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

In the paper

“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.”

What the sources say

• ?Could not verify

  The Introduction says evidence on the effectiveness of EHR-linked interventions for CVD risk control is limited, and the Discussion notes that this trial took place in urban Australian primary care practices. Neither section assesses whether digital-health research is disproportionately concentrated in high-income countries or hospital settings. Searches for those geographic and setting comparisons found no supporting passage in our copy. (LLM, conf=0.75)

  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. sourceExperimental — accuracy not yet measured
• Not checked yetcites [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
• Partly supported

  The Results (Description of included studies; page unavailable) list seven hypertension-intervention studies, most conducted in countries such as the United States, Canada and Finland. But the Results (Description of interventions, Setting; page unavailable) say five studies were in healthcare settings spanning hospitals, community healthcare and outpatient clinics—not predominantly hospital settings. The review also covers hypertension self-management interventions, rather than digital health interventions generally. (LLM, conf=0.86)

  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). sourceExperimental — accuracy not yet measured
• ?Could not verify

  The Methods (Eligibility criteria; page unavailable) restrict this review to urban populations in high-income countries, but that restriction does not establish where digital-health research is disproportionately concentrated. The Introduction and Discussion address underrepresentation of older, lower-education, and minority populations; neither they nor the passages retrieved about study settings compare high- and lower-income countries or establish a concentration in hospital settings. (LLM, conf=0.76)

  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). sourceExperimental — accuracy not yet measured
• Not checked yetcites [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
• ?Could not verify

  The Background discusses implementation examples in England and the United States, including primary care, but does not assess where digital health intervention evidence is concentrated. Searches for high-income countries and hospital settings found no passage establishing the claimed geographic or setting-based imbalance. (LLM, conf=0.74)

  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). sourceExperimental — accuracy not yet measured

In the paper

“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.”

What the sources say

• Supported

  The Introduction describes NCD care as lifelong and says primary health care offers wider opportunities for prevention and control. “Contextualization of frontline health services for NCDs” identifies risk-factor screening and ongoing care as primary-care functions, while “Building community linkages for NCD care” describes efforts to address modifiable risk factors. The paper advocates strengthening primary care for these needs and reserving referral to higher centres for severe or complex cases. (LLM, conf=0.85)

  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
• Supported

  The section on integrated care says NCD risk factors accumulate throughout the life course and identifies primary care as the most appropriate setting for prevention. The Conclusion’s Table 2 describes NCDs as chronic and largely preventable through lifestyle change, with special emphasis on primary care and community-based programs. The paper also calls for care integrated across levels, rather than excluding higher-level facilities. (LLM, conf=0.88)

  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
• Supported

  The ‘Role of primary care in controlling non-communicable diseases’ section describes NCD care as requiring continuity and prevention over time. The ‘Prevention: modify risk factors and promote health’ section lists lifestyle measures, while ‘Next steps’ argues against treating hospitals and subspecialised facilities as the best setting for NCD care. Page numbers are not available in our copy. (LLM, conf=0.87)

  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
• Partly supported

  The Introduction says NCD prevention should target risk factors and promote healthy lifestyles, and calls prevention at primary health care the best buy in low- and middle-income countries. The Problem section describes the costs of long-term NCD treatment. The paper does not specifically describe a continuous need for lifestyle modification or compare primary care with higher-level health facilities; it also stresses environmental and policy factors beyond individual lifestyle. (LLM, conf=0.84)

  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). sourceExperimental — accuracy not yet measured

In the paper

“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.”

What the sources say

• Not checked yetcites [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
• Partly supported

  The Discussion (Principal Findings; page not provided) identifies duplicate data entry and excessive workload as barriers to TeleHAS use. It says integration with records and clinical workflow should stimulate use and may improve usability, but does not establish that integration facilitated successful uptake. (LLM, conf=0.84)

  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). sourceExperimental — accuracy not yet measured
• Partly supported

  Methods (Intervention; page not provided) says the digital tool was designed for easy use by community health workers to support implementation, and Discussion (The role of community healthcare workers; page not provided) describes adapting the program to local contexts. But Discussion (The use of mobile health technology; page not provided) proposes linking the tool to local health records as a future improvement. The paper does not establish that integration into an existing healthcare model facilitated uptake or that unintegrated tools added workload and posed a barrier. (LLM, conf=0.85)

  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). sourceExperimental — accuracy not yet measured

In the paper

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

What the sources say

• Not checked yetcites [29] Buhi, E. R. et al. Mobile phone-based behavioural interventions for health: a systematic review. Health Educ. J. 72, 564–583 (2013). source
• Supported

  The Discussion (Principal Findings; page unavailable) says theories can enhance uptake of desired behaviors and describes their underutilization in eHealth interventions as a major issue. This supports the claim that incorporating behavioral theories can help, while their absence may hinder an intervention; the paper also notes that evidence on effectiveness is mixed. (LLM, conf=0.86)

  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
• Partly supported

  The Discussion’s policy and practice implications section (page unavailable) says behavioural theory can guide the design of mHealth interventions aimed at changing health behaviours, supporting the facilitator idea. It does not say that omitting theory is a barrier, and its discussion is narrower than digital health design generally. (LLM, conf=0.86)

  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). sourceExperimental — accuracy not yet measured

In the paper

“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”

In the paper

“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.”

In the paper

“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.”

In the paper

“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”

In the paper

“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.”

In the paper

“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)”

In the paper

“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.”

In the paper

“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”

In the paper

“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”

In the paper

“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”

In the paper

“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”

In the paper

“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”

In the paper

“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”

In the paper

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

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [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

In the paper

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

What the sources say

• Not checked yetcites [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 yetcites [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

In the paper

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

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [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

In the paper

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

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [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

In the paper

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

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [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

In the paper

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

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [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

In the paper

“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.”

In the paper

“For individuals’ behavioral outcomes, although still mixed, we consistently observed positively inclined results, especially when substantiated by behavioral science theories26,82.”

What the sources say

• Not checked yetcites [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 yetcites [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

In the paper

“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.”

What the sources say

• Not checked yetcites [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 yetcites [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

In the paper

“This included improved user experience, timeliness of and accessibility to health care and information, consistent with studies in other settings20,85,86.”

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [86] Khoong, E. C. et al. Health information seeking behaviors and preferences of a diverse multi-lingual cohort. Med. Care 57, S176 (2019). source

In the paper

“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.”

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [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

In the paper

“the included studies still presented high heterogeneity in the outcomes of using digital health, which was also found in other systematic reviews19–21.”

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [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

In the paper

“The World Health Organization (WHO) further classified digital health interventions according to four types of users, including 28 categories and 87 sub-categories4.”

What the sources say

• Not checked yetcites [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).

In the paper

“suggesting critical under-use and lagging innovation”

In the paper

“However, most of these original studies and reviews focused on high-income countries, hospital settings, or fields other than NCDs15,16,19–22.”

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [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 yetcites [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 yetcites [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 yetcites [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

In the paper

“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.”

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [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).

In the paper

“Primary health care has been recognized as the cornerstone of combating NCDs worldwide6,7.”

What the sources say

• Not checked yetcites [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 yetcites [7] World Health Organization. Declaration of Alma-Ata (World Health Organization, 2000).

In the paper

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

In the paper

“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.”

What the sources say

• Not checked yetcites [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 yetcites [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

In the paper

“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.”

In the paper

“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.”

In the paper

“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.”

What the sources say

• Not checked yetcites [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 yetcites [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

In the paper

“In practice, however, effects are ultimately subject to digital health interventions’ real-world uptake, which is influenced by many factors.”

In the paper

“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.”

What the sources say

• Not checked yetcites [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 yetcites [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

In the paper

“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.”

What the sources say

• Not checked yetcites [3] World Health Organization. WHO Guideline: Recommendations on Digital Interventions for Health System Strengthening: Executive Summary (World Health Organization, 2019).

In the paper

“Existing studies on NCD management listed four major NCD behavioral risk factors—tobacco use, harmful alcohol consumption, unhealthy diet, and physical inactivity11.”

What the sources say

• Not checked yetcites [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

In the paper

“The following steps were guided by PRISMA guidelines (PRISMA-ScR, Supplementary Table 1)92.”

What the sources say

• Not checked yetcites [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

In the paper

“Each article was independently screened by at least two reviewers.”

In the paper

“Finally, the optimal uptake of digital health interventions needs to be enhanced by political commitment for regulation, standardization, and support91.”

What the sources say

• Not checked yetcites [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

In the paper

“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.”

In the paper

“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.”

In the paper

“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.”

In the paper

“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.”

What the sources say

• Not checked yetcites [95] National Heart Lung and Blood Institute. Study quality assessment tools. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools (2022).