⁴ The survey collected data on patients’ IPCs, satisfaction, and continual use intention of virtual visits, along with their demographics and experience. For the purpose of this article, we focused on privacy concern and its association with continued use intention.

PROCEDURE

The survey constructed using Qualtrics was hosted on Amazon Mechanical Turk (MTurk), where Workers (Turkers) complete Human Intelligence Tasks (HITs). MTurk has been used to understand patients’ intention to use online services¹⁵ and privacy concerns.^16,17 Studies found that the validity and reliability of MTurk samples are comparable with those of other sources.

Thomas and Clifford showed that Turkers pay as much attention as other participants from convenience or high-quality commercial samples.¹⁸ Mosleh et al. found that the prevalence of selective types of political news articles suggested by the MTurk sample is consistent with actual observation from Twitter.¹⁹

Respondent parameters for inclusion in the study were (1) ≥18 years old, (2) residing in the United States, (3) used virtual visits for acute conditions after January 2020 when the first case was confirmed in the United States, and (4) an HIT approval rate of >95% to ensure the quality of responses.²⁰ Respondents were compensated $1 for each completed survey.

To ensure the quality of data, response patterns that meet one of the following criteria were excluded¹⁸: (1) responses that were completed unusually fast,^21,22 (2) responses that could rarely occur,²³ and (3) responses that failed to pass all three attention and consistency checks. The first is an attention check that asks respondents to provide a particular answer.¹⁸ The other two are consistency checks, each with 2 questions, to make sure that the respondents reside in the United States and had acute conditions.^18,22,24

Data collection was approved under exempt review procedures of the Institutional Review Board of the authors’ affiliated university.

MEASUREMENTS

Respondents’ general IPCs were measured using the 18-item IPC scale developed by Hong and Thong,²⁵ which includes six dimensions of internet privacy: collection, secondary usage, errors, improper access, control, and awareness. Virtual visit satisfaction was measured by 6 items collected from existing literature with minor adaptation to fit into our specific context.^26–28 For example, we asked participants to rate their agreement on “Virtual visits are as helpful as office visits.”

Continual use intention was measured by four items derived from prior telehealth research.²⁹ For example, one sample item asked participants to rate the statement, “After the COVID-19 emergency is over, I am willing to use virtual visits to complement my traditional care for acute conditions.” All items were measured using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).

Survey items for all three latent variables can be found in Appendix. Respondents’ demographic characteristics include age, gender, race, education, area of living, and daily internet use. The survey also asked whether they used the virtual visit for the first time during COVID-19.

ANALYSES

Validity and reliability for our survey instruments were assessed employing the confirmatory factor analysis, Cronbach’s α, and construct reliability. Bivariate analyses were conducted to assess relationships between respondent characteristics/experience and privacy using one-way analyses of variance for categorical characteristics and Pearson’s correlation for continuous characteristics.

We used linear regression models to examine the relationships between outcomes of interest (privacy and intention) and respondent characteristics. Structural equation modeling (SEM) was also conducted. Ratings of all items for a latent variable were averaged to represent the overall score of that latent variable, which is used in the aforementioned bivariate and regression analyses.

Results

During the last 2 weeks of June 2020, 1,727 responses were collected. Among those, only 1,114 were eligible, completed, and satisfactory in terms of passing all attention checks. We further excluded 55 unreasonable responses, resulting in N = 1,059 for analysis. Table 1 shows the demographic composition of our sample.

Results from the confirmatory factor analysis, Cronbach’s α, and construct reliability confirmed that our 6-item instrument for satisfaction and 4-item instrument for intention were valid and reliable as all test results were within the recommended ranges.^14,30Table 2 shows that results from the confirmatory analysis for privacy are slightly off the recommended ranges, but still exhibit excellent reliability. Since the IPC scale has been rigorously validated,²⁵ we are comfortable with the efficacy of the scale.

As can be seen in Table 3, overall, the average score of IPCs is 5.25, with 87.9%, 0.9%, and 11.1% of respondents having an average score of >4, = 4, and <4, respectively. The average scores of all six dimensions range from 5.11 to 5.33, with Errors having the lowest average score and Collection and Awareness having the highest average scores.

A majority, 81.5% of respondents, used virtual visits for the first time during COVID-19 (Table 1). To answer our first research question, we compared the means of privacy scores between users who used virtual visits for the first time during COVID-19 (first-timers) and those who did not (nonfirst-timers).

We found that the average privacy score for first-timers was significantly higher than that of nonfirst-timers (first-timers 5.28 ± 1.05 vs. nonfirst-timers 5.11 ± 1.02) (p = 0.034) (Table 1). This suggests that privacy concerns do play an important role in telemedicine adoption when users are facing personal risks. We also found that the mean privacy score was significantly different across groups of gender (p = 0.031), education (p = 0.007), and daily internet use (p = 0.049).

The greater privacy concerns of first-time virtual visit participants are also evident in regression results. As can be seen in Model 1 of Table 4, first-timers had significantly higher privacy concerns compared with nonfirst-timers (B = 0.18, p = 0.03). Our multivariable modeling also indicated the same results as the bivariate analysis, except that daily internet use was not a significant factor when other variables are controlled (Model 2 in Table 4).

The following significant differences were found: females in comparison with males had significantly higher privacy concerns (B = 0.14, p = 0.03); respondents with some college education or less, compared with those with college degrees, reported significantly lower privacy concerns (B = −0.22, p = 0.04); and first-timers reported significantly higher privacy concerns than respondents who had used virtual visits before COVID-19 (B = 0.19, p = 0.02).

In examining the relationship between privacy concerns and continued use intention, results indicate that a surprisingly positive association exists, as can be seen in the boxplot in Figure 1. Pearson’s correlation test confirms their significant and positive correlation (Pearson’s r = 0.39, p < 0.001).

This significant and positive association is also found in regression results. Model 1 in Table 5 shows that a one-unit increase in privacy concerns is associated with a 0.5-U increase in continued use intention (B = 0.47, p < 0.001).

Table 5. Regression Analysis of Intention (N = 1,045)

	MODEL 1		MODEL 2		MODEL 3		MODEL 4
	B (ROBUST SE)	p	B (ROBUST SE)	p	B (ROBUST SE)	p	B (ROBUST SE)	p
Intercept	2.749 (0.271)***	<0.001	0.442 (0.156)**	<0.01	0.488 (0.162)**	<0.01	0.161 (0.223)	0.47
Privacy	0.468 (0.050)***	<0.001	0.139 (0.034)***	<0.001	0.141 (0.034)***	<0.001	0.147 (0.035)***	<0.001
Satisfaction			0.765 (0.036)***	<0.001	0.764 (0.036)***	<0.001	0.762 (0.037)***	<0.001
First-timer					−0.064 (0.058)	0.27	−0.064 (0.059)	0.28
Controls	No		No		No		Yes
Adjusted R2	0.148		0.607		0.607		0.614
N	1,059		1,059		1,059		1,045

This significant positive association persists after satisfaction is controlled in Model 2, although the magnitude is attenuated (B = 0.14, p < 0.001). After the dummy variables for first-timers and other controls are included in the model (Models 3 and 4), the result still holds (Model 3: B = 0.14, p < 0.001; and Model 4: B = 0.15, p < 0.001). This result suggests that when patients are facing environmental risks, privacy concerns do not negatively impact their continued use intention.

In Models 2–4, we also observe a significant positive and strong association between satisfaction and continued use intention. For a 1-U increase in satisfaction, continued use intention is expected to increase by 0.7 U, holding privacy concerns and other controls constant (Model 2: B = 0.77, p < 0.001; Model 3: B = 0.76, p < 0.001; and Model 4: B = 0.76, p < 0.001). This result shows that satisfaction is still a strong predictor of continued use intention when users are facing environmental risks.

Considering that some nuances may be overlooked when taking a simple average of all measurement items for a latent variable, we also used SEM. We ran SEM separately on the entire data set, on the data set generated by first-timers, and on the data set generated by nonfirst-timers. Figure 2 shows the results from the three data sets without controlling for any demographics. We see that SEM provides consistent findings as the results from regression analyses.

Specifically, privacy concerns have a significant positive association with continued use intention, with the greatest magnitude being among nonfirst-timers (B = 0.22, p < 0.01). Satisfaction also has a significant positive association with intention, with the greatest magnitude being among first-timers (B = 0.91, p < 0.001). The results still hold when user characteristics are controlled (B = 0.11, p < 0.001, for all participants; B = 0.10, p < 0.01, for first-timers; and B = 0.21, p < 0.01, for nonfirst-timers) (Fig. 3).

Discussion

In commercial settings, it is well known that privacy concerns negatively impact the intention to adopt a service or to share information online.^3,4 There is less knowledge about the role of privacy concerns in telemedicine adoption when people are facing both personal and environmental risks. To that end, this study examines the role of privacy concerns in the adoption of virtual visits when people have acute conditions (personal risks) during COVID-19 (environmental risks).

We find that overall, the average privacy score is 5.25 on a 7-point scale. Among the respondents, 87.9% have an average score of >4, demonstrating their internet privacy concerns. First-timers constitute 81.5% of the surveyed users during COVID-19. The privacy score of first-timers is significantly greater than that of nonfirst-timers (first-timers: 5.28, and nonfirst-timers: 5.11, p = 0.034). This suggests that privacy concerns do play an important role in online technology adoption when consumers are facing personal risks. Our finding is in line with the study by Fietkiewicz and Ilhan,³¹ which found higher privacy concern among nonusers of fitness tracking technologies compared with former users.

Consistent with the literature concerning individuals not under risks,^32,33 we find that when individuals are facing risks, satisfaction is also positively associated with continued use intention, with strong evidence and magnitude, controlling for privacy concerns, whether using virtual visits for the first time, and subject characteristics (B = 0.762, p < 0.001).

This suggests that no matter whether individuals are facing risks, having users satisfied with the online service is a very efficient and effective way to retain them despite their privacy concern levels. This result also applies to users who used virtual visits for the first time during COVID-19.

Interestingly, we find a positive relationship between privacy concerns and continued use intention (B = 0.468, p < 0.001). This result is robust even when satisfaction, whether using virtual visit for the first time, and user characteristics are controlled (B = 0.147, p < 0.001). This result reveals that given the same satisfaction level, the greater the privacy concerns patients have, the greater the intention to continue using virtual visits. This result is opposite to that found in literature on commercial settings, which suggests a negative relationship.² One possible explanation is that people may undergo a different decision process when they are facing immediate and severe risks.

Specifically, the personality or feelings of the patient may play a dominant role in the decision process when people are facing risks, causing a decision that is different from the situation when people are not facing risks. In our study, the environmental risk condition is the risk of contracting COVID-19 if the patient physically went to a medical office. People may perceive and react to this risk differently.

A recent study shows that people who are more conscientious or neurotic would practice social distancing to a greater extent.³⁴ Virtual visits become a great option when people need to seek medical help and want to practice social distancing. Meanwhile, literature has shown that conscientiousness and neuroticism are also positively associated with privacy concerns.^12,33,35 As a result, people who are more conscientious or neurotic are the ones who are more concerned about internet privacy and are also the ones who would have greater intention to use virtual visits during COVID-19.

Conclusions

In this study, we examined behavioral intentions of people with internet privacy concerns when they are facing personal (being sick) and environmental (during COVID-19) risks. When consumers are facing personal risks, privacy concerns still play an important role in online technology adoption. However, when consumers are facing both personal and environmental risks, privacy concerns do not negatively impact their continued use intention.

Our findings expand the privacy literature by providing novel understanding of the behavioral outcomes of privacy when people are facing personal and environmental risks. The results also provide implications for health care practice to improve the adoption of telemedicine. In addition, the results of this research show that despite the fact that people do care about their internet privacy, when they need to see a doctor under environmental risks such as a pandemic, people will still seek medical advice through online technologies. In addition, the people who care more about privacy are the people who have higher intention to continue using virtual visits.

While studies suggest that people tend to trust hospitals,⁷ which is one important moderator of the negative privacy effects on behavioral intention,^3,7 health care providers who provide virtual visits should ensure that patients’ privacy is protected before the trust from these high-standard users could collapse. Once these users are satisfied with the service, there is a high chance that they will continue using the technology. Therefore, the usage experience during COVID-19 plays a pivotal role in determining the continued use of virtual visits postpandemic. Health care providers should always be prepared for future risk events.

A few limitations provide directions for future research. First, due to the use of MTurk data, we are not able to generalize our results to select segments of the population. Future study may provide evidence using under-representative sample segments (e.g., those under 18 or those inexperienced in using computers or videoconferencing technology) of the U.S. population as well as expand to different types of treatments.

In each of these cases, a family member or caretaker may have to set up the technology and participate in the virtual visit along with the patient. This opens up analysis to understand how the family member/caretaker feels about virtual visits in addition to the patient.

Second, given our data, we are only able to provide a plausible explanation of the positive association between privacy concerns and continued use intention when people are facing risks. Future study may examine the role of personality traits in this association.

Future studies are encouraged to investigate the factors that drive this positive relationship. To the best of our knowledge, this is the first study that investigates the role of internet privacy in online service adoption when people are under environmental risks. Health care providers should be prepared for future environmental risk events such as COVID-19 to ensure patients’ privacy is well protected.

Authors’ Contributions

Y.C.K.L. was responsible for the study concept and design, survey design, data collection, analysis and interpretation of data, and initial draft of the manuscript. S.T.T. was responsible for the study concept and design, interpretation of data, and critically revising the survey and manuscript.

Disclosure Statement

No competing financial interests exist.

Funding Information

This research was, in part, supported by a summer research grant from the Frank G. Zarb School of Business, Hofstra University for data collection.

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Appendix

Survey Instruments

Virtual Visit Satisfaction (7-point scale anchored by “strongly disagree” and “strongly agree”)

1.	I feel comfortable communicating with the clinician using virtual visits
2.	Virtual visits are an acceptable way to receive health care services
3.	Virtual visit providers were able to treat or address what was bothering me
4.	Overall, I am satisfied with virtual visits
5.	Virtual visits are as helpful as office visits
6.	Virtual visits are more convenient than an office visit

Continued Use Intention (7-point scale anchored by “strongly disagree” and “strongly agree”)

1.

After the COVID-19 emergency is over, … a. I am willing to use virtual visits to complement my traditional care for acute conditions b. I have the intention to use virtual visits routinely to receive care for acute conditions c. I intend to use virtual visits if it is difficult to get an office visit at a convenient time to receive care for acute conditions d. I would prefer virtual visits to office visits for acute, but nonserious, illnesses

Internet Privacy Concerns (7-point scale anchored by “strongly disagree” and “strongly agree”)

1.	Collection a. It usually bothers me when commercial websites ask me for personal information b. When commercial websites ask me for personal information, I sometimes think twice before providing it c. I am concerned that commercial websites are collecting too much personal information about me
2.	Secondary Usage a. I am concerned that when I give personal information to a commercial website for some reason, the website would use the information for other reasons b. I am concerned that commercial websites would sell my personal information in their computer databases to other companies c. I am concerned that commercial websites would share my personal information with other companies without my authorization
3.	Errors a. I am concerned that commercial websites do not take enough steps to make sure that my personal information in their files is accurate b. I am concerned that commercial websites do not have adequate procedures to correct errors in my personal information c. I am concerned that commercial websites do not devote enough time and effort to verifying the accuracy of my personal information in their databases
4.	Improper Access a. I am concerned that commercial website databases that contain my personal information are not protected from unauthorized access b. I am concerned that commercial websites do not devote enough time and effort to preventing unauthorized access to my personal information c. I am concerned that commercial websites do not take enough steps to make sure that unauthorized people cannot access my personal information in their computers
5.	Control a. It usually bothers me when I do not have control of personal information that I provide to commercial websites b. It usually bothers me when I do not have control or autonomy over decisions about how my personal information is collected, used, and shared by commercial websites c. I am concerned when control is lost or unwillingly reduced as a result of a marketing transaction with commercial websites
6.	Awareness a. I am concerned when a clear and conspicuous disclosure is not included in online privacy policies of commercial websites b. It usually bothers me when I am not aware or knowledgeable about how my personal information will be used by commercial websites c. It usually bothers me when commercial websites seeking my information online do not disclose the way the data are collected, processed, and used