Review of patients perspective’s of m-health adoption factors in the developing world. Development of a framework

Background: Patient perceptions and experiences of mobile health (m-health) systems have been recognised as an important element to consider in the adoption of m-health based technologies. Though much research supports this, published studies that identify m-health use by patients appear to highlight these issues in an indirect rather than holistic manner. Consequently, there is no encompassing framework that serves as a guide for effective implementation and maximum adoption of m-health from the perspective of patients in the developing world. This review documents patient adoption issues specically and uses these to develop a proposed framework of patient adoption issues for m-health in the developing world. Methods: A structured literature search was conducted using PubMed and Scopus. For PubMed a consolidated search string combined ‘MeSH’ terms and ‘All Fields’ terms for selected keywords. For Scopus an equally consolidated search string was used. The searches were restricted to articles in English during the period January 2000 to December 2019 and relevant to the developing world. Duplicate articles were removed. Titles and abstracts were screened by all authors for inclusion, and those studies that met the inclusion criteria were selected for full-text review. Review and data abstraction was performed by two authors. Results: Fifty four (54) articles reported factors that impact patient adoption. Review and data abstraction identied specic factors, initially classied under 22 categories, that promote or impede m-health adoption in the developing world. Continued iterative review and discussion reduced these to 7 primary categories, with 21 sub-categories, which were used to design the proposed framework. Conclusions: The review showed: great inconsistency in the approach and tools used in published studies; multiple factors impact patient adoption of m-health in the developing world; the specic factors vary from setting to setting (e.g., country, rurality, mobile device type) and by recency of ndings. Successful adoption of m-health by patients in the developing world critically depends on addressing the factors identied in the proposed framework and assessing them prior to implementation of m-health initiatives in any specic setting. The proposed framework will serve to increase the consistency of patient adoption studies, form the basis for informed policy decisions by stakeholders, and provide the foundation for greater success of future m-health implementations for patients in the developing world.

Another issue was the ability to keep a mobile phone charged and connected, and the associated costs. In many developing countries power was described as irregular with rural areas being most affected [53,70]. Keeping a mobile phone charged was problematic [33,36,43] and it was common to nd people paying to charge their phones at street side vendors [33,37]. Likewise, phone maintenance in the event of a fault was an equally important factor that might jeopardise adoption [50,53,76].
Sharing of mobile devices was the primary issue identi ed under access to mobile devices. Many projects relied upon shared use of cell phones [19,48,77]. Although the absolute proportion of shared devices varied, for example from 21% [25] to 51.4% [8], it was recognised as a limitation to implementation.
Related to cost and ownership was user characteristic issues, described below.

User characteristics
This category was also commonly reported and addressed the socio-cultural beliefs, perceptions, and overall setting of patients as factors that impact m-health adoption. The four sub-categories included the impact of socio-cultural practices and beliefs, and gender issues which were noted in many studies.
Information and communications technology use in low-income countries is lower among females [44,78,79] and a 'gatekeeper effect' was noted in several studies with women requiring permission from their parents, husband or partner to use a cellphone [25,30,42]. This was exacerbated by being ashamed to raise issues about women's diseases with their gatekeeper [42] or fear of punishment if they accessed a phone without permission [37]. Other cultural factors impacted cellphone use, with boys -unlike girlsbeing allowed to be inquisitive and seek out information about sexual matters [30], and restricted use being enforced through fear of "inappropriate" calling with the opposite sex [37]. In Tanzania, men prevented their wives from owning mobile phones because they believed it facilitated sexual unfaithfulness [62].
Studies reported participants from adolescents to the aged, of both genders, and broad levels of education [21,28,37,53,66]. Some studies suggested that age and gender of patients should be considered when implementing m-health systems, with different age groups having preferences for certain multimedia elements [48,66], and women given less priority in male dominated communities [37,42]. Others reported that children, the elderly and the illiterate needed assistance to initiate a service request [28], or appropriate training for them to use the device [80]. Others found all age groups, genders, and education levels functioned well with m-health interventions [8,21].
Men dominated mobile phone use [21,33,44,66,79,81], although this varied by country [37,42]. Reasons included the gatekeeper effect, but also the lack of primary or higher education for women [8,33]. It was suggested that an appropriate age target for minimally educated women to use m-health would be 17 to 63 years [8,22,25] but in certain parts of the developing world older women were more likely to own and use a mobile phone for m-health than younger women [53], and in South Africa women are the dominant users [37]. Urban women found evening m-health services more convenient and rural women preferred daytime services [19,28,57].
Acceptability and perception of use, and the willingness and ability of patients to use m-Health were identi ed as issues impacting implementation. m-health solutions were more readily accepted and adopted by patients when they addressed a patient recognised health need [24,42,43], were considered acceptable and useful to them [18,21,27,45], were friendly and easy to use [26,27,50], and used appropriate multimedia modes (selected for effective communication by the target user group, whether text message, audio, video, animation, or pictures [65]. It was noted that audio (voice) accommodated those with low literacy and helped to build trust [19,43,59], while SMS messaging accommodated those with a slightly higher level of literacy [20,21,59,69]. Services that did not address patients' perceived needs impacted motivation to use the service [42].
The competence and readiness of healthcare workers to use technology to deliver an m-health solution also impacted patient adoption. Patients expected healthcare workers to respond to any requests in a timely manner [42,77], and to have the requisite competencies to deliver the m-health services [33], highlighting the need for available and e cient training in the use and management of any m-health technology [52].

Language and Literacy
These were considered primary issues for successful m-health adoption [66,67,69]. The clinical bene ts of conversing with a patient in their mother tongue, whether written or spoken were noted [82,83] and mhealth adoption was affected when patients were not con dent in communicating in a language they did not normally use or understand [22,61]. It was suggested that the National o cial language, which generally serves the interest of the majority, should be used in the deployment of m-health systems [46].
To participate in m-health services, patients need to be literate both in the traditional sense (able to read, write, and speak in their mother language), but also in a broader sense (able to understand the technical needs to effectively use a mobile device, and able to understand their health issues and treatment) [24,46]. In poor rural areas where education levels are often lower [42] people may require the assistance of a family or community member to understand the content of a message sent to them [56]. In general mhealth requires minimum literacy on the part of patients for its adoption [65], particularly when patients are appropriately trained to apply the technology [8, 24-26, 48, 49, 66].

Infrastructure
The lack of, or insu cient accessibility to, digital infrastructure in the developing world was noted [1,30]. Unreliable or poor quality infrastructure [1,19,30,40,64,65] leading to mobile network uctuations [8] or inadequate cellular signal [29], and unresolved technical issues [67] were identi ed impediments to mhealth adoption. Technology infrastructure upgrade may be required before m-health implementation to provide dependable network infrastructure, remote accessibility, and seamless connectivity [18,28,31,49,50]. In addition, m-Health interventions are dependent upon reliable electric power [28], although alternate innovative means such as 'pedal power' and solar power have been used to a modest degree [84,85].
Social networks highlighting m-health services provided effective publicity and promoted implementation [53].
Collaboration and Funding m-Health system implementation and patient adoption often relies on the fusion of various independent systems and strong stakeholder collaboration [21,77]. Relevant stakeholder institutions must be willing to actively collaborate and share resources for success. This requires and an appropriate institutional setting that promotes such integration [44], where existing communities, healthcare facilities, technology infrastructure, and other service provider platforms are linked to each other in a seamless connectivity [8,21,70]. Collaboration is also necessary to identify and address patients' challenges during implementation [70]. Very clear stakeholder responsibilities are required to avoid con ict and service ambiguity. The required level of integration can be made possible when there is an existing institutional framework supporting the exchange backed by a comprehensive policy regime. The need to engage policy makers even at the stage of design through to implementation and ensuring that the system does not run in isolation to similar national or local interventions is critical to adoption.
As the government of most countries is either the sole or primary provider -or payer -of healthcare services, government facilitation and sponsorship of m-health implementations will in uence adoption by patients. Government or private sponsorship (or perception of the same) is crucial for m-health adoption among patients [45]. For some patients, just involvement of government is enough to give the project some credibility.
Community ownership of m-health programmes affects patient adoption. Mbuagbaw et al. [52] found that strong community involvement driven by advocacy during home and hospital visits, coupled with active engagement with community leaders, was an important element for patients' adoption. Advocacy both at the level of the community and the healthcare provider is crucial for the undecided user to make up her mind [32]. This system should be implemented to re ect the local contexts in which it is deployed. There must be an effort at mobilising resources from the community to support the project internally rather than a concentration on external funding sources, if the project must succeed [52]. There must be a fusion between the community and the facility-based services for the system to re ect community context and ownership [21,24].
The success of m-health systems depends on securing sustainable funding. Some of this funding will come from external sources and as such may not be reliable. For sustainability there should be mobilisation of community resources as well funding from external (government) sources, and an avoidance of over reliance on less secure external funding [52] (e.g., faith-based organisations and other non-governmental organisations).
There is a high probability of m-health adoption when there is collaboration among relevant governmental and non-governmental agencies, local community organisations, and funding agencies to reduce cost and promote system ownership [54].

Governance
Governance encompasses all of the processes that wield in uence over a social system (country, organisation, village, tribe) through tools such as laws, regulations, or social norms. The patient-related m-health adoption governance issues include legal, regulatory, and ethical issues including data security aspects to maintain the privacy and con dentiality of healthcare information, records and communications [70,86]. Each of these were noted to impact patient adoption of m-health [21,45,59,67].
An enabling regulatory setting requires suitable laws, policies, and a framework that supports m-health adoption by patients. Legal and regulatory challenges to successful m-health adoption were noted [70], requiring appropriate responses using policies, standards, and regulations [86]. The implementation of a regulatory policy must be the responsibility of all stakeholders especially the regulator and the healthcare provider [70].
Maintaining the privacy of data during collection, storage, and sharing for all patient groups was noted as critical for the adoption and sustainability of m-health systems [20,51,59,63,67,76]. Success instilled con dence in patients [17,27,63,87] while failure had a negative impact [52]. Protecting m-health devices against unauthorised access and having effective standard operating procedures was also noted [28].
Some patients wanted all communications sent directly to their personal mobile devices without going through a human intermediary to guarantee con dentiality [62]. Yet where a patient does not own a mobile phone, caregivers must be contacted to make the information available to the patient; some considered this a breach of con dentiality [57,73], because mobile phone is considered a preferred medium for communicating sensitive issues [72]. Con dentiality concerns were even noted regarding asking for socio-demographic information from patients [45].

System Utility
The nal category refers to how useful or bene cial an m-health solution is to patients. Three subcategories were identi ed: Demonstrating clear bene t to patients, the effectiveness of the system, and evaluation and monitoring. m-Health systems were found to be more readily adopted when they demonstrated clear bene ts to patients [32,52,74]. Successful adoption may be limited if there is a lack of awareness of the bene ts to the general public [22]. Some authors identi ed that new or prospective participants may want to know if evidence exists of the bene ts of m-health to patients [88,89]. Patients will adopt services that address their needs and are considered satisfactory [17]. Mobile phone functions that patients viewed as bene cial included automated reminder systems, drug adherence alarms, and appointment reminders from care givers [39,40].
Patients must feel comfortable that an m-health system will successfully deliver what they want, and will avoid adopting an m-health system they are unfamiliar with or for which there is limited evidence of effectiveness [18,24]. Conversely, several papers reported how much patients appreciated and accepted m-health when it met their needs and made them feel valued [21,38,48,90], provided reliable and timely responses that improved quality of life [87], and facilitated two-way communication between the patient and healthcare provider [26]. This phenomenon of leaving the response promptings to the digital awareness of the patients who may have low digital literacy or the benevolence of caregivers is certainly not reliable [40,91].
An oblique observation was that inadequate monitoring and evaluation can adversely impact patient mhealth adoption. Adequate evaluation and monitoring to identify technology, socio-cultural, community, and health related needs that will affect adoption if not addressed before scale-up is not always performed during the pilot stage [49,77]. Similarly, the use of inconsistent indicators and poor evaluation methods made cost-effective uptake of m-health in the developing world di cult to prove [49]. Additionally, adoption of m-health services is facilitated through awareness (marketing and publicity of bene ts and capabilities) [19,25], and managing expectations to ensure they are realistic [22,87].

Proposed Framework
Resources identi ed through the search addressed 'm-health adoption' issues broadly and not 'patient mhealth adoption' issues speci cally, requiring patient related issues to be teased out from the identi ed studies. Based on the ndings, it was considered that for m-health to be maximally adopted by patients in the developing world a framework ( Figure 2) in which all the above identi ed factors are captured must be used to guide the implementation.

Discussion
The study has highlighted great inconsistency of approach, tools, and indicators used in published studies that report on factors that impact patient adoption of m-health in the developing world. The study also revealed a plethora of speci c factors that differed from study to study, that varied in terms of their impactfulness from setting to setting, and whose relevance was questionable given the marked change in technology over time. After iterative review by the authors this spectrum of speci c factors was reduced to 7 primary categories, with 21 sub-categories. The 7 primary categories were used to develop the proposed framework for patient adoption of m-health in the developing world. Development of a framework was chosen as it provides a simpli ed visual aid that encompasses all the key components and helps to order thoughts and actions of decision-makers when addressing complex issues. Successful adoption of m-health by patients in the developing world will depend on assessing and addressing the factors comprising the framework before attempting to implement m-health initiatives in any speci c setting.
The literature showed that certain socio-cultural practices and beliefs can serve as barriers to m-health adoption, requiring the sociocultural context and setting of a community or town to be understood and considered. In addition to sociocultural beliefs is the sometimes high and unrealistic expectations of the capabilities of an m-health system by patients, which can also cause it to fail [19]. Consequently, understanding and managing patient expectations is very important to success [18,32]. Some gender factors were identi ed as location speci c. For example, in Ghana and Malawi, males were more likely to own and use mobile phones than females, while the opposite was true in South Africa, a pattern that has persisted over time [37,53].
Poor awareness of m-health was prevalent and impacted adoption. For example, of over 4500 adolescents in Ghana, Malawi and South Africa "only a handful had ever heard of m-health programmes, let alone participated in them" despite using their cellphones creatively and strategically to seek healthcare [53]. Ironically, patients may not adopt m-health if their expectations of m-health capabilities are unrealistic [22,87]. Consequently, efforts to publicise and make patients aware of the bene ts and capabilities of an m-health services are necessary [19,25].
Access to mobile devices (and accessories) is considered a precursor to successful m-health implementation [8,62,68], but the basic cell or feature phone ("dumb" phones) still predominates in developing countries [71]. The growing tendency for m-health solutions and services to be smartphone and Internet dependent adds to the cost of ownership. This includes both the base cost for purchase of a suitable device, keeping the battery charged, but then also the cost of participating in m-health services. What is the patient's ability and willingness to afford airtime, SMS messaging, and data use to participate in any m-health services accessed? Corporate and project-based tactics employed to ameliorate these impacts have included reduced or subsidised devices and communication costs that can facilitate mhealth uptake and use, but for sustained use by patients how effective and appropriate can such approaches be?
The ubiquity of cellphones was often stated or implied through reporting of high ownership gures. This is perplexing. In the developing world 12.37% of people live on less than USD$ 1.9 purchasing power parity [92]. Furthermore, poverty is associated with an increased burden of disease [69] and low educational levels which reduces income generating capacity thus increasing their likelihood to share mobile devices [44,59,77,79]. To these people ownership of a mobile phone or other mobile device is a luxury and the cost of ownership a stark impediment that may widen the digital divide and impede mhealth solutions and services [41]. Data concerning ownership and use can be confusing and must be interpreted critically. For example, a 2011 International Telecommunication Union report spoke of 6 billion 'subscribers' worldwide. This has frequently been misinterpreted to mean that 6 billion people owned and used mobile phones. What was, in fact, reported was that there were 6 billion active SIM cards in use, with an average of two active SIM cards per subscriber (as of the end of 2019 there were 8.3 billion active SIM cards). Recent reports provide more accurate insight [93,94].
For patients struggling with short battery life for their mobile device, a sustained and accessible power supply is a key consideration to facilitate adoption of m-health. Yet about 1 billion of the global population still live without access to electricity, and about 3 billion still rely on solid fuels and kerosene for cooking and heating [95]. Most without access to reliable electricity live in sub-Saharan Africa where about 6 out of 10 people do not have access to electricity. Even those with access to an electrical grid can face increasingly regular electricity blackouts and brownouts (50 to 4,600 hours annually) due to capacity shortages and infrastructure failures, forcing the population to seek alternative sources, often diesel generators [23].
Mobile network service coverage in the developing world differs from country to country, and even within countries urban cities have better penetration compared to rural towns and villages.
There are over 7,000 languages in the World and in Africa alone there are over 2,000 languages with more than 500 in Nigeria alone [96]. English speakers predominate as users of the www [97] and, as a result, much of the content remains in English, which poses a concern if patients are to relate to and adopt mhealth content. Most people in the developing world will choose their local languages over English for information dissemination because they consider English di cult to understand [55]. The issue of language used by healthcare service providers to communicate to patients, whether written or spoken, can become a barrier to care and m-health adoption when patients are not con dent in communicating in its use or understanding [22,61]. It has often suggested that the National o cial language, which generally served the interest of the majority, should be used in the deployment of m-health systems [24,46,65], but this may severely limit the utility of m-health solutions for rural and remote populations in the developing world.
Relevant stakeholder institutions whose services are necessary for effective m-health delivery must collaborate [21,77] based on a prede ned inter-institutional framework [44] to effectively address the concerns of patients [70]. This may involve the support from government, private sector, and community leaders. Among these three, the government involvement is very crucial since it provides a sense of available funding and system credibility.
There is the need to guarantee the integrity of m-health systems by protecting patients records and communications. Protection of such information is possible in an environment of adequate legal regime and education, and the strict adherence of ethical standards [51,63,70,86].
Based on the review conducted, evidence shows that for m-health to be maximally adopted by patients in the developing world a framework in which all the above identi ed factors are captured must be used to guide the implementation and promote adoption.

Limitations
Only two electronic literature databases were used and inclusion was limited to English language resources only, both of which may have limited the scope and frequency of issues found. Most resources were from the peer-reviewed literature, and searching for reports and other grey literature resources may have found additional or complimentary material. As a consequence the proposed framework may not comprise all possible factors that in uence patient m-health adoption. Validation of the framework will be required through empirical application.

Implications
To the authors' knowledge, this is the rst study to examine, categorise, and summarise factors that affect adoption of m-health by patients in the developing world. Understanding the patient's perspective the ndings can now be used to compare and contrast patient-speci c aspects of m-health adoption from factors impacting m-health and technology adoption in general by healthcare workers, healthcare organisations, and society, thereby enhancing adoption of m-health overall. Three particular ndings are notable. First, a need exists for consideration and assessment, prior to implementation of m-health initiatives, of seven categories of factors that impact adoption of such initiatives by patients in the developing world. Second, given that the spectrum of factors identi ed were much broader and greater in number than considered in any single study, there is the need for consistent consideration of all of these factors in future studies. Third, noting the variability in impact of any single factor in different settings and for different m-health solutions, it is important to avoid blind transfer of results from one study or setting to another. It is necessary to assess the factors in each setting and for each solution. Such a holistic approach will facilitate and enhance the acceptability and usability of m-health resources by patients in the developing world, and thereby the success and sustainability of such initiatives.
Accepting the above, Prior to any m-health implementation factors that may impact adoption by patients in a speci c setting and for a speci c m-health solution must be assessed.
The assessment must be holistic, considering all appropriate and relevant factors described in the themes and sub-categories of the proposed 'Patient m-health Adoption Framework' It must not be assumed that factors impactful to one implementation will be relevant to implementation of a different m-health solution, or the same solution in a different setting.

Conclusion
This review shows that the success of m-health project implementation and adoption by patients in the developing world critically depends on addressing key factors identi ed in the proposed 'Patient m-health Adoption Framework'. The framework will serve as the basis for informed decisions by stakeholders (policy makers, implementers, researchers, evaluators) and provide the necessary blue print for future successful m-health implementation in the developing world for patients.

Declarations
Ethics Approval and consent to participate Table   Table 1   Proposed framework for increased patient adoption of m-health by patients in the developing world.

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