Equity by design principles for digital health interventions.

Background: Despite significant progress in the past decade, health disparities persist. Digital health interventions (DHIs) offer a transformative opportunity to advance health equity but may also exacerbate the digital divide if equity considerations are not embedded from the onset. While there is broad consensus on the importance of equity-centered design, a critical gap re-mains in the form of actionable guidance for both research and practice. Thus, this study aims to develop equity by design principles for DHIs.

Methods: We first synthesized existing scientific knowledge by assessing 42 articles/guidelines and formulated an initial set of 26 actionable, evidence-based design principles for DHIs (July through October 2024). We then conducted three semi-structured expert interviews to refine these principles (November 2024 through January 2025). We finally facilitated end-user workshops with two DHI providers to assess and finalize the design principles with respect to practical relevance and applicability (January through March 2025).

Results: We identified 25 equity by design principles, 15 targeting DHIs, and 10 the organizational context in which DHIs are developed. The DHI-specific principles were categorized according to key process stages: needs assessment, design and development, implementation, and evaluation and dissemination. The organizational context principles were grouped into four domains: strategy, people, processes and structures, and partnerships and advocacy. We further challenged the principles real-world applicability, identifying three overarching challenges that hinder their successful implementation.

Conclusions: The study underscores the necessity of moving beyond DHI-specific design considerations to address health inequities in digital health. By adopting these design principles, digital health companies can embed equity as a core strategic priority, actively contribute to reducing health disparities, and foster a more inclusive healthcare ecosystem.