Bioethical considerations in deploying mobile mental health apps in LMIC settings: insights from the MITHRA pilot study in rural India

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Introduction: In India, untreated depression among women contributes significantly to morbidity and mortality, underscoring an urgent need for accessible and ethically grounded mental health interventions. Mobile health (mHealth) tools offer scalable solutions; however, their implementation in low- and middle-income country (LMIC) settings raises important bioethical considerations. Methods: This study was conducted at the conclusion of a pilot randomized controlled trial evaluating the MITHRA app (Multiuser Interactive Health Response Application), designed for depression screening and treatment among women participating in self-help groups (SHGs) in rural Karnataka, India. Two focus-group discussions were conducted with intervention participants to explore ethical dimensions of app use, including technological proficiency, privacy, informed consent, connectivity, accessibility, and gender-specific interactions. Transcripts were analyzed using thematic coding to identify recurring patterns. Results: Participants preferred a hybrid care model combining mobile app use with human interaction. Technological proficiency varied, and participants demonstrated uncertainty regarding mental health app functionality and limited understanding of privacy policies. In the collectivist cultural context of rural India, autonomy and informed consent were often expressed relationally, shaped by family and community dynamics rather than individual decision-making alone. Discussion: These findings highlight the need to tailor digital mental health interventions to user preferences and local sociocultural contexts. Ethical implementation in rural LMIC settings requires enhanced transparency around data use, culturally aligned consent processes, and integration of ethical, technological, and relational considerations to improve accessibility, trust, and acceptability.

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