Identifying Potential Populations And Regions For Effective Telemedicine Interventions

Identifying Potential Populations And Regions For Effective Telemedicine Interventions

Prepared by:

Maia Adar, maia@cosimoresearch.com and

Marco Farina, marco.farina@sempertherapeutics.com

May 2024

Funded by:

Hippocrat and ResearchHub Foundation

Abstract 2

Population Summaries 3

Rural Elderly Puerto Ricans 3

People in Middle East Conflict Zones 5

Immigrants in the US 7

India 9

Europe 14

Survey Suggestions 19

Recommended Strategies 19

Potential Questions 19

References 21

Abstract

The purpose of this report is to examine the current state of healthcare access and utilization for five underserved populations: rural elderly Puerto Ricans, people in Middle Eastern conflict zones, immigrants in the US, and more broadly, Indians and Europeans. The selection of these populations was based on an identification process that considered factors such as poverty rates, proportion of older adults, and physicians per capita. Each population was assessed for its most pressing healthcare needs, biggest barriers to access, top diseases and disorders, and the potential for telemedicine to improve healthcare outcomes.

We found that telemedicine has the potential to help many of these populations, particularly the ones with better access to internet and video calling technology. Pressing healthcare needs vary between populations, but diabetes, infectious diseases, and mental health disorders are common issues. In Puerto Rico, chronically ill patients in rural areas may benefit from more frequent remote check-ins. For US immigrants, telemedicine can support privacy and culturally sensitive care. Patients in Middle Eastern conflict zones are difficult to help since access to electricity and the internet are often limited. In India and Europe, telemedicine can help provide access to healthcare in medical deserts and underserved rural populations.

In order to better assess telemedicine potential in these areas, we recommend leveraging indirect methods to gather data, such as conducting key informant interviews, secondary data analysis, and SMS surveys.

This Literature review was funded by Hippocrat and ResearchHub to identify potential populations and regions where Hippocrat’s telemedicine application ‘Hippdoc’ could be effectively utilized. The subsequent research study will involve surveying individuals from the identified populations and regions to validate the demand for and potential impact of telemedicine application.

Population Summaries

Rural Elderly Puerto Ricans

[Section prepared by Maia Adar]

Current State of Healthcare & Biggest Obstacles

The Puerto Rican healthcare system is in poor condition. Puerto Rico receives significantly less funding for its healthcare system than US states. Medicaid assistance (Federal Medicaid Assistance Percentage, “FMAP”) is fixed at 55%, despite states with similar poverty rates receiving 83% of their funding from the US Federal Government [1].

In addition, certain laws decrease the amount the Puerto Rican Government can spend on its own healthcare system [2]. After defaulting on its debt in 2016, the financial oversight board PROMESA installed a 30% reduction to Puerto Rico’s annual health care budget [1]. Consequently, receiving medical treatment in Puerto Rico is significantly more difficult than in the mainland US. In a two-year period (2014 to 2015) alone, the island lost nearly 36% of its primary care providers [1], which has increased the difficulty of seeing specialists, in turn increasing wait times and likelihood for patients to end up in emergency departments. For example, wait times in emergency departments in Puerto Rico are three times the national average – 4:18 to be admitted as an inpatient in the US versus 14:30 in PR [3].

Social and economic conditions have critical direct and indirect impacts on health outcomes for older Puerto Ricans. Around 40% of older adults in Puerto Rico live below the poverty line [4,5]. Of the 78 municipalities in Puerto Rico, 72 are designated as medically underserved areas [1,4].

The overburdening of the healthcare system is in part due to a rapidly aging demographic on the island. In 2017, 26% of the population of Puerto Rico was composed of persons 60 or older, and this metric is expected to rise to 40% by 2050 [4].

High out migration of working-age adults creates strains in the healthcare system by decreasing familial support for the elderly [2,5]. The reduction of immediate family members decreases resources such as transportation to and from appointments, and assistance obtaining prescription medications. However, higher social support also may lead to better health outcomes for Puerto Ricans, like other Hispanic communities due to “familism” [5]. Unreliable electricity and the internet also create barriers to care.

Top Diseases/Disorders

Diabetes & Hypertension: 33.5% of Puerto Rican adults 60 years and older report diabetes, compared to 20.8% in the US. Natural disasters have been associated with disease-related morbidity, which could be due to lack of water and nutritious foods, and increased stress. Incidence of diabetes in Puerto Rico is thought to have increased after Hurricanes Irma and Maria [6]. 66.4% of Puerto Rican adults 60 years and older report hypertension, compared to 62.5% in the US.
Mental Health: Puerto Rican adults 60 years and older report higher rates of depression than the same demographic in the US, 20.3% compared to 15.2% [5]. Outmigration has degraded existing senses of community and family support felt by older adults in Puerto Rico [7]. In turn, this lack of community is associated with negative health outcomes, correlating with poorer self-rated health and diminished quality of life [7]. The aftermath of disasters like hurricane Maria poses great mental health challenges for older adults, who are more than twice as likely to develop PTSD from such events [7,8]. In the population as a whole, suicide rates following the hurricane jumped 29% from the previous year [4]. Considering catastrophic hurricanes are expected to become more likely in coming decades, associated mental health consequences should also be expected to worsen.

Potential for Telemedicine

Telemedicine is well suited to address main health challenges of older Puerto Ricans, from chronic diseases like hypertension and diabetes to mental health issues. With a shortage of healthcare workers, telemedicine may increase the capacity of doctors to see more patients. More frequent check-ins with chronically ill patients could decrease emergency room visits. Furthermore, since 14.4% of elderly Puerto Ricans face at least one difficulty with an activity of daily living (ADL) which complicate arriving at medical appointments [5], telemedicine could alleviate the strain of transportation to and from appointments and long waiting times in doctor’s offices for older patients and their families. However, unstable internet and electricity, and lack of technical knowledge and assistance pose challenges for access of older adults. These barriers are exacerbated by disasters like Hurricane Maria, which is also when services like mental health care may be most needed.

People in Middle East Conflict Zones

[Section prepared by Maia Adar]

Current State of Healthcare & Biggest Obstacles

In the Middle East, ongoing conflict has the biggest impact on both poverty and physician access. Top conflict zones, including Gaza, Syria, and Yemen are most medically underserved. However, it is relatively difficult to access accurate data about the medical challenges that these populations face.

Of these countries, Yemen has historically had the worst stats – fewest hospital beds (7.1 per 10k people), lowest life expectancy (66.6), highest infant mortality rate (4.5%), and fewest doctors (5.25 per 10k people) [9]. Yemen has been undergoing a civil war since 2014 that has led to a massive humanitarian crisis affecting 21 million people, including 11 million children [10]. Only about half of the medical facilities are currently functional, mostly due to extremely inadequate funding [11].

Syria was once a middle-income country with relatively good health indicators, but since their civil war began in 2011, they have also seen massive healthcare collapse. Like in Yemen, only half of medical facilities are functional, and people are dying from treatable diseases due to lack of funding for supplies and medical staff [12]. Another challenge in the areas controlled by ISIS is that they often prohibit female doctors or prevent male doctors from attending female patients [12].

Gaza’s healthcare system is disintegrating from the impact of the Hamas-Israel War. As of current writing (May 8, 2024), the last border crossing has been shut down, and the hospitals are days away from running out of fuel as mediators try to make a ceasefire deal. According to UNICEF’s survey, 90% of children under age two are not getting their nutritional needs met [13]. Even if the war ends soon, it is likely that the effects of this situation will lead to extended medical system distress.

It is difficult to sufficiently emphasize how dire are the medical situations in these regions.

Top Diseases/Disorders

Injury: In conflict zones, injuries resulting from warfare such as bombings and shelling are prevalent. The nature of these injuries often requires immediate and advanced medical intervention, which is frequently unavailable due to damaged infrastructure and limited medical supplies.
Infections: Infection rates are higher in conflict areas due to poor sanitation and overcrowded living conditions. In Gaza, sanitation issues have led to major diarrhea outbreaks and acute respiratory infections [13].
Mental health: Warfare commonly leads to anxiety, distress, and PTSD in both adults and children. Mental health issues are usually treated as a lower priority after the more pressing physical health needs. The psychological toll of war is profound, with long-term impacts on individuals and communities.
Malnutrition: When conflict compromises infrastructure for an extended period, malnutrition becomes widespread. In Yemen, ongoing warfare has resulted in widespread food insecurity, with millions of people, including children, suffering from acute malnutrition [9]. The lack of access to adequate nutrition further exacerbates health issues and increases vulnerability to infections and disease.
Infant Death and Maternal Mortality: High poverty rates combined with limited access to healthcare facilities exacerbate the rates of infant death and maternal mortality, particularly in areas hit hardest by conflict where medical infrastructure is compromised. In Yemen, for instance, the healthcare system's collapse has led to one of the highest infant mortality rates globally [9].

Potential for Telemedicine

It is difficult to provide telemedicine in these areas because the same challenges that cause hospitals to lack fuel, electricity, and resources also make it difficult for individuals to access the internet. Hence, telemedicine opportunities for those who need it most are limited.

Telemedicine is a band-aid solution here unless and until the political and socio-economic situation stabilizes in the region.

Immigrants in the US

[Section prepared by Maia Adar]

Current State of Healthcare & Biggest Obstacles

About 13.6% of the US population are immigrants. The most common country of origin is Mexico (23.7%) followed by India (6.0%) and China (4.7%) [14].

Immigrants and their children face less access to healthcare, higher costs, and less satisfaction than US-born individuals. Those without legal status are often ineligible for government programs and they are more likely to lack health insurance [15]. They may have general mistrust of public institutions. Some are unable to communicate with medical professionals due to language barriers, which leads to miscommunications, reduced patient safety, and increased costs associated with using interpreters [16].

Surprisingly, despite these challenges, immigrant populations in the US generally have better health than native-born Americans (lower mortality, less obesity, lower incidence of some cancers) [17]. This broadly applies to both documented and undocumented immigrants. Although it may seem unexpected, consider the fact that the healthiest people will be the most likely to immigrate in the first place. However, the longer they live in the US, the more their health comes to resemble that of natives [17].

Top Diseases/Disorders

Diabetes: Diabetes is common among immigrants, but rates vary between ethnicities. Immigrants from Mexico/Central America/Caribbean and the Indian subcontinent had the highest prevalence of overweight/obesity (71.5 and 73.4%, respectively)[18]. Weight increases the longer immigrants live in the US [17].
Infectious diseases: US immigrants are more likely than natives to suffer from some infectious diseases, e.g. Tuberculosis and HIV [17,19].
Mental health issues: Immigrants from Asia, Latin America, and Africa use mental health services at lower rates than nonimmigrants [20]. Studies show conflicting evidence on whether immigrants have higher rates of mental health issues [16,19]. This may be because of underreporting, but it’s also possible that they have better mental health upon arrival because they are relieved to have left a difficult situation in their home country.

Potential for Telemedicine

Telemedicine can solve several problems unique to the immigrant population. The language barrier issue can be alleviated by telemedicine platforms that support multiple languages and offer culturally sensitive care. They can have more privacy by avoiding the need to physically travel to a clinic, which is a significant concern for immigrants worried about stigma or legal repercussions.

Additionally, mental health services are a good candidate for telemedicine since they can be managed through conversation, and this is one of the top issues for immigrants. Diabetes can also potentially be treated through telemedicine, for example by virtual consultations to make treatment plans. Infectious diseases would be harder to treat remotely.

India

[Section prepared by Marco Farina]

Current State of Healthcare & Biggest Obstacles

India's population is segmented into major cities, other urban areas, rural areas, and tribal areas, each with distinct characteristics and challenges, particularly in healthcare access and quality [21,22]. Major cities are home to about 10% of the population, have advanced infrastructure but are plagued with overcrowding and pollution [21,22]. About 25% of the urban population lives in slums with limited healthcare access [21,22]. In addition migrants and informal workers (15-20%) face socioeconomic and health care barriers. Other Urban areas account for about 20-25% of the population [21,22]. These areas have better care than rural areas, but less than major cities [21,22]. Elderly people, low income families and disabled individuals face significant challenges to healthcare access. Rural areas comprise about 65-70% of the population [21,22]. This comprises predominantly agricultural workers who have limited healthcare and economic opportunities. Amongst these over 50% are underrepresented groups like women, children and elderly [21,22]. The last but not the lease subgroup is tribal areas representing 8-9% of the population [21,22]. This population is unique, geographically isolated and has reluctance to modern healthcare. Major health issues include malnutrition (40-50% of children) and lack of clean water [21,22].

The structure of India's rural healthcare system can be visualized as a pyramid, with each level representing a tier of healthcare delivery that escalates in complexity and specialization as one moves up the pyramid. Here’s how each tier is positioned within this structure: [23] 1) Base of the Pyramid: ASHA/Community Health Workers - They are first contact points, promoting health awareness and basic services. Generally cover 300-500 people in hilly/tribal areas and 500-1000 in other areas [23]. 2) Next are the Sub-centers which provide preventative and minor curative services, maternal and child health. These cover 3000-5000 people [23]. 3) Third are the Primary Health Centers which are referral units offering broader medical services serving 20000-30000 people [23]. 4) Top of the pyramid are the district hospitals providing the highest level of care treating complex health issues covering 80000 to 120000 people [23].

Top Diseases/Disorders

The Indian government has analyzed disease prevalence and incidence to establish the "Ayushman Bharat" program, aiming for health improvements by 2030. This initiative includes the Pradhan Mantri Jan Arogya Yojana (PMJAY) for health insurance and the creation of Health and Wellness Centers, focusing on quality healthcare for underserved communities. By understanding disease distribution, the program allocates resources to address the most pressing health challenges, enhancing public health outcomes by the decade's end [24,25].

Infectious diseases [26,27,28]. Infectious diseases continue to pose a significant threat to public health in India, with notable diseases such as malaria, tuberculosis, and diarrheal diseases affecting millions. Malaria affects approximately 1 million individuals annually in India, contributing to a considerable portion of the global malaria burden. Tuberculosis remains a major public health issue, with India accounting for about 26% of the global cases, translating to roughly 2.69 million people suffering from this disease each year. Diarrheal Diseases also significantly impact the population, particularly among children, with around 443,832 children under five dying each year due to diarrheal illnesses. Dengue and Chikungunya are frequent during the monsoon season due to the proliferation of mosquito breeding sites.
Chronic Wounds [29,30,31] Wounds significantly burden India's healthcare, particularly in poverty-stricken areas with poor hygiene and nutrition. Chronic wounds affect 15.03 per 1,000 people, and acute wounds, including burns and accidents, have a similar incidence. The government's 2030 target focuses on improving wound care management and prevention to reduce these incidences.
Diabetes [32,33] Diabetes is a major health issue in India, with over 77 million diagnosed cases, making it a global hotspot. This high prevalence strains the healthcare system. To address this, the Indian government aims to prevent and control diabetes by 2030 through enhanced screening programs for early detection, promoting healthier lifestyles and improving access to diabetes management resources like medications and technologies. They are also integrating diabetes education into public health messages.
Chronic Respiratory Diseases [34,35] Chronic respiratory diseases, driven by air pollution and smoking, are a major health issue in India, causing significant morbidity and mortality. Poor air quality from vehicle emissions, industrial discharge, and crop burning affects millions. About 93 million people suffer from these conditions, with 266.8 million tobacco users. The government aims to improve treatment and reduce pollution by 2030 through stricter emissions regulations, cleaner fuels, and better environmental standards. Healthcare initiatives focus on strengthening primary care, training workers, improving medicine availability, and using telemedicine for specialist care access.

Potential for Telemedicine

In India, healthcare distribution is skewed, with 75% of doctors in cities while 75% of the population lives in rural areas, limiting access to basic healthcare for 620 million rural inhabitants. The government's health expenditure is only 0.9% of GDP, with minimal funds for remote areas. Rural health centers lack infrastructure, deterring doctors and causing villagers to incur high costs traveling to urban hospitals. Telemedicine, supported by ISRO, offers a cost-effective solution, connecting super-specialty hospitals with remote areas and providing mobile telemedicine units to improve community health services in rural and tribal regions. [36,37]

Infectious disease [38,39,40,41]: Here are reported major telemedicine projects and initiatives that are being implemented in India to manage and reduce the spread of infectious diseases: a) E-Sanjeevani OPD: India's E-Sanjeevani OPD telemedicine service offers remote outpatient consultations nationwide, essential during COVID-19 and for managing other infectious diseases, eliminating the need for physical travel. b) Swasth Foundation Telemedicine: This telemedicine project enhances rural healthcare access, focusing on infectious diseases. It supports remote diagnosis and management, aiding in infection control in underserved areas. c) Apollo Telehealth Services: one of India's largest telehealth providers, offers teleconsultations for various conditions, including infectious diseases. The service provides remote diagnosis and prescriptions, crucial for areas with limited medical facilities.
Malaria: Telemedicine and e-health solutions enhance malaria surveillance and response, providing scalable strategies that improve remote diagnosis, enhance surveillance capabilities, and support targeted interventions. Embracing these advancements in technology promises significant contributions to malaria control and elimination efforts, ultimately alleviating the burden of this deadly disease on affected populations. a) A study by Mody et al. highlights telemedicine's potential in remote malaria diagnosis, leading to systems like ProMED Mail (PMM). PMM is a global e-health surveillance platform offering insights into disease trends and early outbreak detection. b) The "E-Health Points" program in India uses telemedicine to provide rural communities with essential health services, including malaria diagnostics and treatment. These facilities are equipped with medical equipment and staffed by trained workers who connect with doctors remotely.
Wound care [42,43,44,45,46]: Telemedicine improves patient-specialist communication for wound care via image transfer and video conferencing. Proven safe, accurate, and cost-effective, it effectively manages skin lesions. In India, projects like the Indian Space Research Organization's link remote hospitals to urban centers, enhancing access to care. This network of 382 hospitals offers services like tele-ophthalmology. Studies show a 93.6% agreement in treatment plans compared to direct consultations, demonstrating telemedicine's efficiency and addressing specialist shortages. Additional recognized telemedical wound care projects: a) Swasth Foundation Telemedicine: This initiative focuses on enhancing healthcare access in rural areas, which includes services for wound care management. It provides remote consultations and follow-up care, making it easier for patients with wounds to receive professional advice without traveling. b) Apollo Telehealth Services: Apollo Hospitals Enterprise Limited is an Indian multinational healthcare group headquartered in Chennai. It is the largest for-profit private hospital network in India, with a network of 71 owned and managed hospitals. Apollo's telehealth services include wound care as part of their broader telemedicine offerings. They utilize teleconsultations to assess wound healing, provide care instructions, and monitor the treatment progress of patients. c) E-Sanjeevani OPD: As a part of India's national telemedicine service, E-Sanjeevani also provides services related to wound care. Patients can receive remote consultations from wound care specialists, helping to manage chronic wounds and prevent complications.
Chronic respiratory diseases [47,48,49,50,51,52,53,54]: Chronic Respiratory Diseases (CRDs) are a major public health issue in India, especially in rural and impoverished urban areas. Common CRDs include COPD, asthma, pneumoconiosis, interstitial lung diseases, and pulmonary sarcoidosis, worsened by environmental and occupational hazards. COPD and asthma are the most prevalent and significant causes of non-communicable deaths. Improving healthcare access and education through awareness campaigns and training local healthcare workers is crucial for early detection and management. Telemedicine plays a key role in addressing healthcare disparities, providing expert care and consultations in remote areas. Telemedical projects and companies operating in India in the field of CRDs: a) SEHAT (Social Endeavour for Health and Telemedicine): A government initiative connecting rural health centers with urban hospitals to improve chronic disease management, including CRDs. b) eKincare: Offers teleconsultation services for various chronic diseases, including respiratory conditions. c) Mfine: Utilizes AI to assist in diagnosing and managing respiratory diseases through online consultations. d) Practo: Provides online doctor consultations and digital health records management, helpful for patients with chronic respiratory issues. e) E-Health Points: Facilities that provide access to healthcare services via teleconferencing, focusing on chronic diseases. f) Apollo Telehealth Services g) Swasthgram: Focuses on health education and teleconsultations for rural communities also in the field of CRD.
Diabetes [55,56,57,58,59] In rural India, where 70% of the population lives, diabetes care faces challenges like limited healthcare access and economic constraints. The Chunampet Rural Diabetes Prevention Project (CRDPP), started in 2006, addresses these issues in 42 Tamil Nadu villages. Supported by the World Diabetes Foundation and ISRO, CRDPP uses telemedicine and personalized care for diabetes screening and management. It has reduced the need for urban specialist visits through mass screening, early detection, and comprehensive care. Within a year, CRDPP lowered HbA1c levels by nearly 1% with low-cost drugs, with less than 5% of patients needing referrals, cutting transportation costs and treatment expenses.

Funding sources for Telemedical and healthcare projects

In India, telemedicine funding comes from government initiatives, private sector involvement, and international NGOs. The government has allocated INR102.8 billion for health in the current budget, with the HealthSAT project costing about 1% of this budget (INR600 million to INR1 billion). Each village terminal for audiovisual conferences costs about INR0.5 million. This service saves patients money on travel and accommodation expenses.

NGOs: [60,61,62] NGOs in India tackle social issues like education, healthcare, environmental conservation, and community support, but face funding challenges. Their financial support comes from government grants, international organizations, individual donations, and private companies. Despite diverse funding sources, they struggle with regulatory requirements, transparency needs, and competition for funds. A table in the full report lists the most active NGOs, many of which run multi-sectoral projects.

Rotary International: [463,64,65,66,67] Rotary has funded several projects in the fields of telemedicine and digitalization in healthcare to provide technology, training, and medical expertise to serve patients from rural areas. I have listed some of the programs run by Rotary in India and other Countries (see full report). It is also important to mention that, as an international organization, Rotary allows companies to apply for funding opportunities not only in India but also from other continents such as the USA.

Bollywood world: [68,69] Bollywood actors and producers have tight relationships with the Indian government therefore it is crucial to have access to this world. Many are the Bollywood actors funding healthcare related projects in Indian rural areas. I have reported below some of the most known donations: a) Shah Rukh Khan: through his charitable organization Meer Foundation, b) Salman Khan: Through his NGO Being Human, c) Priyanka Chopra: he is a National Ambassador, d) John Abraham: known for his contributions to Habitat for Humanity, e) Shabana Azmi: Through her NGO Mijwan Welfare Society

Europe

[Section prepared by Marco Farina]

Current State of Healthcare & Biggest Obstacles [70,71,72,73,74,75,76,77]

Medical deserts in Europe arise from socio-economic and demographic challenges, unlike in India where infrastructure deficits and vast rural areas are primary factors. In Europe, rural depopulation and economic disparities are key issues. Younger individuals migrate to urban centers for better opportunities, leaving behind an aging population that struggles to sustain healthcare services. This migration reduces local healthcare demand, making it economically viable for medical professionals to operate in these regions. Additionally, high unemployment and low economic growth hinder the maintenance and investment in healthcare infrastructure.

The main drivers to the formation of medical deserts in Europe are:

a) Rural Depopulation: Many parts of Europe, particularly in Eastern and Southern regions, have seen significant rural depopulation due to urban migration. This exodus has resulted in diminished demand for local services, making healthcare provision less economically viable.

b) Economic Disparities: Regions with weaker economic performance struggle to attract and retain medical professionals. Countries like Greece, Portugal, and parts of Eastern Europe have been particularly affected post-2008 economic crisis, exacerbating healthcare access issues.

c) Policy and Planning Gaps: In some cases, national and regional policies have failed to adequately address healthcare distribution. The lack of foresight in planning and resource allocation can lead to underserved regions becoming medical deserts.

d) Aging Populations: Europe has one of the highest proportions of elderly citizens globally. Regions with a higher average age face increased healthcare demands, often without a corresponding increase in healthcare resources or personnel.

e) Immigration: The continuous influx of immigrants from diverse backgrounds places additional demands on healthcare systems, particularly in regions already facing resource shortages. This challenge is exacerbated in areas where infrastructure is not equipped to handle the increased population, contributing further to the creation of medical deserts.

In Eastern Europe, medical deserts arise from rural depopulation and economic issues. Countries like Romania, Bulgaria, and Hungary face healthcare shortages as younger people move to cities, leaving aging populations with poor access. The 2008 financial crisis further reduced healthcare funding. Targeted health policies are needed to improve access in these underserved areas.

a) Romania: 9 million (45% of the population)

b) Bulgaria: 1.75 million (25% of the population)

c) Hungary: 2.5 million (25% of the population)

In Western Europe, medical deserts occur in inner cities of Paris, London, and Berlin due to socio-economic disparities, and in post-industrial cities like Lille and Essen due to economic downturns and migration of healthcare professionals. Population in these cities is generally several million. About 10-20% of this city population is underrepresented. Remote mountainous areas in Switzerland and France also face geographical barriers to healthcare delivery. These examples show how socio-economic and geographical factors create medical deserts across Western Europe.

In Southern Europe's mountainous regions, such as the Alps and Greece's rugged terrains, medical deserts are prevalent. Challenging geography and seasonal road closures hinder healthcare access and emergency responses. Sparse populations deter healthcare professionals from establishing practices, forcing residents to travel long distances for basic medical care. These factors create and worsen medical deserts in these areas. For example, a) Italy (Alpine Regions): 1.8 million (3% of the population), b) France (Alpine Regions): 2 million (3% of the population), c) Switzerland: 1.5 million in mountainous areas (17% of the population), d) Greece (Mountainous Areas): 2.1 million (20% of the population)

In Europe, displaced populations and refugees contribute to medical deserts, especially in major cities and Southern European entry points like the Greek Islands, Lampedusa, and coastal Spain. These areas face healthcare strains from sudden population surges, overwhelming local resources and creating access issues for both residents and newcomers. Targeted health policies are needed to increase capacity and resources. For example, a) Italy and Greece: over 360,000 arrivals fluctuating annually, b) Germany: Over 2.1 million refugees (6 percent of all refugees globally), c) Spain: over 2.1 million refugees

Top Diseases/Disorders

[78,79,80,81,82,83,84,85]

Under-represented populations in Europe which, as listed before, include elderly people, ethnic minorities, immigrants, and economically disadvantaged groups, face unique health challenges that are exacerbated by socio-economic conditions and limited healthcare access. The most frequent and challenges diseases affecting these people are:

Cardiovascular Diseases (CVDs): Among the leading health issues for under-represented groups, particularly in Eastern Europe, CVDs are prevalent due to factors such as poor diet, limited access to healthcare, and higher rates of smoking and alcohol consumption in these communities.
Diabetes: This disease disproportionately affects minority and migrant populations, often related to lifestyle factors, limited access to healthy food options, and lack of early screening and diagnosis facilities.
Respiratory Diseases: Conditions such as asthma and chronic obstructive pulmonary disease (COPD) are more common among under-represented populations living in urban areas with poor air quality and in housing with inadequate ventilation.
Infectious Diseases: Tuberculosis (TB) and HIV remain a significant concern among these populations, particularly in over-crowded living conditions and among those with compromised access to medical care.
Mental Health Disorders: Stress-related disorders, depression, and anxiety are increasingly recognized in under-represented groups, stemming from social isolation, discrimination, and chronic stress of economic hardships.
Wound care/Dermatology: first cause of amputations with a 50% mortality rate within 5 years, chronic wounds mostly affect elderly and poor people due to lack of hygiene, poor alimentation and are always the results of the presence of other diseases which lead to the formation of wounds. Wounds are very painful and limit patients movement and quality of life.

Potential for Telemedicine

Cardiovascular Diseases (CVDs) [86,87] Telemedicine effectively manages cardiovascular diseases, especially for underserved European populations. Remote monitoring and teleconsultations aid early diagnosis and continuous management of hypertension and heart failure, reducing hospital visits and improving outcomes. Projects like the European Health Telematics Association's initiatives provide timely advice and interventions via real-time data, essential in rural and underserved urban areas. Telemedical Projects in Europe for CVDs include: a) Euroaspire: A telemonitoring project aimed at improving adherence to guidelines among patients with coronary heart disease. b) Cardiolink: An initiative that provides teleconsultations across several European countries, enhancing access to cardiology specialists.
Diabetes [88,89,90,91] Telemedicine applications in diabetes care include remote glucose monitoring and online consultations, which help manage blood sugar levels more effectively. This approach not only enhances patient engagement and education but also significantly improves glycemic control, which is critical for preventing complications. Projects like the DIABTel telemedicine trial and the Sweet Talk text messaging support system have been instrumental in providing ongoing support and management tools to diabetic patients across Europe. Telemedical Projects in Europe for Diabetes include: a) MyDiabetes: Online management tools that provide personalized advice and monitoring for diabetic patients. b) DiaCare: A remote consultation service that connects patients with diabetes specialists for regular follow-ups and education.
Respiratory Diseases [93,93] For respiratory conditions such as COPD and asthma, telemedicine offers tools for remote monitoring and management of symptoms, potentially reducing the severity of episodes and improving daily management. Initiatives like the myAirCoach project utilize mobile technology to monitor and advise asthma patients, facilitating better disease control and reducing emergency visits. Such technologies are particularly beneficial for patients in remote areas or for those with limited mobility. Telemedical Projects in Europe for Respiratory Diseases include: a) Telekat: A project aimed at patients with COPD to monitor health status and provide feedback via telecommunication tools. b) SmartAirway: A mobile app that manages asthma and COPD by tracking symptoms and medication use.
Mental Health Disorders [94,95] Telepsychiatry and online psychological support platforms have become increasingly vital in addressing mental health disorders, offering access to therapy and counseling without the stigma or logistical challenges of in-person visits. Projects like the ICare Prevent (Internet-based treatment for depression and prevention of depression in adolescents and young adults) provide crucial resources, making mental health care more accessible and less stigmatizing. Telemedical Projects in Europe for Mental Health Disorders include: a) ICare Prevent: An online platform offering resources and support for individuals suffering from depression. b) e-mental health project: This initiative provides online mental health services across several European countries, helping to bridge the gap in mental health care access.
Wound Care/ Dermatology [96,97,98,99,100] Telemedicine has improved wound care in Europe, especially for remote patients or those with mobility issues. It enables real-time assessments, monitoring, and treatment adjustments without frequent in-person visits. Patients send images and data to specialists via digital platforms, allowing timely interventions and reducing complications. This approach enhances care quality, speeds up healing, and improves patient satisfaction. Telemedicine also offers instant access to educational materials and support, empowering patients in managing their chronic wounds. Telemedical Projects in Europe for Wound Care include: a) Dedalus/Omnidermal Biomedics: usage of the WoundViewer device for remote diagnostic and monitoring of patients fully integrated within the digital folder of hospitals in rural areas in the north region of Italy (Piedmont) b) Bootcare by Telemedicine: This project focuses on improving wound care through telemedicine by creating a web-based platform for storing and sharing wound records. This system ensures consistent communication among healthcare providers and supports interdisciplinary cooperation for better wound management outcomes. c) Telemedicine for Wound Care: This project, as described by WoundEducators, emphasizes the evolution of telemedicine in wound care, especially noting advancements in remote patient monitoring and digital tools that help in assessing wound healing more accurately.

Survey Suggestions

[Section prepared by Maia Adar]

Given the challenges of directly contacting populations in rural areas and conflict zones, a more realistic approach to conducting a survey would involve leveraging indirect methods to gather data.

Recommended Strategies

Key informant interviews: It can be helpful to conduct in-depth interviews with individuals who have extensive knowledge about a community and its healthcare needs, such as local healthcare providers, NGO workers, or community leaders. These interviews provide detailed, qualitative insights and leverage the knowledge of individuals who understand the local context.

Secondary data analysis: Data sources can include reports from international and local organizations (e.g., WHO, UNICEF, local health departments), local health department statistics, and research studies conducted by academic institutions. This method utilizes already available data and can provide a broad overview of the healthcare situation without direct contact with the population. However, data can be outdated or incomplete, and the quality and reliability of the data can vary.

SMS surveys: Since there is high penetration of mobile phones even in rural areas and among immigrant populations, sending questions via text message can reach a wider audience than traditional survey methods, and allows you to ask questions specific to your needs.

Potential Questions

Key Informant Interview Questions

What are the biggest challenges people in this community face in accessing healthcare services?
How have the conflict (for conflict zones) or economic conditions (for rural/immigrant communities) impacted healthcare delivery and access?
What is your perspective on the potential role of telemedicine in improving healthcare access in this community?
How accessible is mobile technology and the internet to the community, and what is the general level of digital literacy?
Has there been any previous attempt to introduce telemedicine services here? If so, what was the outcome?
What kind of support (training, infrastructure, funding) would be needed to successfully implement telemedicine in this area?

SMS Survey Questions

It is recommended to keep surveys relatively short and focus on key questions in order to increase response rates.

Do you have access to the internet?
How often do you receive healthcare?
How healthy is your family?
What type of healthcare services do you most need?
Have you ever heard of telemedicine?
Would you prefer to receive healthcare services through telemedicine if it were available?
How good is access to medications for you?
What are hindrances to getting medications? Cost/Distance to pharmacy/Lack of medicines at pharmacy/Other

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Preprint

Identifying Potential Populations And Regions For Effective Telemedicine Interventions