Framework for ethical and acceptable use of social distancing tools and smart devices during COVID-19 pandemic in Zimbabwe

Abstract

Despite the successful development of vaccines, coronavirus disease (COVID-19) continues to present unprecedented challenges. Besides the ongoing vaccination activities, many countries still rely on measures including social distancing, contact tracing, mandatory face masking among others. Several digital technologies such as smart devices, social distancing tools, smart applications have been adopted to enhance public adherence to reduce secondary transmission. Such technologies use health data, symptoms monitoring, mobility, location and proximity data for contact tracing, self-isolation and quarantine compliance. The use of digital technologies has been debatable and contentious because of the potential violation of ethical values such as security and privacy, data format and management, synchronization, over-tracking, over-surveillance and lack of proper development and implementation guidelines which subsequently impact their efficacy and adoption. Also, the aggressive and mandatory use of large-scale digital technologies is not easy to implement, adhere to and subsequently difficult to practice which ultimately lead to imperfect public compliance. To alleviate these impediments, we analysed the available literature and propose an ethical framework for the use of digital technologies centred on ethical practices. The proposed framework highlights the trade-offs, potential roles and coordination of different stakeholders involved in the development and implementation of digital technologies, from various social and political contexts in Zimbabwe. We suggest that transparency, regular engagement and participation of potential users are likely to boost public trust. However, the potential violation of ethical values, poor communication, hasty implementation of digital technologies will likely undermine public trust, and as such, risk their adoption and efficacy.

1. Introduction

The coronavirus disease (COVID-19) continues to disrupt all aspects of life, posing unprecedented challenges in many health systems to handle public health emergencies. Due to the increasing number of infections and deaths, the World Health Organization (WHO) declared COVID-19 a global pandemic on January 30^th, 2020 followed by stringent regulations and preventive measures [1] such as social distancing, masking, quarantine of suspected and infected persons, self-isolation among others to reduce the catastrophic impact and spread of the virus. Moreover, health systems globally advocate for maintaining social distancing measures to break the chain of contamination by minimizing interactions and physical close contact with people outside of one's household and maintaining a 2-metre distance between person to person [2,3]. Such measures include national lockdown, travel restrictions, closing public places, physical distancing, and closing of borders among others. Several scholars including [3], [4], [5], [6] noted that such aggressive and large-scale measures are not easy to implement, adhere to and subsequently difficult to practice and maintain which lead to imperfect public compliance, especially if there is a significant impact on social and political norms, economy and psychological wellbeing of the affected population. Also, countries are reopening despite the ongoing COVID-19 infections, re-infections and deaths; hence the need for incorporating digital health technologies including technology-based social distancing apps [7], contact tracing apps and Internet of Medical Things (IoMT) devices to strengthen health systems and improve health services delivery is inevitable [8,9]. These advanced emerging technologies can improve compliance, adherence to maintain social distancing and reduce the upsurge of the pandemic. These technologies use health data, symptoms monitoring, mobility, location and proximity data for contact tracing, self-isolation, quarantine compliance, maintaining physical distance and monitor adherence to stay-at-home guidelines. However, the use of social distancing apps, contact tracing apps and IoMT devices have been debatable and contentious because of security and privacy, data format and management, synchronization, over-tracking, and lack of proper development and implementation guidelines which impact their efficacy and adoption [10]. Also, many people worry that the introduction and use of such technologies can normalize greater levels of surveillance and potentially violate the security and privacy of users leading to legal and ethical issues. This is exacerbated by hasty, poor user engagement, ill-prepared or badly communicated implementation of social distancing apps which ultimately influence public trust [9] and uptake of these technologies, and subsequently, risk impeding general effectiveness. Therefore, we propose a framework for ethical and acceptable use of social distancing apps, IoMT during the pandemic.

2. COVID-19 situation analysis and social distancing tools in Zimbabwe

After WHO declared COVID-19 a global pandemic on 11 March 2020, Zimbabwe's Ministry of Health and Child Care adopted several measures in response to the COVID-19 outbreak after the government declared COVID-19 a national disaster on 19 March 2020 to curb transmission and reducing the catastrophic impact of the pandemic on both population and the already overburdened health system [11]. These measures include social distancing, self-isolation and quarantine of returnees from other countries, face masking, banning of all public gatherings and sporting fixtures, dusk-to-dawn curfew, closure of non-essential business, stay-at-home, regular temperature checking and testing [12]. As of 30 January 2021, Zimbabwe recorded 32,952 confirmed COVID-19 cases, 24,872 recoveries and 1,178 deaths [13]. The increased number of infections is exacerbated by several factors including poor testing capacity, the dearth of personal protective equipment [14], limited humanitarian and social support, poor health system, corruption in COVID-19 supply tenders [15], lack of funding, perennial economic challenges [16], dilapidated health care infrastructure, illegal immigration and porous borders especially South Africa and Zimbabwe border, limited intensive care unit beds and ventilators, ignorance, and lack of digital contact tracing systems and social distancing apps [15]. Also, the majority of the populations rely on informal sectors for their livelihoods, which means, recursive national lockdowns and dusk-to-dawn curfews would mean hunger or potential violation of COVID-19 measures, especially compliance with social distancing guidelines. Notably, hand-washing basins were installed in various strategic points in major towns, recently launched national COVID-19 hotline, and also opened a National Microbiology Reference Laboratory in addition to two infectious disease hospitals to support and strengthening COVID-19 testing capacity [16]. Also, some organizations (but not yet rolled out countrywide) started utilizing infrared digital thermometers, smart disinfection tunnels and wearable smart devices including smartwatches, smart hand band and smart helmets (especially in the mining sector) to thwart a recent swell in COVID-19.

The following section provides a comprehensive analysis of IoMT smart devices, social distancing monitoring apps for contact tracing, symptoms monitoring, self-isolation and quarantine compliance, maintaining physical distance and monitor adherence to stay-at-home guidelines during COVID-19 pandemic. Section 3 proposes a framework for ethical and socially acceptable use of IoMT devices and social distancing apps during COVID-19 pandemic. Finally, Section 4 presents the concluding remarks and future work.

2.1. Related Work

Since the outbreak of the pandemic, several emerging technologies such as AI, Internet of Things (IoT), Blockchain, big data, cloud computing, geographical information systems (GIS), virtual reality, robotics, 5G technology and IoMT have been implemented to tackle the pandemic [10]. Globally, researchers, scientists and technologists have been applying artificial intelligence techniques such as deep learning (DL) and machine learning models to screen suspected cases, identify and detect COVID-19, and diagnoses of patients [17] as well as vaccines development[8] and prediction of cases and mortality [18]. For instance, [19], [20], [21], [22], [23], [24] conducted reviews on the application of artificial intelligence models for detecting, identification and modelling COVID-19 using chest computed tomography (CT) or X-ray images. Besides, applying artificial intelligence techniques to tack COVID-19 pandemic, several scholars including [8,10,[25], [26], [27]] conducted reviews of social distancing apps developed using various emerging digital technologies for enhancing stay-at-home guidelines, self-isolation and quarantine compliance, self-isolation adherence, symptoms monitoring, movement tracking, contact tracing activities as well as maintaining social and physical distancing. Social distancing monitoring apps differ extensively on data collection format and usage, data sources, data management and handling, data reporting and data protection [9]. These apps perform various functions including creating awareness by providing users with COVID-19-related information, monitoring people in self-isolation and quarantine facilities, tracing close-contacts, tracking people tested positive for COVID-19. Such apps play a tremendous role to enforce COVID-19 regulations. For instance, [18,[28], [29], [30]] state that some people violate WHO COVID-19 regulations especially social distancing guidelines as well as self-isolation and quarantine compliance and guidelines. In some instances, lack of COVID-19 contact tracing apps [31] and well-synchronized social distancing apps and IoMT devices that provide real-time data of the COVID-19 suspected cases and positive tested individuals [32] also contribute to poor monitoring of people in self-isolation and quarantine facility which ultimately lead to the increasing number of infections.

As countries are reopening, integration of digital technologies and the IoMT is inevitable to ensure smooth easing of restrictive measures while managing the pandemic using data generated from social distancing app, IoMT devices, mobile phones and social media platforms. The high penetration and usage of digital technologies provide tremendous opportunities to tackle COVID-19. For instance, as of December 2019, there were 3.8 billion people active on social media platforms and 204 billion mobile apps were downloaded in the various app store, also, 67% of the world's population subscribed to mobile devices, of which 65% were smartphones [33]. Also, social media platforms such as Facebook, Twitter, Weibo and WhatsApp among others have been used to share COVID-19 information including new cases, mortalities, and prevention measures. Such data amassed in these platforms could be utilized to map COVID-19 hotspots, migration patterns, tracing and tracking close contacts and positive cases [7].

Also, telecommunication companies have been playing a pivotal role in providing location-based services, mobile satellite pinging data and mobility trends of suspected and positive individuals for COVID-19 tracing purposes. Besides COVID-19, these digital technologies including smart applications were successfully applied to fight other pandemics such as Ebola, human immunodeficiency virus / acquired immunodeficiency syndrome (HIV/AIDS), and Swine Flu. This prompt technological companies in partnership with health regulators, researchers and governments to develop and roll-out COVID-19 apps for self-isolation, monitoring, tracking cases, tracing, and maintain social distancing guidelines.

However, a number of factors such as culture, religion, perception, health status, risky health behaviours [34], and living arrangements influence adherence to social distancing guidelines. Culture is one of the factors. Huynh [35] examined the influence of cultural factors in practising social distancing across the world. Data used were drawn from Google COVID-19 community mobility reports and the Hofstede cultural factors for 58 countries. The period covered was from 16 February to 29 March 2020. It was established that culture plays important role in controlling infection behaviour, hence the author suggested core cultural values should be embedded in the public such that people could be pushed to minimize social gathering under the pandemic and also ensure adherence to social distancing. This study provided the evidence that public health strategies and interventions should be effected with the view to minimize the social gathering by ‘uncertainty avoidance’ factor. Similarly, Jaja, Anyanwu and Iwu [36] presented the South African attitudes towards religion, culture and burial ceremony which undermined the efforts of the government to prevent COVID-19. Also, OConnell, Berluti, Rhoads, and Marsh [37] reported on how social distancing is reduced during COVID-19 due to antisocial behaviours and their findings suggested that more antisocial individuals may pose health risks to themselves and their community during the pandemic.

In China, risk perception on social distancing was studied and presented in [38] and their results showed a positive significance of risk perception to the perceived understanding and social distancing behaviours. Thus there is a significant positive correlation between perceived understanding and social distancing behaviours and it was established that this plays a mediating role in the relationship between risk perception and social distancing behaviours.

Social Distancing has been identified as one of the key element of protecting people against COVID-19 infection [39] and it is a community mitigation measure that has been recommended during influenza pandemics [40]. The report of [40] identified social distancing as a measure to reduces or slows influenza transmission in non-healthcare workplaces. However, in practice, some problems are associated with the theory of social distancing such as lack of social distancing datasets and lack of documented knowledge about the corresponding behaviour of the people to the real practice of social distancing. These problems were reported in [39] and the author made use of sensor-based “social distancing belt” to collect social distance data from people in Italy during the critical period of the pandemic outbreak and thus investigated how social distancing was influenced by wearing face masks and some other personal protection equipment. It was established in the report that the use of face mask made people to adopt a counter-intuitively dangerous strategy which negatively affects the effective practice of social distancing.

2.2. Wireless technologies for the IoMT smart devices and Social Distancing apps

To ensure the effective connection of IoMT smart devices and social distancing apps, wireless technologies can be adopted such as Bluetooth technology, wireless fidelity (Wi-Fi) technology, global navigation satellite system, cellular technology. The available IoMT devices and social distancing apps rely on wireless technologies to trace, track, and monitoring adherence to social distance guidelines. These technologies widely differ in terms of data handling, processing data source, handling data security and privacy as well as data gathering and usage [9]. For instance, social distance apps can collect anonymized or pseudonymized proximity or geo-location data using either Bluetooth technology or a global navigation satellite system and store that data in either centralized or decentralized database for further processing or warning of potential exposure. To effectively maintain adherence and compliance with social distancing guidelines, these technologies use wireless technologies such as Bluetooth technology, Wi-Fi technology, global navigation satellite system, radio technology, and cellular technology.

Bluetooth technology is widely used for short distance exchange of data using computing devices. Bluetooth technology has been widely adopted in developing COVID-19 contact-tracing apps and collect proximity data [10]. This technology can be used for COVID-19 contact tracing activities, Crowd detection especially in public places and to maintain a safe distance between two or more people to enhance social distancing. However, this technology requires the majority of the population to use smartphones and always activate Bluetooth to allow the social distancing apps to collect proximity data and close contacts which has security and privacy implications. Also, this technology can only be used by people with smartphones.

The Wi-Fi technology uses the following protocols and standards to establish the communication link between computing devices; IEEE 802.11, IEEE802.11ax and IEEE 802.11b. This technology can be used for crowd detection in various congested places and locations, public place monitoring especially in closed public places and also to detect and monitor quarantined and self-isolated people.

The global navigation satellite system uses technologies such as Global Positioning System (GPS), GLONASS, Galileo and Beidou. GPS can provide real-time position and location of suspected and COVID-19 positive tested persons, automation of services reduces physical contact between healthcare professionals and COVID-19 suspected individuals or positive tested persons. This technology can also be used for mapping migration patterns and trends of people and detect perpetrators or violators of social distancing guidelines. GPS data can be used to map COVID-19 hotspots, traffic movement and monitoring.

Cellular technology has been evolving from the first generation to the latest generation, which is, 5G technologies and strongly become a pillar for the fastest digital communications that support real-time communication and high-speed data transfer [41]. This technology performs better than Wi-Fi technology-based availability and popularity. The latest technology supports real-time monitoring using smart applications, facilitates high-speed data transfer. Cellular technology can be used to determine traffic density and people density prediction based on migration patterns using satellite data. It can also be used to predict network traffic and assist to detect crowdedness. People can consult online through video conferencing tools, telemedicine, e-health among others thereby maintaining social distancing. With the high-speed network, IoMT devices can capture, send, process, synchronize and analyze COVID-19 data in real-time [42]. However, the latest 5G technology requires huge capital investment which might delay its implementation in low-income countries. Also, the use of subscribers’ location data is subject to security and privacy issues. The 5G technology requires synchronization of communication protocols and scaling of the network which might take time and also integrating 5G technology into healthcare requires technical skills which might not be readily accessible because of stringent measures. The massive connection of computing devices makes the system vulnerable to passive and active attacks [43].

2.3. Artificial intelligence-based Social distancing tools

The recent developments of artificial intelligence-based social distancing tools have been used to reduce the catastrophic impact of COVID-19. AI is used for maintaining social distancing and monitoring people in quarantine. If these are not maintained, AI obtains information of involved individuals especially people in close-proximity and recommends further screening and test. Table 1 shows a few selected AI-enabled social distancing tools and their respective functions and associated ethical issues.

Table 1.

AI-enabled social distancing tools and their respective functions and ethical issues.

AI-enabled Social distancing monitoring tools	Description of the AI-enabled social distancing tool	Ethical issues
Proxxi contacts- Wrist-worn band [44].	The tool provides people with social distancing alerts. It is a wrist-worn tool that vibrates to notify the wearer about the distance between him/her and the next person wearing a similar device. When there is a positive case, the tool provides detailed contact tracing data to trace close-contacts for further testing and quarantine. This tool is used for both maintaining social distancing and contact tracing purposes.	Over-surveillance and privacy.
Romware COVID-19 [45].	It is a digital bracelet that maintains social distancing and assists in contact tracing. The bracelet identifies high-risk contacts (i.e. those that fail to observe a safe distance) and alert healthcare professionals. Contact tracing data is deleted after the incubation period of 14 days. No data connection is required because the bracelet uses the Ultra-Wideband.	Privacy and transparency.
Estimote- wireless wearable safety device [46].	It is a wireless wearable safety device that reminds the wearer to maintain a safe distance and directly register contact exposure. The device transmits encrypted signals. The person wearing the device uses a button to report his/her health status, in case of suspicious cases, the device generates contact tracing reports. The device is used for social distancing and contact tracing.	Personal data linked to the device, and stored in the health dashboard can violate the wearer's privacy.
Blackline Safety [47].	It is a G7 safety wearable tool connected to ATEX-certified cloud-connected gas detectors for COVID-19 contact tracing. It detects close contacts and provides real-time proactive warning and alerts. It also uses the Blackline Connect smartphone app to pick users’ location data (GPS) and send it directly to the cloud.	Lack of Transparency, autonomy, security and privacy.
Tended –COVID-19 Solution [32].	It is a wearable device that uses an ultra-wideband proximity sensor connected to the user's smartphone that notifies him/her to maintain a safe distance. Users can see their close contact through the mobile app installed on the user's smartphone. This device is used for both social distancing and contact tracing.	In the case of the COVID-19 infected case, users can see an infected person's close contacts, thus, violating the user's privacy.
Landing AI [48].	It is an artificial intelligence-based social distancing detection tool used to determine a safe distance in video streams.	Transparency, consent, security and privacy issues.
Triax Technologies [41].	It is a proximity trace wearable spot-r tag for maintaining social distancing and contact tracing. All the close contacts are recorded in the web-portal for further analysis.	Privacy of spot-r tag user will be violated.
Lopos – Safe Distance [49].	It is a wearable device that allows configuring minimum distance and warns the user with a beep and vibrates if it's closer than 1.5 meters. The safe distance device communicates with other similar device using ultra-wideband. The safe distance device is used for social distancing.	Data saved in the app dashboard can be accessed which might lead to over-surveillance.
Comarch [39].	It is a contact tracing wearable wristband that uses a button, GPS satellite to collect location data. The device is used by healthcare professionals to also monitor heart rate.	Privacy, consent and transparency.
Social Distancer [50].	It is social distancing wearable personal protective equipment that warns users if they do not keep a safe distance between them by vibrating and sound an alarm.	Autonomy, privacy, beneficence.

These available AI-based social distancing tools shown in Table 1 operate independently and effectively work when connected and communicate with a similar device of the same brand. This poses interoperability, standardization and synchronization challenges when using a different brand. Also, these social distancing apps and contact tracing face implementation challenges such as privacy protection issues, security challenges, scalability, internet access, limited connectivity, legal and regulatory issues as well as ethical issues [17]. Even though some proximity apps have been used in market analysis, workplace, retail locations, transit stations, grocery stores, parks, and residences pre-COVID-19 their usage was much on a smaller scale and for different purposes such as in-store tracking and improving services delivery [51]. However, due to COVID-19 restrictions and guidelines, the development and deployment of different social distancing apps lacked sufficient time to consult public and private partners and relevant authorities to standardize the development process, protocols, data format and semantics regardless of ethical issues [52].

2.4. Smart social distancing monitoring through IoMT smart devices

Wearable smart devices have been used to enhance symptoms monitoring, stay-at-home and social distancing guidelines and also ensuring quarantine compliance during the COVID-19 outbreak [53]. IoMT is a disruptive technology that plays an imperative role in the containment of the pandemic by using artificial intelligence-based mobile health tools connected via the Internet [54]. This includes the use of pervasive mobile apps, sensors, smart infrared thermometers, smart computing devices, smart face shield, smart health bracelets and pendants, and location-based tracking technologies to obtain real-time medical data and to provide health services [53]. Such a network of smart medical devices facilitates machine-to-machine communication over the Internet to improve health care delivery remotely especially during pandemic where physical contact is discouraged. IoMT devices together with other emerging technologies such as 5G technology, big data, artificial intelligence, cloud computing, fog computing, Internet of Things, GIS, Blockchain, virtual reality and smart applications among others tremendously assist in fighting the pandemic. These technologies have been applied to provide healthcare services remotely, enforcing and enhancing COVID-19 guidelines such as social distancing, contact tracing, monitoring of individuals in self-isolation as well as tracking individuals exposed to the pandemic. Thus, IoMT helps patients to receive proper healthcare at home and in quarantine facilities. For instance, telemedicine, mobile health, telehealth, teleconsultation, telenursing, telecare have been facilitating remote monitoring of patients, screening and surveillance of patients and remote diagnosis of diseases during the pandemic [53]. These healthcare services are offered through IoMT smart applications, IoMT smart wearable devices (especially sensor-based) connected via the Internet and storing data in IoMT cloud database. IoMT wearable devices provide real-time data for remote health detection and diagnostic services. For instance, China implemented symptom checkers that generate data that is used for epidemiological modelling, monitoring the virus spread and evaluating public health measures [9]. Therefore, several AI-based IoMT smart devices that have been deployed to tackle COVID-19 pandemic are explained below.

Non-contact Infrared digital thermometer is used to measure person's body temperature. Non-contact infrared digital thermometers have been used to collect real-time data in strategic entry and exit points for COVID-19 screening purposes [55]. The body temperature can be taken from a safe distance and to avoid physical contact thereby reducing the risk of exposure. However, regular checking of temperature in open public places by untrained healthcare professionals violates the privacy of people. If one becomes suspicious he/she is taken for further screening. Also, the device is susceptible to wrong body temperature reading because of fluctuating environmental factors such as humidity and atmospheric temperature [56].

A smart face mask is personal protective equipment equipped with sensors that can monitor the body's temperature, heart rate, blood oxygen levels and respiratory rate by placing sensors near the wearer's earlobes, nose and mouth [57]. This smart device can send COVID-19 symptoms in real-time to healthcare professionals and regulatory authorities. The smart face mask is reusable and washable hence reduce the cost of buying disposal convectional face masks.

Smart face shield is also personal protective equipment that reduces the spread of COVID-19. A smart face shield is equipped with a body temperature sensor, humidity or moisture sensor, blood oxygen sensor, respiratory rate and heart rate sensor that frequently check the health status of the wearer [57].

Smart boots are AI-based digital protective IoMT device that is used for both maintaining social distancing and contact tracing during COVID-19 [58]. The data of close-contacts is recorded in the dashboard app, and the wearer should have a smartphone for data synchronization. The smart boots alert wearers by vibrating when they are in close contact with each other (minimum 2 m distance). This smart device equipped with a temperature sensor and GPS or RFID; and can also send location data and environmental data to the dashboard.

Smartwatches are IoMT sensor-based wearable devices that collect physiological data such as pulse, blood oxygen, temperature and sleeping patterns data for early screening of COVID-19 [59]. Such data can be used for real-time health monitoring, surveillance and to assess the likelihood of COVID-19 incidences.

Smart disinfection tunnel, also known as the smart epidemic tunnel, is an IoMT sensor-based sanitization tunnel that detects an individual in real-time and disinfects that person using sanitiser within 10 s [60]. The tunnel is solar-powered equipped with a sensor and solar power bank for future use at night. The device counts the total number of people who walk-in and also generate daily, weekly and monthly reports. However, the cost of a smart disinfection tunnel might not be affordable by many organizations and individuals in resource-constrained areas [61] hence affect beneficence as one of the integral ethical values.

Smart health bands generally consist of two sensors for checking temperature and pulse rate. They collect body temperature and pulse rate in real-time for COVID-19 early screening purposes. During COVID-19, smart health bands have been deployed to monitor the health condition of people with the underlying condition in real-time. Also, [59] noted that smart health bands have been used to predict the possibility of someone having COVID-19 after analyzing symptoms and also to facilitate contact tracing and social distancing. However, smart health bands do not provide conclusive results that the person is infected with COVID-19 or not. Also, they collect unencrypted health-related data which might compromise the security and privacy of end-users [59].

The smart helmet with a mounted thermal imaging system that can detect the COVID-19 symptoms automatically from the thermal image with less human interactions. It uses GPS to find the location of the person after detecting the high temperature, and a camera to capture the image of the person [57]. However, the device is susceptible to provide false temperature information.

Smart Clothes and garments with built-in sensors empower the far off observing of patients' indispensable COVID-19 signs and further screen for the virus. Smart clothes have built-in sensors for monitoring and tracking body temperature, ECG levels, stress levels, and sleep quality [62]. A combination of these variables could be used for COVID-19 screening purposes.

However, these technologies are subject to human behaviour, environmental factors and technical glitches. For instance, the use of non-contact infrared digital thermometers in public closed places for COVID-19 screening is relatively influenced by numerous human, environmental factors and equipment variables which ultimately affect their accuracy, reproducibility, and relationship with core temperature [63]. Human factors such as lack of training to use non-contact infrared digital thermometers, consumption of alcohol, pregnancy and menstruation might be associated with a raised forehead temperature [64]. Also, the distance between subject-thermometer distance, humidity, ambient temperature affects non-contact infrared digital thermometer readings [65]. Hence there is a need to calibrate non-contact infrared digital thermometers to cater for human, environmental factors and equipment variables based on geographical location. Also, the reliability of non-contact infrared digital thermometers, smart face mask, smart face shield, smart boots, smart health bands, smart helmet, and smart clothes are largely unknown for COVID-19 screening. In support, a study conducted by [66] noted variations in temperature readings in three non-contact infrared digital thermometers that were measured against electronic thermometers, hence the need for testing and checking the reliability of these IoMT smart devices for COVID-19 screening.

2.4. The state-of-the-art, existing gaps and proposed solution

Several countries have been integrating digital tools and smart wearable devices to help enforce and monitor adherence to social distancing measures. For example, in China, non-contact Infrared digital thermometer, smart disinfection tunnel and social distancing apps have been used to tackle COVID-19 [8]. However, it is unfortunate that in some countries, especially low-income economies like Zimbabwe, the integration of information and communication technologies (ICTs) into health systems is still nascent [67] leading to the absence of e-health framework and guiding policy for inclusion and integration of technology-based solutions to improve health service delivery. Also, many countries including Singapore, Israel and China initiated mandatory use of social distancing apps to effectively monitor and tracing the affected populace [7,8,10]. This is not always the case as evidenced by some COVID-19 hard-hit countries like South Africa still battling with security and privacy issues which raise legal and ethical problems and eventually influence public trust towards the use of social distancing apps [68]. South Africa is among COVID-19 hard-hit in the world, and Zimbabwe borders South Africa in the southern part of the country. Both countries reported an exponential rise of confirmed cases especially during public holidays [69]. Therefore, to reduce the catastrophic impact of the pandemic, Zimbabwe launched new technologies and some are still developed, for example, contact tracing apps such as the Sotario contact tracing solution [70].

However, Zimbabwe faces tremendous challenges and barriers to adopt and use social distancing apps and smart devices due to factors such as limited access to ICTs, limited internet access and poor signal strength [71], no adequate infrastructural support, poor ICT culture among healthcare professionals and people, digital illiteracy [72], digital divide, poor electricity supply, high cost of internet data, traditional and insufficient equipment and unskilled manpower [49] and even if present, no ethical framework to guide its use. Owing to the weak health system, socio-economic problems and sustainability of COVID-19 measures, it is therefore imperative to integrate social distancing apps and IoMT devices to monitor, track and trace people in self-isolation and quarantine facilities and their close contacts. However, it is disconcerting that there is no guiding framework designed to integrate digital tools such as smart devices and social distancing apps suited for the socio-economic structure of the country and the ethical values of the citizens to tackle the pandemic. We are yet to find a report on the development of an ethical framework that is acceptable for the adoption and compliance to the use of digital technology. Therefore, our research focuses on developing a framework for ethical and acceptable use of social distancing tools and smart devices during the pandemic situation such as COVID-19.

3. Framework for ethical and socially acceptable use of artificial intelligence devices, IoMT and social distancing tools during COVID-19 pandemic

Notably, several authors including [9,[73], [74], [75], [76], [77], [78]] raise tremendous ethical concerns by developing theoretical frameworks guiding the ethical use of COVID-19 social distancing monitoring tools and contact tracing apps. Table 2 shows published theoretical frameworks guiding the ethical use of social distancing tools amid the pandemic.

Table 2.

Theoretical frameworks for the use of digital technology.

Reference	Ethical values considered	Limitation(s)
[9]	Public health benefit, harm minimization, privacy, justice, liberty/autonomy, solidarity, stewardship, transparency, proportionality, general trustworthiness, reasonableness, accountability, consistency, engagement and reflexivity.	The framework is generalized and not contextualized country-specific yet each country exercises its jurisdiction on e-health policies and use of digital technologies in healthcare service delivery.
[73]	Privacy, scientific validity, consent and voluntariness accuracy, and data necessity, discrimination, repurposing, expiration, digital equality and public benefit.	The study does not provide ways to incorporate ethical values in the development processes of social distancing tools while engaging potential end-users and regulatory authorities.
[74]	Privacy, equity, transparency, fairness and justice, security.	The study did not consider other important ethical values such as solidarity, the balance of power and human dignity.
[75]	Privacy, public trust, security and justice. These ethical values were derived from the European Convention on Human Rights, and the International Covenant on Civil and Political Rights.	The framework is generalized and the list of ethical values considered is not exhaustive even though some trade-offs need to be done based on the laws, values, attitudes and norms in context-specific.
[77]	Transparency, security, privacy, socio-cultural determinants and reversibility.	The study focused on factors influencing ethical and social acceptability of technological tracking implementation, not necessarily a framework for ethical and acceptable use of digital tools amid COVID-19. Hence the need for incorporating other ethical values.
[78]	Privacy, Beneficence, Voluntary, Accessibility and Legal.	The study did not consider security and other important ethical values as it was specifically designed for the Jordanian context.

Some countries including Kazakhstan, Singapore, Italy, Russia, South Korea, Gulf States and India made it mandatory and prerequisite to install a COVID-19 tracing-contact technology for employees, foreigners, people in self-isolation and quarantine facilities: failure to comply, attracts a fine and punishment [78]. The viability of these apps is paramount as a pandemic-response measure that relies on the likelihood of public health benefit effectiveness, and acceptance. To ensure acceptance of these apps, risks should be minimized, ethical values and standards should be prioritized and guide the design and development of these apps as well as their implementation. However, it is imperative to note that little information is available for the adopted ethical frameworks guiding the rolling-out, socially, ethical and acceptable use of these apps.

Also, theoretical frameworks shown in Table 2 are generalized and not contextualized to a specific country yet each country exercises its jurisdiction on e-health policies and use of digital technologies in healthcare service delivery. Hence the need for developing a contextualized ethical frameworks designed for the socio-economic structure of the country and the ethical values of the citizens.

Moreover, after a thorough analysis of raised ethical concerns in Table 2 together with Zimbabwe's e-health policies, we summarized ethical values relevant to the Zimbabwean context and developed a framework centred on security, privacy, justice, human dignity, culture and religion, autonomy, solidarity, beneficence, non-maleficence and balance of power as shown in Table 3 .

• aSecurity

Table 3.

Ethical values for digital technologies in the Zimbabwean health system.

Ethical theme	Ethical values
Security	Data encryption, data safety, app and or device security, device or app authentication and verification, data storage, secure both data and device from malicious and unauthorized users, frequently check security attacks.
Privacy	Consent of participants, engagement of users should be voluntarily (free to participate and withdraw) and transparency should be observed. Data protection from malicious and unauthorized users, keep data confidential, share anonymised data with intended and authorized people or organization, protect data leakage and perform data audit trails.
Justice	No to discrimination and stigmatization, equity in access, data ownership, re-purposing, accountability, inclusiveness and empowerment.
Human dignity	No to dehumanization, no to experimentalization of human beings, no to instrumentalization, observe religion, culture and values of participants.
Autonomy	Potential end-users should practice free of choice, informed about the purpose of the apps/tools, informed consent, type of data collected, right to know the results.
Solidarity	Digital inequality, no to discrimination and promote public benefit and inclusiveness [79].
Beneficence	Inclusiveness, public benefit, scientific validity, conduct risk assessment, show mercy, and kindness.
Non-maleficence	Re-purposing, expiration, accountability, scientific validity.
Balance of Power	Transparency, risk assessment, trust, exploitation, accountability, control, public-private partnerships, procedural values.

Due to social unrest orchestrated by the cybersecurity threats, economic and political meltdown in Zimbabwe, enforcing data and infrastructural security is imperative to ethics because digitization poses security threats to both data and computing resources. Once a computing device connected to the Internet, it becomes susceptible to passive and active security threats that threaten confidentiality and integrity of data, and also the availability of the whole system. Padlocks and barriers should be installed to avoid unauthorized entry and restrict access to computing devices. Also, to ensure over-surveillance and political manipulation of COVID-19 data, data from digital devices should be encrypted as it transverse from one computing device to the data storage device by using modern data and communication link encryption standards and blockchain technology [80]. Also, all authorized users and synchronized apps should be validated and authenticated to avoid unauthorized access to sensitive information or data by malicious and unauthorized users. To ensure that there is no data leakage, authorization, authentication, and auditing methods should be frequently done in social distancing apps and databases. Authorization, authentication, and auditing methods include identity and access management, implementation of homomorphism encryption scheme, which allows data to be processed without being decrypted [81]; audit trail and compliance [82].

• aPrivacy

Consent of participants should be guaranteed from the development to the deployment of social distancing tools, contact tracing apps and smart devices. Consent is the ability of the person who is the custodian of his/her data (health and proximity data) or computing device to willingly use social distancing tools, IoMT and contacting tracing apps, and also participate in data sharing [74]. Consent should guarantee apps users that their data is secured and used specifically for tracing purposes without violating their security and privacy. Hence consent withdrawals and user engagement are paramount in the development process of COVID-19 social distancing apps and contact tracing apps. Also, transparency should be practised and the engagement of users should be voluntary, meaning free to participate and withdraw from participation without exploitation though it is difficult and debatable. Also, data protection from malicious and unauthorized users should be guaranteed, keep data confidential, and share anonymized data with intended and authorized people or organization after attaining ethical approval from regulatory authorities. Also, data leakage should be prevented and regularly perform data audit trails.

• aJustice

To ensure equity in access and inclusive use of COVID-19, social distancing tools and contact tracing apps, people should be well-informed about the nature and purpose of data or information collected from their computing devices including smartphones, tablets and smartwatches. Transparency can be achieved in different ways; make the source code of social distancing and contact tracing apps open, engage potential end-users, regulatory authorities and reputable high-tech companies to develop apps, and this can potentially boost public trust. However, exposing the source code of apps might cause security risks, hence the need for periodic review of source code and security patches. COVID-19-related information such as demographic data, physical address, contact details and profession might be wrongly used for stigmatization, discrimination, over-surveillance and repurposing. Therefore, no discrimination, stigmatization and infringement of personal autonomy should be associated with consent withdrawal and refusal to participate. Also, individuals and organizations should be held accountable for malpractice and malicious use of data.

• aHuman dignity

Artificial intelligence devices, IoMT and social distancing monitoring apps, as well as contact tracing apps, should be utilized to tackle the pandemic while preserving human dignity. For instance, monitoring an individual's movements should be in accordance with the privacy and dignity of that person. Also, IoMT devices that remotely monitor patients’ health status should uphold patients’ dignity and refrain from dehumanization, experimentalization and instrumentalization of human beings [76]. Zimbabwe is a multicultural country with people with different values and religious practices. Instead of the “one-size fit all” approach, the values of people that do not use smartphones because of religion and culture should be preserved and find the best alternative methods for contact tracing without violating their civil rights.

• aAutonomy

Digital health technologies have the potential to undermine not only privacy but also personal autonomy. End-users or participants should practice free of choice, informed about the purpose of the apps, informed consent, type of data collected, right to know the results. During the pandemic, regulatory authorities implemented mandatory checking of body temperature and hand sanitization to reduce transmission of the virus. However, some people are allergic to sanitiser; they should be informed about the type of sanitiser before sanitized. Also, the right to opt-out may not be an option due to public benefit outweighing autonomy rights due to public emergency caused by the pandemic. Also, once the emergency has gone away, a more balanced autonomy would take over.

• aSolidarity

Digital technologies especially mobile technologies are increasingly used to improve health service delivery globally. However, due to the digital divide, poor network coverage, lack of access to computing devices and digital illiteracy, digital technologies are uneven distributed especially in resource-constrained areas which lead to digital inequality. Hence the need for non-digital strategies to be included in COVID-19 containment strategies to avoid discrimination and health inequalities while promoting inclusiveness and public benefit [83]. However, during the pandemic, conflicts are already arising between protecting personal autonomy, beneficence, public benefit, individual rights and civil liberties due to imposed recursive mandatory national lockdown and vaccination. Hence, the need for trade-offs between freedom of movement and containment of the virus.

• aBeneficence

Beneficence is an integral part of ethics that requires compassion and understanding. Professionals must execute actions that benefit end-users or patients [84]. It thrives to provide the best services to the public extrapolated into charity, mercy, kindness, generosity, and supererogatory.

• aBalance of power

During the outbreak of COVID-19, several apps have been developed hurriedly without proper engagement with end-users which affects transparency and public trust [10]. Transparency is important in the public adhesion process to ensure that decisions are made based on scientific validity having done a risk assessment. For instance, to boost public trust in the uptake of COVID-19 contact tracing apps, the population should be well-informed about the importance of such apps in preventing the continuous spread of COVID-19 and guaranteed legal measures for malicious use of such apps to avoid exploitation. From the regulatory perspective, there should be a balance of power and trade-offs between surveillance and privacy of users and also accountability in public-private partnerships.

Fig. 1 shows a framework for ethical and acceptable use of smart devices and social distancing tools in Zimbabwe. The proposed ethical framework includes major stakeholders in COVID-19 apps development which include regulatory authorities, developers and consultancy companies as well as potential end-users in Zimbabwe. The ethical roles and activities of each stakeholder are explained below.

• i)Regulatory authorities

Fig. 1.

Framework for ethical and socially acceptable use of smart devices and social distancing tools.

Regulatory authorities include the Zimbabwe government, the Ministry of Health and Child Care WHO and non-governmental organizations (NGO) involved in the provision of healthcare. These regulatory authorities are responsible for crafting ethical policies and guidelines, electronic health strategies guiding the development, implementation and integration of emerging digital technologies into health systems. Also, they are involved in planning and perform a risk assessment before the integration of digital technologies in the health system. They should make sure that societal needs are met and demonstrated proportionality, health data is secured, ethical procedures and standards are sufficiently followed, ethical risks are mitigated, promote justice, autonomy, solidarity, exercise balance of power, beneficence as well as preserve human dignity, hence the need for frequent monitoring and analyzing activities of digital technologies by frequently engaging potential-users, developers and risk assessment team.

• i)COVID-19 apps developers and consultancy companies

High technological companies involved in developing COVID-19 solutions authority should follow policies and guidelines set by Zimbabwe's regulatory authorities. These developers act in between end-users and regulatory authorities hence the need for establishing public-private partnerships, proactive communication and practice systematic accountability especially when developing and deploying apps. At this level, high-tech companies should observe ethical values such as but not limited to security, privacy, culture and religion, autonomy, solidarity and non-maleficence when design (design-by-ethics) and deploy digital solutions.

• i)Potential end-users and participants

After the successful development of digital solutions to combat COVID-19, end-users will use the digital tool or app regularly. Hence the need for engaging potential end-users both in Zimbabwe's rural and urban communities, on each development stage to boost public trust. This helps to understand user needs and their expectations in order to develop solutions that address their problems and also to boost public trust in the uptake of COVID-19 contact tracing apps. Therefore, the ethical framework in Fig. 1 is supported by ethical, stakeholder and justice theory [85]. The ethical theory comprises deontology, utilitarianism, rights and virtue. Hence, ethical values considered in this study are based on the ethical theme as presented in Table 3, commonly used for digitalization in health technologies.

3.1. Potential policy implications and future research

Despite the importance of ethical values in the context of COVID-19 digital tools, relative privacy infringements are potentially justifiable to save lives and reduce the possible spread of the virus. For instance, many countries imposed blanket lockdown to reduce the spread of the pandemic which constraints liberty and privacy on the affected population though it is, however, justifiable especially during global health emergency [74]. Therefore, in such situations, trade-offs should be made to save many lives. However, there is a need for honesty and transparency in terms of the nature of privacy infringements, the degree of surveillance and future use of the data analysis post-pandemic. For instance, proximity information could be utilized for over-surveillance, abuse of data and political exploitation. In support, [74] and [86] raised the following ethical concerns in the context of COVID-19:

• •Will full privacy protections be reinstated after the epidemic?
• •Will data gathered now be used in unacceptable ways later?
• •Will data gathered during the pandemic be deleted post-COVID-19?
• •What data management policies and framework are in place to counter abuse of data, over-surveillance and political exploitation of user data?
• •As countries re-open, what are international health standards and guidelines are needed for monitoring migrants and verification of their COVID-19 testing certificates?
• •As international borders re-open, how migrants’ COVID-19 health data going to be shared among regulatory authorities regionally and internationally for effective monitoring and tracking?

3.2. Potential managerial implications

For the proposed ethical framework to achieve its main goal, the managers need to put decision-making tools to support the ethical framework into consideration without viewing it from digital technologies perspective only. The measures to implement the digital technologies for the pandemic are not easy to implement, adhere to and difficult to practice which subsequently leads to imperfect public compliance. Therefore, the integration of digital technologies into society can only be seen as a good support to human endeavour if managers can make good decisions based on ethics set out to guide the use of digital tools during the pandemic. If ethical values proposed in the framework are not carefully observed, this might have implications on their core business operations. This can be achieved if the managers adhere strictly to COVID-19 guidelines especially on their business operations, staffs and customers/clients by integrating digital technologies to enhance social distancing and contact tracing. The negative impact of the lockdowns on private and public organizations cannot be overlooked especially on the economic implication whereby the overhead costs are more than the revenue generated and this has led to the closure of some businesses while those still in business are recovering from the economic impact of COVID-19.

3.3. Psychological implication

Some organizations are taking different decisions on how to address COVID-19’s psychological impact on employees by incorporating digital technologies. Several employees have been battling with uncertainties orchestrated by the pandemic which impact their mental, physical and social well-being [87]. To deal with these challenges, some companies in Zimbabwe adopted digital technologies together with the work-from-home approach to enhance social distancing to reduce the number of close-contacts and to eliminate uncertainty on job delivery. For this to be effective, ethical values of employees should be observed and to avoid the further impact of the pandemic on the mental, physical and social well-being of employees

Future pandemics are likely to come. These ethical concerns will assist regulatory authorities to prepare for future pandemics, design and development of international contact tracing and tracking tools guided by international health standards and WHO guidelines. However, the future work will focus on COVID-19 social distancing monitoring tools’ data security vulnerabilities, breach and data leakages, and propose solutions based on evidence gathered.

4. Conclusion

Digital technologies play a paramount role in alleviating the catastrophic impact of the pandemic; however, they are not a panacea but valuable tools that should be involved in the pandemic containment strategy. Despite the valuable impact of digital technologies, their integration in healthcare should be carefully observed to avoid the potential violation of ethical practices and regulatory policies. We identified ethical values and developed a framework centred on security, privacy, justice, culture and religion, human dignity, autonomy, solidarity, beneficence, non-maleficence and balance of power. The list provides a sketch of relevant ethical values important to the development of digital solutions and integration of emerging technologies in the health system. We neither claim that the ethical values considered in this study are complete nor ethical policies be crafted along with these ethical values. Also, ethical values should be context-specific because countries have different health policies [88], jurisdictions and technological infrastructure. Hence our framework focuses on principal aid to address several ethical challenges emanating from the integration of digital technologies in healthcare, especially during COVID-19 pandemic. The analysis is based on Zimbabwe but can be used by any country.

Declaration of Competing Interest

The authors declare no conflict of interest.