https://orcid.org/0000-0001-9043-8126
-
PDF
- Split View
-
Views
-
Cite
Cite
Kath Albury, Samantha Mannix, Digital determinants of sexual and reproductive health—workforce perspectives on digital and data literacies, Health Promotion International, Volume 40, Issue 2, April 2025, daaf013, https://doi.org/10.1093/heapro/daaf013
Close - Share Icon Share
Abstract
This article explores the impact of digital transformation on sexual and reproductive health promotion from an interdisciplinary perspective, focusing on the implications of rapidly evolving policy landscapes for the Australian health promotion workforce. We draw on 29 key informant interviews and workshops with 18 current sexual and reproductive health professionals (aged 18–29). Both groups were invited to reflect on how digital and data literacies are currently understood and applied within the Australian sexual and reproductive health promotion sector. Interviewees shared concerns related to digital and data literacy, equity, and the challenges of integrating digital technologies into health practice. Findings highlight the need for strategic approaches that shift focus away from individual literacies towards broader organisational capabilities. These capabilities include: an understanding of digital policy and platform governance (e.g. in relation to social media content moderation); an understanding of how health consumers and service users currently utilise digital systems to support sexual health and wellbeing; and an understanding of the ways digital equity and data justice can be undermined or advanced in organisational settings. We conclude with recommendations for enhancing workforce digital and data capabilities and integrating DDoH into health promotion policy and practice to improve health equity. Significantly, we conclude that dedicated resources and training are needed to address the complexities of DDoH in the sexual and reproductive health context.
The study explores existing understandings of ‘digital literacy’ and ‘data literacy’ within the Australian sexual and reproductive health workforce.
Gaps in existing workforce understandings of data and digital technologies are contextualised in relation to relevant health policy and guidance.
Findings suggest health promotion policy and implementation should both support individual digital and data literacies, and address the broader factors that may constrain or enable digital and data capabilities in organisational contexts.
Future workforce development strategies should consider how to best engage with digital content, platforms, and systems to meet the needs of health professionals, health consumers, and service users.
INTRODUCTION
Health systems across the globe are currently in the midst of a dynamic and fast-paced digital transformation (WHO 2021). In the Australian context, as elsewhere, this has meant new State and Federal policies; new strategic initiatives for delivering health services via data-driven digital platforms; rapidly evolving regulatory landscapes (Parliament of Australia 2024); and moves to build digital and data capability within health workforces (Australian Government 2023).
The fields of sexual and reproductive health are similarly impacted. Government and non-government agencies globally utilise enterprise digital platforms and technologies to assist in clinical practices and administration (Chidambaram et al. 2024). Health promotion professionals share sexual health and wellbeing content on social media platforms, both competing and collaborating with health ‘influencers’ (Albury and Hendry 2023, Garwood-Cross et al. 2024). Commercial start-up founders promise accessible technological solutions to health inequalities—including filling information and service gaps caused by the underfunding of public sexual and reproductive healthcare (Albury et al. 2023).
However, concerns remain regarding the security of these technologies, with questions raised around user privacy and data justice (Flore and Pienaar 2020, Stardust et al. 2023). At the same time, rapid advances in data-driven digital technologies and platforms—including Artificial Intelligence (AI)—have prompted the World Health Organisation (WHO) to release a technical brief calling for increased attention to the inclusive and responsible use of AI in sexual and reproductive health promotion and clinical service provision (WHO 2024a).
In this article, we respond to Kickbusch and Holly’s (2023) suggestion that the field of health promotion can ‘lead the charge’ in response to the Digital Determinants of Health (DDoH). While the concept is still emergent, DDoH generally refers to ‘the direct and indirect pathways in which digital factors influence health, wellbeing and health equity’ (Tefera et al., 2024, p. 1). Recent literature defines digital determinants in terms of the accessibility, usability, and affordability of digital technologies and platforms, with a number of studies underscoring the central role of ‘digital health literacy’ (Crawford and Serhal 2020, Richardson et al. 2022, Chidambaram et al. 2024).
Specifically addressing the Australian context, Backholer and colleagues (2021) emphasise the importance of understanding the role of data as DDoH. Noting that ‘digital literacy’ and ‘data literacy’ seem to be well-accepted as elements of DDoH, this article explores the question of how current health workforces understand these concepts. Drawing on current Australian policy guidance related to workforce development [including strategies and other guidance provided by the Australian Digital Transformation Agency (ADTA) and the Australian Digital Health Agency (ADHA)], we broadly understand workforce digital literacies as skills and competencies related to ‘the design and delivery of digital services’ (Australian Digital Transformation Agency 2023). Within the Australian public policy context in which we situate our research, ‘data literacies’ have been defined as analytic and other skills that facilitate the use of data (which may be collected via both digital or analogue technologies) to gain ‘insights for better decision-making in policy development, program management and service delivery’ (Australian Public Service Academy 2024).
However, ‘literacies’ are historically contested concepts—particularly in workplace settings (Vee 2017). Indeed, the research outlined in this paper has led us to shift our preferred terminology from literacies to capabilities. On one level, this shift pragmatically reflects Australian policy guidance, which focuses on digital health workforce capabilities as opposed to workforce literacies (Australian Institute of Digital Health 2023). At the level of implementation, we suggest that a focus on capabilities enables a shift away from assessing individual skills (or deficits) to facilitating a broader consideration of the material impacts of digital health policy, infrastructure and training on both health promotion professionals, and health consumers and service users (Albury and Mannix 2023).
This paper draws on two iterative stages of qualitative research undertaken between 2022 and 2024, as part of a project seeking to build digital and data capabilities with the Australian sexual and reproductive health workforce. We apply an interdisciplinary lens, bringing together perspectives from digital media studies and public health to consider how DDoH can be understood in relation to what has been termed the digital transformation of health. We draw on interviews with senior researchers and practitioners (n = 29) in the fields of sexual health, women’s health, youth health, health sociology, and digital and data studies, who were invited to reflect on what ‘digital and data literacies’ might mean in terms of sexual health policy and practice. We extend our understanding by drawing on workshop discussions and interviews with ‘young’ (18–29-year-old) practitioners in sexual and reproductive health promotion (n = 18), for whom digital and data-driven technologies are an everyday source of personal health information and/or a workplace resource.
For the purposes of the present article, we focus on responses to the research questions most relevant to understanding how DDoH might play out in sexual health promotion settings: how are digital literacy and data literacy most commonly defined and understood within sexual health promotion organisations? We conclude by reflecting on the opportunities and challenges presented by interdisciplinary and transdisciplinary approaches to the digital transformation of sexual and reproductive health.
BACKGROUND
The digital transformation of health
This paper brings an interdisciplinary and transdisciplinary (OECD 2020) lens to two contested and evolving concepts—the ‘digital determinants of health’ and ‘sexual health’ as they are brought together under the (contested) umbrella of ‘digital transformation’. The ADTA, which oversees Australian digital public policy—including policy and guidance for health services—frames digital transformation as a strategic process, which will provide ‘simple, secure and connected public services for all people and business through world class data and digital capabilities’ (ADTA 2004). In contrast, the University of Melbourne’s Centre for the Digital Transformation of Health frames digital transformation as an outcome of digital innovation, in which ‘the relationship between clinician and patient is guided by clinical data and enabled by digital health technologies’ (University of Melbourne 2024).
While a comprehensive genealogy of the term is beyond the scope of this paper, we note that critical attention towards the potential impact of digital transformations on existing social and health disparities has been deployed across disparate disciplines (from public health, health sociology, and digital and data studies) over the past decade. Digital advances and the growth—and commodification—of personal health data have also seen the arrival of ‘Big Tech’ (and platform conglomerates such as Apple, Google, Microsoft, and Meta) into the health sector (Yeo 2021). Partnerships between tech companies and government health services are increasingly common, as tech companies develop new platforms (i.e. cloud storage) or provide access to data that governments do not otherwise own/access (Storeng and Puyvallee 2021). Such enterprises have generated growing concerns around the power of tech companies to influence governments and their public health agendas (Sharon 2020, Storeng and Puyvallee 2021).
Critics have cautioned that the priorities and ethical standards of commercial actors may deviate from government and consumer priorities and needs (Thomason 2021, Ferretti and Vayena 2022), particularly where a focus on profit may override the interest in equity and human rights (Dickens 2022, Alberto et al. 2023). Additionally, as the ‘hype’ over generative AI increases, environmental researchers are sounding a warning regarding the disproportionate environmental damage inflicted in the majority world—specifically in relation to water consumption required to process Large-Language Learning models or LLMs (Ren and Weirman 2024).
What are the DDoH?
Within public health literature, the term ‘Digital Determinants of Health (DDoH)’ broadly signifies the diverse digital drivers of health inequities (Jahnel et al. 2022, Richardson et al. 2022, Kickbusch and Holly 2023). Observing that there is yet to be an agreed-upon definition of DDoH, Chidambaram and colleagues (2024) suggest that digital determinants ‘refer to factors intrinsic to the technology in question that impact sociodemographic disparities, health inequities, and challenges with care, accessibility, affordability, and quality outcomes’ (p. 3). Emerging conceptual work positions the DDoH within a digital ecosystem that interacts with social, political, and commercial factors (Özdemir 2021, Kickbusch and Holly 2023), operating across the individual, community, and societal levels (Richardson et al. 2022). Examples include digital literacy and self-efficacy at the individual level, healthcare, and tech infrastructure (i.e. broadband access) at the community level, and data standards and tech policy at the societal level (Richardson et al. 2022.
Fraser and colleagues (2023) observe that the digital transformation of health systems is a key site in which the DDoH can be seen to play out. They offer the example of telehealth to highlight the ambivalent nature of digital technologies, observing that the same digital health services that increase accessibility for health consumers who already possess digital devices and skills are likely to perpetuate exclusion and marginalisation for those who lack the knowledge and material resources required to access online services.
In earlier work, the WHO’s Global Strategy on Digital Health (WHO, 2021)suggests that the DDoH includes ‘literacy in information and communication technologies and access to equipment, broadband and the internet’ (p. 16). The focus here is largely on the ways that health consumers’ sociodemographic factors (such as age, gender, education, disability) interact with the ‘digital’ in terms of access (whether that be through affordability and/or skills) and health information/education. In the Australian context, Backholer and colleagues (2021) also explore questions of access, equity, and affordability as DDoH, addressing both the potential benefits of digital and data-driven technologies for public health and the possibility that digital transformation will exacerbate existing bias and exclusion. Key issues flagged include increased reliance on privatised digital platforms and increased use of automated decision-making and AI within health policy and service provision (Backholer et al. 2021).
Additionally, Backholer and colleagues (2021) reflect on the tensions between the need to ensure health consumer’s data privacy and the need for data-driven decision-making in policy and service provision. Noting that gaps in Australian data collection practices have historically resulted in inadequate or inappropriately targeted health promotion and clinical services, Backholer and colleagues suggest that future data collection and data-sharing initiatives are planned and undertaken in collaboration with health consumers to ensure equitable outcomes (2021, p. s33). The persistence of such exclusions has called attention to healthcare ‘data poverty’ (Gallifant et al. 2023, Paik et al. 2023), a phenomenon Ibrahim et al. (2021) describe as ‘the inability for individuals, groups, or populations to benefit from a discovery or innovation due to insufficient data that are adequately representative’ (p. e260).
While an exhaustive investigation of specific digital technologies is beyond the scope of this paper, the recent and rapid emergence of AI within the healthcare sector (WHO 2024b) is exemplary of the complexities of addressing the DDoH. Since Backholer and colleagues’ 2021 publication, AI has increasingly been framed within both scholarly journals and popular press as a valuable tool for health workers and health consumers alike—even in highly sensitive situations such as end-of-life decision-making (Brender et al. 2024). However, such claims have been highly contested—as can be seen in the case of HeHealth’s US consumer-focused AI ‘Sexually-Transmitted-Infection-detection’ app Calmara, which has been subject to regulatory investigation due to misleading marketing claims and problematic data privacy practices (Feiner 2024). While noting the potential benefits of AI for delivering sexual and reproductive health care and information, recent WHO guidance on the role of AI in sexual and reproductive health also foregrounds the ethical and human rights implications of data governance, privacy, inclusiveness, and equity, particularly given the often sensitive or stigmatised nature of sexual and reproductive health data (WHO 2024a).
The digital transformation of health in the Australian context
Tefera and colleagues (2024) highlight the need for professional development and training of the health promotion workforce, particularly noting the importance of ‘digital literacy’ to contend with the DDoH and leverage the benefits of digital transformation. As Crawford and Serhal (2020) observe, healthcare providers’ own digital literacy and limited understanding of how patients and communities use and experience digital technologies and platforms can exacerbate digital health inequities (see also Kickbusch and Holly 2023). Lawrence and Levine (2024) attribute this, in part, to a lack of standardised digital health competencies and skills across health education contexts. They suggest training efforts need to cultivate a ‘technically and culturally competent’ (p. 2) workforce that can critically examine the intersection between health outcomes, digital technologies, and inequities.
In the Australian context, sexual and reproductive health promotion services are provided by a range of government and non-government agencies, including community-led and community-controlled services that provide both holistic health information, support, and clinical care. While the majority of sexual health providers are funded by the Commonwealth government, they can be seen to exercise varying levels of autonomy, experimentation, and innovation in relation to the uptake of digital platforms and technologies (Williams 2023).
Kickbusch and Holly argue that the Ottawa Charter provides a mandate for health promotion to ‘lead the charge’ in understanding and addressing DDoH (2023, p. 2). This involves moving beyond approaches that centre individuals to better consider how to intervene at the population level, with diverse stakeholders, with often divergent priorities. Kickbusch and Holly further suggest that the ‘advantages and risks for health promotion are not being prioritised in digital development or policymaking’ (2023, p. 2). This is reflected in the number of policies and strategies that have been released under the auspices of the ADHA in recent years, including The National Digital Health Strategy (2023-2028) (ADHA 2023), the National Digital Health Workforce and Education Roadmap (ADHA 2020), and the National Digital Health Capability Action Plan (ADHA 2021).
Although not explicitly naming them as such, the National Digital Health Strategy (ADHA 2023) recognises and responds to elements of the DDoH, particularly in its health system outcome areas ‘person-centred’ and ‘inclusive’. The Strategy considers elements of digital inclusion, particularly related to access, affordability, and skills. Here, the potential for digital health to expand access to care and information for already marginalised consumers is made explicit alongside a caution that the adoption of digital health technologies and platforms does not ‘create new problems and leave people behind’ (p. 42). Approaches include improving consumer digital health literacy, expanding access to virtual care, and enhancing connectivity and accessibility of health data.
These policies and guidelines also outline the need for a skilled and ‘digitally empowered’ (ADHA 2023, p. 31) workforce to ensure the equitable provision of quality health services (including health promotion) in an increasingly digital environment. This approach resonates with a recent review (Iyamu et al. 2022), which highlighted the importance of a skilled public health workforce and leadership to ensure health systems ‘benefit from the potential advantages of digital technologies in public health’ (p. 7). The Australian Digital Health Capability Framework (ADHCF) (AIDH 2023), a non-specialist self-assessment tool for health practitioners, suggests that an awareness of the ‘cultural, ethical and socioeconomic’ issues and inequities attached to the use and storage of data, as well as access to, and use of digital health information and services are necessary capabilities for the digital health workforce (p. 27).
Why might digital transformation be especially challenging for sexual and reproductive health?
As Sandfort and Erhardt (2004) observe, while sexually transmitted infections and issues related to fertility and reproduction have long been part of the overall remit of medicine and healthcare, the framing of sexual health as a separate health domain is a 20th-century innovation, which became more distinctly defined in response to both feminist activism and the global human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS) pandemic (Murphy 2020, Epstein 2022). The WHO’s (2006) definitional guidance is expansive, pointing not only to the absence of disease but other psychological, cultural, and social elements of sexual wellbeing.
In recent years, significant interdisciplinary attention has turned to the role that digital technologies and platforms play in facilitating positive connection, community, and peer-to-peer learning about sexual health and wellbeing (e.g. Patterson et al. 2019, UNESCO 2020, Lim et al. 2022, Albury and Hendry 2023). At the same time, concerns have also arisen regarding the enabling of targeted harassment and surveillance of marginalised communities and/or the circulation of health misinformation via social media (Marwick and Lewis 2017, Are 2024, UN Women 2024). These cultures of harassment do not just impact health consumers and health service users—they also impact health service providers’ capacity to safely engage in digital environments.
Additionally, there has been growing attention towards the negative impacts of digital content moderation policies on both formal sexual health promotion (Williams 2023) and informal peer-learning communities. Health promotion content related to sexual and reproductive health is often flagged as ‘against community standards’ by Meta, TikTok, and other platforms, despite stated exemptions for educational material (Spišák et al. 2021, Garwood-Cross et al. 2024) and explicit recommendations from Meta’s own Oversight Board (2023).
In terms of data, the use of digital surveillance and prediction methods has become increasingly prominent within digital health (Kostkova et al. 2021, Borda et al. 2022), with an immense amount of health data generated through diverse avenues (e.g. via electronic health records, commercial apps, and consumer wearables). Critical studies in health have questioned the ways these data are collected, used, and stored, particularly interrogating issues of trust, privacy, and data justice (Robinson 2022, Smith et al. 2023). For example, research engaging with consumers from stigmatised communities (related to HIV, drug use, sex work, and gender) has highlighted consumer reluctance to participate in electronic health records, stemming from a mistrust of government and a fear of further discrimination (Lupton 2019, Newman et al. 2020).
Given the complexity and multiple sites of interaction between digital environments and sexual and reproductive health, it is unsurprising that digital literacy (or digital health literacy) is often framed as a necessary resource to assist health consumers or health service users. But what might digital literacy (and data literacy) mean for sexual and reproductive health promotion workforces? Our past collaboration with the health promotion sector led us to hypothesise that the contemporary workforce may encounter challenges resulting from historical gaps in training, infrastructure, and/ or resourcing (Albury 2019). Additionally, as outlined above, the work of sexual and reproductive health promotion may be made increasingly difficult where commercial platforms block or censor health promotion content.
Further, the uneven evolution of relevant State and Commonwealth policy and legislation—which often lags behind the pace of technological innovation—may also pose challenges for health promotion professionals, particularly where policy guidance is widely considered to be out-of-date or not fit for purpose. Indeed, as this article underwent review, the Australian Federal government undertook several significant reviews of social media policy and data regulation, including a review of the Privacy Act to strengthen assurances of consumer data privacy (Commonwealth of Australia 2024, Parliament of Australia 2024).
Consequently, we explore the findings of qualitative research with ‘experts/leaders’ and ‘young professionals’ in the Australian sexual health workforce, in order to better understand the current barriers and enablers facing professionals in this space.
METHODS
The Digital and Data Capabilities for sexual health policy and practice is a 4-year program of research that aims to build digital and data capabilities with the Australian sexual and reproductive health workforce. While the project does not explicitly seek to address the DDoH, our research directly seeks to address the question of how ‘digital literacy’, ‘data literacy’, and ‘digital health literacy’ are currently understood in the context of the sexual and reproductive health workforce. This article presents findings from key informant interviews and workshops with sexual and reproductive health practitioners aged 18–29. Two research reports (Albury and Mannix 2023, 2024) have previously been published from this study, and two articles covering different aspects of the research are currently in review in scholarly journals.
Study design
Interviews were conducted in 2022–2023, with key informants who were academics or health practitioners across the (sometimes intersecting) domains of sexual health, public health, and digital media and data studies (see Table 1). Key informant interviews have been used in qualitative health research to gain high-level insight and understanding of everyday aspects of contemporary practice and policy (Lokot 2021, Watts et al. 2022, Pawha et al. 2023). As Michele Lokot notes in her critical feminist analysis, while key informant interviews were initially developed within the domain of ethnography, the methodology has been widely adapted within non-ethnographic qualitative research, particularly where ‘insider knowledge’ is sought (2021, p. 4). Interviews followed a semi-structured interview guide, and key informants were invited to share their definitions of ‘digital and data literacy for sexual health’.
Expert interviewee field of expertise and sites of practitioner experience.
| Field of expertise . | # . | Organisation type . | # . |
|---|---|---|---|
| Public health | 9 | Local health | 9 |
| Digital health | 1 | Sexual health | 1 |
| Sexual health | 6 | Women’s health | 6 |
| Digital, data studies | 4 | ||
| Gender, sexuality studies | 4 | ||
| Youth studies | 1 |
| Field of expertise . | # . | Organisation type . | # . |
|---|---|---|---|
| Public health | 9 | Local health | 9 |
| Digital health | 1 | Sexual health | 1 |
| Sexual health | 6 | Women’s health | 6 |
| Digital, data studies | 4 | ||
| Gender, sexuality studies | 4 | ||
| Youth studies | 1 |
Expert interviewee field of expertise and sites of practitioner experience.
| Field of expertise . | # . | Organisation type . | # . |
|---|---|---|---|
| Public health | 9 | Local health | 9 |
| Digital health | 1 | Sexual health | 1 |
| Sexual health | 6 | Women’s health | 6 |
| Digital, data studies | 4 | ||
| Gender, sexuality studies | 4 | ||
| Youth studies | 1 |
| Field of expertise . | # . | Organisation type . | # . |
|---|---|---|---|
| Public health | 9 | Local health | 9 |
| Digital health | 1 | Sexual health | 1 |
| Sexual health | 6 | Women’s health | 6 |
| Digital, data studies | 4 | ||
| Gender, sexuality studies | 4 | ||
| Youth studies | 1 |
Initial interviewees were recruited based on their research or practice interest in ‘digital literacy’, ‘health literacy’, or ‘digital health’ (as stated on institutional websites and professional biographies) and via respondent-driven sampling. Interview questions invited key informants to reflect on their understandings of how these diverse literacies were currently understood and enacted in sexual and reproductive health policy and practice—including health promotion contexts.
As Lokot (2021) argues, the perceived ‘expertise’ of key informants can lead findings from such interviews to be prioritised over the insights and understandings of ‘ordinary’ research participants. Our project sought to contextualise and complement the perspectives of ‘expert’ insiders alongside those of ‘ordinary’ members of the sexual and reproductive health workforce with a stated interest in digital and data capability building. Consequently, workshops (three) and interviews (one) were conducted in 2024 with 18 young adults aged 18–29 who currently work in the field of sexual and reproductive health in Australia. Workshops were designed to allow sense-checking of earlier findings (see Albury and Mannix 2023, 2024) and deeper reflection on digital workplace transformation and capability building. As in the key informant interviews, we first shared the overall context for the research project. Participants were then invited to reflect on the relevance of our preliminary findings for their professional context, and offer feedback on prototype capability building resources.
Key informant interviews and young adult health practitioner workshops were conducted via Zoom by K.A. (a white settler cisgendered woman with expertise in media, digital and data studies, and experience of sexual health promotion practice) and S.M. (a white settler cisgendered woman with expertise in public health, nursing and education, and experience of sexual health service provision and health promotion practice). Interviews typically lasted up to an hour and were audio-recorded, professionally transcribed, and reviewed by participants. All participants who opted in to future updates on the project subsequently received invitations to research webinars and open-access research reports.
Recruitment
Participants were largely Australian-based, but included researchers and practitioners in the UK, Europe, the USA, and Canada (Table 1). As noted above, key informant interviewees were initially identified via public-facing organisational websites and publications. ‘Young’ (18–29-year-old) Australian sexual and reproductive health practitioners (see Table 2) were recruited via existing project research networks, including sexual and reproductive health peak body mailing lists and the research team’s LinkedIn page. In both instances, respondent-driven sampling was utilised to expand recruitment beyond known contacts.
| Professional role . | # . | Organisation type . | # . |
|---|---|---|---|
| Health promotion | 9 | HIV, STI + LGBTQ + Health | 6 |
| Program and project work | 7 | Women’s health | 6 |
| Clinical (nursing, testing) | 2 | Sexual health and family planning | 1 |
| Local government | 2 | ||
| State government | 2 | ||
| Community health | 1 |
| Professional role . | # . | Organisation type . | # . |
|---|---|---|---|
| Health promotion | 9 | HIV, STI + LGBTQ + Health | 6 |
| Program and project work | 7 | Women’s health | 6 |
| Clinical (nursing, testing) | 2 | Sexual health and family planning | 1 |
| Local government | 2 | ||
| State government | 2 | ||
| Community health | 1 |
| Professional role . | # . | Organisation type . | # . |
|---|---|---|---|
| Health promotion | 9 | HIV, STI + LGBTQ + Health | 6 |
| Program and project work | 7 | Women’s health | 6 |
| Clinical (nursing, testing) | 2 | Sexual health and family planning | 1 |
| Local government | 2 | ||
| State government | 2 | ||
| Community health | 1 |
| Professional role . | # . | Organisation type . | # . |
|---|---|---|---|
| Health promotion | 9 | HIV, STI + LGBTQ + Health | 6 |
| Program and project work | 7 | Women’s health | 6 |
| Clinical (nursing, testing) | 2 | Sexual health and family planning | 1 |
| Local government | 2 | ||
| State government | 2 | ||
| Community health | 1 |
Most participants were only involved in one element of the study—either the key stakeholder interviews or the young adult health practitioner workshops. Only one individual—who responded independently to our young adult practitioner recruitment flyer—participated as both a key informant and a ‘young adult’.
Due to the comparatively small size of the Australian sexual and reproductive health sector, we have not identified interview and workshop participants in terms of personal demographic descriptors, specific professional role, or past experience within this analysis. However, many current key informant health researchers were also practitioners, and a number of clinical and project staff reported past work in health promotion (and vice-versa). We have indicated the current sites of employment for the key informants in Table 1, noting that the overall numbers in both tables equal more than 29 due to participant’s high levels of professional mobility. Table 2provides an overview of young adult health practitioner workshops.
Data analysis
Both authors collaborated on an iterative process of abductive analysis, combining inductive and deductive approaches to undertake focused coding (Tavory and Timmermans 2014, Timmermans and Tavory 2022). Firstly, we coded transcripts according to themes we had previously identified in extant Australian digital health policy and scholarly literature addressing the intersection of digital literacy, digital health, and health literacy—particularly where these occurred in sexual health research. In this analysis, we looked for both expected and unexpected interpretations and definitions of these terms—and the ways they might be understood and enacted in organisational contexts through policy and practice.
We then revisited our data looking for sites of contradiction or friction between the ways relevant policies and strategies framed digital and data literacies and/or capabilities, and the ways our diverse participants did (or did not) experience the contemporary sexual and reproductive health sector as ‘digitally literate’ or ‘data literate’. Here, we brought the data into dialogue with interdisciplinary theories of literacy (Williams 1957, Freire 1968, Vee 2017), health literacy (Nutbeam 1998, 2000, Sørensen et al. 2012, 2021), and capabilities (Nussbaum 2003, 2011, Sen 2004, Alexander 2008). We did not seek to assess the ‘quality’ or ‘accuracy’ of participant’s beliefs, but looked for their explanations as to why they held particular views—which varied according to a range of factors, including professional role and geographical location.
Preliminary analyses were sense-checked in consultation with the Project Reference Group, which includes both academic researchers and representatives of community health and national and state-based advocacy organisations (including youth-led advocacy; migrant and refugee health advocacy; peer advocacy for trans and gender-diverse people, and people living with HIV). Ethics approvals were provided by Swinburne University of Technology’s Human Research Ethics Committee (Approvals 20226416-10783; 20247581-18160) and ACON Health’s Research Ethics Review Committee (Approval D202404).
RESULTS
Why does digital and data literacy matter for sexual health promotion professionals?
A number of key informants expressed the need to validate health consumer’s existing strengths in relation to digital environments, rather than assuming a deficit or lack of literacy. This was also framed as an equity and access issue:
I think it’s really important for health professionals to have challenged in them an understanding of communities as lay and naïve; and medical and health policy jurisdictions as expert and trustworthy. That assumption is not something which is helping with … bringing a more compassionate sense of understanding across different domains, in which we’re trying to achieve greater health and make it equitable and make it accessible and so on. (Sexual health researcher)
While equity and access for consumers were considered important, there were also concerns raised regarding resource allocation within health promotion services. For example:
It’s our responsibility to understand how young people are using those platforms, and then what they want. So how do they want to receive information about sexual health, and use it in a way that’s relevant for them? Because if we don’t, we’re missing them out completely, and then we’re wasting resources and time and money. (Health promotion manager)
When invited to explore what digital and data literacy might mean in a sexual health context, many participants linked these ‘new’ literacies to well-established frameworks, such as health literacy. Others emphasised the importance of understanding the complexity of everyday digital platforms and practices to ensure the quality of health promotion outreach and clinical care services. For example, one participant explicitly linked the understanding of digital sexual health to broader organisational responsibilities:
I think ideally what we should be doing is really also making sure in the way that we talk about health literacy, that whoever is providing whatever that service, information, whatever, is also literate in some way. That they’re really thinking about their messaging, their communication, how easy is it to access and understand. So, I just see it as a two-way thing rather than a one-way thing. (Digital health researcher)
How well prepared are Australian sexual health organisations to address DDoH?
Interviewees raised concerns regarding the siloing of expertise and knowledge, observing that while specialisation is essential in some areas of health service provision, a more interdisciplinary approach is necessary to fully address social and cultural aspects of digital sexual and reproductive health (and, by extension, DDoH):
We’re trained to be very narrow, and it’s not just people in health. It’s people in technology, maybe especially people in technology, who get very “here’s my expertise”, but have never heard of queer theory, have only a vague idea of feminism. Certainly, maybe they’re thinking about health problems, but they’re thinking about them in very specific, largely biomedical terms. (Health promotion researcher)
Participants in the 18–29-year-old health professional workshops and interviews expressed particular concerns about the ways sector leadership currently frames digital platforms and technologies as sites of ‘risk’. They believed that a lack of sector-wide strategy and planning for digital engagements was derailing opportunities for effective digital health promotion:
Especially if you’re on platforms like TikTok - if you miss the boat, then it just comes out cringey and you’d be better off not posting it. So, I think that being able to be responsive and having an organisational culture to prioritise this sort of work would be really beneficial. (Health promotion professional 18-29)
One workshop group raised particular concerns about the impacts of underfunding and lack of training in the sexual and reproductive health sector, suggesting that this led senior managers and policy-makers to ‘fear’ the expense of digital platforms and technologies. This meant that opportunities were missed for responsive service provision and health promotion:
There was a decision made early on that [our service website] didn’t need to be mobile optimised. Which is something that I would really question... Given that we know the majority of young people are accessing information and using phones rather than desktop computers to look at health information. (Health promotion professional 18-29)
Some 18–29-year-old participants suggested that their leaders and managers had a limited understanding of the specific expertise, cultural knowledge, time, and funding required to do digital work well. In some instances, there was a perception that staff under 30 were ‘digital natives’ (Evans and Robertson 2020) and therefore inherently capable of leading and managing digital projects or guiding digital strategies—despite a lack of training and specific domain expertise. This resulted in digital projects that did not employ skilled team members, but instead were ‘add-ons’ for junior staff who were already managing large workloads. As one explained:
Something that I think would be good for people to know is that you need to invest money and time into these digital things. [They] don’t just happen on the back of the young people like us. They do a lot of the time, but they shouldn’t. It needs to be put into the budget that ‘this amount of funding is gonna go towards the digital stuff’, because it’s often that I don’t think it’s counted. (Health promotion professional 18-29)
These concerns resonate with guidance from a key informant interviewee who cautioned health professionals against over-relying on demographic categories to make assumptions about how and why digital platforms and technologies are used. The diversity of global platforms and technologies means that no two users will access them in exactly the same way. Our interviewee suggested that different users might be understood to be using ‘different internets’, and that this has implications for health promotion practice:
This isn’t just, “Oh, I’m a health promotion person and … a cisgender woman … [And I’m] talking to a gay youth... so [I assume] they’re going to be on Grindr”. I don’t mean that. I mean a gay guy [might be] talking to a gay guy HIV tester and they might be on totally different internets and are consuming totally different things. (Sexual health researcher)
How are data—and data literacies—currently understood in sexual and reproductive health settings?
While many scholarly discussions of DDoH point to the importance of ensuring health equity through attention to both health data practices and the commercial ‘datafication’ practices of privatised digital systems (e.g. Backholer et al. 2021, Kostkova et al. 2022), very few of our key informants believed that the sexual health sector had a unified approach to ‘data literacy’. All interviewees agreed the importance of maintaining clinical data privacy was well understood in the sexual and reproductive health sectors, but there was less understanding of the ways data might be generated, stored, and used beyond the context of clinical work.
A number of key informant interviewees suggested that ‘data’ were most often understood as a shorthand term for university-generated peer-reviewed research publications or epidemiological surveillance reports. This meant that the role of data generation within health promotion and project activities (including digital outreach or web-based registration forms) was less understood in day-to-day practice. Subsequently, many participants suggested that health promotion professionals may be unaware of where and how they generated data as part of their work:
I know that most of my [health promotion outreach staff] won’t have any idea what I’m talking about [in terms of] …working with best practice to make sure that our intake form is a bit more inclusive. So, we’re asking about pronouns and sex assigned at birth and things like that. They wouldn’t understand any of that side, but I think it would really add a lot of quality to what we do if they did. … They might be working with a student who’s thinking about accessing our service, and wouldn’t it be great if you could say confidently, “This is how [we] use their data, this is how [we] store it, this is the privacy policy, this is how we address confidentiality”. (Senior health promotion manager)
DISCUSSION
While we did not directly ask our participants to reflect explicitly on the DDoH, issues of equity and access remained central to their understanding of digital and data literacies across both key informant interviews and workshops with ‘young’ health professionals. This was reflected in a critical focus on workforce skills; alongside broader reflections on organisational cultures, policy environments, and a need to better understand how/why sexual and reproductive health consumers and service users engage with specific digital platforms and technologies.
However, our participants indicated that, to date, the Australian sexual and reproductive health sectors have tended to frame digital technologies primarily as either platforms for ‘health interventions’ or sites of ‘risk’. As such, there has been less consideration of the broader socio-political aspects of digital environments that might come under the umbrella of DDoH. One interviewee explained this as an overemphasis on what she termed the ‘low-hanging fruit’ of information provision, with little consideration of how health could be supported through ‘upstream’ advocacy related to digital platforms and technologies:
Linking back to the Ottawa Charter, you know, like we can’t just address building personal skills by providing information. We can have all the information we need and still not be able to get the health outcomes that we want. So, it’s broader thinking about environment, about policy, how can we influence that? What are the other elements there? (Health promotion manager)
Emerging Australian policy initiatives, such as the ADHCF, are seeking to build digital and data capabilities among workforces more broadly—however, the impacts and outcomes of such policies remain to be seen. Further, as Kickbusch and Holly (2023) also note, many of these policies fail to directly engage with the health promotion context. Our research indicates that as public health and health promotion continue to grapple with still nascent conceptualisations of DDoH and the rapidly evolving digital landscape, there is much to be gained from moving beyond traditional disciplinary silos.
Previous studies examining the intersection of sexual and reproductive health promotion and digital cultures have suggested that insights from other professional domains—including digital journalism, cultural research, and social marketing—may offer valuable interdisciplinary perspectives for digital health promotion practice (Albury et al. 2019, McKee et al. 2019, Williams 2023). Similarly, interdisciplinary approaches have the potential to make valuable contributions to understanding DDoH, given the substantial body of scholarship in media and cultural studies (e.g.) investigating the relationship between digital platform policies, design, and marketing practices and everyday experiences of tech use by health consumers (Burgess et al. 2022).
Interdisciplinary and transdisciplinary approaches can facilitate more diverse epistemological and methodological insights into the technical, social, cultural, political, and commercial factors that undermine or reinforce digital health disparities. And, as our participants suggested, this ‘de-siloing’ should not be seen as a one-way process—technology experts may have very little understanding of the priorities of health promotion professionals, and time may be needed to develop shared understandings and vocabularies. As our participants indicated, these forms of capability building require both funding and time to develop.
Further, just as sexual health and wellbeing are impacted by intersectional aspects of culture, lived experience, and identity (Kapilashrami 2020), intersectionality also plays out in digital domains. Consequently, any attempt to instrumentalise or operationalise DDoH within sexual and reproductive health promotion should be based not on generalisations about ‘young people as digital natives’ (or similar generalisations about other priority populations), but should take account of relevant research—including lived experience accounts—that explores the diverse ways digital sexual cultures and practices play out in everyday life.
CONCLUSION
While the ‘digital transformation of health’ is no longer novel, the proliferation of policy and guidance related to digital workforce capability building suggests that it is both timely and necessary to focus on the opportunities and challenges facing specific health workforces—including opportunities to develop new approaches to digital and data policy and practice. Where sexual and reproductive health organisations and practitioners have not yet developed their own digital and data capabilities, they may not be confident to, as Kickbusch and Holly (2023) put it, ‘lead the charge’ in addressing the complexities of DDoH via ‘upstream’ advocacy. They may also face additional challenges when seeking to connect ‘downstream’ with health consumers and service users via digital technologies.
However, given the current digital health policy initiatives (particularly the work of global bodies such as the WHO and national bodies such as the ADHA), opportunities are emerging for ‘midstream’ efforts to build digital and data capabilities in the sexual and reproductive workforce. As our findings indicate, there is a substantial appetite for such work in the Australian context. Our recommendations are subject to limitations due to the focus of our research that primarily addressed the Australian health sector (as opposed to a full survey of global workforce initiatives) and did not explicitly explore understandings of DDoH with participants.
However, we strongly suggest that as leaders in health promotion policy and practice move to integrate DDoH within strategic planning and policy, they must first ensure they are building capacity for shared understandings of what ‘data’ and ‘the digital’ mean for both health consumers and health service providers. This is particularly important in the context of sexual and reproductive health, where clinical data, commercial data, and everyday digital cultures are intertwined with marginalised—and often stigmatised practices and identities. Within this context, the DDoH have the potential to both increase inclusion, access, and equity of information and service level and the potential to further increase exclusion.
Given that our participants suggested that existing disciplinary silos acted as barriers to digital transformation, efforts should be made to build opportunities for interdisciplinary learning—through interdisciplinary and transdisciplinary communities of practice, or by including interdisciplinary perspectives in existing professional training and development activities. Future workforce development strategies should consider how to best engage with digital content, platforms, and systems in order to serve the needs of the health promotion workforce, health consumers, and service users alike. Such strategic approaches demand a shift of focus away from individual literacies towards broader capability frameworks that encompass an understanding of digital policy and governance (e.g. in relation to social media content moderation); an understanding of how health consumers and service users currently utilise digital systems to support sexual health and wellbeing; and a consideration of the ways digital equity and data justice can be advanced in organisational settings (McCosker et al. 2022).
Finally, we note that sexual and reproductive health promotion policy-makers and practitioners may not be able to effectively undertake either upstream advocacy or interventions with priority populations (such as young people) until material resources—including adequate time for training and development—have been allocated for digital and data capability building within the health workforce itself. To this end, the next stage of our project will explore and examine how digital and data capabilities are taken up and appropriated within actually-existing processes of organisational transformation, collaborating with a research partner organisation with stakeholders in their field of practice.
Acknowledgements
Many thanks to Joanna Williams for research assistance and to Daniel Reeders for critical work-in-progress feedback.
Author contributions
Both authors contributed to data collection, analysis, writing, and editing.
Conflict of interest
None declared.
Funding
This research was funded by the Australian Research Council (ARC) Future Fellowship (FT210100085), and partially funded by the ARC Centre of Excellence for Automated Decision-Making and Society (CE200100005).
Data availability
Data are not publicly available due to Human Ethics agreements.
