Contributions of Municipal Initiatives to Digital Health Equity

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript. The study provides valuable insights into the role of several initiatives in promoting digital health equity in Portugal. A few enhancements in the areas of theoretical depth, data analysis, and literature engagement, this manuscript has the potential to make a  contribution to the field. I encourage the authors to further refine the argument and expand the scope of the discussion to increase its impact and relevance. First of all, the literature review need to be expand. Despite the manuscript engages with relevant sources,  recent developments in digital health equity and municipal initiatives literature can be enriched. Incorporating more international and recent scholarship will help contextualize the study within a broader framework. Secondly, The study could benefit from a more robust theoretical underpinning. Although the focus on digital health equity is clear, incorporating established health equity frameworks (e.g., social determinants of health, digital divide theories) could strengthen the argument and provide a solid foundation for discussing the impact of municipal initiatives. Thirdly, The findings are well-presented but lack depth in some areas. Expanding on the analysis, particularly discussing why certain municipal initiatives were more successful than others, would provide richer insights. A more detailed comparison between initiatives or even a case study of the most impactful ones could add significant value to the results. Fourthly, The mixed-methods approach is a strength of the paper, but it would help to clarify how the methods were integrated to reach the conclusions. Were there particular criteria used to evaluate the success of the initiatives? A more transparent discussion of the methodology will improve the replicability of the research and provide greater confidence in the results. Fifthly, the findings are compelling, the discussion could better tie the results back to the broader digital health equity literature. E.g. more emphasis on how these municipal initiatives can be models for other regions or countries facing similar health equity challenges could enhance the practical impact of the study. The policy recommendations provided are a good starting point, but they could be expanded to address more specific actions that municipal governments and policymakers can take based on the study’s findings. Consider providing more detailed recommendations or a step-by-step guide for implementing successful digital health initiatives. Finally, while the study clearly addresses a timely and important issue, it would be helpful to explicitly state how this study advances the current knowledge in digital health equity. By making a clearer statement of its unique contribution to the field, the manuscript will better position itself within the broader academic conversation.

Author Response

We appreciate the review suggestions and comments received by this reviewer. We have provided the responses to the reviewer as attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Comment.

 

Please change the graphs to higher resolution graphs (SVG format resolution) from the programme done in the statistical process instead of the excel format.

 

(1) I don't understand the basis for the 23 years regarding digital technology in healthcare in the introduction.

If it is only digital and communication technology, there are already pioneering examples of its use in World War II, athlete monitoring at the Olympics, care management, etc.

The diffusion also differs from country to country, so please clarify whether these discussions are limited to Portugal or are global discussions within the scope of the journal.

Also, the research design of the overall study is listed on page 5, should this not be listed in the introduction?

 

(2) There are very few literature reviews. Digital technologies in telemedicine, examples in South-East Asia and the United States of America are very well developed and they have been going on for more than 20 years. A more specific discussion of the relationship between those article surveys and summaries regarding the history of digital healthcare and this study should be provided.

 

(3) The scope, subject and time period of the research dataset is unclear. Also, the graphs are very rough.

There is no need for a 3D graph.

Also, please provide an explanation regarding the population.

 

It is also unclear why the graph in Figure 4 is in Venn diagram format.

 

Overall, the explanation of the statistics is questionable. Please be strict.

 

Author Response

We appreciate the review suggestions and comments received by this reviewer. We have provided the responses to the reviewer as attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

“Best of all, I hope you always report good quality research and enjoy it.”

Thank you for giving me the opportunity to review this wonderful manuscript. I was interested in your study about how identify and characterize the municipal initiatives that have been developed in Portugal to promote digital health equity. It proposes 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.

Major Comments:

None.

Minor Comments:

The paragraph numbers are incorrect from the 'Materials and Methods' section to the 'Conclusions' section.

 

1.       Literature Review

Ø  (Lines 158-164) introduce profound changes in access to services, emphasizing e-health and remote monitoring technologies. This is generally well-written, but integrating a smoother transition from health literacy to remote monitoring might improve flow.

2.       Materials and Methods

Ø  (Lines 176-186) The Materials and Methods section introduces three frameworks for digital health equity. However, the explanation of how these frameworks connect or why one was chosen over the others could benefit from more clarification. Consider stating briefly why Richardson et al.’s framework is more applicable to this particular study, especially since it highlights the relationship between digital environments and stakeholders' roles.

Ø  (Lines 188-194) The explanation of mixed methods effectively references the triangulation design model and its increasing use in healthcare research. However, the sentence "allowing to circumvent the limitations of quantitative data analysis" is grammatically awkward. Please consider revising to: “allowing researchers to overcome the limitations of quantitative data analysis.”

Ø  (Lines 217-222) The tools used for data analysis are well-defined, but the significance of using R Software for quantitative exploration and MAXQDA for thematic analysis could be expanded. Briefly mentioning why these specific tools were chosen or how they complement each other would enhance this section.

3.       Results

Ø  (Lines 224-229) In the Results section, the concentration of digital health equity initiatives in certain municipalities  is clearly outlined. However, it would be useful to briefly discuss why only 13 out of 308 municipalities have initiatives in this area. Is there a known cause, such as funding limitations or geographical constraints?

 

Ø  (Line 242-243. Line 251-252) In the text, the author expressed the distribution of projects in the form of 'n, (%)'. Therefore, it would be better to present Figures 2 and 3 as tables.

Author Response

We appreciate the review suggestions and comments received by this reviewer. We have provided the responses to the reviewer as attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

This is a significant improvement from my last post. It seems that the graphs have not been corrected yet, so a correction would be desirable.

Author Response

Thank you very much for your improvement suggestions. We have provided the response letter, and the changes made in the manuscript are identified with the blue color.

Author Response File: Author Response.pdf