The role of digital health in making progress toward Sustainable Development Goal (SDG) 3 in conflict-affected populations

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International Journal of Medical Informatics journal homepage: www.elsevier.com/locate/ijmedinf

The role of digital health in making progress toward Sustainable Development Goal (SDG) 3 in conflict-affected populations☆ ⁎

Yara M. Asia, , Cynthia Williamsb a b

Department of Health Management and Informatics, College of Health and Public Affairs, University of Central Florida, Orlando, FL, United States Department of Public Health, Brooks College of Health, University of North Florida, Jacksonville, FL, United States

A R T I C L E I N F O

A B S T R A C T

Keywords: Digital health Conflict Fragile states SDGs Health Development

Purpose: The progress of the Millennium Development Goals (MDGs) shows that sustained global action can achieve success. Despite the unprecedented achievements in health and education, more than one billion people, many of them in conflict-affected areas, were unable to reap the benefits of the MDG gains. The recently developed Sustainable Development Goals (SDGs) are even more ambitious then their predecessor. SDG 3 prioritizes health and well-being for all ages in specific areas such as maternal mortality, communicable diseases, mental health, and healthcare workforce. However, without a shift in the approach used for conflict-affected areas, the world’s most vulnerable people risk being left behind in global development yet again. We must engage in meaningful discussions about employing innovative strategies to address health challenges fragile, low-resource, and often remote settings. In this paper, we will argue that to meet the ambitious health goals of SDG 3, digital health can help to bridge healthcare gaps in conflict-affected areas. Methods: First, we describe the health needs of populations in conflict-affected environments, and how they overlap with the SDG 3 targets. Secondly, we discuss how digital health can address the unique needs of conflictaffected areas. Finally, we evaluate the various challenges in deploying digital technologies in fragile environments, and discuss potential policy solutions. Discussion: Persons in conflict-affected areas may benefit from the diffusive nature of digital health tools. Innovations using cellular technology or cloud-based solutions overcome physical barriers. Additionally, many of the targets of SDG 3 could see significant progress if efficacious education and outreach efforts were supported, and digital health in the form of mHealth and telehealth offers a relatively low-resource platform for these initiatives. Lastly, lack of data collection, especially in conflict-affected or otherwise fragile states, was one of the primary limitations of the MDGs. Greater investment in data collection efforts, supported by digital health technologies, is necessary if SDG 3 targets are to be measured and progress assessed. Standardized EMR systems as well as context-specific data warehousing efforts will assist in collecting and managing accurate data. Stakeholders such as patients, providers, and NGOs, must be proactive and collaborative in their efforts for continuous progress toward SDG 3. Digital health can assist in these inter-organizational communication efforts. Conclusion: The SDGS are complex, ambitious, and comprehensive; even in the most stable environments, achieving full completion towards every goal will be difficult, and in conflict-affected environments, this challenge is much greater. By engaging in a collaborative framework and using the appropriate digital health tools, we can support humanitarian efforts to realize sustained progress in SDG 3 outcomes.

1. Introduction To bring progress to the world’s development targets, the United Nations (UN) has twice agreed to a specific agenda to be achieved by all 189-member states. The first agreement was the Millennium Development Goals (MDGs) which were set for 2000–2015; the second agreement was the Sustainable Development Goals (SDGs), the current

framework which is for 2015–2030. The MDGs were successful in achieving many of their targets. Estimates suggest that more than 21 million additional lives were saved during this period [50]. However, even early in the MDG period, reports warned that ‘the MDGs cannot be achieved without more progress in fragile states’. Early data suggested that when compared to other low- and middle-income countries (LMIC), fragile states had significantly worse outcomes [28]. At the

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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Corresponding author. E-mail addresses: [email protected] (Y.M. Asi), [email protected] (C. Williams).

http://dx.doi.org/10.1016/j.ijmedinf.2017.11.003 Received 15 April 2017; Received in revised form 30 October 2017; Accepted 4 November 2017 1386-5056/ © 2017 Elsevier B.V. All rights reserved.

Please cite this article as: Asi, Y.M., International Journal of Medical Informatics (2017), http://dx.doi.org/10.1016/j.ijmedinf.2017.11.003

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physical trauma of living in a fragile state is further exacerbated by low immunity to diseases, lack of vaccinations, and overcrowding. The spread of infectious disease is intensified by war as the public health infrastructure and sanitation services collapse and large groups of people move and shelter together, such as the current unprecedented cholera outbreak in Yemen [85]. Cases of tuberculosis in Jordan, Lebanon, and Egypt have spiked as those countries started admitting untreated Syrian refugees [23]. Since 2013, areas that were once polio free have become areas where the incidence of polio is notable due to the movement of displaced persons who carry the disease with them. The health and well-being of women and children are also adversely affected. In 2015, almost 6 million children 5 or younger died of mostly preventable conditions. In some conflict-affected states, such as Syria, Nigeria, and the Democratic Republic of Congo, reports suggested that pregnant women were specifically targeted by militias which prevented them from seeking medical care [5]. Exposure to armed conflict, coupled with the daily stressors of life, can lead to various forms and levels of mental distress [52]. Mental health disorders are rapidly increasing in conflict-ridden areas. Elevated levels of generalized anxiety disorder, post-traumatic stress disorder (PTSD), depression, and other mental health issues are found in war-affected populations [20,65,78]. Mental health injuries perpetuate the difficulty of living in the war environment, such as the ability to attend to basic health needs [25]. War zones face unique environmental challenges that diminish health. Ammunition combustion releases toxins into the environment and military bases themselves can contribute significant amounts of pollutants. Research suggests that these emissions can lead to birth defects in children [68]. Health and well-being is further exasperated by the lack of access and shortage of health workers. The shortages in the healthcare workforce are one of the largest issues in war-affected communities. The negative economic and social effects lead to healthcare workers fleeing to safer places. Workers who do stay suffer from the traumas of war. Security analyses demonstrate that acute attacks are not unusual on healthcare facilities, patients and workers, threatening efforts to treat preventable diseases [1,4]. In 2013, 251 separate attacks killed 155 aid workers, wounded 171 more, and 134 were kidnapped, representing a 66% rise in worker victims from 2012 [79]. These fatal attacks not only affect healthcare workers and their loved ones, but also disrupt the delivery of healthcare services. Aside from simply not having nearby facilities with trained personnel and adequate resources, authorities or security forces may impede or deny access to healthcare services to the wounded or ill [42].

Table 1 Abbreviated Themes of SDG Targets. 3.1 Maternal mortality 3.2 Neonatal and child mortality 3.3 Communicable diseases 3.4 NCDs and mental health/well-being 3.5 Substance abuse 3.6 Road traffic accidents 3.7 Reproductive health 3.8 Universal health coverage and access to medicines 3.9 Pollution and contamination 3.a Tobacco control 3.b Research and development of vaccines and medicines 3.c Health financing and health workforce 3.d Management of national and global health risks

culmination of the MDGs period, a UN report [75] found that “conflicts remain the biggest threat to human development”, and several development indicators worsened in fragile states (2015). While state fragility consists of multiple dimensions and there are several definitions of this term, for the purposes of this paper, we will use the constructs “fragile” and “conflict-affected” interchangeably [81]. The 17 SDGs were enacted to continue the progress of the MDGs. SDG 3 aims to “ensure healthy lives and promote well-being for all at all ages” [84] with several specific targets toward this aim (see Table 1). However, war and political instability have negative effects on the healthcare system, and the casualties of war extend far past the battlefield [58]. As a social determinant of health, conflict significantly contributes to health inequity by decreasing the quality and delivery of care throughout the entire system [17]. For example, in Syria, reports show that more civilians died from healthcare complications than as a direct result of war [74]. The International Committee of the Red Cross (ICRC) argues that one of the largest, yet least appreciated, humanitarian crises of today is insecurity due to conflict and violence [54]. The SDGs challenge the global community to reconsider traditional approaches to health care delivery models. Traditional on-the-ground health facilities, with access to resources and an adequate workforce, are rare in conflict-affected environments, especially those with active violence and high political instability. With estimates that almost 50% of the world’s poorest people are expected to live in conflict-affected areas by 2030 [82], it is evident that to achieve the goals of SDG 3, policymakers and practitioners must be willing to rethink healthcare delivery. The intersection of medicine and technology holds potential to leverage innovative and relatively low-cost platforms in fragile areas to strengthen global and local capacities. In order to “ensure healthy lives and promote well-being for all at all ages,” low income countries must develop some level of independent capacity [22]. Such capacity must be sustainable over geographic barriers and maintain relative stability during times of conflict. Digital health technologies can support access to the internet, the individual’s health and non-health data, and data about the environment, all of which are needed to support global health goals [19]. Digital health technologies, including telemedicine, electronic medical records (EMRs), wireless health devices (wearables), mobile health (mHealth), and innovative software applications, have the potential to revolutionize fragile states. In this descriptive analysis, we argue that an innovative approach is needed to meet the SDG 3 health targets in conflict-affected populations. First, we describe the health needs of populations in conflict-affected environments, and how they overlap with the SDG 3 targets. Secondly, we discuss how digital health can address the unique needs of conflict-affected areas. Finally, we evaluate the various challenges in deploying digital technologies in fragile environments, and discuss potential policy solutions.

3. Digital health applications in conflict-affected environments Digital health has revolutionized the healthcare landscape. Globally, digital health was a $60.8 billion market in 2013, and is expected to nearly quadruple by 2020. It is estimated that by 2018, half of the 3.4 billion mobile phone users worldwide will have used a healthrelated phone application (app). Globally, telemedicine use increased 315% from 2013 to 2014 [27], and mHealth applications are expanding, such as PTSD Coach, which was downloaded over 243,000 times in 96 countries [66]. Digital health can overcome geographic barriers [71]. For example, in the Konobo population, where Kentoffio et al. [43] found that 73% of women surveyed were at least a two hour walk from the nearest clinic, digital tools can mitigate these obstacles. In Table 2, we summarize the potential of digital health adoption on health outcomes in fragile states. 3.1. Telemedicine

2. The health needs of conflict-affected environments and SDG 3

Telemedicine via remote monitoring can provide quality access in areas where workforce safety is compromised or where shortages exist due to lack of training and education. Remote access to specialists expands the reach of services such as physicians trained in infectious

Efforts to reach the SDG 3 goals must consider the special physical, mental and environmental challenges in conflict-affected areas. The 2

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Table 2 Adoption of Digital Health in Conflict-Affected Populations. From

To

Outcomes

Geographically-based care Manual recordkeeping or no data collection Health and technology illiteracy or mistrust

Patient-centered care Collaborative standardized electronic medical records Health and technology literacy and confidence

Improved access to quality care Interorganizational/professional cooperation with accurate data Self-care management; Transparency; Stakeholder support

areas of impending decline in the public health infrastructure. Vaccination data in coordination with geographic information systems could detect areas of low vaccinations. Interorganizational and interprofessional collaborations can enhance data integrity and support epidemiological tracking of health outcomes. Establishing a basic EMR infrastructure that is flexible for future growth could be a significant step forward in disease surveillance and quality improvement. Proper data collection strengthens coordination efforts between donors and aid distribution workers, which are traditionally poorly handled in fragile contexts and lead to wasted resources and mistrust [14]. Streamlining data collection efforts among different agencies and donors can standardize reporting requirements and data warehousing to utilize resources more efficiently [67]. A reputable global body, such as the WHO, should engage in crafting digital health best practices for conflict areas to oversee services, ensure security, and maintain privacy. Due to the transient nature of war-affect populations, the WHO can also recommend standards for interoperability between systems.

disease management [8]. Patients without access to cardiologists can use a Kardia Mobile device, which sticks to the back of a phone, to take an EKG in 30 s, or use the Duo, a digital stethoscope that collects EKG readings and heart sounds that sends data to a physician. The Aeris device is a portable spirometer that can measure asthma symptoms and sends data to an app [60]. In the hands of minimally trained on-theground responders, these types of technologies can assist with diagnosing and treating patients without access to specialized providers. Telemedicine is also a method to increase health literacy, via remote training, online modules, and other outreach mechanisms. Promoting health literacy is one of the most significant ways to meet health-related development goals [31], particularly in reducing non-communicable diseases (NCD) [30]. Gains in health literacy afforded by digital health can bolster prevention efforts and avert health crises [63]. Awareness about the risks of smoking, substance abuse, and unsafe cooking habits may decrease prevalence of these practices. Educational outreach about the dangers of risky driving could reduce traffic fatalities. Women and families could be provided culturally appropriate information modules about breastfeeding and caring for an ill child [2]. Additionally, integrating a digital infrastructure into medical education practice may improve health delivery in dynamic environments [18]. Education policies should include cultural trainings, healthcare knowledge, and computer training. Comprehensive approaches to patient care that includes educating providers and supporting them with a digital infrastructure will enhance communication, decision support, and build trust [15,21]. Digital health should be included in post-graduate medical training to ensure that providers are prepared to integrate these technologies into their practice. Telemedicine in the form of web-based mental health services could provide information about stress, depression and other maladies [12]. Telemedicine education and outreach is vital for workers and patients to learn about the diagnosis, treatments and stigma associated with mental health. Reports indicate that approximately 45% of patients attending a health center in Kenya experiencing anxiety and depression were misdiagnosed [10]. Not only does this skill gap lead to poor patient outcomes, but potentially leads to inaccuracies in data reporting for health indicators. In war-affected populations, bolstering skills and trainings are one of the most cost-effective methods available to improve retention of healthcare workers [70]. The disparity between patients and qualified workforce could be overcome by task-shifting to lay healthcare workers, thus increasing the bandwidth of providers. Lay workers could be trained at little expense by using distance learning modules. This process may be expedited in settings where local capacity is weakest by contracting out services to local NGOs, which typically set up initiatives and train staff more efficiently than state ministries of health [57].

3.2.1. Cloud-based systems Cloud computing is gaining momentum due to its potential to revolutionize distributed computing. Cloud-based systems allow for development and operations of web applications. In conflict areas, where the digital infrastructure is inadequate, cloud computing is a cost-effective method which has demonstrated scalability and interoperability [64]. Cloud-based platforms could transfer data to the cloud-based server and store data while internet services are disrupted. Once internet (or Wi-Fi) services are available, patient data is accessible. Not only does this enable providers to track patients across time, the interoperability allows data sharing amongst providers so that patient history is available to providers of host countries. By instituting program dashboards, health outcomes of refugee groups could be monitored and patient performance tracked. A cloud-based EMR system implemented in Kenya in 2013 demonstrated significant improvement in record keeping, a 42% improvement in missing data [35]. Cloudbased EMR systems that can operate on smartphones have been shown to help health professional check patient status, aid in decision making and facilitate workflow [45]. However, challenges such as data security and privacy must be addressed in cloud-based solutions. 3.3. Mobile health (mHealth) The proliferation of mobile phones, even in regions where other technological development is lacking, has the potential to revolutionize healthcare delivery. More than 95% of the global population has access to at least a 2G cellular network [37]. Using mobile health apps, trained medical professionals can communicate to on-the-ground responders, enabling care to reach those who do not have full freedom of movement due to active violence, checkpoints, and other barriers. The most basic mHealth application can facilitate appointment reminders and other simple tasks. Mobile phone technology was instrumental in quantifying the spread of various diseases such as malaria and Ebola, and mitigating the spread of these contagions [47]. Mobile apps facilitate collection of data on behavioral indicators and results of outreach efforts [24]. Population mapping using existing mHealth data is useful in creating human distribution databases, which aids in assessing public health and navigating unsafe areas [29]. Deployment of mobile phones and solar chargers to low-resource communities by NGOs has allowed them to

3.2. Electronic medical records At the core of digital health is its ability to provide a robust network of communication. Manual recordkeeping and information dissemination methods are insufficient if progress is to be realized in migrant populations. An electronic platform permits collection and maintenance of data in resource-constrained systems that improve interdisciplinary and interagency communication. This encourages increased quality of care, data integrity, and surveillance data in mobile populations. Timely data alerts humanitarian agencies of potential outbreaks and 3

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resources needed for training (one mannequin used for medical training can run upwards of $50,000), or who may need additional training for highly stressful and dangerous environments. Initiatives such as Oculus’ VR for Good are deploying prototypes of such systems in medical schools across the US, and the utility for conflict-affected areas is evident [69].

conduct surveys and interviews frequently to monitor health and wellbeing, as well as track displaced persons and monitor conditions such as waiting times at health facilities [83]. Mobile technology extends the reach of mental health services. Social networking platforms and peer-to-peer mHealth applications may facilitate virtual support groups to increase community resilience and agility in response time. Social networking can be used for alerting people of impending violence, reuniting families after displacement, or spreading accurate information about public health outreach campaigns [38]. These tools promote self-care management, increase the effectiveness of peer helpers, and support outreach to mutual care organizations during and after war [66]. Short messaging services (SMS) or texting support a decentralized framework and enhances social mobilization in planning for disease control. Diseases targeted by SDG 3 may be alleviated by using SMS to increase communication/education, support behavioral change, and promote patient adherence [26]. SMS opens the door for possibilities in mass outreach efforts; for example, it could be used to alert residents of high pollutant areas where they should not shelter or gather food. SMS may also be used for medication reminders, reporting symptoms, and supporting weight loss or smoking cessation efforts. Lastly, mobile phones may be used for activities that may be especially difficult in areas with high insecurity and corruption, such as paying for health services or verifying that medical products are genuine [48]. While the literature shows the potential of mHealth applications, mobile phone deployment should be considered in light of the potential limitations: illiteracy, lack of collaboration among essential actors, and poor network capacities. Mobile health that uses text-based interventions to provide educational materials is limited by high rates of low literacy (addressed by SDG 4). One hundred three million youth worldwide lack basic literacy skills and 60% of them are women [76]. Funding is often inadequate, so the infrastructure and network capacities are ineffective during emergency monitoring [40]. National acceptance of mHealth application is key; health ministers and officials should collaborate with mobile service providers, healthcare professionals, technologists, and funders for meaningful collaboration.

3.5.2. Open source software The Free/Libre and Open Source Software (FLOSS) community advocates for software that is not just “free” in terms of no cost but is accessible to all; this represents political freedom and responsiveness to local needs. There are several existing applications that would significantly increase access and capacity in fragile states. Large-scale data collection software such as RapidSMS supports several projects that are useful in mobile areas. Liga Inan (Mobile Moms) connects expectant mothers to health providers. MTrac digitizes disease outbreaks and facilitates surveillance reports for medication data [61]. Other platforms such as Ushahidi allow for immediate crisis reporting, triage, and response via SMS, e-mail, apps, and Twitter; CrisisCommons connects tech volunteers to on-the- ground practitioners to coordinate disaster response. FLOSS can also be used in conjunction with other technologies to provide innovative solutions, such as the echOpen project, which seeks to design an open source, low-cost echo-stethoscope paired with a mobile phone. The Raspberry Pi, a pocket-sized computer that costs less than $35, is already being used in low resource areas, primarily in schools. New open source software is allowing this single board computer to be used for tasks like real-time monitoring of vital signs, collection of biometric data, and information management in hospital settings. These low-cost systems allow for large scale deployment for use in a complex public health setting. 4. Barriers to successful digital health deployment and policy recommendations Despite the potentials of digital health, barriers to adoption in the developing world are significant and include computer literacy, costs, data security, and poor technological infrastructure [3]. Healthcare providers in fragile nations may express skepticism at the utility of digital health or be unaware of technological advances in healthcare [16,39]. These barriers are confounded in areas with social/cultural/ organizational barriers and lack of governmental support [7]. War-affected areas are plagued by manual or antiquated technological systems. With deficiencies at the most basic level of the technology infrastructure, these regions do not have the resources to collect and disseminate data. For organizations that collect data, conflicts of interests and data integrity deficits contribute to a reactive system where resource demands cannot be reliably predicted and prioritized to critical areas [67]). Healthcare workers in challenging settings have expressed a desire to engage in digital health technologies to increase access to information and enhance communication. However, awareness is still lacking and infrastructure is not adequate [80]. Education initiatives become more complex in a digital environment where health and computer illiteracy become barriers to marginalized populations who have yet to gain access [13].

3.4. Wireless health devices (Wearables) Wearables are a type of mHealth technology that serve to increase access to primary care and disease management in underserved populations [41]. There is significant potential to gather health related data and patient profiles among adults and children [11]. In efforts to utilize scarce hospital beds, Kosovo uses wearables to provide continuous monitoring to lower the number of older adults using inpatient services [55]. During conflict, wearables provide a method for electronic triage; paper triage is inefficient and cannot provide an updated status of a patient’s health condition [55]. Opportunities exist to monitor vital signs in ambulatory settings with a high degree of accuracy, however a paucity of research exists to validate such findings. Limitations on the use of wireless wearable devices include the weight of the sensor, wireless connectivity, reliability of transmission, security, interoperability of platforms, and limited geographic reach [11,55]. 3.5. Software innovation

4.1. Mass displacement and language barriers 3.5.1. Virtual reality Because of its ability to allow participants to have an immersive alternate experience, the potential for virtual reality technology to work in conflict-affected environments is significant. The International Committee of the Red Cross recently hosted a conference that looked at how different applications of extended reality could be used by humanitarian agencies. The winner, “Happy Children,” was created to rehabilitate amputee children in conflict zones, offering a low-resource solution that would greatly increase well-being [36]. Virtual reality can train personnel who do not have access to traditional facilities or the

One of the outcomes of modern warfare is the significant migration and forced displacement of large populations. The UN estimates that at the end of 2016, there were 65.6 million displaced people; 22.5 million were refugees [77]. However, a surprising number hold on to their cellphones, as a link to their families and as a GPS tool [86]. Digital technologies, such as the Refugee Aid App, connect refugees to nearby services such as: health services water, food, and family reunification centers. Language barriers are a significant obstacle to utilizing services in host countries [33,44]. This often leads to poor health outcomes 4

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of wireless networks is a significant component of any disaster relief. This is supported by microstrip or fractal antennas that are low profile, lightweight, and easy to produce [49]). However, in conflict and postconflict environments existing networks may consume too much electricity, face network congestion due to too much traffic, and experience delays [62]. Wireless networks must be constructed with the assumption that there will be points of failure, and a single broken network link should not be able to bring down an entire network. This necessitates the need for multihop wireless networks with redundant nodes [32]. On-the-fly establishment of multihop wireless access networks (OEMAN) are quick and easy to deploy, and require no additional hardware. This permits virtual access points from their mobile devices and allows for data transfer from patients and providers [53]. Other frameworks, including tree based disaster recovery networks (TDRAN), communication for survivors (COMVIVOR), and hybrid networks with a combination of ad hoc and cellular networks have been proposed and examined in the literature [62], and must be evaluated by policymakers in war zones for their efficiency, efficacy, and feasibility. Tech companies like Google, Facebook, SpaceX, and OneWeb are undergoing initiatives to launch satellites, drones, and balloons to bring connectivity to remote and low-resource environments, yet these projects will require years of investment. Where internet connectivity is unstable, mHealth applications such as Open Data Kit allow for data collection on a mobile device and pushing data to a server. This and other similar applications allow for offline data collection in conflicted areas to support health screenings and timely intervention of care [34].

among migrant populations [6]. Language applications, such as Refugee Speaker developed by Universal Doctor, can assist in providing medical translations for refugees and their providers. 4.2. Stakeholders It is difficult to work with state institutions engaged in conflict to promote social development. Even when state actors are viewed as legitimate, their resources are lacking and inadequate for even short-term crisis management. In the worst cases, the state itself is perpetuating the violence. Policy efforts should offer financial incentives that underscore the need for human and digital resources in the form of sustained implementation [9]. Governments need to shift resources to programs that contribute to measurable, cost effective programs that promote population health, and engage with the broader NGO community to bring targeted programs to their people. Providing incentives to promote digital health adoption and promotion by government agencies is a critical part of a successful partnership. Many of the recommendations proposed in this manuscript are dependent on investment and prioritization by international actors that may be inclined to “allow foreign policy considerations to override humanitarian ones” and lose sight of the need for sustained development in conflict-affected communities. States must be engaged and supported by NGOs, not overtaken by them [72]. Until conflict-affected countries establish political stability and can properly fund ministries of health, much of the innovation and infusion of resources will have to come from international NGOs (INGOs) and private organizations. Health policy should emphasize a digital infrastructure that support internet and mobile technology due to wide diffusive capabilities. This requires standardized interoperability among governments, agencies, and providers. Intergovernmental and interagency collaborations must coalesce around sustainable implementation and development of population health to propel and sustain progress [59]. To this end, the UN established the Sustainable Development Solutions Network (SDSN) in 2012 to implement Agenda 2030, which includes the SDGs. The purpose of this initiative is to facilitate communication, data collection, and overall prioritization of stakeholders invested in the SDG process, from local businesses to national governments [73]. Ultimately, long-term planning on the part of all of these actors, many of whom may be unsure of their position in 2030, is vital to achieve the ambitious SDGs. Standardized data collection and meaningful digital technology implementation could play a vital role in this process.

6. Discussion and future research There is very limited information about use of digital health in waraffected settings. Where it does exist, it is often specific to the boundaries of a specific conflict, and usually only a specific village or area. Generalizability is difficult to assess until more data is gathered. The need to engage technology is founded in its ability to help us better understand complex situations and facilitate humanitarian response efforts, thus investment in informatics evaluation with specified outcomes criteria is needed. Action-oriented research frameworks should integrate design, development, and implementation processes [51]. Evaluative efforts should support data integrity, protection, and security across all stages of the data life cycle. Digital applications should measure adoption, utilization, and satisfaction rates of the end user. Evaluations should measure the efficaciousness of digital tools on workflow and health information exchange to affect change in health outcomes and optimize resource utilization. Trust is a significant factor in sustained development of SDG 3 goals; such trust is built on the evaluative outcomes to ensure effective use of scarce resources. Cost effectiveness analyses should provide specific outcome measures of the cost and benefits received from the use of each digital tool. Outcomes on the economic benefits of digital health technologies on delivering care to conflict-affected populations are a valuable tool in garnering governance and financial support. We must determine effective ways of increasing adoption and engagement of efficacious tools and disseminating successful practices to other regions. Kang et al. (2010) recommend that the efficacy of digital health technology on outcomes should be measured in disability-adjusted life years (DALYs) to be comparable to other health interventions. Lastly, the lack of trust between an oppressive government and victimized people can adversely affect reaching SDG 3 goals. Investigating how these forces can be mitigated is paramount to assuring successful integration and maintenance.

5. Supporting digital health technology infrastructure 5.1. Electricity Poor or destroyed infrastructure, political disputes, and resource limitations provide prime conditions for limited electricity availability in many conflict-affected areas. In some areas, energy is disrupted and civilians lack access to power. To maintain viability for digital health technologies in such contexts, governments and NGOs must be willing to invest in backup energy systems, from conventional diesel generators, to photovoltaic/battery systems, to wind power [56]. Experimental technology can also be considered. A group recently built a battery-free phone by eliminating the need to convert analog signals to digital data and relying instead on converting vibrations in the phone’s microphone or speaker to analog radio signals. The tiny amount of required energy can be harvested from a small solar cell. This phone could make a Skype call, giving potentially lifesaving access to communication in areas with little to no power [46].

7. Conclusion

5.2. Internet and wireless networks

The SDGS represent an ambitious attempt for comprehensive reform in the most difficult environments. These laudable goals can be realized if stakeholders are willing to coalesce around the needs of fragile

The disaster management literature indicates that the deployment 5

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10.14569/IJACSA.2011.020808. [8] E. Armstrong, M. Das, H. Mansoor, R. Babu, P. Isaakidis, Treating drug-resistant tuberculosis in a low-intensity chronic conflict setting in India, Conflict Health 8 (25) (2014), http://dx.doi.org/10.1186/1752-1505-8-25. [9] A. Audet, D. Squires, M. Doty, Where are we on the diffusion curve? Trends and drivers of primary care physicians use of health information technology, Health Serv. Res. 49 (1) (2014) 347–360. [10] A.H. Azad, S.F. Mashhadi, I. Bibi, Mental health challenges and solution in low and middle income countries −a health system perspective, Pak. Armed Forces Med. J. 6 (2015) 843–848. [11] A. Basholli, T. Lagkas, G. Eleftherakis, P. Bath, Wireless monitoring systems for enhancing national health services in developing regions, in: M. Bienkiewicz, C. Verdier, G. Plantier, T. Schultz, A.L.N. Fred, H. Gamboa (Eds.), Proceedings of the International Conference on Health Informatics (BIOSTEC 2014). International Conference on Health Informatics (HEALTHINF 2014), March 3–6, 2014, ESEO, Angers, Loire Valley, France, SciTePress, 2014, pp. 511–516 ISBN 978-989-758010-9. [12] K. Bell, J. Brockway, J. Fann, S. Jain, R. Raman, M. Stein, Concussion treatment after combat-trauma: development of a telephone based: problem solving intervention for service members, Contemp. Clin. Trials 40 (2015) 54–62. [13] A. a. Benavot, Assuring quality education and learning: lessons from education for all, Prospects 46 (1) (2016) 5–14, http://dx.doi.org/10.1007/s11125-016-9386-1. [14] R. Bernardi, F. De Chiara, ICTs and monitoring of MDGs: a case study of Kenya HIV/ AIDS monitoring and evaluation in a donor multi-agency context, Inf. Technol. Dev. 17 (1) (2011) 24–41. [15] K. Biegler, R. Mollica, S. Sim, S. Paigne, D. Nguyen, D. Sorkin, Rationale and study protocol for a multi-component Health Information Technology (HIT) screening tool for depression and post-traumatic stress disorder in the primary care setting, Contemp. Clin. Trials 50 (2016) 66–76. [16] S. Biruk, T. Yilma, M. Andualem, B. Tilahun, Health Professionals’ readiness to implement electronic medical record system at three hospitals in Ethiopia: a cross sectional study, BMC Med. Inform. Decis. Mak. 14 (2014) 115, http://dx.doi.org/ 10.1186/s12911-014-0115-5. [17] O. Bornemisza, M. Ranson, T. Poletti, E. Sondorp, Promoting health equity in conflict-affected fragile states, Social Science & Medicine. Sco. Med. 70 (2010) 80–88. [18] A. Bosco, J. j. Sánchez-Valero, J.M. Sancho-Gil, Teaching practice and ICT in Catalonia: consequences of educational policies, KEDI J. Educ. Policy 13 (2) (2016) 201–220. [19] M. Boman, E. Kruse, Supporting global health goals with information and communications technology, Glob. Health Action 10 (Suppl. 3) (2017) 1321904, http:// dx.doi.org/10.1080/16549716.2017.1321904. [20] D. Canetti, S. Galea, B. Hall, R. Johnson, P. Palmieri, S. Hobfoll, Exposure to prolonged socio-political conflict and the risk of PTSD and depression among Palestinians, Psychiatry 73 (3) (2010) 219–231. [21] N. Chiedozie, Sustainable health: the bedrock for sustainable African development, Health Sci. J. 10 (4) (2016) 1–8. [22] K.L. Clifford, M.H. Zaman, Engineering, global health, and inclusive innovation: focus on partnership, system strengthening, and local impact for SDGs, Glob. Health Action (2016) 91–96. [23] S. Cousins, Experts sound alarm as Syrian crisis fuels spread of tuberculosis, BMJ 349 (2014) g7397. [24] Y. De Montjoye, J. Kendall, C. Kerry, Enabling Humanitarian Use of Mobile Phone Data, Brookings Institution, 2014 Retrieved from: ttps://www.brookings.edu/wpcontent/uploads/2016/07/Montjoye-Kendall-Kerry_Humanitarian-use-of-MobilePhone-Data.pdf. [25] M. De Schryver, S. Vindevogel, A. Rasmussen, A. Cramer, Unpacking constructs: a network approach for studying war exposure, daily stressors and post-traumatic stress disorder, Front. Psychol. 6 (1896) (2015), http://dx.doi.org/10.3389/fpsyg. 2015.01896. [26] C. Deglise, L. Suggs, P. Odermatt, SMS for disease control in developing countries: a systematic review of mobile health applications, J. Telemed. Telecare 18 (2012) 273–281. [27] Deloitte, Global Health Care Outlook: Battling Costs While Improving Care, (2016), p. 2016 Retrieved from: https://www2.deloitte.com/content/dam/Deloitte/global/ Documents/Life-Sciences-Health-Care/gx-lshc-2016-health-care-outlook.pdf. [28] Department for International Development (DFID), Why We Need to Work More Effectively in Fragile States, (2005) Retrieved from: https://www.jica.go.jp/ cdstudy/library/pdf/20071101_11.pdf. [29] P. Deville, C. Linard, S. Martin, M. Gilbert, F. Stevens, A. Gaughan, V. Blondel, A. Tatem, Dynamic population mapping using mobile phone data, Proc. Natl. Acad. Sci. U. S. A. 111 (45) (2014) 15888–15893. [30] ECOSOC, Health literacy and the millennium development goals: United Nations Economic and Social Council (ECOSOC) Regional meeting background paper (abstracted), J. Health Commun. 15 (2010) 211–223. [31] U. Evawoma-Enuku, O. Mabel, C. Enuku, Health literacy and the millennium development goals in Nigeria, Education 131 (1) (2010) 106–112. [32] B. Gautam, K. Wasaki, Deployment of wi-fi network as an emergency survival communication network in Wakkanai, Hokkaido, IEEJ Trans. 10 (s1) (2015) S60–S68. [33] M. Green, Language barriers and health of syrian refugees in Germany, Am. J. Public Health 107 (4) (2017) 486, http://dx.doi.org/10.2105/AJPH.2016.303676 486–486 1p. [34] B. Hashemi, S. Ali, R. Awaad, L. Soudi, L. Housel, S. Sosebee, S.J. Sosebee, Facilitating mental health screening of war-torn populations using mobile applications, Soc. Psychiatry Psychiatric Epidemiol. 52 (1) (2017) 27–33.

populations. In this paper, we addressed how a digital infrastructure can contribute to SDG 3 achievement (see Summary points). These complex systems require intergovernmental/interagency partnerships aligned with the SDG 3 targets. Progress toward SDG 3 will not be possible without progress toward SDG 16, which calls for reducing violence, strengthening the rule of law, targeting corruption, and overall promoting institutions of transparent and accountable global governance free of discrimination, exclusion, and injustice. Using appropriate digital health mechanisms can bolster humanitarian efforts to realize sustained progress in SDG 3 outcomes. Author contributions YA: overall concept and design, oversight of literature review and writing, writing, revisions. CW: paper design, writing, revisions. Conflict of interest None. Summary Points What was already known on the topic:

• Progress towards MDGs was positive, but lacking in conflictaffected areas. • Many of these countries were also missing accurate data about health indicators. • SDGs are more ambitious than MDGs, especially in the healthfocused SDG (target 3). • Digital health is a growing industry worldwide. What this study added to our knowledge:

• Digital health overcomes geographic barriers and supports • •

delivery of health care and health related information to persons living in remote, resource-constrained, and physically insecure conflict-affected populations. Digital health optimizes resource utilization by educating community and lay workers and increasing access to specialty services. Digital health tools in a cloud based environment overcomes the lack of infrastructure in conflict areas to enable health information exchange, epidemiological tracking, and provides data that may enhance research using informatics methodologies.

References [1] D. Abu Sa’Da, F. Duroch, B. Taithe, Attacks on medical missions: overview of a polymorphous reality: the case of M’decins Sans Frontiéres, Int. Rev. Red Cross 95 (June (890)) (2013) 309–330. [2] T. Adam, S. Lim, S. Mehta, Z. Bhutta, H. Fogstad, M. Mathai, J. Zupan, G. Darmstadt, Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries, BMJ 331 (2005) 1107, http://dx.doi.org/10.1136/ bmj.331.7525.1107. [3] S. Ajami, T. Bagheri-Tadi, Barriers for adopting electronic health records (EHRs) by physicians, Acta Inf. Med. 21 (2) (2013) 129–134. [4] L. Akil, H. Ahmad, The recent outbreaks and reemergence of poliovirus in war and conflict-affected areas, Int. J. Infect. Dis. 49 (2016) 40–46. [5] A. Akol, S. Caluwaerts, A. Weeks, Pregnant women in war zones, BMJ (2016) 353, http://dx.doi.org/10.1136/bmj.i2037. [6] U.V. Albrecht, M. Behrends, R. Schmeer, H.K. Matthies, U. von Jan, Usage of multilingual mobile translation applications in clinical settings, JMIR mHealth uHealth 1 (1) (2013). [7] F. Anwar, A. Shamim, Barriers in adoption of health information technology in developing societies, Int. J. Adv. Comput. Sci. Appl. 2 (8) (2011), http://dx.doi.org/

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International Journal of Medical Informatics xxx (xxxx) xxx–xxx

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[60] C. Pogash, Heart and Asthma Monitors? There’s an App for That, August, The New York Times, 2017 Retrieved from: https://www.nytimes.com/2017/08/09/ business/heart-and-asthma-monitors-theres-an-app-for-that.html?mcubz=0. [61] RapidSMS, RapidSMS Projects, (2017) Retrieved by https://www.rapidsms.org/ projects/. [62] N. Ray, A. Turuk, A framework for post-disaster communication using wireless ad hoc networks, Integr. VLSI J. 58 (2017) 274–285. [63] S. Ratzan, Connecting the MDGs and NCDs with digital health, J. Health Commun. 16 (2011) 681–685. [64] B.P. Rimal, E. Choi, I. Lumb, A taxonomy and survey of cloud computing systems, NCM 9 (2009) 44–51. [65] G. Ringdal, K. Ringdal, War experiences and general health among people in Bosnia-Herzegovina and Kosovo, J. Trauma. Stress 29 (1) (2016) 49–55. [66] J. Ruzek, E. Kuhn, B. Jaworski, J. Owen, K. Ramsey, Mobile mental health interventions following war and disaster, Mhealth 2 (2016) 37, http://dx.doi.org/10. 21037/mhealth.2016.08.06. [67] J. Saebo, E. Kossi, O. Titlestad, R. Tohouri, J. Braa, Comparing strategies to integrate health information systems following a data warehouse approach in four countries, Inf. Technol. Dev. 17 (1) (2011) 42–60. [68] M. Savabieasfahani, S. Ali, R. Bacho, O. Savabi, M. Alsabbak, Prenatal metal exposure in the Middle East: imprint of war in deciduous teeth of children, Environ. Monit. Assess. 188 (2016) 505. [69] D. Shafrir, Virtual Reality Is Medical Training’s Next Frontier, July, BuzzFeed News, 2017 Retrieved from: https://www.buzzfeed.com/doree/virtual-reality-is-medicaltrainings-next-frontier. [70] M. Smitz, S. Witter, C. Lemiere, P. Eozenou, T. Lievens, R. Zaman, K. Engelhardt, X. Hou, Understanding health workers' job preferences to improve rural retention in Timor-Leste: findings from a discrete choice experiment, PLoS One 11 (11) (2016) e0165940, http://dx.doi.org/10.1371/journal.pone.0165940. [71] W. Smoyer, P. Embi, S. Moffatt-Bruce, Creating local learning health systems: think globally, act locally, JAMA 316 (23) (2016) 2481–2482. [72] F. Stewart, Conflict and the millennium development goals, J. Hum. Dev. 4 (3) (2003) 325–351. [73] Sustainable Development Solutions Network, Getting Started with the Sustainable Development Goals, (2017) Retrieved from: https://sdg.guide/. [74] M. Trelles, L. Dominguez, K. Tayler-Smith, K. Kisswani, A. Zerboni, T. Vandenborre, S. Dallatomasina, A. Rahmoun, M. Ferir, Providing surgery in a war-torn context: the Médecins Sans Frontières experience in Syria, Conflict Health 9 (2015) 36, http://dx.doi.org/10.1186/s13031-015-0064-3. [75] United Nations (UN), The Millennium Development Goals Report 2015, (2015) Retrieved from: http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/ MDG%202015%20rev%20(July%201).pdf. [76] UN, Goal 4: Ensure Inclusive and Quality Education for All and Promote Lifelong Learning, (2017) Retrieved from: http://www.un.org/sustainabledevelopment/ education/. [77] UN, War, Violence, Persecution Push Displacement to New Unprecedented High, June, (2017) Retrieved from: http://www.unhcr.org/en-us/news/press/2017/6/ 5943ec594/war-violence-persecution-push-displacement-new-unprecedented-high. html. [78] UNHCR, UNHCR Report Shows Health Services for Syrian Refugees Increasingly Overstretched, (2013) Retrieved from: http://www.unhcr.org/en-us/news/ briefing/2013/4/517a58af9/unhcr-report-shows-health-services-syrian-refugeesincreasingly-overstretched.html. [79] USAID, Aid Worker Security Report 2014, (2014) Retrieved from: https://www. humanitarianoutcomes.org/sites/default/files/Aid%20Worker%20Security %20Report%202014.pdf. [80] A. Woodward, M. Fyfe, J. Handuleh, P. Patel, B. Godman, A. Leather, A. Finlayson, Diffusion of e-health innovations in post-conflict settings: a qualitative study on the personal experiences of health workers, Hum. Resour. Health 12 (2014) 22, http:// dx.doi.org/10.1186/1478-4491-12-22. [81] M. Woolcock, Engaging with Fragile and Conflict-Affected States. HKS Working Paper No. RWP 14-038, (2014), http://dx.doi.org/10.2139/ssrn.2493166. [82] World Bank, Helping Countries Navigate a Volatile Environment, (2016) Retrieved from: http://www.worldbank.org/en/topic/fragilityconflictviolence/overview. [83] World Bank, The Tech Revolution That’s Changing How We Measure Poverty, July, (2017) Retrieved from: http://www.worldbank.org/en/news/immersive-story/ 2017/07/26/the-tech-revolution-thats-changing-how-we-measure-poverty. [84] World Health Organization (WHO), SDG 3: Ensure Health Lives and Promote Wellbeing for All at All Ages, (2017) Retrieved from: http://www.who.int/sdg/ targets/en/. [85] World Health Organization (WHO), Cholera Count Reaches 500 000 in Yemen, (2017) Retrieved from: http://www.who.int/mediacentre/news/releases/2017/ cholera-yemen-mark/en/. [86] W. Worley, Syrian Woman Explains Why Refugees Need Smartphones. The Independent, May, (2016) Retrieved from: http://www.independent.co.uk/news/ world/europe/why-do-refugees-have-smartphones-syrian-woman-explainsperfectly-refugee-crisis-a7025356. html.

[35] J. Haskew, G. Ro, K. Turner, D. Kimanga, M. Sirengo, S. Sharif, Implementation of a cloud-based electronic medical record to reduce gaps in the HIV treatment continuum in rural Kenya, PLoS One 10 (8) (2015) e0135361. [36] ICRC, Virtual Reality App to Help Amputee Children Wins Humanitarian Hackathon, July, (2017) Retrieved from: https://www.icrc.org/en/document/ virtual-reality-app-help-amputee-children-wins-humanitarian-hackathon. [37] ITU, ICT Facts & Figs. 2016, (2016) Retrieved from: http://www.itu.int/en/ITU-D/ Statistics/Pages/facts/default.aspx. [38] J. Kahn, J. Yang, J. Kahn, Mobile health needs and opportunities in developing countries, Health Aff. (Millwood) 29 (2) (2010) 252–258. [39] M. Kahouei, J. Zadeh, P. Roghani, The evaluation of the compatibility of electronic patient record (EPR) system with nurses' management needs in a developing country, Int. J. Med. Inf. 84 (4) (2015) 263–270. [40] K. Kallander, J. Tibenderana, O. Akpogheneta, L. Conteh, B. Kirkwood, S. Meek, Mobile health (mHealth) approaches and lessons for increased performance and retention of community health workers in low- and middle-income countries: a review, J. Med. Internet Res. 15 (1) (2013), http://dx.doi.org/10.2196/jmir.2130 e17. [41] B. Kamsu-Foguem, C. Foguem, Telemedicine and mobile health with integrative medicine in developing countries, Health Policy Technol. (2014) 3264–3271, http://dx.doi.org/10.1016/j.hlpt.2014.08.008. [42] E. Keelan, Medical care in Palestine: working in a conflict zone, Ulster Med. J. 85 (1) (2016) 3–7. [43] K. Kentoffio, J.D. Kraemer, T. Griffiths, A. Kenny, R. Panjabi, G.A. Sechler, M.J. Siedner, Charting health system reconstruction in post-war Liberia: a comparison of rural vs. remote healthcare utilization, BMC Health Serv. Res. (2016) 161–169, http://dx.doi.org/10.1186/s12913-016-1709-7. [44] A.A. Kousoulis, M. Ioakeim-Ioannidou, K.P. Economopoulos, Access to health for refugees in Greece: lessons in inequalities, Int. J. Equity Health (2016) 151–153, http://dx.doi.org/10.1186/s12939-016-0409-6. [45] S. Kim, K. Lee, H. Hwang, S. Yoo, Analysis of the factors influencing healthcare professionals’ adoption of mobile electronic medical record (EMR) using the unified theory of acceptance and use of technology (UTAUT) in a tertiary hospital, BMC Med. Inform. Decis. Mak. 16 (12) (2016), http://dx.doi.org/10.1186/s12911-0160249-8. [46] J. Langston, Researchers Have Created a Battery-Free Phone That Is Powered by Sunlight, July, World Economic Forum, 2017 Retrieved from: https://www. weforum.org/agenda/2017/07/dont-worry-about-losing-your-charger-this-phonecan-make-calls-without-a-battery. [47] A. Larocca, R. Visconti, M. Marconi, Malaria diagnosis and mapping with mHealth and geographic information systems (GIS): evidence from Uganda, Malar. J. 15 (520) (2016) 1–12. [48] T. Lewis, C. Synowiec, G. Lagomarsino, J. Schweitzer, E-health in low- and middleincome countries: findings from the Center for Health Market Innovations, Bull. World Health Organ. 90 (2012) 332–340. [49] L. Lizzi, R. Azaro, G. Oliveri, A. Massa, Multiband fractal antenna for wireless communication systems for emergency management, J. Electromagn. Waves Appl. 26 (2012) 1–11. [50] J. McArthur, K. Rasmussen, Change of Pace: Accelerations and Advances During the Millennium Development Goal Era, The Brookings Institution, 2017 Retrieved from: https://www.brookings.edu/wp-content/uploads/2017/01/global_20170111_ change_of_pace.pdf. [51] S. Mesmar, R. Talhouk, C. Akik, P. Olivier, I.H. Elhajj, S. Elbassuoni, et al., The impact of digital technology on health of populations affected by humanitarian crises: recent innovations and current gaps, J. Public Health Policy 37 (2) (2016) 167–200. [52] K. Miller, A. Rasmussen, War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks, Soc. Sci. Med. 70 (2010) 7–16. [53] Q. Minh, K. Nguyen, C. Borcea, S. Yamada, On-the-fly establishment of multihop wireless access networks for disaster recovery, IEEE Commun. Mag. 52 (10) (2014) 60–66. [54] V. Nathanson, Delivering healthcare in situations of conflict or violence, BMJ 343 (2011) 1–2. [55] M. Niswar, A.S. Wijaya, M. Ridwan, A.A. Ilham, R.S. Sadjad, A. Vogel, The design of wearable medical device for triaging disaster casualties in developing countries, In Digital Information Processing and Communications (ICDIPC), 2015 Fifth International Conference on 207–212, IEEE, 2015. [56] J. Olauson, A. Goude, M. Bergkvist, Wind energy converters and photovoltaics for generation of electricity after natural disasters, Geografiska Annaler Ser. A Phys. Geogr. 97 (1) (2015) 9–23. [57] N. Palmer, L. Strong, A. Wali, E. Sondorp, Contracting out health services in fragile states, BMJ 332 (7543) (2006) 718–721. [58] D. Pederson, Political violence, ethnic conflict: and contemporary wars: broad implications for health and social well-being, Soc. Sci. Med. 55 (2002) 175–190. [59] J.B. Perlin, Health information technology interoperability and use for better care and evidence, JAMA 316 (16) (2016) 1667–1668, http://dx.doi.org/10.1001/jama. 2016.12337.

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