JMIR Publications

ABSTRACT

Background:

Digital health technologies are transforming healthcare by improving access, efficiency, and quality of care. However, recent studies highlight that digitalization can unintentionally reinforce or deepen existing social and health inequalities, as not all population groups benefit equally from digital progress. The concept of Digital Determinants of Health (DDoH) has emerged to better capture how digital factors shape health opportunities and outcomes. The systematic incorporation of DDoH and their impact into strategic planning remains limited. As a result, health systems may lack structured approaches to identify them and anticipate their equity implications.

Objective:

This study aimed to (1) identify which health determinants are considered most important in the Catalan context, and (2) examine their inclusion in Catalan policies and strategic frameworks.

Methods:

We conducted a modified Delphi study with experts from the Catalan health and digital ecosystem. The list of determinants was derived from a scoping review, which identified 127 determinants emerging or changing with digitalization. Experts living and working in Catalonia, with experience in digital health, public health, health care delivery, social or DDoH, or health equity, were recruited using snowball sampling. Participants rated each determinant on a 5-point Likert scale regarding its importance, across two rounds followed by a final online consensus meeting. For each determinant, the median, interquartile range, and the proportion of experts rating it as 4 or 5 were calculated and classified items into high, moderate, or low relevance according to predefined consensus criteria.

Results:

A total of 43 experts participated in the first Delphi round and 31 completed the second round. Of the 127 assessed determinants, 20 (15.7%) reached high relevance for the Catalan context, including 15 digital, 4 social, and 1 political determinant. Overall, the most important determinants focused on enabling the effective and equitable use of digital health, particularly access, skills, system-level digital capacity and governance, inclusive design, and the responsible use of AI. Comparison with the original global Delphi study showed substantial overlap, but also revealed context-specific priorities.

Conclusions:

This study demonstrates the value of systematically contextualising DDoH and their impact to inform strategic health planning in digitally mature public health systems. The findings show that international digital health agendas require regional re-prioritisation to reflect local infrastructures, governance arrangements and equity challenges. The results suggest that, beyond technological capacity, governance and equity considerations should become central to digital health planning. The proposed approach offers a replicable framework to support more anticipatory, coordinated and equity-oriented digital health strategies.