Developing a Gender Framework for Responsive and Adaptive Design in Digital Health (FORWARD) from a review of reviews.

Background: Despite the increasing use of digital health interventions (DHIs) in low- and middle-income countries (LMICs), gender disparities persist in access, utilization, and outcomes. Barriers to women's phone ownership and use include affordability, digital literacy, and social norms; these are not only technological, but institutional as reflected in the limited integration of gender equity in national digital health strategies. While the body of evidence on DHI effectiveness is growing how to implement gender equitable digital programs is less clear. Methods: We conducted an umbrella review of systematic reviews to synthesize gender-related outcomes on DHIs in LMICs. Eligible DHIs included those used by community health workers and client-facing interventions for health communication, self-management, and symptom monitoring. We included only reviews that reported quantitative outcomes with confidence intervals and reported the study design for included studies. We classified interventions along the Gender Equality Continuum. Findings were reported using PRISMA guidelines. Results: Of the reviews analyzed, only eight (5.5%) explicitly applied a gender lens. Barriers to women's participation in DHIs included limited phone ownership, financial dependence, and socio-cultural norms restricting access to health information. Gender-responsive interventions that accounted for these challenges were rare. Gender-transformative approaches (which seek to shift harmful gender norms), such as engaging men in health-seeking behaviors, showed promise but remain underutilized and under evaluated. Measurement of gender-related barriers and their influence on outcomes was limited. No studies used validated gender scales. Conclusions: Based on these findings, we propose the Gender Framework for Responsive and Adaptive Design in Digital Health (FORWARD) to guide implementers in designing DHIs that address gender disparities. Gender FORWARD emphasizes gender-responsive design at individual (i.e. literacy and access), workforce (i.e. usability, interoperability, and supportive supervision), and ecosystem (i.e. capture and use of gender data in decision-making) levels. This framework offers a critical resource for researchers, implementors, and policy makers to improve digital health equity by ensuring interventions are inclusive, accessible, and sustainable across genders.