Digital health is considered to be an umbrella term encompassing eHealth and mHealth, as well as emerging and developing computing areas such as artificial intelligence and internet of things that support healthcare [1, 2]. Digital health technologies are widely referred to as ehealth technologies and present new or improved ways of delivering health care, conducting health promotion activities and monitoring public health [2, 3]. The technologies are geared toward meeting the growing demand for healthcare [3, 4]. The human resources required to design, deploy, manage and/or use these technologies in support of healthcare need to be properly equipped with ICT skills [5]. They are categorised as health workforce skills, which include skills, experience, and knowledge to apply eHealth in the management and delivery of care to individuals and health ICT workforce, which include skills for design, building, operating and supporting eHealth services [6]. Thus, a diverse workforce herein referred to as Digital Health Worker, needs to be engaged holistically in order to develop, operate and support the national eHealth environment [6]. This workforce can be drawn from multiple professional backgrounds and diverse service providers [4]such as clinicians, health informatics professionals, IT professionals and professional managers [7], some of which lack the basic ICT skills required for them to fully use the digital tools and technologies at their disposal and to carry out their healthcare responsibilities. It takes the right professionals with the right combination of skills to work together to meet the challenges of obtaining data, make meaning and derive useful decisions from it. The social communication skills of digital natives differ from the type of information exchange required in healthcare [8]. In their study, Ahonen et al [9] pointed to the need for a multi-professional curriculum and a combination of trainable competencies for quality digital health and welfare service development. These are greatly lacking not only in the African region but across the world [10].
Academic institutions have continued to have traditional professional curricula without integrated formal coursework or clinical practice specific to using digital technologies for patient care in the professional curricula [8]. However, they lack the multi-professional requirement for a digital health worker skill in the use of digital technology to support healthcare. Consequently, Barakat et al [4], argue for education and training of healthcare professionals in the latest tools and methods to accelerate acceptance and use of digital technologies to collect, use and share information to support healthcare delivery. In addition, as more digital health technologies evolve health workers need more training to use them.
The term digital technology has also been defined as "… any product that can be used to create, view, distribute, modify, store, retrieve, transmit and receive information electronically in a digital form” [11]. Some of the digital health stakeholders are technology innovators, technology providers, and technology users, etc. The technology innovators provide the digital health tools and technologies for which the technology providers supply and / or provide, such as services to the technology users, who apply them or use them in their day-to-day healthcare services. The users need to participate to some extent in the design process. It should be realised that the technology users exist at all levels of the healthcare planning and service delivery including, strategic, tactical and operational [12]. In the African region, the strategic level consists of the Permanent Secretary at the Ministry of Health, the Director General, Directors, Commissioners, and the Senior Management officials among others; the Tactical Level includes the National eHealth Director / Coordinator / eHealth Focal Person, ICT Manager, Local Government / District Management Team (e.g. District Health Officers), etc; while the Operational Level has Doctors, Nurses, Laboratory technicians, Pharmacy Staff, Data entry clerks, IT administrators, etc. The technology users may use different technologies that require different competencies or may use the same technology with broad functionality but still require different levels of competencies. In addition to their professional knowledge, persons working at these three levels require specialised skills in using digital technologies to support healthcare. In fact, the World Health Organisation (WHO) suggest that training and education programmes will need to ensure that the workforce can use digital technologies proficiently in many settings, whether in the delivery of care (operational level), its management and administration (tactical level), or in health systems planning and management (strategic level) [3]. However, most of the health workforce, especially in the African region, lack core competencies that are required to use digital technologies. Thus, the benefits of digital health are not fully realised. Attaining a competent workforce is strained by limited or lack of capacity to develop and sustain such a workforce. Therefore, a curriculum is required to guide the required training of health workers in order to equip them with required competencies to implement, operate and use ehealth technologies [13]. The curriculum can be tailored to train pre-service or in-service health workers. Furthermore, training modules and online courses are suggested for digital health workers who may be remote from training institutions [3].
According to Lynott et al [14] current health systems training is not standardized and lacks content that may be required to address digital health worker needs. They identified the need for a training model that incorporates almost universal ehealth components like electronic health records. Therefore, there is a need to identify and structure the core competencies that a digital health worker should acquire to effectively use technology in support of healthcare services. In this regard, [15] argued for strengthening training programs for health workers to increase the number of qualified providers and hence improve health service quality.
The African Region Digital Health Situation
Besides the shortage of trained healthcare professionals working in Africa, less than 50% of Africans have access to good health facilities [16]. This situation can be improved by digital health technologies. Digital health can find broad applications in developing countries such as those in the African region, where the healthcare workforce and skills are limited. The healthcare service environment continues to experience challenges in the use of ICTs. However, these innovations are not matched to the requisite health worker usage skills [5]. The required ICT skills are needed and should be matched to appropriate Digital Health applications. These ICT applications include healthcare professional skills in mhealth services such as the use of mobile phones and wireless technology in public health education, supportive diagnostics, remote patient monitoring, data collection, helplines, etc., wearable technology/devices to track patient activities, personalised treatment, specific health issue monitoring, etc., and 3D printing in healthcare to produce a three dimensional solid objects like splints for children, 3D printed skin for burn victims. There are lack of skills among health workers for mHealth, eHealth, telehealth, health information technology, and telemedicine applications as well as wearable technologies, big data and use of artificial intelligence in healthcare [7]. The lack of skills exists also for the design, deployment, and management of digital health systems [5]. In fact, all the reviewed ehealth strategies for countries in the African region identified lack of skilled Digital Health (DH) workforce among the challenges to their ehealth strategic objectives [13, 17–23]. One way to solve these gaps is by way of appropriate training of digital health workers.
Actually, countries across the African region are at different stages of implementation of Digital systems. They have identified the need to train a digital health workforce as one of the key components of their digital health programs [17–21]. The last survey on ehealth conducted in 2015/2016 in the region, showed that 18 out of 33 countries were offering pre-service training in ehealth, while 19 out of 33 countries were implementing ehealth capacity building for in-service health professionals [24]. From this survey, it is clear that countries in the African region lack trained health workers with the capacity to design, deploy and manage ehealth projects and programmes [5, 6]. The lack of well-trained ICT professionals, insufficient awareness and experience in the use of ICTs remain important challenges to ehealth success in a developing country [5, 25]. The problem is aggravated by limited opportunities for education in eHealth with most courses available only at the post-graduate level [19]. For example, Uganda’s ehealth strategy expresses this as a deficit of adequate health informatics skills that need to be addressed [20]. Generally, the African region lacks a standard digital health curriculum to guide the training of the health workforce in the region; this poses a risk for fragmented and uncoordinated digital health skills workforce development. Workforce training are activities planned to make digital health knowledge and skills available through internal expertise, technical cooperation, or the private sector [26]. It includes establishing eHealth education and training programs for the digital health capacity building.
Largely, the above problem can be addressed through a mix of continuing education programmes like in-service training and pre-service training courses embedded in the main training curriculum as previously recommended [27]. Specialized ehealth technology training, short ehealth training programmes or online courses should be provided as part of continuing education for health workers; relevant ICT courses can be introduced in the curricula of all healthcare training institutions [5, 27]. To address the lack of ICT skills among the digital health workforce, ITU’s report on ICT for health recommends that a basic start is the adaption of medical students’ curricula to include more courses about the new advancements of ICTs and eHealth [28]. Moreover one of the recommendations of the WHO World Health Assembly A71 resolution on digital health relates to health workforce development and skills in digital health, i.e. “to build, especially through digital means, capacity for human resources for digital health, as appropriate, across both health and technology sectors, and to communicate areas of specific need to the World Health Organization in order to receive appropriate technology assistance” [29]. Ultimately, to address this gap, some countries in the region such as Kenya, Ghana, Rwanda, South Africa, Uganda and Zambia among others embarked on implementing this resolution through the development of ehealth strategies. For example, Uganda’s ehealth strategy identified the need to ‘develop and enforce an eHealth Curriculum Framework to be followed by different training providers in developing and delivering Health training’[20]. A standardized structure for digital health worker curriculum is expected to produce professionals who can adapt to the fast-changing ehealth technological environment and thus, can work across the board.
According to McNay [30], as summarised in Alunyu et al [31], a curriculum can be considered to be a written plan of a degree programme, a syllabus, a course outline, a course study, a course guide, or a learning package. Thus, the digital health curriculum may be a dedicated bio medical/health informatics degree programme or syllabus [27], a course within medical professional pre-service training programme, a specialised ehealth technology study programme, a learning package for the in-service staff or an online ehealth technology training package which must be properly structured and documented. Whether they are in or outside the school, any planned training is considered part of a curriculum [32]. Consequently, this research paper focused on assessing the digital health (DH) worker learning needs and curriculum competencies in the African region, and to propose a structure for in-service health and ICT professional curriculum for the region. The proposed DH curriculum for the African region should be able to produce workforce both health and ICT that satisfy needs of the priority focus areas for ehealth highlighted in many of the human resource needs identified in the ehealth strategies of African countries. We thus discuss some of the current global DH training programmes with an aim to examine how these can easily be adopted for the African region and/or what adjustments and contextualisation should be made to suit the African region settings.
The rest of the paper is organized into sections that discuss the concept of the digital health worker, required competencies and curriculum; the methodology followed to generate the requirements for the digital health curriculum and guidelines for designing the curriculum; a discussion of the results on digital health training; and proposal of the structure of core competencies for the digital health worker curriculum for the African region as well as the Lesotho in-service (particularly health leaders) digital health worker curriculum for the African region and its validation. The paper concludes with recommendations for future work.
The BioMedical/Health Informatics Training Curriculum
In order to produce professionals with the required competencies to perform particular tasks, formal training institutions have used the model of a training curriculum. A curriculum outlines the what, how, why and when learning should happen, that is, a curriculum presents a structured plan for what contents to be delivered, how they should be delivered, the purpose for such training, and when to attain desired learning outcomes [32]. This learning process involves formal or informal interactions of the instructor (professional person) and the learner, personal initiatives of the learner, and or mentorship of a trainee.
The existing medical training curriculum offers formal and informal aspects of training. Whereas, informal training is unintended, i.e., can take place at any time or anywhere; formal training is guided by a structured curriculum. Although evaluating the quality of informal learning may be difficult, [33] argues that the quality of formal training is dependent on the quality of the curriculum. However, this author suggests that the quality of a curriculum should be judged in relation to the processes of curriculum development, implementation, and evaluation [33]. Therefore, to expect the quality of training from a digital health worker curriculum, the due process must be followed, that is, properly planned, consultative and inclusive development led by curriculum professionals, cyclical and sustainable. In this research, as a benchmark, we reviewed existing digital health curricula or programmes that offer components of Digital Health training to establish a basis for future digital health curriculum for the African region.
Types of Training in the Healthcare Profession
Commonly used modes of health worker training include pre-service training and continuing training [34], which were suggested by Asamoah-Odei, et al [5] as part of the systematic education for health workers in Digital Health. Pre-service training is the formal training provided by the health institution. Pre-service training introduces core skills much earlier to health workers especially during formal training [35]. It is integrated as part of the formal health education curricula. Continuing training embodies in-service training, refresher training, and or supportive supervision [36, 37]. In-service training or refresher training is training received by existing staff after their formal/initial professional training. The purpose of in-service is to acquaint employees with new skills, methods, procedures and or processes required to better their work performance [38]. Although in-service training is considered to be expensive requiring the trainees to leave their work places [35, 36], it is also considered to be very effective in healthcare cycles and has greatly facilitated the transfer to ICT-based work skills and routines among health professionals [39]. In addition, supportive supervision is sometimes recommended for healthcare in cases where help to improve staff work performance is tailored by using supervisory visits as opportunities to improve work knowledge and skills [37]. However, Asamoah-Odei, et al [5] argue that such systematic education must be at the heart of any strategy designed to facilitate ehealth. Therefore, the African region will reap the benefits of continuing training and pre-service training. Accordingly, with the need to develop or adopt diverse digital health training programmes such as the academic institutional DH curriculum, the GEEKS and I-LEAD programmes from the Centres for Disease Control (CDC) proposed learning exchange visits. These would provide support for (i) pre-service training, (ii) conduct of in-service training to acquaint employees with new skills, methods, procedures and / or processes, and (iii) structured supportive supervision and sharing of expertise and experiences by digital health practitioners, hence providing broad learning opportunities for Digital Health workers.
As opposed to other training, healthcare training is very demanding and involves the use of humans as study subjects. Besides, new techniques, methods, procedures, and innovations are being frequently discovered or improved for the detection, treatment, and management of conditions, illness, and diseases that affect humanity [4]. To ensure the quality of service to patients/clients, practitioners need to acquaint themselves with these new innovations. Based on the principal objective of a quality curriculum by Stabback [33], the process of such acquaintance should be embedded as part of the healthcare training curriculum to streamline the development of practitioner’s competencies (knowledge, skills, values, and associated capabilities) that make them professionally productive. Such inclusion is required for the new wave of digital health. If careful steps are taken, it may be suitably included in the in-service training curriculum for healthcare practitioners. This continuing education is crucial for quality improvement in healthcare [40]. In addition, Kyabayinze [41] argue for refresher training of new staff to fill gaps created by the high rate of staff turnover. Professional healthcare training continues throughout the life of a healthcare practitioner. Digital health worker training programmes can complement professional healthcare training to produce a competent digital health workforce. To achieve this, we explore competencies that qualify healthcare workers and discuss the need to impart similar competencies to a digital health worker.
Healthcare Professional Competencies
This research used the CanMEDs framework [42], education model for equipping health professionals (with a focus on in-service personnel) with mHealth skills [8] and the European Digital Competence Framework [11, 43] to discuss the professional competencies required for healthcare personnel / health worker.
The CanMEDS Framework
The CanMEDS framework [42] has been widely used across countries to guide training in the different branches of medical education including nursing education [4]. The framework in supplementary Figure 1. online, stipulates six integrated sets of roles to qualify as a medical expert, which covers the medical knowledge, clinical skills, and professional attitudes in the provision of patient-centered care [42]. The competencies of a medical expert draw from the competencies of the roles of a communicator, collaborator, manager, health advocate, scholar and professional. In we summarise the key competencies for the different roles of a medical expert.
Table 1. Competencies of a Healthcare Professional
Roles
|
Brief Description
|
Competencies
|
Communicator
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· Communicator and a facilitator of the dynamic doctor-patient relationship (before, during & after the medical encounter)
|
· Communication skills to establish rapport & trust
· Facilitation skills for shared decision-making & plan of care
|
Collaborator
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· Working in partnership with others involved in the care of an individual/group
|
· Effective collaboration skills
· Domain knowledge/expertise
|
Manager
|
· Active engagement of all physicians as integral participants in healthcare decision-making
|
· Planning & strategic thinking e.g. in resource allocation
· Problem-solving & Decision-making
|
Health Advocate
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· Use of activities to advance the health and well-being of patients, communities, and populations
|
· Health promotion
· Policy formulation
|
Scholar
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· A lifelong commitment to reflective learning, as well as the creation, dissemination, application, and translation of medical knowledge
|
· Create, disseminate, apply and translate medical knowledge,
· Facilitate the education of their students, patients, colleagues, and others.
|
Professional
|
· Dedication to health care of others
· Mastery of a complex body of knowledge and skills, as well as the art of medicine
|
· Clinical competence
· Code of ethics - appropriate attitudes and behaviors, integrity, altruism, personal well-being, and to the promotion of the public good within their domain
|
In training a digital health worker, we argue that since they provide services that support healthcare, their learning outcomes should be aligned to most of the roles of a medical expert in the CanMEDS framework. In addition, use of Digital Health technologies does not exempt healthcare workers and professionals at all the levels (strategic, tactical, and operational) of the healthcare system from utilizing the competencies developed by the CanMEDS framework. In fact, if properly used, the technologies aid their skills in communication, collaboration, decision-making, clinical competence, and health promotion among others, to advance care and wellbeing for all.
Education Model for Equipping Health Professionals with mHealth Skills
Slovensky et al [8] proposed a model for preparing health professionals (with professional clinical knowledge and skills) in the deployment and use of mHealth interventions. Their model presents five key knowledge areas in the preparation of a health professional to use biomedical and communication technologies including digital communication skills, technology literacy, and usage skills, deploying telehealth products and services, regulatory and compliance issues, and telehealth business case (see supplementary Figure 2 online). In addition, they highlight the need to address organizational issues especially as part of in-service training and collaborations. The organizational context in the African region consists of the country’s health system including both the public and private healthcare institutions. The required skills for a digital health worker at the organization may vary depending on the type of digital technologies adopted by the organization. In addition, as membership to the DH workforce is drawn from different professional backgrounds, with varying skills, they require tailor-made induction or in-service training to prepare them for optimal use of the digital health technologies at work.
Thus, in their model for preparing health professionals (with clinical knowledge and associated technical skills) to deploy mHealth, Slovensky et al [8] identified the following as required core competencies for a digital health worker;
- Digital communication skills are provided to acquaint the health worker in the use of various digital communication technologies in a rapidly changing communication environment. Unlike basic communication skills that can be outlined in a simple document, digital communication is a behavioral skill best learned through the application, feedback, and practice [8] and impacts the encounter in an examination room [14].
- Technology literacy and usage skills are required for the digital health worker to use digital technologies and more so, know when to use technology to support healthcare. Rather than the technologies replacing human function in healthcare, it should complement humans such as in-patient consultation.
- Deploying telehealth products and services requires a proper understanding of the technology in addition to using technology to manage multiple stakeholders, policies and organizational
- The health workers must understand the regulatory and compliance issues since they work with personal information regulated by the legislation. The organizational context such as the African region’s health systems should have patient health information sharing guidelines that the digital health worker needs to learn and follow in addition to any other technology compliance regulations.
- Understanding the telehealth business case is required for a digital health worker to appreciate both the clinical and business perspectives for better outcomes. A proper understanding of the business case can enable the digital health worker to recommend a viable case of digital health intervention for the organization.
The model focuses on professionals with an assumed clinical/professional body of knowledge and skills but lacking some or all of the aforementioned body of knowledge/skills to deploy and use mHealth. In this respect, we recommend the model’s suitability to be applied to the training of in-service healthcare professionals especially in the African region where healthcare professionals lack the required ehealth competencies in addition to low levels of basic ICT skills.
The European Digital Competence Framework
The European digital competency framework [11, 43] highlights the major areas of any digital competence, which we associate with the needed competency for a digital health worker including;
- Competency in information and data literacy enables the digital health worker to identify, locate and retrieve relevant health information in addition to storing and managing them in a digital format.
- Communication and collaboration competency enables the use of ehealth technologies to interact, exchange information, engaging in citizenship, and collaborate netiquette and managing the digital identity of clients.
- Handling of healthcare digital content includes creation and management. Data (clinical, referral, care, patient historical data among others) contributes a greater percentage to the digital content created in a healthcare The need for big data analytics (mining) was previously predicted as important skills for the future (the present) informaticians [44]. Therefore, the present and future digital health worker needs skills in big data analytics including an understanding of how to make improvement and integrate information and content into an existing body of healthcare knowledge while following applicable copyright and licenses (authorization) procedures.
- A digital health worker with privacy and safety skills can appropriately enforce protection of digital devices, personal data, and privacy measures. It also covers health protection and wellbeing in addition to protecting the environment.
- Problem-solving competency allows the digital worker to identify digital technology needs and gaps and creatively use digital technologies to solve technical problems. The digital health worker needs to keep to-date with the digital evolution. In addition, competency in problem-solving includes improving/modifying existing solutions in new problem contexts, troubleshooting complex issues that require ehealth technological innovations or even troubleshooting and fixing problems in the technologies. Unlike the European context where expertise is readily available, in the African context the responsibility to fix minor failures e.g., destination unreachable due to the unpowered access point in a facility setting may belong to the health worker.
These competencies would be suitable for the African region; however, limited health worker ICT literacy and usage skills, and digital communication skills among others, challenge them. In order to bridge such gaps, we integrate competencies from the Education Model for Equipping Health Professionals with mHealth Skills [8] and The European digital competency framework [11, 43] to guide the training of the digital health worker’s branch of medical education as per the CanMEDs framework [42] as recommended by [4] (see supplementary Figure 3 Online).
Furthermore, Mantas et al [27] recommend for developing countries to adapt the required knowledge, skills, and competencies with regard to the level of technology. In this regard, we consider competencies for a digital health worker and categorize them (see supplementary Figure 3 online) according to the roles of the CanMEDS framework for a health professional. These are the key components of the training programme, which may guide the structure of the training programme course outlines. The programme course content is aimed at imparting knowledge/skill to the trainees; hence prepare an all-round digital health worker. We develop upon the three domain areas of methods and technologies for healthcare data processing, medical sciences, and health system organization and informatics as recommended by International Medical Informatics Association as highlighted by [44] to meet the expectations of a digital health worker. These expectations include being a good communicator, a collaborator, a professional, an advocate and a manager; analyst of the big health data generated, protect the security and privacy of health data/information in their care and is able to fix minor failures in the technologies they are using. It should be realized that the required levels of competencies might vary according to the expectations of the work position. Some of the training may only be basic/foundational, intermediary, advanced or even specialized / expert [43].
Although Spiget et al [45] identified the content and the duration of the training programme as major considerations in effective training to increase technology literacy regarding the security of mHealth devices and technologies, we argue that any training programme’s content and duration are key contributors (among others) to the success of such training.