Implementation of home-based Digital Rehabilitation in Sub-Sahara Africa – A Scoping Review

Worldwide, about 1.3 billion people live with some form of disability. This represents about 16% of the world's population (World Health Organization, 2023a). A total of 80% of them reside in developing countries such as in the Sub-Saharan Africa (SSA) region. The SSA region consists of 49 countries in the south of the African continent. The SSA had a total population of about 1.18 billion people in 2021 (World Bank, 2023). With their per capita income rising more slowly than GDP due to high population growth, most SSA countries rank last in the world (Marcotrends LLC, 2023). Rehabilitation is an essential component of care for people with disabilities to be as independent as possible in their daily lives and to enable participation in education, work, leisure, and meaningful life tasks (World Health Organization, 2023b). Moreover, rehabilitation is an important component of universal health care and a key strategy for achieving Sustainable Development Goal 3 of the United Nations - "ensure healthy lives for all at all ages and promote their well-being" (United Nations, 2023). Currently, the need for rehabilitation is largely unmet. In some low- and middle-income countries, more than 50% of people do not receive the rehabilitation services they need (World Health Organization, 2023b). The reasons for a high percentage of unmet rehabilitation needs in low- and middle income countries, especially in the SSA region are multifactorial. On the one hand, access to rehabilitation services are limited. This is due to lack of health workers (Ahmat et al., 2022), to high financial costs associated with rehabilitation, to poor transportation possibilities (Magaqa et al., 2021; Adugna et al., 2020; Eide et al., 2015), and to geographically distance (Tawa et al., 2020). Also the lack of privacy in rehabilitation centers and the fear of stigmatization, through the access to healthcare, reduces the utilization of rehabilitation (Adugna et al., 2020). The lack of infrastructure also exacerbates rehabilitation problems, where there are hardly any rehabilitation departments in district hospitals. In addition, poor referral pathways to secondary levels, resulting in lack of follow-ups, compromise the availability of rehabilitation services (Tawa et al. 2020; Magaqa et al., 2021). On the other hand, the burden of non-communicable diseases in the SSA region has increased in recent years (World Health Organization, 2022). Mostly, these diseases require long-term rehabilitation or even rehabilitation over the whole lifespan. Due to the burdened health care systems in the SSA region, these requirements can rarely be met. As the limited resources of the health care systems in the SSA region and the increase in prevalence of ageing population and non-communicable diseases, the number of people who would benefit from rehabilitation close to their homes will also increase. Thus, an adoption of providing new ways of rehabilitation services in SSA are essential, to ensure meeting the demand of rehabilitation and to fulfill the goal of the United Nations promoting well-being to everyone. Incorporating digital solutions in home-based rehabilitation (Digital Rehabilitation) could offer a meaningful possibility. Digital Rehabilitation is an umbrella term that encompasses digital technologies to optimize functioning and reduce disability in interaction with the environment throughout the rehabilitation process (prevention, assessment/diagnosis, intervention, monitoring, and evaluation). This includes, but is not limited to, the use of tele- and remote rehabilitation applications and services, automated services, robotic technologies, wearables, email, video, voice and SMS messaging solutions. Digital Rehabilitation is closely related to the empowerment of individuals and communities (adapted from Arntz et al., 2023; World Health Organization, 2021). Digital Rehabilitation has gained popularity in the SSA region by providing primary health care services, important health information, and supported interventions remotely. Is has been reported that currently over 1000 mobile health services in low-income countries provide health content and diagnostic services (Teriö et al., 2019). Digital solutions have grown in popularity as, more and more people own a cell phone. For example, 414.77 million people subscribed for a smartphone in SSA in 2022; in 2015, it has been 118.1 million people (Ericsson, 2023). In addition, the internet coverage has become better. 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 the fact that by the end of 2021, 22% of the total population in SSA was using mobile internet (and 40% of adults over 18 years of age) (Delaporte, 2023). The application of home-based Digital Rehabilitation in low-resource areas could facilitate access to rehabilitation (Nizeyimana et al., 2022), overcome transportation problems in reaching rehabilitation services (Jousset et al., 2023), and reduce stigma due to the ability to deliver health services anonymously. Digital Rehabilitation could also help health systems deliver care at a lower costs (Nizeyimana et al., 2022), thereby optimizing limited resources, including shortages of health professionals, especially in rural areas. In addition, Digital Rehabilitation can provide care over a long period of time and increase patient and healthcare worker motivation (Bonnechère et al., 2023). Although the conditions and the benefits of Digital Rehabilitation are promising make rehabilitation accessible, the implementation of home-based Digital Rehabilitation in SSA remains poor. A reason for this might be a lack of data to support full implementation of digital health services in the SSA region, while also taking into account the specificities of the SSA region. Although there are guidelines for the implementation for digital health care services globally (World Health Organization, 2019), there is little information on what successful implementation in the SSA region should look like. The region is likely to use different technologies and face different implementation challenges than in the western world due to its culture, resources and infrastructure. Therefore, it is critical to identify the current state of literature on what technologies are being used for Digital Rehabilitation in the SSA region and what factors play a role in implementation of Digital Rehabilitation in the SSA region. Obtaining such data will provide important insights needed for optimal implementation of Digital Rehabilitation in the context of providing rehabilitation for all.