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RESEARCH ARTICLE
Telehealth interventions for substance use
disorders in low- and- middle income
countries: A scoping review
Margaret Isioma OjeahereID
1
*, Sarah Kanana KiburiID
2
, Paul Agbo
3
, Rakesh KumarID
4
,
Florence JagugaID
5
1Department of Psychiatry, Jos University Teaching Hospital, Jos, Plateau State, Nigeria, 2Department of
Psychiatry, Mbagathi Hospital, Nairobi, Kenya, 3Department of Psychiatry, Dalhatu Araf Specialist Hospital,
Lafia, Nassarawa, Nigeria, 4Department of Psychiatry & Deaddiction, G.G.S.M.C, Punjab, India,
5Department of Mental Health, Moi Teaching & Referral Hospital, Eldoret, Kenya
*margaret.ojeahere@gmail.com
Abstract
The increasing prevalence and magnitude of harmful effects of substance use disorders
(SUDs) in low- and middle-income countries (LMICs) make it imperative to embrace inter-
ventions which are acceptable, feasible, and effective in reducing this burden. Globally, the
use of telehealth interventions is increasingly being explored as possible effective
approaches in the management of SUDs. Using a scoping review of literature, this article
summarizes and evaluates evidence for the acceptability, feasibility, and effectiveness of
telehealth interventions for SUDs in LMICs. Searches were conducted in five bibliographic
databases: PubMed, Psych INFO, Web of Science, Cumulative Index of Nursing and Allied
Professionals and the Cochrane database of systematic review. Studies from LMICs which
described a telehealth modality, identified at least one psychoactive substance use among
participants, and methods that either compared outcomes using pre- and post-intervention
data, treatment versus comparison groups, post-intervention data, behavioral or health out-
come, and outcome of either acceptability, feasibility, and/or effectiveness were included.
Data is presented in a narrative summary using charts, graphs, and tables. The search pro-
duced 39 articles across 14 countries which fulfilled our eligibility criteria over a period of 10
years (2010 to 2020). Research on this topic increased remarkably in the latter five years
with the highest number of studies in 2019. The identified studies were heterogeneous in
their methods and various telecommunication modalities were used to evaluate substance
use disorder, with cigarette smoking as the most assessed. Most studies used quantitative
methods. The highest number of included studies were from China and Brazil, and only two
studies from Africa assessed telehealth interventions for SUDs. There has been an increas-
ingly significant body of literature which evaluates telehealth interventions for SUDs in
LMICs. Overall, telehealth interventions showed promising acceptability, feasibility, and
effectiveness for SUDs. This article identifies gaps and strengths and suggests directions
for future research.
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OPEN ACCESS
Citation: Ojeahere MI, Kiburi SK, Agbo P, Kumar R,
Jaguga F (2022) Telehealth interventions for
substance use disorders in low- and- middle
income countries: A scoping review. PLOS Digit
Health 1(11): e0000125. https://doi.org/10.1371/
journal.pdig.0000125
Editor: Valentina Lichtner, University of Leeds,
UNITED KINGDOM
Received: December 20, 2021
Accepted: September 9, 2022
Published: November 2, 2022
Copyright: ©2022 Ojeahere 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.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting
Information files.
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing interests exist.
Author summary
Substance use disorders (SUDs) are an increasing public health problem which affects
both children and adults across the world. Increasing numbers of individuals who live in
low- and middle-income countries (LMICs) are affected by the worsening problems of
SUDs compared to other regions. The wide treatment gap between people who suffer
from the consequences of SUDs compared to those who have access to appropriate treat-
ment ensures that out of reach populations and people in rural areas lack adequate health-
care for SUDs. Repeatedly, studies show that SUDs are chronic and recurring in nature.
Therefore, affordable treatment innovations which integrate holistic strategies, promote
self-monitoring and management approaches, that can be accessed by out of reach popu-
lations should be embraced. Although this may appear unrealistic and implausible in
LMICs, telehealth intervention which is the use of communication technologies (text mes-
sages, phone calls, mobile applications, virtual reality to mention a few) to deliver health-
care across a distance has the potential to reduce this treatment gap. Our scoping review
summarizes published studies which assessed the acceptability, feasibility, and effective-
ness of telehealth interventions for SUDs in LMICs and highlights the gaps and directions
for future research.
Introduction
Substance use disorders (SUDs) are a growing public health concern of global significance
with their impact cutting across all domains of life [1]. The 2021 world drug report of the
United Nations Office on Drugs and Crime (UNODC) estimated that in 2019, 5.5% (275 mil-
lion) of the global population (aged between 15 and 64 years) had used drugs and over 36 mil-
lion people worldwide suffered from SUDs [2]. Using the World Bank country classification of
low-and-middle income countries (LMICs) [3], increasing populations of people with the
highest risk of substance use reside in LMICs and this is projected to increase by 40% in Africa
by 2030 [4]. SUDs is one the world’s leading causes of years lived with disability in LMICs and
its resulting consequences pose major challenges to health systems globally, particularly to
those in LMICs [5].
There is a huge treatment gap for SUDs globally with one in six people who receive treat-
ment for SUDs and one in 11 and 18 people who receive treatment in Latin America and
Africa respectively [6]. Generally, the treatment gap for SUDs ranges from 75% to 95% in
LMICs with higher values reported in rural areas [5,7,8]. Whilst SUDs prevalence have
increased across the world, existing evidence shows that over 80 to 85% of people with mental
disorders in LMICs do not have access to appropriate mental healthcare especially the out of
reach populations [5]. Arguably, there is an overlap between people who require treatment for
SUDs and other mental disorders [9]. Nevertheless, the worsening problems of SUDs continue
to compound the existing unmet mental health needs [5,9].
A considerable number of studies show that SUDs can be chronic, relapsing disorders with
cycles of relapses and remissions [1]. The chronicity of SUDs suggests that an established care
model which provides an integrated care system consisting of self-management and services is
required to prevent relapse in individuals diagnosed with SUDs [10,11]. Several approaches
that address recovery management, improve continuity of care, monitor periods of abstinence,
and early intervention, encourage self-management, mutual aid, other recovery supports, and
system-level interventions have been recommended in the management of SUDs [12]. The
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principal caregivers of affected individuals are they themselves. Therefore, it becomes perti-
nent to explore interventions with potentials for self-monitoring and self-management with
favorable outcomes and reduced economic burden [13]. Present management approaches for
SUDs usually involve a combination of behavioral therapy, brain stimulation techniques, phar-
macological therapies, and the use of telecommunication technologies [1]. One strategy that
has been recommended with favorable outcome in addressing the chronicity of SUDs and
improving access to care especially for out of reach populations is telehealth [14]. Convention-
ally, telehealth interventions involve the use of communication technologies to deliver health-
care across a distance [15].
Emerging evidence shows that telehealth has the potential of reducing the existing treat-
ment gap in LMICs in the diagnosis and management of people with mental disorders and
SUDs. These interventions range from simple and easily accessible forms such as text messag-
ing, and phone calls, to more advanced modalities such as virtual reality, videoconferencing
and the use of innovative web-based platforms and mobile apps [16]. This form of healthcare
intervention has been in existence for over half a century but it remains underutilized in sev-
eral LMICs [17]. Several factors such as user barriers (awareness, level of education, availability
of gadgets, affordability of resources, telehealth literacy), organizational, and program barriers
are contributory to its limited use in LMICs [18]. On the other hand, telehealth interventions
have been better endorsed and used in high income countries (HICs) with most studies assess-
ing use of these interventions for substances such as alcohol use, cannabis, tobacco with lim-
ited use for opioid use disorder and methamphetamines [19–22]. These interventions have
been shown to be effective in improving substance use outcomes and other outcomes such as
quality of life [23,24]. Additionally, participants reported high satisfaction with use [25,26]. In
LMICs there is limited use of digital interventions in SUDs treatment, for example, a system-
atic review on the use of digital interventions for mental health treatment and prevention iden-
tified only six studies who utilized telehealth interventions for SUDs out of the 49 articles [27].
An update of this review in 2021 identified seven articles on SUDs from LMICs [28]. Among
the challenges cited with the use of telehealth interventions for SUDs treatment in LMICs
include high rate of technology evolvement [29], limited access to internet and cost of airtime,
lack or poor literacy skills needed to access these interventions, lack of non-verbal cues, high
phone turnover, privacy, and litigation concerns [30–32].
Growing evidence demonstrates that remote management by means of telecommunica-
tions technology, offers a promising approach in improving accessibility and affordability of
care of individuals with SUDs and has the prospect of facilitating self-monitoring and manage-
ment of individuals with SUDs [33,34]. Several authors have examined feasibility, acceptabil-
ity, and effectiveness of telehealth interventions for SUDs worldwide and have suggested
different definitions for these. Overall, feasibility as a construct in public health practice takes
into cognizance several aspects of intervention delivery. These include demand (is the inter-
vention taken up?), implementation (can it be delivered as planned?), practicality (can it be
delivered despite constraints, such as resources and time?). Feasibility incorporates acceptabil-
ity, i.e how the recipients of (or those delivering) the intervention perceive and react to it [35].
There is a dearth of literature reviews on telehealth interventions for SUDs in LMICs. To
address the gap of research on this topic, we conducted a scoping review of available literature
on this subject to provide a preliminary overview to identify existing gaps from the available
evidence, and to describe trends on this topic while addressing it from a broader perspective,
unlike systematic review which develops critically appraised and synthesized results. There-
fore, the objectives of this scoping review were to summarize literature evaluating the accept-
ability, feasibility, and effectiveness of telehealth interventions for SUDs in LMICs, to identify
evidence gaps and proffer recommendations for future research.
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Materials and methods
Following the conception of the topic, an exploratory search was carried out to determine the
extent of literature on telehealth interventions for SUDs in LMICs, guided by formulation of
the review question and identification of key concepts, search terms, phrase strategy and test-
ing of the search strategy.
Protocol and registration
There was no formal registration of this scoping review with the international systematic review
database (PROSPERO). As of the time of writing this manuscript, it was not a requirement for
scoping reviews to be registered with PROSPERO. The Quality Assessment Tool for Studies with
Diverse Designs (QATSDD) [36], was employed in assessing the quality of studies reviewed.
Although, as of the time of writing, scoping reviews do not typically require quality assessment
unlike systematic review which generally requires quality assessment of included studies [37].
The method used in this review adopted the framework developed by Arksey and O’Malley
[38], and modified by Levac and colleagues [39], and the Joanna Briggs Institute [40]. Consis-
tent with this method, the scoping review was conducted in 5 main stages: Developing the
research question; identifying relevant studies; literature selection; charting the data; and col-
lating, summarizing, and reporting the results.
Stage 1: Developing the research question. We developed a broad research question for
our literature search, asking what the academic literature says about the acceptability, effective-
ness, and feasibility of telehealth interventions for SUDs in LMICs.
Stage 2: Identifying relevant studies. Search strategy: Five different electronic databases:
PubMed, PsychINFO, Web of Science, Cumulative Index of Nursing and Allied Professionals
(CINAHL) and Cochrane Library were used to search for articles published in English or translated
to English to identify relevant studies. Different search engines were engaged and the initial database
searches were conducted from September 30 to October 1, 2020 (S1 Data). Our searches spanned
articles published from 2010 to time of search in 2020. A 10-year timeline was agreed upon by the
authors because the use of digital intervention in LMICs gained prominence in the last decade.
The keywords used for the search in this review were “telehealth OR telepsychiatry OR tele-
medicine OR teleconsultation OR mobile health OR mhealth OR mobile phone OR web OR
video conferencing OR SMS OR short message OR internet OR Substance use OR Substance use
disorder OR substance abuse OR substance dependence OR addiction OR addict OR alcohol use
disorder OR alcohol abuse OR alcohol dependence OR alcohol addiction OR tobacco OR ciga-
rette OR smoking OR nicotine OR cannabis OR marijuana OR bhang OR Khat OR shisha OR
heroin OR opioid OR injecting drug use OR people with injecting drug use OR PWID OR
cocaine OR amphetamine OR methamphetamine OR Feasibility AND Effectiveness”. (S1 Table)
Manual extraction of relevant literature from the reference list of articles included in the
review was done. This entailed consideration of relevant terms, dates, text words contained in
the title, abstracts of retrieved papers and index terms. The PICOS (participants, intervention,
context, outcomes, and study design) framework [41], was used to establish eligibility criteria.
Inclusion criteria. We included articles that examined at least one of the following outcomes
such as acceptability, feasibility, effectiveness of telehealth interventions for substance use if:
(a) the population examined or part of the population was from an LMICs as defined accord-
ing to World Bank country classification (b) the article was an original research (c) there was
evidence of substance use exposure, (d) articles were published in English or had an English
translation available, (e) the studies was conducted among all age groups (f) studies used all
designs quantitative, qualitative and/or mixed. (g) there was evidence of a substance use/SUDs
related intervention outcome such as acceptability/ feasibility and/or effectiveness.
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In this study, feasibility was defined in broad terms and included variables such as: ease of
recruitment of participants, number of participants recruited in relation to targeted sample
size, cost effectiveness, ease of delivery of the telehealth intervention, retention in the program
follow up, and acceptability (perceived usefulness of the intervention, ratio of participants who
dropped out/ requested to be removed from program, likability of the intervention and will-
ingness to recommend intervention to others) [42–46]. For this review, articles that assessed
‘Effectiveness’ were those that described change in substance use following the intervention.
Change in substance use was assessed through self-report, use of standardized tools or criteria
and biochemical tests [44–46].
Exclusion criteria. Studies were excluded if: (a) they were conducted across LMIC and HICs
and did not report LMIC specific results (b) they were review articles, dissertations, conference
presentations or abstracts, case studies, commentaries, editorials, or grey literature (c) the full
text articles were not available.
Stage 3: Literature selection. Following the search, all articles identified were exported to
Mendeley reference manager where the initial removal of duplicates was done. Next, they were
exported onto Rayyan (a software for screening and selecting studies for systematic and scop-
ing reviews and detecting duplicates) [47], whereby, after further removal of duplicates, the
abstracts and titles of retrieved articles were independently screened by two authors (M.O and
F.J) based on the predetermined eligibility criteria for inclusion in the full text screening. A
second screening of full text articles was also done independently by two other authors (S.K
and R.K) and resulted in an 85% agreement. Disagreements during each stage of the screening
were resolved through discussion and consensus. In instances where consensus could not be
reached, a third author was invited to review. Screening of selected studies was performed
between October 2, 2020 to March 30, 2021.
Stage 4: Charting the data. A comprehensive data extraction form was prepared in
Microsoft Excel by the authors. The form was first piloted by F.J and S.K on ten articles to
ensure consistency and necessary adjustments were made to the content thereafter. Data was
extracted by all authors and the final form was entered by M.O and double checked by M.O
and S.K for completeness and accuracy. The draft of the manuscript was written by M.O and
discrepancies were resolved by discussion with S.K and F.J until consensus was achieved. The
following data were extracted: author, year; country; modality of telehealth intervention; tar-
geted substance; study design; sample size; study setting/population; measures of acceptability,
feasibility, effectiveness, and other outcomes. After familiarization with the data, two authors
(M.O and F.J) inductively identified seven specific themes from the data which were reviewed
and affirmed by the other authors.
Stage 5: collating, summarizing, and reporting the results. A narrative account of the
included articles was prepared to present patterns in telehealth interventions as acceptable/
feasible and/ or effective tools or not applicable in the reduction of SUDs in LMICs. The results
have been summarized descriptively and defined by the authors to alleviate the narrative
account and grouped into the following emergent themes: publication trends/ timing of publi-
cation,country of research,population and setting,research design,psychoactive substance of
interest,telehealth modality utilized,measured outcome (S2 Table).
Results
Search results
Our search in five electronic databases identified a total of 2513 articles through PubMed
(1978), Psych INFO via EBSCOhost (128), Web of Science (108), Cumulative Index of Nursing
and Allied Professionals via EBSCOhost (CINAHL) (60), and Cochrane Library (239). A total
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of 301 duplicated articles were excluded and 2212 articles underwent title and abstract screen-
ing. A total of 2085 publications which did not meet the inclusion and exclusion criteria were
excluded and 127 full-text articles were retained. Following full text review, 39 articles were
included in the data extraction (Fig 1).
This method of research was conducted on the basis of a predetermined protocol in accor-
dance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses
(PRISMA) standards for scoping reviews [48] (S1 PRISMA Checklist).
General characteristics of included studies
Original peer reviewed articles that examined the topic have progressively increased in the last
10 years with 37 articles (94.9%) published in the last 5 years of this review (2016–2020). The
year 2019 had the highest frequency of identified publications, n = 12 (30.8%).
Publication trends/ timing of publication
The earliest identified study which met the eligibility criteria was conducted in 2012 [49]. One
study each was found in 2012 and 2013 [46,49]. Our review identified three publications in
2016 [50–52], and six articles in 2017 [53–58]. Thereafter, the number of studies increased
with a total of 28 publications between 2018 and 2020. Ten publications were found in 2018
[13,59–67]. The highest proportion of included literature which met the eligibility criteria for
Fig 1. PRISMA Flowchart describing the selection of studies mapping existing literature on acceptability,
feasibility, and effectiveness of telehealth interventions for SUDs in LMICs.
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this review was published in 2019 with 12 articles [44,68–78] and six published articles were
found in 2020 [16,45,79–82] (Fig 2).
Country of research
A total of 14 countries were represented in this review. The country with the highest number
of included studies was China [44,45,53,54,57,59,60,62,67] and Brazil
[13,56,63,64,66,70,72,73,79] with a total of nine studies each. Turkey [46,49,50,71] and Mexico
[65,68,69,82] had four publications each. India [52,76], Vietnam [61,81], and Romania [55,78]
had two studies each. Other countries such as Argentina [16], Jordan [51], Peru [58], Malaysia
[74], Korea [75], South Africa [77], and Kenya [80] had one article each (Fig 3).
Population and settings
The age range of participants in the included studies was 12–87 years [63,68]. Across studies
identified, four focused on children and adolescents [55,63,74,78], and two had 15 and 17
years as their lower age limit [61,65]. Two studies were on only male patients [53,62], one on
parents of adolescents [66], and one on smoking fathers, non-smoking mothers, and exposure
of their newborns to secondhand smoking (SHS) [54]. Our review identified a heterogeneous
distribution of participants across studies. Participants cut across individuals in the commu-
nity who were dependent on psychoactive substances and indicated a willingness to quit, oil
workers, night club patrons, families, and children and adolescents. Consequently, settings
spanned across workplace [75], general population [16,45,46,49,52,56–59,66,81,82], health
treatment facilities [44,50,51,53,54,60,65,67–71,76,77,79,80], night clubs [13,64], and schools
[55,61,63,72–74,78].
Fig 2. Line graph showing articles published per year (publication trends as of time of data collection).
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Study design and sample size
The selected articles in this review used quantitative, qualitative, and mixed methods. Most
studies primarily used quantitative methods (n = 30). Sample sizes for individuals ranged from
40 to 23054 [62,72]. One study was done prior to implementation of the intervention to assess
the willingness to use a mobile phone application for smoking cessation [61]. Four studies
used qualitative methods [58,66,77,81]. Two studies reported an ecological momentary assess-
ment (EMA) approach to examine psychoactive substance and exposure to social and environ-
mental cues [52,67]. Secondary data analysis was used in three identified studies [67,78,82].
Psychoactive substance of interest
Studies which assessed cigarette smoking across various populations dominated our review
with 25 articles [16,45,46,49–52,54,55,57–59,61,63,65,68–71,74,75,78,79,81,82], followed by
alcohol use in eight articles [13,44,56,64,72,73,76,80]. One study assessed only methamphet-
amine [62], one assessed any psychoactive substance use [66], and one study assessed both cig-
arette smoking and alcohol [77]. Three studies assessed multiple drug use such as heroin or
amphetamine, opioid use, methamphetamine [60,65,67].
Telehealth modality utilized
Studies included in this review used either one or a combination of telehealth interventions
such as SMS, telephone calls, web-based cessation programs, mobile applications, web-based
surveys, emails, virtual reality, hybrid phone counselling, and /or one-on-one consultations.
Eleven studies used short message system (SMS) [46,49–51,54,57,59,68,75,77,81], and twelve
studies incorporated web based mobile interventions programs [44,55,56,64,65,68,69,72–
74,78,79]. Nine of the articles used mobile apps such as “smoker face”,” WeChat”, “What-
sApp”, and S-health [16,44,59,60,62,63,67,80,82]. A considerable number of studies utilized
telephone communication [13,53,64,66,75,76], and some studies applied hybrid forms in deliv-
ering the interventions [13,64,68,70,75]. Psychotherapy and pharmacological interventions
Fig 3. Bar chart showing the distribution of articles per countries.
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were used in addition to telehealth intervention in some studies [44,79,80]. The telehealth
modalities were delivered via digital platforms and face to face consultations. Feedback from
the telehealth modalities utilized were majorly asynchronous and engaged the services of med-
ical students, trained counselors, healthcare providers, and researchers were employed for the
delivery of the respective interventions. Of the 31 quantitative studies, twenty-nine publica-
tions clearly stated how the intervention was administered. Two studies were majorly auto-
mated messages [49,64]. Two others did not report who delivered the intervention [13,50] and
one did not implement the intervention on participants [61]. Five studies clearly reported that
trained counsellors in substance cessation treatments were engaged to deliver the intervention
[53,54,65,68,70]. A heterogenous spread of physicians and allied professionals such as clini-
cians with masters/ degree in nursing/ doctoral degree in clinical psychology/ medical degree
and trained in mental disorders/ occupational nurse with over 10 years’ experience provided
face to face consultations in three studies [44,75,80], and one was delivered by medical stu-
dents [63].
Although the heterogeneity of the frequency and duration of sessions made it difficult to
combine, varying durations of sessions which ranged between 5mins to 60mins across studies
were recorded in our review [65,72]. The number of sessions of the telehealth interventions
conducted ranged between 1 to 42 sessions usually at baseline and at predefined times in the
program [16,68]. Eight authors conducted one session each in the course of their study [63,68–
71,74,79,80]. Three sessions were recorded by Bedendo and colleagues [68], and daily interac-
tions for 4 weeks was reported in a study by Liang and colleagues [60]. Other studies reported
a minimum of 4, 5 and 6 sessions [46,53,55], weekly sessions of 6 and 12, and 20 sessions were
conducted by other authors [44,45,62].
Measured outcomes
Adherence to treatment was assessed in all the 31 quantitative studies identified and rates of
adherence to protocol ranged from 45% to 100% [53,71]. Higher adherence rates of 74.6% to
100% were seen for cessation of smoking among participants [59,71]. Increased adherence
rates were seen with the usage of WhatsApp, text messages, web based and mobile applica-
tions. One study reported poor agreement between mobile application, multiple substances
assessed and laboratory findings [67].
Acceptability as described earlier was recorded in 17 of the selected studies. A range of 51%
to 99.3% favorable reactions to the program were observed among those who provided data on
acceptability [46,63]. Acceptability was not clearly stated or assessed in 22 identified studies
but findings were generally suggestive of a successful program and recommended for future
use [13,44,50–52,54,56–59,62,64,65,67,71–73,75,76,78,80,82]. Most patients rated the interven-
tion sessions as helpful or very helpful and about half of the patients reported reduction in cig-
arette smoking and alcohol use [66,77,80].
Effectiveness was assessed in 37 of the selected publications and several identified studies
showed promising efficacy after preliminary results [16,61,62,68,76]. Twelve studies reported
their outcome as both feasible and effective [44,45,50,52,56–59,63,64,72,75].
Our review identified four qualitative studies [58,66,77,81]. Generally, there was an overall
high interest in those with intention to quit among participants. Findings from the focus
group discussions and in-depth interviews demonstrated that the majority of participants
wanted to quit smoking but did not have a plan, some wanted more digital reminders but all
the participants found the intervention to be helpful [58,81]. Some authors reported no signifi-
cant differences before and after the intervention [53,65,80]. However, only a few authors
reported poor agreement between the type of mobile application used, substance assessed and
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laboratory findings as well as poor outcomes seen with high drop-out rates, low post interven-
tion rates, no significant reduction in the substance use [13,45,46,53,54,67,73,74,78].
Discussion
This scoping review aimed to provide an overview of literature examining the acceptability,
feasibility, and effectiveness of telehealth interventions in the management of SUDs in LMICs
and to highlight areas of gaps in research on this subject.
Overall, our review identified seven main themes. Our findings show that considerable
work has been done on the treatment of SUDs using telehealth interventions globally but with
only a few studies from LMICs and fewer yet from Africa. The earliest identified study was in
2012 [49], and research on this topic has progressively increased over the last 10 years with the
highest number of studies seen in 2019 as at the time of data extraction. This suggests that
more clinicians and researchers in LMICs are realizing the role of telehealth interventions in
addressing SUDs and are embracing this innovative method of healthcare delivery and this
can also be related to increase in availability and use of information technology in recent years
[65,69,79,83,84]. However, in the face of the importance of this subject and the existing evi-
dence from HIC, there is a paucity of research in LMICs [46,85]. Amongst the 14 countries
represented in this review, China and Brazil have the highest number of studies. A plausible
explanation for this may be because China has the highest mobile phone and internet users in
the world with an estimated number of 1.02 billion internet users as of January 2022 [86]. Sim-
ilarly, Brazil has experienced an increasing internet user in the last decade with over 140 mil-
lion and 167.7 million number of users on the web (with the latter equivalent to 77.87 percent
of the country’s population) as of 2018 and 2022 respectively. The smartphone, which was one
of the most commonly used devices as of 2021, among approximately 75.6% of the Brazilian
population (within the 18–55-year-old age group) [87], may also be contributory.
Plausible factors for few or no entries of some LMICs include: factors such as limited/ no
internet access to telecommunication technology especially in rural areas, internet illiteracy,
worsening poverty levels and paucity of research from sub-Saharan Africa [5,7,43]. Arguably,
the consequences of limited/ no resources or poor prioritization for research in SUDs cessa-
tion programs in some LMICs may explain the paucity of data. For example, a country like
Nigeria with the highest number of internet users in Africa estimated at 109 million as of Janu-
ary 2022, was not represented in our review [86]. These suggest that telehealth interventions
may be implemented for SUDs in LMICs but may go unreported or unpublished.
Age
Majority of included literature were among adults with only four studies with their foci on
children and adolescents [55,63,74,78]. Existential evidence is indicative of young adults as the
fastest growing users of psychoactive substances across the world and an increasingly faster
rate of substance use among individuals aged 40 years and above compared to younger popula-
tions [88]. Findings from our review suggest that adolescents can easily be motivated to abstain
from psychoactive substances using telehealth applications [64,74]. Most people who start
smoking in early adolescence are usually curious, fascinated by the practice and influenced by
peer pressure [63,74], an intervention acceptable to peers in this population would have
increased likelihood of favorable outcome. Considering that children and adolescents are in a
phase in life when appearance is of great importance, therefore in mitigating SUDs, innova-
tions which utilizes appearance as a telehealth tool as a school-based program will help to
reduce the number of adolescents who eventually develop SUDs [74].
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Population setting
Our review shows that engaging the use of telehealth interventions early in primary care is fea-
sible and effective in addressing SUDs in healthcare facilities evidenced by several studies in
this review. Its flexibility enables its use in the workplace, nightclubs, schools and among fami-
lies with promising results. In the assessment of SHS among smoking fathers, non-smoking
mothers and their newborn in a parental program, Yu and colleagues reported increased absti-
nence rates and success in the reduction to exposure to smoke [54]. SUD is a public health
problem which affects the individual, the family and society [1], consequently, SUD cessation
programs which target the family and establish structures that protect children and adolescents
in such environments should be encouraged. The majority of the reviewed studies assessed
participants in urban settings, this underscores the need to promote telehealth interventions
for hard-to-reach populations. The use of technology which provides opportunities for cost
effective, improved healthcare and reaching underserved populations and prioritization for
such programs should be encouraged in LMICs.
Study design
Studies differed in interventions and approaches across different domains (sample size, set-
tings, participants, and modalities). The bulk of studies identified in this review used quantita-
tive study design and the majority were randomized controlled trials (RCTs). Identified
articles assessed interventions at individual and group levels and majority of studies examined
interventions and comparison groups which added weight to such studies. Our review suggests
that preliminary results were acceptable, feasible and effective. Mechanisms which contributed
to significant findings had a diverse spread and studies which utilized eclectic approaches may
require subsequent replication across settings to ascertain positive outcomes of telehealth
interventions in the management of SUDs [54,69]. Findings from the qualitative studies show
that the majority of participants enjoyed the sessions but they reported that they did not like
the counseling sessions being recorded and similar reports were noted by the facilitators who
felt recording the session hindered ease of participation. Overall, small sample size, insufficient
power to definitively test the intervention, possible bias from self-reporting, absence of a com-
parison group, lack of regular follow-up, problems with technology, and high attrition rates,
were some of the methodological limitations identified in our review [46,64,65,68,69,72,73].
Psychoactive substance
Selected studies in this review assessed telehealth interventions for tobacco, alcohol, cannabis,
opioids, cocaine, methamphetamine, MDMA, inhalants, hallucinogen, sedatives, and other
psychoactive substances. A great proportion of the included studies examined telehealth inter-
ventions with regards to cigarette smoking, possibly because tobacco use is a major cause of
disease burden and one of the top five preventable causes of death [89]. Studies which assessed
multiple psychoactive substances recommended careful interpretation of results and caution
in the adoption of results [65,67]. Overall, our review highlighted substantial reduction in psy-
choactive substances with telehealth interventions.
Telehealth modality/measured outcomes
Mobile phone text messages are an affordable and effective way of overcoming resource barri-
ers in LMICs, they have the potential of reaching a wide range of people, those in hard-to-
reach areas and people who prefer non-face to face consultations and reducing stigma
[44,70,79]. This may explain why most studies in this review utilized SMS as the telehealth
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intervention of interest. Several studies found text messages to be affordable and feasible
mobile health intervention modalities with promising effectiveness in several of the studies
reviewed [51,56,58,82]. Mobile applications were demonstrated to be effective in reducing
stigma and surmounting barriers to accessing treatment in LMICs [45,79,80]. An innovative
approach with promising effectiveness in addressing the barriers encountered in resource con-
strained settings is web-based information modality [28,56,69,90,91]. This form of telehealth
intervention can be harnessed to provide information and health care services which targets
reduction in SUDs and treatment strategies across a wide population of people [65,68,69,70],
although, some authors reported high rates of attrition using this method [64,72,73]. Studies
conducted among students in high schools and colleges which used a particular facial aging
apps (“smoker face”) reported this intervention as acceptable [63,78]. Participants stated their
preference for this app and described it as interesting [63,78]. The engaging nature and practi-
cality of the app may be plausible reasons for its recommendation by participants. In evaluat-
ing the outcome of included studies, a great number of these studies demonstrated
acceptability and feasibility as favorable outcomes and a considerable number showed promis-
ing effectiveness of telehealth interventions in the management of SUDs. However, not all
authors found mobile apps and other telehealth modalities to be acceptable in the management
of SUDs [46,65,67]. Cultural practices, existing preconceptions, confidentiality, and privacy
issues were possible explanations for the poor acceptability of mobile health interventions
[18,54,61,65]. Furthermore, lack of incentives, poor internet literacy, and limited or lack of
internet connections especially in the rural areas were some of the factors identified as barriers
to feasibility and effectiveness by participants [18,61,64,72,81].
Strengths and limitations
The strengths for this scoping review include being one of the few that have examined out-
comes of telehealth intervention for SUD treatment in LMICs, use of a transparent and repro-
ducible process which states the search strategy, data sources, and data extraction. Our
findings show that a great number of articles have been published on SUDs but only a small
proportion of publications screened in comparison to the total number of selected articles
assessed telehealth interventions as possible feasible, acceptable, and effective tools for SUDs in
LMICs.
In addition to the above, our scoping review identified several limitations which include the
exclusion of grey literature and evaluation of bibliographic databases and journals published
in the English language, this may have resulted in relevant articles published in other languages
to be overlooked. Additionally, not all authors we contacted for the full text of their studies
responded. The study populations of the included studies examined circumscribed popula-
tions, and sample sizes which may make it difficult to generalize results. Our review aimed to
provide an overview of literature published on telehealth interventions and SUDs and to iden-
tify gaps in research. Consequently, it is likely that the heterogeneity of methods used across
studies may have affected the results reported.
Conclusions
The present scoping review adds to the body of knowledge, provides a summary of findings on
application of telehealth interventions in SUDs treatment in LMICs and underscores gaps in
research and areas of emphasis. These findings can guide subsequent research and interven-
tions geared at reduction of SUDs to improve outcomes. The increasingly innovative mobile
health technology can provide opportunities for underserved populations. Existing evidence
suggests its potentials in the reduction of SUDs if appropriately implemented. The evidence
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base is growing, although there is a gap of knowledge in literature examining the effect of tele-
health interventions in the reduction of SUDs in LMICs. Therefore, it is difficult to draw a
firm conclusion on its effectiveness. Future studies with larger scale randomized studies are
required to evaluate the effectiveness of telehealth interventions for individuals with SUDs in
LMICs.
Our recommendations include provision of resources and enabling conditions for telecom-
munication technology to thrive as an interventional health care tool in resource poor settings,
prioritizing research in SUDs cessation programs and promoting publications of such activi-
ties. Future research is recommended on populations with larger sample size, longer follow up
and replication of these methods across different populations to determine if telehealth inter-
ventions are as effective as some preliminary studies suggest. We also recommend that other
unexplored outcomes of telehealth intervention such as issues around privacy, confidentiality,
and cultural applicability of these methods of service delivery in LMICs should be addressed in
subsequent research. Considering that adolescents are a significant proportion of those who
use psychoactive substances [68], we recommend more research in this population with
regards to SUDs. The incorporation of smoking/ substance use cessation programs into school
programs should be supported. In addition, SUDs cessation programs using telehealth target-
ing children and parents should be considered as focus for future observational studies and in
the establishment of favorable policies.
Supporting information
S1 PRISMA Checklist. PRISMA-ScR Checklist.
(TIF)
S1 Data. Database searches.
(ZIP)
S1 Table. Search String.
(DOCX)
S2 Table. Tables of Selected Articles.
(DOCX)
Author Contributions
Conceptualization: Sarah Kanana Kiburi, Florence Jaguga.
Data curation: Margaret Isioma Ojeahere, Sarah Kanana Kiburi, Paul Agbo, Rakesh Kumar,
Florence Jaguga.
Formal analysis: Margaret Isioma Ojeahere, Sarah Kanana Kiburi, Florence Jaguga.
Methodology: Margaret Isioma Ojeahere, Sarah Kanana Kiburi, Florence Jaguga.
Project administration: Margaret Isioma Ojeahere.
Validation: Margaret Isioma Ojeahere, Sarah Kanana Kiburi, Paul Agbo, Rakesh Kumar, Flor-
ence Jaguga.
Writing – original draft: Margaret Isioma Ojeahere.
Writing – review & editing: Margaret Isioma Ojeahere, Sarah Kanana Kiburi, Florence
Jaguga.
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