Addressing the digital determinants of health: health promotion must lead the charge

In 1986, more than 200 people gathered for the 1st International Conference on Health Promotion and laid the foundation for a new public health movement aimed at enabling people to increase control over, and to improve, their health (World Health Organization, 1986). Three years before the invention of the world wide web, the authors of the Ottawa Charter could not have predicted the scale and pace of digital transformation that we are experiencing today or how it might influence health promotion. Digital is now integrated into all aspects of life, including health (Kickbusch et al., 2021). People live, love, work, and play online. The digital world is therefore a new sphere in which health is created. Particularly for current and future generations of young people, the physical and digital worlds are closely intertwined. Like in the physical world, an individual’s experiences in (or exclusion from) digital environments are shaped by other social, political and commercial determinants and can impact their health and wellbeing in both positive and negative ways (Holly et al., 2023). This new setting for health is evolving at an unprecedented speed, as has recently been demonstrated with the rapid and widespread adoption of ChatGPT and other generative AI tools. The formal health system must adjust to this fast-changing reality, as must health promotion. With digitalization changing the way that health is perceived and the way that health care is delivered, there is no question that new forms of literacy are required to navigate this digital world of health. Digitally connected people can now readily access health-related information from websites and social media platforms and use an array of apps, sensors and other devices to manage their own health and wellbeing. As more people take advantage of these tools, dangerous health trends and misinformation are multiplied exponentially (Talabi et al., 2022). Young people from across the globe—who are ardent users and creators of digital tools to support their health and wellbeing—have expressed concerns about the challenges and risks associated with digital transformations of health (Governing Health Futures 2030 Commission, 2021). Digital transformations are now being recognized as important determinants of health. During the COVID-19 pandemic, it became obvious how disparities in digital access and digital literacy affect not only people’s access to health services but their health outcomes (Li, 2022; Adeleke, 2023). Tackling health-related misinformation and disinformation also became a high priority for national and global policymakers (Pomeranz and Schwid, 2021). The digital determinants of health influence equity in health and wellbeing both directly and indirectly (Kickbusch et al., 2021). The digital divide is a major driver of inequity with one-third of the world’s population still without internet access (ITU, 2023). For connected populations, direct impacts are generated through the application of digital technologies and approaches in healthcare. Indirect impacts are shaped by several factors such as the quality of digital connectivity; access to effective digital services (such as those related to education, finance, work, etc.); the nature of online content that users are exposed to; and levels of combined digital, health and civic literacy among healthcare professionals and the general population. The Geneva Charter for Wellbeing, developed in 2021, builds on the Ottawa Charter and other health promotion milestones by calling for action to address the digital determinants of health (World Health Organization, 2021). It recognizes that whilst digital transformations can provide many benefits to populations, there are harmful aspects to both digital exclusion and digital access. Young people’s mental health is a pertinent example of where balancing the positive and negative impacts of technology use is of great concern to caregivers, researchers, and practitioners (Hollis et al., 2020). For health promoters, digital tools and data offer new ways to reach individuals and communities with more personalized and targeted health promotion and disease prevention messages (Taba et al., 2023). Digital platforms provide spaces for people across the world to connect and support each other in improving personal and public health. Digital media can also be used for health promotion advocacy and to help strengthen accountability. But in addition to harnessing the potential of digital transformations, health promoters must also be very focussed on the ways in which poorly governed digital transformations can undermine health. On top of the rise of health-related misinformation, digital environments have opened up new channels for the marketing of unhealthy products and other forms of harmful content and abuse (Thomas et al., 2023). The longer-term effects of digital technology use on our physical and mental health, as well as the environmental impact of digitalization, are all areas of concern and subjects of intensifying research. Despite the all-encompassing influence of digital transformations on our health and wellbeing, their advantages and risks for health promotion are not being prioritized in digital development or policymaking. The health sector too has been distracted by the direct ways in which digital technologies can support health, for example, through stronger health information systems and access to digital health interventions, with insufficient attention paid to the indirect ways in which the broader digital transformations are changing the very nature of health. Too little has been done to curb the practices of powerful digital actors—including algorithmically-driven content and mass extraction of personal data—which undermine individual agency and control and are therefore at odds with the mission of health promotion which puts empowerment into the centre. That is why health promotion must not just be alert to digital transformations, as Thomas and Daube (Thomas and Daube, 2023) propose but tackle them head on. The Geneva Charter calls for coordinated action to address the digital determinants of health. For guidance on what these actions should be, policymakers and other stakeholders need look no further than the five action areas of the Ottawa Charter and the recommendations of the Lancet and Financial Times Commission on Governing Health Futures 2030 (GHFutures2030). Together, these two documents provide a roadmap for the shifts required in our management of health promotion in the digital age. The extent to which these digital determinants promote or undermine health is largely out of an individual’s or community’s—even a country’s—control. Governments are struggling to keep up with the pace of development in AI and other frontier technologies and evidence is limited on how these innovations are impacting on health and wellbeing. Digital actors need to be aware of the health consequences of their decisions and accept their responsibilities for health. GHFutures2030 has therefore argued that to address the digital determinants of health, governments and other stakeholders must take a precautionary and value-based approach to digital and data governance and close gaps in digital infrastructure and literacy (Kickbusch et al., 2021). Digital environments, like other environments, should be safe, stimulating, satisfying, and enjoyable. Continuous assessments should be made of the health impacts of digital environments with rapid action taken to mitigate any risks, especially to young people and marginalized groups. Steps should also be taken to minimize the environmental impact of digital transformations. The relationship between commercial and digital determinants deserves closer scrutiny as the digital and data economies become key drivers of economic development. The empowerment of communities is at the heart of health promotion. GHFutures 2030 highlighted the importance of enfranchising young people to understand and tackle the digital determinants of health. Further opportunities should therefore be created for young people to become confident digital health citizens who can critically examine the potential benefits and risks associated with digital transformations in health and then relay their ideas and concerns to policymakers and technology companies (Governing Health Futures 2030 Commission, 2021). Digital platforms have become a major channel for education, acquiring information, and learning skills. It is therefore critical that equity gaps in digital access and literacy are closed. All people should be equipped with the necessary combination of digital, health and civic knowledge and skills to enable them to distinguish between reliable and inaccurate health-related information and know what to do when faced with content or practices that could be detrimental to their health and wellbeing. As health systems across the world become digital first, it is critical that they leverage digital transformations to enhance health promotion alongside clinical and curative services. Policymakers should advance public participation in all stages of digital health policy technology development with targeted efforts made to enfranchise young people to co-design digital first health systems and services that are responsive to their current and future health needs. The health promotion community must lead the charge in driving these changes. The three basic strategies for health promotion remind us of our collective responsibility. Firstly, we must advocate loudly for digital transformations that are favourable to health. Secondly, we must enable all people to access and engage with digital environments in ways that allow them to achieve their health potential. And finally, we must mediate between the different actors in the digital health ecosystem and align them behind a common agenda of health for all.