Barriers to digital endpoints in data collection in low and middle-income countries

KEYWORDS:

• Economic earrier
• digital endpoints
• technological accessibility
• technological infrastructure
• low and milddle income countries

1. Introduction

Digital endpoints have emerged as an innovative method of data collection, utilizing sensor-generated information gathered outside clinical settings to extract actionable insights [1]. They have broad applications, ranging from measuring clinical outcomes captured with wearable sensors or smartphone-based tools, such as tracking mobility measures in patients with amyotrophic lateral sclerosis, to cough detection in children living with asthma [1].

However, the narrative takes a different turn when applied to low and middle-income countries (LMICs). Healthcare in LMICs faces many challenges, ranging from infrastructure and health policy to health personnel training and poor awareness [2–6].

Fourth Industrial Revolution (4IR) technologies are revolutionizing data collection, yet as of 2023, approximately one-third of the global population (around 2.6 billion individuals) remains offline, with only one out of every four individuals having internet access in low-income countries [7,8]. This digital divide, exacerbated by infrastructure deficiencies and insufficient technological literacy, hinders the adoption of digital endpoints across these regions. Digital Data Collection (DDC) has slowly gained recognition for its benefits within developing country contexts, although its specific challenges must first be meticulously explored [9].

A systematic review reported that electronic data collection tools, although instrumental in pandemic response, are particularly limited in LMICs, which significantly impairs timely decision-making during health crises [10]. During the COVID-19 pandemic, 80% of national statistics offices in LMICs indicated a need for additional support to carry out data collection [11]. Furthermore, over half the deaths and around 40% of the total burden of disease in LMICs result from conditions that could be treated with prehospital and emergency care, indicating a significant gap in data collection and management systems for emergency care in these regions [12]

The existing literature lacks studies addressing the challenges faced by LMICs in the utilization of digital endpoints for data collection. This editorial address the multifaceted barriers, critically examine the underlying determinants, and suggest feasible strategies to cultivate an environment favorable for the adoption of digital endpoints in data collection within LMICs.

1.1. Economic barriers

Implementing digital endpoints in Low and Middle-Income Countries (LMICs) demands substantial capital investments, particularly in procuring essential hardware and software, and establishing a dependable infrastructure for secure data storage. Current literature underscores the importance of a robust digital health foundation to address regulatory and practical challenges in LMICs, often attributed to limited digital healthcare infrastructure [13]. As digital health projects transition from pilot stages to broader implementations, their financial requirements escalate, emphasizing the need for meticulous planning and sustainable funding avenues. Research based on real-life case studies reveals the fiscal implications of scaling and integrating sustainable digital health solutions [14]. Moreover, a collaborative study examining 12 large-scale digital tool deployments across eight LMICs in Africa and Asia pinpointed sustainable business models as pivotal, indicating significant financial planning and commitments are essential for expansive implementations [15].

Once these digital tools and infrastructures are in place, their maintenance, troubleshooting, and upgrades represent a significant financial burden. This spectrum includes tangible aspects like software updates and hardware replacements, as well as operational costs, such as electricity and internet access, coupled with concerns regarding data security and privacy. A major impediment to expanding digital health initiatives in LMICs is the lack of sustainable funding. Steady funding is essential for the survival and growth of digital health programs, which involves training staff and aligning digital health projects with broader healthcare objectives. Sustainable funding was identified as the bedrock of digital health initiatives in LMICs, which highlights its critical role in ensuring long-term financial backing, including potential contributions from the private sector [14]. Real-world instances offer insights into these economic challenges. During the Ebola epidemic from 2014 to 2016, Liberia struggled with data collection due to a lack of dependable real-time mortality data and effective analytical tools [11].

1.2. Accessibility, infrastructure, literacy, and training

In LMICs, technological access and infrastructure are significant barriers to the adoption of digital endpoints. The digital divide is stark: in some underprivileged regions, only one in four individuals has internet access, highlighting both technological and socioeconomic disparities. Consequently, the effectiveness of digital data tools is often compromised, limiting their potential impact [16]. Infrastructure challenges extend beyond fundamental services like broadband and electricity to encompass digital necessities such as data centers and dependable software platforms, hindering the integrated use of equipment, content, and digital standards [17]. For instance, the disparities in accessing modern radiotherapy technology underscore the gap between LMICs and wealthier nations, influencing health outcomes [18]. As projects transition from pilot stages to broader digital health solutions, these obstacles amplify, obstructing healthcare improvement efforts [17]. Indeed, limited technological access continues to pose a major constraint on LMICs’ advancement.

Additionally, technological literacy and training pose significant challenges in LMICs, with prevalent digital illiteracy undermining the efficacy of technological interventions. Many individuals in these regions might encounter advanced digital technology for the first time in a professional or healthcare setting, lacking the essential foundational skills for effective navigation. For example, while schools in many LMICs have computers or e-learning platforms, their teachers often lack the necessary training to incorporate these tools into their curricula effectively. As a result, digital tools frequently remain underutilized or become mere symbols of modernity without delivering tangible community benefits [19]. Moreover, many training programs lack proper contextualization, being imported from technologically advanced areas without adequate adjustments for the distinct challenges and cultural nuances of LMICs. This misalignment exacerbates the gap between tool provision and effective utilization.

2. Conclusion

Digital endpoints offer significant potential for data collection, but their deployment in Low and Middle-Income Countries (LMICs) is fraught with challenges. The digital divide, characterized by limited internet access, insufficient infrastructure, and financial constraints in LMICs, stands as a formidable barrier to their digital aspirations. Further complicating matters is the essential need for technological literacy and specialized training, ensuring that digital tools are not merely available but are used effectively. While the integration of digital tools into healthcare and other sectors is promising, achieving its full potential demands a holistic approach. This entails not just bridging the technological chasm but also equipping LMICs with the necessary tools, knowledge, and financial support. Over the next decade, we may see the emergence of digital solutions specifically designed for LMICs, tackling these challenges through meticulously researched strategies and international partnerships. Such initiatives could catalyze transformative digital advancements in these countries.

3. Expert opinion

LMICs confront multifaceted challenges in adopting digital endpoints for data collection. This editoral provides a sobering insight into these nations’ struggles in the digital age. It becomes evident that the digital divide in LMICs extends far beyond mere Internet accessibility, encompassing infrastructural, financial, and educational realms. A glaring omission in current academic discourse, underscored in this editorial, is the lack of comprehensive studies that directly address these barriers. This research gap impedes the formation of evidence-based strategies and potentially diminishes international interest and investment in addressing these issues.

Given the exponential growth and sway of digital platforms, the potential benefits of seamlessly integrating them into healthcare and other pivotal sectors in LMICs are substantial. The primary aim should not merely be to bridge the digital divide but to equip LMICs with the tools and expertise to harness the full potential of digital advancements. Realizing this goal mandates research attuned to the unique challenges of these nations. Future endeavors should prioritize crafting culturally and contextually relevant solutions that resonate with the socio-economic, educational, and infrastructural realities of these countries. One of the most salient challenges in this journey is securing consistent investments. The necessity for enduring financial support, perhaps best achieved through robust public-private collaborations, is paramount.

Looking to the future, the digital trajectory for LMICs, though seemingly steep, is laden with potential. As technological solutions become increasingly accessible and affordable, and as international cooperative efforts gain momentum, there’s a tangible hope for a methodical yet significant reduction in the prevailing disparities. The coming decade could potentially herald the emergence of localized digital strategies meticulously crafted for LMICs, emphasizing community-driven initiatives. Additionally, addressing healthcare challenges in LMICs often requires creative solutions that overcome limited resources and infrastructure. While developing eHealth systems like electronic medical records is crucial, we can also leverage the widespread availability of mobile phones in LMICs. This mobile-first approach sidesteps the need for extensive infrastructure development and utilizes existing mobile networks for data collection and dissemination. By prioritizing mobile-based solutions, we can rapidly deploy digital healthcare tools, offering a practical alternative that fits within the existing technological landscape and resource constraints of LMICs. This strategy not only simplifies implementation but also enhances the scalability and sustainability of digital health initiatives, ultimately reaching and impacting a larger population. A systematic review addressed the potential of mobile health (mHealth) interventions for non-communicable diseases in LMICs. It revealed that smartphones are the primary platform for mHealth technologies, which are predominantly developed using iOS and Android. These interventions are generally affordable, at an advanced development stage, and designed for use with smartphones. Despite most technologies being developed in high-income countries, some collaborations with LMIC organizations exist [20].

A pivotal area that requires keen focus is the overhaul of training and educational frameworks in LMICs. The editorial astutely notes that the mere availability of digital tools is insufficient for their optimal utilization. Thus, the pressing need is to establish training paradigms that are not only technologically adept but also culturally and contextually aligned. Transitioning populations from passive digital consumers to informed digital participants is a transformative step, and its realization could catalyze meaningful advancements in these nations.

Declaration of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.