Mobile Phones: The Next Step towards Healthcare

Delivery in Rural India?

Sherwin I. DeSouza1*, M. R. Rashmi1,2, Agalya P. Vasanthi1, Suchitha Maria Joseph1, Rashmi Rodrigues1
1 St. John’s National Academy of Health Sciences, Bangalore, India, 2 Department of Community Medicine, Saveetha Medical College, Thandalam, Chennai, Tamil Nadu,
India

Abstract
Background: Given the ubiquity of mobile phones, their use to support healthcare in the Indian context is inevitable. It is
however necessary to assess end-user perceptions regarding mobile health interventions especially in the rural Indian
context prior to its use in healthcare. This would contextualize the use of mobile phone communication for health to 70% of
the country’s population that resides in rural India.

Objectives: To explore the acceptability of delivering healthcare interventions through mobile phones among users in a
village in rural Bangalore.

Methods: This was an exploratory study of 488 mobile phone users, residing in a village, near Bangalore city, Karnataka,
South India. A pretested, translated, interviewer-administered questionnaire was used to obtain data on mobile phone
usage patterns and acceptability of the mobile phone, as a tool for health-related communication. The data is described
using basic statistical measures.

Results: The primary use of mobile phones was to make or receive phone calls (100%). Text messaging (SMS) was used by
only 70 (14%) of the respondents. Most of the respondents, 484 (99%), were willing to receive health-related information on
their mobile phones and did not consider receiving such information, an intrusion into their personal life. While receiving
reminders for drug adherence was acceptable to most 479 (98%) of our respondents, 424 (89%) preferred voice calls alone
to other forms of communication. Nearly all were willing to use their mobile phones to communicate with health personnel
in emergencies and 367 (75%) were willing to consult a doctor via the phone in an acute illness. Factors such as sex, English
literacy, employment status, and presence of chronic disease affected preferences regarding mode and content of
communication.

Conclusion: The mobile phone, as a tool for receiving health information and supporting healthcare through mHealth
interventions was acceptable in the rural Indian context.

Citation: DeSouza SI, Rashmi MR, Vasanthi AP, Joseph SM, Rodrigues R (2014) Mobile Phones: The Next Step towards Healthcare Delivery in Rural India? PLoS
ONE 9(8): e104895. doi:10.1371/[Link].0104895
Editor: Christian Lovis, University Hospitals of Geneva, Switzerland
Received January 18, 2014; Accepted July 17, 2014; Published August 18, 2014
Copyright: ß 2014 DeSouza et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors have no support or funding to report.
Competing Interests: The authors have declared that no competing interests exist.
* Email: [Link]@[Link]

Introduction India and mobile communication technology

With 877 million wireless subscribers, India has the second largest
Wireless technologies now cover 96% of the global population wireless communication subscriber base in the world [4]. Wireless
and penetrate all walks of life. With 6.8 billion mobile-cellular subscribers comprise 96% of telecom subscribers in India and
subscriptions worldwide [1], the technology has successfully contribute to an urban wireless tele-density fourfold that of rural
bridged gaps in communication and ignited economic growth India [4].
and development globally [2]. It has also found a strong One of the reasons for the popularity of mobile phones in India
foothold within the healthcare sector in the emerging field of is the low call tariff. At 1.6 USD/month, India has one of the
‘mHealth’. ‘mHealth’ or ‘Mobile Health’ is healthcare support- lowest mobile call tariffs globally [5]. This makes mobile phone
ed by mobile technology, such as mobile phones, personal communication economical in the Indian context. Further, the
digital assistants and other wireless devices [3]. The emerging average expenditure on mobile phones in rural households is an
use of this technology in healthcare for treatment compliance, estimated five INR/month, while the same is 37 INR/month in
emergency management, mobile telemedicine, health promo- urban poor households. More recent studies indicate that majority
tion and community mobilization, are currently being re- of the urban poor households in India spend approximately 3% of
searched or implemented globally [3]. their monthly income on mobile communication [5]. Given the
overwhelming popularity of mobile phone communication, at low
cost, mHealth in the Indian context holds promise.

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 Rural Healthcare via Mobile Phones

Research studies have explored the acceptability of mHealth domains (i) basic functionality of the mobile phone (ii) delivery and
interventions for supporting adherence to antiretroviral therapy in acceptability of health information via mobile phones (iii) use of
South India and for healthcare consultation in rural North India mobile phones in the management of chronic illnesses (iv) use of
[6,7]. The potential of mHealth is being harnessed by the Indian mobile phones in the management of acute illnesses and (v)
government in the ‘Mother and Child Tracking System’ (MCTS) acceptability of usage of cell phones for health promotion.
within the ‘National Rural Health Mission’ (NRHM) [8,9]. The
MCTS gathers health information from antenatal and postnatal Data Analysis
women in an attempt to ensure healthcare delivery to these Data was analysed using IBM-SPSS version 20. Frequencies,
women and to under-five children. Text messaging or Short means, and standard deviation were used to describe the variables.
Message Service (SMS) technology is also used to communicate Chi-square, Kruksal Wallis test and bivariate logistic regression
with 3.2 million Indian central government employees under the models (standard LR) were used to study associations between
Central Government Health Scheme (CGHS). Plans for its use in demography and outcome variables, i.e. (i) preference for voice
adolescent health, reproductive health and family planning, call to SMS reminders, (ii) more frequent versus less frequent
substance abuse and non-communicable disease prevention and medication reminders in chronic illnesses and (iii) preference for
treatment, are underway [10]. Given that the use of mobile calling a doctor over the mobile phone in times of acute illnesses.
phones, as a mode of communication in healthcare is inevitable, it
is necessary to assess rural end-user perceptions and experiences Ethics statement
with the technology. This would help contextualize healthcare Ethical clearance for the study and its informed consent
delivery via mobile phones to 70% of the country’s population procedures was obtained from the Institutional Ethics Committee,
residing in rural India. St. John’s Medical College, Bangalore, India, a private, non-profit,
We undertook this study to explore the acceptability of tertiary level, teaching, healthcare institution, to which the
delivering healthcare interventions via mobile phones in a village researchers were affiliated. Verbal consent was obtained from all
in South India. Information obtained with this study could aid the potential participants or their guardians (for those ,18 years of
development of appropriate user-friendly applications contextual- age) in the presence of a witness who endorsed the process. In
ized to the health needs of the population they target. addition, assent to participate in the study was obtained from
participants below 18 years of age. Verbal consent was uniformly
Methods administered to all potential participants, some of who were
illiterate, to ensure participation from those hesitant to sign the
This is an exploratory study done at a village, 52 kilometres consent form but willing to participate in the study. This enabled
from Bangalore, Karnataka State, South India between March representation of all demographic subgroups in the study.
2009 and 2010. Karnataka state has a total population of 61
million. With 29,098 villages, the state has a rural population of Results
37,469,335 (61%). The Government provides primary healthcare
to the rural population at no cost through a network of sub- Of the 608 households, 558 were available and willing to
centres, primary healthcare centres and community health centres. participate in the study, of these only 488 owned a mobile phone
Additionally, healthcare can be availed at any of the several and were enrolled. The demographic details of the participants
private facilities that may cater to the rural population for a fee. who owned a mobile phone are described in table 1. Those who
Healthcare at the village where the study was conducted, is owned a mobile phone had a larger median family than those who
available through a public primary healthcare facility and a did not (Median family size 5; IQR 2 versus 4; IQR 2, p-value
private non-profit, faith-based secondary healthcare facility. This Kruksal Wallis test ,0.004).
private healthcare facility supports research and medical intern-
ship training for medical interns from St. John’s Medical College, Basic functionality of mobile phones
Bangalore, South India, the academic institution that the All the 488 respondents routinely used their phones for making
researchers are affiliated with. The hospital also provides a base and receiving calls. On average, the respondents received four
for some of the research work undertaken by the institution. calls, while six outgoing calls were made in a day. Additionally, 70
The village has an agrarian economy and is easily accessible by (14%) used their mobile phones for text messaging, 56 (11%) for
road via the national highway. It has a total population of 3,180 setting alarms, 337 (69%) for listening to music, 72 (15%) for
persons belonging to 608 households. Our survey covered all playing games, 22 (4.5%) for photography and five (1%) for
households in the village. Data was collected by door-to-door visits accessing the Internet. Those who were literate in English and 40
by trained members of the research team. A consenting participant years of age or less were more likely to use the text messaging
above the age of 15 years, who owned a mobile phone, was function than those who were not (unadjusted OR = 7.5,
enrolled in the study from each household visited. Those CI = 3.69, 15.14).
households found locked when visited, were excluded from the Of the 488 respondents who owned mobile phones, 484 (99%)
study. were willing to make an appointment at the doctor’s clinic via the
An interviewer-administered questionnaire was developed. mobile phone and 467 (96%) were willing to share their mobile
Some questions were adapted from the HIVIND study question- number with their doctor. The 21 (4%) respondents who declined
naire that explored mobile phone usage in people living with to share their phone number did so for fear of misuse of contact
HIV/AIDS at an infectious disease clinic in Bangalore, India [7]. details or apprehension with regard to speaking with their doctor
The questionnaire was pretested in the local language i.e. over the phone. Others preferred to meet the doctor in person.
Kannada and suitably modified based on feedback from the
respondents to improve comprehension. The questionnaire Mobile phones in health promotion
assessed the respondent’s demographic profile, mobile phone Of 488 respondents, 484 (99%) were open to receiving health
usage patterns and the acceptability of healthcare interventions information on mobile phones. Topics that participants preferred
delivered via mobile phones. The questionnaire included five information on included healthy living, nutrition, maternal and

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 Rural Healthcare via Mobile Phones

Table 1. Demographic characteristics of the study population (n = 488).

Total (%) (n = 488) Female (%) (n = 360) Male (%) (n = 128)

Age
Median (Inter Quartile Range) 30 (25–40) 30 (25–37) 33 (25–45)
,20 yrs 30 (61) 28 (7) 2 (2)
20–40 yrs 328 (67) 254 (70) 74 (57)
.40 yrs 130 (27) 78 (22) 52 (4)
Formally education#
No 29 (6) 21 (6) 8 (6)
Yes 360 (74) 339 (94) 120 (9)
Literate in English 46 (9) 26 (7) 20 (16)
Currently employed
No 299 (61) 297 (83) 2 (2)
Yes 189 (39) 63 (17) 126 (98)
Landline 40 (8) 27 (7) 13 (10)
Expenditure on mobiles Median (IQR) 100 (IQR: 50–200) 100 (50–200) 100 (52–200)
$
Socio economic status (n = 192)
High 12 (6) 9 (7) 3 (4)
Middle 93 (48) 62 (50) 31 (46)
Low 87 (45) 53 (43) 34 (50)
Family’s with children 84 (44) 50 (59) 34 (40)
Chronic illness reported
No 448 (92) 336 (93) 112 (88)
Yes 40 (8) 24 (7) 16 (13)

#
Formal education i.e. school and college education.
$
Socio economic status as defined by Parasuraman et al (1999).
doi:10.1371/[Link].0104895.t001

child health, vaccination, self-care in chronic illnesses and Mobile phones in the management of chronic illnesses
information on infectious disease epidemics, (Figure 1). (table 2 and 3)
Of the 484 respondents willing to receive health information via For the management of chronic illness, 479 (98%) respondents
mobile phones, 218 (45%) preferred to receive the information preferred to receive medication adherence reminders via mobile
daily, 223 (46%) weekly, and 42 (9%) monthly. A majority 371 phones. Those who refused reported that they remembered to take
(76%) preferred to receive vaccination reminders a day earlier to their medication without reminders. From among those who
the date of vaccination, 73 (15%) on the vaccination day itself and preferred reminders, 424 (89%) preferred only voice calls, 45 (9%)
42 (9%) from a week to a month prior to the date of vaccination. preferred text messages and 11 (2%) had no specific preference.
Most respondents preferred voice calls (419; 86%) and SMSs (319;
65%) in the local language i.e. Kannada. With every year increase
in age, the preference for SMSs was less likely in comparison to
voice calls (adjusted OR = 0.951, CI = 0.917, 0.987). Those who
were literate in English (adjusted OR = 4.579, CI = 2.111, 9.933)
and those currently employed (OR = 2.628, CI = 1.209, 5.714)
were more likely to prefer SMSs alone or SMS and voice calls in
comparison to those who were not literate in English and those
unemployed.
Medication reminders were preferred as often as the medication
was to be taken by 163 (34%), daily by 129 (27%), biweekly by 22
(5%) and weekly by 165 (34%). Respondents who were literate in
English were twice more likely to prefer more frequent reminders
(adjusted OR = 2.264, CI = 1.050, 4.886), while those who
suffered from chronic illnesses were less likely to prefer more
frequent reminders (adjusted OR = 0.459, CI = 0.227, 0.930). We
also found that men were almost twice more likely to prefer more
Figure 1. Type of health information requested over mobile frequent medication reminders in comparison to women (unad-
phone (n = 488). (Uploaded as Figure 1 in TIFF format). justed OR = 1.868, CI = 1.203, 2.902), as were respondents who
doi:10.1371/[Link].0104895.g001

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 Rural Healthcare via Mobile Phones

Table 2. Preference for daily or less frequent medication reminders compared to demographic characteristics (n = 479).

Prefer less frequent Prefer more frequent

reminders (%) (n = 187) reminders (%)(n = 292) Unadjusted OR Adjusted OR

Age 31.569.91 33.13611.09 1.014 (0.997, 1.032) 1.014(0.995, 1.033)

Sex
Female 151 (43) 202 (57)
Male 36 (29) 90 (71) 1.868 (1.203, 2.902) 1.502 (0.780, 2.892)
Formally educated#
No 8 (28) 21 (72)
Yes 179 (40) 271 (60) 0.578 (0.250, 1.330) 0.589 (0.250, 1.391)
Literate in English
No 176 (40) 259 (60)
Yes 11 (25) 33 (75) 2.038 (1.003, 4.141) 2.264 (1.050, 4.886)
Currently Employed
No 129 (44) 165 (56)
Yes 58 (31) 127 (69) 1.712 (1.163, 2.250) 1.198 (0.670, 2.143)
Chronic disease
No 168 (38) 274 (62)
Yes 19 (51) 18 (49) 0.581 (0.296, 1.138) 0.459 (0.227, 0.930)

Logistic Regression Model p-value ,0.001.

#
Formal education indicates education that includes school.
doi:10.1371/[Link].0104895.t002

Table 3. Preference for voice calls only and SMS with or without voice call reminders compared to demographic characteristics
(n = 480).

Prefer voice calls only (%) Prefer SMS or

(n = 424) SMS + voice calls* (%) (n = 56) Unadjusted OR Adjusted OR

Age 33.19610.85 27.4867.64 0.937 (0.905, 0.970) 0.951 (0.917, 0.987)

Sex
Female 314 (88) 40 (12)
Male 110 (87) 16 (13) 1.142 (0.615, 2.120) 0.534 (0.230, 1.243)
Formally educated#
No 26 (90) 3 (10)
Yes 398 (88) 53 (12) 1.154 (0.337, 3.944) 0.575 (0.158, 2.091)
Literate in English
No 395 (91) 37 (9)
Yes 29 (60) 19 (40) 8.196 (4.131, 16.25) 4.579 (2.111, 9.933)
Currently Employed
No 271 (92) 24 (8)
Yes 153 (83) 32 (17) 2.361 (1.342, 4.156) 2.628 (1.209, 5.714)
Presence of chronic disease
No 396 (89) 48 (11)
Yes 28 (78) 8 (22) 2.270 (0.981, 5.248) 1.661 (0.642, 4.296)

Logistic Regression Model p-value ,0.001.

#
Formal education indicates education that includes school.
*This category includes those who preferred the SMS alone or both SMS and voice calls.
AIC: 312.7853, BIC: 342.002.
doi:10.1371/[Link].0104895.t003

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 Rural Healthcare via Mobile Phones

were currently employed (unadjusted OR = 1.712, CI = 1.163, mally intrusive and ensure confidentiality of personal information.
2.250). It is equally important to contextualize every planned intervention
to the population for which it is intended. With the Indian
Mobile phones in the management of acute illness government’s new impetus to use mobile phone technology in
Of the 488 respondents, 367 (75%) were willing to call their healthcare, mHealth services are expected to have a vast rural
doctor using their mobile phones for the management of an acute outreach. Given the immense potential for mHealth in India, we
illness and 487 (99.7%) would call their doctor with their mobile chose to explore experiences and perceptions of rural Indian
phones in a medical emergency. Respondents with a formal mobile phone users towards using mobile phone technology in
education were 6 times more likely to call their doctor over the healthcare.
mobile phone in an acute illness (adjusted OR = 6.866, CI = 3.080,
15.30) as opposed to those literate in English who did not prefer Mobile phone-based reminders
calling the doctor (adjusted OR = 0.114, CI = 0.055, 0.236), A majority of respondents expressed interest in receiving
(table 4). Further, men were less likely to prefer calling their medication adherence reminders for chronic illnesses. Forgetful-
doctor in the management of an acute illness in comparison to ness, a barrier to medication adherence [11], can be minimised
women (unadjusted OR = 0.606, CI = 0.388, 0.948). with the use of reminders. Medication reminders can be sent via
Respondents who did not prefer using their mobile phones in an mobile phones. Such reminders have been found effective in
emergency, did not do so, either due to the proximity of the improving medication adherence, in chronic non-communicable
hospital or because they preferred to consult a doctor in person. disease and communicable diseases like tuberculosis and HIV
infection [12–18].
Challenges to the use of mobile phones in healthcare Further, our respondents also expressed an interest in receiving
From among 488 respondents, 475 (97%) felt that receiving appointment reminders and vaccination reminders. Reviews
health information via mobile phones was not an intrusion into indicate appointment reminders via SMS improve attendance in
their lives. On the contrary, 345 (70%) felt that calling their doctor primary care clinics, chronic disease follow up, family planning
over the phone would disturb the doctor at work. clinics and ophthalmology clinics [19,20]. A study from rural
Prejudice that the mobile phone was a bad influence on the Haryana, reported using mobile phones to obtain appointments
youth and concerns about the health hazards of mobile phone for outpatient visits [21]. The probable reduction in clinic waiting
usage, expressed by 2 of the respondents, were potential barriers to time is assumed to have made the concept more appealing to our
their use in healthcare. respondents.

Discussion Preferred type of communication: SMS versus Voice calls

The second global survey on eHealth reported that SMS
Rapid advances in mHealth call for the development of end- reminders were preferred to voice calls, globally [3]. However,
user friendly mobile phone applications that may be used for most of our respondents preferred voice calls to text messages.
healthcare delivery. These applications should be simple, mini- Employed or English-literate respondents were more likely to

Table 4. Preference for calling the doctor over the mobile phone for acute illnesses compared to demographic characteristics
(n = 488).

Did not prefer calling Preferred calling the

the doctor (%) (n = 121) doctor (%) (n = 367) Unadjusted OR Adjusted OR

Age 31.89610.68 32.72610.64 1.007 (0.988, 1.027) 1.00 (0.979, 1.025)

Sex
Female 80 (22) 280 (78)
Male 41 (32) 87 (68) 0.606 (0.388, 0.948) 1.073 (0.527, 2.183)
Literate in English
No 89 (20) 353 (80)
Yes 32 (70) 14 (30) 0.110 (0.056, 0.218) 0.114 (0.055, 0.236)
Formally educated#
No 17 (59) 12 (41)
Yes 104 (23) 355 (77) 4.835 (2.238, 10.450) 6.866 (3.080, 15.30)
Currently Employed
No 57 (19) 242 (81)
Yes 64 (34) 125 (66) 0.460 (0.303, 0.698) 0.593 (0.307, 1.143)
Chronic disease
No 108 (24) 342 (76)
Yes 13 (34) 25 (66) 0.607 (0.300, 1.228) 0.822 (0.366, 1.844)

Logistic Regression Model p-value ,0.001.

#
Formal education indicates education that includes school.
doi:10.1371/[Link].0104895.t004

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 Rural Healthcare via Mobile Phones

prefer SMS communication. The employed respondents, probably [35] and receiving information on lifestyle modification lowered
due to lesser personal time and privacy at work, preferred reading the incidence of diabetes in men (30–35 years of age) with
an SMS at their own convenience as opposed to answering a impaired glucose tolerance in India [36]. A majority of our
phone call. respondents also consider the mobile phones an acceptable tool for
A study from Mumbai, India reported that only a few women at health education. Mobile phone based communication therefore
an urban antenatal clinic reported using the SMS facility. Their provides an opportunity to promote a healthy lifestyle while
reasons included low literacy levels and even among the literates, satiating the desire for health information in our study population
difficulty in articulating text messages [22]. Similarly, technical [37].
difficulties in responding to both IVR calls and SMS reminders Our respondents also expressed interest in information on
have been reported from South Africa [23]. Voice calls may be maternal health and child. Studies exploring an SMS intervention
more useful in a population with minimal expertise in mobile to promote healthy behaviour during pregnancy showed improved
phone operation or for health conditions that require more direct birth-preparedness and healthy attitudes to alcohol consumption
interaction e.g. suicide hotlines, HIV helplines, contraceptive in a pilot study in Virginia, USA [38]. SMSs were also considered
hotlines [24–26]. The preference for voice calls among older acceptable for sexual health promotion in different settings
respondents indicates a probable discomfort in operating mobile [39,40]. Similar communication to educate women about
phones to access an SMS or a difficulty with reading SMSs. It is antenatal care, maternal nutrition, necessity of iron and folic acid
likely that some of our respondents also found SMS technology (IFA) tablet consumption and newborn care could be explored in
cumbersome to use. While SMS technology may have greater the rural Indian context. The possibility of improving adherence of
appeal among the English literate, maintaining communication in IFA tablets and maintaining obstetric appointments through
the local language could make them more accessible to those reminders should also be considered.
literate only in the local language. It is also worth noting that Health information could be made available passively through
though the language maybe different, the script of communication text and automated voice calls or a system where people call a
is frequently English. This may continue to be a barrier to the use phone number, select the type of information they want by keying
of SMS technology. Studies on HIV-infected populations in our in codes for a particular topic and listen to pre-recorded
setting (South India) have reported similar preferences for voice information regarding the same. Such automated systems may
calls and an association with English language literacy and the however be difficult to operate [23]. Live helplines could provide
preference for voice calls [7,18,27]. real-time assistance in addition to a personal touch. Reports of
Despite SMS not being preferred in our setting, it has been switching from automated HIV helplines to those manned by
found acceptable and effective elsewhere. Hospital attendance personnel are available from Bangalore, India [41]. However,
rates of patients receiving SMS reminders were comparable with establishing and maintaining them is resource-intensive, in
those receiving voice call reminders, with lower cost per comparison to automated communication systems [25].
attendance [28]. Vaccination reminders (text messages) were
found more acceptable than phone calls and letters among Latino Use of mobile phones in acute care and epidemics
mothers in New York City [29] and improved influenza A study from Washington, D.C. reported participants’ willing-
vaccination rates in children and adolescents in low-income urban ness to send photographs of their wounds to physicians for
populations in USA [30]. In populations with low literacy, the diagnosis and recommendations [42]. Majority of our respondents
possibility of using pictorial SMS reminders that use standard were willing to communicate with healthcare providers via mobile
symbols e.g. ASCII art, could be explored [31]. It is therefore our phones in an emergency. However, their limited use of phone
recommendation that in the Indian context, voice calls would be camera (4.5%) and phone-based Internet (1%) minimises the
the best form of communication. Failing this option, pictorial text possibility of using photographs, Internet and MMS. A study from
messages using universally understood symbols maybe used in an Nakuru, Kenya demonstrated that mobile phones were useful in
effort to abstain from using the English script. facilitating communication and decision-making in reproductive
health [40]. This may be due to quicker communication and easier
Frequency of reminders access to information in an emergency. Such use of mobile phones
While language and format are obvious issues, increased could especially benefit rural India, where frequently, patients
frequency of reminders is a significant cause of intervention- must travel long distances to meet a doctor, not only for their most
fatigue and therefore needs attention [32,33]. Respondents literate basic health requirements but also in emergencies. The possibility
in English were twice more likely to prefer more frequent of using emergency helplines that either provide verbal basic or
reminders. This may be explained by the fact that they were also professional assistance could also be explored in this setting.
more likely to be employed (p,0.001) or involved in completing However for the population in our study, accessing healthcare in
their education and therefore likely to forget their medication and an emergency may not pose a significant issue given the presence
would benefit from frequent reminding. By similar reasoning, men of a primary and a secondary level healthcare facility in the village.
and those employed were also more likely to prefer more frequent In our study, those with formal education were more likely to
reminding in comparison to women and those unemployed. contact their doctor via mobile phone, for acute and emergency
Respondents with chronic disease may have already become care. It is possible that this group had better health literacy [43]
accustomed to maintaining a medication schedule without any than the others because of their education. They were likely to
assistance, therefore requiring less frequent reminders. understand the importance of health personnel and urgent
intervention in the management of emergencies. However, those
Use of mobile phones in behaviour change literate in English were less likely to contact their doctor in an
communication emergency. The reasons for this association need to be
Mobile phones have been used in creating health awareness and determined.
bringing about behavioural change [12,34]. SMS has been A study in China used mobile phone technology in a disaster
successfully used to improve physical activity and reduce the management setting for detecting and controlling disease out-
number of servings of red meat in middle-aged men in Australia breaks [44]. Data gathering via mobile phones, was done

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 Rural Healthcare via Mobile Phones

effectively in malaria epidemics in Sub-Saharan Africa [45]. A entirely representative of other rural settings in India, given the
study from Ivory Coast, Africa reported the use of mobile phone- proximity of our study setting to Bangalore city.
based one-to-one communication to create awareness and control Healthcare personnel, who routinely administer services to the
epidemics [46]. Our respondents were also open to such usage of concerned community, were responsible for data collection.
mobile phones in the setting of infectious epidemics. However, Therefore the possibility of social desirability bias or acquiescence
care must be taken to ensure communication is informative while must be considered. Further, as most of the interviews were
not creating panic regarding the epidemic. conducted during the day, the opinions of those who are regularly
away during these hours may not be adequately reflected. This
Privacy and related concerns also explains the large proportion of women in our study. Keeping
While most participants were open to using mobile phones for in mind that we tried to evaluate the acceptability of a new form of
health-related issues, those who were not, generally preferred face- communication; we must consider, having included the opinions
to-face interactions with their healthcare provider. A substantial of more forthcoming respondents, as a possible bias. No specific
proportion felt they would be invading their doctors’ privacy by data on the type of mobile phones or privacy concerns with mobile
calling him or her on the mobile phone. Some of our respondents healthcare communication was obtained in our study. Though the
expressed concern with sharing their phone number with the acceptability of reminders for supporting medication adherence
doctors’ clinic. However, we did not assess specific privacy and was assessed, we did not assess their acceptability for supporting
confidentiality concerns. Studies report minimal privacy concerns adherence to prescribed diet and exercise. Further, as missing data
for communicating laboratory results to HIV patients and wound on socio-economic status reduced the size of the dataset this
images for acute healthcare [42]. Universally acceptable guidelines variable was excluded from the analysis.
addressing confidentiality, privacy and ethical concerns applicable
to mHealth and adaptable to local contexts need to be developed. Conclusion
Our study sought an answer to the question of whether mobile
Women, health and mobile phones phones would be an acceptable next step towards improving
A large proportion of the respondents in our study were women healthcare delivery in India. Our findings have generally
with access to mobile phones. In the Indian context, women are corroborated the acceptability of mHealth interventions and
often responsible for the health and hygiene in their family. They may even direct future endeavours in this area.
are primarily involved in cooking, cleaning and caring for children mHealth interventions such as reminders and information
and elderly in their households [47]. It is therefore not surprising disseminating applications via mobile phone were acceptable in
that nutrition and maternal and child health were popular among our study. The voice call was the preferred mode of communi-
information requested. The existing experience with caregiving cation in our setting, and needs to be considered in light of the
within families may have resulted in women preferring less popularity of SMSs globally. Attention to factors such as English
frequent adherence reminders in our study. Women were also less literacy, education, employment status, and sex of the end user
likely to be employed making their schedules more flexible and would only serve to improve the efficacy of mhealth. Healthcare
conducive to ensuring better medication adherence in comparison communication directed at women via mobile phones, could
to men [32]. Our finding that women were more likely to empower them with the necessary knowledge to promote not only
communicate directly with their doctor in the management of an their own health but also the health of their families. While these
acute illness may indicate that they had lesser knowledge about findings are encouraging to further the development and
health issues and needed assistance. It is also noteworthy that they deployment of mHealth interventions in rural India, the interven-
were able to take cognizance of a situation where they were out of tions designed should be acceptable to the targeted population and
their depth, and were willing to assume responsibility in procuring minimally intrusive while ensuring the privacy of the end user.
the necessary expertise required.
Thus, while reduced autonomy among majority of Indian Supporting Information
women is likely to adversely affect health-seeking behaviour; our
findings indicate that mobile phones may serve to enable women Annexure S1 Questionnaire - Mobile phones in health
to actively participate not only in their own healthcare and but care in rural India. This is the questionnaire that was
also that of their families [47]. Our study was able to capture the developed for the purpose of the study.
opinions of women, a group largely underrepresented in research, (DOCX)
since the interviews were conducted primarily during working
hours. Given that the women in our study have access to mobile Acknowledgments
phones, both the women and the healthcare system have an The authors would like to thank Dr. Sr. Cristeena J, Dr. Sr. Anngrace, Dr.
opportunity to communicate with each other, which can be Sr. Roselet and the staff at Snehalaya Hospital, Solur for supporting the
exploited to improve the population’s health. research team during the study.

Methodological issues Author Contributions

Our study assessed the usage and acceptability of mobile phones Conceived and designed the experiments: APV SMJ RR. Performed the
in healthcare in a rural setting approximately 52 kilometres from experiments: APV SMJ. Analyzed the data: SID MRR APV SMJ RR.
Bangalore city. It is possible that participant responses may not be Wrote the paper: SID RR.

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