Journal of Modern Medical

Introduction
The Picture Archiving And Communication System (PACS) has enabled the optimal management of medical images in hospitals by using digital imaging methods and storing, transferring, displaying and retrieving images. However, one of the important challenges in the establishment of this system is the attitudes of physicians, as the main users of this system, towards it. Based on the Unified Theory of Acceptance and use of Technology (UTAUT), four main factors determine the behavioral intention of people to use a technology which are: performance expectancy (The user’s perception of the usefulness of a technology in his job performance), effort expectancy (Ease of use of technology by the user), social influence (effect of coworkers’ belief in using a technology on the user), and facilitating conditions (effect of technical and organizational infrastructure). The present study aims to design and validating a questionnaire for the evaluation of factors affecting the acceptance and use of PACS by Iranian physicians using the UTAUT. In this study, the UTAUT model was developed; in addition to the four main factors, following factors were added: Computer self-efficacy (user’s ability to use computer) as the main factor, the intention to use PACS as the dependent factor, technology optimism as a mediating factor, and five key constructs of problem solving (analyzing the cause of various problems and solving them by PACS), rationalized decision-making (improving decision making processes and explaining the reasons for making decision based on the PACS), horizontal and vertical integration (coordinating work activities with coworkers and other specialists by using the PACS), and providing health services to clients.
Methods
This is a methodological study with a cross-sectional design conducted in 2019 in two stages: questionnaire design and validity and reliability assessment. The study population consist of 400 physicians (radiologist, general practitioner, resident, specialist, fellow doctor, and super-specialist) working in six hospitals affiliated to Isfahan University of Medical Sciences, in Isfahan, Iran including Noor & Hazrat Ali Asghar, Al-Zahra, Kashani, Imam Hossein, Chamran, and Amin. Participants were selected by stratified random sampling method with the probability proportional to size procedure. The criterion for entering the study was the use of PACS. Non-physician users or physicians with no PACS use were excluded from the study. After examining the tools that have been designed based on the UTAUT in various studies, the localized questionnaire from Hajhir et al.’s study was used as the basis, which had 90 items, excluding 8 demographic items. The qualitative face validity of the questionnaire was determined with the participation of 15 physicians from the target group, health information technology professors, and information technology specialists from Isfahan University of Medical Sciences. The quantitative face validity using the item impact score was determined with the participation of 20 physicians from the target group. The content validity was determined with the participation of 15 health information technology professors and information technology specialists from Isfahan University of Medical Sciences and by calculating the content validity ratio (CVR) and content validity index (CVI). The construct validity was determined with the exploratory factor analysis (EFA) and with the participation of the entire target group. The reliability was determined with test-retest method and calculating intraclass correlation coefficient (ICC), and internal consistency was measured by calculating Cronbach’s alpha coefficient with the participation of 30 physicians from the target group. The data was analyzed in SPSS software, version 20.
Results
In this study, 61.8% of the study population were male. Most of them (78%) were studying in the field of residency, and had a work experience of <10 years (88%). About half of the study population included physicians aged 30-39 (47.3%). Radiologists made up the majority of the study population (20%). Most of the physicians had a10-20 years (94.7%) of experience working with computers and <10 years (97%) of experience working with PACS. Evaluation of face validity by qualitative and quantitative methods and evaluation of content validity led to the removal of a number of items. The face validity was between 1.51 and 3.4, and the content validity index and the content validity ratio in all factors were between 0.6 and 1. With EFA, 12 factors were extracted including performance expectancy, effort expectancy, social influence, facilitating conditions, computer self-efficacy, behavioral intention, technology optimism, problem solving, rationalized decision-making, horizontal integration, vertical integration, and providing health services to clients with 7.5, 7.1, 3.6, 6.2, 3.4, 6, 8.5, 3.8, 6.3, 4, 8.1 and 3.2% of the total variance, respectively that explained 67.86% of the common variance. Finally, 53 items were included in 12 factors. Cronbach’s alpha was 0.92 and the test-retest reliability using the ICC was 0.86 in all samples, which indicated the high reliability of the questionnaire.
Discussion
This study was conducted to design and validate a questionnaire to evaluate factors affecting the acceptance and use of PACS by Iranian physicians using the modified model of the UTAUT. The diversity of the research environment, which included six hospitals led to more dynamics of the study population. This allowed us to benefit from the opinions of many physicians to develop the questionnaire. In addition, we did not only used one type of designed PACS; the use of four types of PACS from four national companies was examined in the hospitals. The 
Questionnaire included 8 items surveying demographic characteristics and 53 items related to performance expectancy, effort expectancy, social influence, facilitating conditions, computer self-efficacy, behavioral intention, technology optimism, problem solving, rationalized decision-making, horizontal integration, vertical integration, and providing health services to clients. The difference between this study and similar studies was the difference in the study information systems, the research environment, the study population, and in the constructs of the UTAUT. The designed questionnaire has good validity and reliability and is recommended as a valid tool for predicting and evaluating factors affecting the adoption and use of PACS by Iranian physicians.

Ethical Considerations
Compliance with ethical guidelines
This study has ethical approval number IR.MUI.RESEARCH.REC.1398.516 of Isfahan University of Medical Sciences (MUI).

Funding
This study was supported by the Deputy for research of Isfahan University of Medical Sciences (MUI).

Authors' contributions
Article design: Kobri Afshari; Editing of the article: Saeed Saeed Bakhsh, Maryam Jahanbakhsh, Zahra Heydari; Review of technical issues: Saeed Saeed Bakhsh, Zahra Heydari.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
We are grateful for the cooperation of professors, doctors and information technology specialists of Isfahan University of Medical Sciences (MUI), whose valuable opinions were used in clinical and technical fields.

References

1. ESR, EFRS. Patient safety in medical imaging: A joint paper of the European Society of Radiology (ESR) and the European Federation of Radiographer Societies (EFRS). Insights Imaging. 2019; 10(1):45.  [DOI:10.1186/s13244-019-0721-y] [PMID] [PMCID]
2. Abodahab AM, Tharwat M, Alserafi A, Fawzy K. Implementations of PACS and teleradiology systems: An updated review of the literature. J Ecol Health Environ. 2020; 8(2):21-5. [Link]
3. Al-Kahtani N, Al-Dhaif E, Alsaihtati N, Farid K, AlKhater S. Clinicians’ perceptions of Picture Archiving and Communication System (PACS) use in patient care in eastern province hospitals in Saudi Arabia. J Multidiscip Healthc. 2021; 14:743-50. [DOI:10.2147/JMDH.S296828] [PMID] [PMCID]
4. Abbas R, Singh Y. Pacs implementation challenges in a public healthcare institution: A South African vendor perspective. Healthc Inform Res. 2019; 25(4):324-31. [DOI:10.4258/hir.2019.25.4.324] [PMID] [PMCID]
5. Taherdoost H. A review of technology acceptance and adoption models and theories. Procedia Manuf. 2018; 22:960-7. [DOI:10.1016/j.promfg.2018.03.137]
6. Hazhir F. [Thestudy of factors affecting the adoption and use of integrated health system from a user perspective using the extended model of unified theory of acceptance and use of technology (Persian)] [ PhD dissertation]. Isfahan: Isfahan University of Medical Sciences; 2017.
7. Dwivedi YK, Rana NP, Jeyaraj A, Clement M, Williams MD. Re-examining the unified theory of acceptance and use of technology (UTAUT): Towards a revised theoretical model. Inf Syst Front. 2019; 21(3):719-34.  [DOI:10.1007/s10796-017-9774-y]
8. Chao C-M. Factors determining the behavioral intention to use mobile learning: An application and extension of the UTAUT model. Front Psychol. 2019; 10:1652. [DOI:10.3389/fpsyg.2019.01652] [PMID] [PMCID]
9. Liu L, Miguel Cruz A, Rios Rincon A, Buttar V, Ranson Q, Goertzen D. What factors determine therapists’ acceptance of new technologies for rehabilitation-a study using the Unified Theory of Acceptance and Use of Technology (UTAUT). Disabil Rehabil. 2015; 37(5):447-55. [DOI:10.3109/09638288.2014.923529] [PMID]
10. Jahanbakhsh M, Nazemi Z, Mohammadi F, Hasanzadeh A. A study of picture archiving and communication system adoption in one hospital: Applying the unified theory of acceptance and use of technology model. J Educ Health Promot. 2018; 7:103. [DOI:10.4103/jehp.jehp_149_17]
11. Abdekhoda M, Salih KM. Determinant factors in applying picture archiving and communication systems (PACS) in healthcare. Perspect Health Inf Manag. 2017; 14(Summer):1c. eCollection 2017 Summer.[PMCID]
12. Ahmadi M, Mehrabi N, Sheikhtaheri A, Sadeghi M. Acceptability of picture archiving and communication system (PACS) among hospital healthcare personnel based on a unified theory of acceptance and use of technology. Electron Physician. 2017; 9(9):5325-30. [DOI:10.19082/5325] [PMID] [PMCID]
13. Vakili MM. Assessment of construct validity questionnaires in psychological and educational research: Applications, methods, and interpretation of exploratory factor analysis. J Med Educ Dev. 2018; 11(30):4-21.  [DOI:10.29252/edcj.11.30.4]
14. Venkatesh V, Morris MG, Davis GB, Davis FD. User acceptance of information technology: Toward a unified view. MIS Q. 2003; 27(3):425-78.  [DOI:10.2307/30036540]
15. Al-Qeisi K, Dennis C, Alamanos E, Jayawardhena C. Website design quality and usage behavior: Unified Theory of Acceptance and Use of Technology. J Bus Res. 2014; 67(11):2282-90. [DOI:10.1016/j.jbusres.2014.06.016]
16. Rupareliya DA, Shukla YU. Face Validity of Gujarati Version of Lower Extremity Functional Scale (LEFS). Indian J Physiother Occup Ther. 2022; 16(1):13-8. [DOI:10.37506/ijpot.v16i1.17742]
17. Lawshe CH. A quantitative approach to content validity. Pers Psychol. 1975; 28(4):563-75. [DOI:10.1111/j.1744-6570.1975.tb01393.x]
18. Waltz CF, Bausell RB. Nursing research: Design, statistics, and computer analysis. Philadelphia: FA Davis company; 1981. [Link]
19. Shrestha N. Factor analysis as a tool for survey analysis. Am J Appl Math Stat. 2021; 9(1):4-11. [DOI:10.12691/ajams-9-1-2]
20. Ngah H, Mohd Hairon S, Hamzah NA, Noordin S, Shafei MN. Development and validation of knowledge, attitude, and practice questionnaire: Toward safe working in confined spaces. Int J Environ Res Public Health. 2022; 19(3):1242. [DOI:10.3390/ijerph19031242] [PMID] [PMCID]
21. Sharma B. A focus on reliability in developmental research through Cronbach’s Alpha among medical, dental and paramedical professionals. Asian Pac J Health Sci. 2016; 3(4):271-8. [DOI:10.21276/apjhs.2016.3.4.43]