Effectiveness of mHealth Behavior Change Communication Interventions in Developing Countries: A Systematic Review of the Literature

The purpose of this study was to conduct a systematic review of research literature to determine how much evidence currently exists for mobile health technologies and telecommunication (mHealth) behaviour change communication (BCC) interventions. In addition to analysing available research for methodological rigour and strength of evidence, the authors assessed interventions for quality, applying a set of 9 standards recommended by mHealth experts.

The authors did a full-text review of 44 articles that met the inclusion criteria. "Eligibility criteria for inclusion were as follows: study used mHealth technology in its interventions for BCC in low- and middle-income countries; study included formative, process, or summative/outcome evaluation that assessed the mHealth intervention; and study was a peer-reviewed article, gray literature, internal organization report, or conference paper/PowerPoint presentation. Given the lack of research available in the field, limiting solely to peer-reviewed literature was not feasible."

Sixteen articles (36%) reported evaluation data from BCC mHealth interventions in a developing country - primarily in Africa and Asia and primarily interventions on HIV/AIDS (n = 10) and family planning/pregnancy (n = 4). The majority of publications (n = 12) described interventions that used two-way communication in their message delivery design.

The following qualities were assessed:

• Technology-related components considered critical to the success of BCC mHealth interventions.
• The ability to ensure privacy.
• Interventions with the intended audience's level of comprehension.
• The timing of communication messages (i.e., time of day, frequency, and sequencing) for end user receptivity.
• Components related to the evaluation.
• Long-term evaluation of mHealth BCC interventions.

The study conclusions indicate the following:

• Selecting the appropriate technology for the intended audience, location, and context - Understanding the audience through research to capture technology used, time of date (as in a monthly contact) and day (as in morning, afternoon, evening), length of contact, frequency of contact, two- or one-way communication, and the types of messages offered to them can inform the intervention development. For example, through in-depth interviews, one formative study determined that voice messages instead of text would be a better delivery method for the population, and another found that a 19-second message was heard all the way through, whereas a 30-second message was not.
• Privacy - The study pointed out that voice calls offer a privacy buffer, whereas texting may not (when phones are shared).
• Language and literacy competency but also the ability to understand and use technology - Linguistic and literacy competency and understanding of the technology were challenges, e.g. the concept of a hotline was not always understood, or the audience was attempting to use voice technology when texting was required.
• Message design considerations, such as creating tailored content which engages the user in two-way communication, allowing users to interact and ask questions instead of simply receiving information - Some interventions required a response indicating that the behaviour had been completed (with follow-up by a nurse if there was no response).
• Long-term evaluation - More evaluations of current interventions need to be conducted to establish stronger evidence. There is a need for studies with long-term follow-up of health effects of mHealth interventions.