Mobile health interventions have the potential to improve the provision of SRH services in LMICs [16, 18, 20, 45, 46] by connecting directly to people in rural areas to engage with HCPs [16, 18, 20, 45, 46]. Rural settings in LMICs may pose both significant opportunities and challenges for mHealth . This review provides evidence on facilitators and barriers for delivering mobile phone based SRH information and services to people in rural settings in LMICs experienced by HCPs [25, 34–44].
Our findings showed that HCPs perceived mHealth to be useful for providing SRH services to rural people . Study participants reported facilitators such as the convenience of using mobile phone to deliver a range of SRH information and services remotely and confidentially [25, 34–44] reducing fear and stigma associated with face-to-face SRH consultations. Also, saving of travel time and costs for both HCPs and users were noted [36, 43, 44], in line with research [6, 48–50].
An important facilitator for providing mHealth was the ability to task shift by delegating duties or responsibilities to lower-level cadre health professionals [34, 44]. HCPs said task shifting helped improved time management and workload for them to perform critical and urgent duties [25, 36, 37, 40, 43]. Task shifting has been identified as a pragmatic response to health workforce shortages in rural settings in LMICs . It is observed however that the burden of task shifting tends to fall disproportionally on HCPs with lower qualifications and volunteers, leading to work overload without corresponding remuneration [51, 52]. To maximize task shifting benefits without placing an undue burden on HCPs who are willing to undertake additional workload, appropriate compensation and training need to be considered, to ensure the sustainability of mHealth programs in rural settings in LMICs .
In this review, services were provided using voice messaging, phone calls, voice calls and SMS text-messaging [25, 34–44]. SMS texting was seen as the most preferred and efficient option for delivering health information and services, due to the ability to transmit multiple health messages to groups of people at the same time and confidentially [34–36, 42]. A preference for delivering health information via SMS text messages in rural populations in LMICs settings has been reported . There is a growing interest for the preference of mHealth interventions platforms in LMICs for SRH information and services for rural population. There is the need for research to understand the benefits and preferences of mobile phone-based platforms for users with greater reach in rural areas especially among lower literate populations.
The review also highlighted technological challenges which hindered the effective delivery of SRH mHealth services [25, 34–44].The major barriers included a lack of technical skills [35, 39, 41, 42] and limited technological infrastructure [39, 41, 42]. These findings have been reported by studies in LMICs [18, 45, 54, 55]. The full realization of the full potential of mHealth SRH services will require investment in the development of technological infrastructure [35, 56] and building the capacity of HCPs to effectively advance mHealth SRH services for rural populations [17, 57, 58].
In this review, HCPs also reported personal and contextual challenges such as cost of mobile phones and lack of electricity for charging mobile phones [36, 38, 39], cost for mobile credit/ airtime [35, 39, 43] and unreliable or weak network connectivity [35, 39, 40, 42]. Several studies conducted in similar settings in LMICs have confirmed these findings [16, 18, 45, 59, 60]. In some instances, HCPs had to bear mobile phone expenses in order to be able to provide the services . A qualitative study in rural South Africa has reported similar findings . Personal cost of providing health delivery services in rural settings in LMICs constitutes a disproportionate share of HCPs already low incomes . Subsidizing mHealth service provision for rural health workers in LMICs is critical for delivery and use of SRH services in rural health systems [15, 61, 62]. Contextual barriers [39, 41, 42] including lack or unreliable network connectivity [38–40, 42, 43], lack of electricity to charge mobile phones [36, 42, 44] and outlets for airtime retailers  influence HCPs ability to effective delivery of services to rural populations.
Although mHealth programs are becoming an integral part of SRH services in rural LMICs [20, 46], investment in the interventions need to be complemented by a thorough evaluation of contextual factors to effectively address provider and user needs for improvement of health outcomes. The review findings provide programme managers and policy makers with evidence to suggest that addressing economic and infrastructure gaps for providing mHealth SRH services in rural settings in LMICs will require a collaboration between governments, nongovernmental organizations and other stakeholders.