Digital inclusion, access barriers and trust calibration in smartphone-based hypertension screening: a mixed-methods policy and implementation study in northern Nigeria
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Objectives
To assess how digital inclusion factors and physical access barriers are associated with user trust in smartphone-based remote photoplethysmography (rPPG) hypertension screening, and to identify implications for digital health policy, procurement and implementation in low-resource settings.
Methods
Cross-sectional mixed-methods survey in five outpatient clinics in Kebbi State, northern Nigeria ( N =287). Trust was measured using comfort, confidence and perceived usefulness Likert scales. Primary analyses used binary logistic models with HC3 robust standard errors; sensitivity analyses are reported in supplementary material. Free-text responses were thematically analysed.
Results
Smartphone ownership was 51.2%; Transsion-brand devices comprised 56.5% of owners. Greater distance to a blood pressure facility was independently associated with lower perceived usefulness (OR 0.51, 95% CI 0.30–0.87; p =0.013) and lower comfort (OR 0.61, 0.37–0.98; p =0.042). Among owners, Transsion versus Samsung showed higher confidence odds (OR 3.82, 1.02–14.27; p =0.046). Qualitative themes supported the implementation interpretation: platform-fit and device speed requests among Transsion owners; connectivity and offline-first concerns among those with greater travel distance. No brand contrast achieved FDR-adjusted significance; brand findings are exploratory.
Conclusions
Digital health policy and health technology assessment for smartphone-based screening should incorporate local device ecology, connectivity constraints, physical access burden and trust-calibration safeguards. Pre-implementation assessment of these factors is necessary for equitable and safe rPPG adoption in low-resource health systems.
Public Interest Summary
Smartphone-based blood pressure screening could improve access to hypertension services in low-resource settings, but safe implementation depends on more than technical accuracy. In five outpatient clinics in northern Nigeria, we found that user trust in remote photoplethysmography was shaped by smartphone access, device brand familiarity and distance from existing blood pressure services. Transsion Android devices—Tecno, Infinix and Itel—were the dominant smartphone type among owners, while users further from blood pressure facilities raised more concerns about internet access and offline use. These findings suggest that digital health policies should not assume a single smartphone-based screening tool will work equally well for all populations. Before implementation, health systems should assess local device ecology, connectivity, access barriers and the need for cuff-based confirmation, so that enthusiasm for new tools does not outpace safe clinical use.
