Multilevel determinants of digital health implementation in African clinical settings: an umbrella review.

Abstract

Digital health tools (DHTs) are increasingly being used in African clinical settings, yet implementation remains uneven across countries, facility levels, and technologies. Existing reviews are fragmented by disease area, tool type, or setting, and global syntheses rarely account for the unique environments shaping digital health implementation in Africa. Few reviews have synthesized the barriers and facilitators influencing digital health implementation in African clinical care using implementation science frameworks. This umbrella review synthesized review-level evidence on these determinants using the Consolidated Framework for Implementation Research (CFIR). This umbrella review included reviews published between 2013 and 2025 in PubMed, Scopus, and CINAHL that reported implementation determinants of digital health tools in African clinical care settings. The team extracted data in duplicate, appraised study quality using the JBI checklist, quantified overlap with the GROOVE tool, and deductively mapped determinants to CFIR domains with inductive coding for non-aligned themes. Six reviews covering 101 unique primary studies met inclusion criteria, spanning diverse African settings and digital health tools, including EMRs/EHRs, telemedicine, mHealth, AI-enabled tools, and other ICTs. None specified the implementation phase examined or explicitly reported using an implementation theory, model, or framework. Innovation-level barriers included complexity, poor interoperability, limited usability, and cost, whereas relative advantage, adaptability, and co-design facilitated implementation. Implementer-level barriers included limited digital literacy, inadequate training, and resistance to change; training, mentorship, and early engagement were facilitators. Inner-setting barriers included unreliable infrastructure, limited organizational resources, workflow incompatibility, and inadequate technical support, while infrastructure investment, supervision, and incentives supported implementation. Outer-setting determinants included regulatory limitations, local attitudes, and partnership arrangements; community trust, government ownership, and cross-sector collaboration facilitated implementation. Implementation-process determinants were infrequently reported. DHT implementation in African clinical settings is shaped by determinants across all CFIR domains. Sustainable implementation requires context-responsive strategies that address these factors collectively.