Journal Information
Download PDF
More article options
DOI: 10.1016/j.bjpt.2020.11.004
Full text access
Available online 29 November 2020
To what extent can telerehabilitation help patients in low- and middle-income countries?
Lívia G. Fernandesa, Bruno T. Saragiottoa,b,
Corresponding author

Corresponding author.
a Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, Rua Cesário Galero, 448, Tatuapé, CEP: 03071-000, São Paulo, SP, Brazil
b Institute for Musculoskeletal Health, University of Sydney, Royal Prince Alfred Hospital (C39), Camperdown, NSW, Australia
Received 30 September 2020
Article information
Full Text
Download PDF
Tables (1)
Table 1. General recommendations for developing Health and Digital Health Literacies in low- and middle-income countries.
Full Text

Brazil is experiencing a major governmental crisis marked by strong disagreement between the Federal and State leaders regarding evidence-based health information on COVID-19. At the state level, leaders endorse protective measures such as quarantine, movement restriction, and social distancing. But these efforts have been subverted by the Federal government encouraging people to return to work. As a result, there has been poor adoption of protective measures against COVID-19, and a major growth in official diagnosed cases of COVID-19 so that Brazil ranks 2nd globally for COVID-19 deaths.

The Brazilian public health system has functioned close to maximum capacity and society is suffering from downturn in business. Mitigation policies for the population were voted and resulted in approval of a BRL 600 (approximately US$108) emergency financial aid for low-income citizens, unemployed, and autonomous workers for an initial period of 4 months. While emergency financial aid was a welcome initiative, the implementation of the program ignored the realities of life for the 107 million Brazilian people who desperately needed this aid. The Brazilian state bank Caixa used a website and app to provide access to the funds, an approach that presumed the intended recipients were health literate and had access to the internet. As a result, long lines have been registered outside Caixa’s physical agencies in many cities. In countries where people struggle to feed themselves and their families, who would benefit from initiatives that demands knowledge and domain over digital and telecommunication technologies, such as telerehabilitation? And how can telerehabilitation initiatives become a democratic alternative within healthcare systems in low- and middle-income countries?

Digital health interventions, such as telerehabilitation, have been recently promoted because of their potential to overcome geographical barriers, increase access to health services, and provide an alternative means to continue treating patients whenever face-to-face encounters are precluded.1,2 However, there are challenges in adoption of telerehabilitation for the low-income population.3 Social determinants such as low income, low education, and low health literacy are already known barriers for participation in programs delivered using digital and telecommunication means.4 An unintended consequence of the implementation of telerehabilitation is the favoring of a privileged minority of patients who are able to bear the costs of consultations in private centers, those able to make adequate use of technology, or with appropriate infrastructure for access (i.e. own a smartphone or a computer, have minimum broadband speed).

In Brazil, digital health interventions will not be an option for the same 107 million people initially assisted by the emergency supply. Brazil has the largest number of internet users in Latin America with 150 million users, but that still means that one third of Brazilian households lack access to the internet.5,6 Among the poorest, only half have access to internet and that is typically of a very basic form: 3 G or 4 G technology through their mobile phones with limited internet package, mostly prepaid.5 In addition, health and digital health literacy is another barrier to effective use of telerehabilitation.4 It is known that people in low- and middle- income countries have lower health literacy levels than those in high-income countries. Despite the lack of national data, studies conducted in Brazilian public health settings revealed an important proportion of older adults with inadequate (low or very low) health literacy levels.7,8

The concept of health and digital health literacy relies on a set of context- and content- specific skills crucial for individual and community health empowerment.9 So, making health information available is not enough; the population must be able to make sense of the information provided to develop a sense of trust and act upon reliable health information. The COVID-19 pandemic has exposed the society to an information overload without proper quality-control,10 and having public health literacy levels would empower people to recognize, implement, and disseminate trustworthy health information, allowing better engagement with telerehabilitation initiatives.4

To implement telerehabilitation in a fair and equitable manner, health service planners need to be aware that strategies for low- and middle- income countries may require solutions at different levels (Table 1). Shifting attention to the advancement of health literacy and digital health literacy could be a compelling way of dealing with the complex health-technology iceberg and reduce health inequities. Achieving adequate levels of health and digital health literacies enables individuals to seek, find, understand, appraise, and implement health information into their situation and context both at individual and community level. Public health systems and the individual have shared responsibilities in developing, shaping, and preserving those skills.11 Governments’ role includes the provision of evidence-based and good quality health information through different medias, stimulating the development of a critical thinking behavior.

Table 1.

General recommendations for developing Health and Digital Health Literacies in low- and middle-income countries.

Level  Public health initiatives
ENVIRONMENT  Broader access to internet Urban areasRural areas  Facilitated by free good quality wi-fi connection in public areasCommon areas (public libraries, central location, easy access) with free access to computers and the presence of technical supportGuarantee broader good quality internet access in rural areas 
SOCIOECONOMIC  Understand the context and adapt  Map sociodemographic realities of specific regions taking into account health literacy strengths and limitations to further design population-specific programs that best matches:Populations’ health needsPopulations’ health literacy levels 
INFORMATION  Up to date evidence-based information  Expose population to what is considered good quality information (evidence-based) through most pervasive medias such as radio, TV, social mediaReassure science’s vital role in healthcare through popularization of science 
INDIVIDUAL  Call for action  Encourage critical thinking by stimulating independent investigation of health information on whichever source is available (internet, newspapers, TV, social media) 

The successful adoption of initiatives embedded in digital and telecommunication domains by the poorest will depend on well-resourced educational initiatives. While high income countries turn their attention towards issues such as data privacy and best technology to deliver care; in low- and middle-income countries a central issue is patients’ readiness for this new mode of health delivery.12 Digital health literacy skills are necessary aiming an adequate and democratic implementation of telerehabilitation. Initiatives for the advance of digital health literacy are based on education and must be structured in different levels (environmental, socioeconomic, information, individual). To achieve the best outcomes, governments must share a common message to flatten not only COVID-19 curve but reduce existing inequities in digital health initiatives’ implementation.

Conflict of interests


M. Fisk, A. Livingstone, S.W. Pit.
Telehealth in the context of COVID-19: Changing perspectives in Australia, the United Kingdom, and the United States.
J Med Internet Res, 22 (2020),
I. Fioratti, F.J.J. Reis, L.G. Fernandes, B.T. Saragiotto.
The COVID-19 pandemic and the regulations of remote attendance in Brazil: New opportunities for people dealing with chronic pain.
BrJP., 3 (2020), pp. 193-194
I. Fioratti, L.G. Fernandes, F.J. Reis, B.T. Saragiotto.
Strategies for a safe and assertive telerehabilitation practice.
Braz J Phys Ther, (2020),
J. Manganello, G. Gerstner, K. Pergolino, Y. Graham, A. Falisi, D. Strogatz.
The relationship of health literacy with use of digital technology for health information: Implications for public health practice.
J Public Health Manag Pract, 23 (2017), pp. 380-387
Statista. Number of internet users in selected Latin American countries as of January 2020. 2020;
Brazilian Internet Steering Committee C. ICT Households - Survey on the Use of Information and Communication Technologies in Brazilian Households. In: Center BNI, ed2018:392.
Rocha MRd, Santos SDd, Moura KRd, Carvalho LdS, Moura IHd, Silva ARVd.
Health literacy and adherence to drug treatment of type 2 diabetes mellitus.
M.T. Carthery-Goulart, R. Anghinah, R. Areza-Fegyveres, et al.
Performance of a Brazilian population on the test of functional health literacy in adults.
Rev Saúde Pública., 43 (2009), pp. 631-638
R. van der Vaart, C. Drossaert.
Development of the digital health literacy instrument: Measuring a broad Spectrum of health 1.0 and health 2.0 skills.
J Med Internet Res, 19 (2017), pp. e27
J. Zarocostas.
How to fight an infodemic.
K. Sorensen, S. Van den Broucke, J. Fullam, et al.
Health literacy and public health: A systematic review and integration of definitions and models.
BMC Public Health, 12 (2012), pp. 80
L.O. Dantas, R.P.G. Barreto, C.H.J. Ferreira.
Digital physical therapy in the COVID-19 pandemic.
Braz J Phys Ther, 24 (2020), pp. 381-383
Copyright © 2020. Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia
Brazilian Journal of Physical Therapy

Subscribe to our newsletter

Article options
en pt
Cookies policy Política de cookies
To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.