Exploring community participation in digital health tool implementation to enhance health equity in low and middle-income countries and humanitarian contexts

Health inequities, arising from socio-economic, political, environmental, and technological determinants, are the unfair differences between population groups. These inequities are widespread within low and middle-income countries and humanitarian contexts and can result in uneven health outcomes. Digital health offers potential to overcome complex health challenges in these contexts. Community participation involves collaborating with communities to address real-world needs. However, superficial participation and digital exclusion can undermine digital health benefits and exacerbate inequities. This research explored how community participation has been adopted as an implementation mechanism for digital health tool development in low and middle-income countries (LMIC) and humanitarian contexts. This research comprised three methodological phases: A systematic scoping review synthesised relevant scholarly literature on this topic. Qualitative interviews with digital health experts and humanitarian practitioners outlined contemporary digital health implementation practices in relation to participation and responded to knowledge gaps identified within the literature. This was followed by an in-depth examination of a unique and intentional community participatory method to develop the ‘Oky’, a smartphone digital health tool to support adolescent girls with menstruation to indicate what is feasible in this regard. The literature indicated a dearth of attention to community participation in digital health tools. Authorship and implementation were largely led by Global North authors, indicating international power dynamics over low-and-middle-income challenges. The interviews revealed that community participation did occur in various forms in practice; however, it tended to be ad hoc, superficial and uneven, due to contextual and organisational factors. The unique community participatory method highlighted the feasibility of community participation in the implementation of digital health tools in diverse low and middle-income and humanitarian contexts. However, its success depended upon contextual, implementation and collaborative conditions. This research found that community participation implementation norms vary in intensity, inclusion, and influence in the development of digital health tools. Current practice highlights that, in general, community participation in digital health implementation is undervalued, under-supported, and underreported. However, when intentionally undertaken and appropriately resourced, community participation is possible in LMIC and humanitarian contexts and can contribute towards health equity gains.