The coronavirus disease-2019 (COVID-19) pandemic has spread to >200 countries and territories1. In the absence of a specific medical intervention, the world is reliant on public health and social measures to slow or halt the spread of COVID-19. These measures include the promotion of respiratory and hand hygiene, physical distancing for the general population, quarantines for the suspected cases, isolation and contact tracing of the infected individuals, and widespread travel bans. India reported its first case on January 30, 2020. As of May 5, 2020, there were a total of 46,433 active cases and 1568 deaths2. The Government of India imposed a nationwide lockdown on March 24, 2020, and rapidly expanded its testing, contact tracing, and home quarantine efforts. However, an unprecedented flurry of misinformation and fake news leading to panic-driven migration, hysteric buying of masks, medicines, essential household commodities and peddling of unproven treatments3.
Digital technology innovations are known to present the possibility of improving the efficacy of the health system response to an epidemic456. The Ebola and Zika virus epidemics have shown the utility of mobile health (mHealth) applications (apps) for improving access to testing, contact tracing, supporting frontline healthcare workers, and raising public awareness789. Recent evidence underscores the potential of mHealth initiatives for the provision of mental health services to support the patients and healthcare providers in dealing with the psychological impact of the COVID-19 pandemic1011. Contact tracing apps have been a crucial component of COVID-19 response in countries such as China, South Korea, Singapore, the United Kingdom, and Israel121314. However, owing to the collection of users' identifiers and data related to location and Bluetooth interactions, privacy experts have raised concerns over the use of these apps.
The Government of India, launched 'Aarogya Setu' mobile app for the containment of COVID-19, through contact tracing and information dissemination15. Further, various State governments and healthcare organizations have developed apps for lockdown enforcement, generating awareness and monitoring of quarantined individuals in India16. The present study was aimed to identify and systematically review COVID-19-related mobile apps in India. Another objective was to describe the functions of the apps, map those against the WHO guidelines on Digital Health Interventions and highlight gaps to inform the development of future mHealth initiatives17.
Material & Methods
The Google Play and the Apple app stores were searched using the terms 'COVID-19', 'coronavirus', 'pandemic', and 'epidemic', individually. In addition, a free-text search was run for COVID-19-related apps using the phrase 'COVID-19 mobile apps in India'. The search was conducted in the first week of April 2020 and updated on May 3, 2020. The preliminary screening of the apps was based on the app titles and full description. The games, apps without English or Hindi language user interface, and apps on infectious disease without a specific focus on COVID-19 were excluded.
A list of COVID-19 specific functions was compiled based on the review of the selected apps, the literature on epidemic surveillance61819, and national and international media reports132021. The WHO guideline on Digital Health Interventions was used to classify the app functions under the categories of the clients (general public), health workers, health system managers and data services17. Information related to name, developer, target user group and COVID-19-specific function was abstracted from the selected apps. Frequencies and percentages were used to summarize the information abstracted from the apps.
A total of 346 potential COVID-19 apps were identified, of which 50 met our inclusion criteria. Figure 1 provides an overview of the app selection process. The excluded apps were general infectious disease apps not focused on COVID-19 (n=141), games (n=87), or did not have an English or Hindi user interface (n=42) (Supplemetary Table for details (available from http://www.ijmr.org.in/articles/2020/151/5/images/IndianJMedRes_2020_151_5_468_284753_sm5.pdf)).
All the apps selected were free to download, with no in-app purchase options/requirements. State health/municipal departments were the launching agencies for 41 (82%) of the existing COVID-19 apps in India. Private/non-government developers and the Government of India launched seven (14%) and two (4%) apps, respectively. Figure 2 provides information about the target users of the apps. Two-thirds of the apps (n=34) were developed for the general public, 19 (38%) for quarantined individuals or foreign travellers currently residing in the Indian States, and two (4%) for caregivers. One (2%) app each was designed for tested individuals, police officials, and researchers, respectively.
The Table I lists the functions of the selected COVID-19 apps and maps these against the WHO guideline recommendations on digital health interventions for health systems strengthening. Dissemination of untargeted COVID-related information on preventative strategies was the function of 27 (54%) apps. Nineteen (38%) apps were developed to monitor the movements of quarantined individuals. On-demand information services through chatbots or telephonic helplines were available only in 19 (38%) apps. Fifteen apps (30%) provided users with a self-risk assessment function based on a set of screening questions related to their symptoms, occupations, travel history, and contact history. Information on the availability of COVID-19 testing facilities was available in six (12%) apps. Four (8%) apps had a provision for booking teleconsultation or testing appointments. The availability of an electronic pass for movement during the lockdown was the only health workforce-specific function available in four (8%) apps. In terms of the data for health managers and policy decisions, nine (18%) apps provide aggregation and visualization of the State governments' data related to confirmed cases and deaths. Eight (16%) apps had a contact tracing and hotspot identification function.
It was found that governments, including the Union government and 22 State and Union Territories, invested in the development of mobile apps to deal with this crisis. While there were differences in the State-specific information in the apps developed by different States, the system architecture and many of the functionalities, including self-testing, quarantine monitoring and contact tracing, were common between these State-level apps. The Ministry of Electronics and Information Technology, Government of India, has taken proactive measures to promote the installation and usage of the Aarogya Setu app, which is currently available in 11 Indian languages22. The penetration of the app is critical to the success of the technology-enabled contact tracing. Evidence suggests that 70 per cent of the population should have the app installed for the digital contact tracing efforts to be effective23. The current technological plurality in the absence of robust data exchange mechanisms and Centre-State coordination, can be detrimental for technology-assisted contact tracing in a heterogeneous country like India, especially once the lockdown ends and free movement of people starts. Overcoming this challenge requires the State and the Union Government to ensure the mass installation of a single contact tracing app collaboratively. In contrast, the State-specific apps would still be a vital medium of providing context-specific information and supporting local health systems.
The review of the app functionalities revealed that information dissemination regarding the preventative measures was the primary function of the majority of the existing apps in India. The apps reviewed in this study did not have specific strategies to deal with the infodemic. Only two apps, had a fake news control segment. Several apps had a provision related to teleconsultations. The Ministry of Health and Family Welfare, Government of India, has formally recognized remote consultation through recent 'Telemedicine practice guidelines'24. With the growing number of COVID-19 cases, there is an urgent need to create integrated teleconsultation options within these apps to assure quality healthcare services, including those with pre-existing conditions. Another notable finding was that the majority of the apps did not have functionalities to assist the hospitals or healthcare workers. In contrast, frontline hospital workers were using mobile apps to compile clinical notes and track the use of protective equipment and ventilator in the United States20.
In terms of privacy, all the contact tracing and quarantine monitoring apps reviewed in this study collected user data such as name, phone number, real-time location, and Bluetooth interactions with other app users. While the collection of the location data is essential for mapping hotspots of disease transmission, privacy experts are concerned about this data being a hazard for an individual's privacy and national security. The collection of location data in South Korea and China has sparked global concerns related to privacy and potential mala fide use of the data25. To counter this, countries like Singapore and Argentina are using tracking apps that only collect Bluetooth interaction data to preserve user privacy26. To ensure transparency, Singapore and Israel have shared their app source code with researchers for an independent audit27. In the absence of a data protection law in India, the Central and State governments need to address these privacy-related concerns to garner public trust that would ensure the deployment of these apps at scale.
This study had a limitation that the user feedback on these apps was not assessed. Despite this limitation, this study has important implications for informing the development of future COVID-19 mHealth initiatives in India. These apps are a medium of disseminating disease-related awareness and knowledge at the population level. In a hysteric environment and a severe shortage of testing facilities, the self-risk assessment function available in the apps may help spot the patients at risk for COVID-19.
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Supplementary material available from http://www.ijmr.org.in/article.asp?issn=0971-5916;year=2020;volume=151;issue=5;spage=468;epage=473;aulast=Bassi
Financial support & sponsorship: None.
Conflicts of Interest: None.