Mobile health interventions were found to have the potential to improve the provision and uptake of SRH services among populations in rural areas of LMICs [16, 17, 25, 27, 50]. mHealth interventions were found to connect rural people directly to HCPs of SRH services and information [16, 17, 25, 27, 50]. This review shed some light on the opportunities and challenges for providing mHealth SRH information and services to young rural people . This review provides evidence on facilitators and barriers for delivering and improving rural access to mobile phone based SRH information and services in rural settings in LMICs [29, 37,38,39,40,41,42,43,44,45,46,47].
Overall, our findings showed that mHealth interventions can be useful to improve provision and uptake of SRH services across a broad range of services among rural people . Study participants reported facilitators such as the convenience of using mobile phone to deliver a range of SRH information and services remotely and confidentially [29, 37,38,39,40,41,42,43,44,45,46,47] reducing fear and stigma associated with face-to-face SRH consultations aligned with quantitative findings . Also, saving of travel time and costs for both HCPs and users were noted [37, 39, 47], in line with research [5, 52,53,54].
An important facilitator for providing mHealth was the ability to task shift by delegating duties or responsibilities to lower-level cadre health professionals [42, 47]. HCPs said task shifting helped improved time management and workload for them to perform critical and urgent duties [29, 37,38,39, 45]. Task shifting has been identified as a pragmatic response to health workforce shortages in rural settings in LMICs . It is observed however that the burden of task shifting tends to fall disproportionally on HCPs with lower qualifications and volunteers, leading to work overload without corresponding remuneration [55, 56]. To maximize task shifting benefits without placing an undue burden on HCPs who are willing to undertake additional workload, appropriate compensation and training need to be considered, to ensure the sustainability of mHealth programs in rural settings in LMICs .
In this review, services were provided using voice messaging, phone calls, voice calls and SMS text-messaging [29, 37,38,39,40,41,42,43,44,45,46,47]. SMS texting was seen as the most preferred and efficient platform for delivering health information and services, due to the ability to transmit multiple health messages to groups of people at the same time remotely and confidentially [37, 40, 42, 46]. A preference for delivering health information via SMS text messages in rural populations in LMICs settings has been reported . There is a growing interest for the preference of mHealth interventions platforms in LMICs for SRH information and services for rural population. There is the need for research to understand the benefits and preferences of mobile phone-based platforms for users with greater reach in rural areas especially among lower literate populations.
The review highlighted several challenges which hinder the effective delivery and uptake of mHealth SRH information and services among young people in rural contexts in LMICs.
These mainly included technological challenges which hindered the effective delivery of SRH mHealth services [29, 37,38,39,40,41,42,43,44,45,46,47]. The major barriers included a lack of technical skills [40, 41, 43, 46] and limited technological infrastructure [40, 41, 43]. These findings have been reported by studies in LMICs [16, 27, 58, 59]. The full realization of the full potential of mHealth SRH services will require investment in the development of technological infrastructure [46, 60] and building the capacity of HCPs and users to effectively use innovative mHealth for the delivery and uptake of SRH services for rural populations [18, 61, 62].
Personal barriers in terms of cost related to mobile phones and credit were cited by participants [37, 41, 44]. Several studies conducted in similar settings in LMICs have confirmed these findings [16, 17, 27, 63, 64]. In some instances, HCPs had to bear mobile phone expenses in order to be able to provide the services . A qualitative study in rural South Africa has reported similar findings . Personal cost of providing health delivery services in rural settings in LMICs constitutes a disproportionate share of cost for HCPs and poor young people with low incomes . HCPs said that subsidizing the cost of mobile phones and call credit for rural health workers and the creation of a hotline dedicated to mHealth SRH services  in rural areas of LMICs is critical for delivery of SRH information and services among rural and remote populations [66,67,68].
Also reported as a personal barrier were technological and health literacy and linguistics barriers [40, 41, 43, 46]. Technological literacy is a skill needed to access digital technology, which is necessary for mHealth uptake. Studies have shown that low or limited literacy skills are more prevalent among rural populations and may disguise HCPs and clients ability to understand health information [69, 70]. This may make health education and communication with HCPs with clients not effective and could lead to poor health outcomes in rural settings . In rural contexts, findings suggested that the involvement of linguistically diverse HCPs to work with clients may be needed in order to meet the diversity of clients that make up various populations .
Emotional burden and workload related to making and receiving too many calls for serving clients were also identified by HCPs as barriers to mHealth provision [38, 39, 42]. The training of more HCPs in Digital health technology to support the delivery of mHealth education could mitigate emotional burden and workload among HCPs. This could also help them to disseminate culturally appropriate and sensitive SRH information among populations in rural contexts in LMICs .
Participants identified infrastructural or contextual barriers to mHealth delivery [40, 41, 43] including lack or weak network connectivity [39,40,41, 44, 45], and lack of electricity to charge mobile phones [37, 40, 47]. To ensure strong internet connectivity, it is suggested that installation of fiber optic and free public Wi-Fi in central areas where rural people can access the internet can improve the speed and access to internet for services. Alternative power sources such as solar panels for charging phones would also help .
The influence of community members and ingrained in socio-cultural norms also impacted use of mHealth for SRH service delivery . In rural settings in LMICs, the provision and uptake of SRH information and services among rural populations is ingrained in traditional social norms [42, 71]. Providing innovative mHealth based SRH information and services was identified as culturally sensitive and user-friendly but this was not always sufficient to overcome cultural barriers . mHealth programs are becoming an integral part of reproductive programs in rural LMICs [25, 50], so investment in education of community members is needed to effectively address socio-cultural and sensitive barriers to service provision in rural contexts in LMICs.
Finally, despite the potential for mHealth interventions to be scalable and integrated in rural healthcare settings, programme managers, policy makers and implementers need to address individual and socio- cultural norms that act as barriers, as well as fill infrastructural gaps. This will require collaboration between governments, nongovernmental organizations and other stakeholders.
Strengths and limitations
A strength of this study is that it gives a clear review of the practical experiences of HCPs on facilitators and challenges for providing mHealth SRH services in rural settings in LMICs. Another strength of this study is that it covered a period of two decades from the inception of mHealth to date. In addition, all primary studies included in this review underwent a rigorous methodological quality appraisal. A major limitation of this study is that only studies written and published in English were included.
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