Background: Research from multiple perspectives to investigate adults’ use of wearable activity-tracking devices is limited. We offer a multiperspective model and provide empirical evidence of what leads to frequent usage of wearable health technologies from a large, nationally representative survey sample.
Objective: This study aims to explore factors affecting the use of wearable activity-tracking devices among health consumers from the perspectives of individual health beliefs (perceived severity, perceived susceptibility, perceived benefits, and self-efficacy) and information-seeking behaviors.
Methods: Our Integrated Model of Wearable Activity Tracker (IMWAT) use and proposed hypotheses were validated and tested with data collected from a telephone survey with a national quota sample. The data were analyzed using a variety of statistical techniques, including structural equation analysis.
Results: The sample comprised 2006 participants. Our results showed that the perceived benefits of physical activity, perceived susceptibility, and self-efficacy toward obesity were significant predictors of information-seeking behaviors, which, in turn, mediated their effects on the use of wearable activity trackers. Perceptions of obesity severity directly promoted wearable device usage.
Conclusions: This study provided a new and powerful theoretical model that combined the health beliefs and information-seeking behaviors behind the use of wearable activity trackers in the adult population. The findings provide meaningful implications for developers and designers of wearable health technology products and will assist health informatics practitioners and obesity prevention communicators.
Obesity is regarded as an ongoing international health problem. Numerous studies have explored behavioral determinants of obesity such as an individual’s psychological beliefs, unhealthy dietary habits, stress levels, and inadequate physical activity . Physical inactivity is a major contributing factor to the rising health care costs of obesity and significant increase in overweight in the adult population [ ]. Such inactivity and low cardiorespiratory fitness can cause subsequent chronic diseases such as type 2 diabetes, coronary heart disease, and stroke [ ]. Obesity requires constant care to manage the serious health risks associated with the symptom, yet obese adults are generally the persons primarily responsible for modifying their own lifestyle and self-managing aggressive interventions [ , ].
Scientists introduced the concept of wearable health technology by suggesting that this type of technology can provide a meaningful solution to obesity issues [, ]. Wearable health technology refers to an electronic device or technology, incorporated into accessories, that can be directly worn on the body [ ], mainly for self-tracking and self-monitoring purposes [ ]. Yet, the scope of wearable health technology is very broad and encompasses many aspects of hardware and software, including mobile apps, wearable sensors, and devices.
Many wearable health devices have been developed to detect and promote physical movement. Such wearable technology delivers accurate physical activity data and changes in dietary intake compared to the conventional method of collecting health information [, ]. Previous medical and informatics studies have mainly focused on the development and implementation of wearable fitness-tracking devices such as Fitbit [ - ]. Yet, theoretical research about the adoption and actual usage of wearable activity trackers is relatively sparse. Namely, much is still unknown about the multifactored mechanism that promotes use of wearable physical activity trackers among both obese adults and healthy consumers [ ].
Thus, this study aims to fill this void; we begin by reviewing the prevailing consensus regarding psychological factors to predict obesity prevention behaviors from the Health Belief Model (HBM) [, ] and connect the HBM with literature on information seeking. To this end, we propose an integrated model of wearable activity tracker use to describe how psychological beliefs influence people’s actions in seeking obesity-related health information online, which, in turn, leads to their use of wearable fitness trackers.
Psychological Factors Pertaining to Wearable Health Technology Use
To develop a theoretical model of health consumers’ wearable health device use, this paper adopts the HBM as a theoretical framework to understand the factors that trigger usage. The HBM was one of the first and best-known social cognition models to explain health-related behaviors . This model was initially formulated in the 1950s to explain low participation in disease prevention programs by examining individual motivations toward behaviors that could improve health or prevent illness.
The HBM explains certain beliefs in regard to threats to oneself (personal threat), together with belief in the effectiveness of a proposed behavior, and predicts the likelihood of engaging in that behavior . In doing so, the HBM provides a cognitive framework that views people as rational individuals who have multidimensional antecedents regarding whether to perform a healthy behavior or not.
Applying this model to the obesity context, perceived susceptibility refers to the degree to which individuals perceive themselves to be susceptible to being obese; perceived severity refers to perceptions on risks or diseases among those who are overweight; perceived barriers equate to strong barriers that prevent individuals from obtaining obesity treatment or practicing intervention behaviors; and perceived benefits are one’s understanding of the tangible benefits of health behavior change such as regular exercise to prevent obesity [, , ]. Rosenstock and his colleagues [ ] later suggested self-efficacy, a separate independent variable along with the traditional health belief variables, and defined it as “the conviction that one can successfully execute the behavior required to produce the outcomes” [ ].
The health belief dimensions can provide reliable, though weak or varying, predictions of health behaviors [, ]. For example, a meta-analysis indicated that self-efficacy (r=0.21), perceived susceptibility (r=0.15), perceived benefits (r=0.13), and perceived severity (r=0.08) were found to be significant factors across previous literature [ ]. Similarly, a meta-analysis of 18 studies revealed perceived severity (r=0.14), as well as perceived benefits (r=0.11) and barriers (r=0.22), to consistently be the strongest predictors of healthy behaviors, while perceived susceptibility was the weakest predictor [ ].
Linkage Between Health Beliefs, Health Information Seeking, and Behavior Change
Research on health information and behavior change has identified antecedents of individuals’ health information–seeking behaviors. Health information seeking is defined as the purposive acquisition of health information from selected sources for determining one’s own health behaviors [, ].
Research on this stream assumes a positive link between psychological factors from the HBM and health information seeking. For example, Johnson and Meischke  introduced a comprehensive model of health information seeking that integrates motivational drivers and health belief factors. From an online survey with a stratified random sample of 1004 mothers, Lee and Kim [ ] applied Johnson and Meischke’s [ ] information-seeking model to the context of diverse sources of childhood vaccination information [ ]. The study incorporated psychological factors, such as perceived severity and self-efficacy, as the driving forces for health information seeking.
Mou and colleagues  also explored consumer acceptance of online health information and empirically tested their integrated health belief and information-seeking model. Their model confirmed the predictive power of psychological variables on health behaviors: not only did susceptibility, benefits, and severity perceptions positively lead to behavioral intentions to utilize online health information services, self-efficacy also moderated the effect of perceived severity on health information–seeking behaviors [ ].
Given the theoretical link between health beliefs and health information–seeking behaviors, it is necessary to ask whether this link is still valid in other contexts, namely, obesity-related information seeking. There is also a theoretical uncertainty associated with some HBM variables in predicting various health behaviors. For instance, perceived susceptibility was the weakest predictor of health behaviors , while it had a strong positive effect on online health information seeking in Mou et al’s work [ ].
Health Beliefs and Health Information Seeking to Predict Wearable Activity Tracker Use
Many studies exploring the multifactored associations between health beliefs and health information–seeking behaviors have mainly focused on the Technology Acceptance Model (TAM) , which is a theoretical framework that explains the adoption of new health technology [ , ]. As mentioned, wearable health trackers were designed to promote a person’s healthy behaviors, while relatively few studies have explored what would directly lead to the adoption and actual usage of wearable activity trackers [ , , ]. According to the TAM, an individual’s acceptance of health technology is determined by his or her intentions to use that technology. Behavioral intentions to use the technology, which, in turn, is driven by one’s attitude toward using the technology, impacts his or her actual use. The TAM is a very parsimonious model that is too obvious to test the linkage between one’s intention to use and actual adoption of technology. Hence, researchers recommend a careful approach when applying the TAM to other contexts and call for additional research that explores the multiple factors associated with one’s acceptance of various technologies and devices [ - ].
One noteworthy survey study of 728 members of 3 internet health portals in South Korea  developed and verified an extended TAM for health care, and added antecedents and mediating variables from the HBM to enhance the model’s explanatory power. The results showed that perceived threat significantly affected health consumers’ attitudes and behavioral intentions, while self-efficacy had a strong indirect impact on attitude and behavioral intention through the mediator of perceived threat [ ].
Health information seekers are defined as people who search for information on health topics . For example, if individuals perceive themselves as obese, they will need information to manage the situation, while that information would simultaneously reassure healthy individuals [ ]. Internet users may search for general health information; however, the need for online health information seeking is greater among individuals who perceive their health condition to be severe [ ]. Concerning the impact of obesity-related health beliefs (ie, HBM factors) on online health information seeking, we propose the following hypotheses:
Hypothesis 1: Perceived susceptibility will influence health information–seeking behaviors.
Hypothesis 2: Perceived severity will influence health information–seeking behaviors.
Hypothesis 3: Perceived benefits will influence health information–seeking behaviors.
Hypothesis 4: Self-efficacy will influence health information–seeking behaviors.
Then, we apply information seeking as a mediating variable between psychological factors (from the HBM) and prediction of wearable activity tracker usage in our theoretical model. Our integrated model considers an individual’s wearable health technology use as dependent on not only their psychological needs but health information–seeking behaviors . Health information seekers are more likely to use wearable activity-tracking devices to monitor their food intake and physical activity levels if they perceive (1) themselves as susceptible to being obese, (2) the issue of obesity or overweight as severe, (3) benefits from such physical movements, and/or (4) any barriers that might hinder them from exercising regularly. Taken together, we present our fifth hypothesis as well as a research question (RQ) to test our proposed model ( ):
Hypothesis 5: Obesity-related information seeking will influence individuals’ wearable activity tracker use.
RQ1: Is the Integrated Model of Wearable Activity Tracker (IMWAT) use an appropriate model to predict wearable technology use, mediated by information-seeking behaviors?
A telephone quota survey was conducted among adults who currently use wearable activity trackers (ie, respondents were asked the filtering question, “ Do you currently use a wearable health product such as Fitbit, Mi Band, or any sort of activity tracker?”), ensuring externally valid data. Participants were recruited by a reputable survey company, and researchers paid $130,000 for data collection, which was carried out over 2 months from August to September 2019. The survey company used random digit dialing to recruit participants; 50% of the data was retrieved from cell phones and the other 50% was collected from landline telephones. The average length of the survey was 24 minutes.
Perceived severity, perceived benefits, and perceived susceptibility were measured with a widely used set of 12 items from the HBM literature, answered on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree” () [ ]. Self-efficacy was measured with an item asking participants to indicate their confidence in their ability to overcome or prevent obesity, using a 5-point scale ranging from 1=“not at all true for me“ to 5=“completely true for me” ( ) [ ].
Health information seeking was measured with the 5-point scale ranging from 1=”not at all” to 5=”very frequently” () [ ]. Use of wearable activity trackers was measured with the filtering question, “Do you currently use a wearable health product such as Fitbit, Mi Band, or any sort of activity tracker?” [ ].
|Construct and item||Description||Reference|
|Perceived susceptibility (PSU)||Champion and Skinner |
|PSU-1||I have a somewhat high chance of having obesity.|
|PSU-2||I never worry about being obese.|
|PSU-3||It is fated that I will have obesity.|
|PSU-4||I can prevent myself from being obese.|
|Perceived severity (PSE)||Champion and Skinner |
|PSE-1||I think obesity increases the risk of many health problems such as heart disease and diabetes.|
|PSE-2||I think obesity leads to suffering.|
|PSE-3||I think having obesity affects my family.|
|PSE-4||I think becoming obese affects my social life.|
|PSE-5||I think obesity in general is expensive to treat.|
|Perceived benefits (PBE)||Champion and Skinner |
|PBE-1||I think screening all adults for obesity (such as through body mass index) detects obesity early.|
|PBE-2||I think regular exercise make a difference.|
|PBE-3||I think multicomponent behavioral obesity interventions do make a difference.|
|Self-efficacy (SE)||Grace-Leitch and Shneyderman |
|SE-1||I have the ability to avoid obesity.|
|SE-2||I believe I can prevent an obesity condition.|
|SE-3||I am confident I will react in the right way if I have obesity.|
|SE-4||I have the ability to get and make sense of information about risks of being obese.|
|Information seeking (IS)||Nikoloudakiet et al |
|IS-1||I seek obesity-related health information on the government department website such as the CDCa or the NIHb.|
|IS-2||I seek obesity-related health information on social networking sites (eg, Facebook, Instagram, Twitter, etc).|
|IS-3||I seek obesity-related health information from online search engines such as Google.|
aCDC: Centers for Disease Control and Prevention.
bNIH: National Institutes of Health.
A total of 2006 participants were recruited to participate in the study.presents the sample’s demographic characteristics. The majority of BMI scores were >25, indicating obesity (n=1301, 66%). More than half of the participants were female (n=1183, 59%), and males accounted for approximately 41% (n=823) of the sample. Most participants were married (n=1374, 69%), and over half had a college degree (n=1100, 55%) and were White or Caucasian (n=1126, 56%), followed by African Americans, Hispanics/Latinos, others, and Asians. and also present summary statistics and histograms of the measurement variables.
|Variable||Participants, n (%)||Perceived susceptibility, mean (SD)||Perceived severity, mean (SD)||Perceived benefits, mean (SD)||Self-efficacy, mean (SD)||Information seeking, mean (SD)|
|Male||823 (41.03)||2.87 (1.54)||3.98 (1.25)||3.99 (1.26)||4.04 (1.28)||2.33 (1.49)|
|Female||1183 (58.97)||3.09 (1.54)||4.05 (1.26)||4.19 (1.21)||4.16 (1.25)||2.60 (1.62)|
|<30 years||195 (9.72)||2.54 (1.46)||3.65 (1.17)||4.00 (1.13)||4.10 (1.08)||3.09 (1.39)|
|30-50 years||710 (35.39)||3.04 (1.52)||4.06 (1.24)||4.16 (1.18)||4.16 (1.23)||2.95 (1.59)|
|>50 years||1101 (54.89)||3.05 (1.57)||4.06 (1.28)||4.09 (1.29)||4.07 (1.32)||2.09 (1.48)|
|White/Caucasian||1126 (56.13)||2.87 (1.50)||4.06 (1.22)||4.09 (1.22)||4.10 (1.28)||2.34 (1.51)|
|Hispanic/Latino||189 (9.42)||3.30 (1.56)||4.08 (1.14)||4.26 (1.08)||4.17 (1.14)||3.12 (1.62)|
|African American||523 (26.07)||3.20 (1.59)||3.88 (1.37)||4.09 (1.31)||4.08 (1.30)||2.60 (1.63)|
|Native American/Pacific Islander||14 (0.7)||3.79 (1.67)||4.86 (0.53)||4.29 (1.27)||4.57 (0.85)||1.82 (1.72)|
|Asian||32 (1.6)||3.01 (1.58)||4.03 (1.20)||4.31 (1.06)||4.16 (1.14)||1.97 (1.49)|
|Others||122 (6.08)||2.73 (1.58)||3.98 (1.30)||4.04 (1.31)||4.13 (1.23)||2.40 (1.62)|
|<18.5||41 (2.07)||1.98 (1.39)||4.05 (1.34)||4.15 (1.32)||3.68 (1.67)||2.34 (1.49)|
|18.5-25||642 (32.36)||2.46 (1.54)||4.05 (1.25)||4.17 (1.20)||4.10 (1.31)||2.48 (1.55)|
|>25||1301 (65.58)||3.28 (1.47)||4.00 (1.26)||4.08 (1.25)||4.13 (1.23)||2.51 (1.59)|
|Yearly income ($US)|
|Low (<$50,000)||1017 (50.70)||3.05 (1.59)||3.95 (1.32)||4.05 (1.30)||3.99 (1.34)||2.44 (1.61)|
|Medium ($50,000-$150,000)||811 (40.43)||2.97 (1.50)||4.09 (1.20)||4.19 (1.14)||4.23 (1.18)||2.49 (1.54)|
|High (>$150,000)||178 (8.87)||2.84 (1.51)||4.11 (1.13)||4.07 (1.23)||4.26 (1.15)||2.79 (1.49)|
|Married||1374 (68.50)||3.02 (1.54)||4.08 (1.23)||4.11 (1.25)||4.10 (1.30)||2.83 (1.61)|
|Single||632 (31.51)||2.95 (1.56)||3.88 (1.30)||4.12 (1.20)||4.13 (1.20)||2.34 (1.54)|
|Low (<high school graduate)||639 (31.85)||3.04 (1.63)||4.05 (1.30)||4.04 (1.33)||3.97 (1.35)||2.21 (1.57)|
|Medium (college graduate)||1100 (54.84)||2.97 (1.53)||3.99 (1.25)||4.12 (1.21)||4.15 (1.23)||2.57 (1.57)|
|High (master’s degree and above)||267 (13.31)||3.02 (1.44)||4.05 (1.19)||4.24 (1.12)||4.25 (1.18)||2.85 (1.53)|
|Variable||Mean (SD)||Perceived susceptibility||Perceived severity||Perceived benefits||Self-efficacy||Information seeking||Use of wearable activity trackers|
|Perceived susceptibility||2.997 (1.548)||1|
|Perceived severity||4.017 (1.258)||0.081 (P<.001)||1|
|Perceived benefits||4.109 (1.235)||0.088 (P<.001)||0.275 (P<.001)||1|
|Self-efficacy||4.107 (1.266)||0.013 (P=.56)||0.272 (P<.001)||0.309 (P<.001)||1|
|Information seeking||2.490 (1.576)||0.055 (P=.01)||0.000 (P=.99)||0.064 (P=.004)||0.076 (P=.001)||1|
|Use of wearable activity trackers||1.909 (1.815)||0.058 (P=.01)||0.032 (P=.15)||0.055 (P=.01)||0.032 (P=.15)||0.145 (P<.001)||1|
The chi-square goodness-of-fit statistic is an index of model adequacy for which a nonsignificant value indicates a good fit of the model to the data. Our work used 4 additional fit indexes to decide how well the specified model explains the data: the comparative fit index (CFI), the root mean square error of approximation (RMSEA), the standardized root mean square residual (SRMR), and the Tucker–Lewis index (TLI). CFI compares the difference between the chi-square value and degrees of freedom (df) of the null (independent) model to the difference between the chi-square value and df of the hypothesized model. Then, this difference is divided by the difference between the chi-square value and df of the null model. CFI is not sensitive to sample size and the recommended cut-off value is ≥0.90 . RMSEA presumes that the best-fitting model has an RMSEA value of 0, that is, an index close to 0 means the model has an excellent fit and a larger index indicates that the model is poor to fit the data. The recommended cut-off value is <0.06 [ ]. SRMR measures the average of standardized residuals between the observed covariance and the hypothesized covariance. An SRMR value of 0 represents a perfect fit; a bigger index means that the model is poor to fit the data. The recommended cut-off value is <0.06 [ ]. TLI measures the ratio of the difference between the ratio of the chi-square value to the df of the null model and the ratio of the chi-square value to the df of the hypothesized model to the difference between the ratio of the chi-square value to the df of the null model and hypothesized model. The recommended cut-off value is ≥0.95 [ ]. After checking the model adequacy, individual paths were tested by the z test.
The structural model (path model) is a special case of structural equation modeling (SEM). In the structural model, each measurement variable connects to each construct, that is, there exists a one-to-one mapping between constructs and measurement variables, and measurement errors become 0. The initially proposed model 1 is represented in. Model 1 posits that perceived susceptibility (SUS), perceived severity (SEV), perceived benefits (BEN), and self-efficacy (SE) together contribute to information seeking (IS), and IS contributes to the use of wearable activity trackers (UOW).
We assumed that all exogenous latent variables were correlated, and all data were analyzed using R, version 3.6.1 (The R Project for Statistical Computing). The lavaan package in R is an open-source program that is extremely powerful and flexible for SEM. The factor analytic models and the path model for model 1 were as follows:
- x1: the measurement variable of SUS;
- x2: the measurement variable of SEV;
- x3: the measurement variable of BEN;
- x4: the measurement variable of SE;
- x5: the measurement variable of IS;
- x6: the measurement variable of UOW;
- ξ1: the exogenous variable (SUS);
- ξ2: the exogenous variable (SEV);
- ξ3: the exogenous variable (BEN);
- ξ4: the exogenous variable (SE);
- η1: the endogenous variable (IS);
- η2: the endogenous variable (UOW).
The factor analytic models for the exogenous and endogenous variables were as follows:
The path model of structural coefficients was as follows:
where β21 is the coefficient of η1 on η2, is the coefficient of ξ1 on η1, is the coefficient of ξ2 on η1, is the coefficient of ξ3 on η1, is the coefficient of ξ4 on η1, and is the vector of equation errors to predict η1 and η2. Since there is a one-to-one mapping between constructs and measurement variables, the measurement errors are zero.
Our model fit statistics included the following: chi-square, CFI, RMSEA, SRMR, and TLI. For the initial model, the SEM analysis indicated that the P value of the chi-square test was .07, which is greater than .05, indicating that this structural model fit the data well. The CFI value was 0.991, the RMSEA value was 0.024, the SRMR value was 0.017, and the TLI value was 0.967.shows the parameter estimates, standard errors, test statistics (z value), and P values for each path in model 1. The coefficients (βs and ) were estimated by maximum likelihood estimation. Susceptibility, benefits, and self-efficacy significantly predicted information seeking, and information seeking was significantly reflected in wearable activity tracker use (=.137, P<.001). However, perceived severity did not give rise to information seeking (=–0.031, P=.30). This may indicate that this model may not be adequate and needs improvement. Therefore, we considered an alternative model.
Our second model posits that susceptibility, benefits, and self-efficacy perceptions together contributed to information seeking, while perceived severity and information seeking together contributed to wearable activity tracker use (). The only difference was that severity perceptions directly predicted wearable activity tracker use.
|Hypothesized relations between constructs||Parameter estimatea||SE||z value||P value|
|Perceived susceptibility → Information seeking||0.057 (0.056)||0.023||2.516||.01b|
|Perceived severity → Information seeking||–0.031 (–0.025)||0.030||–1.044||.30|
|Perceived benefits → Information seeking||0.077 (0.061)||0.031||2.532||.01b|
|Self-efficacy → Information seeking||0.089 (0.071)||0.030||2.975||.003c|
|Information seeking → Use of wearable activity tracker||0.137 (0.119)||0.026||5.373||<.001c|
aThe values in parentheses are standardized estimates.
bSignificance at the .05 level.
cSignificance at the .01 level.
The factor analytic models for exogenous and endogenous variables were the same as model 1, but the path model of the structural coefficients was different from the model 1. The path model of structural coefficients was as follows:
where β21 is the coefficient of η1 on η2, is the coefficient of ξ1 on η1, is the coefficient of ξ3 on η1, is the coefficient of ξ4 on η1, and is the coefficient of ξ2 on η2. Note that the only difference between model 1 and model 2 is the matrices in the middle term.
shows model fit statistics and confirms that the second model has a better fit than the initial model since CFI and TLI were higher, and chi-square, RMSEA, and SRMR were lower. As the second model supports all hypotheses ( ) with better fit indicator scores, we choose the second model as the final model.
demonstrates parameter estimates for our final model (ie, model 2). In short, susceptibility, benefits, and self-efficacy perceptions significantly predicted information seeking, which, in turn, indirectly predicted wearable activity tracker use. Compared to the initial model, severity perceptions directly predicted wearable activity tracker use ( ).
|Model||Chi-square||P value||Model fita|
aCut-off for good fit: CFI≥0.90, RMSEA<0.06, SRMR<0.06, and TLI≥0.95.
bCFI: comparative fit index.
cRMSEA: root mean square error of approximation.
dSRMR: standardized root mean square residual.
eTLI: Tucker–Lewis index.
|Hypothesized relations between constructs||Parameter estimatea||SE||z value||P value|
|Perceived susceptibility → Information seeking (hypothesis 1)||0.056 (0.055)||0.023||2.455||.01b|
|Perceived benefits → Information seeking (hypothesis 2)||0.071 (0.056)||0.030||2.372||.02b|
|Self-efficacy → Information seeking (hypothesis 3)||0.082 (0.066)||0.029||2.822||.005c|
|Perceived severity → Use of wearable activity trackers (hypothesis 4)||0.063 (0.044)||0.032||1.986||.047b|
|Information seeking → Use of wearable activity trackers (hypothesis 5)||0.136 (0.118)||0.026||5.343||<.001c|
aThe values in parentheses are standardized estimates.
bSignificance at the .05 level.
cSignificance at the .01 level.
Since the distributions of variables appeared to be skewed, we also considered the asymptotic distribution-free (ADF) estimator. Even though it is well known that the maximum likelihood estimator is relatively robust to violations of normality assumptions, and a large sample reduces the problem of multivariate nonnormality, it is worth checking our models with ADF. Consistent with maximum likelihood estimation, ADF estimates (not shown) had very similar values to the maximum likelihood estimates, and their P values were also very close to the P values of the maximum likelihood estimates. In the initial model, ADF indicated that SEV (perceived severity) was not significant, whereas all paths were significant in the second model (seefor our final model).
Our multiple analyses generated a meaningful model of health care technology use that provides several contributions to theory and practice.
First, it supports the application of the HBM in the use of wearable activity trackers, which was not present in most existing works. The key factors were identified within two paths: perceived benefits, perceived susceptibility, and self-efficacy influence health information–seeking behaviors, while perceived severity is directly related to adults’ use of wearable fitness trackers. It is meaningful to see how those factors are influencing the actual application of wearable activity-tracking devices with a varying range in significance and directional relationships.
According to standardized estimates, we may identify a relatively stronger predictor of health information–seeking behaviors: self-efficacy. This finding was consistent with a previous study  that found self-efficacy to be the strongest predictor of health-related behaviors. In turn, the linkage between health information–seeking and wearable health technology usage showed the largest impact. With such highlighted findings, this study validates the succinct and powerful model that re-evaluates and reorganizes previous works.
Interestingly, obesity severity perception was not related to online health information seeking, but rather directly related to adults’ use of wearable fitness trackers. One possible explanation for this could be the nature of the predictor. Perceived severity has strong direct influences on behavioral outcomes, as supported by Lee and Kim . Carpenter [ ] also confirmed such discrepancy can happen, presumably due to its small effect size. Specifically, 18 studies with 2702 subjects were used to determine whether measures of the 4 variables (eg, perceived barriers, perceived benefits, perceived susceptibility, perceived severity) could universally predict health behaviors, regardless of the context (prevention vs treatment behaviors). It was found that prevention and treatment behaviors moderated each of the 4 HBM variables’ predictive power; for prevention behaviors in particular, perceived severity (r=0.14) was the second strongest predictor, followed by perceived barriers (r=0.22). In short, the above findings address two concerns: (1) additional research is needed to explore the predictive power of severity perceptions on other health-related contexts, as suggested by our data, and (2) future research should avoid the continued use of the direct and universal effects version of the HBM, as illustrated by our results.
Another thing to note is that our integrated model was confirmed by a large national cohort comprising over 2000 people, and the context was tailored to use of a specific technology—wearable activity trackers. Previously, the TAM has been the only theoretical framework that dominantly explained the actual use of new technology. Our study contributes to the discipline by providing a new theoretical model combining the health beliefs and information-seeking behaviors for wearable activity tracker use. This could lead to additional contributions, such as gaining evidence-based knowledge on the precedents of wearable fitness trackers usage to promote physical activities and improve the outcomes of obesity interventions, and further evaluating its long-term effects. Using the proposed IMWAT, the mechanism underlying wearable health technology use can be explained.
Limitations and Future Works
This study has limitations that should be addressed in future studies. First, we noticed that our endogenous variable, wearable activity tracker use, was skewed. This may have hindered the process of normal SEM; hence, we ran the same analysis to assess model fit and whether the paths were significant using the ADF estimator, which does not require any assumption in the data distribution. Consequently, the analysis with ADF generated the same result as our model tested with maximum likelihood, which does not make this limitation a major issue.
Considering that our sample was skewed to those who were obese (34.4% were healthy adults, while 65.6% reported BMI scores >25), a stratification analysis by individuals’ weight status still needs to be explored in future research. To promote the wider use of wearable activity trackers, future studies also need to examine what triggers adults to adopt wearable health technologies and motivates them to continue using these devices.
Finally, future studies could apply more variables from other major theories of health behaviors, such as the Theory of Planned Behavior. For instance, perceived behavioral control could be a meaningful addition to the current model. This variable is closely related to self-efficacy in the HBM, since they both reflect people’s confidence in performing health behaviors .
Practical Implications and Conclusions
This study provides a theory-driven mathematical model of how different interactions between individual beliefs and multifactors influence wearable fitness tracker use among both obese and healthy adults. Our model holds several managerial implications for health informatics and health care practitioners utilizing wearable activity trackers for public obesity intervention programs . Changing individuals’ daily activity is not an easy task, but practitioners should focus on effective communication strategies that make users feel that use of wearable activity trackers is not a barrier to overcome but a beneficial way of managing oneself. Similarly, health informatics and health care practitioners could benefit from promoting the significance and severity of obesity to their target health consumers, which, in turn, can lead to their actual uptake of health technology (ie, behavior change), as suggested by our model.
As Feng and colleagues  pointed out, not much research attention has been paid to healthy populations, who, despite being generally healthy, tend to have distinct personal health information management needs. With the rising popularity of wearable fitness trackers such as Fitbit [ ], it is now extremely important to offer such wearable technologies as a complement to traditional health care services, rather than as a substitute, because of accuracy and validity of the data they provide [ ].
All in all, the state-level sample of over 2000 people produced nationally applicable results, ensuring the generalization of this study to a wider population and supporting the practical use of the results. The variables employed in this model will assist wearable health technology product developers and designers.
Conflicts of Interest
- Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 2013 Jan 02;309(1):71-82 [FREE Full text] [CrossRef] [Medline]
- McAllister EJ, Dhurandhar NV, Keith SW, Aronne LJ, Barger J, Baskin M, et al. Ten putative contributors to the obesity epidemic. Crit Rev Food Sci Nutr 2009 Nov 02;49(10):868-913 [FREE Full text] [CrossRef] [Medline]
- Adult obesity facts. Center for Disease Control and Prevention. URL: https://www.cdc.gov/obesity/data/adult.html [accessed 2021-06-22]
- Allen JK, Stephens J, Dennison HCR, Stewart KJ, Hauck S. Randomized controlled pilot study testing use of smartphone technology for obesity treatment. J Obes 2013;2013:151597 [FREE Full text] [CrossRef] [Medline]
- Turner-McGrievy GM, Tate DF. Are we sure that Mobile Health is really mobile? An examination of mobile device use during two remotely-delivered weight loss interventions. Int J Med Inform 2014 May;83(5):313-319 [FREE Full text] [CrossRef] [Medline]
- Owens J, Cribb A. ‘My Fitbit Thinks I Can Do Better!’ Do Health Promoting Wearable Technologies Support Personal Autonomy? Philos Technol 2017 Jun 6;32(1):23-38. [CrossRef]
- Patrick K, Griswold WG, Raab F, Intille SS. Health and the mobile phone. Am J Prev Med 2008 Aug;35(2):177-181 [FREE Full text] [CrossRef] [Medline]
- Wright R, Keith L. Wearable Technology: If the Tech Fits, Wear It. Journal of Electronic Resources in Medical Libraries 2014 Dec 03;11(4):204-216. [CrossRef]
- Leong T, Lupton D. Self-tracking cultures: towards a sociology of personal informatics. 2014 Presented at: Proceedings of the 26th Australian Computer-Human Interaction Conference on Designing Futures; Dec 2-5; Sydney, Australia p. 77-86.
- Lieffers JRL, Hanning RM. Dietary assessment and self-monitoring with nutrition applications for mobile devices. Can J Diet Pract Res 2012 Sep;73(3):e253-e260. [CrossRef] [Medline]
- Zhang M, Luo M, Nie R, Zhang Y. Technical attributes, health attribute, consumer attributes and their roles in adoption intention of healthcare wearable technology. Int J Med Inform 2017 Dec;108:97-109. [CrossRef] [Medline]
- Dannecker K, Petro S, Melanson E. Accuracy of Fitbit activity monitor to predict energy expenditure with and without classification of activities. Medicine & Science in Sports & Exercise 2011;43(1):62. [CrossRef]
- Adam NJ, Spierer DK, Gu J, Bronner S. Comparison of steps and energy expenditure assessment in adults of Fitbit Tracker and Ultra to the Actical and indirect calorimetry. J Med Eng Technol 2013 Oct;37(7):456-462. [CrossRef] [Medline]
- Takacs J, Pollock CL, Guenther JR, Bahar M, Napier C, Hunt MA. Validation of the Fitbit One activity monitor device during treadmill walking. J Sci Med Sport 2014 Sep;17(5):496-500. [CrossRef] [Medline]
- Armitage CJ, Conner M. Social cognition models and health behaviour: A structured review. Psychology & Health 2000 Mar;15(2):173-189. [CrossRef]
- Allison D, Basile V, Yuker H. The measurement of attitudes toward and beliefs about obese persons. International Journal of Eating Disorders 1991;10(5):599-607. [CrossRef]
- O'Connell JK, Price JH, Roberts SM, Jurs SG, McKinley R. Utilizing the health belief model to predict dieting and exercising behavior of obese and nonobese adolescents. Health Educ Q 1985 Sep 04;12(4):343-351. [CrossRef] [Medline]
- Becker M. The health belief model and sick role behavior. In: The Health Belief Model and Personal Health Behavior. Thorofare, NJ: Charles S Black, Inc; 1985:82-92.
- Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Educ Q 1988 Sep 04;15(2):175-183. [CrossRef] [Medline]
- Carpenter CJ. A meta-analysis of the effectiveness of health belief model variables in predicting behavior. Health Commun 2010 Dec 30;25(8):661-669. [CrossRef] [Medline]
- Janz NK, Becker MH. The Health Belief Model: a decade later. Health Educ Q 1984 Jan 01;11(1):1-47. [CrossRef] [Medline]
- Harrison JA, Mullen PD, Green LW. A meta-analysis of studies of the Health Belief Model with adults. Health Educ Res 1992 Mar;7(1):107-116. [CrossRef] [Medline]
- Johnson J, Meischke H. A Comprehensive Model of Cancer-Related Information Seeking Applied to Magazines. Human Comm Res 1993 Mar;19(3):343-367. [CrossRef]
- Johnson JD, Donohue WA, Atkin CK, Johnson S. A Comprehensive Model of Information Seeking. Science Communication 2016 Aug 18;16(3):274-303. [CrossRef]
- Lee HO, Kim S. Linking health information seeking to behavioral outcomes: antecedents and outcomes of childhood vaccination information seeking in South Korea. J Health Commun 2015 Dec 24;20(3):285-296. [CrossRef] [Medline]
- Mou J, Shin D, Cohen J. Health beliefs and the valence framework in health information seeking behaviors. ITP 2016 Nov 07;29(4):876-900. [CrossRef]
- Davis FD. Perceived Usefulness, Perceived Ease of Use, and User Acceptance of Information Technology. MIS Quarterly 1989 Sep;13(3):319. [CrossRef]
- Melzner J, Heinze J, Fritsch T. Mobile Health Applications in Workplace Health Promotion: An Integrated Conceptual Adoption Framework. Procedia Technology 2014;16:1374-1382. [CrossRef]
- Adams A, Costa J, Jung M. Mindless computing: designing technologies to subtly influence behavior. 2015 Sep 11 Presented at: UbiComp '15: Proceedings of the 2015 ACM International Joint Conference on Pervasive and Ubiquitous Computing; Sept 7-11; Osaka, Japan p. 719-730. [CrossRef]
- Mercer K, Li M, Giangregorio L, Burns C, Grindrod K. Behavior Change Techniques Present in Wearable Activity Trackers: A Critical Analysis. JMIR Mhealth Uhealth 2016 Apr 27;4(2):e40 [FREE Full text] [CrossRef] [Medline]
- De Choudhury M, Morris M, White R. Seeking and sharing health information online: comparing search engines and social media. 2014 Apr 26 Presented at: Proceedings of the 32nd annual ACM conference on Human factors in computing systems; Apr 26-May 1; Toronto, ON p. 1365-1376. [CrossRef]
- Gottlieb J, Oudeyer P, Lopes M, Baranes A. Information-seeking, curiosity, and attention: computational and neural mechanisms. Trends Cogn Sci 2013 Nov;17(11):585-593 [FREE Full text] [CrossRef] [Medline]
- Longo DR. Understanding health information, communication, and information seeking of patients and consumers: a comprehensive and integrated model. Health Expect 2005 Sep;8(3):189-194 [FREE Full text] [CrossRef] [Medline]
- Kim J, Park H. Development of a health information technology acceptance model using consumers' health behavior intention. J Med Internet Res 2012 Oct;14(5):e133 [FREE Full text] [CrossRef] [Medline]
- Norman CD, Skinner HA. eHealth Literacy: Essential Skills for Consumer Health in a Networked World. J Med Internet Res 2006 Jun;8(2):e9 [FREE Full text] [CrossRef] [Medline]
- Haenen M, Schmidt AJ, Schoenmakers M, Van den Hout MA. Quantitative and qualitative aspects of cancer knowledge - comparing hypochondriacal subjects and healthy controls. Psychology & Health 1998 Nov;13(6):1005-1014. [CrossRef]
- Baumgartner SE, Hartmann T. The role of health anxiety in online health information search. Cyberpsychol Behav Soc Netw 2011 Oct;14(10):613-618. [CrossRef] [Medline]
- Jarrahi MH, Gafinowitz N, Shin G. Activity trackers, prior motivation, and perceived informational and motivational affordances. Pers Ubiquit Comput 2017 Nov 18;22(2):433-448. [CrossRef]
- Champion V, Skinner C. The health belief model. In: Glanz K, Rimer BK, Viswanath K, editors. Health Behavior and Health Education: Theory, Research, and Practice. San Francisco, CA: US Jossey-Bass Press; 2008:45-65.
- Grace-Leitch L, Shneyderman Y. Using the Health Belief Model to Examine the Link between HPV Knowledge and Self-Efficacy for Preventive Behaviors of Male Students at a Two-Year College in New York City. Behav Med 2016 Jun 23;42(3):205-210. [CrossRef] [Medline]
- Nikoloudakis IA, Vandelanotte C, Rebar AL, Schoeppe S, Alley S, Duncan MJ, et al. Examining the Correlates of Online Health Information-Seeking Behavior Among Men Compared With Women. Am J Mens Health 2018 Sep 18;12(5):1358-1367 [FREE Full text] [CrossRef] [Medline]
- Asimakopoulos S, Asimakopoulos G, Spillers F. Motivation and User Engagement in Fitness Tracking: Heuristics for Mobile Healthcare Wearables. Informatics 2017 Jan 22;4(1):5. [CrossRef]
- Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal 1999 Jan;6(1):1-55. [CrossRef]
- Weinstein ND. Testing four competing theories of health-protective behavior. Health Psychology 1993 Jul;12(4):324-333. [CrossRef]
- Feng Y, Li K, Agosto DE. Healthy users' personal health information management from activity trackers: The perspective of gym‐goers. Proc Assoc Info Sci Tech 2017 Oct 24;54(1):71-81. [CrossRef]
|ADF estimator: asymptotic distribution-free estimator|
|BEN: perceived benefit|
|CFI: comparative fit index|
|df: degrees of freedom|
|HBM: Health Belief Model|
|IMWAT: Integrated Model of Wearable Activity Tracker|
|IS: information seeking|
|RMSEA: root mean square error of approximation|
|RQ: research question|
|SEV: perceived severity|
|SRMR: standardized root mean square residual|
|SUS: perceived susceptibility|
|TAM: Technology Acceptance Model|
|TLI: Tucker–Lewis index|
|UOW: use of wearable activity trackers|
Edited by G Eysenbach; submitted 05.08.20; peer-reviewed by D Ho, J Huber; comments to author 18.11.20; revised version received 08.04.21; accepted 13.04.21; published 29.09.21Copyright
©Bokyung Kim, Seoyeon Hong, Sungwook Kim. Originally published in JMIR Formative Research (https://formative.jmir.org), 29.09.2021.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.