Toward a Multidimensional Understanding of Sustainability in Digital Health Interventions: A Scoping Review (Preprint)

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Abstract
BACKGROUND Recent advances in digital health, including Artificial Intelligence-driven interventions, offer new opportunities for remote monitoring, patient-reported outcomes, and even direct treatment. Despite the growing adoption of digital health interventions (DHI), the concept of sustainability in this context remains under-theorized and fragmented in the literature. A clear understanding of sustainability is essential to ensure that DHIs can deliver enduring clinical, organizational, and societal value beyond initial implementation. Here, sustainability refers to ensuring that DHIs remain ethically, equitably, and environmentally responsible while delivering lasting health benefits and minimizing negative societal and environmental impacts. OBJECTIVE To study which frameworks have been applied in digital health for measuring or ensuring sustainability of DHI as well as to assess which dimensions of sustainability have been currently considered and to what extent. METHODS We conducted a scoping review as a concise synthesis of how existing models and frameworks address sustainability in the context of DHI. We examined peer-reviewed papers from 5 databases that described a sustainability framework in the context of digital health. The process followed PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guideline and PRISMA-S (Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension) checklist. Information on the frameworks was extracted including the considered sustainability factors. RESULTS Of 292 records, 53 studies were included and considered for data synthesis. Sustainability was rarely defined in these papers but invoked the concept only implicitly. Sustainability was basically used as a synonym for continued use rather than a multidimensional construct. Correspondingly, frameworks typically addressed usability and user acceptance. The social and technological dimensions of sustainability were addressed most frequently by the included frameworks, while ecological and economic dimensions remained rarely considered. In particular, UTAUT and TAM frameworks were extended by concepts of trust, risk, individual and health-related factors and contextual influences. CONCLUSIONS The current landscape of frameworks applied for sustainability in DHI do not represent the multidimensionality of the concept of sustainability as it would be necessary for ensuring a sustained use of DHI. Future work should therefore focus on strengthening the multidimensional view for addressing sustainability aspects throughout the entire DHI lifecycle.

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