Background
Hypertension is a major risk factor of cardiovascular diseases and a leading cause of death globally, accounting for 10.4 million deaths per year, of which 85% occur in low-middle income countries [
1,
2]. Managing hypertension appropriately requires a long-term care plan, including advice and support for adherence to a healthy lifestyle and treatment for better health outcomes. Unfortunately, non-adherence to disease management plans remains a serious challenge globally, with the situation worse in developing countries [
3‐
9].
Mobile health (mHealth) technologies have been playing a key role in managing disease outcomes including in conditions such as diabetes, hypertension and other cardiovascular diseases, maternal health and psychological disorders [
10‐
14]. The use of mHealth empowers patients, health workers and health system managers to manage care efficiently and effectively through different ways, including providing online guidelines and referral services, reminders and self-management and medication adherence. While studies indicate that mHealth systems can increase patients’ satisfaction with quality health care [
12,
15‐
20], other reports have provided mixed evidence regarding the health benefits of mHealth [
21].
The availability of mHealth initiatives is significantly higher in high-income countries [
22] but the use of mHealth is growing in low-income countries including in underserved rural areas [
17,
19,
22‐
27]. It is also expected that mHealth will continue to grow due to the increasing availability and accessibility of smartphones [
24,
28]. Of mHealth platforms, the most used tool is the short message system (SMS), predominantly focused on patient-centred outcomes [
27]. Currently, 67% of the world population, and around 50% in the Asia Pacific region, have a mobile or smartphone, an increase of 40% from 2016 to 2020 [
29].
Bangladesh is confronting a significant increase in chronic diseases including hypertension [
30,
31] with the pooled prevalence of hypertension was reported to be 41% with a cut-off value of ≥ 130/80 mmHg and/or use of antihypertensive medications [
31]. Nineteen percent of the population use a smartphone and, despite the problems in the usability of mhealth information due largely to network access in rural and remote areas [
25,
29,
32], the country has made significant progress in the use of mHealth [
19,
33‐
35]. In recent years, several studies have been conducted to study the use of mHealth in Rural Bangladesh [
34‐
36]. Factors associated with the use of mHealth reported that young people (age < 30 years), irrespective of their socio-demographic variation, have greater access to mobile phones, and better knowledge and greater intention to use mHealth services for managing their health [
36]. Other essential factors include gender, level of education and socioeconomic status, which influence ownership of mobile phones and hence may impact on the delivery and uptake of mHealth initiatives. Previous studies reported that the proportion of mobile phone use was almost double among men compared to women in rural Bangladesh, with the difference occurring irrespective of their socio-economic status. While men were more aware of available mHealth services there occurred no difference between gender in intention to use services [
34]. Given that problems related to network access are still significantly higher in rural and remote areas compared to urban areas [
25,
29,
32], and that less than 50% of the rural population in Bangladesh own a mobile phone [
34,
36], mHealth solutions are yet to be developed and implemented on a mass scale. The objectives of this study were to estimate the proportion of, participants with high blood pressure (i) who own mobile phones, (ii) who are willing to receive SMS, (iii) who are willing to pay for SMS to receive health information, (iv) who can read, and who read SMS, and (v) how much are individuals willing to spend to receive health information. Sociodemographic factors associated with these objectives were also examined.
Discussion
Ownership of mobile phones and the ability to read and understand SMSs or receive voice messages are the key elements for successfully implementing mHealth technology [
44]. The significant findings from this study include: (1) that in rural Bangladesh, there is a gap in ownership of mobile phones, with about half of the women and half of the older people owning a mobile, (2) irrespective of socio-demographic factors, the willingness to receive SMS for health information was high, (3) half of the participants were willing to pay to receive health information, (4) individuals were willing to pay between 5 to 500 Taka, with the majority were willing to pay 10 Taka, (5) less than half of the people who use their mobile can read SMS, and this percentage is less than one-third among women, housewives, farmer and people from low SES, and (6) only a small percentage of people read all the SMSs, with lower numbers seen in women, farmers, housewife and older people.
In our study, men, younger people, people with higher education or people with higher SES were more likely to own mobile phones compared to women, older people or people with no education, which are consistent with the previous studies in Bangladesh [
34,
36,
45] and other low-middle income countries [
15,
46]. The use of mHealth, including sending text messages, is effective in managing hypertension through varieties of ways, including by providing educational information on a healthy lifestyle, self-monitoring of blood pressure and through providing a reminder of medication adherence. The use of mHealth has been reported to effectively control blood pressure in low-middle income countries, including China and Brazil [
47‐
49]. Our finding that less than half of our population could read SMS identifies further barriers in implementing mHealth programs. Extrapolating to the broader rural population, from our data, if 50% of women own a mobile phone but only 30% can read SMS, only 15% of adult women can be considered to have full access to the potential mHealth benefits enabled by mobile technology.
In low-middle income countries, mobile phone ownership has increased significantly since 2014. In South Asia, women are 28% less likely to own a mobile phone than men, and are 58% less likely to use mobile internet [
50]. In this study, we found that women are 23% less likely to own a mobile phone than men, which is consistent with previous findings in South Asia [
50]. In previous studies among patients with diabetes conducted in Nigeria and Bangladesh, comprising of approximately 60% of women, it was reported that almost everyone owned a mobile phone [
43,
51]. The higher proportion of mobile ownership in previous studies may be due to the financial or educational variation to access mobile and internet facilities, as both studies were urban based. In the current study which was conducted in a rural area, a low level of education, being a housewife and possibly without having a regular income can be reasons for less ownership of mobile devices and impact on one’s ability to read SMS. The differences observed in the present report compared with previous studies may be due to differences in education levels. In the current study, 19% of participants had a secondary school certificate or above, compared to 49% with tertiary education in the Nigerian study [
51] and 71% with secondary or above education level in an urban based tertiary hospital in Bangladesh [
43]. Consistent with previous studies [
34,
46], we found no gap between mobile phones ownership amongst men and women who have at least a secondary school certificate. Although women and girls continue to face a wide range of discriminations, Bangladesh has made significant progress on poverty alleviation, gender equality and women’s empowerment over the past two decades [
52,
53]. A study conducted by Khatun et al. [
34] in 2012–2013 in a rural area reported that 61.8% of men and 34.4% of women had a mobile phone compared to 73% of men and 50% of women in our study. This indicates a positive trend in mobile phone ownership over time, and the gap in ownership of mobile phone between men and women is narrowing, consistent with previous findings [
50].
In terms of reading SMS, a study conducted in Nigeria among participants with diabetes reported that three-quarters of participants were able to read SMS, with no difference between gender [
51]. However, less than three-quarter of men and one-quarter of women in our study could read SMS, which is similar to that reported in a previous study in Bangladesh among patients with diabetes [
43]. In terms of willingness to receive SMS for health information, our results are similar to those reported in previous studies [
43,
51].
Another challenge in delivering effective mHealth solutions is related to the attitude of individuals towards reading SMS. In this study, only a small proportion of participants read the full content of SMSs. In contrast with the findings that there was no difference in ownership of mobile phone between men and women among those with higher education, the proportion of women who read SMS was lower than that in men among the same education group, which is consistent with a previous study [
43]. Empirical evidence suggests that there are significant gender differences in exposure to technology where women's participation is lower than that of men [
54]. In our study, a disadvantaged position among women is evident reflecting the findings that 57% of women compared to 44% of men were reported to be poor, 15% of women compared to 85% of men were professionals and 61% of women compared to 39% of men had no education. This indicates that the intersectionality of confounding factors conspire to disadvantage women and influence their ability to own mobile phones and read SMS.
In our study and consistent with others, many participants were willing to receive and pay for mobile-based health services, [
43,
51] indicating a positive attitude towards SMS in considering its benefits for managing health. Since the participants already were diagnosed with hypertension, they are likely to be aware of medication use or complications associated with the disease. They are willing to receive health information to manage their health and well-being.
Our findings show that younger people are more likely to have mobile phones, read SMSs and are willing to pay for receiving health information. Importantly, engaging the younger generation earlier holds promise for developing and implementing mHealth initiatives in the future [
36]. To increase involvement in mHealth, ownership of a mobile device is not the only barrier. Level of education, health literacy and access to services provide additional inertia. It is important to co-design mHealth interventions appropriate for the individual end-user, considering their demographic details, including age, gender, education, and access to services [
55]. While the use of the internet may be an option to provide health information and personalized service, access, especially in rural areas, is not guaranteed. For example, in the UK, a study by Dobson et al. [
56] reported that more than 90% of their participants used the internet to their mobiles compared to 33.5% who used the same mode of access in Nigeria [
51]. In Bangladesh, 54.8% of urban and 34.8% of rural people use the internet on their mobile phone [
57]. Mobile phone-based health services are reported to be further restricted by intermittent electricity to keep charge on mobile phones, poor network connections and insufficient financial power to regularly buy credits, especially in low-middle income countries [
43,
57].
In Bangladesh, a major barrier in the health system has been identified as the shortage of qualified doctors, especially in rural areas [
58,
59]. The use of mHealth can potentially address this shortage [
34,
36]. Continued development in the rural area is needed to facilitate greater ownership of mobile phones and education to read SMS for the benefits of mHealth to be achieved in women from socio-disadvantaged regions [
34,
36]. Our findings are significant in that they demonstrate that ownership of a mobile phone is not the sole barrier to access mHealth services. Instead, the ability to read or attitudes and habits of reading SMS messaging are important. Although we had not included the option of choosing either SMS or voicemail or phone calls, a previous study showed that participants preferred phone calls and text messages when receiving information associated with education [
51]. Participants with no education or a primary education level had the preference for receiving phone calls [
51]. Given the low education level among older adults and women in our study, direct phone calls may be a more helpful option than sending SMS. The preference of phone calls, although more labour intensive, could assure confidentiality as well as direct contact with providers rather than relying on SMS. Thus, our study provides further insight into the barriers to the use of mHealth in rural areas of Bangladesh, and a possible solution of sending voice mail could be an option but needs further study.
Our study has several strengths: firstly, data was collected face-to-face whilst maintaining social distancing and other health and safety issues. The study had an almost equal number of men and women. However, the study has several limitations. Firstly, the results are from the baseline data recruited for a cluster RCT, and thus the sample size is small. Secondly, the study has been conducted in one district, limiting the generalisation at the national level. However, the rural population in terms of socio-demographic and education level is very similar across Bangladesh [
60].
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