Abstract
Rapid advances in digital health are reshaping clinical practice, creating new opportunities and risks that medical graduates must be prepared to navigate. This necessitates the integration of digital health education as a core component of medical training. While international consensus on the need for digitally competent doctors is growing, evidence to guide digital health education content and effective implementation within crowded medical curricula remains limited. Prevailing assumptions, such as the "digital native" discourse, obscure substantial variation in students' professional digital preparedness. Uncertainty about transferability of international evidence to contexts such as Aotearoa New Zealand (AoNZ) risks leaving graduates underprepared, missing opportunities for future enhancement of healthcare quality and patient outcomes.
This thesis aimed to address these gaps through a multiphase, multimethod realist inquiry. The first phase employed a qualitative, interpretivist-inductive approach to identify the digital health content and educational interventions most likely to enable medical students to achieve the required learning outcomes for digital competence. Primary data were collected through balanced engagement with local learners, educators, and digital health experts, with framework and thematic analysis identifying four essential digital health competence domains:
• Understand the Local Digital Health Ecosystem and Landscape
• Safe, Secure and Ethical Information Literacy and Management
• Proficiency in Digital Health Tools and Associated Technologies
• Scholarly Research and Evidence-based Practice
The focus then shifted to explaining how these competences should be integrated into medical curricula to achieve intended learning outcomes and why their effectiveness varies across educational contexts. The study adopted Pawson and Tilley's theory-driven realist methodology to investigate underlying mechanisms through which educational interventions operate.
Within this framework, hypotheses about the conditions enabling learning transfer, developed iteratively during the preliminary phases and the primary data collection phase, guided the inquiry. These hypotheses were tested through a realist review of international evidence as part of an iterative realist analytic process, which supported theory refinement and interpretation in relation to relevant behavioural and learning frameworks at the macro-, meso-, and micro-levels of the social and educational environment. Iterative analysis and refinement generated four semi-predictable explanatory patterns (demi-regularities), each comprising multiple hypotheses. These were subsequently triangulated against primary interview data to assess explanatory strength and contextual transferability, culminating in an overarching programme theory explaining the conditions under which medical students develop digital health competence.
This approach conceptualised digital health education as a context-dependent system where outcomes arise from interactions between contextual conditions and generative mechanisms. Retroductive reasoning identified theory-informed, empirically grounded strategies for embedding core competences within existing curricula.
The findings address three interconnected questions: what minimum essential digital health competences medical students in AoNZ require, how these can be effectively embedded within existing curricula, and why similar educational initiatives produce variable outcomes. The overarching programme theory is operationalised through a Pawson–Miller Framework that draws on Pawson’s four I’s of social context, configured hierarchically, and Miller’s pyramid of clinical competence. This framework is organised around four complementary pedagogical pillars: curriculum positioning, structured integration, a multidisciplinary educational ecosystem, and role modelling, which are theorised to progressively develop digital health competence across Miller’s levels.