Public acceptance of digital health surveillance tools in Malawi: evidence from a multi-district household survey

Abstract

Digital tools are increasingly used to strengthen public health surveillance, yet limited evidence exists on public willingness to participate in digital surveillance during epidemics in Malawi. Our study aimed to assess the level of public acceptance of digital health surveillance tools in Malawi and to identify factors associated with higher acceptance. We conducted a community-based cross-sectional household survey in June 2025 among adults (≥ 18 years) in 10 purposively selected districts representing high and low combined burden of COVID-19 and cholera. Data were collected using an interviewer-administered electronic questionnaire. Acceptance of digital health surveillance tools was measured using a composite score derived from items on awareness, attitudes/trust, and practices related to digital surveillance; the score was dichotomised at the sample median into high versus low acceptance. Associations were assessed using logistic regression, including sociodemographic characteristics, device ownership, internet access, and knowledge of digital surveillance. Robust standard errors clustered at the district level were used. A total of 1,174 respondents were analysed; 1,032 (87.9%) had high acceptance. In adjusted analyses, acceptance increased with education level compared with no formal education (primary: adjusted odds ratio 2.08, 95% confidence interval 1.14–3.75; secondary: 3.14, 1.58–6.17; tertiary: 4.95, 1.63–18.7). Owning at least one electronic device was independently associated with higher acceptance (1.98, 1.27–3.09), as was prior knowledge of digital health surveillance (2.85, 1.88–4.34). Poor network coverage was frequently reported as a barrier, and privacy concerns were more common among respondents with low acceptance. Acceptance of digital health surveillance tools in Malawi was high but strongly patterned by education, device access, and awareness. Digital surveillance initiatives should prioritise equitable access to basic devices and low-bandwidth channels and strengthen trustworthy public communication on the purpose of surveillance and data protection.