Sustainable value generation from digital health investments: lessons from EU-funded projects preceding the European health data space.

The World Health Assembly Resolution on Digital Health unanimously approved by WHO Member States in May 2018 demonstrated a collective recognition of the value of digital technologies to contribute to advancing universal health coverage (UHC) and other health aims of the Sustainable Development Goals (SDGs). The World Health Organization has just released first ever guideline on digital interventions for health system strengthening. Et the European level, in June 2018 the WHO Regional Office for Europe launched the WHO/Europe initiative for Digitalization of Health Systems and in February 2019 organized the first Symposium on the Future of Digital Health Systems in the European Region. The European Commission in April 2018 published a Communication on Digital transformation of health and care in the digital single market and requested the Expert Panel on effective ways of investing in health (EXPH) to release an evidence-based opinion on how to assess the impact of digital transformation of health services. In such context, the European Public Health Association (EUPHA) has at an early stage acknowledged and understood the crucial importance of applying the potential offered by digitalization to public health. Not only its most prominent members work and research as WHO and EC experts on how to plan, implement and evaluate effective digital public health interventions, but EUPHA itself - as umbrella organization representing public health associations and institutes across Europe had: i) actively participated to the WHO Euro Symposium successfully co-organizing a session on the ‘beautiful marriage’ between digitalization and public health, ii) supported the publication of a EJPH supplement on digital health and iii) has planned to create a EUPHA Section on Digital Health. With the overall goal of positioning the proposed EUPHA Section on Digital Health in the enriching and constructive context of the European Public Health Conference the workshop specifically aims to: present a comprehensive conceptual framework for the application of digital technologies to public health in Europe;present and report on EUPHA collaborative action on digital health, aligned with European institutions;present the structure and content of the EJPH supplement on digital health;present the general aim, specific objectives, scope, mission and preliminary outputs of the proposed EUPHA Section on Digital Health, as well as its synergy with other EUPHA’s Section workPresent the results of two/three specific projects on digital public health to serve as concrete examples of the application of digital solutions to public healthEngage with the audience to promote the active participation of the broader EUPHA community to the activities of the Section, collect interests and best practices, and share ideas and projects worth scaling up at the Section-level. Key messages The ‘beautiful marriage’ between digitalization and public health has to be concretely planned, implemented and evaluated. EUPHA action on digital public health can be further strengthened through the collaborative action and work of its dedicated Section.

BackgroundAs mental illness continues to affect 1 in 5 individuals, and the need for support has increased during the COVID-19 pandemic, the promise of digital mental health tools remains largely unrealized due to a lack of uptake by patients and providers. Currently, most efforts on supporting the uptake of digital mental health tools remain fragmented across organizations and geography. There is a critical need to synthesize these efforts in order to provide a coordinated strategy of supporting the adoption of digital mental health tools.ObjectiveThe specific aim of this project is to develop a web-based resource document to support the engagement of mental health providers and patients in the use of digital mental health tools.MethodsThe web-based resource was developed using a multimethod approach. A grey literature review was conducted in 2019 to identify relevant toolkits that are available in the public domain. This was supplemented with an environmental scan where individuals with expertise in the development, acquisition, implementation, and evaluation of digital mental health tools were invited to contribute additional tools or documents not identified in the grey literature search. An engagement workshop was held with stakeholders to explore how the resource document should be developed and delivered. These findings were collectively used to develop the final iteration of the resource document.ResultsBased on a gray literature review and environmental scan with 27 experts, 25 resources were identified and included in the resource guide. These resources were developed for patients and providers by organizations from 5 countries. An engagement workshop was held with 14 stakeholders, and barriers related to cultural sensitivity, sustainability, and accessibility of the toolkit were identified. The final iteration of the resource document was developed by the research team using findings from the gray literature review, environmental scan, and engagement workshop. The contents of the 45-page resource guide are directed at mental health care providers, administrators, and patients (inclusive of families and caregivers).ConclusionsThe use of a multimethod approach led to the development of a resource guide that builds on existing evidence on digital mental health tools and was co-designed with stakeholders and end-users. The resource guide is now publicly available online for free and is being promoted through digital health and mental health websites. Future work should explore how this document can be integrated into clinical care delivery and pathways.

BackgroundRevealing the full potential of digital public health (DiPH) systems requires a wide-ranging tool to assess their maturity and readiness for emerging technologies. Although a variety of indices exist to assess digital health systems, questions arise about the inclusion of indicators of information and communications technology maturity and readiness, digital (health) literacy, and interest in DiPH tools by the society and workforce, as well as the maturity of the legal framework and the readiness of digitalized health systems. Existing tools frequently target one of these domains while overlooking the others. In addition, no review has yet holistically investigated the available national DiPH system maturity and readiness indicators using a multidisciplinary lens.ObjectiveWe used a narrative review to map the landscape of DiPH system maturity and readiness indicators published in the gray literature.MethodsAs original indicators were not published in scientific databases, we applied predefined search strings to the DuckDuckGo and Google search engines for 11 countries from all continents that had reached level 4 of 5 in the latest Global Digital Health Monitor evaluation. In addition, we searched the literature published by 19 international organizations for maturity and readiness indicators concerning DiPH.ResultsOf the 1484 identified references, 137 were included, and they yielded 15,806 indicators. We deemed 286 indicators from 90 references relevant for DiPH system maturity and readiness assessments. The majority of these indicators (133/286, 46.5%) had legal relevance (targeting big data and artificial intelligence regulation, cybersecurity, national DiPH strategies, or health data governance), and the smallest number of indicators (37/286, 12.9%) were related to social domains (focusing on internet use and access, digital literacy and digital health literacy, or the use of DiPH tools, smartphones, and computers). Another 14.3% (41/286) of indicators analyzed the information and communications technology infrastructure (such as workforce, electricity, internet, and smartphone availability or interoperability standards). The remaining 26.2% (75/286) of indicators described the degree to which DiPH was applied (including health data architecture, storage, and access; the implementation of DiPH interventions; or the existence of interventions promoting health literacy and digital inclusion).ConclusionsOur work is the first to conduct a multidisciplinary analysis of the gray literature on DiPH maturity and readiness assessments. Although new methods for systematically researching gray literature are needed, our study holds the potential to develop more comprehensive tools for DiPH system assessments. We contributed toward a more holistic understanding of DiPH. Further examination is required to analyze the suitability and applicability of all identified indicators in diverse health care settings. By developing a standardized method to assess DiPH system maturity and readiness, we aim to foster informed decision-making among health care planners and practitioners to improve resource distribution and continue to drive innovation in health care delivery.

Nigeria's persistent maternal, newborn, adolescent, and child health (MNACH) crisis impedes Sustainable Development Goal 3 (SDG 3). This paper examines digital health interventions to address systemic healthcare delivery failures and improve MNACH outcomes. Addressing the research gap concerning strategic implementation of digital health for MNACH in Nigeria, it critically assesses the current state, explores opportunities, identifies barriers, and proposes evidence-based policy and strategic recommendations for effective, equitable implementation. This study employs a comprehensive review of peer-reviewed literature, government reports, and grey literature from international organizations (WHO, UNICEF, ITU). Data sources were systematically searched using keywords related to digital health, MNACH, and healthcare in Nigeria. Synthesized and analyzed information identified key trends, challenges, and opportunities. Successful digital health initiatives in Nigeria and LMICs informed policy recommendations through case studies. Findings reveal digital health innovations (telemedicine, mHealth, EHRs) hold transformative potential to improve access, enhance health education, and facilitate timely interventions. Initiatives like MyPaddi app and drone delivery systems demonstrate feasibility and impact. However, significant barriers impede adoption: inadequate digital infrastructure, limited digital literacy, socioeconomic disparities, and public skepticism regarding data privacy and remote care quality. Policy and strategic recommendations focus on addressing these barriers through targeted interventions: investing in infrastructure, building capacity, fostering trust, co-developing culturally tailored mHealth solutions, and reforming policies for data governance, cross-sector partnerships, and sustainable financing. A digital health transformation roadmap for Nigeria (2025–2030) outlines a phased approach to foundational preparation, strategic scaling, and national integration. This roadmap emphasizes multi-stakeholder collaboration, equity-centered systems, and robust accountability mechanisms for sustainable, inclusive implementation. In conclusion, this review underscores the urgent need for a holistic, strategic approach to integrate digital health innovations into Nigeria’s healthcare framework. By addressing barriers and implementing recommendations, Nigeria can leverage digital health to enhance access, improve MNACH outcomes, and progress toward universal health coverage and SDG 3 by 2030, positioning Nigeria as a global leader in inclusive, sustainable healthcare innovation.

Public Health Finance

Sophisticated methodological approaches and measures for scaling up are key elements of effective evaluation Digital health technologies and services are significant contributors to the transformation of health care delivery. It has been estimated that 80% of technology projects fail1 due to uncertainty, abandonment and lack of organisational willingness to adopt.2 In response to the high failure rate, the discipline of benefits management has emerged, with the aim of measuring and optimising the value of digital health initiatives. The development and application of benefits management has received some attention,3 but owing to the infancy of the discipline there has been limited assessment of methodological frameworks and their application. In this article, we describe the framework that is being used to measure and quantify the benefits of the My Health Record system in Australia. We consider the strengths and limitations of this framework in the context of existing frameworks, and its ability to demonstrate digital health system benefits. We also identify priority areas for further development of digital health benefit evaluation frameworks. Further, we provide an overview of the approach to digital health system benefits evaluation in Australia, in the context of the My Health Record system. A role of the Australian Digital Health Agency has been to lead the development of the National Digital Health Strategy, to lay the foundations for a safe, seamless and secure health system.4 This strategy comprises seven priority areas to be achieved by 2022. A key strategic priority is to provide health information whenever and wherever it is needed, and this is underpinned by the My Health Record system. My Health Record is a secure online summary of health information which can be accessed by people and their health care providers, and is patient-controlled. It is a personal health record, enabling people to access, manage and share their health information with their clinicians using a range of privacy controls. This functionality includes the ability to decline access to specific documents, set a control to restrict access to the entire record, see an audit trail of any organisations that have accessed the record, and block organisations from viewing the record. The record can contain summary information from general practice, hospital, pharmacy and other health care settings. It may also contain results of investigations, plus documents that patients create themselves (such as advance care plans and personal notes). In addition, it can provide access to Medicare documents such as Medicare Benefits Schedule and Pharmaceutical Benefits Scheme information, the Australian Immunisation Register and the Australian Organ Donor Register. A multimethod evaluation framework has been developed to comprehensively evaluate the benefits of the My Health Record system. It draws on approaches that have been used overseas and assesses the range of clinical contexts in which the system is used. Connecting people to their own health information has been shown to produce a range of benefits relating to patient engagement and a 60–80% improvement in their adherence to treatment regimens.5 In addition, enabling self-management has been associated with significant financial savings in terms of health care costs and avoided hospital admissions.6 It is also theorised that enabling clinicians across different health care settings to share information will result in improved patient safety (eg, fewer medication errors), improved care coordination, a reduction in unnecessarily duplicated investigations, and efficiency gains for clinicians in terms of time savings. In Australia, 2–3% of hospital admissions each year relate to medication misadventure, costing an estimated $1.2 billion annually.7 Improved access to medication information from a range of settings through the medicines information view in My Health Record should provide clinicians with more comprehensive information, and it is hoped that this will result in a reduction of medication misadventure events. Moreover, the use of digital health records to enable test results to be shared has been shown to reduce duplicated pathology tests by 18% per week,8 and in primary care settings it has been found that 13.6% of visits were missing important clinical information.9 Several lessons relating to the application of digital health research and evaluation frameworks have been learned. Many different "key measures" have been described, and there is an overall lack of consensus as to the "who, why, how, when and what" that should apply to an evaluation.10 The impact of this has been a failure to capture the complete range of players involved in the successful delivery of a system — players who do not necessarily share identical perspectives. A recent systematic review recommends that future frameworks present better methods for stakeholder identification and have a greater focus on understanding the context in which the system is delivered. From a systems perspective, this includes usability and organisational impact.10 The foundations of Australia's digital health system benefits evaluation framework are based on applying a range of measurement methods to capture a broad variety of outcome measures, reflecting a multistakeholder National Digital Health Strategy which offers different types of benefits to its different stakeholders. Five benefit workstreams have been introduced to evaluate the My Health Record system using qualitative, quantitative and mixed-method designs, as well as behavioural economic and health economic evaluation methods (Box). These workstreams are: Perceived improvement in access to patients' information and reduction in the need to order pathology tests and diagnostic imaging Self-reported experience of being able to view information that was previously unknown, and saving time requesting information Reduction in adverse medicine-related events through having access to a patient's medicines information Reduction in unnecessary duplication of pathology tests and diagnostic imaging The workstreams have been designed with data sources in mind to assist with planning and prioritising evaluation measures. These have been ranked by feasibility11 and impact, taking into account the relative importance of each measure to different stakeholders.10 To support two of these workstreams — customer and market insights, and impact evaluations — we have taken a similar approach to Canada's Clinical Adoption Framework.3 The impact evaluations workstream in particular focuses on outcomes and how these are being realised. For example, it focuses on measuring usability and adoption of digital tools from clinicians and consumers from their inception and throughout their development. The behavioural economics workstream refers to the evaluation methods which aim to measure change in the behaviour of system users (eg, clinicians and patients), organisational issues which can affect adoption, and indicators that would inform change management requirements to improve usability and adoption of digital health services.12 The data analytics workstream enables monitoring of trends in adoption and usage. For example, this workstream is investigating, through data modelling, whether My Health Record use is associated with fewer medication errors and reduced unnecessary duplication of pathology tests, to provide comprehensive results from a range of settings. The health economics evaluations workstream evaluates and forecasts indirect population health outcomes and downstream economic benefits using health economics modelling. For example, it is developing a health economics model to inform the ongoing business case for the My Health Record system, and conducting modelling that will support measurement of current and future benefits. To support an iterative process in product and service design, the Australian Digital Health Agency also undertakes user experience research and agile project management methods.13 The advantage of this approach is that it can deliver user insights which inform continual design and development of new features. Further, conducting field research to observe a range of digital system users in their environment is a way of identifying attributes that can influence the methods and measures used more broadly in our benefits evaluation framework. Current approaches and frameworks that have been developed overseas to support evaluation and benefits measurement of digital health services are at various stages of maturity. An increasing range of methods to evaluate digital health technologies is being supported by publications, which recognise that they are being deployed in complex health systems that require a contextual understanding of users, clinical settings and the policy environment in which they operate. We must not underestimate the challenges of evaluating benefits of digital health system delivery, and new methods to support evaluations continue to be developed and validated.2 Benefits evaluation frameworks offer a platform that can guide researchers and policy makers in generating and translating evidence to support future directions and ongoing investment in digital health services. Recent debates highlight the importance of fostering evaluation designs which combine different research methods, using qualitative, quantitative and co-design principles, as well as process measures1 that we have embedded into our benefits framework. To strengthen our current benefits evaluation framework and overall approach to digital health service evaluation, we are actively introducing methods that ascertain how services can be scaled up, to identify enablers and barriers to implementation across a range of settings.1 In this context, we define scalability as "the ability … to be expanded under real-world conditions to reach a greater proportion of the eligible population, while retaining effectiveness".14 Measuring scalability is not a commonly undertaken process and has been described as poorly understood.15 But the Australian Digital Health Agency is working towards applying these methods to build an understanding of impact. These findings form a picture of how, where and for whom the intervention could have the greatest impact and, conversely, what adaptations are needed for interventions to work across different population groups. A practical example of how this is being undertaken through the Agency is the introduction of and investment in a range of "test bed" studies. Test beds are projects assessing new digital-enabled models of care that are instigated and delivered cooperatively through sustainable and viable partnerships between industry, government and other organisations. Their purpose is to promote innovation to address Australia's highest priority health challenges and generate evidence on how the new approaches improve health outcomes. Currently, there are 15 test beds across Australia which are testing digital infrastructure and integration of digital health into clinical workflows.16 Despite ongoing interest in digital health benefits evaluation frameworks, few examples of their use in evaluation of digital health services have been published. The Australian Digital Health Agency's benefits evaluation framework will be used to justify future funding of digital health and to inform community and clinical education material. Moreover, the findings will be used to inform enhancements of the My Health Record system, ensuring that its progress is relevant and appropriate for clinicians and consumers. We are grateful to Darian Eckersley, from the Australian Digital Health Agency, for advice on product design methods. Many thanks to the broader Research Programs team at the Agency for reviewing parts of this manuscript and commenting on an earlier version. We are all employed by the Australian Digital Health Agency. Commissioned; externally peer reviewed.

The use of digital health technologies is becoming increasingly common across the globe as they offer immense potential to enhance health care delivery by promoting accessibility, flexibility, and personalized care, connecting patients to health care professionals, and offering more efficient services and treatments to remote residents. At the same time, there is an increasing recognition of how digital health can inadvertently foment psychological trauma. This phenomenon has led to the adoption of trauma-informed care in designing and deploying digital health technologies. However, how trauma-informed care is defined and characterized, and the various trauma-informed care strategies used in designing and deploying digital health technologies remain unexplored. This scoping review aims to explore and synthesize the literature on how trauma-informed care is defined and characterized in digital health and the various trauma-informed care principles, strategies, or recommendations used in designing and deploying digital health. This review will draw on the Joanna Briggs Institute's updated methodological guidance for scoping reviews. A search will be conducted on CINAHL, PubMed, Embase, Compendex Engineering Village, Web of Science, Scopus, and PsycINFO. This review will consider published research studies and unpublished work (gray literature). Studies will be included if they applied trauma-informed care in designing or deploying digital health for patients across all geographical locations or provide trauma-informed recommendations on how web developers should develop digital health. Studies will be limited to publications within the past 10 years and studies in all languages will be considered. Two independent reviewers will screen the titles and abstracts, and then perform a full-text review. Data will be extracted into a data extraction tool developed for this study. The scoping review was undergoing a full search as of April 2023. The main results will synthesize the peer-reviewed and gray literature on adopting trauma-informed care practices in digital health research and development. The study is expected to be completed by December 2023 and the results are expected to be published in a peer-reviewed journal. This review is expected to provide the knowledge base on the adoption of trauma-informed care in designing and deploying digital health. This knowledge can lead to more engaging, and likely, more effective digital health interventions that have less potential for harm. A synthesis of the various trauma-informed care strategies in digital health will also provide a trauma-informed language by enabling researchers and digital health developers to consider trauma as a critical factor in each stage of the design process. DERR1-10.2196/46842.

The European Nation EU is a promoter of the idea of sustainable development. Projects developed and implemented with the help of European funds can contribute significantly to the transition towards sustainability, as they facilitate innovation, development and knowledge transfer. Mainstreaming sustainability in the EU projects goes hand in hand with the development indicators set by the United Nations and, beyond that, affects regional and local development. The identification of sustainable activities requires from the beneficiaries of EU funds a good knowledge of the sustainability indicators present in the guidelines and funding applications. Even if sustainability does not have a method to be measured, it can be shown through examples of good practice in EU-funded projects. This article tries to fill this gap, contributing to a better understanding of the initiation of project activities related to sustainability by: presenting the sustainability aspects mentioned in the funding guidelines, proposing a framework for describing sustainable activities: With the help of the 5 good practice -examples of projects related to axis 4.1 Reducing carbon emissions in county municipalities through investments based on sustainable urban mobility plans we indicate examples of activities and projects aiming at sustainable urban development. In a critical discussion, we analyzed the need to build a tool to measure sustainability in projects. Finally, we draw conclusions on the potential for growth and development towards sustainability in EU-funded projects, as these projects contribute to local and therefore regional, development.

BackgroundDigital health initiatives such as patient portals, virtual care platforms, and smartphone-based apps are being implemented at a rapid pace in health care organizations worldwide. This is often done to improve access beyond traditional in-person care and enhance care quality. Recent studies have indicated that better outcomes of using these initiatives and technologies may be achieved when patients and their family members are engaged in all aspects of planning, implementation, use, and evaluation. However, little guidance exists for how health care administrators can achieve effective engagement in digital health initiatives specifically.ObjectiveThe objective of this study is to document processes related to planning and implementing patient and family engagement (PFE) in digital health initiatives. This information will be used to develop tangible resources (eg, a field guide) that other organizations can use to implement PFE approaches for digital health initiatives in their organizations.MethodsA previously developed multidimensional conceptual framework for PFE in health and health care contexts will be used to guide this work. To understand the intricacies involved in using PFE approaches in digital health strategies, a case study will be conducted. More specifically, this work will employ an embedded single-case design with PFE in digital health initiatives at a large Canadian mental health and addictions teaching hospital. Multiple digital health projects being undertaken at the study site will be explored to better understand where the PFE is intended to support the design, implementation, and operation of the digital health platform or technology. These projects will form the individual units of analysis. Data collection will involve field notes and artifact collection by a participant observer and interviews with the various digital health project teams. Data analysis will include a content and thematic analysis, triangulation of the findings, and a chronological mapping of data to a PFE process.ResultsFunding for this work was provided by the Canadian Institutes of Health Research (CIHR), via a Health System Impact Fellowship. As of August 2020, digital health projects that will form the case study units have been identified, and the participant observer has started to embed themselves into these projects. Although the development and collection of field notes and artifacts, respectively, have begun, interviews have not been conducted. The study is expected to conclude in September 2021. Once this study is complete, the development of a field guide and resources to support the uptake of PFE strategies in digital health will begin.ConclusionsBy better understanding the processes involved in PFE in digital health projects, guidance can be provided to relevant stakeholders and organizations about how to do this work in an effective manner. It is then anticipated that with the increasing use of PFE approaches, there may be improved uptake, experience, and outcomes associated with using digital health technologies.International Registered Report Identifier (IRRID)PRR1-10.2196/24274

BackgroundThe need to assess the effectiveness and value of interventions involving digital health and health and welfare technologies is becoming increasingly important due to the rapidly growing development of these technologies and their areas of application. Systematic reviews of scientific literature are a mainstay of such assessment, but publications outside the realm of traditional scientific bibliographic databases—known as gray literature—are often not included. This is a disadvantage, particularly apparent in the health and welfare technology (HWT) domain.ObjectiveThe aim of this article is to investigate the significance of gray literature in digital health and HWT when reviewing literature. As an example, the impact of including gray literature to the result of two systematic reviews in HWT is examined.MethodsIn this paper, we identify, discuss, and suggest methods for including gray literature sources when evaluating effectiveness and appropriateness for different review types related to HWT. The analysis also includes established sources, search strategies, documentation, and reporting of searches, as well as bias and credibility assessment. The differences in comparison to scientific bibliographic databases are elucidated. We describe the results, challenges, and benefits of including gray literature in 2 examples of systematic reviews of HWT.ResultsIn the 2 systematic reviews described in this paper, most included studies came from context-specific gray literature sources. Gray literature contributed to the overall result of the reviews and corresponded well with the reviews’ aims. The assessed risk of bias of the included studies derived from gray literature was similar to the included studies from other types of sources. However, because of less standardized publication formats, assessing and extracting data from gray literature studies were more time-consuming and compiling statistical results was not possible. The search process for gray literature required more time and the reproducibility of gray literature searches were less certain due to more unstable publication platforms.ConclusionsGray literature is particularly relevant for digital health and HWT but searches need to be conducted systematically and reported transparently. This way gray literature can broaden the range of studies, highlight context specificity, and decrease the publication bias of reviews of effectiveness of HWT. Thus, researchers conducting systematic reviews related to HWT should consider including gray literature based on a systematic approach.

This position paper could be used by oral health stakeholders to convince their government to implement digital oral health program.

The role of governance in the digital transformation of healthcare: Results of a survey in the WHO Europe Region

The positive energy district (PED) concept is attracting growing research interest; however, the need for practical approaches to facilitate their implementation remains crucial. This study, framed in the COST Action ‘Positive Energy Districts European Network’, offers a comprehensive review of the roadmaps, pathways, and guidelines—namely ‘PED-Transition Approaches’—currently available to support the implementation of district-scale innovative models, thereby advancing energy transitions and enhancing livability at the city level. The review involved a systematic search and web scraping of documents, including scientific and grey literature, as well as EU-funded projects’ reports. The studies were identified according to multiple filters and eligibility criteria, then categorised in a structured repository using a multidimensional matrix, and finally examined following three-levels of detail (i.e., bibliometric study) overview and in-depth analysis. The findings reflect the main characteristics, gaps, and challenges in PED implementation by underlying the growing need for effective step-by-step, user-centric, and context-based transition approaches. In conclusion, the research, building on an extensive literature of multiple inspirational methodologies and their associated use cases, is a strong basis to develop sequential pathways to facilitate PED implementation among key stakeholders in a short–medium-term perspective towards a climate-neutral city vision.

Sharing information safely and securely: the foundation of a modern health care system.

BACKGROUND Older adults with chronic disease are key beneficiaries of digital health technologies, yet adoption remains inconsistent, particularly in rural areas and among certain demographic groups, such as older women who are less likely to engage with digital health compared to men. OBJECTIVE This systematic review aimed to identify barriers and facilitators to digital health adoption among older adults with chronic disease, with particular attention to rural-urban differences, co-design, and equity-relevant factors. METHODS This updated review builds on a previously published review by extending the search to include PsycArticles, Scopus, Web of Science, and PubMed for studies published between April 2022 and September 2024. Grey literature from August 2021 onward was also included. Studies were eligible if they reported barriers and/or facilitators to digital health adoption among adults aged 60+ with chronic disease. Findings were mapped to the Capability, Opportunity, and Motivation Model of Behaviour (COM-B) and analysed using the PROGRESS-Plus equity framework. Quality was assessed using the Mixed Methods Appraisal Tool (MMAT), and all results are reported in line with PRISMA guidelines. RESULTS Twelve studies from the original review were retained, with 17 new peer-reviewed studies added, yielding a total of 29 studies, in addition to 30 documents identified in the grey literature search. Barriers identified included limited digital literacy, physical and cognitive challenges (Capability), infrastructural deficits and usability challenges (Opportunity), and privacy concerns, mistrust, and high satisfaction with existing care (Motivation). Facilitators included tailored training and accessible design (Capability), provider endorsement and hybrid care models (Opportunity), and recognition of digital health benefits (Motivation). Healthcare providers emerged as both facilitators and barriers—positively influencing adoption when engaged and trained but hindering it when lacking confidence or involvement. Comparative analysis of rural and urban contexts was limited by inconsistent reporting of equity-relevant variables. However, grey literature suggested rural users face additional infrastructural challenges but express higher satisfaction with local care, potentially reducing motivation for digital uptake. Gender differences were observed in three peer-reviewed studies and grey sources, with older women showing lower adoption and differing outcome priorities. Co-design enhanced adoption, especially when involving not just older adults but also healthcare providers and community stakeholders. CONCLUSIONS Digital health adoption among older adults is shaped by capability, opportunity, and motivation factors. Effective and equitable digital health strategies must address infrastructural and literacy barriers, engage healthcare providers through training and co-design, and ensure multi-stakeholder involvement. This review highlights that greater attention to standardised reporting of demographic variables, especially gender and rurality, is essential in digital health research to avoid one-size-fits-all approaches and support inclusive implementation. CLINICALTRIAL Not applicable INTERNATIONAL REGISTERED REPORT RR2-https://doi.org/10.3399/bjgp25X742161