How to Build Trustworthy Digital Health Initiatives?

Trust is essential for successful digital health initiatives. It does not emerge spontaneously but demands deliberate, targeted efforts. A four-step approach (understand context, identify levers, implement trust indicators and refine actions) supports practical implementation. With a comprehensive understanding of user trust and traits of trustworthy initiatives, it is important to shift from abstraction to practical action using a stepwise method that delivers tangible benefits and keeps trust from remaining theoretical.

Key Points

• Trust is vital for the acceptance of digital health initiatives and the broader digital transformation of health systems.
• Frameworks define principles that support the development and implementation of trustworthy digital health initiatives.
• Trust performance indicators enable ongoing evaluation and improvement of initiatives.
• Building trust demands proactivity, leadership, resources, system thinking and continuous action.

Trust as a Foundation for Digital Transformation of Health Systems

At the 78th World Health Assembly in May 2025, Dr. Tedros, Director-General of the World Health Organization (WHO), highlighted the importance of trust for the development of digital health systems (WHO 2025a). In the same vein, WHO Europe and the European Observatory on Health Systems and Policies moved trust into the spotlight of the health policy agenda (McKee et al. 2024). At the national level, numerous digital health strategies and applicable legislation on data sharing underscore the importance of trust for the successful implementation and uptake of health data sharing infrastructures, artificial intelligence in medicine, medical and health applications, and national electronic health record systems, to mention a handful of examples (WHO 2025b; Zavattaro et al. 2024). The underlying thinking is that user trust is necessary to support both the implementation and the use of these initiatives. This is particularly critical in the health domain, where these initiatives involve the handling of sensitive personal data.

Mirroring the importance of trust for the acceptance of digital health initiatives and the broader digital transformation of health systems, researchers explored the conceptual underpinnings of what users perceive as a trustworthy digital health initiative. Building on that work, we are currently in the transition phase from concept to practice answering the question: How can we build trustworthy digital health initiatives?

Trust is widely considered a fuzzy concept, difficult to grasp and even more challenging to operationalise within complex digital systems. It is a relational, context-dependent and inherently complex concept which contributes to the absence of a universally accepted definition (Hardin 2002). One way to describe is as “a bet about the future contingent actions of others”, a formulation that underscores the central role of time in trust dynamics (Sztompka 1999). Comparative research shows that building trust largely depends on information related to:

a) past experiences with the actors or the initiative in question,

b) present perceptions of the digital health initiative’s potential to fulfil what it is expected to deliver, and

c) anticipated beneficial outcomes resulting from that trust (Gille 2023).

While we all have a personal understanding of what trust means for us–shaped by our culture, upbringing and life experiences–it can be challenging to describe trust in complex and abstract systems such as health data sharing for primary and secondary use, or AI in medicine. An additional layer of complexity emerges when trust is examined not only at the individual level, but also at the community or population level, such as public, patient or professional trust.

To make trust a useful concept for health policymaking, health system governance, hospital management or the healthcare industry broadly, researchers have developed conceptual trust frameworks. Based on interviews with users–asking, for example, “What makes an AI application trustworthy?”–these frameworks typically describe principles that users associate with trustworthiness, such as data security, privacy protection and accountability, as well as effects resulting from users’ trust, for instance, the adoption of an AI application in practice. Therefore, such frameworks are highly valuable for describing the causes and effects of trust within a specific context and can be used as starting points for operationalising trust-building principles within digital health initiatives. One example is the “Public Trust in Health Data Sharing” framework, which comprises ten principles that the public associates with trustworthy health data sharing (Zavattaro et al., 2024). Each of these principles contributes to fostering public trust in health data sharing.

• Agencies of Accountability: Identifying agencies accountable for the use of health data.
• Autonomy of Choice: Granting individuals control over their health data.
• Benefit in Health Data Sharing: Identifying personal or public benefits of the initiative.
• Communication with Data Subjects: Actively informing individuals on the use of their health data.   
• Data Traceability: Ensuring transparency in how health data is used.
• Deidentification of Health Data: Removing personal identifiers before sharing data.
• Privacy Protection: Protecting individuals’ privacy and health data confidentiality fosters public trust in health data sharing.
• Public Information: Informing citizens on the initiative through government-led public outreach.
• Security: Protecting health data from breaches and misuse.
• Time: Allowing individuals a period of reflection before deciding to share their data.

Several other trust frameworks exist that describe, for example, trust in AI, data spaces, electronic health record systems, medical apps or the health system in general (Daniore et al., 2024; Gille, 2023; Haasteren et al., 2019; Papadopoulos et al., 2024; Starke et al., 2025).

Operationalising Trust-Building Principles in Digital Health Initiatives

When using a trust framework to operationalise trust-building principles in the governance process or architecture of a digital health initiative, we propose the following steps based on our previous and ongoing research on trust in health systems in the context of data use and policy.

To bring trust-building principles into practice, we need to take a systems-thinking approach (Finegood & Yakimov 2024). Trust-building must be considered a holistic activity orchestrated simultaneously on several levels. Research shows that trust-building requires strong executive leadership, resources and continuous engagement by those aiming to build trust (Gille et al. 2025b). We cannot build trust through a one-off action.

Firstly: Understand Your Context

We need to understand the actors involved–i.e. who is trusting whom–to focus our actions on the right target audience and ensure that the trust framework we use is appropriate. For example, when we apply a trust framework describing physicians’ trust in AI applications in medicine, but aim to build a trustworthy initiative for patients, the framework might be of limited relevance. Eventually, conceptual clarity and precise understanding of the context, including the actors involved, are imperative. If we do not know the kind of trust in question–who is expected to trust whom, and which are the actors involved and influencing the trust relationship–any following efforts to build trust are, at best, short on luck, if not useless. Conceptual imprecision has further implications on the ability to comprehensively evaluate trust-building activities, as any type of measurement needs a solid conceptual basis (Streiner et al. 2015).

Secondly: Know Your Levers

When considering the resources we have at hand and what is feasible within a given timeframe, we should map the available levers and options to operationalise each trust-building principle. Usually, there is a set of different levers to operationalise trust-building principles in the context of digital health initiatives. These include, among others, the following areas: communication; digital literacy; governance; law and regulation, and technology.

Data security is widely understood as a vital trait of a trustworthy digital health initiative. It is considered a key trust-building principle: when we see that our data is secure, we are more likely to trust such initiative. The National Cybersecurity Center of Excellence of the U.S. Department of Commerce describes data security as “the process of maintaining the confidentiality, integrity and availability of an organisation’s data in a manner consistent with the organisation’s risk strategy. Before an incident happens, companies must have a security architecture and response plan in place. Once an incident occurs, they must be able to detect the event and respond accordingly. After the incident, the company must be able to recover effectively and efficiently” (National Cybersecurity Center of Excellence 2025). The application of the five levers to the trust-building principle of ‘security’ within a digital health initiative is described in Table 1. These actions are provided for illustrative purposes only, and have been deliberately selected and simplified by the authors to demonstrate the underlying reasoning.

The same exercise should be undertaken with all trust building principles described in a given trust framework to make sure that each principle is comprehensively operationalised and deeply embedded within the architecture of the digital health initiative. Prioritisation of trust building principles in a resource scarce environment is necessary. That said, current research usually neglects this economical constrain which potentially undermines trust building efforts from the outset. One approach to prioritisation is to conduct a ranking exercise with the user community. Such insights can potentially help to conclude which actions needs to be prioritised (Gille et al. 2025a).

Thirdly: Implement Trust Performance Indicators

Following the operationalisation of trust building principles, we want to understand the extent to which the trust building activities achieve their intended purposes. Evaluating their performance is vital to monitor shifts in user trust, enabling targeted resource allocation and evaluating the effectiveness of trust building principles altogether. Without a robust performance assessment methodology in place, there is a risk that trust-building actions may be undermined by insufficient insights and potentially misaligned resource allocation.

In trust research, population surveys are traditionally used to understand levels of trust (Taylor et al. 2023). However, in our view, these methods are not sufficiently comprehensive to assess the performance of trust building activities set in Table 1. A key limitation of surveys is their lack of continuous monitoring, as they are usually disseminated in long time intervals.

To complement survey data, we propose the introduction of trust performance indicators (TPI) (Gille et al. 2024; Gille et al. 2025a). TPIs are intended to bring the data collection method closer to the point of action and to facilitate routine data collection. At present, different research streams have developed evaluation frameworks in the digital health area, which can either complement TPIs or serve as context in which TPIs can be embedded. Examples include the “Design and Evaluation Framework for Digital Health Interventions” and the “Digital Public Health Maturity Matrix” (Kowatsch et al. 2019; Maaß 2024).

TPIs are a set of indicators that, in analogy to Key Performance Indicators or Quality Indicators, provide meaningful data about the performance of each trust-building action. When data output is high-frequency, there is an opportunity to act in time and adjust trust-building actions where needed. In this way, TPIs not only support the evaluation of trust-building efforts but also facilitate the continuous improvement of the digital health initiative itself (Gille et al. 2024).

Fourthly: Refine your actions

Trust-building is not a one-off action; it requires continuous engagement and adjustment. On the one hand, the evaluation of trust-building activities demands corrective measures where necessary. On the other hand, the underlying trust frameworks may evolve over time, especially in heterogeneous communities characterised by rapid digital transformation, the introduction of unfamiliar technologies and spillover effects from trust dynamics in unrelated initiatives beyond the healthcare sector. We advise a proactive approach on two fronts:

• continuous improvement of the initiative in response to internal evaluation; and
• adaptation of the initiative in response to evolving user perceptions of trustworthiness, which may manifest in changing conceptual frameworks.

Ways Forward

Building trustworthy digital health initiatives requires proactivity, leadership, resources, systems thinking and continuous action. We need to overcome the theory–practice gap and move beyond conceptual work describing trust, shifting the focus to concrete, operational steps. At present, we have a good understanding of what user trust is and the characteristics of trustworthy digital health initiatives. It is therefore time to act and confidently start building them.

While calls for action on trust are necessary, we must move beyond abstract debate and start delivering digital health solutions that users can experience – and that offer real, tangible benefits. If we fail to demonstrate these benefits and make such initiatives accessible and meaningful to user communities, we risk remaining locked in theoretical and ultimately unproductive debates about the importance of trust. Too often, we ask users to place their trust in the potential of digital health initiatives – offering promises rather than enabling them to experience concrete value in return. A prominent example in many European countries are the endless attempts to introduce national electronic health systems (Papadopoulos et al. 2025). In Switzerland, for instance, it is hardly possible for professionals and the public to experience the benefits of a fully implemented national electronic health record system, as it is not operationalised in practice; only 0.8% of the population had activated their record as of 2024 (Bundesamt für Gesundheit 2024).

In everyday life, trust is typically built through repeated positive experiences with a technology or another entity. Normally, it remains a silent issue and only surfaces in public discussion when trust is declining or broken. With this insight in mind, our focus should shift away from abstract conversations about trust and towards actively building trustworthy initiatives that deliver clear benefits to the intended user community. A pragmatic, stepwise methodology – such as the four-stage approach proposed above – offers a manageable route through the complexity of large systems. Rather than be puzzled by theory, let us take the first of those four steps and begin operationalising trust in practice.

Conflict of Interest

Felix Gille works at the Federal Chancellery of Switzerland, the views expressed in this article are the views of Felix Gille and not of the Federal Chancellery.