Challenges and experiences in digital health equity: a qualitative exploration of the implementation of the Health Code system in China.

BACKGROUND: During the COVID-19 pandemic, the rapid deployment of digital health technologies (DHTs), exemplified by the Health Code, quickly integrated many older adults, many of whom lacked digital readiness, into the digital society. This accelerated integration revealed a range of challenges faced by older adults in using DHTs. To effectively implement digital epidemic control measures while meeting the daily needs of the elderly, the Chinese government needs to adopt pragmatic policy responses to bridge the digital health divide. OBJECTIVE: This study investigates the barriers faced by older adults in using the Health Code and other DHTs during the COVID-19 pandemic, analyzes the policy measures implemented by the government to address these barriers, and summarizes China's practical experiences in promoting digital health equity. METHODS: This study employed a multi-method qualitative research design, sequentially combining individual interviews and document analysis to comprehensively explore the research questions. Guided by the Unified Theory of Acceptance and Use of Technology, semi-structured interviews were conducted with 23 older adults residing in rural areas of Zhejiang Province to explore the factors that hinder their use of the Health Code and other DHTs. Informed by the Digital Health Equity Thematic Framework, framework analysis was applied to 92 policy documents to analyze governmental responses addressing these barriers. Finally, the results of the individual interviews and document analysis were integrated to achieve a comprehensive understanding of the barriers faced by older adults and the corresponding policy measures addressing them. RESULTS: The interviews identified three major themes influencing older adults' use of DHTs: Preparedness, Receptiveness, and Willingness, along with nine sub-themes. In response to these barriers, the government introduced a series of policy measures targeting five domains: Individual, Community/Social, Systems, Policy, and DHTs. By integrating the results from both phases of the study, we identified three user types based on technology-related barriers- non-users, conditional users, and independent users- and summarized three categories of policy tools: alternative-based tools, nudge-based tools, and boost-based tools. CONCLUSIONS: China's experience offers two key insights for advancing global digital health equity: first, assessing disparities in access, use, and benefits is essential to develop tailored, differentiated policy measures for diverse user groups; second, establishing a multi-stakeholder governance system, facilitated by the "3 C" framework (Create, Co-design, Collaborate), can promote collaboration and co-creation of inclusive digital health solutions.