PLOS DIGITAL HEALTH

REVIEW

An introduction to digital determinants of

health
Swathikan Chidambaram ID1,2*, Bhav Jain ID3, Urvish Jain4, Rogers Mwavu5, Rama Baru6,
Beena Thomas7, Felix Greaves8,9, Shruti Jayakumar1,2, Pankaj Jain ID10,11, Marina Rojo12,
Marina Ridao Battaglino ID12, John G. Meara ID13, Viknesh Sounderajah1,2, Leo
Anthony Celi14,15, Ara Darzi1,2
1 Department of Surgery & Cancer, Imperial College London, St. Mary’s Hospital, London, United Kingdom,
2 Institute of Global Health Innovation, Imperial College London, South Kensington Campus, London, United
Kingdom, 3 Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America,
4 Dietrich School of Arts and Sciences, School of Medicine, University of Pittsburgh, Pittsburgh,
Pennsylvania, United States of America, 5 Mbarara University of Science & Technology, Uganda, 6 Centre
of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India, 7 Indian Council of
Medical Research, National Institute for Research in Tuberculosis, Chennai, India, 8 Science, Evidence and
Analytics, National Institute for Health and Care Excellence, England, United Kingdom, 9 Faculty of Medicine,
School of Public Health, Imperial College London, United Kingdom, 10 Health Plan Consumer and Provider
Technology, Highmark Health, Pittsburgh, Pennsylvania, United States of America, 11 Department of
Marketing, Indiana University of Pennsylvania, Indiana, Pennsylvania, United States of America, 12 Public
Health Innovation Lab, Med School, Buenos AIres University, Argentina, 13 Department of Plastic and Oral
Surgery, Longwood Avenue, Boston, Massachusetts, United States of America, 14 Division of Pulmonary,
Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United
States of America, 15 Laboratory for Computational Physiology, Institute for Medical Engineering and
a1111111111 Science, Massachusetts Institute of Technology, Boston, Massachusetts, United States of America
a1111111111
a1111111111 * [email protected]
a1111111111
a1111111111
Abstract
In recent
AU : Pleaseconfirmthatallheadinglevelsarerepresentedcorrectly:
years, technology has been increasingly incorporated within healthcare for the pro-
vision of safe and efficient delivery of services. Although this can be attributed to the benefits
OPEN ACCESS
that can be harnessed, digital technology has the potential to exacerbate and reinforce pre-
Citation: Chidambaram S, Jain B, Jain U, Mwavu
existing health disparities. Previous work has highlighted how sociodemographic, economic,
R, Baru R, Thomas B, et al. (2024) An introduction
to digital determinants of health. PLOS Digit Health and political factors affect individuals’ interactions with digital health systems and are termed
3(1): e0000346. https://doi.org/10.1371/journal. social determinants of health [SDOH]. But, there is a paucity of literature addressing how
pdig.0000346 the intrinsic design, implementation, and use of technology interact with SDOH to influence
Editor: Mahima Kalla, The University of Melbourne, health outcomes. Such interactions are termed digital determinants of health [DDOH]. This
AUSTRALIA paper will, for the first time, propose a definition of DDOH and provide a conceptual model
Published: January 4, 2024 characterizing its influence on healthcare outcomes. Specifically, DDOH is implicit in the
Copyright: © 2024 Chidambaram et al. This is an design of artificial intelligence systems, mobile phone applications, telemedicine, digital
open access article distributed under the terms of health literacy [DHL], and other forms of digital technology. A better appreciation of DDOH
the Creative Commons Attribution License, which by the various stakeholders at the individual and societal levels can be channeled towards
permits unrestricted use, distribution, and
policies that are more digitally inclusive. In tandem with ongoing work to minimize the digital
reproduction in any medium, provided the original
author and source are credited. divide caused by existing SDOH, further work is necessary to recognize digital determinants
as an important and distinct entity.
Funding: The authors received no specific funding
for this work.

Competing interests: Leo Anthony Celi is the

Editor-in-Chief of PLOS Digital Health.

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PLOS DIGITAL HEALTH An introduction to digital determinants of health

Introduction: What is digital health, and why is it important?

Digital health [DH] refers to the use of technology to deliver healthcare services [1]. The
American Medical Association [AMA] defines it as digital platforms and solutions that
engage consumers for health and wellness purposes, collect and use their clinical data, and
manage health outcomes and quality of care [2,3]. Broadly, it includes categories such as
mobile health, health information technology, wearable devices, health and wellness online
platforms and digital equipment, telehealth and telemedicine, personalized medicine, and
artificial intelligence [AI] tools [4,5]. In recent years, the incorporation of technology in
these forms within healthcare has increased in both developed and developing countries,
marked by the acknowledgement of digital health as a vital component of planning and pro-
viding healthcare services by organizations and governments. For example, the 2019 World
Health Organization [WHO] global strategy report on digital health established the priority
of the digital health strategy and put forward guiding principles, strategic objectives, action
framework, and implementation plans to promote the development of global digital health
and to achieve universal health coverage and health-related sustainable development goals
[6].
Within most Organisation for Economic Co-operation and Development [OECD] coun-
tries, specific organizations such as the Australian Digital Health Agency have been tasked
to implement the use of digital health [7]. Similarly, in India, the Ayushman Bharat Digital
Mission [ABDM] has been created support the integrated digital health infrastructure of the
country in line with other digital government programs such as the Aadhaar identification
program [1]. While digital health confers several benefits and is clearly the way forward,
there is also considerable evidence demonstrating that it can introduce and exacerbate the
existing social disparities [8]. These disparities need to be contextualized alongside the
social determinants of health [SDOH] to help understand the general disparities in univer-
sal healthcare. These could include how sociodemographic, economic, and political factors
affect individuals’ interactions with digital health systems or solutions [9]. However, within
these interactions, the technology is seldom questioned and critiqued for promoting such
health inequities [10]. This understanding is required to ensure that digital technology
addresses these inequities in order that the right interventions are in place if digital health is
to be promoted for better and accessible healthcare. In this paper, we aim to introduce the
concept of digital determinants of health [DDOH], what it comprises of, and how it shapes
the experiences of the individuals and social groups. We will summarize the impact of
DDOH on health inequities, provide introductory examples of these, and link them to other
papers within this series.
In 2000, the Millennium Development Goals acknowledged the potential role for technol-
ogy in elevating the standard of healthcare services globally [11]. Fifteen years later, the rapid
evolution in the functionality of digital technology and its unprecedented uptake by the world
population has transformed it to become the central tenet of healthcare, as part of the Sustain-
able Development Goals to provide universal health coverage [12,13]. This concept was
adopted for better tuberculosis [TB] control with mobile technology to promote better TB
treatment adherence and provide care to the hard to reach populations [14–16]. Furthermore,
the Coronavirus Disease 2019 (COVID-19) pandemic witnessed an exponential rise in digital
health adoption as it became the primary channel of care delivery during the 2020 to 2021 to
address challenges of social distancing and lockdown mandates in major parts of the world
[17]. Taken together, while the benefits of digital technology are well-known, it is imperative
to understand these digitalAU determinants
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to ensure that its benefits are fully realized in the while
most fair and equitable way possible.

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PLOS DIGITAL HEALTH An introduction to digital determinants of health

Digital determinants of health: What do we know?

Digital determinants of health, is a novel, contemporary, and relevant construct, given its sig-
nificant impact in achieving health equity. In the 2020 Lancet and Financial Times Commis-
sion report, the panel alludes to factors that drive and determine the digital transformation of
healthcare [18]. In the editorial borne out of the commission, the authors highlight digital
technologies as a “new determinant of health” in the title [10,19]. Following this, the WHO
acknowledges the term “digital determinants of health” with example of “literacy in informa-
tion and communication technologies and access to equipment, broadband and the internet”
[6]. Accordingly, as early as the 2005 World Health Assembly, the WHO has urged countries
to draw up long-term strategic plans for incorporating digital health in a manner appropriate
for each state’s health priorities and needs [20]. At the national level, digital exclusion has
enormous economic implications. For example, in the United Kingdom, a recent report by the
Good Things Foundation estimated over 11 million people in the UK lack the basic digital
skills to participate meaningfully in the digital economy, which translates to over £22 billion
loss of revenue directly due to digital exclusion [21]. Prior to that, Mühleisen describes digital
transformation as an adaptive and rapid process and lists its economic impact on various
industries, including healthcare [18]. In another report focused on LMICs, McKinsey and
company highlighted how 12 large-scale digital tools were adapted for use in 8 different
nations during the COVID-19 pandemic [22]. All earlier work, as far as we are aware, refer to
digital technology and its various facets as “super social determinants of health” with the ability
to “address all other social determinants of health” [23]. The Pan-American Health Organiza-
tion defines digital inclusion as the “appropriate access, digital skills, and usability and navi-
gability in the development of technological solutions” and proposes it as one of its 8
principles for the digital transformation of the health sector [24]. Regardless of the exact termi-
nology, all previous work agrees on the contextualization of DDOH with respect to the broader
political, societal, and economic processes that they are embedded in. Namely, differences in
societal preferences, socioeconomic contexts, and political and institutional configurations
will generate variations in how digital technologies are incorporated and consumed in the
healthcare ecosystem [1,17].
Although factors of digital health have been studied as part of SDOH, there is little formal
recognition and exploration of the field. In fact, to date, there is no widely accepted or recog-
nized definition of DDOH [10]. Digital determinants highlight how the introduction of new
technologies can influence the access and use of healthcare, and in some cases, potentiate any
existing sociodemographic inequities that further impact health outcomes. In this regard, we
propose a new definition of the DDOH to be used in this series of papers to achieve a common
reference point. DDOH refers to the technological factors that are incorporated to provide
affordable, accessible, and quality care to consumers enhancing their healthcare engagement
and experience. Digital determinants refer to factors intrinsic to the technology in question
that impact sociodemographic disparities, health inequities, and challenges with care accessi-
bility, affordability, and quality outcomes (Fig 1). These include aspects such as ease of use,
usefulness, interactivity, digital literacy, digital accessibility, digital availability, digital afford-
ability, algorithmic basis, technology personalization, and data poverty and information asym-
metry. Taken together, these DDOH interact closely with SDOH. Without significant
empirical evidence, they can be considered as a subset of SDOH, as shown in Fig 1. Both sup-
portive SDOH and DDOH are crucial to promote digital health adoption and health equity
within populations. This calls for more empirical evidence to examine the double mediating
effects of DDOH on health equity.

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PLOS DIGITAL HEALTH An introduction to digital determinants of health

Fig 1. Panel A: Conceptual model for expanded SDOH effects on digital adoption and health equity. Panel B: Dimensions of DDOH.
https://doi.org/10.1371/journal.pdig.0000346.g001

Digital determinants of health and their interdependence with

social determinants of health
The WHO has endorsed the need to focus on SDOH to achieve equitable and accessible care.
They have clearly defined SDOH as nonmedical factors that influence health outcomes. It
broadly includes the conditions in which people are born, grow, work, live, and age, and the
wider set of forces and systems shaping the conditions of daily life [25]. In the Dahlgren and
Whitehead model, these are categorized as individual [age, sex, and constitutional factors];
social and community networks; and general socioeconomic, cultural, and environmental con-
ditions [e.g., education, work environment, living and working conditions, employment,
water and sanitation, and healthcare services] [26]. Unlike digital determinants that concern
the technology itself, social determinants relate to the external social, cultural, economic, and
political factors that affect patient’s interaction with the technology. For example, a person at a
lower income level may only be able to afford a version of a symptom checker with fewer func-
tions and capabilities. While the ability to purchase an advanced version is a social determi-
nant, the existence of different tiers of technology is a digital determinant. Within the
literature, factors related to technology are often incorporated within SDOH. However, the
way technology is designed, validated, used, disseminated, and incorporated within healthcare
has far-reaching consequences that deserve treatment as a distinct construct. Nevertheless,
both DDOH and SDOH have a closely intertwined relationship that must be considered
together in their applications.

Digital determinants of health: Digital health literacy

An individual’s health literacy is defined as the ability to find, understand, appraise, and use
information and services to make health-related decisions correlates with health outcomes
[27,28]. With the increasing use of digital technologies in healthcare, digital health literacy
[DHL] has emerged as a high priority for healthcare organizations and governments to effec-
tively engage consumers in their health and wellness. DHL refers to the ability of an individual
to effectively interface and interact with digital technology, encompassing all the skills they
require to find, understand, appraise, and apply health information specifically from electronic
sources [7,9]. Previous studies have shown that an individual’s DHL influences their effective

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PLOS DIGITAL HEALTH An introduction to digital determinants of health

uptake of digital health [29]. Specifically, individuals with better technological skills are more
informed and empowered in managing their health using digital apps, equipment, platforms,
and telemedicine, which in turn is positively associated with better health-seeking, health-pro-
moting behaviors, health knowledge, and attitudes [23]. It is, therefore, not surprising that
individuals with lower DHL correlate with poorer health outcomes and typically overlap with
those who are already affected by SDOH [8,30]. For example, older adults with lower educa-
tional status or income level often have a lower DHL although they are most likely to benefit
from online health information. Additionally, older adults may struggle due to reduced reac-
tivity or declining functional status or lack of motivation to learn new technology and are less
likely to engage with digital health. There is also a geographical gradient to this trend, with
40% of older adults in the United States using the internet compared to 22.5% in China [31–
33]. Similarly, women face structural and social barriers that hinder their participation in digi-
tal health and subsequently their literacy [34]. For example, in Uganda, men participated twice
as much as women in a short messaging service [SMS]-based HIV campaign, while less than
20% of callers on a family planning hotline were women in the Democratic Republic of Congo
[35,36]. Thus, women are also indirectly forced to be beneficiaries of projects without opportu-
nities to actively engage in and shape such projects more aligned with their needs [34].
Income level determines not only accessibility to digital health but also the quality of interac-
tion. For example, in the UK, there was a 20% difference in smartphone ownership between the
highest and lowest income strata. Low-income workers were also found to be subject to practical
limitations on accessing technology at work and overall had a lower understanding of how mobile
phones can be used to access healthcare services [8]. In India, it is estimated that around 54 per-
cent own smartphones. As in the case of UK, there is a difference in ownership of smartphones
between the lowest and highest income groups. Even if DH sources are accessible, their applicabil-
ity can be compromised due to concerns of healthcare complexity, information overload, and lack
of contextualization [37]. Furthermore, technologies often have complicated interfaces that are
beyond the abilities of individuals with average DHL. Thus, individuals who are most affected by
health inequities tend to have a lower DHL and thus are most affected by their inability to effec-
tively use digital technology. Understanding these factors is important to counteract the concern-
ing trends in DHL inequity and will allow targeted interventions to be developed.

Digital determinants of health: Telemedicine

Telemedicine has come to the forefront of healthcare, especially after the onset of the COVID-
19 pandemic. It refers to traditional clinical diagnosis and monitoring that is delivered by tech-
nology [38] and includes virtual visits, remote patient monitoring, and mobile healthcare.
According to Centers for Disease Control and Prevention report, over 61 million individuals
in the US have a disability [39]. Despite this, telemedicine is often adept at catering to the
healthcare needs of the average individual, and often is not tailored to be inclusive of patients
with disabilities, who are a particularly vulnerable population with unique social, economic,
and environmental disadvantages. Compared to traditional in-person healthcare, telemedicine
poses several barriers to patients with physical disabilities as they are often not the intended
beneficiary of design. For example, using telemedicine requires high-speed internet, but the
Federal Communications Commission has reported that approximately between 21 and 42
million Americans lack high-speed internet access, and of them, physical or mental disability
is a strong predictive factor for not having access to broadband internet. Furthermore, most
telemedicine platforms have not been designed to cater to persons with hearing, visual, or cog-
nitive impairments. Instead, the user interfaces are often challenging and require a keen eye
for interpreting the fine print materials.

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Persons with disabilities may face unique challenges specific to their type of disability. For
example, effective communication over electronic formats can be difficult for individuals with
intellectual disabilities, neurological, or speech disorders. Physical examination of patients
with physical disabilities can be challenging if they cannot interact with the virtual interface.
Patients with mental health issues or behavioral problems are often reassured by in-person
physical presence, and telemedicine has not always been adapted to account for this and
deliver a consultation with the same impact [40]. User interface issues such as screen reader,
sign language, captions, magnification, color, contrast as well as development of novel bio-
peripheral devices for physical assessments also need to be addressed [41]. These unique chal-
lenges need custom solutions to ensure that persons with disabilities are not left behind. Nev-
ertheless, telemedicine has several advantages for patients with disabilities, including a lower
transportation costs, better medication reconciliation communication, and less exposure to
communicable diseases. With a tailored electronic format that considers the barriers also expe-
rienced by these groups of patients, the era of telemedicine has the potential to effect a more
tangible positive impact than anticipated.

Digital determinants of health: Artificial intelligence

Healthcare utilizes a range of data-driven technologies which work by collecting, using, and
analyzing data, including patient health and care data, to support the care of individuals and
patients, the functioning and improvement of health services and public health, and the devel-
opment of medical research and innovation [42]. Artificial intelligence [AI] is one such data-
driven technology that is its infancy for use healthcare. AI has been used in image analysis in
fields such as radiology, histopathology, and dermatology [43,44]. It is the basis for many clini-
cal decision support tools already being used in healthcare provision such as symptom check-
ers, patient monitors, or wearable devices. The application of AI also includes logistical
support such as in automated tools that organize back-office tasks such as scheduling staff
time, predicting clinic visit outcomes, and optimizing slots within clinics to reduce patients’
waiting times [45]. As with other forms of technology, AI-based works are susceptible to health
inequities at every stage of the AI pipeline. Already, several reports have acknowledged the
existence of biases in the design and deployment of AI technologies. For example, the accuracy
of facial recognition systems from IBM is 11% to 19% less accurate in recognizing images of
black men and further to 34% with images of black women [46]. This highlights not only racial
but also gender-based biases within AI systems, despite the increase in ethical guidelines and
standards for AI and machine learning such as the development of quality assessment of diag-
nostic accuracy studies for AI [QUADAS-AI] [47].
There are inherent biases within the AI technologies as a reflection of the biases ingrained
within the society [48–50]. In their paper, Chen and colleagues highlighted 5 distinct stages
within the AI pathway where by such biases can be understood, namely problem selection,
data collection, outcome definition, algorithm development, and post-deployment consider-
ations [51]. At the more strategic level, the healthcare priorities of minority groups are often
not prioritized and hence receive less funding for AI-based solutions. For example, the funding
allocated for sickle cell disease [predominantly black children affected] is 3.5 times less than
that for cystic fibrosis [predominantly white children affected], albeit being a less prevalent
condition [52]. If the research questions concerning disadvantaged groups are not prioritized,
the structural biases will translate to less AI-based solutions as well. Given that AI outputs are
dependent on the databases they are built upon, biases are possible in several ways. Firstly, the
dataset itself may be underrepresented or developed based on representative data but applied
to the unintended minority population [53]. Secondly, data used may have sociohistorical bias

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in terms of how it was entered and collected [54]. Thirdly, the data used may not account for
social categories and determinants of the intended outcome. Models built on datasets with
these 3 types of bias, which account for the majority, will lead to outputs that cannot be applied
to patients who do not typically fit the mold and are often those already affected by health
disparities.
The diffusion of innovation theory argues that individuals or countries of higher social or
economic status are more likely to adopt novel technologies. In their recent MIT technology
review series, Hao and colleagues emphasize that while AI can be extraordinarily useful in
healthcare applications, most research has been focused on serving the more powerful popula-
tions in society. To some extent, they note examples of AI as a vehicle for the “colonization of
healthcare,” whereby the outputs enrich “a powerful few by dispossessing communities that
have been dispossessed before” [55]. The use of AI-based technology has several prerequisites
such as decent internet access, acceptable DHL and a general understanding of how these
forms of technology work and their role in the wider healthcare scene [56,57]. At the stage of
deployment, patients may not be able to access these technologies or might find these technol-
ogies obsolete as it may not be directly applicable to them. This will further reduce their
uptake. Some AI tools are modified based on the data input by end users, and without user
data from minorities, developers may not be able to produce upgraded versions that may also
cater to minority groups. Hence, there needs to be greater clarity on how to measure deploy-
ment, utilization, and patient and clinical outcomes of AI relating to ethnic equity.

Digital determinants of health: Technologies for the atypical

patient
Increasingly, organizations and governments have recognized the significant impact of digital
exclusion and have initiated more efforts to reduce such disparities. For example, in the UK,
the NHS long-term plan acknowledges the strong correlation between digital exclusion and
individuals with characteristics that are protected under the Equality Act 2010 [58]. Conse-
quently, the plan has made a commitment to a more concerted and systematic approach to
reducing health inequities and addressing unwarranted variation in care. Besides accessibility,
there is also the issue of applicability as most technologies come in a one-size-fits-all form and
are not usually tailored to the specific demographic of the patient. The use of generic technolo-
gies in people it was not intended for can lead to further harm. For example, during the
COVID-19 pandemic, the pulse oximeter was a significant development as it provided a non-
invasive, inexpensive way to measure oxygen saturations and enable the early detection of hyp-
oxia. However, given that pulse oximetry works by measuring the difference in light
absorption between oxygenated and deoxygenated blood, the same reference intervals cannot
be used for patients of different skin colors or tones. For example, Jubran and colleagues
showed that while a 92% target was suitable for white Caucasian patients, a higher threshold of
95% was required to prevent significant hypoxemia in black patients. Inaccurate measure-
ments were also twice as frequently seen in black patients than in white patients [59]. Other
studies have consistently reported that different pulse oximeters have overestimated the oxy-
gen saturations during hypoxia in darker skinned individuals [60,61]. This is especially impor-
tant in a post-pandemic landscape where respiratory problems have become a more common
presenting symptom. In a more recent study of 7,126 patients with COVID-19, the authors
suggested that overestimation of oxygen saturation occurs frequently in racial and ethnic
minority groups with that illness and leads to unrecognized or delayed recognition of eligibil-
ity to receive COVID-19 therapies [62]. The involvement of the Medicines and Healthcare
products Regulatory Agency [MHRA] and the NHS Race and Health Observatory in the UK

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to correct this, highlight the importance of regulatory bodies in ensuring that similar technolo-
gies are more digitally inclusive.

Digital determinants of health: Data poverty and information

asymmetry
Glied and Lleras-Muney hypothesized that “improvements in health technologies tend to
cause disparities in health across education groups because education enhances the ability to
exploit technological advances. The most educated make the best use of this new information
and adopt newer technologies first.” [63]. Health data poverty is the inability for individuals,
groups, or populations to benefit from a discovery or innovation due to insufficient data that
are adequately representative [64]. Health data is any information related to the physical or
mental health of a person and encompasses any of the clinical, biochemical, radiological,
molecular, and pathological information of a patient. Increasingly, such information is stored
in an electronic format for use in future consultations. When this is carried out in a large scale,
it gives rise to the amassing of large sets of health data that can be used as the basis for generat-
ing technologies. These datasets can also be used to answer research questions, inform health-
care policies, and develop new treatments. However, as with any pooled dataset, they are
susceptible to biases. Key among them is the underrepresentation of minority groups as major-
ity of the dataset will correspond with those who access it more, while neglecting those who do
not use healthcare services.
Given that various technologies are developed and validated using these datasets, they are
not generalizable to the wider populations, such as children, ethnic minority groups, older
adults, and patients with disabilities [65]. For example, in a study aimed at predicting acute
kidney injury, the model severely underperformed in female patients as only 6.4% of its initial
dataset were from female patients [66]. Another example involves symptom checkers, which
are built on large datasets, but these are usually not published for scrutiny and so may not nec-
essarily incorporate minority groups [67]. Similar instances of underrepresentation have been
seen in diagnosing skin lesions, as most algorithms do not include skin lesions in ethnic
minorities [68]. This can both reinforce existing health inequities and cause possible harm
among minority patients, giving rise to other associated ethical issues. Instead of narrowing
the health gap, such technologies widen the digital divide through the health data poverty
borne out of asymmetrical datasets.

Policy implications and future work: Where do we go from here?

Based on the above discussion, there are many and significant implications of using digital
health technology. These can be analyzed in terms of the stakeholders involved, namely the
individual patient, developers of digital technology, service providers [hospitals and physicians
in both public and private sectors], and government bodies. Future work must take into con-
sideration these implications within the broader context of social, demographic, and economic
profiles of each individual; the healthcare structure they are embedded in; and the healthcare
priorities of the broader community.

Individuals
At the individual level, patients and public need to be more aware of the digital transformation
of health services. The COVID-19 pandemic has unpredictably ushered and in some cases
forced patients and providers to adopt digital health. These experiences have also highlighted
that not all factions of a population and care providers are prepared to use digital health, spe-
cifically if it becomes the only mechanism to deliver care. Consequently, there is resistance to

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adopt digital health until trust is established in regards to its reliability, quality, ease of use, and
usefulness (Fig 1). Individuals need to develop a better awareness of their limitations, appreci-
ate the benefits, and be motivated to acquire new skills that will enable them to use digital tech-
nology. The physician–patient relationship, in most instances, is already not an equitable
relationship given that the physician and patient have large differences in healthcare expertise
and access to specific details that create information asymmetry and consequently influence
decision-making. The premature adoption of technology can potentially exacerbate this imbal-
ance in an era where shared decision-making is actively encouraged. Furthermore, there are
several government initiatives and programs aimed at improving individuals’ DHL and
obtaining their views on potential digital technologies through patient and public involvement
and engagement [PPIE] schemes. Patients can participate in these programs to ensure their
views and profiles are incorporated into relevant policy-making exercises.

Developers
Digital health technology takes various forms, including AI-based tools, telemedicine, symp-
tom checkers, mobile phone applications, precision medicine, and robotic technology. While
profit margins, revenue and return on investments are key factors in the design and develop-
ment of these technologies, in the future era developers need to consider their social impact as
well [69]. The importance of digital inclusion must become a core principle at the outset of
technology design and not an afterthought as it currently is with many health tools. For exam-
ple, as of 2021, there are approximately 3 million applications on Google Play store alone, with
health and fitness being the biggest category [70]. Although this figure is expected to rise fur-
ther, the majority of the world population still does not have access to either a smartphone or
high-speed internet to access these apps. To achieve this, developers can conduct market
research to better understand the socioeconomic, demographic, and political profiles of their
end users, and finetune their technology accordingly. For example, the same presenting symp-
toms will yield a different set of possible diagnoses in different countries, so symptom checkers
can map out the epidemiological differences of medical conditions between different countries
and modify their algorithms to account for local trends [71]. Within most randomized clinical
trials, there is now a greater requirement for PPIE. The same approach can be extended to
technology development, whereby developers incorporate the views and needs of their end
users to ensure the production of an inclusive technology [72,73].

Service providers: Partnerships in public and private sectors

Service providers serve as the bridge between developers, government organizations, and the
end users [patients and the public]. Hospitals have become more open to using technology for
delivering healthcare in recent years, but they have not necessarily been equipped with the nec-
essary infrastructure. In the post-pandemic era, physicians have adopted digital health but
may not be cognizant of their own biases and limitations. For example, not many physicians
may have been trained to carry out clinic consultations in a virtual format prior to the
COVID-19 pandemic [74]. When patients with physical disabilities, visual or hearing impair-
ments are involved, the challenges multiply and can reduce the effectiveness of the health epi-
sode. Accordingly, telehealth medicine training is being incorporated into current training
systems [75,76].
Compared to previous healthcare interventions, the boundaries between private and public
healthcare players become more blurred. In the digital health market, there is a significant
interaction between service providers and private companies. For example, over 184 venture
capitalist investments were made by service providers in 105 companies over the 2011 to 2019

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PLOS DIGITAL HEALTH An introduction to digital determinants of health

period [69]. All major technology companies, including Alibaba, Alphabet, Amazon, Apple,
Facebook, Jio, Microsoft, and TenCent are now expanding their reach into the health sector.
Significant examples include Amazon Care and the TenCent Smart Hospital, where the former
was formally recruited by the Chinese government as part of the national AI strategy [77,78].
Telecommunication networks will need to buy into the digital strategy to support with neces-
sary information and communications technology [ICT] software and hardware. While such
partnerships can foster better transfer of information and ideas, it also belies the risks of data
privatization of extreme privatization of health data and exacerbate existing health inequities.
In a corporate environment motivated by economic gains, service providers must ensure that
the patient is still prioritized and placed at the center of healthcare provision.

Government bodies and organizations

Governments need to employ an equity and rights-centered approach towards digital health
and give importance to the needs of people with least power and most dependent on the gov-
ernment, including children, youth, elderly, women, people with disabilities, and other minor-
ity and marginalized factions of society [79–81]. This can be achieved by ensuring that
individuals are “digital health ready.” Digital health readiness refers to the variable extent to
which individuals and countries have the capacity to use digital technology and data for
improving their own or their population’s health and wellbeing [1]. Governments can identify
individuals who lack digital health readiness and implement policies that directly alleviate it.
Simultaneously, governments can partner with service providers, developers, and companies
to ensure that digital health technology produced is ethical and equitable by including the
needs and sentiments of minority groups [82].
Within countries, there are dedicated public organizations which are responsible for
approval of digital technologies, such as the MHRA in the UK, Food and Drug Administration
[FDA] in the USA, Central Drugs Standard Control Organisation in India, and National Med-
ical Products Administration in China. These organizations can play a bigger role in monitor-
ing health technologies. Within the UK, there is already an increased awareness of digital
health inequities and has led to initiatives such as increased funding solely dedicated to resolv-
ing them [45,83]. Currently, there is a specific emphasis by regulatory bodies on the safety and
effectiveness of digital tools. Future priorities of regulation must be an equally strong focus on
health technology being equitable and inclusive. Regulatory bodies can also play a greater role
in the concomitant monitoring and reevaluation of any digital technology approved for use.
Ultimately, stronger and more collaborative digital relationships between countries and net-
works such as the European Union or the OECD need to be forged to allow for smooth transi-
tion and sharing of newer technologies, data, and ideas and provide development assistance
for digital health in LMICs. To date, the US Agency for International Development has pub-
lished its plans in a report entitled Vision for Action in Digital Health. Within economic and
geopolitical networks, a more coordinated plan is necessary to elevate the overall introduction,
implementation, and evaluation of digital technologies globally.
There is global variation in the uptake of digital health. As per the WHO global strategy on
digital health, more than 120 member nations have adopted such policies, but this implies the
lack of similar strategies in the remaining countries [6]. Furthermore, the effectiveness of these
policies is variable, questionable and unknown in most settings. Of course, there is a diverse
range of work carried out confirming the effectiveness of digital technology in developed
countries, but these studies also characterize a variation in the demographic reach even in
high-income countries, with the lower socioeconomic cohorts inevitably left behind. If this is
the case in wealthier nations, the variation in the reach of digital health technologies and the

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PLOS DIGITAL HEALTH An introduction to digital determinants of health

respective policies is doubtful and alarming. For example, the 99DOTS program is a mobile
phone-based initiative for monitoring tuberculosis medication adherence among more than
150,000 patients in India’s public health sector. Although hailed as a successful public and digi-
tal health initiative, studies have reported poor medication adherence and premature cessation
of therapy due to poor cell phone accessibility, cellular signal, and literacy [15]. Similarly, the
COVID-19 pandemic led to increased and accelerated global uptake of telemedicine, symptom
checkers, and mobile phone applications [84]. While success stories have been reported in
wealthier nations, similar reports are more scarce in LMICs [85,86]. Lastly, the political sys-
tems of different countries introduce another complexity to how digital health can be priori-
tized on the agenda [87,88]. Overall, even if there is a widespread digital health strategy
present, its practical implementation is open to challenges, and governments need to con-
stantly introduce, evaluate, and adapt their digital health policies.

Conclusion
With the increasing use of digital health in healthcare, the potential for health inequities it
poses must be addressed. In tandem with ongoing work to minimize the digital divide cause
by existing SDOH, further work is necessary to recognize digital determinants as an important
and distinct entity. This will allow for dedicated efforts to address their impact and lobby orga-
nizations, regulatory bodies, health systems, and governments to design technology that is
truly digitally inclusive. In the remainder of the series, we will evaluate on each of the subtopic
outlined in this introductory topic and expand upon their impact and implications on delivery
of healthcare services in a safe and equitable manner.

References
1. Kickbusch I, Piselli D, Agrawal A, Balicer R, Banner O, Adelhardt M, et al. The Lancet and Financial
Times Commission on governing health futures 2030: growing up in a digital world. Lancet. 2021;398.
2. Shuren J, Patel B, Gottlieb S. FDA regulation of mobile medical apps. JAMA. 2018;320. https://doi.org/
10.1001/jama.2018.8832 PMID: 29971339
3. Palacholla RS, Fischer N, Coleman A, Agboola S, Kirley K, Felsted J, et al. Provider- And patient-
related barriers to and facilitators of digital health technology adoption for hypertension management:
Scoping review. JMIR Cardio. 2019;3. https://doi.org/10.2196/11951 PMID: 31758771
4. Frank SR, Williams JR, Veiel EL. Digital health care: where health care, information technology, and the
Internet converge. Manag Care Q. 2000; 8(3).
5. Food and Drug Administration (FDA). What is Digital Health? [Internet]. 2020. Available from: https://
www.fda.gov/medical-devices/digital-health-center-excellence/what-digital-health.
6. WHO. Global strategy on digital health 2020–2025 [Internet]. 2020 [cited 2022 Jun 1]. Available from:
https://www.who.int/docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d.pdf.
7. Department of Health and Social Care. NHSX: new joint organisation for digital, data and technology.
Dep Heal Soc Care. 2019;(February 2019).
8. Honeyman M, Maguire D, Evans H, Davies A. Digital technology and health inequalities: a scoping
review. Cardiff Public Heal Wales NHS Trust. 2020.
9. Islam MM. Social determinants of health and related inequalities: Confusion and implications. Front
Public Health. 2019;7.
10. The Lancet Digital Health. Digital technologies: a new determinant of health. Lancet Digit Health.
2021;3.
11. Lomazzi M, Borisch B, Laaser U. The Millennium Development Goals: Experiences, achievements and
what’s next. Global Health Action. 2014;7. https://doi.org/10.3402/gha.v7.23695 PMID: 24560268
12. World Health Organization. Health in 2015: from MDGs, Millennium Development Goals to SDGs, Sus-
tainable Development Goals. World Heal Organ. 2015.
13. Menne B, Aragon De Leon E, Bekker M, Mirzikashvili N, Morton S, Shriwise A, et al. Health and well-
being for all: An approach to accelerating progress to achieve the Sustainable Development Goals
(SDGs) in countries in the WHO European Region. Eur J Public Health. 2020:30.

PLOS Digital Health | https://doi.org/10.1371/journal.pdig.0000346 January 4, 2024 11 / 14

PLOS DIGITAL HEALTH An introduction to digital determinants of health

14. Thomas BE, Kumar JV, Periyasamy M, Khandewale AS, Mercy JH, Raj EM, et al. Acceptability of the
medication event reminder monitor for promoting adherence to multidrug-resistant tuberculosis therapy
in two indian cities: Qualitative study of patients and health care providers. J Med Internet Res. 2021; 23
(6). https://doi.org/10.2196/23294 PMID: 34110300
15. Thomas BE, Vignesh Kumar J, Onongaya C, Bhatt SN, Galivanche A, Periyasamy M, et al. Explaining
differences in the acceptability of 99DOTS, a cell phone-based strategy for monitoring adherence to
tuberculosis medications: Qualitative study of patients and health care providers. JMIR Mhealth
Uhealth. 2020; 8(7). https://doi.org/10.2196/16634 PMID: 32735220
16. Thomas BE, Kumar JV, Chiranjeevi M, Shah D, Khandewale A, Thiruvengadam K, et al. Evaluation of
the Accuracy of 99DOTS, a Novel Cellphone-based Strategy for Monitoring Adherence to Tuberculosis
Medications: Comparison of DigitalAdherence Data with Urine Isoniazid Testing. Clin Infect Dis. 2020;
71(9). https://doi.org/10.1093/cid/ciaa333 PMID: 32221550
17. Coiera E. The cognitive health system. Lancet. 2020;395.
18. Mühleisen M. The long and short of the digital revolution. Finance Dev. 2018;55.
19. Finlayson A. Nuclear Medicine or Nuclear Weapons: The Digital Determinants of Health. 2019.
20. WHO. Fifty-Eighth World Health Assembly. Geneva, 16–25 May 2005. Resolutions and Decisions.
Annex. WHA58/2005/REC/1. 2005.
21. Good Things Foundation, Yates S. The Real Digital Divide? Understanding the demographics of non-
users and limited users of the internet: an analysis of Ofcom data. Good Things Found. 2017;(June).
22. Unlocking digital healthcare in lower and middle income countries [Internet]. 2021. Available from:
https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/unlocking-digital-
healthcare-in-lower-and-middle-income-countries.
23. Sieck CJ, Sheon A, Ancker JS, Castek J, Callahan B, Siefer A. Digital inclusion as a social determinant
of health. Digit Med. 2021; 4:npj. https://doi.org/10.1038/s41746-021-00413-8 PMID: 33731887
24. Etienne CF. 8 Principles for Digital Transformation of Public Health [Internet]. 2021. Available from:
https://www.paho.org/en/information-systems-and-digital-health/8-principles-digital-transformation-
public-health.
25. Marmot M. The Solid Facts: the social determinants of health. Health Promot J Austr. 1999; 9(2).
26. Dahlgren G, Whitehead M. The Dahlgren-Whitehead model of health determinants: 30 years on and
still chasing rainbows. Public Health. 2021;199.
27. Bresolin LB. Health literacy: Report of the council on scientific affairs. JAMA. 1999; 281(6).
28. Norman CD, Skinner HA. eHealth literacy: Essential skills for consumer health in a networked world. J
Med Internet Res. 2006;8.
29. The King’s Fund. Digital health care: our position. Kings Fund. 2019.
30. Estacio EV, Whittle R, Protheroe J. The digital divide: Examining socio-demographic factors associated
with health literacy, access and use of internet to seek health information. J Health Psychol. 2019; 24
(12). https://doi.org/10.1177/1359105317695429 PMID: 28810415
31. Yoon H, Jang Y, Vaughan PW, Garcia M. Older Adults’ Internet Use for Health Information: Digital
Divide by Race/Ethnicity and Socioeconomic Status. J Appl Gerontol. 2020; 39(1). https://doi.org/10.
1177/0733464818770772 PMID: 29661052
32. Cherid C, Baghdadli A, Wall M, Mayo NE, Berry G, Harvey EJ, et al. Current level of technology use,
health and eHealth literacy in older Canadians with a recent fracture—a survey in orthopedic clinics.
Osteoporos Int. 2020; 31(7). https://doi.org/10.1007/s00198-020-05359-3 PMID: 32112118
33. Lyu S, Sun J. Internet use and self-rated health among Chinese older adults: The mediating role of
social capital. Geriatr Gerontol Int. 2021; 21(1). https://doi.org/10.1111/ggi.14090 PMID: 33280230
34. George AS, Morgan R, Larson E, Lefevre A. Gender dynamics in digital health: Overcoming blind spots
and biases to seize opportunities and responsibilities for transformative health systems. J Public Heal
(United Kingdom). 2018:40. https://doi.org/10.1093/pubmed/fdy180 PMID: 30307517
35. Chib A, Wilkin H, Ling LX, Hoefman B, Van Biejma H. You have an important message! Evaluating the
effectiveness of a text message HIV/AIDS campaign in Northwest Uganda. J Health Commun. 2012;
17(SUPPL. 1).
36. Corker J. “Ligne Verte” toll-free hotline: using cell phones to increase access to family planning informa-
tion in the Democratic Republic of Congo. Cases Public Heal Commun Mark. 2010:III.
37. Crocco AG, Villasis-Keever M, Jadad AR. Analysis of cases of harm associated with use of health infor-
mation on the internet. JAMA. 2002;287.
38. Implementing Telehealth in Practice: ACOG Committee Opinion Summary, Number 798. Obstet Gyne-
col. 2020; 135(2).

PLOS Digital Health | https://doi.org/10.1371/journal.pdig.0000346 January 4, 2024 12 / 14

PLOS DIGITAL HEALTH An introduction to digital determinants of health

39. Centers for Disease Control and Prevention. Facts About Developmental Disabilities. Center for Dis-
ease Control and Prevention. 2020.
40. Aggarwal NK, Pieh MC, Dixon L, Guarnaccia P, Alegrı́a M, Lewis-Fernández R. Clinician descriptions
of communication strategies to improve treatment engagement by racial/ethnic minorities in mental
health services: A systematic review. Patient Educ Couns. 2016;99. https://doi.org/10.1016/j.pec.2015.
09.002 PMID: 26365436
41. Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedi-
cine worldwide: A systematic review. J Telemed Telecare. 2018;24. https://doi.org/10.1177/
1357633X16674087 PMID: 29320966
42. Dezateux C, Banner N, Boomla K, Chessell M, Michie S NJ. Our data-driven future in healthcare: Peo-
ple and partnerships at the heart of health related technologies. 2018.
43. Niazi MKK, Parwani AV, Gurcan MN. Digital pathology and artificial intelligence. Lancet Oncol.
2019;20.
44. Young AT, Xiong M, Pfau J, Keiser MJ, Wei ML. Artificial Intelligence in Dermatology: A Primer. J Invest
Dermatol. 2020;140. https://doi.org/10.1016/j.jid.2020.02.026 PMID: 32229141
45. NHSX. Artificial Intelligence: How to get it right. Nhsx. 2019;(October).
46. Bobrowski D, Joshi H. Unmasking A.I.’s bias in healthcare: The need for diverse data. Univ Toronto
Med J. 2019; 96(1).
47. Sounderajah V, Ashrafian H, Rose S, Shah NH, Ghassemi M, Golub R, et al. A quality assessment tool
for artificial intelligence-centered diagnostic test accuracy studies: QUADAS-AI. Nat Med. 2021;27.
https://doi.org/10.1038/s41591-021-01517-0 PMID: 34635854
48. Gianfrancesco MA, Tamang S, Yazdany J, Schmajuk G. Potential Biases in Machine Learning Algo-
rithms Using Electronic Health Record Data. JAMA Intern Med. 2018;178. https://doi.org/10.1001/
jamainternmed.2018.3763 PMID: 30128552
49. O’Reilly-Shah VN, Gentry KR, Walters AM, Zivot J, Anderson CT, Tighe PJ. Bias and ethical consider-
ations in machine learning and the automation of perioperative risk assessment. Br J Anaesth.
2020;125. https://doi.org/10.1016/j.bja.2020.07.040 PMID: 32838979
50. Parikh RB, Teeple S, Navathe AS. Addressing Bias in Artificial Intelligence in Health Care. JAMA.
2019;322.
51. Chen IY, Pierson E, Rose S, Joshi S, Ferryman K, Ghassemi M. Ethical Machine Learning in Health-
care. Annu Rev Biomed Data Sci. 2021; 4(1).
52. Strouse JJ, Lobner K, Lanzkron S, Haywood C. NIH and National Foundation Expenditures For Sickle
Cell Disease and Cystic Fibrosis Are Associated With Pubmed Publications and FDA Approvals. Blood.
2013; 122(21).
53. Mathur R, Bhaskaran K, Chaturvedi N, Leon DA, Van Staa T, Grundy E, et al. Completeness and usabil-
ity of ethnicity data in UK-based primary care and hospital databases. J Public Heal (United Kingdom).
2014; 36(4).
54. Densley JA, Pyrooz DC. The Matrix in Context: Taking Stock of Police Gang Databases in London and
Beyond. Youth Justice. 2020; 20(1–2).
55. Hao K. Artificial intelligence is creating a new colonial world order. MIT Technol Rev. 2022.
56. Laz TH, Berenson AB. Racial and ethnic disparities in internet use for seeking health information
among young women. J Health Commun. 2013; 18(2).
57. Agarwal R, Animesh A, Prasad K. Social interactions and the “digital divide”: Explaining variations in
internet use. Inf Syst Res. 2009; 20(2).
58. Improvement NHS. NHS Long Term Plan Implementation Framework. NHS Improv. 2019;(June).
59. Jubran A, Tobin MJ. Reliability of pulse oximetry in titrating supplemental oxygen therapy in ventilator-
dependent patients. Chest. 1990; 97(6).
60. Bickler PE, Feiner JR, Severinghaus JW. Effects of skin pigmentation on pulse oximeter accuracy at
low saturation. Anesthesiology. 2005; 102(4).
61. Feiner JR, Severinghaus JW, Bickler PE. Dark skin decreases the accuracy of pulse oximeters at low
oxygen saturation: The effects of oximeter probe type and gender. Anesth Analg. 2007; 105(SUPPL. 6).
62. Fawzy A, Wu TD, Wang K, Robinson ML, Farha J, Bradke A, et al. Racial and Ethnic Discrepancy in
Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-19.
JAMA Intern Med. 2022 May.
63. Glied S, Lleras-Muney A. Technological innovation and inequality in health. Demography. 2008; 45(3).
64. Ibrahim H, Liu X, Zariffa N, Morris AD, Denniston AK. Health data poverty: an assailable barrier to equi-
table digital health care. Lancet Digit Health. 2021;3.

PLOS Digital Health | https://doi.org/10.1371/journal.pdig.0000346 January 4, 2024 13 / 14

PLOS DIGITAL HEALTH An introduction to digital determinants of health

65. Mitchell UA, Chebli PG, Ruggiero L, Muramatsu N. The Digital Divide in Health-Related Technology
Use: The Significance of Race/Ethnicity. Gerontologist. 2019; 59(1).
66. Tomašev N, Glorot X, Rae JW, Zielinski M, Askham H, Saraiva A, et al. A clinically applicable approach
to continuous prediction of future acute kidney injury. Nature. 2019; 572(7767).
67. Knitza J, Mohn J, Bergmann C, Kampylafka E, Hagen M, Bohr D, et al. Accuracy, patient-perceived
usability, and acceptance of two symptom checkers (Ada and Rheport) in rheumatology: interim results
from a randomized controlled crossover trial. Arthritis Res Ther. 2021; 23(1).
68. Du-Harpur X, Watt FM, Luscombe NM, Lynch MD. What is AI? Applications of artificial intelligence to
dermatology. Br J Dermatol. 2020;183. https://doi.org/10.1111/bjd.18880 PMID: 31960407
69. DeSilva J. 2020 Market Insights Report: Chasing a new equilibrium [Internet]. 2020. Available from:
https://rockhealth.com/insights/2020-market-insights-report-chasing-a-new-equilibrium/.
70. Tangari G, Ikram M, Ijaz K, Kaafar MA, Berkovsky S. Mobile health and privacy: Cross sectional study.
BMJ. 2021:373.
71. Chambers D, Cantrell AJ, Johnson M, Preston L, Baxter SK, Booth A, et al. Digital and online symptom
checkers and health assessment/triage services for urgent health problems: Systematic review. BMJ
Open. 2019; 9(8). https://doi.org/10.1136/bmjopen-2018-027743 PMID: 31375610
72. Zidaru T, Morrow EM, Stockley R. Ensuring patient and public involvement in the transition to AI-assis-
ted mental health care: A systematic scoping review and agenda for design justice. Health Expect.
2021;24. https://doi.org/10.1111/hex.13299 PMID: 34118185
73. McInerney C, McCrorie C, Benn J, Habli I, Lawton T, Mebrahtu TF, et al. Evaluating the safety and
patient impacts of an artificial intelligence command centre in acute hospital care: a mixed-methods pro-
tocol. BMJ Open. 2022; 12(3).
74. Pourmand A, Ghassemi M, Sumon K, Amini SB, Hood C, Sikka N. Lack of Telemedicine Training in
Academic Medicine: Are We Preparing the Next Generation? Telemed e-Health. 2021; 27(1). https://
doi.org/10.1089/tmj.2019.0287 PMID: 32294025
75. Kirkland EB, DuBose-Morris R, Duckett A. Telehealth for the internal medicine resident: A 3-year longi-
tudinal curriculum. J Telemed Telecare. 2021; 27(9). https://doi.org/10.1177/1357633X19896683
PMID: 31888396
76. Wong R, Ng P, Spinnato T, Taub E, Kaushal A, Lerman M, et al. Expanding Telehealth Competencies
in Primary Care: A Longitudinal Interdisciplinary Simulation to Train Internal Medicine Residents in
Complex Patient Care. J Grad Med Educ. 2020; 12(6). https://doi.org/10.4300/JGME-D-20-00030.1
PMID: 33391599
77. Ng Alexander. How technology can improve the patient experience: A view from Tencent’s Alex Ng.
McKinsey Co. 2019.
78. Jing M, Dai S. China recruits Baidu, Alibaba and Tencent to AI ‘national team.’. South China Morning
Post. 2017.
79. WHO. Ethics and Governance of Artificial Intelligence for Health: WHO guidance. World Health Organi-
zation. 2021.
80. Bærøe K, Miyata-Sturm A, Henden E. How to achieve trustworthy artificial intelligence for health. Bull
World Health Organ. 2020; 98(4). https://doi.org/10.2471/BLT.19.237289 PMID: 32284649
81. Kerasidou A. Ethics of artificial intelligence in global health: Explainability, algorithmic bias and trust. J
Oral Biol Craniofacial Res. 2021; 11(4).
82. Murphy K, Di Ruggiero E, Upshur R, Willison DJ, Malhotra N, Cai JC, et al. Artificial intelligence for good
health: a scoping review of the ethics literature. BMC Med Ethics. 2021; 22(1).
83. Corbett J, d’Angelo C, Gangitano L, Freeman J. Future of Health: Findings from a survey of stakehold-
ers on the future of health and healthcare in England. Future of Health: Findings from a survey of stake-
holders on the future of health and healthcare in England. 2017.
84. McDonald S. Coronavirus: A Digital Governance Emergency of International Concern. Centre for Inter-
national Governance Innovation. 2020.
85. Goggin G. COVID-19 apps in Singapore and Australia: reimagining healthy nations with digital technol-
ogy. Media Int Aust. 2020; 177(1).
86. Crawford A, Serhal E. Digital health equity and COVID-19: The innovation curve cannot reinforce the
social gradient of health. J Med Internet Res. 2020;22. https://doi.org/10.2196/19361 PMID: 32452816
87. Fountain J. The Wicked Nature of Digital Transformation: A policy perspective. Dubai Policy Rev. 2019;
1(1).
88. Lewandowsky S, Smillie L, Garcia D, Hertwig R, Weatherall J, Egidy S, et al. JRC Science for Policy
Report: Technology and Democracy—Unterstanding the influence of online technologies on political
behaviour and decision-making. Skupno raziskovalno središče. 2020.

PLOS Digital Health | https://doi.org/10.1371/journal.pdig.0000346 January 4, 2024 14 / 14