Technologies that empower women for better access to healthcare in India – A scoping review

ABSTRACT

Women from low- and middle-income countries face challenges in accessing and utilising quality healthcare. Technologies can aid in overcoming these challenges and the present scoping review is aimed at summarising the range of technologies used by women and assessing their role in enabling Indian women to learn about and access healthcare services. We conducted a comprehensive search from the date of inception of database till 2022 in PubMed and Google Scholar. Data was extracted from 43 studies and were thematically analysed. The range of technologies used by Indian women included integrated voice response system, short message services, audio–visual aids, telephone calls and mobile applications operated by health workers. Majority of the studies were community-based (79.1%), from five states (60.5%), done in rural settings (58.1%) and with interventional design (48.8%). Maternal and child health has been the major focus of studies, with lesser representation in domains of non-communicable and communicable diseases. The review also summarised barriers related to using technology – from health system and participant perspective. Technology-based interventions are enabling women to improve awareness about and accessibility to healthcare in India. Imparting digital literacy and scaling up technology use are potential solutions to scale-up healthcare access among women in India.

KEYWORDS:

• ‘Access to healthcare’
• technology
• women and India
• maternal and child care

Introduction

The UN Sustainable Development Goals (SDG), adopted in 2015, underline the importance of universal health coverage and access to quality health care to achieve overall health and wellbeing (Asma et al., 2020). SDG aimed to decrease gender gap in many scenarios including healthcare access and utilisation by 2030 (Mariani et al., 2017). Despite efforts made over last few decades, women face many challenges in accessing and utilising healthcare, especially in low- and middle-income countries (LMICs) (United Nations, 2022). The COVID-19 pandemic slowed progress for women, and in many countries, their participation in healthcare reduced drastically. A 2020 study estimated that the indirect health impact of COVID-19 pandemic on income, nutrition and healthcare access could result in 24,000–113,000 additional maternal deaths and 417,000–1.8 million additional child deaths, in LMIC (Roberton et al., 2020).

A recent report has showcased the magnitude of excessive gender discrimination in health care access by women in India and has called for an urgent societal and governmental action to correct this scenario (Mahase, 2019). In India, traditionally, women have poorer health-seeking behaviour compared to their male counterparts, and often resort to no treatment or where possible, treatment limited to the confines of their home (Kapoor et al., 2019). There is a complex interplay of factors such as poor health literacy, economic dependence as a consequence of lack of education, culturally prescribed gender roles in the prevailing patriarchal system and inaccessibility of basic health care, that further increases the gender disparity in healthcare access in India (Das et al., 2018; Faizi & Kazmi, 2017; Reddy et al., 2020). While technology can partly bridge gender inequality in accessing healthcare through digital solutions, there is a marked disparity in use of technology between men and women in India. Indian women are less likely to own a mobile phone and use internet by 15% and 33% respectively, compared to men (Nikore, 2021). The existing gender gap worsens with increasingly sophisticated digital technology, such as smartphones, where ownership rates of these phones were 14% in women, compared to 37% in men, in 2019. National Family Health Survey (NFHS)-4 and NFHS-5 have reported that rural women were at greater disadvantage in terms of digital access compared to their urban counterparts and probable reasons could be poor digital literacy, social norms and prohibitive costs of digital devices and data package, further narrowing down their opportunities to access digital technology (James et al., 2021; Tyers et al., 2021; World Bank Group, 2021). This gender disparity in use of technology deprived women of access to healthcare through virtual platform, despite multi-fold increase in telehealth consultations in India during COVID-19 era (Nikore, 2021).

Recent NFHS-5 data showed underachievement in terms of indictors of women empowerment in India, with only 32% of currently married women representing workforce, of which 15% have worked without being paid. Further, decisions about spending of women’s earnings as well as their healthcare were still made by husbands in 14% and 17% of families, respectively (James et al., 2021). Empowering women with technological aids can help them gain autonomy and make strategic life choices to overcome gender bias and achieve access to healthcare (Mackey & Petrucka, 2021; Nasrabadi et al., 2015). Programmes such as ‘mMitra’, ‘Kilkari’, ‘Arogya Sakhi’ and ‘moderately underweight children (MUW)’ have been implemented in several states in India over last decade to leverage mobile-based technology use among women to access information on preventive health and utilise health services (ARMMAN, n.d.). Evidence from certain geographies report the impact of technologies in improving health literacy and health outcomes among women, thereby advancing reduction in mortality among pregnant women and children at the national level (ARMMAN, n.d.; Modi et al., 2019; Murthy et al., 2019). With rapid expansion of smart phone coverage in population recently and reduction in internet charges in future, the use of technology is identified to have a greater potential in improving health outcomes among women (Abbas, 2021; Krithika, 2021). At this juncture, a situational analysis of various technology platforms that are in use by women to access various health services in India is warranted to support policy decisions on choosing appropriate technologies that can have potential impact in addressing key health issues of women in India. A scoping review format was deemed fit to determine the scope of literature with regard to above and provide a broad overview of evidence (Arksey & O’Malley, 2005; Munn et al., 2018). Our scoping review aimed at identifying the range of technologies used by women to access healthcare, understanding their scope and assessing their impact in enabling Indian women to learn about and access various healthcare services – with particular focus on maternal, reproductive and child health; communicable and non-communicable diseases across all levels of healthcare. This review also reports barriers faced by women while using these technologies in a resource constrained settings like India.

Methods

A scoping review of the available evidence was conducted following the Arksey and O’Malley’s methodological framework (Arksey & O’Malley, 2005). This review is presented according to Preferred Reporting Items for Systematic reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) checklist (see Appendix 1). Briefly, the review followed five steps: research question identification, identification of relevant studies, selecting studies based on predefined eligibility criteria, synthesising evidence and reporting the findings. The protocol for this review was registered in open science forum (OSF) registries (https://doi.org/10.17605/OSF.IO/3CAZ6).

Theoretical framework considered in this review

This review considered its study population as adult biological women including women of elderly age group, to understand technology utilisation in accessing health care by women. Studies pertaining to transgender or transwomen were not included in this review, as our preliminary search showed obtaining data pertaining to this subgroup is difficult. Gender disparity in accessing healthcare services in Indian context is shown to exist mainly at household level with a bias in prioritising healthcare spending for women compared to men and difficulty in accessing nearest health facilities owing to their greater distance (Dupas & Jain, 2021). To overcome these shortcomings, technology can serve as an approach in universalising healthcare among women in India through improving access to health services, improving quality of service delivery and improving diagnosis, prevention, treatment and care for diseases (Chaudhuri et al., 2022). Optimal penetration of technology such as mobile-based ones in the community can help women learn about and access healthcare services. Thus empowerment of women is theorised as a process where women gain capacity to exercise personal choice related to healthcare, after acquiring sufficient health information and knows-how to access health services through technologies. This individual empowerment can contribute to collective gain at community level in terms of better health indicators (Huis et al., 2017).

Search strategy

We conducted an exhaustive literature search of each database from inception to the date of search (3rd February 2022) that included – the MEDLINE via PubMed and Google Scholar using the search terms under four broad headings – ‘technology’, ‘access to healthcare’, ‘women’ and ‘India’, as described in Supplementary file 1. The search strategy was built with the inputs from librarian and subject experts. This review considered ‘technology’ to include wide range of terms pertaining to mHealth, telemedicine, remote sensing technologies, wearable electronic devices, social media and health information system to account for various technologies used by women. Search terms for ‘access to healthcare’ included key words such as availability, affordability, approachability and access, to represent ‘access’; and preventive, promotive, curative, treatment and rehabilitative services to cover dimension of ‘health services’. Further, search terms for ‘health services’ were expanded to include key terms covering maternal, reproductive and child health; communicable and non-communicable diseases across various levels of healthcare.

Screening process and criteria for study selection

The search results of 6035 records were imported into a literature review software, DistillerSR and five duplicate citations were removed. First step involved title and abstract screening, where four review authors (MS, GM, NM and MK) screened the articles based on following criteria – if the article reported use of technology and provided information pertaining to any health-related outcome. The full texts of the articles were retrieved and reviewed if the relevance could not be ascertained by screening the title and abstract. In the second step, 277 articles found eligible in title and abstract screening were subjected to full text screening independently by two groups of review authors (group 1: MS & GM and group 2: NM & MK). Full texts were considered eligible for inclusion if they reported active utilisation of technology by women – either operated by women directly or with the help of family members or frontline health workers (FLHWs), and that were translated into measurable health outcomes specific to women. Additionally, articles that had both men and women as study participants were included if they reported health outcomes specific to the women subgroup. We included primary research (observational and experimental designs), letters and grey literature (unpublished studies, dissertation abstracts, reports). Published opinion pieces, correspondence, narrative reviews, systematic reviews, meta-analyses, studies reporting women and/or girls outside India, non-English literature and articles without full-text were excluded. Disagreements while screening full texts were resolved through discussion between the authors of each group. Initially, 38 full-text articles were included for data extraction, with an additional 5 articles that were included after screening references of the included articles. Steps of screening process along with reasons for exclusion were provided in PRISMA flow diagram (Figure 1).

Figure 1. PRISMA 2020 flow diagram for the scoping review (Page et al., 2021).

Data extraction

Three review authors (MS, GM and NM) extracted data from 43 articles using a pre-designed data abstraction form in DistillerSR software, after pilot testing of the form using a sample of included studies.

Following characteristics were extracted from each study:

1. Administrative details: Name of the first author and year of publication

2. Study specific details: Title of the study, type of study, aims and objectives of the study, study setting (state; urban or rural; hospital (including level of care) or community), study participants (involves women and/or girls only, or women and/or girls form a subgroup of the overall study participants), sample size

3. Participant specific information: Type of study participants (women or mothers with their children and involvement of family members), age and morbidity status

4. Intervention specific details: Type of intervention, point of intervention delivery, need for trained healthcare workforce, choice of healthcare worker for intervention delivery, intervention duration and study comparison group

5. Study outcomes: Outcomes measured, method of outcome measurement, impact of the intervention on health outcomes, determinants (both facilitators and barriers) for technology utilisation or non-utilisation

6. Study recommendations.

Study characteristics of included articles are summarised in Table S1 of Supplementary File 2. Data analysis was performed by thematic analysis, where findings from each study were further categorised into subthemes and broader themes.

Role of funders: Funders of this study have no role in conduct of this review, data analysis or publication of the results.

Results

Synthesis of evidence retrieved from included articles revealed range of technologies used by women. This included short message services (SMS), interactive voice response system (IVRS), phone calls or helpline services, exposure to mass media such as radio and television, telemedicine services, audio–visual (AV) aids with assistance of Frontline health workers (FLHWs) and use of mHealth or web-based technologies operated by FLHWs. Various health outcomes reported in the studies were broadly classified under themes such as maternal health, child health, mental health, chronic diseases and communicable diseases.

Study characteristics

This review synthesised data from 43 publications which were done across India, predominantly over last decade evaluating technology use in women’s health. 26 (60.5%) out of 43 articles were based on studies done in 5 Indian states; 8 from Maharashtra, 5 each from Madhya Pradesh and Uttar Pradesh, and 4 each from Delhi and Karnataka. A lack of representation of studies is noted from Jammu & Kashmir, north-eastern states, West Bengal, Odisha, Rajasthan and Kerala. Most of the published articles (34 out of 43) were based on community-based studies, with three-fourth of these being done in rural settings. Quasi-randomised and randomised controlled trials were most adopted study designs, in 21 out of 43 articles. Healthy women were study participants in most of the studies, except for seven studies that had women participants with co-morbidities such as hypertension, diabetes mellitus, tuberculosis, HIV and psychiatric morbidities. Women between 18 and 49 years were participants in most of the studies, with lack of representation of data from elderly women (see Table S2).

Type of technologies used

Studies have reported wide range of technologies being utilised by women. Nearly half of the published articles (23 out of 43) reported the use of mobile-based technologies that facilitated one-to-one channel of communication between healthcare provider and women. Of these, 10 articles reported use of short message services (SMS) (Chandra et al., 2014; Khokhar, 2009; Kumar et al., 2021; Murthy et al., 2020; Patel et al., 2018; Santra et al., 2021; Seth et al., 2018; Shinde et al., 2018; Shukla et al., 2020; Suryavanshi et al., 2020), 14 articles utilised interactive voice response system (IVRS) (Chakraborty et al., 2021; Johri et al., 2020; Mohan et al., 2021; Murthy et al., 2019, 2020; Scott et al., 2021; Seshu et al., 2021 ) and phone calls or helpline services (Chandra et al., 2014; Gulati et al., 2020; Kannure et al., 2021; Kulathinal et al., 2019; Patel et al., 2018; Ragesh et al., 2020; Santra et al., 2021). Seven articles reported using AV aids for health education by FLHWs, either on a one-to-one basis by showing videos to women or by playing audio clips in small group meetings with women participants (Adhisivam et al., 2017; Hiremath et al., 2020; Kalokhe et al., 2021; Karri et al., 2022; Ramagiri et al., 2020; Suryavanshi et al., 2020; Ward et al., 2021). Exposure to mass media such as radio and television was noted in five articles where health education messages pertaining to reproductive health were broadcasted to communities (Dhawan et al., 2020; Fatema & Lariscy, 2020; Lam et al., 2019; Pakrashi et al., 2022; Speizer et al., 2014). Notably, nine articles reported use of mHealth or web-based technologies by FLHWs such as ASHAs, AWW and/or staff of primary health centres (PHC) to provide health education and track preventive, screening and curative services offered to beneficiaries at community level (Bhatt et al., 2018; Carmichael et al., 2019; Choudhury et al., 2021; Ilozumba et al., 2018; Maulik et al., 2017; Modi et al., 2019; Pant Pai et al., 2019; Prinja et al., 2017; Shah et al., 2019). Telemedicine platform has been used in three studies which enabled women in remote locations to reach healthcare providers for healthcare, contraceptive services and new-born screening for hearing loss (Chourasia & Tiwari, 2012; Lo, 2011; Ramkumar et al., 2013) (Table 1).

Table 1. Various technologies used by women across studies in India (n = 43 articles).

Themes	No. of articles^#
Audio visual aid	7
IVRS technology	7
SMS reminders	10
Phone calls/helpline services	7
Mass media (television, radio and/or movie)	5
mHealth/web technology aided health workers in primary care	9
Telemedicine	3

^# Number of articles are not mutually exclusive.

Health outcomes assessed

Broadly, five themes emerged while grouping health outcomes reported across studies. Maternal and child health were two major themes covering key outcomes reported in 18 and 21 articles, respectively. Mental health, chronic diseases and communicable diseases were other themes identified, which included fewer number of articles (Figure 2).

Figure 2. Thematic analysis of health outcomes assessed in studies among women in India (n = 43 articles).

Maternal health

Technologies such as IVRS, SMS, mass media, telemedicine and mHealth application as a job aid to FLHW have been utilised to improve maternal health in India. The use of specific technology in a setting has been largely driven by socioeconomic status and maternal literacy of study population. The main outcomes pertaining to maternal health are improvement in knowledge and practice regarding antenatal, intrapartum, and postpartum care, and family planning services. Early detection of anaemia and blood-borne infections was other important maternal health outcomes reported. IVRS platform has been extensively studied in rural Madhya Pradesh under Kilkari project where pregnant mothers received health education messages in Hindi regarding nutrition, supplementation of calcium, iron and folic acid, pregnancy care, family planning and child care (Mohan et al., 2021; Scott et al., 2021). Kilkari health messages were delivered as 72 once weekly voice calls to mothers between 18 weeks of pregnancy until first-year birthday of child and contents constituted 10% on pregnancy care, 16% on family planning, 13% on infant feeding and 11% on child immunisation, predominantly (LeFevre et al., 2019). Currently, Kilkari programme has been scaled up to 18 states and union territories with a reach over 24.6 million women subscribers (ARMMAN, n.d.). In another study in urban Mumbai, IVRS and SMS have been found useful in improving knowledge and practice related to ANC care such as receiving tetanus toxoid immunisation [OR: 1.6 (95% CI: 1.1–2.4)], consulting doctor in case of spotting or bleeding [OR: 1.7 (95% CI: 1.1–2.8)] and for delivery in hospital facility [OR: 2.5 (95% CI: 1.5–4.4)], compared to mothers who received standard of care (Murthy et al., 2020). Population-based studies such as ImTeCHO, ICT-CCS and ReMiND have evaluated translational value of providing mHealth application as a job aid to FLHWs in improving maternal health outcomes (Carmichael et al., 2019; Modi et al., 2019; Prinja et al., 2017). The use of mHealth application enabled FLHWs to schedule and track beneficiary home visits, thereby showing an increase in number of home visits to ANC and PNC mothers by 15.7% and 12%, respectively compared to mothers who received standard of care. FLHWs used mHealth platform to counsel and provide health education to mothers using its AV features and easily accessed guided protocols for screening and referral of maternal illnesses identified during their home visits (Carmichael et al., 2019; Modi et al., 2019; Prinja et al., 2017). Television exposure, having dedicated toll free helpline services and telemedicine provision centres in communities, was useful for the transmission of knowledge and improving practice related to family planning services among women in rural communities (Kulathinal et al., 2019; Lo, 2011; Pakrashi et al., 2022; Speizer et al., 2014).

Child health

Technologies used in studies based on child health included SMS, IVRS and mHealth application, provided as a job aid to FLHWs. Key outcomes related to child health include improvement in awareness regarding home based new-born care, knowledge regarding infant and child feeding practices, growth and development during childhood and immunisation practices. Lactation counselling through daily SMS reminders and weekly calls to postnatal mothers have been found effective in increasing rate of exclusive breast feeding at 6 months to 97% in intervention group, compared to 49% in control group (Patel et al., 2018). SMS-based health education about early childhood development and nutrition provided at the level of study families and FLHWs in study district has promoted discussions at community about best child care practices and facilitated overall reduction in undernutrition and stunting by 19% and 9% respectively, in the intervention area compared to control area (Kumar et al., 2021). The use of IVRS and SMS platform for improving knowledge about childhood immunisation and sending out vaccination reminders to parents was effective and reported an increase in fathers’ knowledge on childhood immunisation [OR: 1.2 (95% CI: 1.0–1.5)], and improvement in timeliness of childhood immunisation (Chakraborty et al., 2021; Seth et al., 2018). mHealth application as a job aid to FLHWs facilitated effective tracking and improvement in practices related to home-based new-born care, infant and child feeding, and childhood immunisation, by increasing coverage of home visits and counselling services provided by FLHWs in the community (Carmichael et al., 2019; Modi et al., 2019; Prinja et al., 2017; Shah et al., 2019).

Mental health

Only five articles have reported mental health outcomes that were evaluated through platforms such as – helplines, IVRS, SMS, AV aid and mHealth application. The synthesis of evidence from studies pertaining to mental health showed that positive mental health, prevention and management of perinatal depression and improving knowledge about screening and referral of common mental disorders as important health outcomes. Helpline services hosted by trained counsellors were adopted in two studies, where a study among postnatal mothers with psychiatric illness reported effective use of helpline for enquiring broad range of problems such as medications, sleep problems, domestic violence, and infant and child feeding practices (Chandra et al., 2014; Ragesh et al., 2020). In another study ‘SMS for mental health’, young women received SMS messages on positive mental health tip and information about the availability of helpline services as part of intervention. Of these, 63% of women reported to have utilised helpline services for seeking mental health services during study period and stated that intervention was supportive for improving their mental wellness (Chandra et al., 2014). A rural community-based study adopted ‘SMART’ – mHealth application, which is a technology-based intervention package and was tested to deliver mental health services in the community by constituting a linkage between ASHAs and PHC staff for screening, referral and management of people with common mental disorders in community. As a part of this study, IVRS messages were also sent to participants who screened positive for mental disorders to motivate them to continue the treatment in addition to multimedia-based stigma reduction campaigns that were conducted in communities. This study demonstrated that technology use has increased screening and management for common mental disorders among women of rural communities (Maulik et al., 2017).

Chronic diseases

Technology use for chronic diseases was reported in the five studies for screening and management of chronic diseases such as hypertension, diabetic retinopathy and cancer in women. Health outcomes related to chronic diseases included improving treatment adherence to anti-hypertensive medications and screening services for diabetic retinopathy, cervical and breast cancer in community. Of the two studies based on blood pressure management, one study utilised telephone services for providing health education and reminders for follow-up clinic visits to participants with hypertension, and it was found that better blood pressure was achieved among women following intervention (Kannure et al., 2021; Shukla et al., 2020). In the other study, SMS reminders for blood pressure medications were sent to participants and 62% increase in adherence to medication compared to baseline was reported (29). One of the few studies done among elderly women found that health education delivered through videos were two times more effective than pamphlets to motivate women to get screened for diabetic retinopathy (Ramagiri et al., 2020). There was a single study that concluded a negative result, where mHealth application, when provided as a job aid to FLHWs for screening cancers in community did not improve treatment rates among women who were screened positive for cervical or oral cancer, compared to the modality of routine primary care services offered by FLHWs (Bhatt et al., 2018).

Communicable diseases

Four studies have utilised technology to address health outcomes related to tuberculosis, HIV, dengue and diarrhoeal illness in children. Outcomes reported in the domain of communicable diseases included improving adherence to anti-tuberculosis medication and anti-retroviral treatment and knowledge about prevention of dengue and chikungunya. In a study, mothers with HIV who received SMS reminders for follow-up visits and health education through AV aid were twice as likely to practice exclusive breastfeeding and adhere to early infant diagnosis for HIV by 6 weeks, compared to mothers who received standard of care, and thereby resulting in better retention of mother and baby in HIV care (Suryavanshi et al., 2020). SMS and phone call-based reminders to women with tuberculosis reported 5% increase in adherence to DOTS medications in intervention group compared to control group that showed an increase of only 2% (Santra et al., 2021) (Table 2).

Table 2. Mapping of various technologies to health outcomes assessed in studies done among women in India.

Themes	Subthemes
Audio visual aid	Video-based health education to enable mothers screen for biliary atresia in newborns to improve knowledge about exclusive breast feeding, awareness about intimate partner violence, and, prevention practices for dengue and chikungunya in community to motivate diabetic women for diabetic retinopathy screening to improve adherence to anti-retroviral medications among postnatal women with HIV and follow-up testing in newborns Audio-based health education played by Front-line health worker in village meetings to improve maternal knowledge and practices regarding reproductive, maternal and child health
IVRS technology	Maternal knowledge on antenatal care practices, nutrition and well-being exercises during pregnancy, childhood immunisation, and, prevention and, management of childhood illnesses Family planning services, practices related to exclusive breastfeeding and, infant and child feeding
SMS reminders	Antenatal care practices, childhood immunisation and practices related to exclusive breastfeeding, infant and child feeding Positive mental health tips Adherence to self-breast examination, anti-hypertensive and DOTS TB medications
Phone call/helpline	Infant and child feeding practices, and, contraception Maternal knowledge about mental health and child care among postnatal women with psychiatric illnesses Treatment and follow-up of hypertension, and, adherence to DOTS TB medications Follow-up care for children with epilepsy
Mass media (radio, television and movies)	Family planning campaign and practices related to antenatal and postnatal care Promotion of use of oral rehydration therapy and/or zinc for diarrhoeal illnesses in children
mHealth/web technology aided health worker in primary care	Mobile application to help ASHAs schedule home visits, postnatal counselling and increase community-based care seeking for maternal and newborn illnesses to improve maternal knowledge on antenatal care, track childhood immunisation and refer to checklists/referral algorithms for maternal and child related illnesses during home visits to track cancer screening services and screen for common mental disorders in community Web-based application to administer point of care test and track results among pregnant women
Telemedicine	Fetal heart rate monitoring in homes of pregnant women Mobile van-based testing for auditory brainstem response in newborns Improve uptake of family planning services and care seeking for common illnesses in women

Barriers and recommendations

Barriers reported in the studies are – technology related, issues at field level, those pertaining to participant’s knowledge and attitude while adapting to newer technologies and, challenges posed by participants’ families while women accessed these technologies. Technology related barriers included poor network coverage in study areas resulting in non-delivery of messages or calls to participants and other technical glitches related to hardware and software of the mobile applications (Bhatt et al., 2018; Kumar et al., 2021; Modi et al., 2019). Field level barriers were encountered among FLHWs, who reported a perceived difficulty to adapt to newer technologies and faced increased job responsibilities while having to serve in an already overburdened health system (Carmichael et al., 2019; Modi et al., 2019). Knowledge barriers such as poor literacy of women and linguistic challenges limited the penetration of health messages to participants (Hiremath et al., 2020; Kumar et al., 2021; Ragesh et al., 2020; Scott et al., 2021). Additionally, reluctance among participants in adapting to healthy practices that were discordant to their traditional beliefs further limited achieving health outcomes despite of successful technology penetration (Lo, 2011; Scott et al., 2021). Having to share mobile phones with family members, being financially dependent on husbands to recharge their mobile phones and lack of autonomy amongst women in making decisions pertaining to their health were challenges that participants faced at family level (Chakraborty et al., 2021; Chandra et al., 2014; Ilozumba et al., 2018; Kannure et al., 2021; Mohan et al., 2021; Seshu et al., 2021; Suryavanshi et al., 2020). Recommendations provided in studies to overcome technology and field related barriers included – provision of adequate training to staff while introducing newer technologies, and having a single application that allows data capture of various health outcomes in a comprehensive manner (Bhatt et al., 2018; Modi et al., 2019). The inclusion of photos or videos during health education sessions among populations with lower literacy was suggested to overcome participant related barriers (Bhatt et al., 2018; Dhawan et al., 2020). Studies also advised tailoring health messages as per norms of the community based on real time feedback during the course of the intervention (Mohan et al., 2021; Scott et al., 2021) (Table 3).

Table 3. Barriers encountered while using technologies by women and recommendations provided in the studies.

	BARRIERS	RECOMMENDATIONS
Themes	Subthemes	Subthemes
Technology related barriers	Poor network coverage, non-delivery of calls from study team and cap on number of messages that can be sent daily Hardware and software issues with device and application Issues with electricity supply	Support through adequate training and establishment of call centre/help line to rectify technical glitches
Participant’s attitude related barriers	Fear of using new technology, losing real doctor experience in telemedicine consultation and stigma of getting diagnosed with diseases Lesser uptake of messages that are not being aligned with community norms	Tailoring of health messages as per feedback from community during the study period
Field level barriers	Limited smart phone users in community, and, change of sim/phone by participants, Lack of motivation to use new technology among staff and need for extensive training Incremental job responsibilities for field level workers in an overburdened health system	Establishing integrated health app to enable health workers to enter various health outcomes in a comprehensive platform Digitalising immunisation records and GPS enabled tracking of caregivers
Knowledge level barriers	Poor literacy status in women resulting in difficulty in comprehension of health messages that are too technical Linguistic barriers	Use of mass media / IVRS in population with lower literacy status Reinforcement of health messages delivered through mhealth platform by face to face counselling by healthcare workers or mass media Inclusion of photos/videos in application for better understanding
Family level barriers	Lack of mobile phone ownership and dependence on family members, which challenges transmission of health messages to women Lack of autonomy for women in patriarchal families, work commitments at home and prevailing reservations that women face in talking to helpline service providers of male gender Economical barriers faced by women with regards to recharging mobile accounts	In-built provision in research studies to overcome linguistic and socio-cultural barriers in community Evaluation of cost effectiveness of interventions are needed
Barriers in mode of delivery	Difficulty into ensuring active involvement of women while health messages are delivered through passive technologies such as IVRS and SMS	Need to compare effectiveness of technology that are provided directly to participants Vs. those delivered through healthcare worker assistance

Discussion

This scoping review serves as a synthesis of evidence on technology utilisation in achieving women’s health exclusively from an Indian context. This review adds to context-specific findings from the literature based on India and supplements to the body of evidence from an already review synthesised from a global perspective (Mackey & Petrucka, 2021). This review synthesised evidence from 43 articles published between 2009 and 2022, listing out various technologies accessed by Indian women and health outcomes that were attained and the facilitators and barriers to their use. Technologies have been useful in improving healthcare access for women in India by serving as a medium for the transmission of health-related information as well as in assisting for the management of specific diseases. Fewer studies have documented that technology based on telemedicine helped women come into contact with health systems by overcoming physical barriers to access health services. Mirroring India’s priority to reduce maternal and under-five mortality as a part of millennium development goals and SDG, the major focus of studies included in this review has been to address maternal and child health related outcomes with the help of technology driven solutions.

This review found that mobile-based technologies (such as IVRS, SMS and helplines), telemedicine platforms and FLHW-operated mHealth applications were frequently used to offer continuum of care in the field of maternal and child health. Similar to findings of this review, a systematic review from Ethiopia has reported the predominant use of mHealth applications, calls, SMS, information and communication technology, and telemedicine in their country to address maternal and child health related health priorities. Furthermore, studies in Ethiopia have also described technologies related to artificial intelligence and cloud-based applications for the screening of diseases and diagnosis, which underscores the possibility of exploring such technologies in Indian setting as well in future studies (Manyazewal et al., 2021).

Studies included in this review aimed to improve ANC and PNC services, with specific focus on maternal knowledge and practice related to ANC attendance, maternal immunisation, micronutrient supplementation, facility-service utilisation and contraception services via technological aid. Future studies could focus on investing technologies to address pregnancy related complications such as gestational diabetes, pregnancy induced hypertension and heart disease complicating pregnancy in India. Taking inputs from developed countries, India must scale up technology utilisation in maternal health that are based on advanced RMNCH application, sensors and wearable-based interventions, which can offer diverse functionalities for mothers, instead of simple algorithm-based SMS interventions that focus only on health education and promotion (Chen et al., 2018). Studies related to child health in this review demonstrated successful utilisation of IVRS and SMS platform for knowledge dissemination regarding infant and child feeding practices and sending out reminders to parents for increasing the coverage of childhood immunisation. This finding ties well with evidence from Latin America, sub-Saharan Africa, Asia-Pacific and southern Asia, where the effectiveness of these platforms has been evaluated in increasing immunisation coverage in children (Atnafu et al., 2015; Bossman et al., 2022; Kabongo et al., 2021).

This review identified very few studies addressing other health challenges such as tuberculosis, HIV and chronic diseases such as diabetes, hypertension, cancer and mental illnesses among women with the help of technology. While India is moving towards the goal of eliminating tuberculosis in near future, it is important to scale up patient centric approaches using digital technologies such as digital pill boxes, ingestible sensors, smart phone-based technologies and video assisted DOTS therapy, compared to traditional DOTS, for achieving better medication adherence and treatment outcomes among women (Subbaraman et al., 2018). With regard to studies that evaluated blood pressure control as an outcome in this review, the utilisation of technology was limited only to SMS and phone calls for improving adherence to medications and follow-up clinic visits in women. Studies from sub-Saharan Africa have used technology to establish linkages between healthcare provider and patients using bluetooth enabled devices to transmit information on blood pressure recordings and medication intake of patients to healthcare providers, for further follow-up (Kabongo et al., 2021). Furthermore, wearable devices enable real-time monitoring of blood pressure, glucose, daily exercise, diet, heart rate and weight to provide tailored health recommendations to patients with non-communicable diseases and have been tested in high income countries. While it is ambitious in our context to implement advanced technologies based on wearable devices as demonstrated in high income countries, it is still possible that these approaches would benefit subset of Indian women belonging to higher socio-economic status, if tested effective (Bossman et al., 2022).

This review also found limited utilisation of technology for cancer care for women in India. The focus of these studies has been limited to improving cancer screening using technologies, but has failed to address deficiencies in of cancer treatment, rehabilitation and palliation. Further studies among cancer patients can explore the possibility of establishing effective digital counselling environment by linking them to health counsellor or clinicians for self-management support and utilise mobile-based technologies for improving adherence to cancer medications and quality of life among women in Indian setting (Huang et al., 2022; Moradian et al., 2018).

This review shows possibility for diversifying technology use by women in India, in addition to increasing their geographic coverage and population outreach of these technologies. Parallely, at the societal level, women need to be empowered to use these technologies effectively. Major setbacks that limited effective use of technology by women, as identified in this review were poor digital literacy, lack of sole ownership of mobile phones, community norms that limited women’s access to digital technologies, threats to their safety and higher costs incurred by women while using mobile-based technologies. Barriers reported in this scoping review is similar to a recent review based on global literature that reported privacy, confidentiality, security concerns and sociocultural challenges to be key concerns women face while using technologies pertaining to healthcare (Moulaei et al., 2023). Potential solutions to overcome some of these technology related barriers among women are improving awareness, offering skill-based training, adopting user-friendly design of technologies and providing incentives for using technologies (Moulaei et al., 2023).

In the Indian context, improving digital literacy among women is a key element of focus and literature has provided examples based on field experiences from certain geographies in India (Tyers et al., 2021). This include establishing internet kiosks, telecentres and community resource centres in the locality so that women can access these centres for digital outreach and training. Establishing community liaison is an important strategy, wherein women, along with their family members, can acquire digital literacy from community workers or through peer educators, as evidenced in ‘Internet Saathi’ and ‘iSocial Kallyani’ programmes. Another initiative that can be planned at government level for empowering women to access technology would be free distribution of phones and providing data access for female family heads of underprivileged societies, as piloted in Chhattisgarh state under ‘Sanchaar Kranti Yojana’ (Tyers et al., 2021).

Technology expansion in a resource-limited settings like India is accompanied with important challenges pertaining to sustained funding support for such technologies, participant’s data security and other cybersecurity issues with data platform. With women in India representing vulnerable section of the society, particularly owing to their limited digital literacy, there is a strong emphasis on building-in cybersecurity measures into health-related technologies. Crucial solutions to address cybersecurity threats at health system level include applying firewalls against cyberattacks, restrict technologies and devices used by health staff with security regulations, applying multifactor authentication, improve staff awareness pertaining to cybersecurity and developing strong culture of cyber vigilance (He et al., 2021). At country level, there is a need for policies and regulations to mitigate cybersecurity threats at various levels such as guiding manufacturers to become more security-minded while designing medical devices (He et al., 2021).

Strengths of this review include the use of an exhaustive search strategy, formulated in collaboration with an experienced healthcare research librarian and evaluation of eligibility of full-texts independently by more than one reviewer. Limitations of this review include the exclusion of studies that used technologies and reported health outcomes, yet did not report results for women as a subgroup and exclusion of literature in languages other than English. Although a comprehensive number of records were identified from two databases in our review, possibility of missing few relevant studies from other databases exists.

Conclusion

This scoping review identified a wide range of technologies such as integrated voice response system, short message services, audio–visual aids, telephone calls and front line health worker-operated mobile applications, as the predominant technologies that women used in India to access healthcare. Information on prevention and health promotion was transmitted through these technologies to address predominantly maternal and child health, followed by non-communicable and communicable diseases under a limited scope. Imparting digital literacy and improving access to technology among women are potential solutions to empower women in achieving better access to healthcare in India.

Acknowledgement

This article has been written as part of the research for the Lancet Citizens’ Commission on Reimagining India’s Health System. The Lancet Commission has received financial support from the Lakshmi Mittal and Family South Asia Institute, Harvard University; Christian Medical College (CMC), Vellore; Azim Premji Foundation, Infosys; Kirloskar Systems Ltd.; Mahindra & Mahindra Ltd.; Rohini Nilekani Philanthropies; and Serum Institute of India. The views expressed are those of the author(s) and not necessarily those of the Lancet Citizens’ Commission or its partners. Authors extend their acknowledgement to Mrs. Vasumathi Ganesh from QMed foundation for her guidance in finalising the search terms in the databases and also Dr Dipinwita Sengupta for her technical support during conduct of this review.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Appendix 1.

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.

Table

Section	Item	PRISMA-ScR checklist item	Reported on page #
TITLE
Title	1	Identify the report as a scoping review	Page 1
ABSTRACT
Structured summary	2	Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives	Page 1
INTRODUCTION
Rationale	3	Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach	Pages 2, 3 & 4
Objectives	4	Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g. population or participants, concepts, and context) or other relevant key elements used to conceptualise the review questions and/or objectives	Page 4
METHODS
Protocol and registration	5	Indicate whether a review protocol exists; state if and where it can be accessed (e.g. a Web address); and if available, provide registration information, including the registration number	Page 4
Eligibility criteria	6	Specify characteristics of the sources of evidence used as eligibility criteria (e.g. years considered, language, and publication status), and provide a rationale	Page 5
Information sources*	7	Describe all information sources in the search (e.g. databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed	Page 4
Search	8	Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated	Supporting information – Supplementary file – Table S1
Selection of sources of evidence†	9	State the process for selecting sources of evidence (i.e. screening and eligibility) included in the scoping review	Page 5
Data charting process‡	10	Describe the methods of charting data from the included sources of evidence (e.g. calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators	Page 6
Data items	11	List and define all variables for which data were sought and any assumptions and simplifications made	Page 6
Critical appraisal of individual sources of evidence§	12	If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate)	Not appropriate
Synthesis of results	13	Describe the methods of handling and summarising the data that were charted	Page 8
RESULTS
Selection of sources of evidence	14	Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram	Supporting information – Figure 1 (PRISMA chart)
Characteristics of sources of evidence	15	For each source of evidence, present characteristics for which data were charted and provide the citations	Supporting information – Supplementary file – Table S2
Critical appraisal within sources of evidence	16	If done, present data on critical appraisal of included sources of evidence (see item 12)	Not appropriate
Results of individual sources of evidence	17	For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives	Pages 7 - 16
Synthesis of results	18	Summarise and/or present the charting results as they relate to the review questions and objectives	Pages 7–16
DISCUSSION
Summary of evidence	19	Summarise the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups	Pages 17–21
Limitations	20	Discuss the limitations of the scoping review process	Page 21
Conclusions	21	Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps	Page 21
FUNDING
Funding	22	Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review	Page 27

JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

* Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms and Web sites.

† A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g. quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote).

‡ The frameworks by Arksey and O’Malley (6) and Levac and colleagues (7) and the JBI guidance (4, 5) refer to the process of data extraction in a scoping review as data charting.

§ The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of ‘risk of bias’ (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g. quantitative and/or qualitative research, expert opinion, and policy document).

From: Tricco et al. (2018).