Barriers associated with the implementation, adoption, scale-up and sustainability of mHealth in Sub-Saharan Africa: a systematic review guided by the NASSS Framework

Clinical Snapshot

Key Findings

• P Value: Not applicable - no statistical testing

• Effect Size: Technical barriers most common (27% of all barriers)

• Primary Outcome: 409 barriers identified across 91 studies

• Nnt Or Sensitivity: 24% of barriers not captured by NASSS Framework, indicating framework limitations in LMIC settings

• Confidence Interval: Not applicable - descriptive review

Clinical Application

Framework provides practical categorisation but requires LMIC-specific adaptations Limited direct applicability to Australian healthcare system, though technical and organisational barriers may be relevant for Indigenous health programs and rural/remote service delivery Healthcare organisations implementing digital health solutions in resource-limited settings

Abstract

OBJECTIVES: The objectives of this study were to highlight and evaluate the factors affecting the non-adoption, abandonment of and challenges to scale-up, spread and sustainability of mHealth in Sub-Saharan Africa (SSA) and to assess the appropriateness of the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) Framework in the SSA context. METHODS: A systematic search of published research was conducted using PubMed and Embase research databases from 2012 to 2025. Peer-reviewed studies from SSA countries, evaluating mHealth interventions, were included in this study. Papers were analysed to identify barriers according to the seven domains of the NASSS Framework, which are (1) condition, (2) technology, (3) value proposition, (4) adopters, (5) organisation(s), (6) wider system, (7) embedding and adaptation over time RESULTS: This study identified 409 barriers across 91 papers. 309 barriers were covered by the seven NASSS Framework domains, while 100 were unaddressed by the framework. The main barriers were associated with domain 2, the technical aspects of the technology (27%). Other prominent barriers related to the wider system (18%), the adopter (11%), the organisation (9%) or condition (8%), with the value proposition (1%) and embedding and adaptation over time (1%), least hindering implementation. Challenges which were unaddressed by the framework (24%) included socioeconomic and infrastructural issues, distinct to lower and middle-income countries (LMIC). DISCUSSION: This paper highlights the importance of evaluating rudimentary aspects of mHealth and preparing infrastructure before addressing more complex issues during mHealth implementation in SSA. CONCLUSION: Although the NASSS Framework is applicable to the SSA region, it would benefit from some further development to improve its applicability in LMICs.

References

1. 1.Murray, J., Connolly, T., Haq, Z., & Naughton, B. D. (2026). Barriers associated with the implementation, adoption, scale-up and sustainability of mHealth in Sub-Saharan Africa: a systematic review guided by the NASSS Framework. BMJ Health & Care Informatics. https://doi.org/10.1136/bmjhci-2025-101485