Challenges in the development of digital public health interventions and mapped solutions: Findings from a scoping review

“Our reports adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for scoping reviews.(13) Data sources”

“We followed Arksey and O ’ Malley ’ s framework for scoping reviews, 11 with adaptations suggested by Levac et al.. 12 Our reports adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for scoping reviews.”

“We followed Arksey and O’Malley’s framework for scoping reviews,(11) with adaptations suggested by Levac et al..(12) Our reports adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for scoping reviews.”

“9 However, public health action requires wide-ranging public engagement, a population health perspective, and prompt information exchange and cooperation across diverse organizations and public health agencies.”

“24,39,40 43 Health equity.”

“52,154 There is an ethical imperative to implement such strategies as misinfor-mation and disinformation ampli fi ed through digital technology has signi fi cant public health consequences.”

“163,164 However, we remain con fi - dent that the broad challenges and strategies identi fi ed in this review remain relevant in our current context.”

“Further, the iterative and fast-paced evolution of digital technologies is not matched by current research methods which are often rigid and slow to adapt.(27,36,43,45,77,82,83,88,89) There is also a lack of widely agreed-upon standards for assessing outcomes(55,90) and reliable outcome measures that extend beyond use…”

“48,92 Reliance on non-validated user-provided information was also said to reduce chances of successful follow-up in cases of attrition 93 and reduce the representativeness of data.”

“35,48,77,82,83,86,90,91 Further, interventions were frequently implemented on a small scale and their associated evaluations were described as poorly generalizable.”

“56, 69, 104, 105 The nature of such platforms that Unreliability of available data.”

“44,72,134,145 Transparent communication and public engagement.”

“Articles suggested that digital technologies may propagate a reductionist view on public health that ignores underlying social, economic, environmental, and commercial determinants of health, reducing their effectiveness.(17,38,41,42,87,106,112) Further, inherent biases in assumptions and algorithms facilitating techn…”

“157,158 Leveraging these key pillars as a central aspect of a digital public health strategy can be an effective starting point to ensure the successful development of the fi eld.”

“89,116,125 Further, the unreliability of unvalidated or anonymous user-generated and/or observational data 52,56,79,80,83,91,92,118,126 – 128 were said to bias reports.”

“25,37,54,73,110,136 The public health workforce has not been supported to develop these capacities at the same pace as the push for development of the technologies required in digital public health.”

“24,39,40 43 Health equity.”

“52,154 There is an ethical imperative to implement such strategies as misinfor-mation and disinformation ampli fi ed through digital technology has signi fi cant public health consequences.”

“Articles suggested that digital technologies may propagate a reductionist view on public health that ignores underlying social, economic, environmental, and commercial determinants of health, reducing their effectiveness.(17,38,41,42,87,106,112) Further, inherent biases in assumptions and algorithms facilitating techn…”

“67 This also involves wide-ranging collaboration and action among government agencies, in partnership with other stakeholders, to ensure that data governance and accountability frameworks are adaptable, proactive, and person-centered.”

“21,38,40,46,73,85,89,91,101,116,125,129,130 Fragmented, isolated, and unsustainable systems.”

“56, 69, 104, 105 The nature of such platforms that Unreliability of available data.”

“21,38,40,46,73,85,89,91,101,116,125,129,130 Fragmented, isolated, and unsustainable systems.”

“35,48,77,82,83,86,90,91 Further, interventions were frequently implemented on a small scale and their associated evaluations were described as poorly generalizable.”

“Articles suggested that digital technologies may propagate a reductionist view on public health that ignores underlying social, economic, environmental, and commercial determinants of health, reducing their effectiveness.(17,38,41,42,87,106,112) Further, inherent biases in assumptions and algorithms facilitating techn…”

“7,8 Many of these challenges apply to digital health generally and are not speci fi c to digital public health.”

“These technologies were said to sometimes draw false associations and conclusions, perpetuate stigma, and widen health disparities.(28,36,113,114)”

“Overall, the authors suggest that these challenges result in poor health behaviors and over-medicalization of common health problems,(56,62,77,80,108) with public health practitioners struggling to control the messaging within these fast-moving media platforms.(95)”

“22,73,118,132,138,139 More robust computing infrastructure, 25,64,132,138 including high-bandwidth, low-latency computer networks and clusters of machines for computation 19,25,60 are required to take advantage of high-volume data.”

“6,7,115,155 For example, privacy and security issues have been documented in relation to public health surveillance.”

“New methodology suitable for the peculiar pace of development and application of digital technologies, with appropriate measures of health outcomes, are also required to advance research and evaluation in digital public health.(21,27,40,48,58,77,146,149,152) Mechanisms for actively sharing these methods were emphasize…”

“21,27,40,48,58,77,146,149,152 Mechanisms for actively sharing these methods were emphasized, including networks and inter-sectorial communities of practice.”

“21,38,40,46,73,85,89,91,101,116,125,129,130 Fragmented, isolated, and unsustainable systems.”

“21,38,40,46,73,85,89,91,101,116,125,129,130 Fragmented, isolated, and unsustainable systems.”

“21,27,40,48,58,77,146,149,152 Mechanisms for actively sharing these methods were emphasized, including networks and inter-sectorial communities of practice.”

“These identified solutions which we refer to as key pillars of digital public health, validate suggestions made by the European Public Health Association (EUPHA).(2) These pillars must be closely considered in tandem with the foundational principles guiding public health practice to create a clear agenda for the ongoi…”

“Articles suggested that digital technologies may propagate a reductionist view on public health that ignores underlying social, economic, environmental, and commercial determinants of health, reducing their effectiveness.(17,38,41,42,87,106,112) Further, inherent biases in assumptions and algorithms facilitating techn…”

“Our methods and findings about the definition of the field have been described in detail elsewhere.(5,10) Here we focus on the challenges and recommended solutions to support the development and implementation of digital public health interventions.”

“66,77,148 Standardized reporting systems and requirements, 22,77,145 data quality standards, and shared digital architecture 22,23,77,144,145 were suggested as mechanisms to ensure reliable and interoperable data systems to foster improved use of data for decision making.”

“The transdisciplinary nature of digital public health interventions and the diversity of regulatory bodies involved in their development and implementation further reinforces the inadequacy of existing policy interventions.(22,32,54,77)”

“Further disease and/or areaspecific funding for digital interventions(99,131) and ad hoc design of these systems were said to result in multiple isolated systems developed by different agencies and technology providers.(4,27,31,133) The development and implementation of piecemeal interventions with limited funding tha…”

“21,38,40,46,73,85,89,91,101,116,125,129,130 Fragmented, isolated, and unsustainable systems.”

“122 Further, data quality issues, including incomplete data, were said to be a challenge, 24,40,120,123,124 especially for big data in public health surveillance and research, where noisy data (i.e. poor quality data) reduces ef fi ciency.”

“98 Many public health agencies lack access to such computing or IT power.”

“89,116,125 Further, the unreliability of unvalidated or anonymous user-generated and/or observational data 52,56,79,80,83,91,92,118,126 – 128 were said to bias reports.”

“55 Where there are standards, public health professionals have been shown to have sub-optimal awareness of existing data reporting standards 22 and data quality requirements across systems.”

“27,53,145,148 Such partnerships were also deemed important for creating coherent and coordinated interoperability, governance, and research frameworks, and garnering required resources, knowledge, and capacities to harness the potential of digital public health interventions.”

“6,7,115,155 For example, privacy and security issues have been documented in relation to public health surveillance.”

“22,32,54,77 Paucity of high-quality evidence.”

“21,26,33,35,38,40,73,74 Widespread lack of digital health equity implementation frameworks and rigorous evaluation of the equity impacts of these digital technologies may further complicate equity challenges.”

“89,116,125 Further, the unreliability of unvalidated or anonymous user-generated and/or observational data 52,56,79,80,83,91,92,118,126 – 128 were said to bias reports.”

“– 87 Articles noted the inad-equacy of cost – analysis evidence, speci fi cally the costs of these interventions to individuals and health systems, 36,64,77 and the mostly retrospective use of data in existing research that may be biased or have missing data.”

“17,98”

“30,40,117,136,149 Further, recommendations involved integrating research and evaluation in all stages of development and implementation of digital interventions.”

“21,38,40,46,73,85,89,91,101,116,125,129,130 Fragmented, isolated, and unsustainable systems.”

“Yet, resistance to these new approaches within public health and the tendency to suppress data especially with suboptimal interventions, introduce additional challenges that must be navigated.(3) The speed of technological development must also be considered in these frameworks.”

“35,48,77,82,83,86,90,91 Further, interventions were frequently implemented on a small scale and their associated evaluations were described as poorly generalizable.”

“22,37,43,63,64,73,98,99,123,131,135 Public health agencies are said to have challenges with engaging and retaining highly demanded tech-savvy public health analysts.”

“56, 69, 104, 105 The nature of such platforms that Unreliability of available data.”

“89,116,125 Further, the unreliability of unvalidated or anonymous user-generated and/or observational data 52,56,79,80,83,91,92,118,126 – 128 were said to bias reports.”

“21,38,40,46,73,85,89,91,101,116,125,129,130 Fragmented, isolated, and unsustainable systems.”

“21,27,40,48,58,77,146,149,152 Mechanisms for actively sharing these methods were emphasized, including networks and inter-sectorial communities of practice.”

“24,39,40 43 Health equity.”

“162 Further, for pragmatic policies to be made and implemented appropriately, public health policy makers, practitioners, and researchers will require continued education on new working methods in a digital environment.”

“Further, inherent biases in assumptions and algorithms facilitating technologies like artificial intelligence, big data, and social media in public health were reported to potentially make them counterproductive to public health goals.(21,28,36,47,113,114) These technologies were said to sometimes draw false associati…”

“27,36,43,45,77,82,83,88,89 There is also a lack of widely agreed-upon standards for assessing outcomes 55,90 and reliable outcome measures that extend beyond user engagement metrics.”

“26,31,32,35,33 34 Additional ethical barriers include the potential identi fi cation of individual disease risks and exposures through digital technologies without clear remedies, 36 – 38 perpetuation of stigma through data collection methods that do not acknowledge the existing context.”

“Further, the iterative and fast-paced evolution of digital technologies is not matched by current research methods which are often rigid and slow to adapt.(27,36,43,45,77,82,83,88,89) There is also a lack of widely agreed-upon standards for assessing outcomes(55,90) and reliable outcome measures that extend beyond use…”

“21,38,40,46,73,85,89,91,101,116,125,129,130 Fragmented, isolated, and unsustainable systems.”

“122 Further, data quality issues, including incomplete data, were said to be a challenge, 24,40,120,123,124 especially for big data in public health surveillance and research, where noisy data (i.e. poor quality data) reduces ef fi ciency.”

“Articles described challenges with policy keeping pace with evolving digital technologies in public health, 20,23,26,40,50,63,64,75 – 79 resulting in reactive policies that are restrictive (often limiting data exchange), inadequate to support the development and implementation of digital…”

“4,22,64,103,141 Standards for evaluating the impact of digital technologies on health outcomes are also suboptimal.”

“21,38,40,46,73,85,89,91,101,116,125,129,130 Fragmented, isolated, and unsustainable systems.”

“36,64,108,136 Suboptimal design and implementation of digital technologies.”

“35,48,77,82,83,86,90,91 Further, interventions were frequently implemented on a small scale and their associated evaluations were described as poorly generalizable.”

“19 Articles suggest that such curricula may be made open through communities of practice and interdisciplinary workforce exchanges to foster equitable knowledge uptake.”

“122 Further, data quality issues, including incomplete data, were said to be a challenge, 24,40,120,123,124 especially for big data in public health surveillance and research, where noisy data (i.e. poor quality data) reduces ef fi ciency.”

“35,48,77,82,83,86,90,91 Further, interventions were frequently implemented on a small scale and their associated evaluations were described as poorly generalizable.”

“The overly enthusiastic assumption that digital technologies provide a catchall solution to public health challenges without due consideration of alternative approaches and foundational principles of public health was noted.(18,38,40,111) Articles suggested that digital technologies may propagate a reductionist view o…”

“22,23,26,28,50,103,121,131,132 This partly results from privacy and con fi dentiality concerns, 22,37 and infrastructure/capacity gaps.”

“44,72,134,145 Transparent communication and public engagement.”

“89,116,125 Further, the unreliability of unvalidated or anonymous user-generated and/or observational data 52,56,79,80,83,91,92,118,126 – 128 were said to bias reports.”

“54 Governance challenges in supporting interjurisdictional digital interventions were also highlighted, 20,22,29,30,50 especially for technologies not requiring in-person attendance.”

“66,77,148 Standardized reporting systems and requirements, 22,77,145 data quality standards, and shared digital architecture 22,23,77,144,145 were suggested as mechanisms to ensure reliable and interoperable data systems to foster improved use of data for decision making.”

“35,48,77,82,83,86,90,91 Further, interventions were frequently implemented on a small scale and their associated evaluations were described as poorly generalizable.”

“159,160 However, we must note that achieving transdis-ciplinary partnerships will be challenging given differences in vocabulary across disciplines and varied epistemological viewpoints that guide practice and research.”

“22,37,43,63,64,73,98,99,123,131,135 Public health agencies are said to have challenges with engaging and retaining highly demanded tech-savvy public health analysts.”

“122 Further, data quality issues, including incomplete data, were said to be a challenge, 24,40,120,123,124 especially for big data in public health surveillance and research, where noisy data (i.e. poor quality data) reduces ef fi ciency.”

“22,133,137 Infrastructure gaps.”

“Where there are standards, public health professionals have been shown to have suboptimal awareness of existing data reporting standards(22) and data quality requirements across systems.(36,64,108,136)”

“22,36,134,140 Standards in vocabulary and health information exchange and coordination are lacking, resulting in suboptimal interoperability of varied systems relevant to public health functions.”

“25,37,54,73,110,136 The public health workforce has not been supported to develop these capacities at the same pace as the push for development of the technologies required in digital public health.”

“26,66,98,124,138,149 Open science, equity-based frameworks were also recommended with a focus on including outcomes for marginalized populations in publications.”

“54 Governance challenges in supporting interjurisdictional digital interventions were also highlighted, 20,22,29,30,50 especially for technologies not requiring in-person attendance.”

“22,32,54,77 Paucity of high-quality evidence.”

“21,73,121,147 Further, standardized ethical, legal, and regulatory frameworks are required to ensure seamless, secure data exchanges between health agencies and authorities.”

“22,37,43,63,64,73,98,99,123,131,135 Public health agencies are said to have challenges with engaging and retaining highly demanded tech-savvy public health analysts.”

“122,142 Mapped solutions to overcome technical and nontechnical challenges Potential solutions, as described in the literature, are summarized in Table 3.”

“21,26,33,35,38,40,73,74 Widespread lack of digital health equity implementation frameworks and rigorous evaluation of the equity impacts of these digital technologies may further complicate equity challenges.”

“This may be further exacerbated through the economic incentive to target high-income users with commercial digital health interventions.(71) Other equity challenges described include disparities in the impact of overlooked potential consequences of digital technologies, such as data privacy breaches, data misuse, and…”

“33–35,56,69,104,105 The nature of such platforms that leverage user-generated content(35,51,62,106) with relative anonymity(51,107) and unclear guidelines(43,105) were said to spread unverified and often questionable information.(34,43,51,52,108) Further, information overload on the public and the burden of health-inf…”

“135 Considering the heterogeneity of data required for public health functions, reporting standards are required to effectively pool data; however, these standards are yet to be developed.”

“43,94 Resource and economic interest barriers.”

“22,23,26,28,50,103,121,131,132 This partly results from privacy and con fi dentiality concerns, 22,37 and infrastructure/capacity gaps.”

“In addition to comprehensive training for PHC providers, continuous monitoring, updates, and quality assurance mechanisms must be embedded within these digital interventions in order to maximize the benefits of digital tools while minimizing the potential risks [85].”

“Ideally, hospital-system and research stakeholders need to identify constructs that have been shown to influence implementation processes and outcomes, understand potential mechanisms of change, and identify potential barriers and facilitators to successful implementation [13, 14].”

“Most often, complex health-related interventions are implemented in dynamic and diverse contexts [7, 43, 44].”