What do we talk about when we talk about digital determinants of health? – A systematic review

Abstract

Objectives

Digital determinants of health (DDoH) are a recently articulated category of health determinants. While research on digitalisation and health has grown rapidly, DDoH remain relatively understudied as a distinct concept. Understanding how DDoH are defined, which components are recognised, and how they relate to other determinants of health (e.g., social, political, and commercial) is essential for guiding research, informing public health interventions, supporting education, influencing policy, and promoting health equity. This study aimed to examine how academic publications define DDoH, which components are identified, and how relationships with other determinants of health are characterised.

Methods

We conducted a systematic review following PRISMA 2020 guidelines. Scopus, PubMed, and EBSCOhost were searched for publications up to 2 September, 2025, using predefined keywords related to DDoH. Reference lists and targeted Google Scholar searches were also screened. Extracted data were analysed thematically and organised into themes and overarching domains.

Results

Of 225 records identified, 65 met inclusion criteria. A definition of DDoH was provided in 28 publications, and 79 distinct DDoH components were identified in 63 publications. Relationships between DDoH and other determinants of health were discussed in 28 publications. No consensus exists on the definition of DDoH or whether they are a subset of social determinants of health or a standalone category. Approximately one-third of identified DDoH involved internet access, access to digital technology, or digital health literacy; the remaining components were fragmented and less frequently reported.

Conclusion

This review provides a comprehensive overview of DDoH, including their definitions, components, and interconnections with other determinants. The findings clarify how DDoH are conceptualised in current literature and highlight challenges in developing a coherent, unified framework for their study.

Introduction

The ‘determinants of health’ are widely defined in academic literature and global health policy as the factors that shape health outcomes, either positively or negatively. They include biological, psychological, behavioural, social, economic, and environmental factors, and socially or politically conditioned inequalities in their distribution can lead to health inequities within or between countries. ¹ The concept gained prominence in the 1970s, particularly after the publication of the Lalonde Report, which challenged the dominance of biomedical models and emphasised lifestyle, environmental, and nonmedical factors as key influences on health. ² Early determinants frameworks highlighted individual-level factors, but from the 1990s onward, attention increasingly shifted toward broader structural and social influences, prompted by the recognition that investments in clinical care and preventive services were not producing proportional improvements in population health. ³ Influential ecological models grouped determinants into environment, heredity, lifestyle, and health care services, providing a broader perspective on the multiple factors influencing health.^4,5

Building on the work of the World Health Organization’s Global Commission on the Social Determinants of Health, particularly its reports Closing the Gap in a Generation (2008) and A Conceptual Framework for Action on the Social Determinants of Health (2010) by Solar and Irwin, the first decade of the 21st century was characterised by a strong focus on social determinants of health.^6,7 In the following decade, critical reflections on the limitations of this framework, intensified by the global financial crisis of 2008, contributed to the emergence of political and commercial determinants of health. ⁸

Digital determinants of health (DDoH) are a relatively recent concept. They reflect the increasing role of digital technologies in enabling access to high-quality health care and the factors that can limit many individuals’ ability to benefit fully from these tools. ⁹ Interest in DDoH has grown since 2020, coinciding with the COVID-19 pandemic, which highlighted the role of digital technologies in maintaining health system operations and supporting access to care and service quality.^10–12

DDoH can be considered from two complementary perspectives. They influence health equity and well-being directly through the use of digital technologies in healthcare, and indirectly via factors such as connectivity quality, access to digital services, exposure to online content, and the combined digital, health, and civic literacy of professionals and the public. ¹³ Understanding these determinants is crucial for developing equitable and effective health systems. Considering digital determinants across individual, interpersonal, community, and societal levels can inform policies and interventions aimed at improving digital inclusion. ¹⁴

In 2024, the first scoping review on DDoH was published (retracted in 2025), which analysed only eight studies. This illustrated the emerging and limited nature of the field. ¹⁵ In the same period, van Kessel et al. conducted a broader scoping review mapping the evolution of social, commercial, political, and digital determinants of health in the context of recent digital transformation, covering publications up to September 2023. ¹⁶ Their work explored health determinants in the digital era, illustrating how digitalisation influences health outcomes and offering a clear definition of DDoH with key components. Other research has focused on specific DDoH components, such as digital health literacy,^17,18 or, more broadly, on digital transformation, ¹⁰ underscoring the need for a clearer conceptual framework.

The rapid development of the field highlights the importance of reviewing how DDoH are defined, which components are recognised, and how they relate to other determinants of health. Understanding these aspects can support future research, inform public health practice, guide education, and assist policymakers, ultimately promoting more equitable and effective health systems. To explore these questions, we conducted a systematic review following PRISMA 2020 guidelines. ¹⁹ This review included studies published both before and after 2023, the period covered by van Kessel et al.’s scoping review.

Materials and methods

Search strategy and study selection

We systematically searched Scopus, PubMed, and EBSCOhost (all databases) for publications available up to 2 September, 2025, using a pre-specified set of keywords related to DDoH (see Supplemental File A for full search strategies). Retrieved records were imported into Rayyan for deduplication and screening. Two reviewers independently screened titles and abstracts. For publications without abstracts—such as editorials, letters, or book chapters—executive summaries or tables of contents were used to assess relevance. Any disagreements were resolved through discussion, with a third reviewer consulted when consensus could not be reached. Reference lists of included publications and targeted Google Scholar searches were also examined to identify additional sources (Supplemental File C).

Eligible publications included peer-reviewed research and other scholarly works addressing human health or related topics. They encompassed editorials, commentaries, opinion pieces, letters, conference proceedings, and book chapters. Inclusion criteria were:

• Focus on DDoH or related areas such as public health, planetary health, global health, mental health, or digital determinants of a specific health condition or intervention.

• Provision of a definition of DDoH and/or description of its components, and/or discussion of its relationship with other determinants.

Studies were excluded if DDoH could not be identified as a distinct determinant or did not meet the above criteria (Supplemental File D).

Data extraction and thematic analysis

An inductive thematic analysis was used to identify recurring patterns and develop thematic categories aligned with the study objectives. A coding matrix in Microsoft Excel was employed to extract information on author(s), year, publication type, study design, country of first or corresponding author, DDoH definitions, components, and any described relationships with other determinants (Supplemental File B).

Two reviewers independently applied the coding matrix to the first ten full-text publications to ensure consistent interpretation. Any disagreements were resolved through discussion, with a third reviewer consulted when consensus could not be reached. The matrix was refined iteratively to support identification of components and themes and to quantify the frequency of DDoH components. Findings were reported in accordance with PRISMA 2020 guidance.

Quality assessment

As DDoH represent a developing conceptual area, this review did not conduct a formal methodological quality appraisal, focusing instead on characterizing the scope and nature of the literature. Standard risk-of-bias tools (e.g., CASP for qualitative studies) were considered unsuitable. Instead, we report the type of publications and the nature of evidence in the Results, and discuss the use of theoretical or conceptual frameworks in the Discussion.

Protocol and registration

A protocol was developed a priori to define objectives, eligibility criteria, and analytical methods. This protocol guided the conduct of the review but was not registered in a public registry (e.g., PROSPERO) and has not been published. This study is part of a series of systematic reviews that aim to identify definitions, components, and relationships among different determinants of health.

Results

Overview of included publications

The database searches yielded 172 records, of which 59 articles were selected for full-text assessment after screening titles and abstracts. After applying the predefined inclusion and exclusion criteria, 48 publications were considered eligible. An additional 17 publications, identified through citation chaining and targeted Google Scholar searches, were included. In total, 65 publications were included in the final analysis (Figure 1; Supplemental File E).

Figure 1.

PRISMA flowchart.

The temporal distribution of publications indicates a marked increase in output over time. More than one-third of the included publications (35.4%, n = 23) were published in 2025, while 18 publications (27.7%) appeared in 2024. Overall, 41 publications (63.1%) were published within the last two years. Earlier contributions were less frequent, with 12 publications in 2023, seven in 2022, four in 2021, and one in 2020 (Supplemental File F).

Geographic distribution

Most publications originated from high-income countries, based on the first or corresponding author’s affiliation. The majority of publications were from the United States (36.9%, n = 24) and Australia (15.4%, n = 10). The remaining publications originated from 18 additional countries, with the number of publications per region as follows: from Europe (27.7%, n = 18), Asia (10.8%, n = 7), and smaller contributions from South America (2 publications), Africa (1 publication), and Canada (2 publications). One article listed dual affiliations with both the United States and China (Supplemental File G). Europe, Asia, Africa, and South America were grouped by region, while the United States, Australia, and Canada were reported separately due to higher publication volume.

Publication characteristics

Nearly half of the included publications were research articles (40%, n = 26). A slightly larger proportion consisted of other peer-reviewed formats (55.4%, n = 36), including narrative reviews, editorials, and commentaries. One book chapter and two conference papers also met the inclusion criteria (Supplemental File G). The scoping review [15], which was subsequently retracted by the journal and the scoping review by van Kessel et al. [16] were not analysed directly; the latter was included solely as background references.

Definitions and conceptualisations of digital determinants of health

Among the reviewed literature, 43.1% of publications (n = 28) provided either an explicit definition or a conceptualisation of DDoH (Table 1). The earliest definition identified was proposed in 2022, when Richardson et al. described DDoH as “conditions in the digital environment that affect a wide range of health, functioning, and quality of life outcomes and risks”. ¹⁴ Shukla used a narrower interpretation, defining DDoH as “the degree of access people have to the internet and to assistive and communication devices, and their level of digital literacy”. ²⁰

Table 1.

Digital determinants of health (DDoH) definitions.*

Richardson et al., 2022	The DDoH are conditions in the digital environment that affect a wide range of health, functioning, and quality of life outcomes and risks.
Shukla, 2022	The degree of access people have to the internet and to assistive and communication devices, and their level of digital literacy.
Davis, 2023	The digital determinants of health are not a naturally occurring phenomenon: they have been manufactured by individuals and groups, for profit, quite recently. Unlike rainbows, the digital turn is something that humans have produced and can potentially shape, through voting or collective action.
Fraser et al., 2023	DDoH is a recent concept that recognizes the increasingly important role digital health plays in access to high-quality healthcare worldwide and the factors that prevent many people from fully benefiting from these tools.
Holmes Fee et al., 2023	Digital determinants of health (DDoH) are the factors intrinsic to technology that when applied to the provision of healthcare services can have a major impact on health outcomes.
Kickbusch and Holly, 2023	The digital determinants of health influence equity in health and wellbeing both directly and indirectly. 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.
Chidambaram et al., 2024	There is a paucity of literature addressing how the intrinsic design, implementation, and use of technology interact with SDoH to influence health outcomes. Such interactions are termed digital determinants of health [DDoH). DDoH refer to the technological factors that are incorporated to provide affordable, accessible, and quality care to consumers enhancing their healthcare engagement and experience. Digital determinants refer to factors intrinsic to the technology in question that impact sociodemographic disparities, health inequities, and challenges with care accessibility, affordability, and quality outcomes.
Geracitano et al., 2024	Digital health determinants, such as internet access and digital literacy, have been referred to as “super” social determinants, as these affect the capacity to address all other determinants.
Holly et al., 2024	The digital determinants of health (DDoH) offer a helpful framing to consider the range of direct and indirect ways in which digital transformations, both within and beyond the health sector, can both boost or undermine health and wellbeing.
Iyamu et al., 2024	“Digital transformation” is a process accompanied by widespread societal adoption of digital technologies that influence health behaviours, access to health resources and health outcomes. These influences are recognized as “digital determinants of health,” and affect individual lifestyle, social, cultural and environmental determinants of health. This recognition expands previous, narrower views of digital determinants as being restricted to inequities in access to digital health interventions (i.e. differences in digital literacy and access) to include an understanding of how digital technologies are inequitably distributed in other facets of life, with direct and indirect effects on public health outcomes.
Lawrence and Levine, 2024	DDoH refer to antecedents within the digital environment that impact a patient’s ability to access, use, and satisfactorily experience the health care system.
Miao et al., 2024	Factors related to the accessibility or availability of technology that contribute to health outcomes and quality of life.
Naccarella et al., 2024	The unique elements of people’s experiences with the digital health environment.
Philpot et al., 2024	DDoH are hypothesized to constitute several levels of factors, which can be translated into relevant individual, health care system, and policy interventions to mitigate and reduce disparities in health.
Partridge et al., 2024	Digital determinants of health encompass the conditions within the digital environment that impact a wide range of health outcomes and risks.
Wolff et al., 2024	Unique factors that lead to inequity in digital healthcare… DDoH reflect a growing digital divide that separates those who have access to digital health and those who do not, prompting researchers and policymakers to urge the inclusion of equity principles in the design and implementation of digital healthcare solutions before inequities become embedded in digital health.
Yang et al., 2024	“Super social determinants of health”
Albury and Mannix, 2025	DDoH generally refer to ‘the direct and indirect pathways in which digital factors influence health, wellbeing and health equity’... Digital determinants ‘refer to factors intrinsic to the technology in question that impact sociodemographic disparities, health inequities, and challenges with care, accessibility, affordability, and quality outcomes’. Within public health literature the term ‘Digital determinant of health’ broadly signifies the diverse digital drivers of health inequities.
Cuadros et al., 2025	DDoH refer to the digital and technological factors that affect health outcomes... At their core, digital determinants are about the capacity of individuals and communities to engage with, benefit from, and be included in the digital aspects of health services. However, these determinants extend far beyond individual access or use of technology. They include broader systemic factors such as digital policies and the availability of digital health services, as well as the effective integration of technology into healthcare systems.
Kim et al., 2025	Digital determinants of health are an emerging concept that refers to the various factors within the digital environment that impact individuals’ health outcomes, healthcare experiences and quality of life.
Miranda et al., 2025	Conditions that impact a variety of risks and outcomes related to health, functioning, and quality of life, that operate at the individual, interpersonal, community, and societal levels of influence.
Mooney et al., 2025	Digital determinants of health (DDoH) are an emerging concept that captures domains relating to both digital health adoption and health equity... DDoH refer to the design, use, and implementation of technological factors that may interact with sociodemographic disparities and health inequities to influence health outcomes and delivery of affordable, accessible, and quality care. Without consideration of these determinants, digital health interventions risk exacerbating existing health disparities, as they may fail to address the needs of all population groups. This in turn will impact upon the effectiveness of digital interventions.
Narayan et al., 2025	A constellation of factors, including literacy in digital technologies and access to broadband Internet, computers and connected devices, across cultural and language barriers.
Powell-Wiley et al., 2025	The digital determinants of health are important adjuncts to the social determinants and operate at the individual, interpersonal, community, and societal levels.
Raeside, 2025	The digital determinants of health refer to the technological factors that are incorporated to provide affordable, accessible and quality care to consumers enhancing their healthcare engagement and experience, considering both the adoption of digital tools and health equity.
Razaq and Allana, 2025	The DDoH are conditions in the digital environment that affect a wide range of health, functioning, and quality of life outcomes and risks.
Tefera et al., 2025	Digital determinants of health encompass the direct and indirect pathways in which digital factors influence health, wellbeing and health equity.
Yuguero et al., 2025	The concept of digital determinants of health has emerged as a critical framework for understanding how digital environments shape health outcomes and access.

^*Definitions are reproduced verbatim or lightly edited for clarity; terminology varies across sources, reflecting the absence of a standardised definition of digital determinants of health.

In the following three years, publications continued to conceptualise DDoH in relation to digital transformation and health-related technologies, with several authors referring to them as “super determinants of health”. Lawrence & Levine and Naccarella et al. emphasised patients’ and individuals’ experiences within digital health environments.^21,22 Cuadros et al. focused on the capacities of individuals and communities “to engage with, benefit from, and be included in the digital aspects of health services”, while Miranda et al. explicitly noted that DDoH operate across individual, interpersonal, community, and societal levels.^23,24 Narayan et al. highlighted the relevance of cultural and language barriers. ²⁵

Components of digital determinants of health

The majority of included publications (96.9%, n = 63) described at least one DDoH component (Supplemental File H). Across these studies, numerous components of DDoH were initially identified. Closely related components were then grouped where appropriate, resulting in 79 distinct components. For example, automation in healthcare, telemedicine, and the adoption of electronic medical records and patient portals were combined under the broader category of “availability of digital health services”. The number of components identified per publication varied substantially, ranging from one or two in many studies to a maximum of 28, reported by Park and Jang. ²⁶

Identified components were first organised into themes and subsequently aggregated into broader domains. This process resulted in five overarching domains encompassing 17 themes: Digital health infrastructure; Digital health technology, platform and service providers (Digital health providers); People who interact with digital health (Digital health users); Community and society, and the Healthcare system (Table 2). Overall, components clustered predominantly at the individual level—particularly literacy and user-related factors—while healthcare system-level and societal determinants were less frequently conceptualised. As domains were mutually exclusive, theme-level frequencies represent the sum of their constituent themes. Each specific DDoH component was counted once per publication, so frequencies reflect the number of publications identifying the component rather than its relative importance.

Table 2.

Domains, Themes, Components, and frequencies of digital determinants of health.*

Domains	Themes	Components
Digital health infrastructure (94)	Digital health infrastructure (94)	Digital infrastructure (14); Broadband internet (28); Digital (including mobile) technology availability, accessibility and affordability (42); Integration of digital resources into community and health infrastructure (7); Utilities (e.g., electrical grid) (3)
Digital health technology, platform and service providers (75)	Providers and their services (12)	Digital health providers (1); Digital spaces (2); Access to digital health information (4); Artificial intelligence (3); Device calibration (1); Technical system features (1)
	Interaction between providers (12)	Communication between stakeholders (1); Technology sharing, co-design (1); Expanded connectivity between applications (1); Data/design standards (9)
	Positive interaction between providers and users (15)	Technology personalisation (6); Technology-oriented training (2); Technical support (3); Cultural and linguistic inclusion (language concordance) (2); Digital representation (1); Customer feedback mechanism (1)
	Context-dependent interaction between providers and users (11)	Marketing strategies (3); Digital privacy and security (7); Nature of online content to which users are exposed (1)
	Negative interaction between providers and users (25)	Data poverty and information asymmetry (8); Digital exclusion (1); Ageism (1); Algorithmic bias (15)
People who interact with digital health (121)	Digital health literacy (43)	Health literacy, digital literacy, digital health literacy, civic literacy (43)
	Users’ attributes (32)	Attitudes toward and trust in technology, ideologies, willingness to engage, and cultural interpretations (16); Educational attainment (2); Disease status (1); Language (1); Sexuality (1); Age (1); Race (3); Gender (1); Class (1); Income (1); Social security status (1); Place of residence (1); Socioeconomic status (2)
	Users’ practices (8)	Internet use (2); Exposure to and use of social media and digital platforms (5); Children’s use of digital technologies (1)
	Users’ experience (29)	Ease of use (6); Perceived usefulness (6); Interactivity (6); Personal experience (2); Satisfaction (2); Digital self-efficacy (6); Online racism (1)
	Interpersonal level determinants (9)	Interdependence (5); Inherent and implicit technological biases (4)
Community and society (39)	Digital systems and agendas (20)	Digital systems (1); Digital agendas (2); Digital transformation (1); Digitalisation (2); Digital policies (11); Data governance (1); Impact of digital technologies (1); Policymakers’ willingness to invest in digital infrastructure (1)
	Social environment (19)	Community and societal norms and perceptions related to technology (10); Individual or collective contributions to digital health knowledge repositories (1); Community partnerships (3); Structural bias, inequality and discrimination (2); Changes in employment type (1); Sociodemographic characteristics (1); Regional differences (1)
Healthcare system (28)	Capacities (12)	Capacity to integrate digital platforms into healthcare systems (1); Availability of digital health services (8); Quality of healthcare system digital infrastructure (1); Technologies designed for atypical patients (2)
	Patients’ characteristics (8)	Use of digital resources for health-seeking (7); Patient diversity (1)
	Medical complexity (1)	Medical complexity and individual symptom burden (1)
	Interactions (7)	Patient–provider communication via digital tools (3); Patient–technology–clinician relationships and power dynamics (3); Significant patient-to-patient relationships (1)

^*Frequencies represent the number of publications in which a given component was identified; each component was counted once per publication.

Digital health infrastructure

Digital health infrastructure was a frequently reported domain (f = 94). Within this domain, which included only one theme, the most commonly identified components were the availability, accessibility, and affordability of digital technologies (f = 42), followed by broadband internet availability, accessibility, and affordability (f = 28). Availability was the aspect most frequently highlighted for broadband. Together, these components were among the most frequently reported across all identified DDoH components.

The general availability of digital infrastructure was also identified as a relevant component (f = 14). In contrast, the integration of digital resources into community and health infrastructure was infrequently reported (f = 7), and utilities necessary for the use of digital technologies, such as access to a reliable electrical grid, were mentioned in only three publications.

Digital health technology, platform and service providers (Digital health providers)

Digital health providers constituted another prominent domain (f = 75). Components within this domain were organised into five mutually exclusive themes: providers and their services (f = 12), interactions between providers (f = 12), positive interactions between providers and users (f = 15), context-dependent interactions between providers and users (f = 11), and negative interactions between providers and users (f = 25).

Within this domain, a small number of components appeared repeatedly across publications. Data design and standards (f = 9) encompassed increasing sophistication in the acquisition, screening, analysis, interpretation, and application of large and diverse datasets [11] as well as standardisation efforts related to language, application design configuration, and adherence to Web Content Accessibility Guidelines.^14,26 Technology personalisation (f = 6) referred to users’ ability to customise digital tools to enhance accessibility and adaptability to physical, cognitive, or language-related needs. ²⁷

Negative interactions between providers and users accounted for the largest theme. Within this category, data poverty and information asymmetry (f = 8) and algorithmic bias (f = 15) were the most frequently reported domains. Health data poverty refers to the inability of individuals, groups, or populations to benefit from discoveries or innovations due to insufficient or inadequately representative data. ²⁸ Algorithmic bias was described as encompassing bias arising from machine-learning and artificial-intelligence systems, as well as racial bias embedded in health algorithms that do not rely on advanced computational methodologies. ¹⁴ Despite frequent discussion of algorithmic bias and data-related inequities, artificial intelligence itself was rarely conceptualised as a standalone digital determinant of health, being identified as an explicit component in only three publications.

People who interact with digital health (Digital health users)

Digital health users represented the most frequently reported domain overall (f = 121). This domain comprised five mutually exclusive themes: digital health literacy (f = 43), users’ attributes (f = 32), users’ practices (f = 8), users’ experiences (f = 29), and interpersonal level determinants (9).

Literacy-related components were the most prominent within this domain. The term “literacy” encompassed digital literacy, health literacy, digital health literacy, data literacy, and civic literacy. Chidambaram et al. defined digital health literacy as “the ability of an individual to effectively interface and interact with digital technology, encompassing all the skills required to find, understand, appraise, and apply health information from electronic sources”. ²⁹ Park and Jang define it as “the proficiency and capability of technology access, encompassing the language, hardware, and software necessary for the successful exploration of digital technologies”. ²⁶

Beyond functional access to information, Davis highlights the importance of promoting digital human rights literacy and health data governance literacy. ³⁰ Kickbusch et al. distinguish digital literacy, understood as the ability to use digital technologies and understand associated risks, from health literacy, defined as the capacity to assess and apply health information to maintain or improve health and wellbeing. ¹⁰ Van Kessel et al. further argue that the relationship between digital, health, and digital health literacy is multidimensional, with some digital health literacy competencies not fully encompassed by either digital or health literacy alone. ¹⁷ Both Kickbusch et al. and van Kessel et al. also include civic literacy, defined as the knowledge and capacity to participate in society and community life. In addition, Van Kessel et al. introduce science literacy (civic, digital media and cognitive science literacy), financial literacy, and consumer literacy.

Users’ attributes included attitudes toward and trust in technology, ideological beliefs, cultural interpretations, willingness to engage with digital tools, socio-demographic and other individual factors. Users’ practices focused on patterns of internet use and engagement with digital platforms, including social media and children’s use of digital technologies. Users’ experiences captured components such as ease of use, perceived usefulness, interactivity, satisfaction, personal experience, digital self-efficacy, and exposure to online racism.

We combine the interpersonal level with other themes in the People who interact with digital health domain for two reasons. It shapes how users engage with digital technologies and is still underexplored, with only implicit tech bias and interdependence identified in the literature. As defined by Narayan et al. “implicit bias refers to assumptions made by the health-care professionals (including community and social workers) that exclude individual access, such as assuming that a device is ‘too difficult to use’,” while dependence on others can hinder access to digital health technologies when devices are unavailable or when sharing could expose sensitive data. ²⁵

Community and society

The Community and society domain was reported less frequently overall (f = 39) and comprised two themes: digital systems and agendas (f = 20) and the social environment (f = 19). Within this domain, digital policies (f = 11) and relevant community and societal norms and perceptions (f = 10) were the only components reported in more than two publications.

Other components reflected broader societal readiness for digital health and the influence of community-level factors on digital health adoption. These included willingness to invest in digital infrastructure, community partnerships, structural bias and discrimination, changes in employment types, contributions to digital health knowledge, and regional and sociodemographic differences.

Healthcare system

The Healthcare system domain was the least frequently reported overall (f = 28). Components within this domain primarily related to system-level capacities to adopt and integrate digital platforms, including the availability and quality of digital health services and healthcare system digital infrastructure. Other components addressed interactions among healthcare actors, such as patient–provider communication via digital tools and evolving patient–technology–clinician power dynamics.

Only one publication addressed patient diversity, and only one highlighted challenges associated with medical complexity, including symptom burden. These findings indicate that, relative to individual-level determinants, healthcare system characteristics are less frequently conceptualised as DDoH in the current literature.

Interpersonal DDoH could also fit within the Healthcare system’s Interactions theme. However, they are placed under People who interact with digital health because they extend beyond patient–provider interactions to include family and community relationships. This example illustrates that assigning components to broader themes or domains can be somewhat arbitrary, as clear boundaries between them often do not exist.

Relationships between digital determinants of health and other determinants of health

Explicit relationships between DDoH and other determinants of health were described in 28 (43.1%) publications (Supplemental File I). Most publications focused on the relationship between DDoH and SDoH. While some authors explicitly position DDoH or one of its components as a part of SDoH,^27,31–33 others emphasise the importance of distinguishing DDoH as a separate entity.^34,35 Oliveira et al. argue that placing digital factors under the umbrella of SDoH could overshadow the attention needed for epistemic, political, and social action on the complex and hybrid processes that materiality imposes today. ³⁴ Similarly, Phuong et al. highlight that DDoH represent conceptually distinct facilitators and barriers compared with SDoH. ³⁵ In addition, six publications recognise DDoH as a “super determinant of health” or a “super social determinant of health”.

A larger group of publications discuss the relationship between DDoH and SDoH in more detail. For example, Chidambaram et al. concluded: “Without significant empirical evidence, they can be considered as a subset of SDOH... Within the literature, factors related to technology are often incorporated within SDOH. However, the way technology is designed, validated, used, disseminated, and incorporated within healthcare has far-reaching consequences that deserve treatment as a distinct construct. Nevertheless, both DDoH and SDoH have a closely intertwined relationship that must be considered together in their applications.” ¹³

Northcott provides a brief overview of the relationship between DDoH and commercial, political, and environmental determinants of health. ³⁶ Jahnel et al. argue that instead of creating a completely new and separate level of influence, existing determinant categories can serve as a practical framework for analysing and addressing digital health inequities by identifying how digital factors operate within these levels. ³⁷ Lupton points out that the literature is divided on whether political and commercial determinants should be viewed as social “forces” or super-social elements shaping the social determinants and suggests that a similar debate applies to DDoH. ³⁸ She concludes that from a theoretical perspective, the traditional four categories of health determinants are broad, whereas DDoH represent a more specific subset that overlaps with them. While not every social, commercial, political, or environmental determinant is digital or digitalised, all DDoH necessarily incorporate elements of these dimensions.

Discussion

Digital determinants of health represent the most recently articulated category of health determinants. Their first explicit mention in an academic publication can be traced to 2020. ¹¹ Despite a rapid increase in publications addressing digitalisation and health, DDoH remain relatively understudied as a distinct concept. This gap likely reflects the limited recognition of DDoH as an independent category of health determinants, as well as the longstanding dominance of SDoH in both research and educational curricula. The slow adaptation of academic and training programmes to emerging digital health evidence may have further contributed to this situation. ²¹

The first structured attempt to define components of DDoH was proposed by Crawford and Serhal in 2020, who identified six components encompassing access to digital resources, their use for health seeking or health avoidance behaviours, digital health literacy, beliefs related to digital health and digital resources, values and cultural norms, and the integration of digital resources within communities and health infrastructure. ¹¹ Within the Digital Health Equity Framework, DDoH were positioned in relation to broader socio-economic, cultural, and health system determinants. Two years later, Richardson et al. proposed their Framework for Digital Health Equity, which described the interaction between six domains (biological, behavioural, physical/built environment, digital environment, sociocultural environment, and healthcare system) across four levels of influence (individual, interpersonal, community, societal). The digital environment included 16 components spread across four levels. ¹⁴

Van Kessel et al. proposed a substantially broader conceptualisation of digital determinants of health, identifying 37 digital determinants and 100 other (social, political, and commercial and economic) health determinants that have emerged or changed during the digital transformation of society. ¹⁶ Rather than positioning DDoH as a discrete set of factors, their framework conceptualises digitalisation as a cross-cutting force permeating all other determinants of health. This approach captures the systemic and interdependent nature of digital transformation and highlights how digital determinants intersect with broader structures shaping health inequities. However, its intentionally expansive definition—encompassing any factor linked to the digital world that directly or indirectly influences health or well-being—may dilute analytical focus and blur conceptual boundaries between determinant categories.

To address this challenge, van Kessel et al. emphasised prioritisation, identifying specific determinants across domains, such as moderation of harmful content and misinformation, and model accuracy and algorithmic validation. ¹⁶ While this framework represents a clear conceptual shift away from earlier domain-based models, including those proposed by Crawford and Serhal, its breadth contrasts with the more focused and empirically driven approaches adopted in much of the existing literature. ¹¹

These frameworks have substantially advanced the conceptualisation of DDoH; however, important gaps remain. The literature continues to concentrate on access, availability of digital technologies, and digital literacy, and no updated synthesis has systematically integrated developments after 2023. In addition, the positioning of DDoH relative to SDoH and broader structural (“super”) determinants remains conceptually unresolved. Building on prior work, our concept-focused systematic review synthesises fragmented components across the literature and identifies five interrelated domains—Digital health infrastructure, Digital health technology, platform and service providers (Digital health providers), People who interact with digital health (Digital health users), Community and society, and the Healthcare system — which together offer a high-level organising structure.

The observed narrowed approach in the literature becomes especially apparent when considering populations facing multiple vulnerabilities. Recent work by Matlin et al. underscores how digital determinants of health operate in the context of migrants and refugees. Their socio-technical framework highlights that deficits in connectivity, equitable device access, data security, and participatory approaches critically shape the effectiveness of digital health solutions. These findings illustrate how broader DDoH themes identified in our review—such as infrastructure, access and equity, and community-level factors—manifest in highly vulnerable populations, reinforcing the need for comprehensive and context-sensitive DDoH frameworks. ³⁹

The geographic distribution of the literature further reinforces this limitation. More than one third of included studies originate from the United States, with the vast majority conducted in high-income countries. This concentration introduces a structural bias into prevailing DDoH frameworks and limits their applicability in low- and middle-income settings. For example, utilities and community infrastructure, such as stable electricity supply, receive minimal attention, despite being fundamental prerequisites for digital health in many contexts, particularly in settings affected by conflict, displacement, or climate-related disruptions. ³⁵

Importantly, access to digital technologies and digital health literacy alone does not guarantee positive health outcomes. Multiple barriers discourage engagement with digital health tools, including limited accessibility for users with sensory, linguistic, or cognitive needs, as well as the substantial time and effort required for installation, updates, training, and navigation of frequently changing platforms and interfaces.^40–42 In addition, digital services are increasingly mandatory in the absence of nondigital alternatives, such as digital-only appointment scheduling or payment systems. In such contexts, concerns related to privacy, data security, and confidentiality may remain unaddressed, while users are simultaneously exposed to unwanted commercial or promotional content embedded within digital environments.^43–45

Relatively little attention has been paid to the purpose and content of digital engagement in health contexts. While DDoH are often discussed in relation to telemedicine, electronic health records, and health system digitalisation, far fewer studies examine health-related information encountered in digital spaces. This omission is notable given that exposure to online health information is the most common point of contact between individuals and digital health environments. The COVID-19 pandemic, along with pre-pandemic declines in vaccination coverage in some communities, demonstrated the significant health impacts of infodemics driven by misinformation and disinformation on social media platforms.^46–48 Nevertheless, the role of digital information ecosystems remains insufficiently integrated into DDoH frameworks.

A similar gap is evident in relation to artificial intelligence (AI). Although AI presents both opportunities and risks for health systems and population health, ⁴⁹ it is rarely conceptualised as a distinct digital determinant of health.^13,50 AI may function both as enabling infrastructure embedded within digital systems— for example, natural language processing algorithms integrated into electronic health records, and as a mediator of information and decision environments, such as AI-driven clinical decision support systems, predictive alerts, or conversational tools that guide clinical reasoning and patient management.^51–53 As these technologies increasingly shape access to health information, decision-making, and service delivery, it remains unclear whether AI should be conceptualised as a distinct DDoH component or as a cross-cutting determinant operating across existing categories. Further empirical research is needed to clarify its appropriate positioning within DDoH frameworks.

Across existing frameworks, insufficient attention is paid to digital health technology, platform and service providers as a distinct societal category. Communities and policy environments are often treated as proxies for both user characteristics and technological features, yet this overlooks the central role of commercial actors in shaping digital health ecosystems. Technology owners, platform providers, and data-driven market actors exercise significant influence over access, design, content, and governance of digital health tools. As Northcott argues, the convergence of digital and commercial determinants—driven by pervasive data analytics, targeted advertising, and influencer content—amplifies health-harming impacts that are largely beyond the control of individuals, communities, and even national governments. ³⁶ Provider-related biases, including exclusion of users with specific cultural, linguistic, biological, or health-related needs, as well as algorithmic bias, further reinforce digital health inequities.

Finally, intersections between DDoH and environmental determinants of health remain largely absent from the literature. With the exception of Kickbusch et al. who discuss the broader role of digital transformation in shaping social and environmental determinants, ¹⁰ and Jahnel et al. and Lupton who highlight intersections between digital and environmental and other determinants,^37,38 other authors do not address the role of digital technologies in environmental degradation, climate change, or the spread of climate-related misinformation. Similarly, biological determinants and condition-specific health needs receive limited attention in current DDoH frameworks.

This study has several limitations. The rapid evolution of digital health research means that any literature review is likely to be partially outdated at the time of publication. Although broad inclusion criteria were applied, relevant studies may have been missed due to database restrictions or language limitations. The exclusion of non–English-language publications likely omitted valuable perspectives. Most importantly, more than half of the included studies originated from only two countries, resulting in a pronounced geopolitical and cultural bias that limits the generalisability of current DDoH frameworks. Finally, despite the rigorous efforts undertaken by the screeners, it is possible that some DDoH were overlooked in the reviewed literature. Our study focused on publications in which authors explicitly defined DDoH or described their components and relationships with other determinants, so studies that discussed these concepts more implicitly may not have been captured. For example, when artificial intelligence was discussed in relation to health inequities but not explicitly identified as a digital determinant of health or as a component thereof, it was not coded as part of the DDoH framework in our analysis. Similarly, broader discussions on the role of digital transformation across determinants of health (e.g., Kickbusch et al. ¹⁰ ) may not have been captured when these were not explicitly framed as digital determinants of health. Consequently, the reported frequencies should be interpreted as approximate rather than absolute. Nonetheless, such omissions are expected to be infrequent and are unlikely to affect the overall conclusions.

Conclusion

Our literature review reveals a lack of consensus regarding what constitutes the digital determinants of health, their components, and their relationship to other determinants of health. While some authors conceptualise DDoH as a subset of the social determinants of health or as a “super SDoH,” others argue that they should be treated as a distinct category due to their unique characteristics. The broad definition proposed by van Kessel et al.—defining DDoH as any factor rooted in, contingent upon, or inextricably linked to the digital world that can directly or indirectly influence health or well-being—captures the complexity and breadth of these determinants. However, there remains a need for a DDoH-specific framework that positions them independently from other DoH, while explicitly highlighting their interrelationships. Such a framework should extend beyond internet access, digital technologies, and digital health literacy, and should emphasise the role of individual characteristics, including specific needs, preferences, and lived experiences, as well as cultural, linguistic, age-related, disease-related, and other contextual factors. Furthermore, the roles of digital health technologies, service and information providers, and commercial interests should be explicitly addressed.

Supplemental material

Supplemental material - What do we talk about when we talk about digital determinants of health? – A systematic review

Supplemental material for What do we talk about when we talk about digital determinants of health? – A systematic review by Predrag Duric, Smiljana Rajcevic, Jelena Djekic Malbasa and Danica Mulic in Digital Health.

Supplemental material

Supplemental material - What do we talk about when we talk about digital determinants of health? – A systematic review

Supplemental material for What do we talk about when we talk about digital determinants of health? – A systematic review by Predrag Duric, Smiljana Rajcevic, Jelena Djekic Malbasa and Danica Mulic in Digital Health.