Cocreating Principles for Digital Health Equity: Cross-Sectional, Qualitative Study for Participatory Human-Centered...

Digital health technologies promise to democratize health care access yet often exacerbate existing inequalities when developed through traditional top-down approaches that prioritize technology implementation and exclude end users from design processes. The COVID-19 pandemic accelerated digital transformation while simultaneously exposing how technology can both bridge and widen gaps in health care access. Understanding how to systematically integrate equity considerations into digital health transformation across entire health systems has become increasingly urgent.

This study aims to cocreate actionable design principles for equitable digital health transformation through a large-scale participatory human-centered design (PHCD) process involving diverse stakeholders across Catalonia's health care ecosystem (northeast Spain), with the aim of establishing guidelines for information systems that support a person-centered, integrated, and longitudinal care delivery model.

We conducted a qualitative PHCD research study involving 265 participants representing diverse stakeholder groups: citizens and informal caregivers (n=106), health care professionals (n=83), health care managers and leaders (n=50), and experts representing various domains of digital health innovation (n=26). Through two sequential rounds of participation between June 2024 and April 2025, we used design thinking methodologies and cocreation tools in 24 sessions across Catalan geography and 7 topic-specific expert sessions. Data collection used innovative visual tools, including journey mapping, care model animations, future scenario storyboarding, and facilitated ideation techniques. Analysis followed an inductive-deductive approach combining affinity mapping, thematic synthesis, and participant validation to transform stakeholder proposals into actionable design principles.

Participants identified critical barriers to digital health equity, including digital literacy gaps, fragmented information systems, a lack of user involvement in design, and insufficient consideration of vulnerable populations' needs. The cocreation process yielded 10 fundamental principles: (1) the person and their care circle at the center, (2) health for everyone, everywhere, (3) tools for more compassionate care, (4) a better professional experience, (5) an active role of the population, (6) personalized and proactive care, (7) systematic use of data for decision-making, (8) integrated quality data working for health, (9) an information system that builds trust, and (10) collaboration as a driver of innovation.

This study shows how large-scale, rigorously conducted PHCD can uncover and address equity barriers in health information systems. Beyond producing 10 actionable design principles, it highlights how engaging diverse stakeholders can turn complex inequities into practical guidance for equitable digital transformation. The resulting principles provide a framework for creating person-centered systems that are robust, inclusive, and accessible to all, while underscoring the need for enduring partnerships among public institutions, researchers, design experts, and communities as a foundation for sustainable and equitable digital health innovation.