A narrative review of leveraging mHealth to reduce internalised stigma among men who have sex with men with human immunodeficiency virus in low- and middle-income countries

Abstract

Background

mHealth interventions offer significant potential to reduce internalised stigma among men who have sex with men (MSM) living with HIV in low- and middle-income countries (LMICs). These digital tools offer private, accessible and culturally adaptable support to address self-stigmas related to mental illness, HIV and internalised homonegativity.

Objective

This narrative review explores mHealth interventions targeting self-stigma related to mental illness, HIV and internalised homonegativity, using the behavioural intervention technology (BIT) model as a guiding framework.

Design

Narrative review.

Methods

Studies on digital interventions addressing internalised stigma in the context of HIV, mental health and sexual identity were identified and synthesised. The BIT model guided the analysis of intervention content, theoretical underpinnings and technical features.

Results

Most interventions lacked a clear theoretical framework, culturally tailored content, and detailed reporting of behaviour change strategies and technical design—factors limiting scalability and effectiveness.

Conclusion

Future interventions to reduce internalised stigma among MSM living with HIV in LMICs employing mHealth tools should be grounded in theory, culturally relevant messaging, with clearly specified innovative technical features.

Keywords

mHealth internalised stigma HIV MSM digital health low- and middle-income countries

Introduction

Mobile health (mHealth) is reshaping the delivery of mental health care. However, for men who have sex with men (MSM) with HIV in low- and middle-income countries (LMICs), internalised homonegativity, HIV-related stigma and mental health stigma create substantial barriers to accessing support. mHealth interventions can help mitigate these challenges by providing accessible, discreet and user-centred platforms for care, and they have demonstrated potential to reduce self-stigma directly through tools such as meditation apps,¹ teletherapy² and mood tracking tools.³ Nguyen et al.⁴ conducted a systematic review of mHealth interventions aimed at improving mental health in LMICs and identified only six eligible studies published between 2014 and 2022, indicating limited utilisation of mHealth solutions for adolescent mental health in these settings. More importantly, their findings highlight the marked underuse of mHealth interventions targeting a critical mental health concern: internalised stigma.

This gap is especially pronounced for MSM living with HIV in LMICs, where overlapping stigmas compound psychological distress and impede engagement in care. Similarly, a systematic review by Zhang and colleagues found that 88% of e-health stigma-reduction interventions for people living with HIV were conducted in high-income countries (HICs), underscoring disparities in intervention availability. Accordingly, this study aims to comparatively assess internalised homonegativity, HIV-related stigma and mental health stigma and to examine their combined implications for developing and implementing mHealth interventions to reduce internalised stigma among MSM with HIV in LMICs.

Internalised stigma, or self-stigma, arises when individuals absorb negative societal attitudes toward their identity, leading to detrimental effects on mental health and behaviours, such as increased depression, anxiety, low self-esteem and social withdrawal.^1,2 This issue is particularly pronounced among MSM with HIV in LMICs, where stigmas surrounding mental illness, sexual orientation and HIV status are pervasive and reduce engagement with healthcare services.^3,5 Addressing this issue is crucial to improving health outcomes and addressing disparities in care for this vulnerable population.

Globally, HIV-related stigma remains pervasive, with over half of individuals reporting discriminatory attitudes toward people with HIV.⁶ A study by Kuchukhidze, Boily⁷ analysing data from over 842,169 individuals across 33 African countries (including 70,109 people with HIV) revealed stigma's substantial impact on HIV care, particularly in reducing engagement at critical stages like testing. Extensive research further highlights stigma's detrimental effects on treatment adherence, appointment attendance and overall mental health.^8–13 MSM living with HIV often face significant mental health challenges that are deeply influenced by internalised stigma.^14,15 This form of stigma—where negative societal beliefs about HIV and same-sex behaviour are absorbed and directed inward-plays a critical role in intensifying psychological distress. Internalised stigma contributes to heightened levels of depression, anxiety, substance use disorders and suicidal ideation by reinforcing feelings of shame, isolation and diminished self-worth. When compounded with external discrimination and social exclusion, it presents a serious public health burden by undermining access to care, treatment adherence and long-term health outcomes, for example, cardiovascular disease, neurocognitive decline and higher mortality rates.

MSM worldwide face a disproportionately high burden of HIV alongside intense stigma.^16–18 In regions like Sub-Saharan Africa, the Caribbean and Southeast Asia, HIV prevalence among MSM is markedly higher than in the general population.^14,15,19,20 However, most research on stigma focuses on HICs, leaving a critical gap in understanding how to alleviate the effects of stigma among MSM with HIV in LMICs. This oversight is particularly concerning given the unique barriers to care in these settings, where stigma poses a significant obstacle to treatment and mental health services.²¹

In LMICs, cultural, social and religious factors often exacerbate the stigma experienced by MSM with HIV, while structural challenges such as the criminalisation of same-sex behaviour, inadequate healthcare infrastructure and insufficiently trained personnel further compound the issue.^5,17,22,23 These barriers, coupled with limited access to resources, underscore the potential of mHealth as a tool to address internalised stigma. By providing culturally adaptable, private and accessible interventions, mHealth can empower individuals, reduce self-stigma and improve health outcomes. Exploring how mHealth can be tailored for MSM in LMICs offers a critical pathway to reducing internalised stigma and improving care in these settings. The behavioural intervention technology (BIT) model provides a framework for designing, evaluating and optimising digital health interventions by in integrating behavioural science with technology.²⁴The objectives of this exploration are to (1) identify the technological and behavioural components of mHealth interventions aimed at reducing internalised stigma across three types of self-stigma: (a) mental illness stigma, (b) HIV self-stigma and (c) homonegativity self-stigma; (2) use the BIT framework to evaluate these interventions and (3) propose recommendations for mHealth tools to alleviate internalised stigma among MSM with HIV in LMICs.

Methods

Study design

This study employs a narrative review methodology, which is well-suited for synthesising diverse sources and offering a conceptual overview without the constraints of systematic inclusion criteria.²⁵ Unlike systematic reviews, narrative reviews provide flexibility in exploring theoretical frameworks and emerging trends, making them ideal for analysing the intersection of mHealth, stigma and MSM in the health outcomes among MSM with HIV in LMICs.^26,27 This approach facilitates a comprehensive examination of theoretical frameworks, behavioural strategies and technological components without the constraints of a systematic review.

Effectively addressing the complexities of internalised stigma among MSM with HIV in LMICs requires a structured approach to evaluating the behavioural and technological components of mHealth interventions. The BIT model is a framework for designing, evaluating and implementing digital health interventions integrating behavioural science with technology.²⁸ The model guides the identification of behavioural targets, intervention strategies and technological features needed to achieve specific health outcomes. This paper applies the BIT model to explore the potential of mHealth interventions and propose recommendations for future strategies tailored to MSM with HIV in LMICs.

While some studies explore related themes, such as mHealth for HIV prevention, mental health and stigma reduction in LMIC contexts,^29–32 they often lack a direct focus on the intersection of internalised stigma, MSM, HIV and mHealth technology. The available literature includes examples of mHealth interventions targeting MSM and populations affected by HIV in LMICs. Still, these typically address broader issues like testing, prevention, or general stigma rather than the specific topic of internalised stigma.^4,33,34

BIT model

The BIT model, introduced by Mohr and associates,²⁸ provides a comprehensive multidisciplinary framework for developing and implementing technology-enabled interventions targeting health-related behaviour change. This model is particularly significant as it aligns with the increasing convergence of digital technology and mental health, necessitating adapting behavioural interventions for delivery through digital formats such as mobile applications, web portals and wearable devices. The foundation of the BIT model is the theory that addresses the ‘Why’ of the intervention. This component provides the theoretical framework underlying the intervention's goals. The ‘What’ follows the theoretical framework, which represents the behaviour change tools employed to achieve targeted treatment outcomes. In this model, the ‘What’ translates theoretical principles into actionable technological implementations, forming a crucial connection between the intervention's conceptual objectives and the practical actions individuals undertake to achieve their goals. The ‘What’ and ‘How’ of an intervention—its practical and technical implementation—are the focus of instantiation, the final component of the BIT model. The ‘What’ in instantiation specifies the intervention components delivered to users, such as educational modules, interactive exercises, feedback, reminders and features designed to foster social support. The ‘How’ pertains to the technical delivery methods, including mobile apps, web-based interfaces, user interface design, implementation timing and frequency, and tools for monitoring progress and providing feedback.

The World Health Organization and numerous studies have emphasised the importance of contextual factors, such as culture, economy and health care systems, in promoting meaningful and sustainable positive behavioural change. Reports such as those by Airhihenbuwa, Ford,³⁵ the Institute of Medicine,³⁶ and the Whoqol Group³⁷ underline this critical aspect. Based on these findings, we propose including context as an additional element to supplement the BIT model. This addition underscores the importance of the cultural, social, economic, political and healthcare service delivery contexts in shaping the success of the intervention in LMICs.

The BIT model is applied in this exploration to examine the use of mHealth interventions to address three distinct areas of internalised stigma: related to mental illness, homonegativity and HIV-related stigma experienced among MSM with HIV. The examination of mHealth interventions in these areas considers four primary domains: the context in which the intervention is implemented, the theoretical framework underpinning the ‘Why’, the ‘What’ of behavioural change strategies and the ‘What and How’ of specific technical elements. While not exhaustive, the examples demonstrate the potential of mHealth technologies to alleviate the internalised stigma faced by MSM with HIV in LMICs.

Search strategy and selection criteria

The narrative review used four bibliographic databases across disciplines and specialist databases: Web of Science, PubMed, PubMed Central and Google Scholar. Studies published from 2014 onward were included to capture the latest advancements in mHealth tools and their applications in addressing internalised stigma, reflecting the rapid pace of technological change. Peer-reviewed protocols and studies were included.

To enhance clarity, the search strategy is summarised in Table 1 below.

Table 1.

Summary of search strategy keywords.

Conceptual category	Search terms
Digital health technologies	‘mHealth’, ‘mobile health’, ‘digital health’, ‘eHealth’ ‘mobile app’, ‘smartphone intervention’, ‘digital intervention’
Stigma focus	‘internalised stigma’, ‘self-stigma’, ‘HIV stigma’, ‘homonegativity’
Population	‘MSM’, ‘men who have sex with men’
Geographical context	‘low- and middle-income countries’, ‘LMICs’
Health condition	‘HIV’, ‘mental health’

Inclusion criteria: studies were included if they involved digital or mobile technology as a core component of the intervention, addressed internalised stigma or self-stigma and had a focus on MSM or HIV-positive Lesbian, Gay, Bisexual, and Transgender (LGBT) populations. Peer-reviewed study protocols were also considered. Exclusion criteria: studies were excluded if they (1) did not involve digital or mobile technology as a core intervention component; (2) did not address internalised stigma/self-stigma; (3) lacked a focus on MSM or HIV-positive LGBT populations; or (4) were commentaries, non-English publications, or conference abstracts without full texts. Studies focused only on medical records and health information systems were also excluded. Countries were categorised using the World Bank classification system.³⁸ Given the limited number of LMIC studies, the scope was broadened to include HIC research when relevant for transferability.

Building on the framework of contextual characteristics, theoretical underpinnings, behavioural change strategies and technical elements, the following sections explore advancements and research evidence demonstrating the potential of mHealth technologies to mitigate self-stigma among MSM with HIV in LMICs while identifying critical gaps that require further attention. This exploration begins with a focused examination of how mHealth interventions address internalised stigma in specific contexts, starting with mental illness self-stigma.

Results

The findings from the narrative review present a structured analysis of mHealth interventions designed to reduce internalised stigma among MSM with HIV in LMICs. Using the BIT model, this section examines how these interventions address three key forms of self-stigma: (1) mental illness stigma, (2) HIV self-stigma and (3) homonegativity self-stigma. Table 1 presents a summary of the reviewed literature to facilitate comparison and synthesis. This review examines 17 studies relevant to reducing internalised stigma using mHealth tools for LMICs. Out of these 17 studies, six specifically focused on LMICs, including research conducted in China,³⁹ India,³⁰ Kenya,^29,39 South Africa,³² Nigeria⁴⁰ and Romania.⁴¹

Mental illness self-stigma

While not all studies in this section directly target MSM living with HIV, they are included as contextual evidence. Mental illness stigma frequently co-occurs with HIV-related stigma, particularly among MSM populations,^38,42 and thus findings from broader interventions can provide transferable lessons for mHealth approaches in HIV contexts. Significant progress has been made in developing mHealth interventions designed to reduce the internalised stigma faced by individuals experiencing mental illness. Research indicates that users are generally receptive to digital mental health services, valuing them for convenience, personalised support and confidentiality.^29,43–45 Numerous studies have also investigated the application of mHealth technology in managing stigmas associated with mental illness.

For instance, the study protocol outlined by Guo, Hong³⁰ details the design of an mHealth intervention aimed at enhancing the mental health of individuals in China with HIV who exhibit heightened depressive symptoms. However, the protocol does not explicitly address cultural, social, or economic contextual factors, which limits the intervention's transparency and replicability in other settings. Although no explicit theoretical model or the ‘Why’ was elaborated, the protocol referenced cognitive behavioural theory to inform the development of stress-reduction strategies. In addition to targeting depressive symptoms, Guo et al.¹⁵ also explicitly addressed internalised HIV-related stigma, showing that cognitive-behavioural strategies can concurrently reduce psychological distress and HIV stigma among people living with HIV. The behaviour change strategies employed in the intervention included education, monitoring and feedback, aligning with key elements of cognitive-behavioural change principles delivered through nine core sessions and three review sessions over 12 weeks (3 months).

The Technical elements or the ‘What’ of intervention delivery relied on smartphones, employing features such as notifications, passive data collection, messaging and weekly reports to facilitate real-time interactions with participants. The Technical elements or the ‘How’ of intervention delivery, included participants receiving up to five follow-up phone calls from research staff to provide social support, scheduled at intervals of 1, 2, 5 and 8 months post-enrolment.

Rodríguez-Rivas et al.⁴⁶ reviewed technology-based interventions aimed at reducing mental illness stigma. Although the review did not focus specifically on MSM, it offers a valuable global overview of how technological innovations are being leveraged to reduce stigma toward people living with mental illness. In the context of study locations, most studies were conducted in HICs, with 44% (four studies) based in Europe and 22% (two studies) in North America. In contrast, only one study (11%) was conducted in each of the following regions: Asia, Australia (both classified as HICs) and Latin America, which represents an LMIC setting. Rao et al.⁴⁷ demonstrated that e-Health modalities provide ‘social contact’ through features such as moderated peer chat rooms, virtual group sessions and interactive message boards, which create opportunities for stigma reduction by normalising shared experiences. The Positive Living Program²⁵ reduced HIV-related stigma by combining psychoeducation with coping skills training, empowering participants to reframe internalised beliefs and strengthen self-efficacy in managing disclosure and adherence. This review did not examine the theoretical framework or the ‘Why’ driving the development and implementation of the interventions. Key details regarding behavioural change strategies (the ‘What’) were also missing. The review highlighted that interventions frequently utilised innovative technologies (the ‘What’), such as virtual reality and electronic simulations. However, details regarding the technical aspects of the ‘How’ (such as workflow, usage frequency and task completion rules) were not addressed.

The systematic review by Rodríguez-Rivas et al. highlights a clear imbalance in the representation of HICs versus LMICs in studies on technology-based interventions for reducing mental health stigma. Most of the included studies were conducted in high-income regions—primarily Europe and North America—and focused on university students in urban settings. This limits the generalizability of the findings to broader and more diverse populations. Advanced technologies like virtual reality and e-contact were commonly used, but these may be impractical in many LMICs due to limited infrastructure, digital literacy and access. While the interventions demonstrated a moderate overall effectiveness, the lack of cultural adaptation and minimal inclusion of LMIC contexts reveal significant research gaps. The review underscores the need for more inclusive studies that address socioeconomic and technological disparities and prioritise culturally relevant, low-cost solutions. The meta-analysis reported a medium effect size in reducing public stigma, suggesting that mHealth tools hold promise—but also highlighting the importance of aligning behavioural change strategies, technical design and implementation.

In conclusion, studies suggest that mHealth interventions are a rapidly emerging approach in reducing mental illness stigma, offering benefits such as convenience, personalisation and confidentiality. Studies across various contexts highlight user receptiveness but reveal gaps in theoretical frameworks, behavioural change strategies and implementation details. Research in Portugal and other HICs has focused on cognitive-behavioural strategies, psychoeducation and virtual reality, while studies in China and other LMIC have often employed cost-effective methods such as Short Message Service (SMS). These findings show that mHealth interventions can be adapted to different settings to reduce internalised stigma. Issues such as limited digital access, persistent stigma and high data costs underscore the need to develop context-specific, theory-driven mHealth interventions. Limited or unreliable connectivity, reliance on shared or low-end devices, and privacy concerns require interventions that are technologically feasible and responsive to local usage patterns. At the same time, the pervasive intersection of mental-illness, HIV-related, and sexual-minority stigma in these settings underscores the importance of grounding intervention content in robust theoretical frameworks—to address the social and psychological processes that sustain stigma effectively. High data costs further necessitate efficient, low-bandwidth designs informed by behaviour-change theory to ensure that even brief digital interactions can meaningfully shift attitudes and promote help-seeking. Overall, although many mHealth tools addressing mental illness stigma have not yet been tested directly among MSM with HIV, their core methods—such as cognitive behavioral therapy (CBT), psychoeducation and virtual reality (VR)—offer a transferable foundation for tackling internalised stigma in this population.

HIV self-stigma

Rao and associates⁴⁷ reviewed e-health technologies for reducing HIV-related stigma to enhance engagement in care for people with HIV. However, this brief assessment did not include details on contextual characteristics. This study found that behavioural change strategies, such as psychoeducation and cognitive behavioural therapies, effectively reduced emotional stress. The authors highlight the benefit of technological elements ‘What’, such as SMS messaging and online chat rooms, in providing anonymous social support. Additionally, as noted by the authors, the use of various e-Health modalities has the potential to address different stigma mechanisms by providing education, social contact and coping skills. These interventions can counter mechanisms such as labelling, stereotyping, isolation, and the sense of powerlessness or loss of social control. The Rao et al.⁴⁷ review lacked detail on contextual factors influencing intervention outcomes. They found that behaviour change strategies—such as psychoeducation and cognitive behavioural therapy—effectively reduced emotional stress. The authors also highlighted the role of technological elements like SMS messaging and online chat rooms in offering anonymous social support. They noted that different e-health modalities have the potential to address various mechanisms of stigma. The review also indirectly points to disparities between HICs and LMICs in how e-health interventions are developed, delivered and evaluated. While HICs have advanced complex, multimedia digital tools for specific populations, LMICs often remain in the pilot phase, constrained by limited infrastructure and workforce shortages. Interventions in HICs typically function as self-help tools, whereas those in LMICs rely more on lay health workers and basic technologies like SMS or tablet-based education. Despite growing interest, stigma is rarely a primary outcome in these interventions—particularly in LMICs. The authors emphasise the need for more rigorous, context-sensitive research to identify effective components and to ensure equitable access across different socioeconomic and geographic settings.

The development of The Positive Living Program, a multimedia behavioural intervention aimed at addressing HIV-related stigma and depression among African immigrant people in the United States with HIV, placed significant emphasis on cultural considerations.⁴⁸ Insights gathered from stakeholder interviews highlighted the necessity of accommodating cultural and linguistic diversity in the intervention's delivery strategies. Consequently, the program was narrated by an African immigrant physician, with character scenarios and storylines enacted by African immigrant actors to represent the lived experiences of African immigrant people with HIV (PWH) authentically.

Delivered individually through a tablet-based multimedia platform incorporating visual, audio and video components, the intervention did not adhere to a specific theoretical model ‘Why’. The technical components ‘What’ included culturally tailored multimedia modules, including audiovisual content delivered via tablets. The behaviour change strategies ‘How’ focused on mood monitoring and behavioural activation, fostering self-reflection and problem-solving. Despite these features, details regarding implementation workflows, the technical ‘How’ were not provided. The findings showed that the tablet-based program was effective in reducing internalised stigma score and depressive symptoms between the intervention and 1-week follow-up.

Digital platforms designed specifically for MSM living with HIV in LMICs have demonstrated potential. One such platform, HealthMpowerment (HMP). The HMP platform^26,27 is a mobile-friendly digital intervention designed specifically for MSM, integrating peer interaction, gamification and HIV prevention tools to promote engagement and stigma reduction. HMP is an online mobile phone- and we-based platform designed to support the health and well-being of young Black men MSM and transgender women. It provides interactive tools, educational resources, peer support forums and behaviour change features aimed at reducing HIV-related stigma, improving health knowledge and promoting safer behaviours. The effectiveness of HMP is strongly influenced by its implementation environment.^49–51 Key contextual factors include the target population, primarily young Black and Latinx MSM and transgender individuals at higher risk for HIV.^51,52 HMP is grounded in behavioural and social science theories that explain why users engage with the intervention and adopt healthier behaviours. The theoretical models (Why) underpinning HMP include social cognitive theory (SCT), the information-motivation-behavioural (IMB) model, minority stress theory, and gamification and engagement models.^51,53,54 Key contextual factors include the target population, primarily young Black and Latinx MSM and transgender individuals at higher risk for HIV.^51,52 HMP is grounded in behavioural and social science theories that explain why users engage with the intervention and adopt healthier behaviours. The theoretical models ‘Why’ underpinning HMP include SCT, the IMB model, minority stress theory, and gamification and engagement models.^53,54

HMP employs core behavioural strategies ‘What’ focused on HIV prevention, health promotion and risk reduction through digital engagement. To optimise behavioural change effectiveness, HMP incorporates various digital and technical elements. A key technical ‘What’ element is the platform's mobile-friendly design, making it easily accessible via smartphones and web browsers for user convenience. Regarding the technical ‘How’ elements, personalised content delivery is enabled through algorithms that customise health information based on user responses and engagement. Gamification and a rewards system enhance user interaction by incorporating quizzes, progress tracking and incentives that promote behaviour change. Peer-led discussions and support groups offer anonymous forums where users can share experiences, ask questions and seek support. Emphasising confidentiality and security, the platform ensures a safe environment for MSM and transgender individuals. Additionally, it integrates with health services, linking users to HIV testing centres, pre-exposure prophylaxis (PrEP) providers and mental health resources.

Bauermeister, Muessig⁵² explored the connection between engagement in stigma-related discussions and changes in stigma scores among young Black American MSM using HMP. Participants who discussed experiencing HIV stigma in the forums reported decreases in perceived HIV stigma over time. Those who challenged sexuality-related stigma in forums had lower internalised homophobia. However, the study did not examine contextual influences, discuss the theoretical framework (the ‘Why’), or address behavioural change strategies. From a technical standpoint the ‘What’, participants had access to three interactive spaces designed for sharing and support. The Forum facilitated discussions on topics such as health, relationships and current events. The Ask Dr W. section allowed users to anonymously submit questions to a board-certified infectious disease specialist, with responses publicly available. The Getting Real space enabled users to share self-created multimedia or web content. However, the study did not provide specific technical details the ‘How’ regarding the platform's design or the rules for task completion.

Dulli et al.⁴⁰ evaluated a smartphone-based social media intervention in Nigeria. Although the program targeted psychosocial barriers, including stigma and depression, the trial reported no statistically significant differences in HIV-related stigma outcomes between intervention and control groups, underscoring the difficulty of reducing deeply entrenched stigma. While the study did not explicitly address contextual factors, the fact that both the researchers and participants were Nigerian and that the study took place in Nigeria suggests that these factors played a role in the intervention's design and implementation. The authors highlighted challenges related to internet connectivity and confidentiality. The study did not specify a theoretical framework the ‘Why’ guiding the intervention's design and delivery. However, it incorporated behaviour change strategies the ‘What’, including role modelling, educational videos and interactive polls to foster peer engagement and social support. From a technical perspective the ‘What’, the intervention was delivered through private Facebook groups, relying on mobile access to the platform. The ‘How’ of the intervention involved weekly delivery of educational and interactive content designed to enhance retention in HIV care over 22 weeks. Despite these efforts, the intervention did not significantly improve retention rates compared to the control group, highlighting the need for a deeper understanding of how health behaviour change interventions can be effectively integrated with mHealth solutions.

Batchelder, Moskowitz⁵⁵ explored internalised stigma and shame among individuals with HIV and substance use disorders. This study developed and tested a brief emotion regulation intervention to improve HIV self-care among people living with HIV and active substance use disorders. The intervention combined individual sessions targeting internalised stigma and shame with personalised text messaging to reinforce self-compassion and adherence to treatment. Results from the proof-of-concept pilot showed high engagement and acceptability, supporting further evaluation in larger trials. The study was conducted in the United States; however, contextual factors were not explicitly addressed in the intervention description. The intervention was guided by the theoretical framework ‘Why’ The Revised Stress and Coping Theory, but details on behavioural change ‘What’ strategies were not provided. The technical ‘What’ components included daily self-assessment prompts and weekly check-ins. However, details regarding the technical ‘How’ were lacking.

Chory et al.²⁹ piloted a WhatsApp-based intervention aimed at adolescents living with HIV in Kenya. The study tested the feasibility and acceptability of a mobile intervention to support mental health and adherence among adolescents with HIV in Western Kenya. Contrary to expectations, reports of stigmatising beliefs increased throughout the 6 months of the study. The authors infer that this may be an effect of intervention in providing a heightened anti-HIV stigma awareness, and the context of the evaluation, which may have led participants to more readily report these feelings and symptoms. This study underscores the potential for mHealth interventions to foster connections, provide support and promote awareness of stigma experiences.

The Support for Adolescent Female Initiative program²⁹ employed digital peer support to address psychosocial barriers to HIV care, including stigma and isolation. Over a 6-month intervention period, participants reported a significant increase in perceived stigma, with more than half experiencing community stigma. The authors suggest that this rise may reflect heightened awareness resulting from participation in discussion groups. These findings underscore the need for mobile interventions to incorporate flexible, context-specific strategies that respond to changes in stigma perceptions over time. While contextual factors were not explicitly discussed, the study was led by Kenyan researchers at a local site. However, infrastructural challenges, such as power outages and limited internet connectivity, posed significant barriers to feasibility in LMICs. The study did not specify the theoretical framework the ‘Why’ guiding the intervention, but its focus on behaviour change strategies ‘What’ incorporated peer support and counsellor-led guidance. The technical element ‘What’ leveraged WhatsApp's accessible interface, making it a suitable platform for the target population.

The ‘Positive Peers’ app is designed to engage and retain young adults in the United States with HIV in care.⁵⁶ The Positive Peers app reduced stigma by offering a secure, anonymous space where people living with HIV could connect with peers, access reliable health information and share personal stories. Overall, stigma scores declined throughout the 18-month study period.⁵⁷ This combination of community support, education and privacy helped users feel less isolated and more empowered to challenge stigma.⁵⁶ The authors address contextual factors by stating that the ‘Positive Peers’ app was developed with a deep awareness of users’ cultural and socioeconomic challenges. The research team incorporated the perspectives of affected individuals, ensuring that the app was relevant and sensitive to their needs. Regarding the theoretical framework ‘Why’ the app leverages media affordances theory, social support theory and health communication principles to provide a structured digital intervention that addresses the psychological and social challenges of HIV care. Regarding the behavioural change strategies ‘What’, the app uses a combination of reminders, community support, education content and privacy protection to encourage positive health behaviours and reduce stigma. The app is structured around three core functionalities, each with specific technical ‘What’ elements: health management features, resource Hub (which includes user-generated stories and blog articles, including stigma and treatment topics) and peer networking features. Information on technical elements of ‘How’ is lacking. Additional technical considerations include cross-platform compatibility, data privacy measures and user activity tracking.

Zanoni, Archary³² recently tested the acceptability, feasibility and preliminary effect of a mHealth intervention aimed at improving retention in care among adolescents with HIV. This study also explored modifiable variables, including internalised HIV-related stigma. The study was conducted in South Africa; however, it did not address contextual factors or specify a theoretical framework guiding the intervention's development and implementation. The behavioural components ‘What’ included structured peer-led support groups, allowing participants to share experiences and receive guidance, as well as personalised messages designed to enhance motivation and adherence to care plans. A review of the study protocol⁵⁸ identified the technical (What) element as the mobile phone-based approach, utilising WhatsApp's user-friendly interface. This technical element, ‘What’ facilitated the technical ‘How’ capabilities for enabling real-time communication through group chats, medication adherence reminders and interactive polls to encourage engagement. The WhatsApp-based peer support intervention yield mixed results: although participants appreciated the reminders and group discussions, there was no definitive evidence of reduced internalised HIV-related stigma. The program also incorporated the technological ‘How’ component, enabling periodic monitoring by healthcare providers who offered individualised feedback and support through the platform.

In summary, mHealth interventions have been explored as tools to reduce HIV-related self-stigma and improve care. Studies have utilised various approaches, including psychoeducation, cognitive behavioural therapies and peer support, often leveraging mobile and digital platforms like SMS, WhatsApp and social media. Programs such as the Positive Living Program⁴⁸ and HMP⁵⁰ tailored interventions to specific populations, incorporating cultural and behavioural elements. However, many studies lacked explicit theoretical frameworks, contextual considerations, or detailed implementation strategies. Despite challenges such as infrastructure limitations and digital accessibility, interventions demonstrated potential to reduce stigma among diverse populations. Overall, while mHealth interventions offer promising strategies to reduce stigma and support people with HIV, gaps in theoretical guidance, contextual integration and implementation details remain key areas for further research and optimisation.

Homonegativity self-stigma

Growing evidence supports the effectiveness of mHealth in addressing internalised homonegativity self-stigma,^32,33 though studies remain limited. mHealth interventions are increasingly recognised as essential tools in addressing internalised homonegativity and self-stigma within the LGBT community.^41,51,59,60 These interventions leverage mobile technology to enhance mental health outcomes, providing avenues for peer support, education and resources that empower individuals to embrace their identities and mitigate the adverse effects of stigma. One notable intervention is Releasing Internalized Stigma for Empowerment (RISE), which demonstrates the potential of interactive and adaptive learning to challenge negative stereotypes and promote self-acceptance.

Developed by Lin and colleagues,⁶¹ RISE is an innovative online group-based intervention designed to help sexual and gender minorities in the United States with HIV reduce internalised stigma by using cognitive restructuring, self-compassion practices and peer support to promote empowerment and improve well-being. Reference to cultural context is made including content on LBGT cultures. Grounded in the minority stress theory the theoretical ‘Why’ and social psychological theories concerning attitude formation and change, the intervention utilises behaviour change strategies ‘What’ such as adaptive learning, which customises educational and motivational content to meet individual needs, ensuring personalised engagement. RISE incorporates technical elements ‘What’ in an online intervention, timely feedback, and peer support options ‘How’, which enhance user interaction and encourage meaningful, sustained communication throughout the intervention. The intervention's workflow ‘How’ is designed to accommodate self-paced modules and flexible engagement rules, allowing users to interact with the content conveniently. Specific events, such as task completion or time-based reminders, trigger responses. The RISE intervention has been modified and tested as Project RISE, a self-guided single-session intervention to ameliorate internalised stigmas among LGBT youth.⁶² The findings from this study showed that participants in Project Rise reported more significant decreases in internalised stigma than participants in the control condition. RISE and Project Rise are mobile-based interventions delivered via mobile-responsive web platforms or mobile applications.

Project Cummica, developed by Lelutiu-Weinberger and Manu,⁴¹ is an intervention designed to reduce HIV risk and improve mental health among gay and bisexual men in Romania. It addressed homonegativity self-stigma by combining motivational interviewing and cognitive-behavioural strategies to help participants challenge negative beliefs about their sexuality, build self-acceptance and develop healthier coping skills. The program included individual counselling sessions that focused on reducing internalised stigma, increasing self-efficacy and supporting safer sexual behaviours.

Recognising the significant influence of cultural and contextual factors, such as stigma and discrimination, the intervention was designed to be both relevant and responsive to the unique challenges faced by the population. Grounded in (the What) motivational interviewing and cognitive behavioural skills training, the intervention operated within a syndemic framework, acknowledging the interconnected nature of HIV risk, mental health struggles and substance use. To drive behavioural change ‘What’, the intervention integrated multiple techniques, including education and skills-building activities. A key technical ‘What’ element was delivering the intervention through a secure mobile platform ‘What’. A technical ‘How’ element of the intervention was its delivery through four core components: chat-based counselling service, providing direct support and guidance; a resource and education hub, offering comprehensive information on health and well-being; a behavioural and affective tracking tool, enabling users to monitor their progress; and a confidential, private digital environment, designed to protect user data and encourage engagement.

In summary, mHealth interventions are increasingly recognised as effective tools for addressing internalised homonegativity and self-stigma within the LGBT community by providing peer support, education and resources that promote self-acceptance. The RISE intervention⁶¹ and its adaptation, Project RISE,⁶² leverage minority stress theory and social psychological models to challenge negative stereotypes through personalised, adaptive learning. Delivered via mobile-responsive platforms, these interventions incorporate timely feedback, peer support and flexible, self-paced engagement. Similarly, an mHealth intervention developed by Lelutiu-Weinberger, Manu⁴¹ targeted young gay and bisexual men in Romania, addressing HIV risk, alcohol use and mental health through motivational interviewing and cognitive behavioural skills training. This intervention integrated education, behavioural tracking and chat-based counselling via a secure mobile platform, ensuring confidentiality while promoting engagement. These studies highlight the potential of culturally responsive, mobile-based strategies in mitigating stigma and improving mental health outcomes for LGBT individuals.

Discussion

This study is the first to address the internalised stigma faced by MSM with HIV in LMICs through the lens of mHealth technology. The integration of mHealth technologies into mental health care has the potential to improve access and impact interventions targeting internalised stigma among MSM with HIV in LMICs. However, notable gaps persist—particularly in contextual relevance, theoretical grounding, behavioural strategies and technical design. These shortcomings may, in part, reflect limitations and requirements imposed by journals, which can constrain how comprehensively these aspects are addressed or reported in published studies. Examining the intersection of mental health stigma, HIV-related stigma and internalised homonegativity offers valuable insights. By identifying both shared and distinct features across mHealth interventions addressing these stigmas, we can better assess their effectiveness, identify gaps and refine strategies to make them more inclusive, targeted and impactful for MSM with HIV in LMICs.

To ensure the successful implementation and impact of mHealth interventions in addressing internalised stigma among MSM with HIV in LMICs, it is crucial to examine key dimensions that influence their effectiveness. This includes assessing these interventions’ cultural and contextual relevance, the theoretical frameworks that guide their development, the behavioural strategies they employ, and the technical design considerations that shape their usability and optimisation. By exploring these components, we can identify best practices, address existing limitations and refine mHealth solutions to meet the needs of the target population better.

Cultural and contextual relevance

Stigma is deeply embedded in social, religious and cultural structures, especially in LMICs, where MSM face heightened discrimination due to legal and social restrictions. Interventions such as the Positive Living Program⁴⁸ have taken steps to ensure cultural sensitivity by incorporating narrations from African immigrant physicians and culturally resonant storytelling. Similarly, HMP^49,50 tailors its digital platform to Black and Latinx MSM, recognising the distinct experiences of these populations. However, many studies neglect to examine systematically how cultural factors shape the adoption and effectiveness of interventions. For example, while Dulli, Ridgeway⁴⁰ conducted their intervention in Nigeria, the study did not explicitly explore the broader sociocultural influences on intervention uptake. Likewise, studies such as those by Zhang, Ni³⁹ and Batchelder, Moskowitz⁵⁵ omit detailed contextual considerations despite being conducted in distinct regional settings. The lack of culturally and contextually adapted interventions remains a significant limitation, as generic mHealth tools may not resonate with users facing stigma embedded in their specific socio-political realities.

Theoretical frameworks and behavioural change strategies

Theoretical frameworks are essential for designing effective interventions, yet many mHealth programs lack a clear theoretical foundation. The BIT model²⁸ offers a structured approach to integrating digital health interventions with behaviour change strategies, but its application in mHealth interventions remains inconsistent. Some interventions, such as HMP, explicitly draw upon multiple theories, including SCT, the IMB model and minority stress theory, to explain user engagement and behaviour change.⁵¹ Similarly, the RISE intervention⁶¹ is grounded in the minority stress theory and social psychological models, aligning its intervention goals with well-established theories of stigma reduction. In contrast, many studies fail to define their theoretical underpinnings. For instance, Johnson, Sanghvi⁶³ reviewed technology-based mental health interventions but found that only a few were explicitly guided by theory. Without a clear theoretical foundation, interventions may lack coherence and fail to address the psychological mechanisms driving internalised stigma. This omission weakens the intervention's ability to produce meaningful, sustained behaviour change.

The use of behavioural strategies is critical to translating theoretical frameworks into practical, impactful interventions, yet the diversity and effectiveness of these strategies vary significantly. Many interventions leverage psychoeducation and cognitive behavioural strategies to challenge negative beliefs and reduce self-stigma. For example, RISE⁶¹ employs adaptive learning techniques that personalise educational content to users’ needs, enhancing engagement and effectiveness. Similarly, the Positive Peers app⁵⁶ incorporates social support and community-driven education to foster behavioural change. Other interventions, such as the WhatsApp-based program piloted by Chory and colleagues²⁹ employ peer support mechanisms to create a safe space for MSM with HIV to engage in stigma-reduction discussions. However, the depth of behavioural strategies employed is often inconsistent. Some interventions, such as those reviewed by Rodríguez-Rivas and associates,⁴⁶ fail to detail the specific strategies used to drive behaviour change, leaving gaps in understanding how interventions achieve their intended outcomes. Additionally, while digital interventions offer anonymity and privacy, which are crucial for stigmatised populations, they must also provide meaningful engagement strategies that extend beyond passive content consumption.

Technical design and workflow optimisation

Technical design and workflow optimisation remain areas of both innovation and challenge in mHealth interventions. Workflow optimisation addresses internalised stigma by standardising and normalising care processes, reducing opportunities for stigmatising interactions and ensuring consistent, supportive engagement with patients. Many interventions leverage mobile-friendly, accessible platforms such as SMS, WhatsApp and interactive web portals. The HMP platform, for example, integrates gamification, peer-led discussions and personalised content delivery to enhance engagement and interaction.⁵³ Workflow organisation can reduce stigma by providing structured engagement through scheduled reminders, consistent peer support and guided modules, which normalize help-seeking and reduce isolation^.⁴ Advanced technology features—such as anonymity settings, adaptive personalisation and gamification—further mitigate stigma by ensuring privacy, tailoring content to user needs and reframing engagement in empowering rather than deficit-focused terms.³⁴ Similarly, the RISE intervention utilises a mobile-responsive platform with self-paced modules and interactive learning features.⁶¹ However, despite these advancements, many interventions fail to specify key technical elements such as task completion rules, implementation workflows and frequency of interaction. Studies such as those by Zanoni et al.³² highlight infrastructural challenges, including limited access to personal devices, unreliable internet connectivity and high data costs, which can hinder the scalability of digital interventions in LMICs. Furthermore, security and confidentiality concerns remain paramount, especially for MSM with HIV, who face legal and social risks. The Positive Peers app⁵⁶ addresses this issue by incorporating data privacy measures, but many interventions do not explicitly discuss their security protocols, raising concerns about user safety.

Overall, while mHealth interventions present significant potential for reducing mental health stigma, HIV-related stigma and internalised homonegativity stigma among MSM in LMICs, critical gaps remain in cultural adaptation, theoretical grounding, behavioural strategies and technical implementation. Culturally responsive interventions, guided by robust theoretical frameworks and leveraging effective behaviour change strategies, are essential for meaningful impact. Additionally, improving the technical design of interventions, ensuring accessibility and addressing security concerns will enhance their effectiveness and reach. Addressing these gaps will be essential in refining mHealth strategies to create inclusive, stigma-free digital health solutions that empower MSM with HIV and improve their mental health outcomes in LMICs.

Limitations

This narrative review provides valuable insights into the potential of mHealth interventions to address internalised stigma among MSM with HIV in LMICs. However, its limitations must be acknowledged. As a narrative review, it lacks the systematic methodology of a meta-analysis or systematic review, potentially introducing selection bias in study inclusion and synthesis. The heterogeneity of the reviewed studies, including differences in theoretical frameworks, intervention designs and technical implementations, makes direct comparisons challenging. Furthermore, while the review highlights the importance of contextual adaptation, many studies fail to systematically assess how socio-cultural, religious and legal factors influence intervention effectiveness in LMICs. The focus on short-term outcomes, rather than long-term sustainability and behavioural change, further limits the ability to determine lasting impacts. Additionally, the lack of comprehensive reporting on implementation details, such as engagement metrics and scalability considerations, makes it difficult to assess how effectively these interventions can be integrated into healthcare systems in resource-limited settings.

Recommendations

Empirical evidence is essential for understanding the relationship between contextual characteristics (environment and setting), the ‘Why’ (theoretical foundations) guiding the intervention design, behavioural change strategies (‘How’ change is facilitated), technology elements (‘What’ tools are utilised), technical characteristics (‘What’ features define the intervention) and workflow (‘When’ and ‘How’ it is implemented) in designing effective interventions to reduce stigma, particularly internalised stigma among MSM with HIV in LMICs. Future intervention recommendations incorporate insights from contextual, theoretical and technical perspectives:

Contextual Sensitivity: Cultural sensitivity is crucial for interventions targeting MSM in LMICs, where social, economic and political barriers, along with limited healthcare resources, significantly impact access to support. Tailoring content to local contexts by incorporating inclusive language and addressing challenges such as stigma, discrimination and restrictive legal environments is essential. Economic constraints, including limited internet access and high data costs, hinder digital engagement, making accessibility and affordability key considerations. Data privacy and confidentiality are particularly critical in regions where disclosing one's identity can lead to severe social and legal consequences. Collaborations with local stakeholders, as seen in Project Comunică,⁴¹ help develop culturally relevant content that resonates with target communities, fostering trust and engagement. By integrating localised approaches, interventions can better navigate structural and cultural barriers, ensuring they effectively address the unique challenges MSM face in LMICs. Innovative strategies are essential for overcoming infrastructural challenges in LMICs. Offline functionalities, zero-rated services through partnerships with mobile network providers and alternative communication channels such as SMS or Interactive Voice Response systems can enhance accessibility for users with limited connectivity. Additionally, subsidising low-cost smartphones and offering digital literacy training can further reduce barriers, ensuring more equitable access to mHealth interventions.

Integration of Advanced Technological Features: Advanced technological features are crucial for enhancing user engagement and achieving better outcomes. Tools such as anonymous digital communication, tailored educational content and automated reminders help reduce stigma by protecting privacy, increasing access to accurate information and empowering individuals to manage their health discreetly and confidently. Additionally, adaptive learning algorithms should be implemented to tailor intervention content dynamically based on user responses and behavioural trends. AI-driven personalisation ensures users receive support aligned with their needs and engagement levels, reducing the risk of drop-off and disengagement. Gamification techniques, such as stigma-reduction challenges, can sustain user interest, while adaptive algorithms dynamically tailor content to individual user progress. Workflow optimisations, such as scheduled reminders and progress tracking, further support sustained behaviour change. By leveraging scalable and user-friendly designs, as exemplified by interventions like Positive Peers, mHealth tools can ensure consistent interaction, reduce stigma and support HIV care efforts. Virtual communities within mHealth platforms can foster peer interaction and reduce stigma by creating safe spaces for shared experiences. Interventions like Positive Peers have demonstrated the potential of peer networks to enhance mental health literacy and resilience. Leveraging existing platforms, such as Grindr and Hornet, for resource dissemination and peer support can amplify these efforts. Collaborations with local health centres and NGOs can extend access through community-based initiatives.

Additional recommendation

Long-Term Impact Evaluation: To address the short-term focus of many existing interventions, longitudinal studies are recommended to assess sustained behaviour change and mental health outcomes. Real-time monitoring systems and mixed-method evaluations can track user engagement and stigma reduction over time. Interventions like HMP illustrate the importance of structured evaluations, although expanded efforts are required to assess long-term effectiveness comprehensively. Implementation tracking tools should be integrated into mHealth platforms to assess user activity patterns, adherence rates and engagement trends. By collecting and analysing longitudinal data, researchers can refine interventions to ensure they maintain effectiveness across different populations and settings. Additionally, cost-effectiveness and digital infrastructure must be considered in LMICs, where access to stable internet, smartphone devices and digital literacy varies. Future research should explore strategies such as zero-rated mobile health services, offline functionalities and partnerships with local health organisations to enhance accessibility (Table 2).

Table 2.

Digital and Mobile health interventions for mental health, HIV and homonegativity internalised stigma reduction: a comparative analysis using the BIT framework

Study	Context	Theory (why)	Behaviour (what)	Technical (what and how)
Batchelder et al.⁵⁵ ^a	US; HIV + with substance use	Revised stress and coping	Not reported	Daily self-assessments and weekly check-ins; lacks workflow info
Bauermeister et al.⁵² ^a	US; young Black MSM	Not explicit	Online stigma discussion forums	Three interactive spaces (forum, Q&A, user content); workflow details sparse
Chory et al.²⁹ ^a	Kenya; adolescents with HIV	Not specified	Peer support and counsellor guidance	WhatsApp-based delivery; affected by connectivity issues
Dulli et al.⁴⁰ ^a	Nigeria; youth with HIV	Not specified	Role modelling, videos, polls for peer support	Private Facebook groups; weekly over 22 weeks
Guo et al.³⁰ ^b	China; HIV + with depression	CBT (stress reduction)	9 sessions + 3 reviews over 12 weeks	Smartphone app: notifications, messaging, passive data, follow-up calls
Johnson et al.⁶³ ^b	HICs (Australia focus)	Not clearly stated	Psychoeducation to destigmatize mental illness	1–2 module internet programs; limited workflow info
Lelutiu-Weinberger et al.⁴¹ ^c	Romania; YGBM and MSM	Minority stress theory, MI and CBT	Stigma, HIV risk reduction, mental health support	Mobile app with structured modules, behavioural tracking and peer-led support
Lipira et al.⁴⁸ ^a	African immigrants in US	Not specified	Mood monitoring and behavioural activation	Tablet-based multimedia modules; workflow not provided
Rao et al.⁴⁷ ^a	Broad PLWH context	Not specified	Psychoeducation and CBT for emotional stress	SMS and online chat rooms; limited implementation details
Rodríguez-Rivas et al.⁴⁶ ^b	Mostly HICs; one LMIC	Not addressed	VR/electronic simulations for stigma reduction	Advanced digital tools; workflow details missing
Madonsela et al.³¹ ^b	Adolescents in LMICs (Nigeria, China, Kenya, India)	Not addressed	Not reported	SMS texting; minimal duration/workflow details
Muessig et al.⁵¹ ^a	US; young Black/Latinx MSM and transgender	SCT, IMB, minority stress, gamification	HIV prevention, stigma and risk reduction	Mobile-friendly, personalised, gamified; peer-led discussions and health service integration
Shen et al.⁶² ^c	LGBT youth	Minority stress theory	Single-session intervention to reduce internalised stigma	Online, mobile-accessible, interactive modules with real-time feedback
Step et al.⁵⁶ ^a	US; young adults with HIV	Media affordances, social support, health communication	Reminders, community support and education	App with health management, resource hub and peer networking; workflow details sparse
Zanoni et al.⁵⁸ ^a	South Africa; adolescents with HIV	Not specified	Peer-led support and motivational messages	WhatsApp-based group chats, adherence reminders and provider feedback
Zhang et al.³⁹ ^a	RCTs in US, China, Kenya, Australia	Some use IMB and self-efficacy; others none	Not specified	App-based (one study); sessions weekly 4–24 weeks; limited tech details

Abbreviations: HICs: high-income countries; LGBT: lesbian, gay, bisexual, transexual; YGBM: young gay bisexual men; CBT: cognitive behavioural therapy; SCT: social cognitive theory; IMB: information-motivation-behavioural skills model; VR: virtual reality.

HIV-related stigma.

Mental health-related stigma.

Internalised homonegativity stigma.

Ethical and Privacy Considerations: Given the sensitive nature of HIV status and sexual identity, ethical considerations are paramount in designing and implementing mHealth interventions. While some studies emphasised confidentiality and secure user engagement, data privacy, informed consent, and risks of digital surveillance remain concerns, particularly in LMICs where legal protections for MSM and people with HIV are weak. Future mHealth interventions should incorporate robust cybersecurity measures, anonymous user participation options and clear data privacy policies to protect vulnerable populations. Furthermore, AI-driven personalisation must be balanced with ethical safeguards to avoid potential bias, algorithmic discrimination, or unintended breaches of confidentiality. Community-driven frameworks that involve ethics boards, community advisory panels and participatory design methods should be adopted to ensure interventions are both secure and culturally responsive.

Conclusion

This exploration highlights the transformative potential of mHealth interventions in reducing internalised stigma among MSM living with HIV in LMICs. These interventions offer an opportunity to provide accessible, private and scalable mental health support. However, significant gaps remain in cultural adaptation, theoretical foundations, behaviour change strategies and technical implementation. Many interventions lack contextual sensitivity, failing to account for socio-cultural and economic factors that shape stigma and healthcare engagement. In contrast, others are not grounded in well-defined theoretical models, limiting their effectiveness in driving sustained behaviour change. By addressing these challenges, mHealth can become a powerful tool for reducing disparities, empowering MSM with HIV in LMICs and fostering stigma-free digital health solutions tailored to the needs of marginalised populations.

Footnotes

Acknowledgements

Phumla P. Dlamini would like to thank Swelihle Msomi and Paul Martin Henry for reading early versions of the manuscript and providing valuable feedback to improve clarity and conceptual coherence. Although not involved in formulating the research idea, their perspectives on readability and feasibility strengthened the overall quality of the manuscript. Special appreciation is extended to Nelson Mandela University and the Centre for Community Technologies for providing financial and academic support through a postdoctoral fellowship awarded to Dr Phumla P. Dlamini. Their support was instrumental in conducting and completing this research.

ORCID iDs

Phumla P Dlamini

Darelle Van Greunen

Scott Edward Rutledge

John B Jemmott

Larry D Icard

Ethical considerations

This manuscript reviews published studies and does not collect primary data from human participants. Therefore, it did not need ethical approval.

Author contribution

Dr Phumla P. Dlamini was involved in conceptualisation and formal analysis, oversaw project administration, drafted the original manuscript and participated in the review and final editing process. Dr Darelle Van Greunen was involved in conceptualisation, reviewing the original manuscript and contributing to the final review and edits. Dr Omar Martinez contributed to the study's conceptualisation, helped write the original draft and reviewed and edited the final version. Dr Scott Edward Rutledge participated in conceptualisation, writing the original draft and reviewing and refining the final manuscript. Dr John B. Jemmott assisted in drafting the original manuscript and contributed to reviewing and final editing for scientific. Dr Larry D. Icard led the conceptualisation of the manuscript, contributed to the methodology, data curation and analysis, wrote the original draft and reviewed and edited the final manuscript. All authors reviewed and approved the final version of the manuscript.

Funding

Phumla P. Dlamini received a postdoctoral fellowship from Nelson Mandela University to support this research. The Centre for Community Technologies hosted the fellowship and provided money and academic guidance. The research, authorship, and publication of this article did not receive any other outside funding.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Guarantor

Phumla P Dlamini guarantees this article and takes complete responsibility for the work's overall integrity.

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