Article Text
Abstract
Objective To identify the barriers and facilitators for uptake of telemedicine services in low-income and middle-income countries (LMICs).
Design The rapid review approach to identify the barriers and facilitators for the uptake/delivery of telemedicine in health system from both the provider and the patient’s perspective. A two-stage sequential screening process was adopted. Data extraction was done using a piloted data extraction form.
Data sources A search on PubMed (NCBI), Embase (Ovid), the Cochrane Library (Wiley), Scopus (Elsevier) and the WHO Global Index Medicus was conducted.
Eligibility criteria for selecting studies Studies published between 1 January 2012 and 1 July 2022 on barriers and facilitators for uptake of telemedicine services in LMICs were included.
Results Database search identified a total of 2829 citations. After removing 1069 duplicates, 1760 were taken forward for title and abstract screening. A total of 43 articles were included at full text stage and 8 articles were included in this overview for narrative synthesis. Barriers and facilitators to telemedicine adoption and use were categorised under four subheadings, namely organisational and environmental, individual and cultural barriers, financial barriers and technological barriers. Providers, patient and health policy-makers perspectives were captured.
Conclusion Any development of telemedicine services should engage the primary users such as patients and their family caregivers to design people-centred digital health systems and services. Usability studies must be commissioned by the governments and host agencies to enhance the interaction experience pending which investments would remain futile. Future research should employ mixed methods or multi methods approaches to understand the interaction between patients and providers.
- Public Health
- Health services research
- Health Care Quality, Access, and Evaluation
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What is already known?
There has been an increasing focus on telemedicine use and its applicability in recent times, especially post COVID-19 pandemic.
Telemedicine has proven to be effective in salvaging the dwindling healthcare system in low-income and middle-income countries (LMICs) but there are certain roadblocks that may create health inequalities.
What are the new findings?
Multilevel factors work together to influence the implementation and utilisation of telehealth technologies in different contexts with similar socioeconomic disadvantages.
The determinants of success of telemedicine extend beyond healthcare, such as the area of IT governance, human resource, capacity building and infrastructure requirements for the delivery of telemedicine services.
This overview mapped the barriers on the basis of a theoretical model identified by Schreiweis et al and in line with the WHO’s health system building blocks framework.
To achieve significant coproduction in telemedicine policy output that are need based and relevant to society, an intersectoral and interactor advocacy and governance in telemedicine is needed.
Educational and behaviour change interventions for strengthening digital health use among healthcare providers may increase their participation in digital health development in LMICs.
Introduction
Telemedicine is defined as, ‘the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies (ICTs) for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities’.1 During the COVID-19 pandemic, consultations were transformed from the traditional face-to-face interactions to using a screen to reduce the risk of infection.2 Prior to the pandemic, both patients and providers had limited experience with telemedicine.3 Some observed benefits of telemedicine for patients included cheaper healthcare expenditures, lower transportation costs, greater drug reconciliation communication, reduced exposure to infectious diseases particularly during a pandemic and a reduced demand for paid personal support services.4 5 An active engagement from both the government and private sectors was observed.
E-Sanjeevani—India’s free telemedicine service launched in 2019 scaled up to over 7 million consultations till July 2021.6 Post COVID-19 pandemic, there is a substantial shift towards the adoption of telemedicine in the healthcare delivery system.7 8 Initiatives such as ‘eSanjeevani OPD’ in India offered free consultation services to patients. It is offering 420 online speciality and superspeciality OPDs in 5 states and is managed by premium institutes such as All India Institute of Medical Sciences.6
Bangladesh having a fragile healthcare system with low doctor to patient ratio especially in rural areas is slowly taking steps towards telemedicine.9 A survey in Bangladesh showed that 33% of the participants used telemedicine services either rendered by the hospitals or mobile applications for telemedicine services. HelloDoc, Daktarbhai, Praava Health and Daktarbhai are a few providing telehealth services in Bangladesh.10
In Nepal, during COVID-19, a steep rise in accessing health services through online mode such as what’s app and Viber, etc was observed.11
Evidence suggests that there are a plethora of barriers and facilitators for implementing and adopting telemedicine services.12 The barriers from healthcare providers perspective include issues with ICT proficiency, connectivity issues, legal concerns, increased administrative burden and fear of inability to conduct thorough examinations with reliance on subjective descriptions.13–16 The highest risk of telemedicine was observed in cases of misdiagnosing.15 However, few facilitators for uptake of telemedicine that included training for clinicians on use of online consultation and delivery.17–21 Due to certain challenges of telemedicine peculiar to low-income and middle-income countries (LMICs), there are insufficient healthcare resources available and are yet unevenly distributed due to the rural–urban divide.22 LMICs are characterised by a wider gap between the high-income earners and low-income earners with the latter constituting the larger percentage of the population.23 The disparity in these challenges denies particular population’s access to telemedicine services based on income, ethnicity, literacy and others.24
Telemedicine has shown potential in salvaging the dwindling healthcare system in LMICs but faced certain challenges that may create new health inequalities especially based on income.23 The health system framework as proposed by WHO describes the entire system under of six core ‘building blocks’ namely service delivery; health workforce; health information systems; access to essential medicines; financing and leadership/governance.25 Through existing practices and published literature, it is well recognised that telemedicine plays a vital role in catering to health systems need. However, despite its usefulness telemedicine has not been used in routine healthcare systems. Thus, it is important to identify the barriers and facilitators to support decision making towards the development of telemedicine solutions through technological advancement, elevate its accessibility and usability thereby improving the entire healthcare system.
Review question
The rapid review approach was adapted for this overview as there are existing scoping and systematic reviews on factors related to telemedicine services. This rapid overview will provide a comprehensive picture of the factors and later discuss them from a governance perspective. Our research question is ‘What are the various facilitators and barriers for the uptake of telemedicine services in the LMICs?’
Methodology
Protocol
The protocol is registered with PROSPERO (PROSPERO 2022 CRD42022346769).26
Design
This overview of reviews was developed for the purpose of conducting a rapid evidence synthesis. The reason for selecting this design was to provide comprehensive evidence from multiple systematic and scoping reviews. Also, it helps in improving the policy practice by speeding up the review process. Rapid reviews are a form of knowledge synthesis in which components of the systematic review process are streamlined to produce information in a timely manner.27 28
We have adapted the reporting guideline for overviews of reviews of healthcare interventions for this overview.29
Eligibility criteria
The eligibility criteria were formulated based on PICO format.30
Inclusion criteria
We included the studies, which met the following criteria:
Population.
Reviews that included adults, geriatrics, adolescent and children as participants irrespective of whether they are suffering from any health condition were included.
Intervention.
We included reviews that have included any telemedicine intervention (the digital transmission of medical imaging, remote medical diagnosis and evaluations, video consultations with specialists, teletreatment and medication management) that have looked into providers or patient or user perspective on barriers and facilitators associated with telemedicine use. We have only considered studies where intervention was defined as telemedicine or telecare or tele care or telehealth or teleconsultation or telemedicine services or telemonitoring.
Context.
Studies published between 1 January 2012 and 1 July 2022 on barriers and facilitators for uptake of telemedicine services in LMICs were included. The 2020–2021 World Bank country income classification was used to identify and include relevant studies from LMICs.
Outcome.
Outcome included any factors which act as barrier or facilitators in use of telemedicine services from patient or consumers perspective.
Study design.
This overview included systematic reviews, scoping reviews and rapid reviews which had a focus on telemedicine intervention.
Exclusion criteria
Studies published in languages other than English.
Protocols of systematic and scoping reviews, and any other individual studies, editorials, concept notes, social media posts, magazine reports to provide timely evidence were not included.
We excluded records whose abstracts and full texts are not available.
Information sources and search strategy
Search strategies were created by an information specialist with experience in systematic reviews (CP). Each strategy contained controlled vocabulary, where appropriate, with keywords for the concepts of low-income and middle-income countries and telemedicine. The information specialist used the Cochrane Low-income and Middle-Income Filter updated in 2019 and based on the World Bank list of countries.31 PubMed (NCBI), Embase (Ovid), the Cochrane Library (Wiley), Scopus (Elsevier) and the WHO Global Index Medicus were searched on 22 July 2022. The search was not peer reviewed. No limits to language were applied to the search, however, the date was limited to 1 January 2012 to 22 July 2022 because of the evolution and advances made in telemedicine care since that time. Each database search strategy is included in online supplemental file 1.
Supplemental material
Study selection
All the search results from different database were imported to Rayyan software.32 After deduplication, the remaining articles underwent a two-stage sequential screening process. Multiple (EGM, JBK and VSD) authors screened title and abstract as this has been an acceptable practice for rapid reviews. Three authors conducted screening at the full text stage (VSD, JBK and EGM) and any disagreement on the selection of the article was discussed in consultation with NG. A list of excluded studies with reasons is provided in online supplemental file 2.
Data extraction and management
Rayyan software was used for data management and screening. Data from included reviews was extracted using a predesigned data extraction form on Microsoft excel.
Data were extracted by three reviewers independently (VSD, JBK and EM) and cross-checked by two authors (VSD and JBK). Relevant data on country/region, sample characteristics, study designs, barriers and facilitators were extracted.
Assessment of risk of bias and quality assessment of included studies
Assessment of quality of included studies and Risk of Bias was not performed as the goal of this rapid overview was to provide an overview of literature, and therefore, the quality of the included studies will have no influence on the results and its interpretation.
Data synthesis
A narrative approach was used to summarise the findings aided by tables and figures, where appropriate. A theoretical model identified by Schreiweis et al, was adapted to summarise the findings on the barriers and facilitators for up taking telemedicine in LMICs.33 We have also supplemented the findings in line with WHO’s health system building blocks framework as proposed by WHO.25 The rapid overview is reported according to the PRIOR checklist (online supplemental file 3).
Results
Search results
Database search yielded 2829 citations: 942 in Medline (through PubMed), 1202 in Embase, 27 in Cochrane Library, 600 in Scopus and 58 in the WHO Global Index Medicus. After removing 1069 duplicates, 1760 were taken forward for title and abstract screening. At this stage, 1717 articles were excluded and 43 were taken forward for full text screening. A total of 35 articles were excluded at full text stage and 8 articles were included in this overview for narrative synthesis. The articles at the full text stage were excluded based on following reasons as article did not meet the inclusion criteria for intervention (n=03), outcome (n=13), population (n=02), study design (n=05). However, in some articles, data were not provided separately for LMICs (n=05) and for some full text was not available (n=07). Study selection procedure and articles included and excluded at different stages are is depicted in figure 1.
Characteristics of included studies
The characteristics of included studies in this overview are provided in table 1. We included six systematic reviews,34–39 one mixed-methods systematic review40 and one scoping review.41
Geographical locations was limited to sub-Saharan Africa,36 40 Middle Eastern countries,34 Ethiopia,39 developing countries—Brazil and India.37 Three reviews captured data from all around the globe.26 29 32
The intervention and its definition are: telehealth/mhealth implementation and use interventions considered include applications related to tele-education, telemedicine and telematics (associating telecommunications and computer science) for healthcare,40 telehealth technologies—telehealth means the provision of diagnostic, treatment and educational services when there is a distance between the service providers and the clients in terms of time and place, and this distance can be bridged by ICT,41 telemedicine and telehealth—international use of telemedicine in cleft lip and cleft palate surgery,35 intersection of telemedicine and health policy—WHO definition of telemedicine,38 the delivery of healthcare services, where distance is a critical factor, by all the healthcare professionals using ICT for the exchange of valid information for the diagnosis, treatment and prevention of disease, research and evaluation (WHO definition),34 38 telemedicine, e-health, telehealth, electronic health, electronic health record.36
Barriers to telemedicine adoption and use
Table 2 describes the barriers and facilitators for telemedicine uptake. In this overview, a theoretical model identified by Schreiweis et al,33 was adapted to summarise the findings on the barriers and facilitators for uptake and use of telemedicine in LMICs.
The barriers were categorised under four subheadings, and both providers and patient perspectives were captured. Factors lacking in the system (barriers) lead to inaccuracies in diagnosis and delay the process of diagnosis and treatment.36 Barriers to adoption and implementation of telemedicine intervention are presented in figures 2 and 3.
Organisational and environmental barriers
The organisational and environmental barriers were identified in three reviews34–36 39 41 and are further categorised under three subheads:
Legal barriers reported are lack of governmental support, lack of e-policy frameworks/implementation model/guidelines,34 36 39 protection of medical data,36 security and privacy.36
Regulatory barriers identified were ethical issues, security and safety, privacy concerns,35 confidentiality, medical practice laws/policies.34
Financial barriers were mentioned in two studies.34 36 Our review showed that financial issues are a major barrier for the uptake of telemedicine. The subcategories mentioned under financial barriers were shortage of sponsorships or funding, feasibility studies, the capital expenses for technology start up and maintenance, economic constraints and decline, budget restrictions imposed by private hospitals and government for implementation of technology and training.34 These barriers were noted from provider and health policy-makers perspective.
High cost of telemedicine systems, ICT infrastructure, telecommunication, import duties on equipment, electricity supply, operational/implementation services with limited medical budget and lack of funding to meet the expenses of the technology were noted as barriers in both patient and provider perspective for the adoption of telemedicine services.36
Infrastructural barriers included lack of ICT or Hardware infrastructure for telemedicine services39 41 and lack of integration with other systems39 41 were the barriers that hinder the adoption. Electricity was also reported in one study as the major barriers to access the telemedicine services.39
Healthcare professional related barriers included the lack of competence and training to healthcare professional in use of ICTs, low e-awareness and readiness,36 39 staff turnover.39
Individual and cultural barriers
Individual and cultural factors were found to influence the acceptability and usability of telemedicine interventions/services.34 These barriers are reported from patient and providers perspectives.
Patient perspectives
Lack of education is found to be the most prominent factors affecting acceptability of the telemedicine service adoption.39 Lack of knowledge, unawareness about the availability of telemedicine services39 and skills/limit of computer or e-health literacy34 39 were few other barriers associated with education.
Cultural factor is a major barrier reported when it comes to use of telemedicine services especially for women as they are not even allowed to attend awareness campaigns.39 Religious and social restrictions, resistance to change,39 traditional beliefs, and linguistic distinction34 39 were other cultural factors reported. Access to the mobile phone is affected by socioeconomic factors.39
Provider perspectives
Perceived threat to professional control and insufficient training and skills, conflict of interest, resistance to change, job demand, and illiteracy rate,36 additional workload, limited IT readiness36/technically challenged staff,39 lack of clinicians with hybrid expertise,36 anxiety.39
Patient-to-provider relationship—Researchers noted clinicians felt a loss of personal connection with patients when using telemedicine interventions, and the lack of face-to-face interaction could be deleterious to the ‘patient-to-provider relationship’ and termed it as ‘less personal’.38
Technological barriers
Technological barriers were mentioned in three studies.34–36 Technological barriers noted in our review were generally related to the IT infrastructure. Internet quality in terms of connectivity issues, speed, service cost, system quality, service quality, image quality, information quality, lack of technical support were the commonly noted barriers.34–36 Additionally, access to the technology,34 35 data entry and data retrieval in the use of telemedicine technology,34 lack of adequate telemedicine infrastructure and unstable electricity power supply36 were mentioned as barriers. These barriers were noted from patient, provider and health policy-makers perspective.
Facilitators to telemedicine adoption and use
The facilitators related to organisational and environmental aspects envisaged that a well-organised health system and effective coordination is the key to the successful implementation of the telemedicine services. The focus was also on the capacity building of the healthcare providers to successfully administer the activities. A strong commitment from the governments in terms of providing the support to strengthen the health systems, national policies, infrastructure and framework for telemedicine implementation.40 Facilitators like having ‘cellular network’ and ‘internet infrastructure’ were also reported as enabling factors for telemedicine.38
With regard to the individual factors that aid the implementation and adoption telemedicine services were ‘the use of the local language’, providing mobile to both provider and patient along with training for its use, user acceptance and utility of the telemedicine services, explained to both provider and patient can strengthen the adoption and implementation of telemedicine services.40 Reduced costs and travel time for accessing the telemedicine were few facilitators reported37 as it is feasible to access the service without taking a leave from work especially in rural areas.38
Technological factors which resulted in successful use of telehealth and mhealth were technical support availability, good network coverage, user-friendly applications, privacy protection, involvement of users in the design and implementation for accurate use of technology. Factors which improves user acceptance of technology includes, technology which meet staff demands or needs, adequate literacy level, providing telephones to end users with appropriate training, use of local language and communication between participants through personalised messages.40 Financial factors included providing funding for telehealth projects, strong commitment from the private sector to finance telehealth projects for reducing the communication costs were mentioned as facilitators for the uptake of telemedicine. These facilitators are mentioned as patient and provider perspective.40
Discussion
This overview systematically assessed the barriers and factors associated with adoption of telemedicine programmes and services in LMICs. The findings of this overview suggested that multilevel factors work together to influence the implementation and utilisation of telehealth technologies in different contexts with similar socioeconomic disadvantages. Systems level challenges such as policy gaps, legal barriers, lack of institutional or regulatory processes, insufficient safety and security of individual and institutional data and digital resources may affect the use of digital technologies for improving health services and outcomes.42 43
Moreover, health systems in LMICs are often struggling with limited resources and leadership challenges.44 45 In such scenarios, new technologies may not be widely appreciated and accepted as a key approach for health service delivery. Such crises may create a digital divide in healthcare despite a growing availability of evidence-based digital health services and resources.46
One major challenge reported across multiple studies was the scarcity of funding and high cost of digital infrastructure required for telemedicine in LMICs. Innovative health systems financing approaches such as community owned telemedicine services, local healthcare entrepreneurship, public-to-private partnership, and equitable distribution of local and regional resources with special attention to marginalised communities may address such crises to a greater extent.47–49
However, prescriptive measures should be kept minimal and digital health development should be encouraged involving local decision-makers and stakeholders for designing contextually appropriate resource management strategies. Moreover, management and leadership challenges should be addressed through strengthening health systems that may enable organisations to promote telemedicine in their serving communities. A participatory approach for optimal health development may empower organisations and communities to bridge their health gaps in an equitable way.
Technological problems such as poor or inadequate infrastructure, lack of electricity or network resources, and insufficient human resources to operationalise and sustain telemedicine programmes may affect their application in LMICs.50 Local and global stakeholders should promote strategic planning that emphasises the use of low-cost, sustainable, locally available and acceptable technologies that may support rapid deployment of telemedicine.51
Regulatory and legal challenges associated with telemedicine adoption may potentially delay the development of digital health infrastructures and services in LMICs, which is a critical global health concern.42 Such policy gaps would necessitate the involvement of other policy actors such as the lawmakers, legislators, administrators, organisational representatives, technology providers, funding institutions and existing regulatory bodies.52 A collaborative approach should be taken for shared decision-making that may address existing legal and regulatory gaps, promote transparency and improve digital health adoption across populations.
At the provider level, healthcare workers in LMICs may not have adequate knowledge, experience and positive attitude to adopt telemedicine services. Several studies demonstrated the need for building digital health competencies among healthcare providers and empower them to integrate telemedicine in healthcare operations.53 54
Educational and behaviour change interventions for strengthening digital health use among healthcare providers may increase their participation in digital health development in LMICs. Moreover, such advancements will require strong organisational commitments and engagement of multidisciplinary healthcare teams to fully realise the potentials and address the pitfalls of telemedicine in respective contexts. In addition, data-driven decision-making on health workforce development would be critical for optimal telemedicine deployment and evaluation of future advancements.
Telemedicine adoption in LMICs can be slow across communities and populations who may not be familiar with such technologies. Also, the perceived need for telemedicine or perceived utility of any such services can be low as their benefits are not widely acknowledged and understood.55 56 Several studies have highlighted the role of patients and their caregivers in developing digital health resources that fit their health needs and socioeconomic contexts. In addition, several reviews reported language issues and cultural barriers that require a proactive approach to develop socioculturally acceptable telemedicine services in different LMICs. Any development of telemedicine services should engage the primary users such as patients and their family caregivers to design people-centred digital health systems and services. Moreover, client-level barriers and facilitators are inadequately studied and addressed in LMICs, which should be considered as an implementation research priority.
Need for governance of telemedicine
The need for governance of telemedicine has been historically debated for the advantages it offers in creating leadership infrastructure thereby optimising the value to the stakeholders.57 58 With various actors and sectors involved in delivering care through telemedicine, it is imperative for them to have a participatory approach and a governance framework for telemedicine which will facilitate in realising the seamless experience for the patient. An example of such efforts is evident from Arizona case study where a council was created to oversee the functioning of the programme. Such governing bodies are recommended at different national and subnational levels in the LMICs. A similar example was seen in the UK-India Telemedicine project where various governance issues59 were resolved during the pandemic fostering better support to the counterparts. The determinants of success of telemedicine extend beyond healthcare in the area of IT governance, human resource capacity building and infrastructure requirements for the delivery of telemedicine services, rules, regulations and institutional mechanisms to incentives telemedicine services.60 To achieve significant coproduction in telemedicine policy output that are need based and relevant to society an intersectoral and interactor advocacy and governance in telemedicine is needed.
Conclusion
There is a need for exploring the tools to overcome these barriers. Although some barriers are common across geographies, these are contextual in nature. Future studies can employ qualitative and mixed-methods approaches where perspectives from healthcare leaders, technology providers, and patient-caregiver-healthcare workers are understood to inform better design, deployment and sustainability of these interventions. Periodic monitoring and evaluation of technological innovations and resources have to be conducted to understand the perceived need as technology alone cannot be a silver bullet to healthcare delivery. There is a need for developing a robust evidence-informed decision-making capacity for digital health services at large and telemedicine in particular. Usability studies must be commissioned by the governments and host agencies to enhance the interaction experience pending which investments would remain futile. Future studies can use other forms of synthesis techniques such as realist synthesis approach which could offer contextual findings.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @vsdhyani, @GudiNachiket
Contributors NG and EGM conceptualised the idea. NG, EGM, VSD, JBK and CP developed the search terms and CP conducted the searches on various databases. VSD, JBK, EGM, NG, MMH, SP and SZ drafted the manuscript. All the authors have proofread the manuscript and given the final approval of the version to be published.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.