Digital Health Promotion (DHP)

General considerations based on our external pagenarrative reviewcall_made of the scientific literature.

• Ethical challenges specific to implementing digital health promotion for young people in low- or middle-income country settings have not been explored in depth in the research literature.
• Digital health promotion can complement traditional public health efforts by expanding access to more individuals, offering personalized content, and supporting positive health choices in the influential early years of life. Failure to realize its potential will leave many health needs unmet.
• Significant barriers can limit the effectiveness of DHP for young people. The digital divide and realities of structural injustice in data practices, as well as fair distribution of benefits, must be taken into account, in order for DHP efforts to be truly effective and beneficial for all. Health data privacy and safeguards against misinformation are essential to ensure safety and security for users. Finally, DHP cannot act as a substitute for addressing widespread socioeconomic determinants of health in the population of youth in a given country.
• The literature assessment yielded several important recommendations. Social determinants of health among the youth population must be addressed, while low-cost DHP might simultaneously be deployed as a timely response to health challenges. Funding for IT infrastructure and broadband internet access should be increased, together with DHP content in local languages that promotes greater autonomy in LMICs, with access to digital technologies understood as one social determinant of health. Safety, in terms of data privacy, attention to bias, and scientifically reliable interventions, must be guaranteed. Technology for health requires appropriate oversight, with ethical standards clearly defined. Finally, engaging members of the local target population is essential to address needs that are specific to their economic, cultural, and social context.

Specific findings from our scoping external pageliterature reviewcall_made examining youth perspectives on DHP.

• Adolescents and young adults are receptive towards using digital tools for health promotion, in particular formats such as mobile applications and social media, and see technology as extending the reach of traditional healthcare. 
• Young people express nuanced views concerning the importance of aspects such as confidentiality and need for a safe space to engage with digital health promotion tools, varying from one area of health to another. A clear and user-friendly format, and information that is brief and direct, were mentioned as appealing characteristics in DHP tools, while youth expressed concern over qualities such as technological friction or a lack of personalization. 
• There is a need to better understand views of young people in the Global South, whose voices are underrepresented in the research literature on the topic of digital tools for promotion of health. Of the studies included in the scoping review, only 9 out of 50 reported perspectives from youth in LMICs.

Key discussion points emerged during the Experts Workshop on How to Unlock the Potential of Digital Health Promotion for Young People in LMICs

• Despite the increasing availability of DHPs technologies for young people in LMICs, there has been a notable absence of research on whether the existing ethical and policy frameworks are adequate to address the challenges and opportunities in these settings. The workshop aimed to contribute to filling this gap by bringing together experts from various fields to explore the ethics and governance of DHP for young people in LMICs.
• Workshop participants highlighted the absence of specific ethical frameworks tailored to DHP for youth in LMICs, suggesting that existing digital health ethics principles should serve as a foundation but need further refinement and adaptation based on local youth input. Some level of regulation of digital health promotion tools and developers can enhance technology's reputation and encourage youth adoption.
• Participants recognized the need to address barriers and shortcomings in DHP adoption in LMICs to ensure young people can fully benefit from these technologies. To do so, ethical considerations relevant to the local context must be carefully analyzed and addressed, and ethical frameworks tailored, ensuring that policies facilitate effective implementation of principles. Concepts of autonomy, equity, safety, accountability, and sustainability should be interpreted in the context of the specific values and socio-cultural perspectives of Sub-Saharan Africa, rather than relying solely on a Western-centric interpretation of these principles, as effectiveness can be weakened when applied in vastly different contexts.
• The workshop's work has led to the potential translation of these five fundamental ethical principles into principles into concrete policy recommendations. The resulting policy roadmap calls on policy makers, regulators, developers, and implementers to take specific actions to establish more ethically aligned DHPs that prioritize the needs and well-being of young people, particularly in LMICs in Sub-Saharan Africa. It emphasizes the importance of incorporating local perspectives, values, and youth-centered considerations to ensure that DHP technologies are not only ethically sound, but also effective and accessible.

Findings from out taxonomy study analysis examining selected examples of DHP for youth in Ghana, Kenya, and South Africa.

• The study identified 31 DHP tools in Ghana, Kenya, and South Africa. The most common health focus among these tools was sexual and reproductive health, with funding primarily originating from local NGOs, foundations, and international organizations. These tools were predominantly web- and social media-based, aiming to expand health knowledge and access for young people. 
• Ethical principles are relevant in the development and deployment of DHP tools. The study highlights the need for inclusiveness, equity, transparency, effectiveness, and personalization in these technologies. Neglecting ethical considerations can jeopardize the quality and safety of DHPs. 
• Engaging with young people in meaningful ways to understand their concerns is crucial in the development of DHP tools. As research on youth perspectives on digital health progresses, technology development should adapt and incorporate this knowledge and feedback to create sustainable and effective tools. Additionally, increasing investment in the health sector and empowering local developers is crucial for expanding access to DHPs in low- and middle-income countries. 

Key elements emerging during the South African youth engagement workshop.

• During the workshop, South African medical students emphasized the prevalence of digital health promotion tools among young people in their country. They acknowledged that digital technologies are already being used for health promotion yet such tools are not equally distributed among young South Africans.
• The workshop participants raised a series of ethical concerns related to digital health promotion. These concerns revolved around five core areas: autonomy, privacy, equity, safety, and accountability. They questioned the level of autonomy young people have in utilizing digital health tools, discussed the importance of safeguarding individuals' personal health data, highlighted the challenge of addressing socioeconomic inequalities and ensuring universal access, underscored the need for reliable and valid health information in digital platforms, and stressed the importance of clear accountability in the development and deployment of these tools.
• During the workshop, participants offered valuable suggestions to improve the development and use of digital health promotionfor youth in South Africa. Firstly, they recommended to implement oversight mechanisms to assess and ensure the safety and effectiveness of DHPs. Secondly, it was suggested that young people should be actively engaged in the design and development of health promotion tools to address their unique concerns and needs effectively. Additionally, the importance of increased investment in digital education was emphasized, to equip young individuals with the necessary skills and knowledge to make the most of digital health promotion resources. Lastly, participants underlined the necessity of addressing the digital divide, ensuring that digital health promotion solutions are accessible to all South African youth, regardless of their socioeconomic or geographic circumstances.

This project produced peer-​reviewed publications published in international outlets.  

• Ferretti, A., Vayena, E., Blasimme, A. (2023). Unlock Digital Health Promotion in LMICs to Benefit the Youth. Plos Digitl Health, doi: external pagehttps://doi.org/10.1371/journal.pdig.0000315call_made
  
• Ferretti, A., Hubbs, S., Vayena, E. (2023). Global youth perspectives on digital health promotion. A scoping review. BMC Digital Health, doi: external pagehttps://doi.org/10.1186/s44247-023-00025-0call_made

Papers under review:

• Ferretti, A., Hubbs, S., Cengiz, N., Jamalie, M.A., Wright, J., Moodley, K., Vayena, E. (forthcoming - under review) Listening to the Voices of the Youth: Perspectives on Digital Health Promotion from Medical Students in the Western Cape, South Africa. 
• Ferretti, A., Hubbs, S., Dzikunu, R.M., Moodley, K., Wekesah, F., Wright, J., Vayena, E. (forthcoming - under review) Taxonomy and ethical considerations of digital health promotion tools for youth: Selected examples from three Sub-Saharan African countries.
• Ferretti, A., Adjei, K.K., Ali, J., Atuire, C., Ayuk, B.T., Banougnin, B.H., Cengiz, N., Gichoya, J., Jjingo, D., Juma, D.O., Kotze, W., Krubiner, C., Littler, K., McCradden, M.D., Moodley, K., Naidoo, M., Nair, G., Obeng-Kyereh, K., Oliver, K., Ralefala, D., Toska, E., Wekesah, F.M., Wright, J., Vayena, E. (forthcoming - under review) Digital Tools for Youth Health Promotion: Principles, Policies, and Practices in Sub-Saharan Africa. 

The findings of this project have been presented at scientific conferences and international events.

Agata Ferretti:

• Oxford Global Health and Bioethics International Conference 2022 (06/2022)
  Oxford, United Kingdom
  Presentation: “Unlocking the Potential of Digital Health Promotion in LMICs”
• Digital Mental Health: A Real Opportunity for Healthcare or Technology-​Driven Solutionism? (11/2022)
  Online workshop supported by GLOHRA
  Invited Talk: “Promoting Mental Health with Digital Technologies: Young People’s Views”
• The National Academies – Board on Science Education (03/2023)
  Washington DC, United States
  Invited Talk and Expert Panelist: “Effective Health Communications within the Current Information Environment and the Role of the Federal Government. Focus on Digital Data and Information Systems”
• Institute for History and Ethics of Medicine, TU München (05/2023)
  Munich, Germany
  Invited Talk: “Enabling Digital Health Promotion in Low-​and Middle-​Income Countries.”
• Oxford Global Health and Bioethics International Conference 2023 (06/2023)
  Oxford, United Kingdom
  Presentation: “Young people perspectives on digital health promotion. Ethical considerations and future recommendations.”