Situational Analysis of the impact of COVID-19 pandemic on digital health research initiatives in South Asia

The objective of this paper was to evaluate and compare the quantity, and sustainability of digital health initiatives in the South Asia region pre-pandemic and during the COVID-19 pandemic. The study used a two-step methodology of a) Descriptive analysis of digital health research articles published from 2016-21 from South Asia in terms of stratication of research articles based on diseases and conditions they were developed, geography, tasks wherein the initiative was applied. b) A simple and replicable tool was developed by authors to assess the sustainability of digital health initiatives using Experimental or Observational study designs. The results from descriptive analysis highlight; a) 40% increase in the number of studies report in 2020 when compared to 2019, b) The three most common diseases and conditions wherein substantive digital health research has been focused are Health Systems Strengthening, Ophthalmic Disorders, and COVID-19, c) Remote Consultation, Health Information delivery and Clinical Decision support systems are the top three commonly developed tools. We We conclude that impact on with in the of digital health and in sustainability score of studies published during COVID-19.

from quality assessment Economic Evaluation studies, Qualitative analysis studies were excluded from quality assessment A review of various tools available for assessment of sustainability across various sectors like Manufacturing(8,9), Corporate Management (10), Multisectoral sustainability assessment tool (11), and Program Sustainability Assessment tool(12), Clinical Sustainability Assessment tool(13) developed by Centre for public health systems sciences, Washington University in St. Louis, however, none were found suitable to assess the sustainability of digital health initiatives, thus a simple tool was developed based on the objectives and vision stated in Global Digital Health Strategy 2020-2025 and principles of Public Health Data Standards (14). Two independent raters AM, SB and AS reviewed the eligible studies for three key areas a) Multisectoral and Cross-Sectoral engagement, b) Standards and Interoperability, c) People-Centric Approach. The sustainability score for the study was determined as the average score given by two independent raters. When the studies were strati ed based on study design, Review Articles and Guidelines made up to 65% of all the studies published on digital in past ve years with a maximum number of review articles published in 2020. Figure   2 visualizes the study design and year was a trend.  (24) The studies on remote consultation were most commonly reported, followed by information delivery systems and clinical decision support systems as visualized in Figure 4. Figure 5; Health Information Exchange has been the most common digital tool for the majority of conditions, while all the digital initiatives in Metabolic Disorders (Diabetes), Tobacco and Alcohol Cessation, HIV prevention and Control were found to of Health All the experimental studies pre-pandemic and during pandemic had an active involvement of IT, Data management team while developing the intervention and were either part of the team writing manuscript or dully acknowledged indicating the multisectoral team involved in developing and testing of the initiatives.

Cross-tabulation of Conditions and type of digital tool used is visualized in
10 out of 18 experimental studies involved engagement of multiple sectors, for example, Swendenmen et, al (25) included behavioural scientist, HIV care providers, Front line health workers for the implementation of the study.
All the experimental studies mentioned adherence to data standards like WHO or ICDS classi cation of diseases, however, adherence to data interchange standards like HL7, was not mentioned.
All the experimental studies have either conducted a gap analysis or referred to previously published authors papers on gap analysis, community needs assessment for the development of initiatives All the experimental studies have mentioned feedback collection from end-users, delivery providers and have mentioned changes made in digital initiative upon receiving feedback.
Overall the average sustainability of experimental studies on digital health was 80%, and there was no statistically signi cant difference in overall sustainability score between the studies published Pre-pandemic (85.6%) and During Pandemic (76.4%) (p-value -0.33). Table 3 and Figure 6 presents the study wise assessment score summary and percentage of sustainability scores based on the author's judgement.   Figure 7 presents the study wise assessment score summary and percentage of sustainability scores based on the authors' judgement.  Table 5 and Figure 8 presents the study wise assessment score summary and percentage of sustainability scores based on the authors' judgement. Overall the average sustainability of Diagnostic studies on digital health was 45%, and there was no statistically signi cant difference in overall sustainability score between the studies published Pre-pandemic (45%) and During Pandemic (55%) (p-value 0.5) Table 6 and Figure 8 presents the study wise assessment score summary and percentage of sustainability scores based on the authors' judgement. Overall the average sustainability of Pilot and Development studies on digital health was 65%, and there was no statistically signi cant difference in overall sustainability score between the studies published Pre-pandemic (56%) and During Pandemic (63%) (p-value 0.28) Table 7 and Figure 9 presents the study wise assessment score summary and percentage of sustainability scores based on the authors judgement The COVID-19 pandemic saw a huge increase in research of digital health initiatives, our study hypothesis was based on the increased number that has affected the sustainability of the research initiatives; and the intrinsic factors of research initiatives like multisectoral involvement, gap analysis, stakeholder engagement.
In this paper, we descriptively analyzed the impact of the COVID-19 pandemic on the volume of research in digital health. To ascertain the sustainability, we searched for standardized tools available for sustainability assessment, however, the tools didn't suit the needs presented in this study. This led to the development of a simple tool for the assessment of sustainability. The assessment of sustainability was undertaken for 87 articles and the tool can determine intrinsic sustainability factors and give summary estimates on how well the authors incorporate sustainability in digital health research.
In our study we found the number of digital health interventions research increased signi cantly during the COVID-19 pandemic, and most authors took initiative to have oversight on the sustainability of their digital health initiatives. Contrary to our hypothesis, the sustainability score of cross-sectional studies was higher for studies published during the COVID-19 pandemic as compared to studies published before the COVID-19 pandemic.
From our study its is clear that choice of digital tool, disease and study design vary highly based on study objectives and research, however, the patterns presented over ve years show higher research interest in Ophthalmic Disorders, Health Systems Strengthening, while Health Information Exchange tools have been exclusively used. The underlying reasons can be further explored and taken up for further research and help derive recommendations at a policy level.

Conclusion And Recommendation
We conclude that the COVID-19 pandemic had a silver lining and it positively impacted Digital health research, with improving the number of research initiatives undertaken from South Asia and with researchers able to develop a long term vision for digital health initiatives.
The momentum and interest in digital health gained due to the COVID-19 pandemic should be sustained postpandemic world and with our sustainability analysis, there is certain con dence about the researchers able to develop a vision to sustain the initiative, much however depends on extrinsic factors like availability of skilled manpower, conducive policy environment, access to internet and hardware amongst target population. Figure 1 Year wise trend in number of publication Sustainability assessment, Experimental studies (What do the three colors represent A legend is needed Figure 7 Sustainability Assessment, Cohort studies Sustainability Assessment, Diagnostic studies Figure 10 Sustainability Assessment, Pilot and Development studies Figure 11