Contributions of Municipal Initiatives to Digital Health Equity

Abstract

Sustainable initiatives play a crucial role in promoting digital health equity by addressing barriers to access and ensuring equitable use of digital health technologies and services. These initiatives may arise in various contexts, including local collaborative networks that emerge in the municipal context. This study aims to identify and characterize the municipal initiatives that have been developed in Portugal to promote digital health equity. It adopts a mixed methods approach to initially quantify the distribution of these projects in the Portuguese territory and, at a later stage, to understand the level of influence of these projects, considering their impact on individual, interpersonal, community, and societal levels. The findings identified 22 municipal sustainable initiatives and concluded that there is a strong relationship between the areas of community and individual influence. The results of this study are relevant to deepening the knowledge of bottom-up innovation in the digital health field and establishing public policies to increase the impact of these projects at the territorial level, the communities involved, and the social objectives addressed, contributing to greater social cohesion.

1. Introduction

The adoption of digital technologies in healthcare has been driven by several factors, including the need to improve healthcare outcomes [1], reduce costs [2], and increase access to healthcare services [3]. Municipalities, in particular, have an important role to play in promoting and facilitating access to healthcare systems and the adoption of digital health technologies. As recognized in the review work done by Quilling et al. [4], municipalities should promote the health of their citizens and promote a healthy lifestyle. The transfer of competencies to municipalities that has been occurring in Europe allows for the close monitoring of health responses, ensuring continued access to quality health services, with the ability to constantly adapt resources to the needs identified on the ground [5]. This strategy of competence transfer aims to mitigate and reduce the effects of health inequalities, considering the specificities of each territory.

Municipalities, as the local government entities responsible for the management of a territory, play a critical role in promoting sustainability. Sustainability is viewed by the United Nations as “meeting the needs of the present without compromising the ability of future generations to meet their own needs” [6]. This vision makes it evident that promoting sustainability is the responsibility of everyone. Individuals, organizations, governments, and society must work together to promote sustainable practices, protect the environment, and ensure a sustainable life for future generations. Municipal sustainable initiatives refer to policies, programs, and practices that protect the environment, support economic growth, and promote social equity [7,8,9]. These initiatives can take a variety of forms, including the adoption of green technologies, the implementation of sustainable transportation policies, and the promotion of healthy lifestyles.

Municipalities also play a key role in the development of digital health ecosystems. Following the vision of Iyawa et al. [10], a digital health ecosystem refers to the interconnected network of healthcare providers, technology developers, and other stakeholders that work together to develop and implement digital health technologies. Municipalities can support the development of these ecosystems by bringing together stakeholders from different sectors, providing funding and resources, and creating an environment that supports collaboration and innovation [11].

The study conducted by Almeida [12] shows that the emergence of bottom-up innovation initiatives promoted by civil society and local actors will lead to greater territorial cohesion and will be an important element in combating the social exclusion of the most vulnerable populations. In the same line of research, Pesch et al. [13] report the role of civic engagement in initiatives to achieve community goals, and Adisa et al. [14] further add the role of information and communications technology (ICT) in bringing these projects to fruition. Despite the relevance of these studies in demonstrating the relevance of this line of research, there are no empirical studies that focus exclusively on the area of digital health and that allow for the exploration of the role sustainability initiatives at the municipal level can play in greater inclusion and access to healthcare for the populations of each municipality. This study was applied to the municipalities of Portugal. It adopts a mixed methods methodology based on a triangulation design model first to identify and catalog these initiatives, considering territorial asymmetries, and, in a second phase, to explore in detail the typologies of these initiatives and their impact on local populations. To this end, this study sought to answer two research questions:

• RQ1. What are the characteristics of sustainability projects promoted at the municipal level that promote digital health equity, and how many are there?
• RQ2. Which digital health equity dimensions are addressed by municipal sustainability projects?

This study advances current knowledge of digital health equity by providing a structured, practical framework for municipalities to implement digital health initiatives that address health disparities. Unlike existing approaches that often generalize digital health equity challenges, this study emphasizes a context-specific approach, considering bottom-up projects that emerge in the context of each Portuguese municipality. Furthermore, this study bridges the gap between theoretical health equity models and real-world applications by detailing collaborative strategies for engaging governments, healthcare organizations, technology providers, and community stakeholders in addressing the digital divide. It highlights how a triangulated mixed methods approach, incorporating both quantitative and qualitative data, can produce a deeper understanding of digital health disparities and support a more responsive and inclusive program design. This localized, participatory approach fosters sustainable solutions that can be adaptable to other municipalities with similar digital equity goals.

The manuscript is structured as follows: First, a theoretical contextualization is carried out on the role of digital health and digital transformations in this sector to promote equity in the access to health. After that, the study methodology, the data collection process, and the methods adopted to explore the results are presented. This is followed by the presentation and discussion of the results, considering their relevance to understanding the factors that have contributed to the implementation of digital health equity. Finally, the main conclusions of this study are listed, also highlighting the limitations of the study and suggesting future lines of research in the field.

2. Literature Review

The fourth industrial revolution is changing at an unprecedented pace the way we live, work, and relate to each other. Behind the concept of Industry 4.0 addressed in studies such as Groumpos [15], Suleiman et al. [16], and Vaidya et al. [17] and supported by a panoply of technologies working in an integrated way, there is a process of profound transformation in the way we think, learn, produce, compete, and cooperate. Industry 4.0 has also enabled the emergence of new products and services at increasingly competitive prices and is supported by a new generation of digital technologies [18,19].

The healthcare sector is one of those that will undergo the greatest changes due to digitalization processes. There are several areas where digitization could revolutionize healthcare and the way it is delivered. Stoumpos et al. [20] highlight the role of digitization in improving healthcare, Rosenlund et al. [21] look at the role of digital health in increasing the proximity between the patient and healthcare providers, while Su et al. [22] explore the emergence of new models of care organization and healthcare structures. In sum, the innovation sparked by digitalization in health will create new opportunities in the field of human–machine collaboration through the creation of new smart products and services that will lead to the emergence of new services and new ways of collaborating in health.

New technologies in healthcare have led to the development of multiple areas. Telemedicine has enabled patients to consult with doctors remotely, saving time and effort. Patients can communicate with doctors through video calls, text messages, and emails, making it easier for patients in rural areas or those with limited mobility to access medical care [23]. Electronic health records (EHRs) have made it easier for healthcare providers to access patient information, streamline workflows, and reduce errors. At the same time, patients can also access their own medical records online, allowing them to better manage their health [24]. Artificial Intelligence (AI) has the potential to revolutionize the healthcare industry by providing accurate diagnoses, predicting diseases, and identifying treatment plans. AI algorithms can also be used to analyze patient data and identify patterns, helping doctors make informed decisions [25,26,27,28]. Mobile health (mhealth) apps have made it easier for patients to manage their health by providing access to information and tools to help them monitor their symptoms, medications, and appointments. Mobile health apps can also provide medication and appointment reminders, making it easier for patients to take control of their healthcare [29,30,31]. Finally, wearable devices, such as fitness trackers and smartwatches, have become increasingly popular, providing patients with real-time health data. These devices can track vital signs such as heart rate, blood pressure, and sleep patterns, providing valuable information about a patient’s health [32,33,34].

The digital transformation of the health system has allowed the integration of technological solutions and information sharing between providers and clients, contributing to a significant improvement in service quality and reduction of access times. Da Fonseca et al. [35] conducted a systematic review that concludes that eHealth has improved people’s health and well-being through the use of ICT. eHealth encompasses a range of applications that leverage digital technology to enhance healthcare delivery, accessibility, and patient outcomes. It includes mobile devices and apps that enable users to track health metrics, manage conditions, and receive reminders for medications or appointments [36]. Health information systems store and organize patient records, facilitating efficient sharing among healthcare providers, which is vital for accurate diagnoses and coordinated care [37]. Telemedicine allows for virtual consultations, breaking down geographic barriers and providing healthcare access to remote or underserved areas [38]. Similarly, telemonitoring enables the continuous observation of patients’ health through wearable devices or home monitoring systems, allowing for real-time adjustments to treatment plans and reducing the need for in-person visits [39]. These applications collectively contribute to a more integrated, accessible, and efficient healthcare system that supports patients and providers in managing health proactively and collaboratively. Several factors such as interoperability, customer-centricity, and ease of use are determining elements for eHealth to function without entropy, transforming data into information and information into knowledge [40,41]. The ability to monitor healthcare has generated a large volume of data supported by the concept of big data, which in the future will enhance the development of precision medicine supported by predictive tools that will allow the earlier identification of typologies and propose personalized medical care [42]. Developments in this field are important for people’s quality of life, as well as for the sustainability of health systems that will have to manage an aging and more demanding population.

Health equity is a theoretical lens that emphasizes fairness in health and healthcare by addressing the social determinants of health and removing avoidable, unjust barriers that affect people’s access to and quality of care. Health equity focuses on creating equal opportunities for all people to achieve their full health potential, regardless of their socioeconomic status, ethnicity, geography, or other social identities. It acknowledges that health disparities are often rooted in structural inequalities, such as income inequality, housing insecurity, access to quality education, and systemic discrimination [43,44,45]. Health inequities are differentiated from health inequalities by their moral and ethical dimensions; inequities imply that differences in health are not only present but also unfair and preventable. As recognized by Allen [46], this approach calls for policies that address root causes, such as poverty alleviation, education reform, anti-discrimination measures, and universal healthcare. From a practical standpoint, health equity requires that health systems adopt culturally responsive and linguistically appropriate services, prioritize preventive care, and ensure access to quality care for all, particularly marginalized or underserved populations. Effective access to healthcare will also depend on any barriers to appropriate healthcare utilization, be they economic, social, organizational, or cultural [47]. The same scenario can be applied in the context of eHealth. Equal access to eHealth refers to ensuring that everyone has the same opportunities to access and benefit from eHealth services [48]. This involves bridging gaps in technology access, such as ensuring reliable internet connectivity and device availability, as well as addressing variations in digital literacy by offering training and support tailored to diverse populations. Baker et al. [49] and Coetzer et al. [50] advocate that equal access also means designing eHealth services that consider the needs of marginalized groups, including accessible interfaces for those with disabilities and language options for non-native speakers. Several ways can be identified to promote equality of access to eHealth. Infrastructure in eHealth access is a primary element. Stroetmann et al. [51] recommend that governments work together with healthcare organizations to ensure that all communities have access to the necessary infrastructure (e.g., broadband internet, mobile applications, etc.). Education is another pillar for eHealth adoption. Therefore, Rosenlund et al. [21] suggest that the public should be educated about eHealth services and how they can benefit from them. This includes raising awareness about the availability and usefulness of these services, as well as training people to use them effectively. Accessibility concerns must be present to serve a diverse target audience. Therefore, eHealth services should be designed to be accessible to people with disabilities [52]. Finally, privacy and security should also be considered. In this regard, Keshta and Odeh [53] state that eHealth services should be designed with strong privacy and security measures to protect confidential health information.

Finally, it becomes important to highlight the effects of COVID-19 on eHealth. Wang et al. [54] concluded that the use of eHealth accelerated dramatically during the coronavirus pandemic. eHealth provides innovative solutions to help manage and contain the spread of the virus and ensure that health services are available to everyone, regardless of their location. During the pandemic, mobile digital contact-tracking tools such as apps were developed to help identify individuals who may have been exposed to COVID-19. These tools made it easier to track the movement of infected individuals and alert others who may have been in close contact with them [55]. Access to services has also undergone profound changes. eHealth has made it easier for people to provide health information and education. Online resources, such as videos, articles, and webinars, have been used to educate people about COVID-19, its symptoms, and how to prevent the spread of the virus [56]. In addition, remote monitoring technologies have seen significant growth. These technologies have contributed to remotely monitoring the health of COVID-19 patients. This helped reduce the need for hospitalization and ensured that patients received adequate care even when they were not in the hospital [57]. It is also pointed out by Hsieh and Lai [58] and Tetik et al. [59] that health literacy significantly enhances the effectiveness of remote monitoring by enabling patients to understand, interpret, and act on their health data. Accordingly, when patients understand how to use remote monitoring tools and the significance of the data collected, they are more likely to engage consistently with these tools.

3. Materials and Methods

There are several frameworks for digital health equity, which aim to ensure that digital health interventions and technologies are accessible and equitable for all populations, particularly those who may experience health disparities. Robinson [60] presents the Health Equity and Access under the Law for Telehealth (HEALTH) Framework: This framework was developed by researchers at the University of Colorado. It outlines five key principles for promoting health equity and access through telehealth: prioritize the needs of underserved populations, engage and empower patients and communities, promote cultural humility and sensitivity, address health disparities through targeted interventions, and evaluate and monitor the impact of telehealth on health equity. However, this framework is specific to telehealth services and not digital health. A more comprehensive framework, entitled the eHealth Equity Framework (eHEF) is proposed by Antonio and Petrovskaya [61] and outlines four key dimensions of eHealth equity: access to technology and infrastructure, health literacy and digital skills, user preferences and values, and social support networks. This framework is important for health policymakers, but it does not allow them to capture the role of the various actors in each stage of the process. Finally, the framework for digital health equity proposed by Richardson et al. [62] considers the relationship between the digital environment and the role of entities in this process, establishing four levels of influence (i.e., individual, interpersonal, community, and societal). This study adopts the latter framework, given the possibility of identifying the players and the impact of each solution on digital health services. Digital environments involve diverse stakeholders (e.g., customers, employees, suppliers, and regulators), each with different expectations, needs, and impacts on digital initiatives. Furthermore, by fostering clarity around each stakeholder’s digital role, this framework promotes collaboration, inviting stakeholders to actively participate in innovation processes. Moreover, it is also considered that the levels of influence are not mutually exclusive.

This study adopts mixed methods to understand the contributions of municipal sustainability initiatives to digital health equity. Figure 1 presents how the quantitative and qualitative data collection processes are combined, considering a triangulation design model as proposed by Fielding [63], in which both results are merged to compare, interrelate, and validate the results. Wasti et al. [64] further add that the mixed methods approach has been progressively more used in healthcare and has become useful in obtaining a more complete understanding of a phenomenon, using the advantages of both approaches and allowing researchers to overcome the limitations of quantitative data analysis, particularly in small sample sizes. This approach is especially relevant for health digital equity initiatives, where factors like digital literacy, access to technology, and trust in digital health resources vary widely across different populations within municipalities. Moreover, another advantage of the triangulation design is its ability to validate findings through data convergence. When quantitative and qualitative data points align, it strengthens the credibility of the results, confirming that observed disparities in digital health equity are consistent across different data sources.

The sustainable development initiatives were collected from the ODSLocal portal. This portal uses the Agenda 2030 framework and collects municipal initiatives promoted by the public sector, private sector, and civil society. The portal monitors the progress of municipalities against the 17 sustainable development goals (SDGs). This study collected the following information from ODSLocal:

• Name and a brief description that serves as a characterizing element of each project. The description also serves as an element of identification of themes in the qualitative analysis, which seeks to identify the scope, goals, and impact of the initiatives;
• Municipality and NUTS 2 of the geographical area of the initiatives. NUTS 2 is made up of seven units, the regions, five of which are on the continent, and the territories of the Autonomous Regions of the Azores and Madeira;
• Target represents the potential target audience for each initiative. This information is filled in by the promoters of the initiatives;
• Implementation status of each initiative, considering that the implementation level of a project can be heterogeneous; namely, they are projects that are already heavily implemented on the ground while others are new to the market;
• Influence level, considering its framework in the implementation of digital health equity according to the framework proposed by Richardson et al. [62].

The data collection process was performed in April 2023 using the Scrapy tool written in Python. After that, the exploration of the project’s quantitative data was carried out using R Software v.4.3, while the themes arising from the thematic analysis were identified using MAXQDA v.24. R’s rigorous quantitative analysis offers statistical validity, while MAXQDA’s systematic thematic coding adds reliability to the qualitative findings. The combination of these two tools enables us to triangulate data, which gives a more comprehensive analysis of the digital health initiatives promoted at the municipal level. According to Nowell et al. [65], a thematic analysis allows us to discover patterns and themes that may not be obvious on a first reading of the data and allows us to explore these themes in depth, identifying the nuances and variations in the data that may be missed in other analysis techniques. Furthermore, a thematic analysis follows a systematic approach to data analysis, which increases the reliability of the results [66].

4. Results

To answer RQ1,

Table 1. Digital health equity initiatives.

Project	Municipality	Description
Growing up to Play	Cascais	Growing up to Play aims to promote the development of social and emotional skills, psychological adjustment, and academic performance, preventing or reducing emotional and behavioral problems in primary school children.
Baby on the Cuddle Project	Cascais	The Baby on the Cuddle Project aims to combat and prevent parental negligence and social exclusion in pregnant women and/or caregivers of babies up to one year old, through the promotion of healthy behaviors.
iREC—innovate recycling	Cascais	iREC meets the challenges of the circular economy and promotes recycling through an innovative approach to the management of single-use packaging, bringing together for this purpose an experienced team of retailers, collection services, research centers, and waste companies.
Algarve 360° Health Space	Faro	The ES360° Algarve is a project to promote health literacy in vulnerable elderly people, which has social and territorial cohesion as its axis, fighting a social problem with high prevalence—illiteracy in health.
Partnerships for Science Education	Lisboa	PAFSE “Partnerships for Science Education” is a science education project that promotes science-based literacy in current and emerging problems related to public health.
ASAS—Village of Knowledge and Affection	Loulé	ASAS aims to create a community of suppliers, in which the senior population can be empowered in the areas of agriculture and the artisanal processing of products, involving neighbors in situations of job insecurity, lay-off, or unemployment.
Air Quality Monitoring	Loulé	This project monitors the air quality through the use of sensors. It performs a continuous evaluation of several parameters that influence the air quality index at a local level.
APP Inclusive Vilamoura	Loulé	One of Inframoura’s main ideals is to build an inclusive territory, so that all residents and people who visit us feel safe in their displacement. Inframoura provides an inclusive app for the assistance of people with visual impairment or reduced mobility, supporting their displacement and relationship with the public space of Vilamoura, the Marina, and beaches, through voice indications.
T(r)ocar and Reparar—Technical Help Bank	Matosinhos	The “T(r)ocar and Reparar” aims to provide materials and reconditioned technical equipment, to mitigate the consequences of a lack of mobility, disability, or impairment and provide the individual or caregiver with the ability to perform daily tasks as normally as possible.
Major Proximity	Ovar	This project aims to facilitate access to healthcare, offer support appropriate to the needs of each person, and minimize feelings of loneliness and insecurity, using new technologies.
Socialize	Pombal	The Socialize project provides an outreach biopsychosocial support service, run by a social gerontologist, a nurse, and a psychologist who promote various activities aimed at the active and healthy aging of isolated elderly people.
Health at Home	Pombal	The Health at Home program works to prevent the frailties associated with aging, combining health and social care at home, safely, comfortably, and in a personalized manner.
Grandparents Networking	Pombal	This project offers the community the opportunity to learn the basic notions of computer science, enabling its participants to perform simple exercises that can be very useful in daily life, and combat isolation. It targets the senior population over 60 years old.
Creative Seixal	Seixal	Seixal Criativo is a learning and experimentation center based on projects in the areas of science and technology. This learning and experimentation center will have work, meeting, and leisure rooms and laboratories with equipment for software development and the rapid prototyping of hardware projects. It will also include seminars with guest speakers.
Fishing	Setúbal	Fishing is a project to empower the population of the central urban area of the former Freg. da Anunciada/Setúbal, to prevent the spread of the COVID-19 pandemic, circulating information and increasing digital and administrative literacy, health literacy, and solidarity and cooperation.
QualAr	Setúbal	To monitor the levels of pollution in the air we breathe, the municipality of Setúbal has joined the QualAr project, which consists of collecting air quality data continuously at three local stations.
CLIMA.AML	Setúbal	CLIMA.AML aims to create an integrated solution that allows meteorological monitoring through a metropolitan network of certified sensors and an online platform to query information, to understand the patterns associated with climate change and their impacts on local communities.
Digital Resource Center	Sintra	The Digital Resource Center is a space for empowering the community at the computer and multimedia levels, enhancing access to online services, to better adapt to the reality brought by the COVID-19 pandemic.
Sintoniza-T	Sintra	The intention is to create a communication channel, with information programs about the territory, the community, and organizations, starting with themes such as access to health, the regularization of documents, etc.
Recreate in Community	Tavira	The strategic plan of the Recreate in Community Project counts on initiatives that promote active aging in a holistic way, increase digital and health literacy, facilitate intergenerationally, and allow the rehabilitation and reuse of local infrastructure.
We are Community	Torres Vedras	This project promotes the exercise of citizenship and the active participation of the community, mobilizing the arts and various tools and means of communication. It provides diverse socio-cultural activities to the community weekly.
Rough People	Viana do Alentejo	This project targets the senior population, and it is supported in three vectors: Active Aging; Accessibility/Mobility; and the Promotion and Enhancement of historic centers and material heritage. In this perspective, the project foresees integrating in its intervention several key areas such as the promotion of health, exercise, accessibility, and mobility.

presents the 22 digital heat equity initiatives that were found in the ODSLocal portal. There is a strong concentration of initiatives in some municipalities, such as Cascais, Loulé, Pombal, and Setúbal. In these four municipalities, we have found a total of 12 projects, which represent 54.55% of municipal initiatives in the field. Furthermore, of the 308 municipalities in Portugal, only 13 (4.22%) of them have digital health equity initiatives. This situation can be attributed to several factors, including resource constraints, varying levels of digital literacy, and differing policy priorities.

Table 2. Geographical distribution of the projects.

Region	No.	%
Alentejo	1	4.55
Algarve	5	22.73
Lisboa Metropolitan Area	10	45.45
Center	5	22.73
North	1	4.55

presents the geographical distribution of the projects considering the NUTS referential, which is the geocode standard for referencing country subdivisions for statistical purposes. This nomenclature was created by Eurostat in the early 1970s, aiming at the harmonization of statistics from various countries in terms of the collection, compilation, and dissemination of regional statistics. The nomenclature is subdivided into three levels (NUTS 1, NUTS 2, NUTS 3), defined according to population, administrative, and geographical criteria. In this study, we adopted NUTS 2, which divides Portugal into seven geographical areas. Most of the projects are in the Lisbon Metropolitan Area (n = 10), which represents 45.45% of the projects. Madeira and the Azores do not have health digital equity projects, and, consequently, they are not represented in Table 2.

After that, we sought to understand the target audience addressed by each project, considering the population addressed by each project. A quantitative scale consisting of six classes (i.e., from 10–25 to more than 10,000 people) was adopted.

Table 3. Number of people addressed by projects.

Number of People Addressed	No.	%
≥10,000	2	9.09
5000–10,000	2	9.09
500–5000	6	27.27
100–500	7	31.82
25–100	1	4.55
10–25	4	18.18

indicates the number of people reached by each project. Most of the projects address between 100 and 5000 persons. These two classes have 13 projects (59.09%). It is also noted that four projects (18.18%) address a community larger than 10,000, appearing mainly in more populated municipalities.

Table 4. State of projects.

State	No.	%
In fruition	17	77.27
Taking root	4	18.18
In seed	1	4.55

presents the implementation status of these projects. Three different states of implementation were identified for each project, namely (i) the seed stage, when a project is still in the conceptual stage and presents some prototyping initiatives to the market; (ii) taking root, when a project is active and already exists in the field but is still establishing its relationships with the community, territory, or target audience; and (iii) the fruition stage, when a project is very active and the results of the work are identified and can serve to ensure the future viability of the project or give rise to new seed projects. A total of 77.27% of the projects (n = 17) were in the fruition stage, indicating a strong market implementation of these initiatives. Only one project, which was located in the municipality of Ovar, was still in the seed stage.

The response to RQ2 starts by characterizing the level of influence of the projects according to the framework proposed by Richardson et al. [62] as presented in

Table 5. Projects’ level of influence.

Project	Individual	Interpersonal	Community	Societal
Growing up to Play	◘	◘	■	□
Baby on the Cuddle Project	■	□	◘	□
iREC—innovate recycling	■	◘	■	□
Algarve 360° Health Space	■	◘	◘	□
Partnerships for Science Education	□	□	◘	■
ASAS—Village of Knowledge and Affection	■	□	■	□
Air Quality Monitoring	□	□	■	□
APP Inclusive Vilamoura	■	◘	■	□
Exchange and Repair—Technical Help Bank	■	■	◘	□
Major Proximity	■	□	◘	□
Socialize	■	■	◘	□
Health at Home	■	◘	■	□
Grandparents Networking	■	◘	■	□
Creative Seixal	■	□	◘	□
Fishing	■	□	■	□
QualAr	□	□	■	□
CLIMA.AML	□	□	■	□
Digital Resource Center	■	□	■	□
Sintoniza-T	□	□	■	□
Recreate in Community	■	□	◘	□
We are Community	□	□	■	□
Rough People	■	□	■	□

. The following scale was used: ■ area fully addressed by the project; ◘ area partially addressed by the project; □ area not addressed by the project. It is noted that most of the projects address individual and community areas. Fifteen of the projects (68.18%) fully address the community and individual levels. Moreover, all the projects address the community area even partially. On the opposite side, societal challenges are only addressed in the project “Partnerships for Science Education” by creating education clusters in four countries (i.e., Portugal, Cyprus, Greece, Poland), which promote science-based literacy in current and emerging public health-related problems. Initiatives such as “Fishing” and “Digital Resource Center” emerged in the context of COVID-19 as a response to healthcare access gaps. The necessity for widespread COVID-19 testing and vaccinations revealed that equitable distribution was not only a moral imperative but also a public health necessity to control the virus. The main differences among health equity initiatives include their focus areas, digital components, scale, and degree of community engagement. Some municipalities prioritize access to primary healthcare, targeting underserved or remote populations with mobile health units or partnerships with local clinics. Other municipalities focus on preventive care, emphasizing health education programs around chronic disease management, mental health support, and vaccination drives. For example, urban municipalities with a higher population density, such as Cascais and Setúbal, concentrate on digital solutions to improve access to information and streamline healthcare services, while rural municipalities tend to focus on overcoming geographic barriers by improving local health infrastructure or transportation services.

Finally, a thematic analysis was performed, considering the full description of each project submitted by the promoters on the ODSLocal portal. The most frequently found keywords are identified in Figure 2 through a histogram. It includes terms related to social (n = 34), community (n = 31), people (n = 23), quality (n = 23), digital (n = 21), and empowerment (n = 18). It is evident that digital health equity initiatives are strongly linked to social phenomena and community actions. Equally relevant are the ways of promoting quality, both in terms of services and quality of life. Empowerment is another relevant element that refers to the strengthening and empowerment of people, allowing them to take control of their lives, make autonomous decisions, and exert influence over their environment.

5. Discussion

The relationship between digital health equity initiatives in municipalities and the history of digital healthcare is intertwined with efforts to bridge technological gaps and address disparities in healthcare access. Over recent decades, as digital healthcare has evolved from basic telemedicine to advanced, integrated health systems, a growing awareness has emerged around the unequal distribution of healthcare resources and technological tools. This has shaped the trajectory of digital health equity initiatives, particularly at the municipal level, where local governments are uniquely positioned to understand and respond to the needs of their communities. Municipalities have increasingly recognized the importance of addressing these digital divides to create a more inclusive healthcare landscape. The historical evolution of digital healthcare also reflects a shift towards viewing digital health as a public good, not merely as a service. As recognized by Schultz et al. [67] and Wang and Guo [68], local government institutions are moving beyond focusing solely on healthcare providers and are instead considering the broader technological, educational, and infrastructural needs required to create digital health equity.

The concentration of digital health equity initiatives in municipalities like Cascais, Loulé, Pombal, and Setúbal highlights a significant imbalance in the distribution of these projects across Portugal. With only 13 of the 308 Portuguese municipalities implementing such initiatives, this suggests that the availability and reach of digital health equity programs are limited to a small subset of locations and likely concentrated in areas with greater resources or existing infrastructure. This disparity can often be traced back to a few key factors. Resource constraints as revealed by Alexandre et al. [69] are a major challenge, as municipalities with limited financial or technical resources may struggle to invest in digital health solutions. Moreover, varying levels of digital literacy across Portuguese regions can impact the adoption and effectiveness of such initiatives [70]. Communities with higher digital literacy rates are generally more prepared to utilize and benefit from digital health interventions, while lower digital literacy levels can hinder participation and engagement, even when resources are available. Policy priorities also play a crucial role; some municipalities may prioritize other social services or infrastructural developments over digital health. This concentrated approach may reinforce health disparities, as municipalities lacking digital health initiatives could miss out on advancements in health equity and accessibility that are increasingly supported through digital means. Addressing these regional disparities may require a more unified policy framework at the national level, promoting a better equitable resource distribution.

Community initiatives play a crucial role in promoting healthcare equity by addressing disparities and ensuring that everyone has access to quality care. These initiatives are designed to engage local communities, empower individuals, and improve health outcomes for underserved populations. These community-based initiatives are quite diverse and include projects such as iREC, which aims to innovate recycling through an incentive scheme and a gamification system. The promoters of iREC state that “the project also allows us to evaluate the effectiveness of this incentive system in the selective collection rate and to study environmental behaviors, thus producing valuable and unprecedented knowledge to inform decision-making and the transition to the new mandatory recycling system”. These types of initiatives are recognized in studies such as those by Giovanis et al. [71] and Lenzen et al. [72] as strategies that help promote health equity through their contributions to pollution reduction, natural resource conservation, and improved air quality. Another community-influenced project is Sintoniza-T, which provides a channel of communication on health issues. One of the innovative aspects of this initiative is that it allows local communities to run the sessions, which allows the inclusion of different cultural identities. The promoters state that “Sintoniza-T will allow the development of positive narratives about the territory and its residents, in a context of social emergency in which we feel there is a tendency to polarize perceptions about migrant groups”. As recognized by Raposo and Violante [73], a lack of information and knowledge about the local healthcare system may lead migrants to be unfamiliar with the healthcare system of the destination country, including the available services, healthcare-seeking procedures, and patient rights. Lack of information can make it difficult to navigate the healthcare system in host countries. Finally, notable in this initiative is the search for compatibility between health sustainability and financial health by establishing that this communication channel will also serve the objective of the dissemination of local trade, which at this stage is experiencing difficulties in financial sustainability.

Community influence initiatives are also combined with actions directed at a specific target audience and with a strong focus on the individual. The empowerment of individuals is widely highlighted in health equity promotion initiatives. As Kamruzzaman [74] argues, empowerment can help decrease social inequalities by providing people with the resources and confidence to overcome barriers and seize opportunities. Several reasons justify the importance of individual empowerment in accessing digital health. Access to information is an important component in projects such as the Algarve 360° Health Space and Health at Home. These initiatives allow citizens to search for reliable sources, become informed about various health conditions, preventive measures, and treatment options, and make informed decisions about their healthcare. At the same time, these initiatives contribute to active participation in healthcare. Digital health empowers people to take an active role in managing their own health. Another benefit of individual digital health equity initiatives is their contribution to personalized healthcare. As argued by Butcher and Hussain [75] and Cuff [76], digital health tools enable personalized health experiences tailored to the specific needs of each person. Empowered individuals can use digital health platforms to access personalized health recommendations, receive targeted interventions, and participate in remote consultations with health professionals, leading to more effective and efficient care. In addition, digital health platforms can be used to educate and engage individuals in adopting sustainable lifestyle choices. Mobile apps and online platforms provide personalized health information, send reminders for medication and appointment adherence, and encourage healthy behaviors.

Finally, the role that the COVID-19 pandemic played in accelerating these initiatives is recognized. To minimize the risk of virus transmission and reduce the burden on healthcare systems, digital health has emerged as a crucial solution. At an early stage, it allows patients to consult health professionals remotely, using video calls, phone calls, or online messaging. The convenience and accessibility of digital health became highly relevant during the pandemic, allowing patients to receive medical advice and prescriptions and even monitor the safety of their homes [77]. These initial benefits were also extended after the pandemic. Technological advances and the community’s greater willingness to accept digital health solutions and services in their daily lives have encouraged the emergence of new initiatives based on digital health platforms and mobile apps. These tools offer services such as symptom checkers, contact tracking, mental health support, and health education [78,79,80]. They have been instrumental in disseminating accurate information, facilitating self-assessment, and promoting public health measures.

6. Conclusions

Sustainable digital health solutions focus on preventive care and health promotion, empowering individuals to make informed decisions about their well-being. Wearable devices, mobile apps, and online platforms provide tools to monitor vital signs, physical activity, sleep patterns, and nutrition, enabling users to take proactive steps to maintain good health. These technologies have the potential to improve access, delivery, and health outcomes, but only if they are accessible to all individuals and communities. By promoting digital health equity, health systems and policymakers aim to reduce disparities in access to health, improve health outcomes, and empower individuals to actively participate in their own care. This requires collaborative efforts between governments, healthcare organizations, technology developers, and community stakeholders to eliminate the digital divide and create a more equitable health landscape. This is the challenge that municipal sustainability projects have addressed, and they seek to respond to this challenge through community- and individual-influencing actions. They focus on addressing health inequalities, improving access to care, and promoting health equity. This involves ensuring that health services are accessible, affordable, and of high quality for all individuals, regardless of their socioeconomic background, geographic location, or other demographic factors. Accordingly, implementing successful digital health initiatives at the municipal level requires a structured, step-by-step approach that addresses both the technical and social dimensions of health access. It is fundamental to start by assessing the digital health needs of the local population. This can be done through surveys, interviews, and focus groups, to gather data on digital literacy levels, access to digital devices, internet availability, and current health challenges. Based on the needs assessment, it is important to set measurable and specific goals for the digital health initiative. After that, it is crucial to build partnerships with key stakeholders, which may include healthcare organizations, technology providers, community leaders, and local government officials. Only after this phase does the implementation phase occur, with the development of digital health solutions that are accessible and user-friendly for all population groups. It is recommended to start with a pilot phase to test the initiative within a small population segment, such as a specific neighborhood or demographic group. Finally, digital literacy is a key component that should be considered for enabling residents to use health technologies effectively.

This study offers both theoretical and practical contributions. From a theoretical perspective, it offers relevant contributions to the development of a theory of regional sustainability through the exploration of municipal sustainability initiatives for the promotion of digital health equity. From a practical perspective, the results of this study are relevant for understanding the territorial asymmetries in the implementation of these initiatives and for understanding the characteristics of these initiatives, considering their scope at the individual, interpersonal, community, and societal levels. Through this information, public policies can be established to increase the geographic reach of these projects and help establish collaborative networks to sustain their technical implementation and increase their social impact on their target communities.

This study presents some limitations that are relevant to note. Firstly, the impact of each project is estimated, considering the target population reached by each initiative. It is considered that future studies in the area should seek to quantify this impact considering multiple indicators (e.g., environmental, economic, social). Statistically, it would also be relevant to analyze the correlation between the emergence of projects in each municipality and the development index of each territory. This study did not attempt to explore the typology of the promoters of these initiatives. The promoters may be the municipalities, but also a wide and diversified set of local agents and civil society. As future work, it is recommended that a study be conducted to characterize the collaborative networks that emerge in the development of these initiatives. Finally, this study did not explore the SDGs addressed by digital health equity initiatives. The initiatives identified in this study do not fall only under SDG 3 on good health and well-being. Other SDGs (e.g., SDG 5, SDG 6, SDG 11) are also addressed by these initiatives. Thus, and as future work, it is also considered relevant to explore the relative importance of each of them and the effects that the combination of several SDGs can have in increasing the impact of these initiatives, considering their multiple aspects.