# Digital healthcare services in the context of age-friendly community initiatives in China: a realist evaluation

## TL;DR

This study evaluates how digital healthcare services work in age-friendly communities in China, focusing on what makes them effective for older adults.

## Contribution

The paper introduces a realist evaluation methodology to understand digital healthcare services in top-down age-friendly community initiatives.

## Key findings

- Six context-mechanism-outcome configurations were identified in digital healthcare service implementation.
- Government-led initiatives and bottom-up approaches both play critical roles in improving outcomes for older adults.
- Collaboration between healthcare professionals and local monitoring can enhance the sustainability of these services.

## Abstract

Understanding digital healthcare services in age-friendly community (AFC) initiatives and their implementation is crucial for developing evidence-based policies and practices. In this study, we aim to explore the question, “What is it about digital healthcare services that work, for whom, and under what circumstances?” in top-down AFC initiatives using Shanghai, China, as a representative case.

We employed a novel realist evaluation methodology and gathered insights from critical informants and users, including policymakers, community officers responsible for implementing AFC initiatives, and older adults.

The findings revealed six context-mechanism-outcome configurations. The government-led top-down AFC initiative, along with its related policies, serves as a critical context for supporting the provision of digital healthcare services and improving outcomes for older adults and their communities. A bottom-up approach values individual demand-oriented methods, providing digital healthcare services in AFC initiatives by considering older adults’ health and social situation as a critical context, utilizing digital care services and support as resources, and enhancing user experience. A feasible path forward is to support healthcare professional-led collaboration in developing and implementing digital healthcare services, aligning bottom-up and top-down practices, and focusing on individual demand, social equity, privacy concerns, and data-driven feedback.

Top-up support, active engagement of providers, and closer local monitoring of digital healthcare service implementation in AFC initiatives may encourage long-term effectiveness and sustainability.

The online version contains supplementary material available at 10.1186/s12913-025-13846-8.