ENSIGN GLOBAL COLLEGE, KPONG EASTERN REGION, GHANA FACULTY OF PUBLIC HEALTH DEPARTMENT OF COMMUNITY HEALTH A SYSTEMATIC REVIEW OF DIGITAL HEALTH INTERVENTIONS IN GHANA MCLORD SELASI AZALEKOR (237100261) SEPTEMBER, 2024 ENSIGN GLOBAL COLLEGE, KPONG EASTERN REGION, GHANA FACULTY OF PUBLIC HEALTH DEPARTMENT OF COMMUNITY HEALTH A SYSTEMATIC REVIEW OF DIGITAL HEALTH INTERVENTIONS IN GHANA BY MCLORD SELASI AZALEKOR (237100261) mclord.azalekor@st.ensign.edu.gh A THESIS SUBMITTED TO THE FACULTY OF PUBLIC HEALTH, DEPARTMENT OF COMMUNITY HEALTH, ENSIGN GLOBAL COLLEGE, KPONG IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF PUBLIC HEALTH SEPTEMBER, 2024 file:///C:/Users/PC/Desktop/mclord.azalekor@st.ensign.edu.gh ii DECLARATION I, McLord Selasi Azalekor, hereby declare that this dissertation for my Master of Public Health degree is the result of my independent research work, except where references to other people's works and publications are made, which have been duly acknowledged. To the best of my knowledge, this work has not been submitted, wholly or in part, for any degree or academic honor at any other institution. McLord Selasi Azalekor (237100261) …………….…… ....…..…………. (Student) Signature Date Certified by: Dr. Millicent Ofori Boateng ………………… .……………….. (Supervisor’s Name) Signature Date Certified by: Dr. Stephen Manortey ……………… ……………….. (Head of Academics Program) Signature Date 30/9/2024 30/09/2024 iii DEDICATION I dedicate this work to the Almighty God, my source of wisdom, strength, and inspiration. This thesis is also dedicated to my family and friends, whose unwavering support, sacrifices, and encouragement have been my greatest strength. A special dedication goes to my supervisor, Dr. Millicent Ofori Boateng, whose guidance have been invaluable throughout this journey. Finally, for all those who strive to make a difference in the field of public health, this work is a tribute to their passion and commitment. iv ACKNOWLEDGEMENT First and foremost, I express my deepest gratitude to God for his guidance and blessings throughout this journey. I extend my sincere appreciation to my advisor, Dr. Millicent Ofori Boateng, for her invaluable insights, support, and encouragement throughout this study. We thank the faculty and staff of the Department of Community Health at Ensign Global College for providing a nurturing academic environment. Your expertise and dedication are nothing short of being spectacular. I also acknowledge my fellow students and colleagues for their camaraderie and stimulating discussions. v DEFINITION OF TERMS Artificial Intelligence (AI) in Healthcare The use of complex algorithms and software to emulate human cognition in analyzing, interpreting, and understanding complicated medical data. Big Data in Healthcare Large and complex datasets generated from digital health systems, EHRs, medical imaging, and other sources, requiring advanced data processing for interpretation. Blockchain in Healthcare Distributed ledger technology that allows for secure, transparent, and tamper-proof storage and sharing of healthcare data. Digital Health Literacy The ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge to solve a health problem. Health Information Exchange (HIE) The electronic movement of health-related information among organizations according to nationally recognized standards. Health Information System (HIS) A system designed to manage healthcare data, including the collection, storage, management, and transmission of patient EHRs and hospital operational data. Interoperability The ability of different IT systems and software applications to communicate, exchange data, and use the information exchanged. Remote Patient Monitoring (RPM) The use of digital technologies to collect health data from individuals in one location and securely transmit it to healthcare providers in another location. vi LIST OF ABBREVIATIONS DHIs Digital Health Interventions eHealth Electronic Health EHRs Electronic Health Records eDSS Electronic Decision Support Systems HIS Health Information Systems mHealth Mobile Health WHO World Health Organization MeSH Medical Subject Headings MCH Maternal and Child Health PICOS Population, Intervention, Comparator, Outcomes, Study Design) PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses UHC Universal Health Coverage ICT Information and Communications Technology SDGs Sustainable Development Goals vii ABSTRACT Background: Digital health interventions have gained significant attention in recent years as a means of improving health care delivery and outcomes. In Ghana, where access to quality healthcare services remains a challenge, exploring the strengths, and limitations of digital health interventions is crucial. General Aim: This systematic review aimed to explore the trends, strengths, and limitations of digital health interventions in Ghana. By analyzing the characteristics of the included studies, targeted populations, intervention strategies, comparators, outcomes, and study designs, this study offers a comprehensive overview of the status of digital health initiatives in the country. Methodology: Employing a systematic review methodology, this study involved a literature search across multiple databases, data extraction, quality appraisal, and synthesis. Two independent reviewers screened and assessed studies for inclusion, with data extraction forms pilot-tested for accuracy and consistency. The analysis utilized the PICOS framework, focusing on both qualitative and descriptive synthesis. Findings: This review identified 29 relevant studies, published between 2004 and 2024, which address diverse health interventions using digital technologies across Ghana. 22 digital health interventions were identified in Ghana. These DHIs include mHealth, telemedicine, health information management systems, and electronic health records (EHRs), predominantly targeting general healthcare delivery, maternal and child health, disease surveillance, and specific conditions like dermatology and ophthalmology. 54.5% of these interventions were directed at both rural and urban areas, highlighting the country’s effort to address healthcare disparities. Findings indicate that DHIs enhance patient care, data management, and access to healthcare, especially in remote regions. They facilitate improved communication between patients and healthcare providers, viii reduce logistical barriers, and streamline healthcare processes. However, several limitations were identified, including infrastructural challenges like unreliable power supply and internet connectivity, human resource constraints, financial limitations, and the need for improved user training and system design. These factors hinder the full utilization and impact of DHIs, particularly in rural settings. Despite these barriers, the study concludes that digital health interventions hold significant potential for improving healthcare delivery in Ghana, provided that technical and operational challenges are addressed. Conclusion: Digital health interventions hold substantial promise for addressing healthcare challenges in Ghana. This systematic review provides a detailed analysis of current initiatives, revealing their potential to improve healthcare accessibility, efficiency, and outcomes. The study underscores the need for strategic planning, stakeholder engagement, and policy support to foster the sustainable integration of DHIs into the healthcare system. The insights gained can guide future research, policy formulation, and implementation of digital health strategies in Ghana, contributing to the achievement of universal health coverage and the Sustainable Development Goals. Keywords: Digital health, eHealth, mHealth, Telemedicine, Ghana ix TABLE OF CONTENTS DECLARATION........................................................................................................................... ii DEDICATION.............................................................................................................................. iii ACKNOWLEDGEMENT ........................................................................................................... iv DEFINITION OF TERMS ........................................................................................................... v LIST OF ABBREVIATIONS ..................................................................................................... vi ABSTRACT ................................................................................................................................. vii LIST OF FIGURES ................................................................................................................... xiv LIST OF MAPS........................................................................................................................... xv LIST OF APPENDICES ........................................................................................................... xvi CHAPTER 1 .................................................................................................................................. 1 1.0 INTRODUCTION................................................................................................................... 1 1.1 Background Information .................................................................................................... 1 1.2 Problem Statement .............................................................................................................. 3 1.3 Rationale of Study ............................................................................................................... 4 1.4 Conceptual Framework ...................................................................................................... 6 1.5 Research Questions ............................................................................................................. 7 1.6 General Objective ................................................................................................................ 7 1.7 Specific Objectives ............................................................................................................... 7 1.8 Profile of Study Area ........................................................................................................... 8 1.9 Scope of Study.................................................................................................................... 10 1.10 Organization of Report ................................................................................................... 10 CHAPTER 2 ................................................................................................................................ 11 2.0 LITERATURE REVIEW .................................................................................................... 11 2.1 Introduction ....................................................................................................................... 11 2.2 What is Digital Health? ..................................................................................................... 11 2.3 Types of Digital Health Interventions ............................................................................. 13 2.3.1 Mobile Health (mHealth) ........................................................................................... 14 2.3.2 Telemedicine................................................................................................................ 15 2.3.3 Electronic Health Records (EHRs) ........................................................................... 15 2.3.4 Health Information Systems (HIS) ........................................................................... 16 2.3.5 Wearable Devices ........................................................................................................ 16 2.3.6 Health Education and Training ................................................................................ 17 x 2.3.7 Digital Therapeutics ................................................................................................... 17 2.4 Health Conditions Addressed by Digital Health Interventions .................................... 18 2.5 Evolution of Digital Health Interventions ....................................................................... 21 2.6 Strengths and Limitations of Digital Health Interventions ........................................... 23 CHAPTER 3 ................................................................................................................................ 27 3.0 METHODOLOGY ............................................................................................................... 27 3.1 Study Design ...................................................................................................................... 27 3.2 Study Site ........................................................................................................................... 27 3.3 Study Population ............................................................................................................... 28 3.4 Inclusion Criteria .............................................................................................................. 28 3.5 Exclusion Criteria ............................................................................................................. 28 3.6 Sample Size ........................................................................................................................ 29 3.7 Data Collection Methods and Instruments ..................................................................... 29 3.7.1 Search Strategy ........................................................................................................... 29 3.7.2 Selection Process ......................................................................................................... 30 3.7.4 Data Extraction ........................................................................................................... 32 3.8 Pre-testing .......................................................................................................................... 33 3.9 Data Handling .................................................................................................................... 33 3.9.1 Management and Documentation of Search Results............................................... 33 3.9.2 Confidentiality and Privacy ....................................................................................... 34 3.10 Quality Appraisal ............................................................................................................ 34 3.11 Data Analysis ................................................................................................................... 36 3.12 Dissemination of results .................................................................................................. 37 3.13 Ethical Considerations .................................................................................................... 38 3.14 Limitations of Study ........................................................................................................ 38 3.15 Assumptions ..................................................................................................................... 38 CHAPTER 4 ................................................................................................................................ 39 4.0 RESULTS .............................................................................................................................. 39 4.1 Introduction ....................................................................................................................... 39 4.2 Description/Characteristics of Included Studies ............................................................ 39 4.2.1 Quality Appraisal Results .............................................................................................. 49 4.2.1.1 Quality Appraisal for Qualitative Studies ............................................................. 49 xi 4.2.1.2 Quality Appraisal for Quantitative Studies .......................................................... 49 4.2.1.3 Quality Appraisal for Descriptive Studies............................................................. 50 4.2.1.4 Quality Appraisal for Mixed Method Studies ....................................................... 50 4.3 Health Conditions and Focus Areas Targeted and Addressed by DHIs in Ghana ..... 50 4.3.1 Types of Digital Health Interventions in Ghana ......................................................... 50 4.3.2 Health Conditions & Focus of Digital Health Interventions in Ghana ..................... 51 4.4 The Trend in Digital Health Interventions in Ghana .................................................... 55 4.4.1 General Trends in Digital Health Interventions in Ghana ......................................... 55 4.4.2 Temporal Trends in Digital Health Interventions in Ghana...................................... 56 4.5 Strengths and Limitations of Digital Health Interventions in Ghana .......................... 58 4.5.1 Limitations of Digital Health Interventions in Ghana ................................................ 59 4.5.2 Strengths of Digital Health Interventions in Ghana ................................................... 67 CHAPTER 5 ................................................................................................................................ 74 5.0 DISCUSSION ........................................................................................................................ 74 5.1 Introduction ....................................................................................................................... 74 5.2 Types of Digital Health Interventions ............................................................................. 74 5.3 Health Conditions & Focus of Digital Health Interventions ......................................... 76 5.4 Trends in Digital Health Interventions ........................................................................... 77 5.5 Strengths and Limitations of Digital Health Interventions ........................................... 78 CHAPTER 6 ................................................................................................................................ 82 6.0 CONCLUSIONS AND RECOMMENDATIONS .............................................................. 82 6.1 Introduction ....................................................................................................................... 82 6.2 Conclusion .......................................................................................................................... 82 6.2 Recommendations ............................................................................................................. 83 6.3 Implications for Policy and Practice ................................................................................ 83 6.4 Suggestions for Future Research ..................................................................................... 84 REFERENCES ............................................................................................................................ 85 LIST OF APPENDICES ............................................................................................................ 94 Appendix 1 - Results ................................................................................................................... 94 Appendix 1.0: Distribution of Included Digital Health Studies in Ghana by Publication Year .......................................................................................................................................... 94 Appendix 1.1: Types & Focus of Digital Health Interventions in Ghana .......................... 95 Appendix 1.2: Glossary of The Types of DHIs ..................................................................... 98 xii Appendix 1.3: Distribution of Digital Health Interventions in Ghana by Setting........... 100 Appendix 1.4: Target Populations of Digital Health Interventions in Ghana ................. 101 Appendix 1.5: Coding Frame for Themes & Codes ........................................................... 102 Appendix 1.5.1: Themes Related to Strengths of DHIs.................................................. 102 Appendix 1.5.2: Coding Frame for Themes Related to Limitations of DHIs .............. 102 Appendix 1.6: Quality Appraisal Results ............................................................................ 104 Appendix 1.6.1: Results of CASP Qualitative Checklist ................................................ 104 Appendix 1.6.2: Results of Standard Quantitative Checklist ........................................ 105 Appendix 1.6.3: Results of CRAAP Checklist ................................................................ 106 Appendix 1.6.4: Results of Mixed Methods Appraisal Tool (MMAT) ......................... 106 Appendix 2.0 - PRISMA 2020 Checklist ................................................................................. 107 Appendix 3.0 – Quality Appraisal Tools ................................................................................. 109 Appendix 3.1: CASP Qualitative Checklist ..................................................................... 109 Appendix 3.2: Standard Quality Assessment Checklist for Quantitative Studies ....... 110 Appendix 3.3: Mixed Methods Appraisal Tool (MMAT), version 2018 ...................... 111 Appendix 3.4: The CRAAP Test ...................................................................................... 113 Appendix 4.0: Ethical Clearance ............................................................................................. 114 xiii LIST OF TABLES Table 3.1: Database Search Results.........................................................................................29 Table 4.1: Characteristics of Included Studies...........................................................................41 xiv LIST OF FIGURES Figure 1.1: Digital health predisposing characteristics, needs, and enabling resources framework………………………..…………………..………………………………………….6 Figure 1.2: Map of Ghana............................................................................................................9 Figure 2.1: Subsets of Digital Health..........................................................................................14 Figure 3.1: PRISMA 2020 Flow diagram for new systematic reviews which included searches of databases and registers only....................................................................................32 Figure 4.1: Distribution of Study Designs.................................................................................40 Figure 4.3: Types of DHIs in Ghana..........................................................................................51 Figure 4.4: Focus of DHIs in Ghana..........................................................................................53 Figure 4.7: Temporal Trends of DHIs in Ghana......................................................................56 Figure 4.8: Types of DHIs Introduced in Ghana Over the Year.............................................58 Figure 4.9 Limitations of Digital Health Interventions in Ghana...........................................59 Figure 4.10 Strengths of Digital Health Interventions in Ghana............................................67 xv LIST OF MAPS Map 1.1: Map of Ghana [Source: (Andoh et al., 2020)] ............................................................ 9 xvi LIST OF APPENDICES LIST OF APPENDICES ............................................................................................................ 94 Appendix 1 - Results ................................................................................................................... 94 Appendix 1.0: Distribution of Included Digital Health Studies in Ghana by Publication Year .......................................................................................................................................... 94 Appendix 1.1: Types & Focus of Digital Health Interventions in Ghana .......................... 95 Appendix 1.2: Glossary of The Types of DHIs ..................................................................... 98 Appendix 1.3: Distribution of Digital Health Interventions in Ghana by Setting........... 100 Appendix 1.4: Target Populations of Digital Health Interventions in Ghana ................. 101 Appendix 1.5: Coding Frame for Themes & Codes ........................................................... 102 Appendix 1.5.1: Themes Related to Strengths of DHIs.................................................. 102 Appendix 1.5.2: Coding Frame for Themes Related to Limitations of DHIs .............. 102 Appendix 1.6: Quality Appraisal Results ............................................................................ 104 Appendix 1.6.1: Results of CASP Qualitative Checklist ................................................ 104 Appendix 1.6.2: Results of Standard Quantitative Checklist ........................................ 105 Appendix 1.6.3: Results of CRAAP Checklist ................................................................ 106 Appendix 1.6.4: Results of Mixed Methods Appraisal Tool (MMAT) ......................... 106 Appendix 2.0 - PRISMA 2020 Checklist ................................................................................. 107 Appendix 3.0 – Quality Appraisal Tools ................................................................................. 109 Appendix 3.1: CASP Qualitative Checklist ..................................................................... 109 Appendix 3.2: Standard Quality Assessment Checklist for Quantitative Studies ....... 110 Appendix 3.3: Mixed Methods Appraisal Tool (MMAT), version 2018 ...................... 111 Appendix 3.4: The CRAAP Test ...................................................................................... 113 Appendix 4.0: Ethical Clearance ............................................................................................. 114 1 CHAPTER 1 1.0 INTRODUCTION 1.1 Background Information Digital health, dubbed a prominent domain of practice, denotes the application of digital technologies in healthcare, leveraging both conventional and cutting-edge forms of information and communications technology (ICT) to tackle health issues effectively. Digital health has become an essential component of global healthcare systems, with initiatives such as the WHO Global Strategy for Digital Health emphasizing the importance of effective public participation and transparency in decision-making processes (Godinho et al., 2023). The term digital health was introduced as “a broad umbrella term encompassing eHealth (which includes mHealth), as well as emerging areas such as the use of advanced computing sciences in ‘big data,’ genomics, and artificial intelligence”. Digital health includes categories such as mobile health (mHealth), health information technology, wearable devices, telehealth, telemedicine, personalized medicine, eHealth, self-tracking, artificial intelligence, and information systems in healthcare (Shin, 2019; Guo et al., 2020; Wienert, Jahnel and Maaß, 2022). In the pursuit of universal health coverage (UHC), Science, Technology, and Innovation, such as digital health, play a pivotal role in achieving the Sustainable Development Goals (SDGs) outlined in the 2030 Agenda. Specifically, Sustainable Development Goal 3.8 underscores the significance of ensuring access to quality, safe, effective, and affordable healthcare for all (Osei, Kuupiel and Mashamba-Thompson, 2020; Bekyieriya, Isang and Baguune, 2023). The WHO's global strategy on digital and mobile health for 2020 to 2025 stresses the significance of employing digital technologies in healthcare. Digital health interventions offer opportunities to 2 target specific groups, reduce implementation costs, and enhance population health (Parums, 2021; Stark, Geukes and Dockweiler, 2022). Existing evidence indicates that digital health applications may be useful in improving maternal, neonatal, and child health, including increased antenatal care attendance, facility usage, skilled attendance at birth, and postnatal care (Sondaal et al., 2016; Osei et al., 2021). The utilization of digital health services has significantly increased globally, particularly owing to the challenges brought about by the COVID-19 pandemic (Rosenlund, Kinnunen and Saranto, 2023). In the 2018 Digital Health Consumer Adoption survey by Rock Health in the US, 89% of consumers reported adopting at least one digital health tool, in early 2020, healthcare systems rapidly adopted new digital services to manage the COVID-19 pandemic (Shah, Nghiem and Ranney, 2021). The digital health adoption rate in Africa varies across regions and countries. However, 53.4% of digital health solutions have been established in Sub-Saharan Africa (Karamagi et al., 2022). Limited resources in Ghana pose significant challenges, particularly for hard-to-reach populations, leading to concerns about inadequate access to and quality of healthcare services. Additionally, Ghana, like other Sub-Saharan African countries face the dual burden of infectious and non- infectious diseases, weakening the already fragile healthcare systems (Agyemang-Duah et al., 2019; Osei et al., 2024). In an attempt to combat issues with the healthcare system, the Government of Ghana has demonstrated a commitment to enhancing the digitization of healthcare systems, increasing the training and deployment of skilled health professionals to rural communities, and expanding mobile network coverage in rural areas of the country (de-Graft Aikins et al., 2014; Osei et al., 2021). 3 In July 2010, the Ministry of Health (MoH) launched an eHealth strategy to guide digital health, specifically e-health adoption in Ghana. The plan focused on four key areas: streamlining regulations for health data management, enhancing sector capacity for eHealth solutions, using Information and Communication Technology to improve access and equity in healthcare, and transitioning to a paperless records system (Ministry of Health, 2010). The adoption of digital health in Ghana has progressed more slowly than anticipated, particularly in contrast to the rapid integration of ICT in other sectors of business and society. Digital health remains in its early stages, with most hospitals only partially digitalized. This slow adoption has been viewed as having significant negative impacts on healthcare delivery in the modern era (Achampong, 2012a). Ghana is home to several digital health interventions. These initiatives vary in scale, reach, and purpose, ranging from community health worker (CHW)-operated registration and data collection tools to SMS appointment reminders as well as targeted patient messaging and applications for monitoring essential medicine supplies. Given the persistent shortage of healthcare workers to meet the increasing demand, there is an urgent need for innovative healthcare delivery models, such as digital health, that aim to enhance patient experience, achieve cost savings, and improve accessibility of care (Hampshire et al., 2017). However, no single systematic review has provided a comprehensive overview of existing digital health interventions in Ghana. This systematic review bridges this gap by critically examining the existing evidence on digital health interventions in Ghana. 1.2 Problem Statement The advent of digital health interventions has shown significant potential in improving healthcare delivery, accessibility, and outcomes across various regions globally. In Ghana, where healthcare challenges such as limited access to healthcare facilities, inadequate healthcare personnel, and a 4 high disease burden persist, digital health interventions could play a transformative role (Kesse- Tachi, Asmah and Agbozo, 2019; Peprah et al., 2020; Demuyakor, 2021; Adachi et al., 2022; Agormedah et al., 2022). Despite numerous pilot projects and initiatives aimed at integrating digital health solutions within the Ghanaian healthcare system (Hampshire et al., 2017), a thorough search of the Google Scholar and PubMed databases shows a lack of comprehensive evidence synthesizing their impacts, effectiveness, and scalability. Moreover, there is a limited understanding of the contextual factors that limit or strengthen the adoption and success of these interventions, including infrastructural barriers. Without a systematic review specific to Ghana, the country may miss valuable insights into behavior change techniques, user engagement strategies, and design processes that have proven effective in other contexts. This lack of evidence hinders policymakers, researchers, and healthcare providers’ understanding of the full spectrum of digital health outcomes and limits their ability to identify barriers, facilitators, and effective solutions for implementing context-specific digital health interventions in Ghana. Conducting a systematic review focusing on digital health in Ghana is essential to inform evidence-based decision making, policy formulation, and the successful implementation of digital health initiatives in the country. 1.3 Rationale of Study Leveraging digital health technologies such as mHealth initiatives aims to enhance healthcare access, communication, and service delivery (Peprah et al., 2020; Hampshire et al., 2021). This systematic review of digital health interventions in Ghana is highly relevant to the United Nations 5 SDGs. Specifically, it addresses SDG 3 - "Ensure healthy lives and promote well-being for all at all ages" (Afarikumah, 2014a; Kesse-Tachi, Asmah and Agbozo, 2019). This study directly contributes to improving population health outcomes in Ghana. The findings from this review also have significant policy relevance for Ghana. The Ghana eHealth Strategy, published in 2010, is the official policy framework guiding the country's use of digital health (Kesse-Tachi, Asmah and Agbozo, 2019). However, this strategy lacks clarity on addressing digital health inequalities faced by end-users, especially those in rural communities and vulnerable populations. This review provides important insights that can inform revisions to the eHealth Strategy and guide the development of more inclusive digital health policies in Ghana. It is not only timely, but the rationale for conducting a systematic review of digital health interventions in Ghana is rooted in the need to address healthcare disparities, understand target populations, track evolution and trends, and assess their strengths and limitations. By synthesizing the findings from various studies, this review sheds light on what works, what does not work, and why it does in Ghana. 6 1.4 Conceptual Framework Figure 1.1 Digital health predisposing characteristics, needs, and enabling resources framework [modified from (Opoku, Stephani and Quentin, 2017)]. This is a framework for understanding the contribution of digital health interventions to improved access to care for patients and explains how, why, for whom, and in what circumstances digital health interventions work in this context. This shows that the main contribution of digital health is that it facilitates (remote) access to previously unavailable and often specialized services. The framework consists of three main elements: predisposing characteristics (such as positive attitude, basic knowledge, and fluency in language); needs (such as a high burden of disease and a lack of capacity of first-contact providers); and enabling resources such as the availability of a stable communication network, accessible maintenance services, and regulatory policies. The framework shows that the predisposing characteristics, need, and enabling resources influence the perceived usefulness and ease of use of digital health interventions, which in turn determine 7 the sustained use of digital health interventions and improved access to care for patients. The framework also shows that digital health interventions can take different forms, such as patient- to-provider or provider-to-provider consultations, and can target different types of health conditions. The framework can help policymakers and program managers to design, implement, and evaluate digital health interventions in Ghana, taking into account the context-specific factors that affect their success. 1.5 Research Questions 1. What are the characteristics (Population, Intervention, Comparators, Outcomes, Study design) of studies on digital health interventions in Ghana? 2. Which specific health conditions are targeted and addressed through digital health interventions in Ghana? 3. How have digital health interventions evolved over time in Ghana? 4. What are the strengths and limitations associated with the utilization of digital health interventions in Ghana? 1.6 General Objective To explore the trends, strengths, and limitations of digital health interventions in Ghana. 1.7 Specific Objectives 1. To describe the characteristics (Population, Intervention, Comparators, Outcomes, Study design) of digital health studies in Ghana. 2. To identify the specific health conditions targeted and addressed through digital health interventions in Ghana. 3. To investigate trends in digital health interventions in Ghana. 8 4. To assess the strengths and limitations of digital health interventions in Ghana. 1.8 Profile of Study Area Ghana, officially known as the Republic of Ghana, is a country in West Africa. It abuts the Gulf of Guinea and Atlantic Ocean to the south, sharing borders with the Ivory Coast in the west, Burkina Faso in the north, and Togo in the east. Ghana covers an area of 239,535 km2 (92,485 sq. mi), spanning diverse biomes ranging from coastal savannas to tropical rainforests. With over 32 million inhabitants, Ghana is the second most populous country in West Africa after Nigeria. The capital and largest city is Accra; other major cities are Kumasi, Tamale, and Sekondi-Takoradi. Ghana is characterized by rich cultural heritage and diverse geographic regions. The country has been divided into 16 regions, 261 metropolitan, municipal, and district assemblies, and 275 constituencies that focus on population size, share and growth, sex composition, population density, number of households, and household size by region, district, and type of locality. More than half of the population is from the Greater Accra Region (17.7%), Ashanti Region (17.6%), Eastern Region (9.5%), and Central Region (9.3%), and other citizens are from the Northern Region (7.5%), Western Region (6.7%), Volta (6.7%), Upper East (4.2%), Bono Region (3.9%), Upper West (2.9%), Western North (2.9%), Oti Region (2.4%), and Northeast Region (2.2%). The Savannah Region (2.1%) and Ahafo Region (1.8%). Overall, there were more females (8,961,329; 51.3%) in urban areas than males (8,511,201; 48.7%). Nevertheless, in rural areas, there were slightly more males (50.1%) than females (49.9%). Regarding Ghana's healthcare landscape, healthcare accessibility and quality vary considerably between regions. Urban centers, such as Accra, Kumasi, and Tamale, boast relatively better 9 healthcare infrastructure, including well-equipped hospitals and clinics. In contrast, rural and remote areas often face limited access to healthcare, transportation, and availability of healthcare providers (GSS, 2021). Figure 1.2 presents the map of the study area, Ghana. Figure 1.2 Map of Ghana [Source: (Andoh et al., 2020)] 10 1.9 Scope of Study The scope of this systematic review of digital health interventions in Ghana covers a comprehensive exploration of various digital health initiatives implemented within the Ghana healthcare landscape. This study focused on a wide range of digital health interventions, including, but not limited to, mobile health (mHealth) applications, telemedicine platforms, electronic health records (EHRs), health information systems (HIS), and electronic decision support systems (eDSS). 1.10 Organization of Report This thesis is structured into six chapters. Chapter 1 introduces the study by outlining the background of digital health interventions in Ghana, identifying challenges in healthcare delivery, and setting the objectives and scope of the research. Chapter 2 reviews the relevant literature, organized by the main study variables, such as intervention strategies, to offer a theoretical foundation and context for the research. Chapter 3 details the systematic review methodology employed, emphasizing the rigorous literature search, data extraction, and quality appraisal processes. It covers research methods, data- handling processes, data analysis strategies, and ethical considerations. Chapter 4 presents the findings from the systematic review, summarizing key variables and trends in digital health interventions in Ghana. Chapter 5 discusses these findings in relation to the research questions and objectives, highlighting their strengths, limitations, and implications for healthcare policies and practices. Finally, Chapter 6 concludes with a synthesis of key insights and provides actionable recommendations for policymakers, healthcare providers, and researchers aiming to guide future digital health strategies in Ghana. 11 CHAPTER 2 2.0 LITERATURE REVIEW 2.1 Introduction The rapid advancement of digital technologies has significantly impacted the delivery of healthcare services worldwide, with digital health interventions emerging as a promising approach to address various healthcare challenges. This chapter presents a thorough review of the existing literature on digital health interventions, with a specific focus on identifying the health conditions targeted, the evolution of these interventions over time, and the strengths and limitations inherent in their utilization. This literature review serves as the foundation for addressing the research questions, guiding the subsequent analysis and discussion within the thesis. 2.2 What is Digital Health? In recent years, digital health has emerged as a transformative force in healthcare. However, the term "digital health" has been defined and interpreted in various ways, leading to ambiguity and potential confusion, which can be a hurdle for research, policy, and practice in this field (Fatehi, Samadbeik and Kazemi, 2020). The term “Digital Health” came about as an attempt to provide an all-encompassing definition that included all these aspects of technological development. One of the first to use the term was Seth Frank in 2000, who said it was the combination of Internet-based apps and media being used to improve medicine (Walker, 2024). Early definitions emphasized the use of information and communication technologies (ICT) in healthcare. These definitions highlight the role of technology in data collection, analysis, and communications. With the rise of mobile health (mHealth) and wearable devices, newer definitions 12 have shifted the focus towards empowering individuals. The World Health Organization (WHO) defines digital health as a comprehensive term that includes eHealth, mHealth, and the utilization of advanced computing sciences such as big data, genomics, and artificial intelligence (WHO, 2019a). This broader definition encompasses not only clinical applications but also digital tools that individuals use for self-management and wellness. Meskó et al. (2017) too defined digital health as “the cultural transformation of how disruptive technologies that provide digital and objective data, accessible to both caregivers and patients, leads to an equal level doctor-patient relationship with shared decision-making and the democratization of care”. Recent definitions acknowledge the multifaceted nature of digital health. The US Food and Drug Administration (FDA) defines digital health as “the broad scope of digital health includes categories such as mobile health (mHealth), health information technology (IT), wearable devices, telehealth and telemedicine, and personalized medicine” (Shin, 2019). This definition reflects the diverse range of technologies and services that fall under the umbrella of digital health. Neves and Burgers (2022) define digital health as "the convergence of digital technologies with health, healthcare, living, and society, aiming to deliver high quality care". Kostova also defined digital health as the “use of information and communications technologies to improve human health, healthcare services, and wellness for individuals and across populations (Kostkova, 2015). Healthcare Information and Management Systems Society (HIMSS) stated that “Digital health connects and empowers people and populations to manage health and wellness, augmented by accessible and supportive provider teams working within flexible, integrated, interoperable and digitally-enabled care environments that strategically leverage digital tools, technologies and services to transform care delivery” (Evans et al., 2022). Unlike other definitions focus more on 13 individual technologies or applications, HIMSS's definition considered the broader healthcare ecosystem. Eric Topol defined Digital Health as “the convergence of smartphone-enabled mobile computational and connectivity capabilities is only one aspect of digital medicine; it also encompasses genomics, information systems, wireless sensors, cloud computing, and machine learning that can all be incorporated into new systems of health management, built around real- world, patient-generated data” (Topol, 2012, 2016). Some common themes appear in these definitions. All definitions acknowledge the fundamental role of digital technologies in healthcare. There is also a consistent focus on enhancing health, wellness, or care quality. The majority of these definitions recognize digital health as an umbrella term encompassing various technologies and applications (Fatehi, Samadbeik and Kazemi, 2020). A comprehensive review of digital health definitions conducted by Fatehi, Samadbeik and Kazemi (2020) revealed common themes emerging around the use of technology to improve health outcomes, with a particular emphasis on mobile health, data-driven approaches, and wellbeing. The concept of digital health has undergone significant evolution since its inception in the 1990s. Initially, digital health primarily referred to the digitization of health information and libraries. However, with the advent of the internet in the 2000s and subsequent advancements in computer science and informatics, the concept expanded to cover a broader range of technologies and applications (Fatehi, Samadbeik and Kazemi, 2020). 2.3 Types of Digital Health Interventions Digital health interventions vary, with mobile apps and computer-based programs being the most reported, while others, such as videocassettes and IoT, are less common. These interventions, 14 which include web-based cognitive-behavioral therapy, teleconsultation, and mobile apps, offer alternatives to traditional face-to-face interventions (Berry, Bucci and Lobban, 2017; Sasseville et al., 2021a; Ibrahim et al., 2022). Figure 2.1 presents the diverse subsets of digital health and how interrelated they are. Here is a comprehensive overview of the different types of digital health interventions: Figure 2.1: Subsets of Digital health [based on (Shin, 2019; WHO, 2019b)] 2.3.1 Mobile Health (mHealth) Mobile health (mHealth) is a subset of eHealth and is defined as “the use of mobile wireless technologies for health. The WHO defined m-health as a ‘medical and public health practice 15 supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices’ (WHO, 2019a; Istepanian, 2022). Examples of mHealth interventions include mobile applications that provide health-related information, self-management tools, and access to healthcare services; SMS or Text messaging- based interventions for health promotion, appointment reminders, medication adherence, and disease management; and remote consultations between patients and healthcare providers using mobile devices and video conferencing (Labrique et al., 2013). 2.3.2 Telemedicine Telemedicine involves the delivery of health care services, where patients and providers are separated by distance. Telemedicine is defined by three characteristics: (1) using information and communication technologies, (2) covering a geographical distance, and (3) involving professionals who deliver care directly to a patient or a group of patients (Timpel et al., 2020; WHO, 2023) Broadly, there are three main types of telemedicine: store-and-forward (asynchronous exchange of medical information, such as images or test results, for review and consultation by healthcare providers), remote monitoring, and real-time interactive services (Garavand et al., 2022). 2.3.3 Electronic Health Records (EHRs) An electronic health record is defined as an electronic version of a medical history of the patient as kept by the health care provider for some time period and it is inclusive of all the vital administrative clinical data that are in line to the care given to an individual by a particular provider such as demographics, progress reports, problems, medications, important signs, medical history, immunization reports, laboratory data and radiology reports (Keshta and Odeh, 2021). 16 These are usually computerized records of the patient’s medical history in an organization and is used by specialists, pharmacists, and laboratory services of that specific organization. EHRs are made up of widespread patient IDs linked to lifetime medical history that is valid and may be shared across numerous organizations (Bajeh et al., 2021). 2.3.4 Health Information Systems (HIS) Health information systems (HISs) are computing systems that capture, store, manage, or transmit this vast amount of information as it pertains to the health of individuals, clinical care, or the activities of health-related organizations. HISs can be divided into 4 categories namely foundational systems, financial systems, departmental systems, and electronic medical records (EMRs) (Sirintrapun and Artz, 2016). Health information systems produce information aimed at supporting decision-making and actions at each level of a health system and healthcare organization. These systems include Hospital management systems and Public health surveillance systems (Rodrigues and Gattini, 2017). 2.3.5 Wearable Devices Wearables are seamlessly embedded portable computers worn on the body. Examples include consumer products promoted as wellness gadgets, like Apple smartwatches and Fitbit activity trackers, as well as more specialized medical devices that can monitor electrolyte levels or detect cancer cells in blood samples. In the medical sector, wearable devices are utilized for monitoring patients and aiding in diagnoses, empowering individuals to take an active role in their health and gain better control over their lives (Kang and Exworthy, 2022). 17 There are different types of wearable devices including different noninvasive wearables (including skin-based wearables), biofluidic-based wearables (including saliva, urine, and tears) (Iqbal et al., 2021). 2.3.6 Health Education and Training Digital health interventions also encompass tools and platforms for health education and training, targeting both healthcare professionals and the general public (WHO, 2019a). These include E-learning modules (interactive, web-based educational resources for healthcare workers and patients), health information websites, and virtual reality (VR) training simulations for healthcare professional training and patient education (Car et al., 2022; Pang, Lee and Murshed, 2023). 2.3.7 Digital Therapeutics Digital therapeutics, is a subdivision of digital health, defined by the Digital Therapeutics Alliance (DTA) as “delivering evidence-based therapeutic interventions to patients that are driven by software to prevent, manage, or treat a medical disorder or disease. They are used independently or in concert with medications, devices, or other therapies to optimize patient care and health outcomes” (Abbadessa et al., 2022). Digital therapeutics are evidence-based digital health tools, often Food and Drug Administration approved that can collect a high volume of user data from a variety of sources, ranging from traditional clinical biomarkers to physiologic sensors and social patterns. Digital Therapeutics tools include diverse screen devices such as smartphones, tablets, computers, and videogame platforms that converge with software algorithms and that can be applied for improvement of 18 therapy management and rehabilitation (Khirasaria, Singh and Batta, 2020; Kuwabara, Su and Krauss, 2020). 2.4 Health Conditions Addressed by Digital Health Interventions Digital Health Interventions (DHIs) have been employed to address a wide spectrum of health conditions across diverse global contexts. In developed nations, chronic diseases and mental health have been primary focuses, while in developing countries, infectious diseases and maternal-child health have received significant attention. These interventions leverage digital technologies to provide accessible and scalable solutions for various health issues by promoting behavioral change, improving health outcomes, and enhancing healthcare delivery in terms of effectiveness, efficiency, accessibility, safety, and personalization (Murray et al., 2016; Michie et al., 2017; WHO, 2018, 2019a). Spatz et al.(2024) demonstrated the efficacy of wearable devices and remote monitoring systems in managing hypertension, heart failure, and atrial fibrillation in the western world. These findings were corroborated by a subsequent scoping review by Soon et al. (2020) emphasizing the potential of wearable devices for remote vital signs monitoring in outpatient settings. Diabetes has also been addressed through DHIs. In the United States, Bennett et al. (2018) conducted a randomized controlled trial evaluating a smartphone application that incorporated interactive voice response, SMS text messaging, and smart scale integration to facilitate behavior change and provide tailored feedback for weight management. Similarly, Ofili et al. (2018) reported on "Health 360x," an app-based intervention that demonstrated sustained improvements in systolic blood pressure, blood glucose levels, and physical activity over a 12-week period. 19 In Germany, Kempf et al. (2017) highlighted the TeLiPro telemedicine lifestyle intervention program for advanced type 2 diabetes, which decreased medication use among participants. Similarly, Agarwal et al. (2019) explored the use of a mHealth intervention called Bluestar for self-management of type 2 diabetes in Canada. A study conducted in Saudi Arabia by Al Hayek, Robert and Al Dawish (2021) examined the FreeStyle Libre flash glucose monitoring system, finding out that it led to increased healthcare utilization among patients with type 2 diabetes. In Europe, Poppe et al. (2019) evaluated "MyPlan" in the Netherlands, a web-based intervention promoting physical activity and healthy eating among adults with type 2 diabetes. In the United Kingdom, Cooper et al. (2022) explored "myCOPD," a digital health intervention for managing chronic obstructive pulmonary disease (COPD), further expanding the application of DHIs to respiratory conditions. Mental health conditions have been increasingly targeted by DHIs in developed nations. In the United States, Dahne et al. (2019) revealed that a smartphone app adaptation of Brief Behavioral Activation for depression resulted in a significant decrease in Beck Depression Inventory-II scores compared to usual care. Yu et al. (2018) reported on an app delivering guided cognitive behavioral therapy for anxiety, which led to a mean reduction in GAD-7 scores over two months. In Germany, Baumeister et al. highlighted the effectiveness of WARD-BP, a guided internet- and mobile-based intervention for patients with chronic back pain and depression. In Sweden, Bonnert et al. explored an exposure-based online treatment targeting excessive avoidance behavior to reduce asthma-related anxiety. In sub-Saharan Africa, DHIs have predominantly addressed infectious diseases and maternal-child health. Karamagi et al. (2022) and Manyazewal et al. (2023) noted that HIV/AIDS, malaria, 20 tuberculosis, and maternal and child health were the most common health conditions targeted by DHIs in this region. In Western Kenya, a mobile phone-based intervention was implemented to deliver individual counseling services and facilitate peer support for adolescents living with HIV (Chory et al., 2022). In Mozambique, Nhavoto, Grönlund and Klein (2017) highlighted an SMS-based intervention supporting adherence to both HIV and TB treatment. Similarly, Lesotho saw the implementation of SMS reminders to support HIV/TB treatment in the START study (Hirsch-Moverman et al., 2017). South Africa has seen DHIs applied to cancer screening, with Moodley et al. (2019) exploring the use of SMS reminders to improve adherence to follow-up colposcopy appointments after abnormal cervical cancer screening results. Malaria management has been addressed through DHIs targeting healthcare provider behavior. In Kenya, Zurovac et al. (2011) highlighted the use of SMS reminders to ensure health workers' adherence to malaria treatment guidelines. A similar intervention was evaluated in Malawi by Kaunda-Khangamwa et al. (2018) for malaria, pneumonia, and diarrhea case management. In Nigeria, an mHealth application boosted antenatal care attendance and outcomes by sending educational and reminder messages to pregnant women via mobile phones (Olajubu et al., 2020). Beyond infectious diseases, some digital health interventions have targeted non- communicable diseases in Africa. In Nigeria, Nelissen et al. (2018) explored a pharmacy-based hypertension care model which involved using a smartphone app to support blood pressure monitoring and medication management for hypertensive patients. 21 2.5 Evolution of Digital Health Interventions According to Sophie et al. (no date), digital health’s roots trace back to the 1970s with the advent of computational biology. In the 1970s, the foundations of digital health were laid with the emergence of computational biology and bioinformatics, which leveraged the growing computational power to complement traditional biological research. These early computational approaches paved the way for the development of more sophisticated tools and disciplines, such as systems biology and computational genomics, that could generate, store, and interpret vast amounts of medical data. A study by Wall, Hetherington and Godfrey (2023) on the rise of wearables and smartphones in decentralizing healthcare revealed that wearable technology and smartphones are driving a transformative shift in patient monitoring and personalized healthcare, signaling a new era in digital health. Wearable devices, equipped with advanced sensing technologies such as accelerometers for tracking movement and optical sensors for monitoring heart rate, are gaining recognition for their vast potential in remote patient monitoring, diagnostics, and therapeutic applications. Similarly, smartphones, which have evolved far beyond their original role as communication devices, are now pivotal instruments in health monitoring. With their integrated sensing capabilities and Internet of Things (IoT) connectivity, smartphones are facilitating a seamless shift from conventional healthcare practices to a more interconnected, digitally-driven healthcare landscape. Wilson and Maeder (2015) revealed in their study on recent directions in telemedicine, that telemedicine has transitioned from a niche technology to a critical component of healthcare delivery across various specialties. Although its adoption began in the 1990s, early development was limited by inadequate telecommunications infrastructure and high costs of peripheral devices. 22 In the twenty-first century, advancements in technology have facilitated widespread use of telehealth. Today, telemedicine is integral to healthcare in both developed and an increasing number of developing countries, encompassing diverse settings from mobile patient applications to complex clinical interactions in tertiary hospitals. A study conducted by Alam et al. (2020) on the adoption of mHealth services in Bangladesh has demonstrated a growing popularity of mHealth in developing countries. Many governments are increasingly acknowledging the potential benefits of mHealth and have incorporated it into their strategies to achieve health system objectives, including Sustainable Development Goals (SDGs). Additionally, the study highlights variability in acceptance rates of mHealth services across different age groups, with younger users showing a higher propensity for engagement due to their reliance on smartphone technology. In his study on high-performance medicine, Topol, (2019) highlighted the emergence of AI and ML as transformative technologies in healthcare. These technologies offer advanced capabilities in diagnostics, treatment planning, and personalized medicine. Over the past decade, AI and ML algorithms have been increasingly utilized to analyze complex datasets, including medical images and genomic information, resulting in more accurate and timely diagnoses. 23 2.6 Strengths and Limitations of Digital Health Interventions Digital health interventions have several strengths associated with their implementation. A qualitative study conducted by O’Brien et al. (2023) in Sub-Saharan Africa reported that digital health technologies enhance the accessibility of healthcare at the patient level. The authors further explained that DHIs ensured both the accessibility and continuity of care, particularly in relation to hard-to-reach populations and during the COVID-19 pandemic. Additionally, it was observed that improved accessibility through digital platforms not only expands reach but also increases patient usage and adherence to healthcare interventions. A scoping review by Palacholla et al. (2019) on digital health technology adoption for hypertension management revealed that DHIs enhance patient monitoring to prevent adverse health outcomes. The study found that some patients benefited from using digital health technologies to monitor their blood pressure readings, which helped alleviate health-related anxiety. Similarly, in their study on remote monitoring and digital health tools in cardiovascular disease management, Cowie and Lam (2021) highlighted a closed-loop system that integrates remote monitoring with patch technology. This system continuously tracks blood sugar levels and is connected to a wearable insulin pump, offering advanced care for patients with type 1 diabetes mellitus. Another strength of digital health interventions (DHIs), particularly electronic health records (EHRs), is their ability to enhance decision-making in clinical practice. A study by Kataria and Ravindran (2020) highlights that the structured and processed format of patient information, combined with real-time tracking, offers busy clinicians unparalleled decision-making opportunities compared to the cumbersome nature of paper-based records. Additionally, the study reported that EHRs provide time-sensitive alerts and reminders that align with patient 24 management, prevention, and screening protocols, which have been shown to improve the quality of care, especially in managing chronic diseases. Digital health interventions (DHIs) have significantly improved communication between patients and healthcare providers, particularly in remote or hard-to-reach areas. A study by Hirsch- Moverman et al. (2017) focusing on the use of mHealth for HIV and tuberculosis (TB) treatment support in Lesotho exemplifies this. Mobile phone technology, a key component of DHIs, facilitates easy and remote communication between health workers and patients in communities where access to healthcare is limited due to poor infrastructure or transportation challenges. Another notable strength of DHIs is their role in promoting the self-management of disease conditions. A study by Nhavoto, Grönlund and Klein (2017) on a mobile health treatment support intervention for HIV and TB patients in Mozambique highlighted how mHealth reminders from health workers helped patients adhere to treatment protocols. These reminders ensured that patients collected their medication on time and attended clinical appointments regularly, ultimately supporting better disease management and improving health outcomes. However, the implementation of digital health interventions has certain limitations that must be carefully addressed. A study conducted by LoBuono et al. (2023) in the northeast US identified poor product design as a significant barrier to the effective use of digital health platforms. Participants reported that the design of many technological devices was not suitable for the population. Specific design issues included screens that were too small for those with impaired vision, as well as touchscreens and buttons that were either too small or incompatible with conditions such as tremors. These design flaws limit the accessibility and usability of digital health technologies, particularly for vulnerable groups. 25 Poor internet connectivity, compounded by unreliable electricity supply, poses significant challenges to the adoption and implementation of digital health technologies in Sub-Saharan Africa (SSA). A study by Owhor, Abdulwahab and Oluwaseun (2023) on Digital Health in Sub- Saharan Africa highlights that inadequate electricity supply is a major obstacle to the effective use of digital health interventions across the region. Frequent power outages are prevalent in countries such as Nigeria, South Sudan, Chad, Malawi, Niger, and Sierra Leone, severely limiting the consistent operation of digital health platforms and telemedicine services. Onsongo et al. (2023) corroborated this in a similar study in Kenya stating thar internet connectivity in many parts of Africa remains either non-existent or slow, further constraining the quality and reliability of digital health services. The combination of these infrastructural challenges significantly impedes the region's ability to fully harness the potential of digital health technologies. A study conducted by Kasoju et al. (2023) in India, reported interoperability as another significant challenge in the evolution of digital health, as many digital health systems struggle to effectively communicate with one another. This lack of compatibility hinders the seamless exchange of patient data between different healthcare platforms, creating barriers to efficient care delivery. The inability to integrate and share crucial health information can impede healthcare providers' access to comprehensive patient records, which in turn can negatively impact patient outcomes. A systematic review by Kaboré et al. (2022) revealed that the high cost of services associated with digital health interventions poses a significant challenge to their sustainability, particularly in low- and middle- income countries. This financial burden limits the long-term viability of these technologies in resource- constrained settings. Similarly, a study by Onsongo in Kenya identified the high cost of equipment, software, and initial setup as a substantial barrier to the adoption of telemedicine. These expenses create obstacles for healthcare systems and providers seeking to implement digital health solutions, further complicating efforts to scale and sustain these interventions in economically disadvantaged regions. 26 Another significant limitation of DHIs is their lack of integration with existing healthcare systems. A scoping review by Whitelaw et al. (2021) identified the poor integration of DHIs with electronic medical records as a key clinician-level barrier to their adoption. This disconnect complicates the seamless use of digital tools in clinical practice. Additionally, findings from study by Onsongo et al. (2023) in Kenya emphasized that the limited or non-existent integration of telemedicine services into the daily workflow of healthcare providers poses a major obstacle to their widespread adoption. This lack of alignment between digital health technologies and existing healthcare operations hinders their effective utilization and acceptance by practitioners. A qualitative study by Kaihlanen et al. (2022) exploring the experiences of vulnerable groups in accessing digital health services during the COVID-19 pandemic found that many participants faced significant barriers due to a lack of suitable devices. This lack of access to essential technology, such as smartphones or computers, hindered their ability to utilize digital health services effectively. Similarly, a scoping review by Godwin et al. underscored that the absence of smartphones and computers was a fundamental barrier to the adoption and use of mobile health applications. 27 CHAPTER 3 3.0 METHODOLOGY This chapter explains the methods employed in conducting this systematic review encompassing various components including study design, selection criteria for inclusion and exclusion of studies, search strategy, data extraction methods, and synthesis techniques. 3.1 Study Design A systematic review was conducted to capture all studies on digital health interventions implemented in Ghana. This study was primarily qualitative and descriptive, with no statistical analysis conducted. Systematic reviewing is a method used to synthesize the available scientific evidence to address a clearly formulated research question. It enables researchers to collate relevant studies, assess the quality of evidence, and generate conclusions and/or identify knowledge gaps. The current review employed methods informed by Cochrane guidance on conducted reviews and results are reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021). The protocol for this systematic review was published in the PROSPERO Database in June 2024 (reference: CRD42024555221). 3.2 Study Site The study site for this systematic review was Ghana. The research included all eligible studies conducted within the geographical boundaries of Ghana. 28 3.3 Study Population The study population for this systematic review included all digital health interventions implemented in the Ghana. This includes but was not limited to mobile health (mHealth) applications, text message-based programs, telemedicine platforms, electronic health records (EHRs), health information systems (HIS), electronic decision support systems (eDSS), and other digital health solutions aimed at improving healthcare delivery, patient outcomes, and health system efficiency in Ghana. 3.4 Inclusion Criteria Studies that met all of the above criteria were included in this systematic review: a. The study must be conducted in Ghana b. The study must focus on digital health interventions c. Studies must be published in English d. Studies must be published between the years 2004 and 2024 This systematic review considered all primary study designs including observational studies like cross-sectional studies, case studies, and cohort studies. 3.5 Exclusion Criteria a. Studies conducted outside of Ghana b. Studies not focusing on digital health interventions c. Studies published before 2004 or after 2024 d. The review excluded studies that were not primary research, including systematic reviews, meta-analyses, and secondary analyses. 29 e. Studies not published in English 3.6 Sample Size Due to the nature of this study, there was no traditional sample size calculation. Instead, this review involved the synthesis of existing literature rather than the collection of primary data. The review strived to be as inclusive as possible, incorporating all relevant studies meeting the predetermined inclusion criteria. 29 eligible studies were identified through systematic search strategies across various databases and sources. 3.7 Data Collection Methods and Instruments This section outlines the strategies and tools that were employed to collect, select, and extract data pertinent to the research objectives. This section is further divided into three integral subsections: “Search Strategy”, “Selection Process”, and “Data Extraction”. 3.7.1 Search Strategy The search strategy attempted to balance sensitivity with specificity in its results. Keywords were used to ensure more specificity in the search. Previous systematic reviews conducted on digital health studies, alongside insights from review helped inform the search strategy. The electronic databases of PubMed, Google Scholar, ProQuest, and The Lens were searched on 4-6th April 2024 to find relevant studies. The complete search strings are included in Table 3.7. Some of the keywords and terms used included ‘digital health, ‘eHealth, ‘mHealth’, ‘telemedicine,’ ‘Ghana,’ and ‘Electronic Health Records. Groups of keywords relevant to a specific category (for instance, setting) type were combined using the ‘OR’ Boolean term (e.g., mobile health OR mHealth OR eHealth) and categories of keywords were then combined using the AND Boolean operand (see Table 3.7). Restrictions were placed on country of origin, language, and accessible 30 peer-reviewed papers published since 2004. Additionally, the research team scanned the reference lists of included papers and contacted experts in the field to help identify other potentially relevant studies. Table 3.7 Database search results Database Intervention Terms (OR) Setting (AND) Results Google Scholar digital health, ehealth, electronic health records, mHealth, m-Health, mobile health, mobile-based care, telemedicine, telehealth, telenursing, teleconsultation, health technology Ghana 30,200 PubMed digital health, ehealth[MeSH Terms], mHealth, m-Health, telemedicine[MeSH Terms], telehealth[MeSH Terms], telenursing[MeSH Terms], electronic health records[MeSH Terms], mobile health[MeSH Terms], mobile-based care, teleconsultation[MeSH Terms], health technology[MeSH Terms] Ghana 353 The Lens digital health, ehealth, electronic health records, mHealth, m-Health, mobile health, mobile-based care, telemedicine, telehealth, telenursing, teleconsultation, health technology Ghana 28,000 ProQuest digital health, ehealth, mHealth, m-health, mobile health, Electronic Health Records, Telemedicine, telehealth, health technologies Ghana 825,613 3.7.2 Selection Process The online specialized systematic review website, Rayyan, was employed to manage the review. Rayyan enables multiple reviewers to independently screen records, it displays conflicts and tracks the number of papers excluded and reason for exclusion at each phase of the systematic review (Ouzzani et al., 2016). Two reviewers independently screened record titles and abstracts based on the eligibility criteria. Where there was any disagreement or ambiguity, a third reviewer assessed the relevant records and consensus was reached on eligibility through discussion, and, where appropriate, retrieval and review of the full-text document. Studies were excluded when access to 31 full-text articles were not available, even after having attempted to contact the corresponding author by email. The reasons for rejecting papers at each stage were be recorded. 3.7.3 Search results This systematic review followed a comprehensive search and selection process, as illustrated in the PRISMA flow diagram (Figure 3.1). The PRISMA flow diagram effectively illustrates the systematic and thorough nature of the study selection process, ensuring that the most relevant and high-quality studies were included in the final review. The initial search of databases yielded a total of 884,166 studies, demonstrating the broad scope of the initial search strategy. The screening process involved several steps. From the initial pool of 884,166 studies, 560 duplicates were identified and removed, leaving 883,606 unique records for further screening. A thorough review of titles and abstracts led to the exclusion of 883,392 studies. These were excluded based on predefined criteria that deemed them irrelevant to the review's objectives. The remaining 214 studies were assessed for eligibility through full-text review. During this phase, an additional 185 studies were excluded for various reasons, including insufficient detail in describing the digital health intervention, not being peer-reviewed, inaccessibility of full texts, lack of relevance to the review objectives, and absence of reported intervention outcomes. After the rigorous screening and assessment process, a total of 29 studies met all eligibility criteria and were included in the final review. These studies comprised 17 quantitative studies, 8 qualitative studies, 1 mixed-method study, and 3 descriptive articles. 32 This final set of 29 studies forms the basis for the in-depth analysis and synthesis of findings in this systematic review. The varied range of study types included allows for a comprehensive examination of digital health interventions in Ghana from multiple methodological perspectives. Figure 3.1: PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only 3.7.4 Data Extraction A structured data extraction form to capture information from the relevant records was developed in Microsoft Excel 2021. Consistent with recommendations for best practice for systematic reviews of interventions (Hoffmann et al., 2017), the data extraction template collected 33 information relevant to: study details (country of study, setting/context); study design, characteristics of study populations (PICOS), and limitations and strengths of digital health interventions; duration of intervention(s). The data extraction form was shared and allowed both reviewers to extract data independently and enabled comparisons between reviewers. 3.8 Pre-testing Before full-scale data extraction, the research team conducted a thorough pretesting of the data extraction forms. This crucial step ensured the forms' reliability, consistency, and ability to capture all relevant information accurately. A sample of 5 different studies from the initial search results were used for this process. Two independent reviewers extracted data from these studies using the draft forms. The results were compared to identify any discrepancies, ambiguities, or missing elements in the forms. Based on this feedback, the forms were refined and adjusted as necessary. 3.9 Data Handling This section delineates the procedures and protocols that were used to manage, document, and protect the data used in this study. The section is structured into two key subsections: "Management and Documentation of Search Results" and "Confidentiality and Privacy," each offering a transparent account of the prospective data handling process. 3.9.1 Management and Documentation of Search Results All references from the electronic searches were imported into Endnote reference management software, where duplicates were identified and automatically removed. A manual revision was done for verification. This software was also used to manage the inclusion and exclusion process. Each included and excluded study was documented with reasons for exclusion. 34 For further screening and collaboration, the references were imported into Rayyan. Rayyan was used to manage the flow of articles within the review, facilitate blinded screening, tagging, and categorizing of studies. The complete search strategy for each database has been included in table 3.7 to ensure transparency and reproducibility. This included the search terms used and the number of results returned for each term or combination of terms. 3.9.2 Confidentiality and Privacy All data collected during the review process, including study records, extracted data, and any other related documents, were securely stored in password-protected electronic folder accessible only to authorized members of the review team. While individual participant confidentiality is not a primary concern in systematic reviews, measures were taken to anonymize and remove personal identifying information from the data extraction forms to maintain privacy. Regular backups of all data were maintained to prevent data loss. Additionally, all steps involved in data handling have been documented to ensure transparency and reproducibility, in alignment with PRISMA guidelines. The data will be retained for a period of 5 years after the completion of the review, in accordance with institutional policies and relevant regulations, providing sufficient time for reference in the publication process. 3.10 Quality Appraisal As appropriate to the study design, methodological quality assessment frameworks including an adapted version of the Critical Appraisal Skills Programme (CASP) Qualitative tool (CASP-UK, no date), a 14-item “Standard Quality Assessment Checklist for Quantitative Studies” (Duden, Gersdorf and Stengler, 2022), CRAAP test (Esparrago-Kalidas, 2021), and the Mixed Method Appraisal Tool (MMAT) (Pace et al., 2012) were used to evaluate the quality of included studies. 35 The CASP was employed to evaluate the 17 qualitative studies in the review. This 10-item checklist was systematically applied to each study, with responses recorded as "Yes," "No," or "Can't Tell" for each criterion. The cumulative scores, out of a possible 10, provided an overall quality assessment for each study. Those meeting all 10 criteria were deemed of the highest quality, while studies meeting 9 out of 10 were still considered high quality but with minor limitations. The CASP checklist facilitated a thorough examination of key aspects of qualitative research, including clarity of aims, methodological appropriateness, recruitment strategies, data collection methods, researcher-participant relationships, ethical considerations, analytical rigor, clarity of findings, and the overall value of the research. For the evaluation of the 9 quantitative studies, the Standard Quality Assessment Checklist for Quantitative Studies was utilized. This 14-item checklist was applied to each study, with responses recorded as "Yes," "No," "Partial," or "N/A" (Not Applicable) for each applicable criterion. The overall quality of each study was determined by tallying these responses against the total number of applicable criteria. Studies meeting all applicable criteria were considered to be of the highest quality, while those with "Partial" or "No" responses in certain areas were noted to have specific limitations. This checklist assessed various aspects of quantitative research, including clarity of objectives, appropriateness of study design, subject description, outcome measures, sample size, analytic methods, reporting of results, and support for conclusions. The CRAAP test was employed to assess the quality of 3 descriptive studies included in the review. Each study was evaluated on the five CRAAP criteria, with scores ranging from 1 to 5 assigned for each criterion. An overall score out of 5 was then calculated by averaging the scores across all criteria. Studies scoring above 3.8 were considered to demonstrate good overall quality and 36 credibility. This test was particularly valuable for assessing the overall credibility and relevance of information sources in descriptive studies that may not adhere to strict research methodologies. The Mixed Methods Appraisal Tool (MMAT) was used to evaluate the single mixed methods study in the review. The study was assessed against all applicable criteria in the tool, with responses recorded as "Yes," "No," or "Can't Tell." The overall quality was determined based on the number of criteria met, with particular attention paid to the integration of qualitative and quantitative components. In all cases, two reviewers independently applied these tools to each study, and any disagreements were resolved through discussion or consultation with a third reviewer. This process ensured a rigorous and consistent approach to quality assessment across all included studies. 3.11 Data Analysis As this review includes studies with large heterogeneity in interventions and measures, a statistical analysis was inappropriate (Campbell et al., 2019). A thematic synthesis was employed to describe the outcomes of evidence for each study. Thematic analysis was employed to identify and explore themes aligned with each study objective. The analysis of data extracted from the 29 included articles followed a rigorous thematic analysis approach, facilitated by ATLAS.ti software. This method was chosen for its flexibility and capacity to identify, analyze, and report patterns within data (Maguire and Delahunt, 2017). The process adhered to the six-phase framework proposed by Braun and Clarke (Maguire and Delahunt, 2017), ensuring a systematic and comprehensive analysis of the strengths and limitations of digital health interventions in Ghana. 37 Initially, the researchers immersed themselves in the data through repeated reading of the articles, noting preliminary ideas and potential coding schemes. This familiarization phase was crucial in developing a holistic understanding of the content and context of the studies. Subsequently, the coding process commenced, utilizing ATLAS.ti to assign codes to relevant excerpts from the articles. The coding was inductive, allowing themes to emerge from the data, and deductive, guided by the research objective of assessing digital health interventions in Ghana. As the coding progressed, related codes were clustered to form potential themes. This iterative process involved constant comparison and refinement, ensuring that the emerging themes accurately represented the coded data and addressed the research question. The themes were then reviewed for coherence and distinctiveness, with some being merged, split, or discarded as necessary. Each theme was subsequently defined and named to capture its essence and relevance to the strengths and limitations of digital health interventions. The PICOS (Population, Intervention, Comparators, Outcomes, Study design) framework was used to analyze each included study as well. Results were reported in accordance with PRISMA guidelines and current recommendations on the description of interventions in systematic reviews. Descriptive analysis was also conducted, including the development of a charts using Excel version 2021 and R software to depict trends in studies and DHIs. 3.12 Dissemination of results The results of this study were shared with Ensign Global College, the Ghana Health Service, and relevant NGOs. Findings from this systematic review are set to be presented at health conferences, seminars and in a peer-reviewed journal. 38 3.13 Ethical Considerations Given the nature of systematic reviews, there was no direct interaction with patients or access to individual patient data. Instead, it involved the analysis of previously published data which mitigated privacy concerns. Confidentiality was maintained by anonymizing data and securely storing all research materials. Findings from included studies were objectively reported exactly as the author(s) reported. Additionally, ethical approval was sought from the Institutional Review Board of Ensign Global College to ensure compliance with ethical research standards. 3.14 Limitations of Study Potential limitations of this systematic review include publication bias, heterogeneity, language and accessibility. The review might have been subject to publication bias, as studies with positive findings are more likely to be published. The diversity in study designs, interventions, and outcome measures might limit the comparability of findings. Also, studies published in languages other than English and those not readily accessible were excluded, which might limit the comprehensiveness of the review. 3.15 Assumptions The review assumes that the included studies accurately reported their findings and that the search strategy was comprehensive enough to capture all relevant studies. 39 CHAPTER 4 4.0 RESULTS 4.1 Introduction This chapter presents the results of this systematic review. The findings are organized to address the specific research questions and objectives outlined in the introduction. The results are drawn from a comprehensive analysis of selected studies, highlighting the characteristics, strengths, and limitations of digital health interventions in the Ghanaian context. This chapter has two key sections: Section 1 – Description of included digital health studies (sub-heading 4.2), and Section 2 – Assessment of Digital Health Interventions in Ghana (sub-headings 4.3, 4.4, and 4.5). 4.2 Description/Characteristics of Included Studies A total of 29 studies were included in this systematic review. These studies were selected based on predefined inclusion and exclusion criteria and further appraised using standard quality assessment tools to ensure the relevance and rigor of the evidence collected. The studies utilized various research designs, including observational studies, qualitative studies, and mixed-methods studies. Figure 4.1 shows the distribution of study designs of included studies. 40 Figure 4.1: Distribution of Study Designs The publication years of these studies ranged from 2004 to 2024 with the majority (17) of them published in the last 5 years, accounting for approximately 58.6%. Refer to Appendix 1.0 for more details. The characteristics of the included studies are summarized in Table 4.1. The included studies were diverse in terms of their population, intervention types, outcomes measured, and study designs. The DHIs described in these papers varied widely across key populations in Ghana including healthcare providers, such as doctors and nurses; patients and caregivers; the general population; and health system administrators. Regarding the outcome component in PICOS, the included studies covered outcomes including usability and acceptability of digital health technologies, impact on healthcare quality and efficiency, user satisfaction (both healthcare providers and patients), health outcomes (like 41 maternal and child health indicators), cost-effectiveness and resource utilization, data quality and completeness, as well as healthcare access and utilization patterns Regarding interventions, the digital health interventions studied in Ghana included telerehabilitation, teleconsultation, health information management systems, Electronic Health Records (EHR), and mobile health (mHealth). With reference to the comparators’ component in the PICOS framework, majority of the studies did not explicitly define comparators, as many were observational or qualitative in nature. However, some studies implicitly compared digital health interventions with standard practices or no intervention scenarios. Key comparators identified were traditional paper-based systems (particularly for EHR studies), standard care without digital support, as well as, pre-intervention baselines. 42 Table 4.1 Characteristics of Included Studies Author/Year (Citation) Title Study Design Purpose/Rationale Target Population Setting Key Findings Conclusion (Paul et al., 2024) Views of Service Users, Their Family or Carers, and Health Care Professionals on Telerehabilitation for People with Neurological Conditions in Ghana: Qualitative Study Qualitative Study Investigate the views of service users, their family or carers, and health care professionals (HCPs) on telerehabilitation for people with neurological conditions in Ghana. Service users with neurological conditions (stroke and Parkinson's disease), their family or carers, and healthcare professionals (speech and language therapists, physiotherapists, occupational therapists, medical staff, nurse, industry representative) Ghana/Komfo Anokye Hospital, Kumasi Participants generally had a positive view of telerehabilitation, favoring a hybrid model that combines initial in- person sessions with subsequent telerehabilitation. They noted benefits such as convenience, lower costs, higher therapy doses, and improved access for remote individuals. However, they also identified challenges including unstable internet connections, the cost of phones and data packages, and low literacy levels. Implementation issues involved ensuring cultural relevance, managing information governance, and increasing familiarity with the platforms used (mainly WhatsApp). Additionally, many participants were unaware of telerehabilitation. Telerehabilitation, especially in a hybrid model, has potential in Ghana for neurological rehabilitation. Challenges such as reliable internet, cultural relevance, and costs need to be addressed. Clinical trials of low-cost, contextualized telerehabilitation interventions are required. (Opoku, Scott and Quentin, 2015) Healthcare Professionals’ Perceptions of the Benefits and Challenges of a Teleconsultation Service in the Amansie- West District of Ghana Qualitative Study To assess healthcare professionals’ perceptions of the benefits and challenges of a teleconsultation service and identify possible areas for improvement Community health nurses (CHNs) and teleconsultation center (TCC) healthcare professionals Amansie-West District, Ghana The teleconsultation service improved the quality of care at health centers, reducing the need for patient referrals to the district hospital. Practical challenges included inadequate information over the phone, delays in responding to calls, and additional workload for teleconsultation staff. Teleconsultation services can enhance the quality of care in rural communities but face operational challenges that need to be addressed to ensure sustainability. Adequate training and workload management are essential. (Okyere Boadu et al., 2024) Healthcare providers' perception towards utilization of health information applications and its associated factors in healthcare delivery in health facilities in Cape Coast Metropolis, Ghana Descriptive cross- sectional study To investigate healthcare professionals' perceptions of health information applications and their associated factors in Cape Coast Metropolis health facilities Healthcare professionals Ghana (Cape Coast Metropolis) Barriers included insufficient computers, frequent system downtime, low system performance, and inadequate staff training. Bivariate regression analysis indicates that education, work experience, profession, and IT training significantly influence attitudes towards IT adoption. While healthcare professionals in the Cape Coast Metropolis acknowledge the moderate benefits of IT in healthcare, they encounter significant barriers such as inadequate resources and insufficient training. Therefore, targeted interventions and policies are essential to enhance IT utilization and maximize its potential benefits in this region. (Mensah, Boadu, et al., 2023) Electronic health records post- implementation challenges in selected hospitals: A qualitative study in the Central Qualitative study To explore post-implementation challenges affecting the deployment of EHRs and their use in selected health facilities in Ghana Health workers and facility management members using EHR systems in two selected hospitals Ghana (Central Region) Key challenges identified: 1) Lack of technical support, 2) Inadequate equipment, 3) Unfriendly software design, 4) Poor user-interface and workflow issues, 5) Unreliable internet/network connectivity, 6) While EHR post-implementation challenges facing health facilities are surmountable, managerial sup