1.5 Application in Sub-Saharan Africa (SSA)
In recent years, more and more technologies have appeared on the market that are intended for the healthcare and rehabilitation sectors. The types of technologies are limitless, as technology companies can develop technologies that meet almost any client need with a new or updated technology. In Chapter 6, you will learn about the most commonly used digital technologies in rehabilitation. The potential of digital technologies is very relevant for the provision of healthcare services - not only in a global context but also in low-income countries. Among other aspects, digital technologies can enable the provision of rehabilitation services to people living in rural and remote areas of developing countries. Digital technologies are not only important to improve health care but are also necessary for health systems to achieve the goals of universal health coverage defined by the WHO (see subchapter 1.2. for further potentials of Digital Rehabilitation).
It is reported that over 1000 mobile health services currently offer health content and diagnostic services in low-income countries [14]. Digital solutions have become increasingly popular as more and more people own a mobile phone. For example, 414.77 million people in sub-Saharan Africa (SSA) subscribed to a smartphone in 2022, up from 118.1 million people in 2015 [15]. In addition, internet coverage has improved. A mobile broadband network now covers most urban areas. In 2021, 83 % of SSA's population lived in an area covered by a mobile broadband network. This leads to 22 % of the total population in SSA using mobile internet at the end of 2021 (and 40 % of adults over 18 years) [16].
Although the benefits and conditions of Digital Rehabilitation are promising, the implementation of Digital Rehabilitation in SSA remains poor. A paper suggests that the majority of Digital Health initiatives within African countries remain a test bed [17]. Most of the research on Digital Rehabilitation in this region has been aimed at assessing the acceptance of clients, their families and healthcare providers for the use of digital technologies, while there is still a lack of guidance how to implement these services.
In this chapter, we provide an overview of the use of the most common technologies that are already in use in SSA. If you are more interested in the factors that drive or hamper the implementation of Digital Rehabilitation in the SSA context, please go to chapter 5 ”Barriers and Facilitators”.
Text messaging interventions display the most applied Digital Rehabilitation intervention in the sub-Saharan context. Text messaging could be used via an app like WhatsApp or via a mobile phone. Various text messaging interventions have been evaluated in Kenya, Nigeria, Uganda, Cameroon and South Africa [14,18–22]. In this context, text messaging was used as digital counselling and peer support for people with HIV [19], as a therapy reminder aiming at improving adherence to diabetes/depression therapy, as a motivator to promote physical activity [14,18,21], as a digitally supported intervention that targeted maladaptive cognitions in older people experiencing loneliness [20], and as a client education on the knowledge of the disease and glycaemic control [22]. While text messaging interventions seemed to be acceptable for the users and have proven to be successful and effective in improving health outcomes [18,20,22] some challenges were also identified. These challenges include technical issues, slow speed, lack of digital literacy of the clients, doubts about its effectiveness, and costs [14,18–22]. Although these challenges were addressed in these studies, this suggests that even low-cost solutions could come with challenges. As such, when implementing simple digital solutions for healthcare purposes in African countries, technical issues, slow speed, lack of digital literacy, doubts about effectiveness, and cost should not be overlooked as these could hamper the effective use of digital solutions.
During the RADIC project, we conducted a scoping review to give an overview of already implemented Digital Rehabilitation practices in sub-Saharan Africa. As an additional methodological step, we included stakeholders to give more insight about that topic. During a meeting, we asked stakeholders to give their opinion about the most relevant technologies for Digital Rehabilitation practices in sub-Saharan Africa. The stakeholders were a Digital Rehabilitation specialist (n=1), an e-learning manager (n=1), educators for health sciences (n=2), rehabilitation professionals, a research assistant (n=1) and physiotherapists and occupational therapists as researchers (n=6). Seven stakeholders out of the eleven participants already had prior experience with Digital Rehabilitation. The majority of the stakeholders believe that text messaging via SMS is a powerful tool, especially in rural areas, because it does not require an internet connection. In addition, these stakeholders emphasize that SMS is less dependent on literacy and therefore accessible and usable by more people.
Apps, web-based programs, and videoconference are also used for rehabilitation purposes in Ethiopia, Kenya and South Africa. While these technologies are used to improve therapy adherence [23,24] and deliver peer support via group chats and digital platforms [25], they are also used to provide interventions for people with depression [26–28], with stroke [29] and for people with symptoms of stress and emotional exhaustion [30]. Users were overall satisfied with the interventions and motivated to use it, the digital services seem to be effective to improve the quality of life [24] depression [29] and produces minimal costs [24,28,31,32]. Besides all these positive results, there are also barriers, such as clients' low Internet skills and lack of access to functioning devices.
The stakeholders believe also that apps, web-based programs, and videoconference will be the most important technologies for rehabilitation in sub-Saharan Africa in the future. They think that mobile apps are very useful to increase the engagement in rehabilitation. Even though that research results show that videoconferencing is feasible and acceptable in the SSA countries, it is not implemented yet.
3D printing is not widely used in sub-Saharan Africa yet but compared to manufactured prosthetics this emerging technology could decrease the manufacturing time for prosthetic devices and thus reduce costs. One project carried out in Uganda, Tanzania, Cambodia [33] moved 3D printers to a rural area where prosthetics were directly printed for people with transtibial amputation almost without waiting time. Even though the effectiveness of 3D printed prostheses is comparable to conventionally manufactured prostheses and the usability of usual manufactured prostheses scores better, relevant interest groups consider 3D printing as important for rehabilitation, as it can reduce the cost of producing prostheses.