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. 2026 Feb 5;6(2):e0005025. doi: 10.1371/journal.pgph.0005025

Adopting telehealth for mental health support in stroke rehabilitation in Sub-Saharan Africa: A conceptual analysis using Rogers’ Diffusion of Innovation Theory

Delight Tsogbe 1,*, Tettey Martin 1, Akuffo Bernice Gyanmea 1
Editor: Razak M Gyasi2
PMCID: PMC12875508  PMID: 41642834

Abstract

Stroke rehabilitation in Sub-Saharan Africa (SSA) faces persistent gaps in mental health service integration. Post-stroke depression, anxiety, and cognitive impairments remain underdiagnosed due to workforce shortages, stigma, and infrastructural constraints. Telehealth technologies offer a potential mechanism to expand access to psychological care, yet adoption across SSA remains uneven. This paper provides a conceptual, theory-driven synthesis exploring telehealth adoption for mental health support in stroke rehabilitation across SSA, guided by Rogers’ Diffusion of Innovation Theory. A structured conceptual review was conducted using literature from PubMed, Scopus, AJOL, and Google Scholar (2005–2024). Inclusion criteria focused on SSA studies addressing telehealth or mHealth in mental health or rehabilitation contexts. Thematic synthesis was guided by Rogers’ five innovation attributes, relative advantage, compatibility, complexity, trialability, and observability, to assess adoption facilitators and barriers. Telehealth adoption is influenced by cultural compatibility, simplicity of design, perceived relative advantage, observable benefits through pilot projects, and supportive policy environments. Successful initiatives in Ghana, Kenya, Nigeria, and Uganda demonstrate the importance of localized adaptation and user engagement. Telehealth provides a scalable pathway to address post-stroke mental health needs in SSA. Effective adoption requires culturally responsive design, targeted capacity-building, and policy alignment with national and regional digital health strategies.

Introduction

Stroke remains one of the leading causes of disability and mortality in Sub-Saharan Africa (SSA). The mental health sequelae of stroke, such as depression, anxiety, and cognitive impairment, significantly reduce recovery outcomes. However, mental health services are severely limited due to infrastructural barriers, insufficient specialists, and sociocultural stigma [1,2].

Telehealth, encompassing video consultations, mobile health (mHealth), and remote rehabilitation, has emerged as a potential solution to overcome geographic and workforce barriers [3]. Despite increasing attention, telehealth adoption in SSA remains inconsistent, constrained by cost, digital literacy, and fragmented policy environments [4].

To understand these challenges conceptually, this paper applies Rogers’ Diffusion of Innovation Theory [5] to synthesize evidence on telehealth adoption for mental health support in stroke rehabilitation across SSA.

Methods

Conceptual design

This study adopts a theory-driven conceptual synthesis approach using Rogers’ Diffusion of Innovation Theory as the analytical framework. The approach integrates existing empirical and theoretical evidence to derive implementation insights rather than generating primary data.

Theoretical framework

Rogers’ Diffusion of Innovation Theory provides a systematic lens for understanding how new technologies, such as telehealth, are adopted within health systems. The theory categorizes adopters into five groups, innovators, early adopters, early majority, late majority, and laggards, each differing in their readiness to embrace innovation. It also identifies five key innovation attributes that influence adoption decisions: relative advantage (the perceived improvement over existing methods), compatibility (alignment with users’ values and needs), complexity (ease of use), trialability (the ability to experiment on a limited basis), and observability (visibility of benefits and outcomes). Applying this framework offers a structured understanding of how telehealth can be effectively adopted to provide mental health support during stroke rehabilitation across Sub-Saharan Africa, highlighting the social, technological, and contextual factors that shape diffusion dynamics. A schematic representation of these five innovation attributes and their relationship to telehealth adoption in stroke rehabilitation is illustrated in Fig 1.

Fig 1. The five innovation attributes influencing telehealth adoption in stroke rehabilitation (adapted from Rogers, 2003).

Fig 1

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Search strategy

Databases searched included PubMed, Scopus, AJOL, and Google Scholar between 2005 and 2024. Search terms included:

“telehealth”, “mental health”, “stroke rehabilitation”, “Sub-Saharan Africa”, “digital health”, and “Diffusion of Innovation Theory”.

Inclusion criteria

  • Focus on Sub-Saharan Africa

  • Telehealth or mHealth interventions for mental health or stroke rehabilitation

  • Articles discussing implementation, barriers, or adoption outcomes

  • Peer-reviewed or credible institutional reports

Exclusion criteria

  • Non-SSA contexts

  • Studies unrelated to telehealth or mental health

  • Commentary pieces lacking implementation evidence

Data extraction and synthesis

Eligible studies were screened manually and coded under Rogers’ five innovation attributes. Key data extracted included country, intervention type, health condition, findings, and coded attribute. Reporting transparency followed ENTREQ and PRISMA-ScR recommendations. A summary of the reviewed studies across Sub-Saharan Africa is presented in Table 1.

Table 1. Summary of Reviewed Studies (2005–2024).

Country Intervention Type Focus Area Key Findings Innovation Attribute
Ghana Telepsychiatry pilot (mHealth) Post-stroke depression Improved follow-up and access Compatibility
Kenya Mobile rehab platform Stroke rehabilitation continuity Feasible, low dropout rate Trialability
Nigeria Video-based teletherapy Mental health counselling Effective but limited by bandwidth Complexity
South Africa Hybrid telehealth for chronic care Cognitive rehab post-stroke Improved adherence Relative Advantage
Uganda SMS mental health support Depression screening Enhanced patient engagement Observability
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Results and discussion

Compatibility

Telehealth initiatives aligning with local clinical routines and cultural contexts show better uptake. Culturally adapted interventions, such as Ghana’s community telepsychiatry model, demonstrated higher engagement due to language inclusivity and integration with existing health infrastructure [6]. Lack of alignment with cultural norms or poor stakeholder involvement often hinder scalability [7].

Complexity

Adoption depends heavily on technology usability and digital literacy. Simplified platforms with training modules have succeeded in Kenya and Ethiopia [8]. Conversely, high system complexity, unstable connectivity, and English-only interfaces create barriers for rural populations [9].

Relative advantage

Perceived benefits, such as reduced travel costs, improved access to specialists, and enhanced continuity of care, drive adoption. Evidence from South Africa and Nigeria indicates that telehealth can complement face-to-face models by reducing logistical burdens [10,11].

Trialability and observability

Pilot programs in Ghana and Uganda improved stakeholder trust by allowing experimentation in controlled settings. Observable benefits, such as improved therapy attendance and patient satisfaction, further encouraged diffusion [12]. Documented visibility of success is a strong determinant of scaling efforts across SSA [13].

Critical appraisal of evidence

Most studies reviewed were small-scale or pilot interventions, limiting generalizability. Few reported long-term outcomes or cost-effectiveness analyses. The evidence base remains fragmented, highlighting the need for empirical studies that measure clinical outcomes, sustainability, and economic viability.

Equity and ethical considerations

Digital health adoption in SSA must address digital exclusion, particularly among rural women, the elderly, and low-literacy groups [14]. Ethical concerns around data privacy, informed consent, and trust are also significant, given limited digital governance structures. Culturally sensitive design and strong data protection frameworks are essential for equitable telehealth expansion.

Policy and implementation recommendations

  • Integrate telehealth within national eHealth and UHC frameworks.

  • Establish digital literacy training for health workers and patients.

  • Support pilot-to-scale pathways through public-private partnerships.

  • Ensure affordable digital infrastructure and regulatory oversight.

  • Align strategies with African Union’s Digital Health Strategy (2023).

Conclusion

Telehealth represents a transformative opportunity to strengthen post-stroke mental health rehabilitation in SSA. Adoption success depends on alignment with cultural and infrastructural realities, simplicity of design, visible benefits, and supportive policy ecosystems. A systems-level, equity-focused approach can ensure that telehealth advances inclusion rather than exacerbating digital divides.

Limitations

This conceptual synthesis draws on secondary literature and does not include primary data collection. Findings depend on the quality and availability of existing evidence, which varies across SSA contexts.

Data Availability

This study is a conceptual and theory-driven synthesis based on previously published literature. All data supporting the findings of this study are derived from publicly available sources cited within the manuscript’s reference list. No new datasets were generated or analyzed during the current study.

Funding Statement

The authors received no specific funding for this work.

References

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PLOS Glob Public Health. doi: 10.1371/journal.pgph.0005025.r001

Decision Letter 0

Razak Gyasi

9 Oct 2025

PGPH-D-25-02080

Adopting Telehealth for Mental Health Support in Stroke Rehabilitation in Sub-Saharan Africa: A Conceptual Analysis Using Rogers’ Diffusion of Innovation Theory

PLOS Global Public Health

Dear Dr. TSOGBE,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Nov 23 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Prof Razak Gyasi, PhD, PD

Academic Editor

PLOS Global Public Health

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Global Public Health’s publication criteria?>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?-->?>

Reviewer #1: N/A

Reviewer #2: N/A

Reviewer #3: No

Reviewer #4: No

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3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

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Reviewer #1: Review of Manuscript: Telehealth for Mental Health Support During Stroke Rehabilitation in Sub-Saharan Africa: A Conceptual Analysis Using Rogers’ Diffusion of Innovation Theory

General Assessment

This manuscript presents a theory-driven conceptual synthesis examining how telehealth interventions could support mental health during stroke rehabilitation in Sub-Saharan Africa (SSA). By applying Rogers’ Diffusion of Innovation Theory, the authors analyze opportunities and barriers to telehealth adoption. The paper is well-motivated, addresses a significant gap in public health, and is generally clear and accessible. However, as this is not an empirical study but a conceptual review, the scope, methodology, and claims need to be carefully calibrated to align with PLOS Global Public Health standards.

Evaluation Against Editorial Criteria

1. Original Research

The article presents conceptual and synthesis-based research rather than empirical primary data collection. While conceptual analyses can be original and valuable, the framing should be explicitly described as a narrative/theoretical synthesis. Currently, some sections imply empirical rigor (e.g., “methods” structured like a systematic review), which may confuse readers about the nature of the evidence.

Recommendation: Clarify the scope of originality and emphasize that this as a conceptual/theory-driven contribution that synthesizes available evidence.

2. Novelty / Prior Publication

The results do not appear to be published elsewhere. No concerns here.

3. Technical Rigor & Methodological Transparency

The methods are described as a “structured narrative review” guided by Rogers’ framework. Inclusion and exclusion criteria are mentioned, but search and selection procedures lack reproducibility (e.g., no PRISMA flowchart, no list of final included studies). The categorization of findings under the five attributes is reasonable but could be more systematic.

Recommendations:

• Provide a table summarizing included studies (country, population, intervention, findings, attribute coded).

• Specify how many articles were retrieved, screened, and finally included.

• Consider referencing relevant reporting standards (e.g., ENTREQ for qualitative evidence synthesis).

4. Validity of Conclusions

The conclusions, that telehealth is promising but requires cultural adaptation, training, and policy integration, are well-supported by the thematic synthesis. However, the strength of evidence is variable since it relies heavily on small pilot programs and conceptual reasoning. The authors should temper claims by highlighting the paucity of robust empirical evidence in SSA.

Recommendation: Add explicit caveats that the findings are primarily conceptual and based on limited empirical data.

5. Clarity of Writing

The manuscript is written in clear and intelligible English. Minor grammatical inconsistencies exist (e.g., “five type’s” instead of “five types”). The flow between theory, methods, findings, and discussion is logical, though the paper occasionally repeats theoretical definitions.

Recommendation: Minor copyediting to improve grammar and eliminate redundancy.

6. Ethical Standards

No ethical concerns arise, as this is not human-subject research. Declarations of ethics approval, consent, and competing interests are appropriately noted.

7. Reporting Standards & Data Availability

• The article does not include primary data but synthesizes published studies.

• Reporting standards such as PRISMA for scoping reviews or ENTREQ could be referenced to strengthen transparency.

• No data repository is applicable here, but a supplementary appendix listing included studies would enhance rigor.

Contextualization and Literature

The authors situate their arguments within relevant telehealth and adoption literature, citing both global and SSA-specific sources. However, some references are outdated or not region-specific (e.g., reliance on general telemedicine reviews). There is room to engage more deeply with SSA-based digital health scholarship.

Recommendation: Expand references to include recent SSA-focused telehealth evaluations (post-2019), particularly in Ghana, Nigeria, Kenya, and South Africa.

Significance for the Discipline

The paper highlights an underexplored but highly relevant topic: integrating digital tools into stroke rehabilitation and mental health care in SSA. It contributes by applying a structured theoretical framework, which could guide future empirical research and policy interventions. However, without stronger methodological transparency, its impact may be limited.

Recommendation

Decision: Major Revision

The manuscript addresses an important gap and has the potential to be published in PLOS Global Public Health after revisions. The main issues are:

1. Clarify that this is a conceptual/theory-driven synthesis, not empirical research.

2. Strengthen methodological transparency with structured reporting of search and study inclusion.

3. Provide summary tables/appendices of reviewed studies.

4. Temper claims to reflect limited empirical evidence.

5. Minor copyediting and grammar corrections.

6. Expand engagement with recent SSA telehealth literature.

With these revisions, the paper could make a meaningful contribution to the field.

Reviewer #2: The manuscript is presented in the way to make easily understanding of the findings and the conclusions are stated appropriate. In case this abstract has been accepted for publication I encourage the authors to its wide diffusion. I did not register any potential competing interests on the part of the authors, data availability, or research ethics.

Reviewer #3: Topic of the manuscript is unique which is good but it shall be difficult for the reader to conceptualize how the author came up with this conclusion in the absence of proper methodology. While reading the paper, there is a confusion between conceptual commentary or a narrative or systematic analysis. The paper says, conceptual analysis but it lacks transparent search strategy, appropriate analysis, and clear exclusion and inclusion criteria.

Reviewer #4: The topic is highly relevant, addressing a pressing health system challenge in low-resource contexts. The manuscript is clearly written and accessible to a multidisciplinary readership.

However, the current version is limited by its largely conceptual orientation, limited methodological transparency, and insufficient critical engagement with existing empirical evidence. The paper would benefit from a stronger methodological account, deeper exploration of practical and equity implications, and clearer policy recommendations for stakeholders in SSA.

Review Comments-

1. Methodological Transparency

The methods section currently provides limited information on how the literature was identified and synthesised. For reproducibility, readers need details of databases searched, timeframe, inclusion/exclusion criteria, and number of articles reviewed.

Even if framed as a conceptual synthesis, adopting elements of PRISMA reporting would increase rigour.

2. Critical Engagement with Evidence

The findings are presented descriptively (e.g., “pilot studies showed promising outcomes”) but lack critical appraisal of study quality, effect sizes, or sustainability.

Please incorporate discussion of strengths and weaknesses of the underlying studies, including why some interventions succeeded or failed.

3. Equity and Ethical Dimensions

While digital adoption challenges are mentioned, the manuscript underplays issues such as digital exclusion (e.g., rural women, older adults, low-literacy groups) and ethical concerns around privacy, data ownership, and trust.

Expanding on these issues would strengthen alignment with PLOS Global Public Health’s equity-focused mission.

4. Policy and Implementation Implications

The conclusion is currently broad (e.g., “strategies should be developed”), without concrete pathways.

Please provide specific, actionable recommendations for policymakers, ministries of health, and digital health funders in SSA — for example, integration into UHC frameworks, African Union digital health strategies, or workforce training models.

5. Balance Between Theory and Practice

While Rogers’ Diffusion of Innovation Theory structures the analysis well, the paper risks being overly abstract.

Consider adding case vignettes or short examples from actual SSA telehealth implementations (e.g., Nigeria, Kenya, South Africa during COVID-19). This will ground the conceptual analysis in lived practice.

6. References: Several citations are dated or not SSA-specific (for e.g., Davis 1989; Czaja 2006). Please incorporate more recent African digital health literature, including WHO Africa telehealth initiatives and COVID-era studies. Try to include more references to provide a wide range of literature to the reader.

7. Limitations: Explicitly acknowledge that findings are derived from secondary sources, not primary empirical data.

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what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: Ivan Calder

Reviewer #2: Yes: Placido Monteiro Cardoso,MD,Msd,D.sc, Guinea-Bissau

Reviewer #3: No

Reviewer #4: Yes: Dr. Ratendra Chauhan

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PLOS Glob Public Health. doi: 10.1371/journal.pgph.0005025.r003

Decision Letter 1

Razak Gyasi

5 Jan 2026

Adopting Telehealth for Mental Health Support in Stroke Rehabilitation in Sub-Saharan Africa: A Conceptual Analysis Using Rogers’ Diffusion of Innovation Theory

PGPH-D-25-02080R1

Dear Mr TSOGBE,

We are pleased to inform you that your manuscript 'Adopting Telehealth for Mental Health Support in Stroke Rehabilitation in Sub-Saharan Africa: A Conceptual Analysis Using Rogers’ Diffusion of Innovation Theory' has been provisionally accepted for publication in PLOS Global Public Health.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

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Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Global Public Health.

Best regards,

Professor Razak Gyasi, PhD, PD

Academic Editor

PLOS Global Public Health

***********************************************************

Reviewer Comments (if any, and for reference):

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

publication criteria?>

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?-->?>

Reviewer #1: N/A

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: The revised manuscript is substantially improved. The authors have clearly distinguished the work as a conceptual, theory-driven synthesis and have expanded methodological transparency (databases searched, timeframe, inclusion/exclusion criteria, coding approach). The addition of a summary table and the new sections on evidence limitations, equity/ethics, and policy recommendations strengthen the contribution and align the paper with PLOS Global Public Health priorities.

Reviewer #2: Comment 1: The rationale for selecting the 2005–2024 timeframe should be briefly clarified.

Comment 2: Equity issues are discussed but insufficiently translated into the policy recommendations.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #1: No

Reviewer #2: No

**********

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    Attachment

    Submitted filename: Response to Reviewers.docx

    pgph.0005025.s002.docx (19.1KB, docx)

    Data Availability Statement

    This study is a conceptual and theory-driven synthesis based on previously published literature. All data supporting the findings of this study are derived from publicly available sources cited within the manuscript’s reference list. No new datasets were generated or analyzed during the current study.

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