Biomedical engineers provide meticulous care for MDs, procure high-end equipment, manage maintenance contracts, and oversee the overall structure of the hospital, including floor plan design. Observations from field studies carried out in SSA [1,2,3,4] showed that, overall, there is a limited number of practising biomedical engineers in this region, and that most often than not, BME professionals were more likely to be substituted with technicians in hospitals; either internally (i.e., within the hospital), or when called out for emergencies (e.g., in the case where devices and equipment malfunction and it is not possible to directly access the manufacturer). These studies also documented the fact that many BMETs working in hospitals in low resource settings (LRSs) are not particularly skilled in the maintenance of MDs. In a general sense and particularly in healthcare settings, maintenance of medical equipment and devices is defined by activities and strategies deployed to ensure their reliability, longevity, optimal performance, and safety. Moreover, effective maintenance practices are key to reducing downtime, ensuring continuous equipment availability and reducing costs [5, 6]. Maintenance strategies are usually classified into corrective, preventive, and predictive maintenance.

In SSA, we found that most job specifications are usually limited to the corrective rather than the preventive aspects of maintenance, while in more advanced settings, preventive maintenance is the most commonly implemented in hospitals. Corrective maintenance is performed only when an equipment or device breaks down. Preventive maintenance is performed on a regular basis within a scheduled time or after a certain amount of equipment usage irrespective of the condition. Predictive maintenance is an advanced maintenance strategy which leverages technology, data, and analytics to predict equipment failure or performance degradation [5, 6]. New innovations in predictive maintenance strategies employ historical data (e.g., time series and big data), real-time device monitoring (sensors and sensor networks), data analytics and AI (machine or deep learning algorithms and statistical models), smart technologies (e.g., internet of things (IoT) and cloud computing, ), etc. to predict maintenance timelines for MDs. In addition, advanced technologies such as augmented reality (AR), virtual reality (VR) and mixed reality (MR), as well as blockchain and robotics are also being used in different ways to increase the accuracy and efficiency of MD maintenance practices, and can also be harnessed for training purposes [7,8,9].

For example, utilizing an internet of things (IoT) based maintenance strategy that incorporates sensors for collecting normal and failure related real-time data will provide a better picture of equipment health by providing status warnings that can induce scheduling a maintenance action before the MD breaks down. Further, data analysis tools and machine learning/deep learning algorithms can be incorporated to predict and classify healthy and faulty equipment status. Adapting this method can shorten diagnostics time to uncover failure causes, minimize spare parts inventory holding costs, lower maintenance costs and effort, allow better capacity planning, and assess the usage and functionality of MDs [10, 11]. Soft savings such as patient satisfaction and shorter times to patient diagnosis can also not be overlooked [8]. Extended reality (XR) – comprising of augmented reality (AR), virtual reality (VR), and mixed reality (MR) – is an umbrella term for any sort of technology that changes known reality by adding digital elements to the physical or real-world environment by any degree, thus blurring the line between the physical and digital world. These technologies differ in how much they rely on physical or digital elements. Specifically, AR technology allows the superposition of digital elements into the real-world environment; VR allows the creation of a fully immersive digital environment; MR allows the user to see and interact with both digital and physical elements. These technologies can be used to support maintenance of MDs for clinical practice. Examples of use in the literature include guidance through unfamiliar maintenance tasks and visualization of information directly in the spatial context of AR, location of spare parts and sending maintenance repair instructions over mobile devices [10, 12], and mobile app offering detailed information about different MDs using AR [13]. Likewise, VR can be used in maintenance training/education, aid in the resolution of complex maintenance challenges by inexperienced BMETs, and facilitate the simplification of user/maintenance guides [14]. Finally, as previously mentioned, AI can significantly enhance and supplement the work of BMETs by providing real-time monitoring, predictive maintenance, and troubleshooting support [6, 14, 15].

Interestingly, an aspect of maintenance-related tasks that is usually overlooked is the issue of sociocultural perspectives, which suggests that maintenance tasks are perceived as unattractive and degrading by men. From an analysis of the culture prevalent in the SSA countries that were visited in these studies, we noticed that despite being patriarchal countries [16,17,18], women traditionally play leading roles in tasks pertaining to the maintenance of the house and family [17, 19]. The observations and results documented in these studies led to the research hypothesis driving this present study, which is a collaborative effort between researchers with different competencies such as biomedical engineers, clinical engineers (CEs), electrical and electronics engineers, mathematicians, economists, sociologists, and bioethicists - all with a peculiar interest in LRSs. Because of the multidisciplinary nature of this work, our initial research questions were approached from different perspectives, such as the humanistic and technical angles, with particular attention to the subjective (i.e., sociological, ethical, religious and local culture contexts) and objective aspects (i.e., clinical engineering measurements within hospitals, including the analysis of the quality of the electrical current, the availability and working status of medical devices, the possibility of procuring spare parts, and the accessibility of specialised users).

According to Shoola [20], the cultural-ideological concept of hegemony [17, 21] is pervasive in SSA societies and is held by the ruling elite. Even though a few exceptions exist such as the case of the Akan of Ghana, the true picture is that numerous facets of life in SSA (e.g., the political, economic, educational, and legal aspects) are dominated and controlled by men. This cultural concept whereby males are given or assume positions of power that are not usually available to women, therefore, supports the observation that the number of women working as BMETs is very low. It is noteworthy, however, that although these notions are mainly exacerbated in regions such as these, gender bias is still an existing challenge, even in higher-income countries like those in Europe [22], with many domains being affected such as pay inequalities or diversity in leadership roles. The scant involvement of women in science is also a lingering challenge in these countries. However, years of campaigns and tailored initiatives contributed to mitigating the negative effects of this phenomenon.

To have a better idea of the critical nature of the phenomenon in SSA, some of the authors of this study did a comparison between enrolled students in the BME faculties in the University of Abomey-Calavi (Benin) and the Polytechnic University of Turin (Italy). As of November 2019, between six to eight women were enrolled in the biomedical engineering faculty of the University of Abomey-Calavi, compared to 45–50 men, which equates to about 13.8% females and 86.2% males. Comparatively, the Polytechnic University of Turin had 54.6% females and 45.4% males enrolled for the same course of study in 2019. It should be noted here that these numbers are quite high for the Polytechnic University of Turin in respect of other engineering streams, e.g., mechanical engineering – a course where only 14.6% of the students were females in 2019. However, if we apply this same reasoning, we can expect the numbers to be even lower, if not null, for mechanical engineering students in the University of Abomey-Calavi. It is also interesting to note that out of all students enrolled at the University of Abomey-Calavi in any particular year, only 20% (10% of which are females) will continue their education to PhD levelFootnote 1. The limited number of BMETs, coupled with the gender-biased cultural perception of maintenance culminates in the inability of the BMETs’ leadership to negotiate increased budget allocations for BMET personnel and clearly articulate the importance of BMETs’ role in maintenance tasks in SSA and more generally, in hospitals situated in LRSs. This situation leads to incredibly low availability of funds, tools, and training for maintenance tasks, which are vital for the safe and effective functioning of medical devices.

Moving on from these observations, we decided to deepen our understanding of the experiences of women in EST in LRSs, by leveraging local cultural factors and domestic traditions to investigate gender-biased and cultural perceptions of maintenance-related tasks among engineers/technologists/technicians in BME and other allied professions, who maintain and repair medical devices in LRSs​. We believe the results obtained from this study will help us better understand this phenomenon and could lead to the creation of sensitization and awareness programs that could increase the leadership and numbers of BMETs in SSA, with a special focus on women in the profession​. Another important aim of this study is to create critical awareness of the importance of women accessing leading roles in maintenance of MDs through scientific and technical studies such as engineering within specific programs and in partnership with relevant associations. We believe this will increase the visibility of women in this much needed field and also significantly improve their employment into BME related professions in order to eliminate or reduce gender-biased inequalities.