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Cited by 126Mobile Health and mHealth ApplicationsDigital Mental Health InterventionsTelemedicine and Telehealth Implementation

Digital health interventions for non-communicable disease management in primary health care in low-and middle-income countries

Open access
Xiong, Shangzhi, Lu, Hongsheng, Peoples, Nicholas, Duman, Ege K., Najarro, Alberto, Ni, Zhao, Gong, Enying, Yin, Ruoyu +6 more·2023·npj Digital Medicine
DOI 10.1038/s41746-023-00764-4PMC PMC9889958
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Abstract

Current evidence on digital health interventions is disproportionately concerned with high-income countries and hospital settings. This scoping review evaluates the extent of use and effectiveness of digital health interventions for non-communicable disease (NCD) management in primary healthcare settings of low- and middle-income countries (LMICs) and identifies factors influencing digital health interventions’ uptake. We use PubMed, Embase, and Web of Science search results from January 2010 to 2021. Of 8866 results, 52 met eligibility criteria (31 reviews, 21 trials). Benchmarked against World Health Organization’s digital health classifications, only 14 out of 28 digital health intervention categories are found, suggesting critical under-use and lagging innovation. Digital health interventions’ effectiveness vary across outcomes: clinical (mixed), behavioral (positively inclined), and service implementation outcomes (clear effectiveness). We further identify multiple factors influencing digital health intervention uptake, including political commitment, interactivity, user-centered design, and integration with existing systems, which points to future research and practices to invigorate digital health interventions for NCD management in primary health care of LMICs.

AI snapshot

Written from the paper’s full text.

TL;DR

This scoping review synthesizes evidence on digital health interventions for non-communicable disease (NCD) management in primary health care in low- and middle-income countries (LMICs), finding under-use relative to WHO classifications and mixed effectiveness across outcomes. It identifies political commitment, interactivity, user-centered design, and integration with existing systems as key factors influencing uptake.

Key findings

  • Of 8,866 records, 52 studies met eligibility criteria: 31 reviews and 21 trials; only 14 of 28 WHO digital health intervention categories were found, indicating “critical under-use and lagging innovation.”
  • Effectiveness varied by outcome: clinical outcomes were “highly mixed,” behavioral outcomes were “more positively inclined,” and service implementation outcomes showed “clear effectiveness” or “consistently positive” results.
  • Identified interventions were mainly used by primary healthcare providers (8 types) and clients (5 types), with 2 used by both; no interventions were found for health system managers.
  • Factors influencing uptake were grouped into policymakers (n = 2), technological industry (n = 4), digital health designers (n = 7), and digital health users (n = 6), including political commitment, interoperability, co-design, training, and incentives.

Methods

  • Scoping review guided by PRISMA-ScR, searching PubMed, Embase, and Web of Science from January 1, 2010, to April 30, 2021, for reviews and experimental studies on digital health for NCD management in primary healthcare settings in LMICs.
  • Three rounds of screening by title, abstract, and full text were conducted by trained reviewers, with at least two independent reviewers per article; 52 papers were included.
  • Data extraction covered study characteristics, digital health interventions, effectiveness by outcomes, and factors influencing uptake; analysis used WHO digital health classifications, WHO quality of care dimensions, and inductive content analysis. Trial quality was assessed with National Heart, Lung, and Blood Institute tools.

Limitations

  • The paper states it focused only on academic publications in English and could not include grey literature, especially from non-English-speaking settings.
  • The paper states high heterogeneity prevented rigorous quantitative synthesis such as meta-analysis, so it used narrative synthesis instead.
  • Evident from the text: more than half of included trials were of suboptimal quality (n = 12), commonly due to lack of randomization (n = 11), lack of evidence on sample size sufficiency (n = 10), and absence of pre-specification for study outcomes (n = 7).

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1038/s41746-023-00764-4

Cites

87 of 87 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 115 cited sources checked · 0 supported · 0 flagged

  • Findingnone given

    Multiple factors influence digital health intervention uptake, including political commitment, interactivity, user-centered design, and integration with existing systems.

    “We further identify multiple factors influencing digital health intervention uptake, including political commitment, interactivity, user-centered design, and integration with existing systems”
    Quote in the paperSubstantial claim
  • Findingown data

    Communication-related digital health interventions were the most widely explored in the included studies.

    “the communication-related digital health interventions (i.e., SMS, multimedia message services, and online platforms, shown in different shades of blue) were the most widely explored in the included studies”
    Quote in the paperNot a substantial claim
  • Findingcitation

    The development in technologies and infrastructures provides solid ground for digital health advancement, including penetration of cell phones and the internet.

    “The development in technologies and infrastructures provide solid ground for digital health advancement, including penetration of cell phones and the internet.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [23] Agarwal, R., Bills, J. E., Hecht, T. J. W. & Light, R. P. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension 57, 29–38 (2011). source

      Not checked in the free run.

    • cites [24] Almutairi, N., Hosseinzadeh, H. & Gopaldasani, V. The effectiveness of patient activation intervention on type 2 diabetes mellitus glycemic control and self-management behaviors: a systematic review of RCTs. Prim. Care Diabetes 14, 12–20 (2020). source

      Not checked in the free run.

    • cites [26] Beishuizen, C. R. L. et al. Web-based interventions targeting cardiovascular risk factors in middle-aged and older people: a systematic review and meta-analysis. J. Med. Internet Res. 18, e55 (2016). source

      Not checked in the free run.

  • Findingown data

    Both trials and reviews suggested that digital health interventions aimed at strengthening providers' capacities (decision support systems and online trainings) were substantially mixed in almost all clinical and behavioral outcomes.

    “both the trials and reviews suggested that digital health interventions that aimed to strengthen providers’ capacities (i.e., decision support systems and online trainings, shown in different shades of purple) were substantially mixed in almost all the clinical and behavioral outcomes.”
    Quote in the paperSubstantial claim
  • Findingown data

    No digital health interventions used by health system managers were found in the selected studies.

    “We did not find any digital health interventions that were used by health system managers from the selected studies.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 40
  • Classified as probably not a substantial claim. 16

  • May combine two claims.

    Findingown data

    Three major types of outcomes were found: eight clinical outcomes, six behavioral outcomes, and seven implementation outcomes.

    “We found three major types of outcomes from all included studies: (1) eight types of clinical outcomes for individuals including control for blood pressure, blood glucose, hospitalization, and mortality; (2) six types of behavioral outcomes for individuals, including self-management activities such as medication adherence, and health behaviors such as diet and physical activity; and (3) seven ty”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    52 papers met eligibility criteria, comprising 31 reviews and 21 trials.

    “Of 8866 results, 52 met eligibility criteria (31 reviews, 21 trials).”
    • Also stated in: § Search results · plain
      “A total of 52 papers were included for final analysis.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    More than half of the included trials were of suboptimal quality (n=12), with eight of good quality and one of fair quality.

    “For quality assessment, more than half of the included trials were of suboptimal quality (n = 12), with eight of them of good quality and one with fair quality.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Behavioral outcomes of digital health interventions were more positively inclined, with many studies showing a significantly positive impact on disease self-management activities and healthy lifestyles.

    “the effects of digital health interventions on individual behavioral outcomes were more positively inclined, where many studies showed a significantly positive impact on disease self-management activities and healthy lifestyles”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Digital-based clinical practices (screening, diagnosis, prescribing, monitoring) were consistently effective in all types of outcomes in trials, but in reviews their effectiveness in clinical outcomes was mixed.

    “the digital-based clinical practices (i.e., screening, diagnosis, prescribing, and monitoring, shown in different shades of orange) were found to be consistently effective in all types of outcomes in the trials, but in the reviews their effectiveness in clinical outcomes were mixed.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    The most common factors compromising study quality were lack of randomization (n=11), lack of evidence on sample size sufficiency (n=10), and absence of pre-specification for study outcomes (n=7).

    “The most common factors that compromised the studies’ quality were the lack of randomization (n = 11), lack of evidence on sample size sufficiency (n = 10) and absence of pre-specification for study outcomes (n = 7)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In trials, several quasi-experimental studies documented positive effects of communication-related interventions on control of blood pressure, glucose, lipids, and weight, and many RCTs found effectiveness in improving adherence to medication and health services.

    “Among the trials (Fig. 2), several quasi-experimental studies documented the positive effects from these interventions in the control of blood pressure, glucose, lipids, and weight, and many RCTs also found their effectiveness in improving people’s adherence to medication and health services.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Multiple factors influencing uptake were identified and classified into four groups: policymakers (n=2), technological industry (n=4), digital health designers (n=7), and digital health users (n=6).

    “we identified multiple factors influencing the uptake of digital health interventions for NCD management in primary health care of LMICs (Table 2). Based on the nature of different stakeholders, we further classified these factors into four groups: (1) factors regarding policymakers (n = 2), (2) factors regarding technological industry (n = 4), (3) factors regarding digital health designers (n = 7”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Most digital health interventions focused on improving health service efficiency (n=9) and accessibility (n=9), followed by effectiveness (n=9), while acceptability (n=6), equity (n=5), and safety (n=4) were less addressed.

    “most of these digital health interventions focused on improving health service efficiency (n = 9) and accessibility (n = 9), followed by effectiveness (n = 9), while acceptability (n = 6), equity (n = 5), and safety (n = 4) issues were relatively less addressed”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Clinical outcomes of digital health interventions were highly mixed, with both positive and negative/neutral results common in trials and reviews.

    “the findings for clinical outcomes, such as blood pressure and blood glucose control, were highly mixed, where both positive and negative/neutral results were common in both trials and reviews”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    There was major under-use of digital health interventions compared with the WHO classification, with no interventions in citizen-based reporting, client financial transactions, referral coordination, health worker activity planning and scheduling, and no interventions for healthcare managers such as human resource management and supply chain management.

    “Compared with the WHO classification, there were major under-use of digital health interventions in these studies. For example, there was no intervention in “citizen-based reporting”, “client financial transactions”, “referral coordination”, and “health worker activity planning and scheduling”, and there were no digital health interventions for healthcare managers, such as “human resource manag”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Eight of the identified digital health interventions were used by primary healthcare providers, five by healthcare clients, and two by both.

    “Eight of the identified digital health interventions were used by primary healthcare providers, such as EHR, decisions support systems, and telemonitoring devices. Five interventions were used by healthcare clients (i.e. people with NCDs), including short messaging services (SMS), multimedia message services, and interactive voice responses or phone calls. Two were used by both healthcare provider”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Health service implementation outcomes of digital health interventions were consistently positive, with improvements in accessibility, user experience, provider capacities, and/or cost-effectiveness.

    “for health service implementation outcomes, results were consistently positive among both trial reviews, where digital health interventions improved the accessibility and user experience in health service delivery, improved primary healthcare providers’ capacities, and/or with better cost-effectiveness”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Adequate high-quality personnel training for primary healthcare providers is a facilitator for digital health uptake, while lack of that could be a barrier.

    “Adequate high-quality personnel training for primary healthcare providers is a facilitator for digital health uptake, while lack of that could be a barrier.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [40] Kim, B. Y. & Lee, J. Smart devices for older adults managing chronic disease: a scoping review. JMIR mHealth uHealth 5, e69 (2017). source

      Not checked in the free run.

    • cites [53] Zapata, B. C., Fernández-Alemán, J. L., Idri, A. & Toval, A. Empirical studies on usability of mHealth apps: a systematic literature review. J. Med. Syst. 39, 1 (2015). source

      Not checked in the free run.

    • cites [55] Beratarrechea, A. et al. Using mHealth tools to improve access and coverage of people with public health insurance and high cardiovascular disease risk in Argentina: a pragmatic cluster randomized trial. J. Am. Heart Assoc. 8, e011799 (2019). source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Digital health designs that were integrated into existing healthcare model was a facilitator for successful uptake, and unintegrated digital health interventions that impose additional workload for primary healthcare providers is a barrier.

    “Digital health designs that were integrated into existing healthcare model was a facilitator for successful uptake, and unintegrated digital health interventions that impose additional workload for primary healthcare providers is a barrier.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [24] Almutairi, N., Hosseinzadeh, H. & Gopaldasani, V. The effectiveness of patient activation intervention on type 2 diabetes mellitus glycemic control and self-management behaviors: a systematic review of RCTs. Prim. Care Diabetes 14, 12–20 (2020). source

      Not checked in the free run.

    • cites [70] Silveira, D. V. et al. Development and evaluation of a mobile decision support system for hypertension management in the primary care setting in Brazil: mixed-methods field study on usability, feasibility, and utility. JMIR mHealth uHealth 7, e9869 (2019). source

      Not checked in the free run.

    • cites [71] Tian, M. et al. A cluster-randomized, controlled trial of a simplified multifaceted management program for individuals at high cardiovascular risk (SimCard trial) in rural Tibet, China, and Haryana, India. Circulation 132, 815–824 (2015). source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Incorporating users' feedback on acceptability and satisfaction is a facilitator, and lack of that could be a barrier and is currently under-addressed.

    “Incorporating users’ feedback on acceptability and satisfaction is a facilitator, and lack of that could be a barrier and is currently under-addressed.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [33] Dounavi, K. & Tsoumani, O. Mobile health applications in weight management: a systematic literature review. Am. J. Prev. Med. 56, 894–903 (2019). source

      Not checked in the free run.

    • cites [43] Mair, F. S. et al. BotWHO. Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review. Bull. World Health Organ 90, 357–364 (2012). source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Designing incentives/motivations for primary healthcare providers and patients to use digital health facilitates the uptake, while lack of that could be a barrier.

    “Designing incentives/motivations for primary healthcare providers and patients to use digital health facilitates the uptake, while lack of that could be a barrier.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [34] El-Gayar, O., Timsina, P., Nawar, N. & Eid, W. A systematic review of IT for diabetes self-management: are we there yet? Int. J. Med. Inform. 82, 637–652 (2013). source

      Not checked in the free run.

    • cites [45] McNatt, Z. Z. Addressing noncommunicable diseases among urban refugees in the Middle East and North Africa-a scoping review. Confl. Health 14, 1–14 (2020). source

      Not checked in the free run.

    • cites [51] Wang, Y., Xue, H., Huang, Y., Huang, L. & Zhang, D. A systematic review of application and effectiveness of mHealth interventions for obesity and diabetes treatment and self-management. Adv. Nutr. 8, 449–462 (2017). source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Tailored design and personalized contents for patients is a facilitator, and one-for-all unified contents and designs could be a barrier.

    “Tailored design and personalized contents for patients is a facilitator, and one-for-all unified contents and designs could be a barrier.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [34] El-Gayar, O., Timsina, P., Nawar, N. & Eid, W. A systematic review of IT for diabetes self-management: are we there yet? Int. J. Med. Inform. 82, 637–652 (2013). source

      Not checked in the free run.

    • cites [39] Kebede, M. M., Liedtke, T. P., Möllers, T. & Pischke, C. R. Characterizing active ingredients of eHealth interventions targeting persons with poorly controlled type 2 diabetes mellitus using the behavior change techniques taxonomy: scoping review. J. Med. Internet Res. 19, e348 (2017). source

      Not checked in the free run.

    • cites [50] Pai, R. R. & Alathur, S. Bibliometric analysis and methodological review of mobile health services and applications in India. Int. J. Med. Inform. 145, 104330 (2021). source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Incorporating behavioral theories in digital health design is a facilitator, and the absence of that could be a barrier.

    “Incorporating behavioral theories in digital health design is a facilitator, and the absence of that could be a barrier.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [29] Buhi, E. R. et al. Mobile phone-based behavioural interventions for health: a systematic review. Health Educ. J. 72, 564–583 (2013). source

      Not checked in the free run.

    • cites [39] Kebede, M. M., Liedtke, T. P., Möllers, T. & Pischke, C. R. Characterizing active ingredients of eHealth interventions targeting persons with poorly controlled type 2 diabetes mellitus using the behavior change techniques taxonomy: scoping review. J. Med. Internet Res. 19, e348 (2017). source

      Not checked in the free run.

    • cites [52] Watkins, J. A. et al. mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review. BMJ Glob. Health 3, e000543 (2018). source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Digital health tools that enable two-way human interactions are better accepted, while replacing human communications with automatic responses is less favored.

    “Digital health tools that enable two-way human interactions are better accepted while replacing human communications with automatic responses is less favored.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [26] Beishuizen, C. R. L. et al. Web-based interventions targeting cardiovascular risk factors in middle-aged and older people: a systematic review and meta-analysis. J. Med. Internet Res. 18, e55 (2016). source

      Not checked in the free run.

    • cites [32] de Jongh, T., Gurol-Urganci, I., Vodopivec-Jamsek, V., Car, J. & Atun, R. Mobile phone messaging for facilitating self-management of long-term illnesses. Cochrane Database Syst. Rev. 12, Cd007459 (2012).

      Not checked in the free run.

    • cites [34] El-Gayar, O., Timsina, P., Nawar, N. & Eid, W. A systematic review of IT for diabetes self-management: are we there yet? Int. J. Med. Inform. 82, 637–652 (2013). source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Easily navigable interface is a facilitator, and poor/complicated interface is a barrier for the uptake of digital health tools.

    “Easily navigable interface is a facilitator, and poor/complicated interface is a barrier for the uptake of digital health tools.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [34] El-Gayar, O., Timsina, P., Nawar, N. & Eid, W. A systematic review of IT for diabetes self-management: are we there yet? Int. J. Med. Inform. 82, 637–652 (2013). source

      Not checked in the free run.

    • cites [40] Kim, B. Y. & Lee, J. Smart devices for older adults managing chronic disease: a scoping review. JMIR mHealth uHealth 5, e69 (2017). source

      Not checked in the free run.

    • cites [47] Müller, A. M., Alley, S., Schoeppe, S. & Vandelanotte, C. J. I. JoBN, Activity P. The effectiveness of e- & mHealth interventions to promote physical activity and healthy diets in developing countries: a systematic review. Int. J. Behav. Nutr. Phys. Act. 13, 109 (2016). source

      Not checked in the free run.

  • May combine two claims.

    Findingnone given

    Current digital health interventions in LMICs relied on importing existing technologies from other settings to places they were not created for, sometimes in one-off research projects.

    “However, current digital health interventions in LMICs relied on importing existing technologies from other settings to places they were not created for, sometimes in one-off research projects.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    In the included studies, digital health interventions for individuals' behavioral outcomes showed positively inclined results, although mixed, especially when substantiated by behavioral science theories.

    “For individuals’ behavioral outcomes, although still mixed, we consistently observed positively inclined results, especially when substantiated by behavioral science theories26,82.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [26] Beishuizen, C. R. L. et al. Web-based interventions targeting cardiovascular risk factors in middle-aged and older people: a systematic review and meta-analysis. J. Med. Internet Res. 18, e55 (2016). source

      Not checked in the free run.

    • cites [82] Ajay, V. S. et al. Development of a smartphone‐enabled hypertension and diabetes mellitus management package to facilitate evidence‐based care delivery in primary healthcare facilities in India: the mPower Heart Project. J. Am. Heart Assoc. 5, e004343 (2016). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Some studies attributed the highly mixed and neutral results on clinical outcomes to study design limitations, such as small sample size and short follow-up durations.

    “some studies attributed the highly mixed and neutral results to the study design limitations, such as small sample size and short follow-up durations40,52.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [40] Kim, B. Y. & Lee, J. Smart devices for older adults managing chronic disease: a scoping review. JMIR mHealth uHealth 5, e69 (2017). source

      Not checked in the free run.

    • cites [52] Watkins, J. A. et al. mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review. BMJ Glob. Health 3, e000543 (2018). source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    In the included studies, digital health interventions improved timeliness of and accessibility to health care and information.

    “This included improved user experience, timeliness of and accessibility to health care and information, consistent with studies in other settings20,85,86.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [20] Khoong, E. C. et al. Mobile health strategies for blood pressure self-management in urban populations with digital barriers: systematic review and meta-analyses. npj Digit. Med. 4, 1–12 (2021). source

      Not checked in the free run.

    • cites [85] Khoong, E. C. et al. Patient interest in and barriers to telemedicine video visits in a multilingual urban safety-net system. J. Am. Med. Inform. Assoc. 28, 349–353 (2021). source

      Not checked in the free run.

    • cites [86] Khoong, E. C. et al. Health information seeking behaviors and preferences of a diverse multi-lingual cohort. Med. Care 57, S176 (2019). source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    The mobilization of local communities with local capacity improvements is a facilitator to enhance the use of digital health tools, and lack of those could be a barrier.

    “The mobilization of local communities with local capacity improvements is a facilitator to enhance the use of digital health tools, and lack of those could be a barrier.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [43] Mair, F. S. et al. BotWHO. Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review. Bull. World Health Organ 90, 357–364 (2012). source

      Not checked in the free run.

    • cites [59] dos Santos, M. V. R., de Oliveira, D. C. & Novaes, M. D. A telehealth strategy for increasing adherence in the treatment of hypertension in primary care. Telemed. E-Health 19, 241–247 (2013). source

      Not checked in the free run.

    • cites [70] Silveira, D. V. et al. Development and evaluation of a mobile decision support system for hypertension management in the primary care setting in Brazil: mixed-methods field study on usability, feasibility, and utility. JMIR mHealth uHealth 7, e9869 (2019). source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    The included studies presented high heterogeneity in the outcomes of using digital health, which was also found in other systematic reviews.

    “the included studies still presented high heterogeneity in the outcomes of using digital health, which was also found in other systematic reviews19–21.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [19] McLean, G. et al. Digital interventions to promote self-management in adults with hypertension systematic review and meta-analysis. J. Hypertens. 34, 600 (2016). source

      Not checked in the free run.

    • cites [20] Khoong, E. C. et al. Mobile health strategies for blood pressure self-management in urban populations with digital barriers: systematic review and meta-analyses. npj Digit. Med. 4, 1–12 (2021). source

      Not checked in the free run.

    • cites [21] Xiong, S. et al. Effectiveness of mHealth interventions in improving medication adherence among people with hypertension: a systematic review. Curr. Hypertens. Rep. 20, 1–15 (2018). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The World Health Organization classified digital health interventions according to four types of users, including 28 categories and 87 sub-categories.

    “The World Health Organization (WHO) further classified digital health interventions according to four types of users, including 28 categories and 87 sub-categories4.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] World Health Organization. Classification of Digital Health Interventions v1. 0: A Shared Language to Describe the Uses of Digital Technology for Health (World Health Organization, 2018).

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Current evidence on digital health interventions is disproportionately concerned with high-income countries and hospital settings.

    “Current evidence on digital health interventions is disproportionately concerned with high-income countries and hospital settings.”
    • Also stated in: § Introduction · plain
      “However, most of these original studies and reviews focused on high-income countries, hospital settings, or fields other than NCDs15,16,19–22.”
    Quote in the paperSubstantial claim0 of 6 sources checked
    • cites [15] Redfern, J. et al. A digital health intervention for cardiovascular disease management in primary care (CONNECT) randomized controlled trial. npj Digit. Med. 3, 117 (2020). 2020/09/10. source

      Not checked in the free run.

    • cites [16] Chow, C. K. et al. Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: a randomized clinical trial. J. Am. Med. Assoc. 314, 1255–1263 (2015). source

      Not checked in the free run.

    • cites [19] McLean, G. et al. Digital interventions to promote self-management in adults with hypertension systematic review and meta-analysis. J. Hypertens. 34, 600 (2016). source

      Not checked in the free run.

    • cites [20] Khoong, E. C. et al. Mobile health strategies for blood pressure self-management in urban populations with digital barriers: systematic review and meta-analyses. npj Digit. Med. 4, 1–12 (2021). source

      Not checked in the free run.

    • cites [21] Xiong, S. et al. Effectiveness of mHealth interventions in improving medication adherence among people with hypertension: a systematic review. Curr. Hypertens. Rep. 20, 1–15 (2018). source

      Not checked in the free run.

    • cites [22] Mohr, D. C., Lyon, A. R., Lattie, E. G., Reddy, M. & Schueller, S. M. Accelerating digital mental health research from early design and creation to successful implementation and sustainment. J. Med. Internet Res. 19, e7725 (2017). source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    The finding that only 14 of 28 WHO digital health intervention categories were present indicates critical under-use and lagging innovation in digital health interventions for NCD management in LMIC primary care.

    “suggesting critical under-use and lagging innovation”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    NCDs are characterized by long disease durations and a continuous need to anticipate and mitigate risk factors through lifestyle modifications, which is better addressed by primary health care than higher-level health facilities.

    “This is because NCDs—such as hypertension, diabetes, and cardiovascular diseases—are characterized by long disease durations and a continuous need to anticipate and mitigate risk factors through lifestyle modifications8–11, which is better addressed by primary health care than higher-level health facilities.”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [8] Mahipala, P., Dorji, G., Tisocki, K. & Rani, M. A critical review of addressing cardiovascular and other non-communicable diseases through a primary health care approach in the South-East Asia Region. Cardiovasc. Diagn. Ther. 9, 150 (2019). source

      Not checked in the free run.

    • cites [9] Demaio, A. R., Nielsen, K. K., Tersbøl, B. P., Kallestrup, P. & Meyrowitsch, D. W. Primary health care: a strategic framework for the prevention and control of chronic non-communicable disease. Glob. Health Action 7, 24504 (2014). source

      Not checked in the free run.

    • cites [10] Varghese, C. et al. Better health and wellbeing for billion more people: integrating non-communicable diseases in primary care. BMJ 364, l327 (2019). source

      Not checked in the free run.

    • cites [11] Ndubuisi, N. E. Noncommunicable diseases prevention in low- and middle-income countries: an overview of health in all policies (HiAP). INQUIRY: J. Health Care Organ. Provis. Financing 58, 0046958020927885 (2021). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Most original studies and reviews on digital health interventions focused on high-income countries, hospital settings, or fields other than NCDs.

    “However, most of these original studies and reviews focused on high-income countries, hospital settings, or fields other than NCDs15,16,19–22.”
    Quote in the paperSubstantial claim0 of 6 sources checked
    • cites [15] Redfern, J. et al. A digital health intervention for cardiovascular disease management in primary care (CONNECT) randomized controlled trial. npj Digit. Med. 3, 117 (2020). 2020/09/10. source

      Not checked in the free run.

    • cites [16] Chow, C. K. et al. Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: a randomized clinical trial. J. Am. Med. Assoc. 314, 1255–1263 (2015). source

      Not checked in the free run.

    • cites [19] McLean, G. et al. Digital interventions to promote self-management in adults with hypertension systematic review and meta-analysis. J. Hypertens. 34, 600 (2016). source

      Not checked in the free run.

    • cites [20] Khoong, E. C. et al. Mobile health strategies for blood pressure self-management in urban populations with digital barriers: systematic review and meta-analyses. npj Digit. Med. 4, 1–12 (2021). source

      Not checked in the free run.

    • cites [21] Xiong, S. et al. Effectiveness of mHealth interventions in improving medication adherence among people with hypertension: a systematic review. Curr. Hypertens. Rep. 20, 1–15 (2018). source

      Not checked in the free run.

    • cites [22] Mohr, D. C., Lyon, A. R., Lattie, E. G., Reddy, M. & Schueller, S. M. Accelerating digital mental health research from early design and creation to successful implementation and sustainment. J. Med. Internet Res. 19, e7725 (2017). source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Substantial gaps exist in most primary healthcare systems, particularly in LMICs, including limited human resources and capacity, shortages in medicines and equipment, and suboptimal quality of care.

    “The literature, however, has shown that substantial gaps exist in most primary healthcare systems, particularly in low-and middle-income countries (LMICs), including limited human resources and capacity, shortages in medicines and equipment, and suboptimal quality of care11–13.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [11] Ndubuisi, N. E. Noncommunicable diseases prevention in low- and middle-income countries: an overview of health in all policies (HiAP). INQUIRY: J. Health Care Organ. Provis. Financing 58, 0046958020927885 (2021). source

      Not checked in the free run.

    • cites [12] Bitton, A. et al. Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017. BMJ Glob. Health 4, e001551 (2019). source

      Not checked in the free run.

    • cites [13] Yan, L. L. et al. Strengthening primary health care for the prevention and management of cardiometabolic disease in low-and middle-income countries. New Delhi: World Health Organization Regional Office for South-East Asia (2019).

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Primary health care has been recognized as the cornerstone of combating NCDs worldwide.

    “Primary health care has been recognized as the cornerstone of combating NCDs worldwide6,7.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [6] World Health Organization. Global Conference on Primary Health Care, 25–26 October 2018—Astana, Kazakhstan. Accessed March 10th, 2021. https://www.who.int/teams/primary-health-care/conference.

      Not checked in the free run.

    • cites [7] World Health Organization. Declaration of Alma-Ata (World Health Organization, 2000).

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Premisereasoning

    The literature on digital health interventions for NCD management in primary healthcare settings and LMICs is fragmented and sparse.

    “The literature on digital health interventions for NCD management in primary healthcare settings and LMICs are fragmented and sparse.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationcitation

    This disagreement may result from differences in study locations (high-income countries or LMICs), populations (general population or less advantaged populations), and study settings (hospitals or primary health care).

    “This disagreement may result from differences in study locations (high-income countries or LMICs), populations (general population or less advantaged populations), and study settings (hospitals or primary health care)19,20.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [19] McLean, G. et al. Digital interventions to promote self-management in adults with hypertension systematic review and meta-analysis. J. Hypertens. 34, 600 (2016). source

      Not checked in the free run.

    • cites [20] Khoong, E. C. et al. Mobile health strategies for blood pressure self-management in urban populations with digital barriers: systematic review and meta-analyses. npj Digit. Med. 4, 1–12 (2021). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Digital health as an emerging field might be too broad and inclusive a concept to draw definitive conclusions at least for now, especially at settings where rigorous evidence is sparse.

    “this could also imply that digital health as an emerging field might be too broad and inclusive a concept to draw definitive conclusions at least for now, especially at settings where rigorous evidence is sparse.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Based on the scoping review, digital health interventions are essentially an empowerment strategy for individuals' health and disease management and for health facilities' service delivery.

    “Based on our scoping review, it could be safely inferred that digital health interventions are essentially an empowerment strategy for individuals’ health and disease management and for health facilities’ service delivery.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationcitation

    User-centered design is important for digital health uptake and should entail user engagement in co-design, customization to personal needs and preferences, and feedback evaluations.

    “Second, the importance of user-centered design was repeatedly mentioned in the literature, which should entail user engagement in co-design, customization to personal needs and preferences, and feedback evaluations22,87.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [22] Mohr, D. C., Lyon, A. R., Lattie, E. G., Reddy, M. & Schueller, S. M. Accelerating digital mental health research from early design and creation to successful implementation and sustainment. J. Med. Internet Res. 19, e7725 (2017). source

      Not checked in the free run.

    • cites [87] Bhattacharyya, O., Mossman, K., Gustafsson, L. & Schneider, E. C. Using human-centered design to build a digital health advisor for patients with complex needs: persona and prototype development. J. Med. Internet Res. 21, e10318 (2019). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    The effects of digital health interventions are ultimately subject to their real-world uptake, which is influenced by many factors.

    “In practice, however, effects are ultimately subject to digital health interventions’ real-world uptake, which is influenced by many factors.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    The mixture of findings on clinical outcomes added to the conflicting evidence in the existing literature, where many meta-analyses of related topics disagreed on outcomes such as blood pressure reduction.

    “This mixture of findings on clinical outcomes added to the conflicting evidence in the existing literature, where many meta-analyses of related topics disagreed on outcomes such as blood pressure reduction19,20.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [19] McLean, G. et al. Digital interventions to promote self-management in adults with hypertension systematic review and meta-analysis. J. Hypertens. 34, 600 (2016). source

      Not checked in the free run.

    • cites [20] Khoong, E. C. et al. Mobile health strategies for blood pressure self-management in urban populations with digital barriers: systematic review and meta-analyses. npj Digit. Med. 4, 1–12 (2021). source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    The WHO guideline on digital interventions expected more on health system strengthening, including improving health service coverage, service awareness and utilization, availability and capacity of human resources, availability of commodities and equipment, and service continuity and effectiveness.

    “Although this is promising, the WHO’s guideline on digital interventions expected even more on health system strengthening3, including improving health service coverage, service awareness and utilization, availability and capacity of human resources, availability of commodities and equipment, and service continuity and effectiveness.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3] World Health Organization. WHO Guideline: Recommendations on Digital Interventions for Health System Strengthening: Executive Summary (World Health Organization, 2019).

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Existing studies on NCD management list four major NCD behavioral risk factors: tobacco use, harmful alcohol consumption, unhealthy diet, and physical inactivity.

    “Existing studies on NCD management listed four major NCD behavioral risk factors—tobacco use, harmful alcohol consumption, unhealthy diet, and physical inactivity11.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Ndubuisi, N. E. Noncommunicable diseases prevention in low- and middle-income countries: an overview of health in all policies (HiAP). INQUIRY: J. Health Care Organ. Provis. Financing 58, 0046958020927885 (2021). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The study's steps were guided by PRISMA guidelines (PRISMA-ScR).

    “The following steps were guided by PRISMA guidelines (PRISMA-ScR, Supplementary Table 1)92.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [92] Moher, D. et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement (Chinese edition). J. Chin. Integr. Med. 7, 889–896 (2009). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Each article was independently screened by at least two reviewers.

    “Each article was independently screened by at least two reviewers.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    Optimal uptake of digital health interventions needs to be enhanced by political commitment for regulation, standardization, and support.

    “Finally, the optimal uptake of digital health interventions needs to be enhanced by political commitment for regulation, standardization, and support91.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [91] van den Wijngaart, L. S. et al. Barriers and facilitators when implementing web-based disease monitoring and management as a substitution for regular outpatient care in pediatric asthma: qualitative survey study. J. Med. Internet Res. 20, e284–e284 (2018). source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Trained reviewers independently extracted data and compared their results for consistency.

    “Trained reviewers (S.X., H.L., E.D., A.N., R.D., and S.K.) independently extracted the following data and compared their results for consistency.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    The study conducted a narrative synthesis with the available information, which sufficed to address the research questions and pointed to future research directions.

    “Instead, we conducted a narrative synthesis with the available information, which sufficed to address our research questions and also pointed to future research directions to conduct more quantitative synthesis on specific types and elements of digital health interventions.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductnone given

    The study only focused on academic publications in English and could not include grey literature relating to digital health, especially in non-English speaking settings.

    “First, we only focused on academic publications in English, and could not include grey literatures relating to digital health, especially in non-English speaking settings.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductcitation

    The study assessed the quality of included trials using National Heart, Lung, and Blood Institute's Study Quality Assessment Tools, categorizing them into good, fair, or suboptimal quality based on research practices including randomization, blinding, sample size sufficiency, pre-specification of outcomes, and intent-to-treat analysis.

    “We assessed the study quality of the included trials, following National Heart, Lung, and Blood Institute’s Study Quality Assessment Tools for the quality assessment95. The trials were categorized into good, fair, or suboptimal quality, considering their research practices including randomization, blinding, sample size sufficiency, pre-specification of outcomes, and intent-to-treat analysis.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [95] National Heart Lung and Blood Institute. Study quality assessment tools. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools (2022).

      Not checked in the free run.

50 of 50

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Access to digital tools remains uneven.

    “However, despite the emergence of digital health tools for chronic disease prevention and self-management, access to digital tools remains uneven [62].”

    From Economic evaluation of wearable fitness trackers versus metformin for preventing type 2 diabetes in the UK population (2025) · cites this paper as [62]

  • There are more reports from communities of health researchers in the global south demonstrating the effectiveness of technology-supported, locally informed innovations in delivering care for NCDs and injuries.

    “With each passing year, there are more reports from communities of health researchers in the global south demonstrating the effectiveness of technology-supported, locally informed innovations in delivering care for NCDs and injuries.86–88”

    From Global health 2050: the path to halving premature death by mid-century (2024) · cites this paper as [88]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Reference 27 is labeled as both a trial and a review

    Minor

    The short-message-services row lists reference 27 among trials, but the paper identifies references 23-53 as reviews.

  • Reference 55 is repeatedly labeled as a review

    Minor

    Table 2 places reference 55 in its review lists, although the paper identifies references 54-74 as trials. Reference 55 also appears in a trials list in the same table.

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. World Health Organization. Global Conference on Primary Health Care, 25–26 October 2018—Astana, Kazakhstan. Accessed March 10th, 2021. https://www.who.int/teams/primary-health-care/conference.
  2. Ajay, V. S. et al. Development of a smartphone‐enabled hypertension and diabetes mellitus management package to facilitate evidence‐based care delivery in primary healthcare facilities in India: the mPower Heart Project. J. Am. Heart Assoc. 5, e004343 (2016). · DOI · Paper page

Cited by

Sorted by citations

Related

Authors
Xiong, S., Lu, H., Peoples, N., Duman, E. K., Najarro, A., Ni, Z., Gong, E., Yin, R., Ostbye, T., Palileo-Villanueva, L. M., Doma, R., Kafle, S., Tian, M., & Yan, L. L.
Affiliations
  • UNSW Sydney (AU)
  • Wake Forest University Health Sciences (US)
  • Baylor College of Medicine (US)
  • University of Oxford (GB)
  • Peking University (CN)
  • Yale University (US)
  • Chinese Academy of Medical Sciences & Peking Union Medical College (CN)
  • Nanyang Technological University (SG)
  • Duke University (US)
  • Harbin Medical University (CN)
  • Northwestern University (US)
Corresponding author
  • Xiong, Shangzhi
  • Yan, Lijing L.
ORCID
Venue
npj Digital Medicine
Publisher
Springer Science and Business Media LLC
Published
2023-02-01
Volume
6
Issue
1
Pages
12-12
ISSN
2398-6352 (ISSN-L)
DOI
10.1038/s41746-023-00764-4
PMC
PMC9889958
OpenAlex
W4318816231
Cited by
126
References
87
Citations by year
2026: 45 · 2025: 51 · 2024: 25 · 2023: 5
FWCI
6.37
Type
journal article
Language
en
Open access
Licence
Locations
  • npj Digital Medicine (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DR-NTU (Nanyang Technological University) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
  • The George Institute for Global Health, University of New South Wales, Sydney, Australia
  • WHO | Asia Pacific Observatory on Health Systems and Policies (201963885)
  • Duke Kunshan University, Jiangsu Province, China
Topics
  • Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
Keywords
digital health interventions, non-communicable disease management, primary care, low- and middle-income countries, user-centered design, political commitment, health system innovation

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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