ONLINE JOURNAL OF PUBLIC HEALTH INFORMATICS Joshi et al

Review

The Health Impact of mHealth Interventions in India: Systematic

Review and Meta-Analysis

Vibha Joshi1, PhD; Nitin Kumar Joshi2,3, PhD; Pankaj Bhardwaj2,3, MD; Kuldeep Singh1, MD; Deepika Ojha1, BTECH;
Yogesh Kumar Jain2,3, MPH
1
Resource Centre Health Technology Assessment, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
2
School of Public Health, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
3
Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences Jodhpur, Jodhpur, India

Corresponding Author:
Vibha Joshi, PhD
Resource Centre Health Technology Assessment
All India Institute of Medical Sciences Jodhpur
B110 Krishna Nagar
Basni-I
Jodhpur, 342005
India
Phone: 91 8290163030
Email: drvibhajoshi@gmail.com

Abstract
Background: Considerable use of mobile health (mHealth) interventions has been seen, and these interventions have beneficial
effects on health and health service delivery processes, especially in resource-limited settings. Various functionalities of mobile
phones offer a range of opportunities for mHealth interventions.
Objective: This review aims to assess the health impact of mHealth interventions in India.
Methods: This systematic review and meta-analysis was conducted in accordance with the PRISMA (Preferred Reporting Items
for Systematic Reviews and Meta-Analyses) guidelines. Studies conducted in India, and published between April 1, 2011, and
March 31, 2021, were considered. A literature search was conducted using a combination of MeSH (Medical Subject Headings)
terms in different databases to identify peer-reviewed publications. Thirteen out of 1350 articles were included for the final review.
Risk of bias was assessed using the Risk of Bias 2 tool for RCTs and Risk Of Bias In Non-randomised Studies - of Interventions
tool (for nonrandomized trials), and a meta-analysis was performed using RevMan for 3 comparable studies on maternal, neonatal,
and child health.
Results: The meta-analysis showed improved usage of maternal and child health services including iron–folic acid supplementation
(odds ratio [OR] 14.30, 95% CI 6.65-30.75), administration of both doses of the tetanus toxoid (OR 2.47, 95% CI 0.22-27.37),
and attending 4 or more antenatal check-ups (OR 1.82, 95% CI 0.65-5.09). Meta-analysis for studies concerning economic
evaluation and chronic diseases could not be performed due to heterogeneity. However, a positive economic impact was observed
from a societal perspective (ReMiND [reducing maternal and newborn deaths] and ImTeCHO [Innovative Mobile Technology
for Community Health Operation] interventions), and chronic disease interventions showed a positive impact on clinical outcomes,
patient and provider satisfaction, app usage, and improvement in health behaviors.
Conclusions: This review provides a comprehensive overview of mHealth technology in all health sectors in India, analyzing
both health and health care usage indicators for interventions focused on maternal and child health and chronic diseases.
Trial Registration: PROSPERO 2021 CRD42021235315; https://tinyurl.com/yh4tp2j7

(Online J Public Health Inform 2023;15:e50927) doi: 10.2196/50927

KEYWORDS
mobile applications; mobile apps; cost-benefit analysis; telemedicine; technology; India; patient satisfaction; pregnancy

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cluster RCTs and quasi-experimental studies), and prospective

Introduction parallel cohort studies conducted in India were included. Studies
The use of mobile computing and communication technologies published between April 1, 2011, and March 31, 2021, were
in health care and public health are seen as a rapidly expanding considered, and the search was initiated on September 10, 2020,
area within eHealth. The World Health Organization’s Global until March 10, 2021. Studies reported in the English language
Observatory for eHealth defined mobile health (mHealth) as and conducted in India, which addressed the impact of mobile
“medical and public health practice supported by mobile devices, technology, using SMS text messaging or cellular telephone
like mobile phones, patient monitoring devices, personal digital interventions for any disease (eg, diabetes, hypertension,
assistants, and other wireless devices” [1]. Devices used in cardiovascular disease, chronic respiratory disease, and cancer)
mHealth interventions include laptops, tablets, mobile phones, and maternal and child health, and measured outcomes including
smartphones, palmtops, notebooks, and netbooks. morbidity, mortality, hospitalization rates, behavioral or lifestyle
changes, the process of care improvements, clinical outcomes,
Features of mobile technology, including mobility, instantaneous patient and provider satisfaction, compliance, and
access, and direct communication, permit faster transfer of cost-effectiveness, were included in the review.
health information, which aid in medical and public health
practices. mHealth services range from simple apps to complex Literature Search
technologies including voice messaging, SMS text messaging, A literature search was conducted using a combination of text
multimedia message service, Bluetooth technology, and others, and Medical Subject Headings (MeSH) keywords in major
which could transform the worldwide delivery of health services, databases, including PubMed, MEDLINE, Scopus, Cochrane
especially in low- and middle-income countries [1]. Library, Web of Science, and Google scholar, to identify
peer-reviewed publications. The MeSH keywords included the
Various functionalities such as SMS text messaging, voice
following: Text Messaging, Health Literacy, Mobile
messaging, mobile internet browsing, Voice over Internet
Applications, Smartphone, Cell phone, Health Impact
Protocol services (eg, Skype), instant messaging services,
Assessment, Developing Countries, Multimedia, Cell Phone,
photographic capabilities, and a wide variety of device-based
Telemedicine, Medication Adherence, India, Hypertension,
applications available through mobile technology offer a range
Primary Health Care, Risk Reduction Behavior, healthcare
of opportunities for mHealth interventions, such as text message
cost, Health Information Management, and Information Systems.
and interactive voice response campaigns and content to mobile
The search field was limited to the title or abstract (or both),
phone–based imaging (which have potential diagnostic
and the type of publication was limited to original articles or
capabilities) [2,3]. This technology has a broad extent and
full-length research articles. We excluded cross-sectional
accessibility, which can be efficiently leveraged for health care
studies, letters, case reports, study protocols, reviews, opinions,
delivery in areas where access is a major constraint [4].
gray literature, and non–peer-reviewed publications. The
mHealth is increasingly being used for medical services and reference lists of articles were also examined to identify other
public health practice for patient communication, monitoring, potentially relevant articles. The protocol for this systematic
and education [5,6]. The interventions have also shown to reduce review and meta-analysis has been registered in PROSPERO
the burden of diseases linked with poverty and an improvement 2021 (CRD42021235315).
in the accessibility of the health services in terms of clinical
diagnosis, treatment adherence, and chronic disease management Study Selection and Characteristics
[1,7-9]. There is considerable interest in mHealth interventions Two researchers (VJ and DO) independently screened the titles
with an enormous potential for beneficial effects on health and and abstracts to identify potentially eligible studies, and further
health service delivery processes, especially in resource-limited assessment was performed by 2 authors (NKJ and YKJ). Only
settings such as India [10]. full-text articles published between 2011 and 2021, written in
the English language, were included. The authors excluded
This paper provides a review of evidence regarding the health duplicates and studies conducted outside India.
impacts of mHealth interventions in India. The purpose of this
review is to assess health impact in terms of measurable changes Initial searches identified 1393 titles. After removing duplicates,
in mortality, morbidity, disability-adjusted life years (DALYs), 1120 articles were included for initial screening. Of these, 920
and improved disease detection rates. articles were excluded after screening by title and abstract,
leaving 200 articles, which were considered in more detail. A
Methods further 187 papers were subsequently excluded for not meeting
the relevant criteria. Thirteen of the eligible studies were
Study Design intervention studies, comprising 3 RCTs; 5 quasi–RCTs; 1
This systematic review and meta-analysis was conducted in cluster RCT; 1 prospective, parallel-group cohort study; and 1
accordance with the PRISMA (Preferred Reporting Items for quantitative, single-arm, pretest, posttest interventional study
Systematic Review and Meta-Analyses) guidelines [11]. (Figure 1).
Randomized controlled trials (RCTs), non-RCTs (including

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Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram for database searches of studies on mobile
health interventions conducted in India in 2011-2020.

to the inclusion of an article were resolved through consensus

Data Extraction among the authors.
The extracted data included the names of the authors, year of
publication, study design, study location, sampling, and main Quality Assessment and Assessment of Risk of Bias
results. All these details were captured and recorded in an Excel Risk of bias of each study was assessed using the Risk of Bias
(Microsoft Corp) spreadsheet. The information reported in or 2 tool for RCTs and Risk Of Bias In Non-randomised Studies
calculated from the included studies was used for analysis. - of Interventions for non-RCTs [12,13]. Risk-of-bias grading
Corresponding authors of the articles were not contacted for for the different components of each study is shown in Table
unpublished or additional information. Disagreements related 1. Four of the intervention studies were graded as being at low
risk of bias, 6 as moderate, and 1 as high.

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Table 1. Characteristics and results of studies investigating the effectiveness of mobile health (mHealth) interventions in India during 2011-2020.
Study (year; loca- Study population Intervention and control Results Study outcome
tion) [overall risk
of bias]
Prinja et al [14] • Population: data ob- • Intervention: pregnant • Increase in the coverage IFAd • Significant improve-
(2017; Uttar tained from the 2011 women and mothers using supplementation (12.58%; 95% ment in IFA supplemen-
Pradesh, India) AHSa and 2015 an mHealth app; control: CI 0.086-0.27) tation, identification,
[low] women and mothers not • and self-reporting of
CEAHHb survey Self-reporting of illnesses or
using mHealth applica- complication during pregnancy illnesses during preg-
among women or
tions (13.11%) and after delivery nancy and after deliv-
mothers with 1-year-
(19.6%) ery
old children
• Preintervention: 1508 • The coverage of ≥3 ANCe vis-
c its (10.3%; 95% CI 0.039-0.98)
ASHAs (intervention:
n=99; control: n=99); • Coverage of ≥2 tetanus toxoids
postintervention: 1028 (4.28%; 95% CI 0.055-0.68)
(intervention: n=534; • Institutional delivery (95% CI
control: n=534) 0.044-0.59)
• Full immunization (95% CI
0.20-1.032)
• No change in the quality of
ANC care

Modi et al [15] • Population: rural tribal • Intervention (with an • ANC of ≥4: intervention • ImTeCHOi mobile
(Gujarat, India) communities of Gu- mHealth package): 11 (n=622, 79.2%); 89.5, 95% apps and web-based
[low] jarat, India (neonates PHCs and 280 ASHAs; 87.6-91.3); control (88.7, 95% applications, ASHAs,
and mothers); popula- population: 234,134 CI 86.6-90.6) and PHC staff im-
tion: 22 PHCf clusters • Control (without an • TTg during the last pregnancy: proved the coverage
(intervention: n=11; mHealth package): 11 intervention (n=771, 98.2%; and quality of MNCHj
control: n=11) PHCs and 281 ASHAs; 98.2, 95% CI 97.4-98.9); con- services in difficult-to-
population: 242,809 trol (n=694, 98.3%; 96.8, 95% reach areas
CI 96-97.6) • Improvement in cover-
• Delivered at an institution or age home visits by
hospital: intervention (n=580, ASHAs during the ante-
73.9%; 83.2, 95% CI 80.4- natal period, postnatal
85.9); control (n=600, 85.0%; period, early initiation
84.9, 95% CI 82.1-87.6) of breastfeeding, and
• ASHAs present during deliv- exclusive breastfeeding
ery: intervention (n=267,
34.0%); control (n=267,
37.8%)
• MACCIh: intervention (31%);
control (31%)
• ASHA visit at home at least
twice in the first week of deliv-
ery: intervention (n=149,
19.0%; 32.4, 95% CI 29.7-
35.1); control (n=99, 14.0%;
22.9, 95% CI 20.2-25.6)
• Low Birth Weight (≤2 kg) at
the time of birth: intervention
(3.5, 95% CI 2.3-4.7); control
(6.6; 95% CI 5.4-7.8)
• Practice breastfeeding at 6
months: intervention (n=151,
19.2%; 57.4, 95% CI 54.1-
60.8); control (n=95, 13.5%;
45.1, 95% CI 41.8-48.4)

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Study (year; loca- Study population Intervention and control Results Study outcome
tion) [overall risk
of bias]
Murthy et al [16] • 2016 pregnant women, • Intervention group re- • Infant care practices that the • mMitra voice-based
(Mumbai, India) aged 18 years or older: ceived mMitra voice mes- intervention group performed mHealth intervention
[moderate] intervention (n=500); sages twice per week better: infant feeding at 6 to demonstrate a posi-
control (n=1516); ana- throughout their pregnan- months of age (ORk 1.4, 95% tive impact on infant
lyzed (intervention: cy and until their infant CI 1.08-1.82; P=.009), fully birth weight—a health
n=1038; control: turned 1 year of age immunizing the infant (OR outcome of public
n=379); time 1 (inter- • Control group received no 1.531, 95% CI 1.141-2.055; health importance
vention: n=1516; con- mMitra voice message P=.005)
trol: n=500); time 2 • Control group performed better
(intervention: n=1113; on practices: increase in baby
control: n=402); time weight within 3 months
3 (intervention: (P=.03; OR 0.77, 95% CI 0.6-
n=1038; control: 0.98)
n=379) • In infant care knowledge: in-
crease in baby solid food by 6
months in the intervention
group (OR 1.89, 95% CI
1.371-2.605; P<.01); the ideal
birth weight is >2.5 kg (OR
2.279, 95% CI 1.617-3.213;
P<.01)

Ilozumba et al • Population: women be- The study has 3 groups, all of • The odds of having a higher • This study showed that
[17] (2018; tween the ages of 18 which received standard care score on maternal health women in the interven-
Jharkhand, India) and 45 years who had government programs that in- knowledge significantly in- tion group reported
[low] delivered a baby in the cluded the recruitment and creased when comparing inter- higher levels of mater-
past 1 year (N=2200; support of ASHAs: vention and control groups nal health knowledge
intervention: n=733; • An intervention group that • Women in the MfM group than those in the NGO
control: n=739) were more likely to attend 4 or intervention or those
received MfMl in addition
more ANC visits than those in who received standard
to an NGO’sm existing in- the standard care group (OR care
terventions 1.36, 95% CI 1.30-1.42) and • The primary outcomes
• A quasi-control group that the NGO group (OR 1.23, 95% of interest were mater-
received NGO programs CI 1.17-1.29) nal health knowledge,
• A standard care group that • The odds of a women in the ANC attendance, and
only received standard MfM group were significantly delivery in a health fa-
care government programs higher than the odds of women cility
in the standard care group (OR
1.34, 95% CI 1.28-1.41) and
the NGO group (OR 1.19, 95%
CI 1.13-1.25)
• Higher maternal health knowl-
edge -MfM versus standard
care (intervention: OR 1.19,
95% CI 1.13-1.25; control
[reference] OR 1.00)
• Attended 4 or more ANC visits
(intervention: OR 1.38, 95%
CI 1.32-1.44; control [refer-
ence] OR 1.00)
• Delivered at a health facility
(intervention OR 1.35, 95% CI
1.29-1.42)

Prinja et al [18] • Intervention: pregnant • ReMiNDn resulted in a cost • mHealth intervention

(2018; Uttar women and mothers using o as part of the ReMiND
saving of US $90 per DALY
Pradesh, India) an mHealth app; control: program is cost-saving
averted US $2569 per death
[low] women and mothers not from a societal perspec-
averted. From the health sys-
using mHealth applica- tive
tem perspective, ReMiND in-
tions
curred an incremental cost of
12,993 (US $205) per DALY
averted and 371,577 (US
$5865) per death averted

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Study (year; loca- Study population Intervention and control Results Study outcome
tion) [overall risk
of bias]

• Population: data ob-

tained from the 2011
AHS and 2015
CEAHH survey among
women or mothers
with 1-year-old chil-
dren
• Preintervention: 1508
ASHAs (intervention:
n=99; control: n=99);
postintervention: 1028
(intervention: n=534;
control: n=534)

Modi et al [19] • Population: rural tribal • Intervention (with an • ImTeCHO is a cost-effective • mHealth intervention
(2020; Gujarat, communities of Gu- mHealth package): 11 intervention at an incremental as part of the ImTe-
India) [low] jarat, India (neonates PHCs and 280 ASHAs; cost of US $74 per life years CHO program is cost-
and mothers; popula- population: n=234,134 saved or US $5057 per death effective and should be
tion: N=22 PHC clus- • Control (without an averted considered for replica-
ters: intervention: mHealth package): 11 • Total births in the study area tion
n=11; control: n=11) PHCs and 281 ASHAs; (n=3014)
population: n=242,809) • Cost per live birth (US $54)
• Cost per 1000 live births (US
$54,360)
• Infant deaths averted per 1000
live births (n=11)
• Life years saved (life expectan-
cy=68.35 years; n=735)
• Cost per infant deaths averted
(US $5057)
• Cost per life years saved due
to infant deaths averted (US
$74)
• IMRp as intention-to-treat in
the study area (cost per ASHA
(US $578.95)

Pfammatter et al • Population: adults aged • Intervention: 1 million • Intervention group: 24.71% of • A text messaging inter-
[20] (2015; India) 18 years and older Nokia subscribers who them improved their fruit and vention was feasible
[moderate] (N=1925; intervention: opted into mDiabetes for vegetable intake and reduced and showed initial evi-
n=611; control: n=632) 6 months their fat intake; 128 (20.95%) dence of effectiveness
• Control: non-Nokia phone improved their preventive be- in improving diabetes-
subscribers havior related health behav-
• Control group: 36.55% decline iors
in the number of participants’
healthy behaviors; 73 (11.55%)
improved their preventive be-
havior

Kleinman et al • Population: aged 18-65 • Intervention: participants • Significantly more par-

[21] (2017; India) years with type 2 dia- received the mHealth app ticipants in the interven-
[low] betes 6 months from and a mobile phone data tion group than in the
baseline (N=90; inter- stipend for 6 months control group
vention: n=44; control: • Control: manage their dia-
n=46) betes as usual

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Study (year; loca- Study population Intervention and control Results Study outcome
tion) [overall risk
of bias]

• Primary outcome: intervention

mean 1.1-1.5; control mean
0.8-1.6 (P=.02)
• Secondary outcomes: interven-
tion mean 32.6-66.4; control
mean 23.5-70.0 (P=.55)
• BMI change: intervention
mean 0.1-1.0; control mean
0.1-1.1 (P=.53)—patient-report-
ed values improved from base-
line to 6 months (intervention:
n=16, 39.0%; control: n=5,
12.8%; P=.03)
• Medication adherence (inter-
vention: 39.0%; control:
12.8%; P=.03)
• Increased frequency of blood
glucose self-testing (interven-
tion: 39.0%; control: 10.3%;
P=.01)

Prabhakaran et al • Population: rural popu- • Effectiveness of the • Incremental benefit of

[22] (2019; India) lation (CHCsq), ≥30 mWellcare app for 5 mWellcare over en-
[moderate] years of age, confirmed chronic conditions (hyper- hanced usual care in
diagnosis of hyperten- tension, diabetes mellitus, chronic conditions
sion or diabetes melli- current tobacco and alco- • The trial did not find
tus hol use, and depression) any significant differ-
• Population: 40 clusters; vs usual care (intervention ence in the primary
intervention: n=20 group: [mWellcare arm]: outcomes, that is, reduc-
(mWellcare) 20 clus- EUC NCDs nurses with tion in SBP or HbA1c,
ters; 1842 participants the mWellcare system; and Secondary out-
enrolled (N=2140); control group: EUC NCD comes, that is, fasting
control: 20 CHCs (allo- nurses Without the blood glucose, total
cholesterol, predicted
cated to EUCr) and 20 mWellcare system)
10-year risk of CVD,
clusters; 1856 partici-
BMI, depression, and
pants enrolled
tobacco and alcohol
(N=2130)
use between the 2 arms

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Study (year; loca- Study population Intervention and control Results Study outcome
tion) [overall risk
of bias]

• Primary outcomes:
• Change in SBPt: control:
mean –12.7 mm Hg; inter-
vention: mean –13.7 mm
Hg (effect size –0.3, ad-
justed 95% CI –3.9 to 3.3;
P=.87)
• Change in HbA1cu: con-
trol: mean –0.58%; inter-
vention: –0.48% (effect
size 0.08, adjusted 95%
CI –0.27 to 0.44; P=.66)

• Secondary outcomes:
• Change in fasting blood
glucose: control: mean
–22.7 mg/dL; interven-
tion: –15.0 mg/dL (effect
size 8.4, adjusted 95% CI
–9.6 to 26.5; P=.37)
• Change in total choles-
terol: control: mean 2.0
mg/dL; intervention:
mean 0.1 mg/dL (effect
size –2.5, adjusted 95%
CI –7.1 to 2.0; P=.29)
• Change in CVDv risk
score: control: mean
0.6%; intervention: 2.4%
(effect size –0.4, adjusted
95% CI –2.3 to 1.5;
P=.66)
• Change in BMI: control:
mean 0.08 kg/m2; inter-
vention: 0.16 kg/m2 (ef-
fect size –0.05, adjusted
95% CI –0.47 to 0.37;
P=.82)
• Change in tobacco use:
control: mean –7.0%; in-
tervention: mean –0.6%
(effect size –0.8, adjusted
95% CI –5.7 to 4.2;
P=.76)
• Change in alcohol use:
control: mean –3.8%; in-
tervention: mean –2.4%
(effect size 0.7, adjusted
95% CI –3.7 to 5.1;
P=.74)
• Change in alcohol use
score: control: mean 10.0;
intervention: 9.4 (effect
size –0.6, adjusted 95%
CI –3.2 to 2.1; P=.68)
• Change in depression
score: control: mean 12.4;
intervention: mean 10.9
(effect size –1.6, adjusted
95% CI –4.4 to 1.2;
P=.28)

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Study (year; loca- Study population Intervention and control Results Study outcome
tion) [overall risk
of bias]
Garner et al [23] • Population: urban slum • Intervention through an • Study aim 1: to assess the effec- • The mHealth app pro-
(2020; India) and rural slum dwellers mHealth app to improve tiveness of an mHealth app to vides an effective and
[moderate] (n=346) hypertension health litera- improve hypertension health valuable culturally tai-
• Pretest (n=87): those cy literacy among participants in lored educational re-
who earned an 8 or India source for nurses and
above on the pretest • Study aim 2: to estimate rela- other health to improve
paired t test tionships between participant hypertension health lit-
• Posttest (n=259): those hypertension health literacy eracy among popula-
who earned a 7 or be- and sociodemographic vari- tions in India
low on the pretest ables
• Pretest: participants who per-
formed moderately well on the
pretest also had improved
posttest scores (significant
mean difference between
pretest and posttest scores
2.49; P<.001 [paired t test])

Gautham et al • Population: rural health • Intervention group: given • Control group scored signifi- • This study supports the
[24] (2015; Tamil providers (n=16) and applications on their mo- cantly higher than the experi- implication that mM-
Nadu, India) patients (n=126; exper- bile phones mental group (control group: RIGsw comprise a fea-
[high] imental: n=65; control: • Control group: no applica- mean 13.68; experimental sible and effective solu-
n=61) tion given; only the phone group: 9.51; P<.05) in the tion for standardizing
and a set of paper guide- posttraining evaluation. and enhancing the
lines to use in the field • Control: mean pretraining quality of care deliv-
score 8.58 out of 19 (SD 2.03); ered by millions of
experimental: mean pretraining frontline rural health
score 7.01 out of 19 (SD 1.85; providers with varying
P=.19) levels of training and
• Control: mean posttraining literacy
score 13.68 out of 19 (SD
2.17); experimental: mean
posttraining score 9.51 out of
19 (SD 2.48; P<.05)

Praveen et al [25] • Population: ASHAs, • The CDSSy was field- • The CDSS recommend referral • A tablet-based CDSS
(2014; Andhra NPHWsx, and PHC tested in 11 villages and 3 to a doctor to 128 of 227 adults implemented within
Pradesh, India) physicians. 227 adults PHCs. CVD risk factor and did not recommend referral primary health care
[moderate] screened by ASHAs, profile for participants to 99 of 227 adults. systems has the poten-
65 adults screened by screened by ASHAs • High CVD risk was noted in tial to help improve
PHC physicians (n=227) and doctors 88 of 128 (69%) adults, and in CVD outcomes in In-
(n=65) another 40 of 99 (31%) adults. dia
• Blood pressure lowering medi-
cation given to 29 of 65 (45%)
adults and not to 36 of 65
(55%) adults.
• The other assessment of behav-
ior change (COM-Bz model)
revealed 3 themes: (1) potential
to transform prevailing health
care models, (2) task-shifting
of CVD screening to the
ASHA was the central driver
of change, and (3) system-level
barriers such as access to doc-
tors and medicines are still
present

Jadhav et al [26] • Reinforcement of oral

(2016; Maharash- health education
tra, India) [moder- through SMS text mes-
ate] sages is effective me-
dia to improve oral
health

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Study (year; loca- Study population Intervention and control Results Study outcome
tion) [overall risk
of bias]

• Population: adults aged • Intervention group: the • Gender-wise distribution of

18-20 years having a message was reinforced participants: 137 male and 63
personal mobile phone through SMS text mes- female participants in the inter-
with SMS text messag- sages from mobile phones vention group and 149 male
ing capability (N=400; • Control: no oral and 51 female participants in
control: n=200; inter- health–related SMS text the control group (P>.05)
vention: n=200) messages or any kind of • Mean OHIaa score at different
health education was giv- intervals between the interven-
en to the participants tion and control groups showed
no significant difference at
baseline (P=.28) and after the
first month (P=.58); however,
it was significantly lower in the
intervention group after the
second, third, and sixth months
(P<.01)
• Mean GIab scores at different
intervals between the interven-
tion and control groups were
significantly no different at
baseline (P=.39) and after the
first month (P=.85); however,
it was significantly lower in the
intervention group after the
second, third, and sixth months
(P<.01)

a
AHS: Annual Health Survey.
b
CEAHH: cost-effectiveness analysis household.
c
ASHA: accredited social health activist.
d
IFA: iron–folic acid.
e
ANC: antenatal care.
f
PHC: primary health center.
g
TT: Tetanus toxoid.
h
MACCI: modified accredited social health activist–centric composite coverage index.
i
ImTeCHO: Innovative Mobile Technology for Community Health Operation.
j
MNCH: maternal, neonatal, and child health.
k
OR: odds ratio.
l
MfM: Mobile for Mothers.
m
NGO: nongovernmental organization.
n
ReMiND: reducing maternal and newborn deaths.
o
DALY: disability-adjusted life year.
p
IMR: infant mortality rate.
q
CHC: community health center.
r
EUC: enhanced usual care.
s
NCD: noncommunicable disease.
t
SBP: systolic blood pressure.
u
HbA1c: hemoglobin A1c.
v
CVD: cardiovascular disease.
w
mMRIG: media-rich interactive guideline.
x
NPHW: nonphysician health care worker.
y
CDSS: clinical decision support system.
z
COM-B: capability, opportunity, and motivation.
aa
OHI: Oral Hygiene Index.
ab
GI: Gingival Index.

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Meta-Analysis A pseudo-RCT conducted in Mumbai (Maharashtra, India) by

There was substantial heterogeneity among studies in their Murthy et al [16], assessed the impact of age- and stage-based
mHealth interventions and outcomes, except for studies on mobile phone voice messaging for pregnant women on reduction
maternal, neonatal, and child health. Consequently, we in low birth weight and child malnutrition and improvement in
performed a random-effects meta-analysis using the women’s infant care knowledge and practices. They observed
Mantel-Haenszel method in RevMan [27] for 3 comparable that the intervention group performed well in infant care practice
studies, which had all used cell phones rather than routine indicators: administering supplementary feeding to the infant
prenatal care as the intervention and had assessed increases in at 6 months of age (odds ratio [OR] 1.4, 95% CI 1.08-1.82;
the number of antenatal check-ups, tetanus toxoids administered P=.009) and fully immunizing the infant (OR 1.531, 95% CI
to pregnant women, institutional deliveries, and iron–folic acid 1.141-2.055; P=.005). Moreover, women in the intervention
to assess the effect of health care usage. However, as the relevant group had increased knowledge of giving infants solid food by
intervention for the purpose of this review, we exclusively 6 months of age and of the fact that the ideal birth weight is
compared the cell phone group to the usual care group in the >2.5 kg [16]. A study from Jharkhand used a mobile app to
meta-analysis. However, given the small number of studies, we support home visits by community health workers; Ilozumba
did not undertake possible sensitivity analyses. et al [17] found that women receiving the mHealth intervention
were more likely to attend 4 or more ANC visits and had
Results significantly higher odds of delivering a baby at a health center
than those receiving standard care and those receiving other
Types of Outcomes Examined interventions from a nongovernmental organization. Moreover,
the usage of ANC services and delivery at a health center were
Four studies examined the indicators of maternal, neonatal, and
associated with the education level of the spouse [17].
child health [14-17]—these reported the number of antenatal
check-ups [14,15,17]; birth weight [15]; institutional delivery Cost-Effectiveness
[14-17]; knowledge of the danger signs of pregnancy [14,15]; Prinja et al [18] assessed the cost-effectiveness of the ReMiND
indicators of infant feeding and breastfeeding [14]; usage of (reducing maternal and newborn deaths) program in Uttar
antenatal, intrapartum, and postnatal care [14,15,17]; indicators Pradesh, India; both the societal and health care perspectives
of self-efficacy [15,17]; uptake of immunization [14,15]; and were taken into account. Overall, the ReMiND program was
maternal health knowledge [17]. We found two studies considered a cost-saving intervention from the societal
evaluating the cost-effectiveness of mHealth programs [18,19]. perspective. It resulted in a cost saving of US $90 per DALY
Other outcomes included improvement in diabetes risk behaviors averted US $2569 per death averted. From the health system
and increased awareness about the causes and complications of perspective, the ReMiND program incurred an incremental cost
diabetes [20], improvement in medication adherence and the of 12,993 (US $205) per DALY averted and 371,577 (US
frequency of blood glucose testing [21], change in systolic blood $5865) per death averted [18]. A study conducted in Gujrat,
pressure and hemoglobin A1c levels [22], quality of care India, found the ImTeCHO (Innovative Mobile Technology for
delivered by primary health workers [23-25], and oral health Community Health Operation) intervention to be cost-effective
education [26]. The results are organized below in accordance at an incremental cost of US $74 per life-years saved or US
with the types of outcomes examined in each study. $5057 per death averted [19].
Effects on Maternal, Neonatal, and Child Health Effect on Chronic Conditions
A pre-post quasi-experimental study used an mHealth Study conducted by Pfammatter et al [20] to examine the effect
application in the Kaushambi district in Uttar Pradesh, India, of mDiabetes—a text messaging program to improve diabetes
to increase the quality of counseling by community health risk behaviors—on fruit, vegetable, and fat intake and exercise
volunteers, resulting in improved uptake of maternal, neonatal, among Nokia phone users in India. A greater improvement in
and child health services. A significant increase in coverage the health behavior composite score over 6 months was observed
iron–folic acid supplementation and identification and among participants who received the text messages than among
self-reporting of illnesses or complications during pregnancy those who did not receive text messages [20]. An RCT
and after delivery were seen in the intervention area, but there conducted by Kleinman et al [21] at 3 sites in India assessed
was no change in the quality of antenatal care (ANC) care [14]. the impact of an mHealth diabetes platform on clinical
Similarly, an mHealth application was used in an open cluster outcomes, patient-reported outcomes, patient and provider
RCT conducted in 22 primary health centers in 6 tribal blocks satisfaction, and app usage. There was decrease of 1.5% in mean
of Bharuch and Narmada districts in Gujrat, India, to assess the hemoglobin A1c levels in the intervention group and 0.8% in
increase in the coverage of maternal, neonatal, and child health the usual care group, an improvement in self-reported
services and that of at least 2 home visits by accredited social medication adherence from baseline, and an increase in blood
health activists within the first week of birth. There were glucose testing in the intervention group from baseline compared
significant improvements in coverage home visits by accredited to that in the control group (39.0% vs 10.3%, respectively;
social health activists during the antenatal and postnatal period, P=.01) [21]. Prabhakaran et al [22] conducted a cluster-RCT
early initiation of breastfeeding, and exclusive breastfeeding using the mWellcare system for integrated management of 5
[15]. chronic conditions (hypertension, diabetes mellitus, current
tobacco and alcohol use, and depression). No evidence of

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difference in systolic blood pressure and hemoglobin A1c levels cardiovascular disease outcomes, but system-level barriers have
was observed between the intervention and control groups [22]. an impact on limiting the access to medical care. Jadhav et al
[26] assessed the effectiveness of the reinforcement of oral
Other Effects health education SMS text messages and reported that mean
Garner et al [23] determined the effectiveness of an mHealth Oral Hygiene Index and Gingival Index scores in the
application to improve hypertension health literacy among intervention group were significantly lower than those in the
vulnerable populations in India. A significant improvement in control group (P<.01).
the understanding of hypertension through the innovative
animated application was observed [23]. In the RCT conducted Effect on Health Care Usage
in rural areas of Tamil Nadu, India, Gautham et al [24] observed Among pregnant women, those using mHealth interventions
that mobile app–based procedural guidance for rural frontline were more likely to take a complete dose of iron–folic acid
health care providers had significant potential for attaining supplements (OR 14.30, 95% CI 6.65-30.75; Figure 2), both
consistently standardized quality of care with patients’ doses of the tetanus toxoid (OR 2.47, 95% CI 0.22-27.37; Figure
acceptance. Praveen et al [25] showed that implementation of 3), and to attended 4 or more antenatal care check-ups (OR 1.82,
a mobile clinical decision support system for cardiovascular 95% CI 0.65-5.09; Figure 4) than those who received routine
disease management by public nonphysician health care workers prenatal care. No strong evidence of differences regarding
and physicians in a rural Indian setting increased the number institutional deliveries (OR 1.14, 95% CI 0.26-4.95) were found.
of referrals to the physician and had potential to help improve
Figure 2. Meta-analysis of the effect of mobile health interventions versus standard care on the intake of complete doses of iron–folic acid supplements
during prenatal care. IFA: iron–folic acid; mHealth: mobile health; OR: odds ratio; SC: standard care.

Figure 3. Meta-analysis of the effect of mobile health interventions versus standard care on taking 2 doses of the tetanus toxoid during pregnancy.
mHealth: mobile health; OR: odds ratio; TT: tetanus toxoid.

Figure 4. Meta-analysis of the effect of mobile health interventions versus standard care on 3 or more antenatal care check-ups conducted during
pregnancy. mHealth: mobile health; OR: odds ratio; SC: standard care.

of disease, rapid population growth, and challenges of extending

Discussion health care to underserved populations. We identified 13 studies
Principal Findings showing the impact of mobile technology–based interventions
designed to improve health care service delivery processes in
mHealth is an implicit, promising tool for addressing several the Indian setting. Most studies were at moderate and low risk
health care system limitations in transitional countries, such as of bias. Heterogeneity among studies did not allow the
a limited health care workforce, scarce resources, high burden calculation of a pooled estimate for all the parameters. However,
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a meta-analyses of 3 studies arbitrated to be sufficiently All the studies included in this review provide evidence that the
homogenous showed that mHealth interventions used for interventions conducted for the chronic diseases had an impact
maternal and child health improved the usage of prenatal on clinical outcomes, patient and provider satisfaction, app
services including the intake of a complete dose of iron–folic usage, and improvement in health behavior (except for the study
acid supplements, taking both doses of the tetanus toxoid, and conducted by Prabhakaran et al [22]). Similar findings were
attending 4 or more antenatal care check-ups. No strong described in the review conducted by Beratarrechea et al [31]
evidence of differences regarding institutional deliveries were for chronic diseases in transitional countries, which addressed
found. A similar review conducted by Lee et al [28] for low- to more than 1 outcome and reported a positive impact on chronic
middle-income countries showed that mHealth technologies are disease outcomes.
rapidly being used to promote health care use, improve the
quality of pre- and postnatal care, and collect data on pregnancy
Limitations and Conclusion
and child health. This paper reviews the comprehensive use of mHealth
technologies in all sectors of health care in India. We used a
In our systematic review, we could not use economic thorough, extensive, and highly sensitive literature search
evaluation–tailored reporting standards (such as the CHEERS technique in this systematic review, which analyses both health
[Consolidated Health Economic Evaluation Reporting and health care usage indicators, encompassing the entire scope
Standards] checklist [29]) for full economic evaluation due to of relevant mHealth technologies including those focusing on
the lack of sufficient economic evaluation studies, as indicated maternal and child health and chronic diseases. All comparative
by Iribarren et al [30], who described the evidence related to reviews have been conducted for low- to middle-income
economic evaluations of mHealth interventions in low- to countries and mainly focused on the either chronic disease or
middle-income countries and in the evaluation of 2 mHealth maternal and child health [28,30-38].
interventions in India: ReMiND [18] and ImTeCHO [19]. These
studies included a comparison of the effectiveness of a However, due to a small number of studies for a single set of
health-related outcome and reported economic data. Both the interventions, a meta-analysis for all the impact indicators was
studies showed a positive economic impact considering the not conducted. Additional work is needed to improve and test
societal perspective. this with a larger set of interventions, and to determine how to
best integrate it with different conceptual frameworks that have
been published.

Conflicts of Interest
None declared.

Multimedia Appendix 1
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.
[DOCX File , 32 KB-Multimedia Appendix 1]

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Abbreviations
ANC: antenatal care
CHEERS: Consolidated Health Economic Evaluation Reporting Standards
DALY: disability-adjusted life year
ImTeCHO: Innovative Mobile Technology for Community Health Operation
MeSH: Medical Subject Headings
mHealth: mobile health
OR: odds ratio
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
RCT: randomized controlled trial
ReMiND: reducing maternal and newborn deaths

Edited by E Mensah; submitted 26.02.22; peer-reviewed by VJ Latha Bommu, P Boakye; accepted 03.02.23; published 04.09.23
Please cite as:
Joshi V, Joshi NK, Bhardwaj P, Singh K, Ojha D, Jain YK
The Health Impact of mHealth Interventions in India: Systematic Review and Meta-Analysis
Online J Public Health Inform 2023;15:e50927
URL: https://ojphi.jmir.org/2023/1/e50927
doi: 10.2196/50927
PMID: 38046564

©Vibha Joshi, Nitin Kumar Joshi, Pankaj Bhardwaj, Kuldeep Singh, Deepika Ojha, Yogesh Kumar Jain. Originally published
in the Online Journal of Public Health Informatics (https://ojphi.jmir.org/), 04.09.2023. This is an open-access article distributed
under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits

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https://ojphi.jmir.org/2023/1/e50927 Online J Public Health Inform 2023 | vol. 15 | e50927 | p. 16

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