Atrial fibrillation (AF) is the most common supraventricular arrhythmia and affects 2%–4% of the population globally (1), and exceeds 5% for those 75 years and older (2). AF is strongly associated with stroke, increasing its risk 5-fold (1). Furthermore, 38.2% of AF patients are asymptomatic, and 25% of AF diagnoses are missed because of its paroxysmal nature (3). Actively screening for AF reduced the combined endpoints of stoke, myocardial infraction, systemic embolism, and death (4). The community is a good setting for AF screening (5), and general practitioners (GPs) support for screening is available (5). The 12-lead ECG is the most common screening device in primary care. However, it is difficult to detect paroxysmal AF by 12-lead ECG because patients may be asymptomatic or have long intervals between episodes (6).

Wearable electrocardiographic devices (WEDs), which are worn on the body as an accessory to continuously collect electrocardiographic (ECG) data (7), are recommended by existing multinational AF guidelines for early screening for AF (1, 5, 8, 9). WEDs are being rapidly developed for AF screening, with more than 400 wearable monitors available, and the number is expected to double in 2021 (10–12). Moreover, WEDs increased new AF detection by 3.0% after 4 months in a randomized controlled trials (13).

Unfortunately, about 1/3 of the community residents were reluctant to accept wearable devices (14, 15), and 47.1% of the users were unwilling to continually wearing the WEDs (16). In the primary care, users tend to defer their decision to GPs, which plays a pivotal role in use of internet-related technologies (17, 18). Several studies have investigated the influencing factors of users’ acceptance of WEDs but have not taken into account GPs’ intentions to recommend them (19–22). Therefore, it is necessary to identify the factors that influence GPs’ intentions to adopted WEDs (Figure 1).

This study adopted the UTAUT to explore the adoption of WEDs to screen patients for AF among GPs in Sichuan Province of China. Performance expectancy, social influence, and price perception increased the GPs’ intention to utilize WEDs, while perceived risk decreased usage intention. Effort expectancy and facilitating conditions did not affect usage intention.

For GPs who stated that they would utilize WEDs to screen for AF, the more effective the devices, the stronger the willingness to adopt them. This finding was consistent with previous studies (22, 52, 56). Performance expectancy was an indispensable independent variable in the UTAUT model. Considered to be the most important influencing factor for usage intention in previous studies (53, 60, 61). A qualitative study by Volpato et al. showed GPs expressed a desire to become more involved in the development of wearables technologies because it play an increasingly central role in daily practices (62). But health professionals still had concerns about efficacy in illness and disease prevention for its use (63). The performance expectations were based on the GP’s belief that the equipment was reliable. Therefore, randomized controlled trials are required to provide higher quality evidence for the reliability and usefulness of WEDs.

In addition, social influence was positively affected the willingness of GPs to utilize WEDs in their practice. This finding was consistent with the original assumptions of the UTAUT model and previous studies (22, 64). In our study, the more recommended these devices were by the social environment (e.g., guidelines, peers), the stronger the practitioners’ intention was to use them. And the social influences that affect practitioners’ use of WEDs were mainly their peers, higher-level physicians, and academic guidelines. However, different guidelines had different recommend for using wearable ECG devices. For example, the European Society of Cardiology (ESC) had recommended wearable technology in AF screening (65), but the National Institute for Health and Care Excellence (NICE) did not (66). Undoubtedly, there are many challenges and barriers to adoption of WEDs for practitioners and rigorous studies are warranted (67). It will be beneficial to adoption and promotion if the researchers can provide high-quality evidence for diagnostic performance.

If GPs were skeptical about the safety of WEDs, these devices would be rejected. Here, the perceived risk had a negative impact on the intention to use WEDs. The higher the perceived risk is, the lower the intention to use the device. This is consistent with previous results (64). Drehlich et al. conducted semi-institutional interviews with 144 adolescents and found that perceived risk was an important factor affecting adolescents’ acceptance of the combination of wearable pedometers and Facebook (68). How to ensure the data security while using wearable devices is a problem worth studying (69). In our study, many GPs were concerned that the device could leak patients’ private health information. Therefore, manufacturers of WEDs should strengthen the protection of user information (62, 70, 71).

A better price perception was related to a stronger willingness to utilize WEDs to screen patients for AF. GPs in China were required to provide basic medical services for residents in the area under their jurisdiction (72). Often, local medical institutions could not carry out expensive auxiliary examinations due to limited resources. As long as the equipment was of sufficient quality, GPs hoped that the devices would be inexpensive, thus enabling WEDs to become more accessible to people.

If a device was simple to use, people would be more likely to use it. However, in this study, there was no significant correlation between effort expectancy and usage intention. This was inconsistent with the original assumptions of the UTAUT model and also in contrast to most previous research results (22, 24). The reasons might be as follows. The GPs were intellectuals who received good information technology education (73), and they believed that WEDs were easy to operate. In their questionnaire responses, the GPs stated that operating and wearing the WEDs was simple and convenient and that it was easy to learn and use these devices. Therefore, the influence of effort expectancy on the intention to use was not a driving factor. The higher the degree of facilitating conditions, the stronger the usage intention. The results of the model showed that the facilitating conditions had no effect on usage intention, which was inconsistent with most findings (20, 22). The reason might be that, in general, medical resources were insufficient in primary care, and most of the GPs worked under conditions that were unable to promote the use of these devices. Finding ways to improve the facilitating conditions of local medical institutions was worth further discussion.

This study confirmed the significant roles of performance expectancy, social influence, price perception and perceived risk in predicting the intention of GPs to utilize WEDs in their practice. To our knowledge, this was the first study to specifically investigate the intention of GPs to utilize wearable devices. Previous studies on people’s willingness to use wearable technology mostly focused on specific consumer groups, such as older adults, women, teenagers, and patients with diabetes (21, 22, 29, 42, 68, 74, 75). Our study provided a preliminary foundation for the selection and continuous use of these devices in primary care. It used stratified sampling in Sichuan Province, located in southwest China. This sampling strategy was an improvement over previously used simple sampling methods. Our sample population was more representative than in previous studies and avoided selection bias, to some extent. Furthermore, the sample size was larger than in previous studies. We collected 1,004 valid questionnaires in multiple prefectures, and effectively avoided the problem of a small sample size. Finally, the structural equation model was used in our study; this analysis method has advantages over the multiple linear regression method of Macdonald’s study (75).

There were limitations in this study. First, it investigated only the GPs’ intention to use WEDs without further researching actual usage behaviors. The intention to use may not completely represent actual usage. Usage behavior could be investigated and explored to determine various latent variables and their influence on usage intention and actual usage behavior. Second, although it was based on the UTAUT model, with perceived risk and price perception added to clarify the direct impacts on usage intention, it explored only four moderating variables: gender, age, education level, and general training. In real life, usage might be affected by other variables, such as personal cognition, attitudes, and behaviors. Thus, the model could be further improved in the future. Third, the study is based mainly on GPs from Sichuan Province and the applicability of these results with different demographics should be investigated further. In addition, this study examined the willingness of GPs who worked in primary healthcare facilities; practitioners who work in tertiary general hospitals should also be investigated. Fourth, each of the constructs of “usage intention” get at different aspects of use. “I would like to learn it in the future” is much more hypothetical and future. “I am willing to keep trying to use it for patients.” is much more concrete and current. It is necessary to consider looking into relationships between the constructs and each individual usage question in future.

Based on the UTAUT model, this study constructed a model for predicting GPs’ willingness to adopt WEDs to screen patients for AF. Performance expectancy, social influence, and price perception positively affected the willingness of GPs to utilize WEDs in their practice. Perceived risk negatively affected the willingness to utilize WEDs (Figure 4). Effort expectancy and facilitating conditions did not affect usage intention in this research model. Therefore, researchers should improve the usability of WEDs, and carry out study to provide high-quality evidence for safety and efficacy of these devices, which will benefit their promotion. The theoretical and practical implications were provided for GPs to increase use of WEDs in their healthcare activities.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Human Ethics Committee of West China Hospital of Sichuan University. The patients/participants provided their written informed consent to participate in this study.

YY, ZL, YH, YZ, and XL conceived and planned the study. ZG performed the analysis. YY, ZL, and DL wrote the original draft with input from all authors. QZ, YL, and YLZ visualized the results. ZG, ZZ, and YL contributed to the interpretation of the results. ZG, YZ, and XL critically revised the article. YZ and XL supervised the entire process. All authors contributed to the article and approved the submitted version.

This work was supported financially by the Science and Technology Department of Sichuan Province (2020YFSY0014), the Sichuan Province Health Research Project (19PJ094), and the Sichuan Medical Association (HX-H1910211).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.